Adolescents report their need for and use of health care services

PURPOSE

The goals of this study were to describe student access to health care services, identify populations of students who remained in need of health care services, and highlight particular unmet needs for health care identified by these adolescents.

METHODS

Students in Grades 9-12 attending 50 schools in Oregon completed the Youth Risk Behavior Surveillance Survey (YRBS). Questions requesting adolescents to report their need for specific types of health care, and access to general and specific types of care were added to the core YRBS. Multivariate logistic regression analysis was used to determine independent relationships between student or community characteristics and health care access or unmet needs for care.

RESULTS

Almost 14,000 adolescents completed surveys, of whom 75% reported visiting one or more health care provider within the last 12 months. Nineteen percent of adolescents reported that they had not received 1 or more of 10 specific types of care when needed in the last year. Females, some racial/ethnic minorities, rural, and sexually active adolescents were more likely to report unmet needs for health care. Most frequently, adolescents reported they needed but did not receive care for an illness (7%) or for personal or emotional problems (6%). In addition, about 400 (3%) students reported they needed birth control that they did not receive.

CONCLUSIONS

A majority of high school-age adolescents had visited health care providers within the year prior to study. However, the number of adolescents who reported unmet specific health care needs within the same time period remained substantial.

The Sexual Health Help Centre: a service for young people

BACKGROUND

The Sexual Health Help Centre (SHHC) was opened in 1995 to provide treatment, advice and information on family planning and sexual health issues for young people under the age of 20 years, in a way which is open and non-threatening. This paper describes an evaluation conducted during the first 9 months of service operation.

METHODS

Young people's experience of the SHHC were elicited, and compared with their experiences of conventional family planning services in Glasgow.

RESULTS

The SHHC has been successful in attracting young people for help with family planning problems and provides a more acceptable environment than conventional family planning services. However, a greater number of young men and young people under the age of 16 should be encouraged to attend the service.

CONCLUSION

Young people are more likely to visit family planning services if they are offered a wide range of family planning and sexual health services in a non-judgmental, non-threatening environment.

Barriers to health care for street youth

This study investigates the barriers to health care faced by runaway adolescents. A convenience sample of 89 street youth located through community agencies was surveyed to elicit their perceptions of barriers to care. Results indicated that these youth experience a wide range of barriers to health care, both objective and subjective. They also experience fears with regard to receiving health care, many of which seem developmental in nature. The relative isolation of these youth compounds the objective barriers they face, yet many overcame these barriers and received needed care.

Child and adolescent psychiatry in-patient facility

The short-term in-patent facility of the Child and Adolescent Psychiatry Unit in the National Institute of Mental Health and Neurosciences, Bangalore is described. Its clientele over one year is reviewed. Totally 152 admissions were made. Hysterical neurosis (30.8%), Psychoses (25.2%), Conduct disorder (10.5%) and Hyperkinetic syndrome (9.8%) were the most common diagnoses observed in this population who needed short-term intervention. Average duration of stay was 4-12 weeks. All children were admitted with a parent. In 95.8% of the cases the treatment expenses were borne partially/fully by the hospital. The policy and functioning of the facility is discussed.

Health care access and utilization among pregnant adolescents

PURPOSE

To assess access to and use of health care by adolescents prior to their becoming pregnant.

METHODS

An interviewer-administered questionnaire was completed by all pregnant adolescents (n = 65) entering the Rochester Adolescent Maternity Program (RAMP) between January and June 1994. Questions addressed access and utilization issues including routine care and other services used, and existence of a regular source of care prior to pregnancy.

RESULTS

Sixty-one adolescents (94%) completed questionnaires. Almost all (93%) had made a doctor or clinic visit, and 77% had had a checkup in the prior year. Most had Medicaid (85%) or private insurance (13%). The median number of visits to a regular source of care was 2.0 (range 0-10). Most frequently reported sources of regular care were hospital clinics (43%), community health centers (26%), and private physician offices (15%). Two-thirds (66%) reported having used multiple sources of care. Of those who used other sources in addition to a primary care source, 40% used reproductive health clinics. Adolescents whose primary care source was a traditional physician's office were more likely to also use reproductive health clinics than those who reported using more comprehensive primary care sources.

