Disparities in adolescent health and health care: does socioeconomic status matter?

The impact of socio-economic status on health related quality of life for children and adolescents with heart disease

Background

Socioeconomic status (SES) is known to influence children’s health-related quality of life. Many SES indicators assess distinct dimensions of a family’s position rather than measuring the same underlying construct. Many researchers, however, see SES indicators as interchangeable. The primary aim of this study was to determine which measure of SES had the strongest impact on health-related quality of life.

Methods

This is a secondary analysis of the Pediatric Cardiac Quality of Life Inventory Validation Study. The SES variables were family income, Hollingshead Index (occupational prestige), and highest parent educational attainment level. Health-related quality of life was measured using the Pediatric Cardiac Quality of Life Inventory. Correlations tested the relationship among the three SES indicators. Regression-based modeling was used to calculate the strength of the association between SES measures and the Pediatric Cardiac Quality of Life Inventory.

Results

The correlations among the SES measures were moderately high, with the correlation between the Hollingshead Index and parental education being r = 0.62 (95% CI = 0.56-0.65). There were equally high correlations between family income and the Hollingshead (r = 0.61, 95% CI = 0.57-0.65) and a slightly lower correlation between family income and parental education (r = 0.55, 95% CI = 0.52-0.59). Family income had the highest explanatory value compared to the Hollingshead Index or parental educational attainment, while controlling for sex, race, current cardiac status, and original diagnosis, accounting for 4-5% of the variation in patient and parent Pediatric Cardiac Quality of Life Inventory Total score, respectively, compared to the other SES measures.

Conclusion

Family income as an SES measure demonstrated the greatest fidelity with respect to health-related quality of life as measured by the Pediatric Cardiac Quality of Life Inventory across respondent groups and explained more of the variation compared to the Hollingshead Index or highest parental educational attainment.

Socioeconomic status and in-hospital pediatric mortality

OBJECTIVE

Socioeconomic status (SES) is inversely related to pediatric mortality in the community. However, it is unknown if this association exists for in-hospital pediatric mortality. Our objective was to determine the association of SES with in-hospital pediatric mortality among children's hospitals and to compare observed mortality with expected mortality generated from national all-hospital inpatient data.

METHODS

This is a retrospective cohort study from 2009 to 2010 of all 1,053,101 hospitalizations at 42 tertiary care, freestanding children's hospitals. The main exposure was SES, determined by the median annual household income for the patient's ZIP code. The main outcome measure was death during the admission. Primary outcomes of interest were stratified by income and diagnosis-based service lines. Observed-to-expected mortality ratios were created, and trends across quartiles of SES were examined.

RESULTS

Death occurred in 8950 (0.84%) of the hospitalizations. Overall, mortality rates were associated with SES (P < .0001) and followed an inverse linear association (P < .0001). Similarly, observed-to-expected mortality was associated with SES in an inverse association (P = .014). However, mortality overall was less than expected for all income quartiles (P < .05). The association of SES and mortality varied by service line; only 3 service lines (cardiac, gastrointestinal, and neonatal) demonstrated an inverse association between SES and observed-to-expected mortality.

CONCLUSIONS

Within children's hospitals, SES is inversely associated with in-hospital mortality, but is lower than expected for even the lowest SES quartile. The association between SES and mortality varies by service line. Multifaceted interventions initiated in the inpatient setting could potentially ameliorate SES disparities in in-hospital pediatric mortality.

Exploring the relationship between population density and maternal health coverage

Background

Delivering health services to dense populations is more practical than to dispersed populations, other factors constant. This engenders the hypothesis that population density positively affects coverage rates of health services. This hypothesis has been tested indirectly for some services at a local level, but not at a national level.

Methods

We use cross-sectional data to conduct cross-country, OLS regressions at the national level to estimate the relationship between population density and maternal health coverage. We separately estimate the effect of two measures of density on three population-level coverage rates (6 tests in total). Our coverage indicators are the fraction of the maternal population completing four antenatal care visits and the utilization rates of both skilled birth attendants and in-facility delivery. The first density metric we use is the percentage of a population living in an urban area. The second metric, which we denote as a density score, is a relative ranking of countries by population density. The score’s calculation discounts a nation’s uninhabited territory under the assumption those areas are irrelevant to service delivery.