CONCLUSIONS

Most pregnant adolescents in this sample had previously used routine primary care, usually in hospital clinics or health centers. Many of those adolescents also use multiple sources of care, most often for reproductive services. Access to reproductive health services does not seem to have been a problem for these adolescents prior to their pregnancies.

Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care. A randomized controlled trial

CONTEXT

Adolescents' concerns about privacy in clinical settings decrease their willingness to seek health care for sensitive problems and may inhibit their communication with physicians.

OBJECTIVE

To investigate the influence of physicians' assurances of confidentiality on adolescents' willingness to disclose information and seek future health care.

DESIGN

Randomized controlled trial.

SETTING

Three suburban public high schools in California.

PARTICIPANTS

The 562 participating adolescents represented 92% of students in mandatory classes.

INTERVENTION

After random assignment to 1 of 3 groups, the adolescents listened to a standardized audiotape depiction of an office visit during which they heard a physician who assured unconditional confidentiality, a physician who assured conditional confidentiality, or a physician who did not mention confidentiality.

MAIN OUTCOME MEASURES

Adolescents' willingness to disclose general information, willingness to disclose information about sensitive topics, intended honesty, and likelihood of return visits to the physician depicted in the scenario were assessed by anonymous written questionnaire.

RESULTS

Assurances of confidentiality increased the number of adolescents willing to disclose sensitive information about sexuality, substance use, and mental health from 39% (68/175) to 46.5% (178/383) (beta=.10, P=.02) and increased the number willing to seek future health care from 53% (93/175) to 67% (259/386) (beta=.17, P<.001). When comparing the unconditional with the conditional groups, assurances of unconditional confidentiality increased the number of adolescents willing to return for a future visit by 10 percentage points, from 62% (122/196) to 72% (137/190) (beta=.14, P=.001).

CONCLUSIONS

Adolescents are more willing to communicate with and seek health care from physicians who assure confidentiality. Further investigation is needed to identify a confidentiality assurance statement that explains the legal and ethical limitations of confidentiality without decreasing adolescents' likelihood of seeking future health care for routine and nonreportable sensitive health concerns.

Programs and services to prevent pregnancy, childbearing, and poor birth outcomes among adolescents in rural areas of the southeastern United States

PURPOSE

To illustrate how rural adolescents' needs for pregnancy prevention and improved birth outcomes are currently being addressed, and to suggest strategies for future programs.

METHODS

Local and state-level informants knowledgeable about services to adolescents in the Southeastern United States were identified. Semistructured interviews were used to determine the program start date and time frame, funding sources, target population, participating counties, implementing agency or organization, specific program services, and status of program activities. These programs were categorized by the type of services offered and the population targeted.

RESULTS

The most common adolescent services in the rural Southeast attempt either to improve life options of youth, reduce sexual activity, or provide prenatal and postnatal care. Unlike urban areas where there are a variety of family planning providers, in the rural Southeast, health departments are the primary source of family planning for adolescents. There are no abortion providers in most rural areas of the Southeast. The majority of rural programs that include adolescents among the population served are developed for all women rather than specifically for adolescents. Programs specific to rural adolescents are described.

CONCLUSIONS

The majority of programs in the rural Southeast address only selected adolescent health issues. Successful interventions require locally supported, multipronged, intensive approaches with consistent messages targeted to high-risk populations. Evaluation tools are needed to determine the effectiveness of each component of prevention programs.

Statewide coverage of very low birth-weight infants and young teenage mothers in North Carolina's Child Service Coordination Program

North Carolina's statewide, interagency Child Service Coordination Program (CSCP) serves children under five years of age with or at-risk for diverse health and developmental conditions. Preliminary assessment of the CSCP linked existing datasets to examine program coverage for two target populations: mothers < 15 year of age and infants < 1,500 g. The expectation that statewide program coverage would be higher for both risk groups in 1993 than in 1991 was true for mothers less than 15 years of age but not for infants < 1,500 g. This efficient method of evaluation can direct program outreach to the areas where it is most needed and provide a focus for more detailed program evaluation.

Factors associated with child mental health service use in the community

OBJECTIVE

To determine the association of parent, family, and child factors with mental health services need and utilization.

METHOD

Possible determinants of services need and utilization were assessed in a general population sample of 2,227 children aged 4 to 18 years.

RESULTS

3.5% of the total sample had been referred for mental health services within the past year. The most potent factors associated with service need and utilization were the child's problem behaviors (both internalizing and externalizing) and academic problems and family stress. Socioeconomic factors and the child's sex were not in itself associated with help-seeking factors. Parental psychopathology, life events, and family psychopathology lowered the parents' threshold for evaluating the child's behavior as problematic but did not increase the likelihood of referral.

CONCLUSION

Referred children are more likely to live in families under stress than are children with the same level of problems who live in well-functioning families. Clinicians and researchers who make inferences from findings in clinical samples should realize, therefore, that children from problem families are overrepresented in their samples.

Access to ambulatory care for adolescents: the role of a usual source of care

Using data from the 1987 National Medical Expenditure Survey, characteristics of ambulatory service utilization for adolescents aged 11 through 17 were examined. Access to health care was further explored by identifying adolescents at risk of not receiving an ambulatory service in the event of symptomatology. Approximately two-thirds of an estimated 25 million adolescents experienced an outpatient visit. African American race, Hispanic ethnicity, middle income, and lack of insurance and a usual source of care placed adolescents at risk for not receiving an ambulatory service. Sixteen million adolescents experienced symptomatology, but only one-third saw a physician. Those lacking a usual source of care were at greater odds of not receiving care. For symptom-based care, inequities were related more to lack of usual source of care rather than socioeconomic characteristics. Health care reform efforts may benefit from ensuring that adolescents have an identified usual source of care to ensure equity of access to care.

Adolescents' attitudes to general practice in north London

A questionnaire-based survey, undertaken in North London state secondary schools, illustrated some stumbling blocks and a lack of knowledge that is likely to inhibit an effective use of general practice among 12-18 year olds. A review of the current arrangements and some adjustment of current services might increase the likelihood of achieving Health of the Nation targets for teenage pregnancies, and may also improve health care for this important and vulnerable section of the population.

Gender-specific factors in the utilization of medical services during adolescence

Although adolescents suffer from a variety of complaints, they do not often consult a doctor. Following a high rate of medical consultation during infancy and childhood, the rate dramatically decreases at the age of 10 and increases again around the age of 16. In this study we investigated factors that influence the use of medical services during adolescence. We focused our attention on gender-specific differences and examined the following hypotheses: (i) Girls and boys differ generally in their consultation behaviour; and (ii) the use of medical services depends on the kind of prevailing illness and is influenced by gender-specific factors. The investigation is based on a standardized questionnaire answered by 2300 schoolgirls and -boys, aged 12 to 16. The topics of the questionnaire were, apart from sociodemographic variables: subjective state of health; prevailing illnesses and complaints; health-related cognitions; quality of the parental relationship; stress at school; and satisfaction with previous medical treatment. The results showed that girls reported suffering significantly more frequently from most illnesses than boys. However, there was no difference between girls and boys in the general consultation rate. In a regression analysis we found that subjective impairment, satisfaction with the previous medical consultation and the tendency to be concerned with one's health were the best statistical predictors of consultation behaviour. Age, social status, sex, stress at school and the quality of the relationship between adolescents and their parents were not significantly related to consultation rate. A discriminant analysis (consultation vs. non-consultation) revealed that, depending on specific illnesses, different factors influenced the decision to consult a doctor.

Utilization of Medicaid mental health services by nondisabled children and adolescents

OBJECTIVE

Mental health service use and costs for nondisabled children and adolescents in the Medicaid programs of Michigan and Tennessee were examined to improve understanding of patterns of service use in this population.