Results

We find significantly positive relationships between our maternal health indicators and density measures. On average, a one-unit increase in our density score is equivalent to a 0.2% increase in coverage rates.

Conclusions

Countries with dispersed populations face higher burdens to achieve multinational coverage targets such as the United Nations’ Millennial Development Goals.

Impact of socioeconomic status on ionizing radiation exposure from medical imaging in children

PURPOSE

To characterize cumulative radiation exposure from diagnostic imaging (CEDI) in pediatric patients and to investigate its relationship to patients' socioeconomic status and comorbid medical conditions.

METHODS

A retrospective cohort study of >19,000 pediatric patients seen within the outpatient clinic system of an academic tertiary care urban medical center during the month of January 2006 was conducted to estimate CEDI from all procedures performed within 3 years of the index visit (until January 2009). Socioeconomic status was estimated from census tract geocoding. Comorbid medical conditions were identified from the electronic medical record.

RESULTS

A total of 19,063 patients underwent imaging tests within the index month. The mean age was 8.9 ± 6.3 years. Most had private insurance (56%), with 36% receiving Medicaid and 8% private payers. Our population lived in census tracts in which 27 ± 16% of the population were below the federal poverty level with 62% living in areas in which 20% of residents were living below the poverty level. There were differences in CEDI (P < .0001) by age, insurance type, and percentage poverty in the census tract of residence but not among racial groups (P = .6508). The association between poverty and CEDI was generally explained by the 26 Elixhauser diagnoses, with the exception of rheumatoid arthritis.

CONCLUSION

Patients living in areas of greater poverty were exposed over time to more radiation from diagnostic testing than those living in areas with lower percentages of residents living in poverty. This association was explained almost entirely by the presence of disease burden. No direct association was found between socioeconomic status and CEDI.

Understanding the Gap in Primary Care Access and Use Between Teens and Younger Children

Primary health care use among teenagers falls short of clinical recommendations and consistently lags behind that of younger children. Using the Medical Expenditure Panel Survey, the authors explore three explanations for this age-related gap: family composition, parental awareness of children’s health care needs, and the relative role of predisposing, enabling, and need-based factors for teens and younger children. Teenagers are 64% more likely to have no usual source of care and 25% more likely to have had no health care visit in the prior year relative to younger children. The gap narrows in families with children from both age-groups and among children with special health care needs. The largest disparity in primary care access exists between teens in families with no younger sibling(s) and younger children in families with no teen(s). A resolution to the age-related access gap will likely require understanding of, and intervention into, family-level determinants of poor access.

Self-reported adolescent health status of extremely low birth weight children born 1992-1995

OBJECTIVES

To compare the self-reported health of extremely low birth weight (ELBW, <1 kg) adolescents with that of normal birth weight (NBW) controls and the children's assessments of their general health at ages 8 versus 14 years.

METHODS

One hundred sixty-eight ELBW children and 115 NBW controls of similar gender and sociodemographic status completed the Child Health and Illness Profile-Adolescent Edition at age 14 years. It includes 6 domains: Satisfaction, Comfort, Resilience, Risk Avoidance, Achievement, and Disorders. At age 8 years, the children had completed the Child Health and Illness Profile-Child Edition. Results were compared between ELBW and NBW subjects adjusting for gender and sociodemographic status.

RESULTS

ELBW adolescents rated their health similar to that of NBW adolescents in the domains of Satisfaction, Comfort, Resilience, Achievement and Disorders but reported more Risk Avoidance (effect size [ES] 0.6, P < .001). In the subdomain of Resilience, they also noted less physical activity (ES -0.58, P < .001), and in the subdomain of Disorders, more long-term surgical (ES -0.49) and psychosocial disorders (ES -0.49; both P < .01). Both ELBW and NBW children reported a decrease in general health between ages 8 and 14 years, which did not differ significantly between groups.