METHODS

Data from the Medicaid Analysis Project for States, sponsored by the Health Care Financing Administration, were examined for nondisabled children and adolescents under 19 years of age who were continuously enrolled in Medicaid in 1990 and who received Medicaid mental services, including treatment for alcohol and drug abuse. Recipients of mental health services constituted 5 and 7 percent of the nondisabled children and adolescents in the Medicaid programs in Michigan and Tennessee, respectively.

RESULTS

Total expenditures for mental health care recipients were three or more times higher than the level suggested by their proportion in the general Medicaid nondisabled population. Their psychiatric hospitalizations were much longer, with mean lengths of stay of 44 days in Tennessee and 60 in Michigan. Although inpatient utilization rates were similar in the two states, outpatient utilization differed by type of problem treated, provider, and type of treatment. About a third of mental health recipients received psychotropic drugs; cerebral stimulants were the most commonly prescribed type.

CONCLUSIONS

Results illustrate the need to learn more about Medicaid mental health services for younger children and the use of psychotropic drugs. They also suggest that states reforming their Medicaid programs to contain costs should pay particular attention to the use of mental health services by children and adolescents.

A profile of human immunodeficiency virus-infected adolescents receiving health care services at selected sites in the United States

OBJECTIVE

To determine the demographic/clinical profile of human immunodeficiency virus (HIV)-infected adolescents in care at selected sites.

METHODS

We mailed surveys requesting prevalence data from physicians in government-funded HIV research and care programs on HIV-infected youth (10-21 years) receiving care.

RESULTS

A total of 49% responses yielded information on 978 subjects. Vertical, blood, and sexual were predominant transmission modes. Three-quarters were of an ethnic/racial minority; 50% were female. The earliest median CD4 count was 0.467 x 10(9)/liter (467/microliter). Percent asymptomatic varied by transmission: vertical (16%), blood products (40%), male-male sexual (67%) and female-male sexual (M:73%) (F:74%). Clinical indicated Pneumocystis carinii pneumonia prophylaxis was differentially prescribed: vertical (96%), blood (89%), and sexually (male-male-47%) (female-male: M: 36% and F: 56%). Of these youth 78% are not represented in national AIDS case data.

CONCLUSIONS

Examination of numerator data from selected sites indicates three transmission-driven adolescent HIV epidemics with different characteristics. Minority youth are disproportionately represented; many vertically infected infants are surviving to adolescence; sexual activity is a significant transmission avenue. HIV-infected youth appear to enter care with considerable immunosuppression. Clinical profiles and treatment patterns appear to differ by transmission mode. Further study is needed on adolescent HIV disease progression and determinants of access to care and treatment.

Influence of school enrollment on adolescent emergency department visits

PURPOSE

This study examined the influence of school enrollment on the spectrum of adolescent problems seen in emergency department.

METHODS

Medical charts of all adolescent patients presenting to an urban general emergency department for 2 years (1991-1993) were retrospectively reviewed. Data obtained included date, time, and means of arrival, triage acuity score, primary diagnosis with disposition, and whether enrolled in school.

RESULTS

Of 3,269 charts reviewed, 36% of visits were the result of injuries and 64% owing to acute medical complaints. Of all visits, 7% were for sexually related complaints. A total of 86% of adolescent patients had no medical insurance or federal assistance. Based on emergency department triage criteria, 40% of all visits were judged nonemergency. Ambulance arrivals accounted for 4%, admissions 4%, and those not currently enrolled in school 40%. Adolescents not enrolled in school had a similar spectrum of medical illnesses and significantly more injuries (45% vs. 30%), and were triaged as emergency (8% vs. 4%) or nonemergency (48% vs. 34%) significantly more often than adolescents enrolled in school. There were no significant differences by sex or race.

CONCLUSIONS

Adolescents use the emergency department as a source of primary care and injury treatment. Adolescents presenting to the emergency department who are not enrolled in school have significant differences in diagnosis and severity of illness compared with adolescents enrolled in school. General emergency departments must be prepared to deal with the unique needs of all adolescents, especially those not enrolled in school, including nonemergency primary care and injury management.

Update on adolescent health care in pediatric practice

PURPOSE

To determine current adolescent health care practices of pediatricians and evaluate whether changes have taken place during the past decade.

METHODS

A questionnaire completed by 101 pediatricians in 1985 was abbreviated and adapted by Committee on Youth of Chapter 2, District II of the American Academy of Pediatrics and sent to 1,633 members of the Chapter in June 1993.

RESULTS

Forty-three percent of the 436 respondents in 1993 were female, 43% < or = 40 years of age and 53% were in private practice. Most accept new patients > or = 16 years of age (76%), continue to see patients > or = 19 years of age (63%), and interview adolescents without their parents (86%). Although between one-third and two-thirds of respondents report having equipment for gynecologic examinations, most indicate they are "not entirely comfortable" treating adolescent issues and therefore refer to others for management. Between one-quarter and one-half indicate they are "very interested" in learning more about adolescent issues and an additional 40-50% are "somewhat interested." Obstacles to providing adolescent care include: "image as a baby doctor" (65%), fear that parents would object (61%), no separate hours (57%), difficulty in providing confidential care (56%), and difficulty in charging appropriate fees (47%). Females and younger pediatricians are more comfortable with some aspects of gynecologic care and more likely to be satisfied with the adolescent care they are providing. There were few differences between responses in 1993 and 1995.

CONCLUSIONS

Few of the pediatricians surveyed provide comprehensive care to adolescent patients. Future policy decisions and medical education must respond to these realities in pediatric practice.

Reproductive and sexual health at the school-based/school-linked health center: an analysis of services provided by 180 clinics

PURPOSE

This article reports on the reproductive and sexual health services available on site to clients at school-based and school-linked health centers as reported in a 1993 survey of these centers. The study reviews the range of services and contraceptives available, length of time since opening that contraceptive services were made available and restrictions on contraceptive availability based on the setting (on or off campus), geographic location, grade levels served, sponsor and length of operation.

METHOD

One hundred and eighty (180) administrators completed a self-administered mail survey of health center operations. One section of the survey focused on questions regarding the reproductive and sexual health services provided on the health center site.

RESULTS

Reproductive health services make up 20 percent of all health center visits. Centers in operation at least 10 years, located in urban and suburban areas or off campus, provided the broadest range of services. Thirty-three percent of centers made at least one contraceptive method available; most of these centers initiated the service at the center's opening. Restrictions on contraceptive services (reported by 82 percent of respondents) came mainly from school district policy.

CONCLUSIONS

School-based and school-linked health centers offer a promising mechanism to deliver reproductive health services to young people. To date, however, external and internal policies restrict the availability and scope of these services.

Use of health services by urban youth: a school-based survey to assess differences by grade level, gender, and risk behavior

PURPOSE

The purpose of this study was: (a) to describe reported access to health care among urban youth, and (b) to compare intention to seek care and risk behaviors for youth who did and did not seek care.

METHODS

A cross-sectional survey measuring knowledge, attitudes, self-efficacy, and behavioral intentions related to sexuality and use of and access to health care was administered to 3,677 urban middle and high school students in health education classes.

RESULTS

A total of 13% of students reported no established health care, whereas 25% reported no care within the past 6 months. A physical examination was the most common reason for seeking care. Younger teenagers, males, and those not under care were less aware of teen clinics, thought it more difficult to access care, and had less intention to seek care within the next year (P < .001). Older students had greater knowledge and self-efficacy concerning sexual matters, were less positive about abstinence, and higher life and sex risk scores (P < .001). Females reported greater self-efficacy regarding sexual matters, were more positive about abstinence, and had lower life risk scores (P < .001). Adolescents receiving care had higher knowledge and self-efficacy scores, were more positive about condoms, had greater intention to seek care, but had higher life and sex risk scores.

CONCLUSIONS

Awareness and use of health care remain low for a sizable number of at risk urban youth, especially younger and male teenagers. The school is a setting in which adolescents not under care can be reached for provision of information about health care.

Do adolescents want to hear preventive counseling messages in outpatient settings?

BACKGROUND

In response to the high prevalence of health-risk behaviors among adolescents, policy agencies have urged primary care clinicians to discuss these behaviors with all adolescents. Yet such discussions frequently do not take place. A commonly mentioned barrier is the clinician perception that patients are not interested in, or are embarrassed by, such discussions. The purpose of this study was to assess the accuracy of this perception by conducting a survey of adolescents.

METHODS

Self-administered questionnaires were distributed to 305 adolescents, ages 11 to 16 years, waiting to be seen in three community health centers and three private practices. The questionnaire queried adolescents' willingness to talk about eight preventive counseling topics with health care practitioners, and information was collected on variables that might influence willingness. Descriptive frequencies were generated. Chisquare analysis and stratification assessed differences between groups.

RESULTS

A majority of adolescents felt that it is a clinician's job to discuss health risk behaviors. On the current visit, however, fewer than 20% wanted to talk about drugs, alcohol, cigarettes, or depression; fewer than 40% about sex; and fewer than 55% about diet or exercise. Adolescents reporting previous conversations on a topic were more likely to want to talk about that issue at the current visit. Willingness to talk did not vary by visit type (well care vs acute care).

CONCLUSIONS

This study confirms that adolescents are hesitant to discuss health risk behaviors with clinicians, but the findings also suggest that receptivity increases if clinicians address these topics on repeat occasions.

[The Adolescent Sexuality Hot-line--a 4-year study]

The first Adolescent Sexuality Hot-Line in Denmark was launched in January 1992. The hot-line offers anonymous, professional telephone counselling to teenagers. During its initial four years, 6174 persons called, consisting of approximately 60% boys and 40% girls. Four major categories were: "basic information" (22.8%), "sexual problems" (21.5%), "contraception" (11.3%) and "pregnancy" (9.1%). Characteristically, callers (especially boys) have become significantly older over the four-year-period, coincident with a significant prolongation of the length of the calls. This might be seen as a reflection of a genuine-but as yet unaccommodated-need for sexual counselling in age groups older than the intended target-group. The need for sufficient sexological counselling in a mature population is well established in several other Danish studies.

Utility of the theories of reasoned action and planned behavior for predicting physician behavior: a prospective analysis

The utility of the theory of reasoned action (TRA) and the theory of planned behavior (TPB) for prospectively predicting physicians' delivery of preventive services was compared. Primary care physicians (N = 765) completed 2 mail surveys at periods 6 months apart. The addition of perceived behavioral control to the TRA model significantly increased the variance accounted for in behavioral intention and subsequent behavior (p < .001). TPB constructs were related to physicians' intentions to educate adolescents about sexually transmitted disease transmission (R = .52, p < .001) and to their subsequent delivery of this service (R = .63, p < .001). Perceived behavioral control had direct effects on behavior and interacted with social norms and behavioral intentions. Applications of models such as the TRA or TPB have focused primarily on predicting the behavioral intentions and behaviors of patients. Results suggest that these models have relevance for studying the behavior of health care providers as well.

The nurse practitioner in the school setting

This article discusses primary care as it is provided in a school-based health center by a nurse practitioner and a health care team. The description of the practice includes the population served, the range of services, obstacles to care, future goals, and job satisfaction of the nurse practitioner.

Dental caries in Danish children and adolescents 1988-94

The present study is based on data reported from the Danish Municipal Oral Health Service for children and adolescents to the National Board of Health from 1988 to 1994. Only data from municipalities with public clinics for children and adolescents and only age-groups for which reporting was compulsory are included. When each cohort was followed during the years 1988 to 1994, it was shown that caries increment had only decreased slightly in both the deciduous dentition (from 3 to 6 yr) and in the permanent dentition (from 7 to 15 yr) during the beginning of the period and was now almost identical from one cohort to the next. The distribution of individuals in four selected age-groups according to defs and DMFS has become constant during the late 1980s and the early 1990s. It is concluded that the constant decrease in dental caries in Danish children and adolescents observed during the 1970s and early 1980s has now come to a halt.