CONCLUSIONS

ELBW adolescents report similar health and well-being compared with NBW controls but greater risk avoidance. Both ELBW and NBW children rate their general health to be poorer at age 14 than at age 8 years, possibly due to age-related developmental changes.

Effectiveness and cost of immunization recall at school-based health centers

BACKGROUND AND OBJECTIVE

Effectiveness of recall for immunizations has not been examined in the setting of school-based health centers (SBHCs). We assessed (1) immunization rates achieved with recall among sixth-grade girls (demonstration study); (2) effectiveness of recall among sixth-grade boys (randomized controlled trial [RCT]); and (3) cost of conducting recall in SBHCs.

METHODS

During October 2008 through March 2009, in 4 Denver public SBHCs, we conducted (1) a demonstration study among 265 girls needing ≥ 1 recommended adolescent vaccine and (2) an RCT among 264 boys needing vaccines, with half randomized to recall and half receiving usual care. Immunization rates for recommended adolescent vaccines were assessed 6 months after recall. First dose costs were assessed by direct observation and examining invoices.

RESULTS

At the end of the demonstration study, 77% of girls had received ≥ 1 vaccine and 45% had received all needed adolescent vaccines. Rates of receipt among those needing each of the vaccines were 68% (160/236) for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, 57% (142/248) for quadrivalent meningococcal conjugate vaccine, and 59% (149/253) for the first human papillomavirus vaccine. At the end of the RCT, 66% of recalled boys had received ≥ 1 vaccine and 59% had received all study vaccines, compared with 45% and 36%, respectively, of the control group (P < .001). Cost of conducting recall ranged from $1.12 to $6.87 per recalled child immunized.

CONCLUSIONS

SBHC-based recall was effective in improving immunization rates for all adolescent vaccines, with effects sizes exceeding those achieved with younger children in practice settings.

Contextual factors and anxiety in minority and European American youth presenting for treatment across two urban university clinics

The current study compared ethnic minority and European American clinically-referred anxious youth (N=686; 2-19 years) on internalizing symptoms (i.e., primary anxiety and comorbid depression) and neighborhood context. Data were provided from multiple informants including youth, parents, and teachers. Internalizing symptoms were measured by the Multidimensional Anxiety Scale for Children, Child Depression Inventory, Child Behavior Checklist and Teacher Report Form. Diagnoses were based on the Anxiety Disorders Interview Schedule for Children. Neighborhood context was measured using Census tract data (i.e., owner-occupied housing, education level, poverty level, and median home value). Ethnic minority and European American youth showed differential patterns of diagnosis and severity of anxiety disorders. Further, ethnic minority youth lived in more disadvantaged neighborhoods. Ethnicity and neighborhood context appear to have an additive influence on internalizing symptoms in clinically-referred anxious youth. Implications for evidence-based treatments are discussed.

The effects of school poverty on adolescents' sexual health knowledge

Using National Longitudinal Study of Adolescent Health data, hierarchical linear modeling was conducted to estimate the association of school poverty concentration to the sexual health knowledge of 6,718 adolescents. Controlling for individual socio-economic status, school poverty had modest negative effects on sexual health knowledge. Although not directly associated with sexual health knowledge, after controlling for demographic characteristics, school poverty interactions showed that sexual health knowledge was associated with higher grade point average (GPA) and age. The combination of low GPA and high-levels of school poverty was especially detrimental for students' sexual health knowledge. There are differences in the sexual health knowledge of adolescents attending low poverty and high poverty schools that can be attributed to the school environment.

Demand for and utilization of dental services according to household income in the adult population in Norway

OBJECTIVES

The aim of this study was to describe the effect of income on demand and utilization of dental services according to household income in the adult population.

METHODS

The data were collected using a questionnaire, which was sent to a random sample of Norwegians aged 20 years or older living at home, 1861 persons in total. Demand was measured according to whether the person had been to the dentist during the last year. Utilization was measured as expenditure for dental treatment for those who had been to the dentist during the last year. The independent variables were the respondents' household income, age, gender, education, dental status and the mean fee for a dental consultation in the municipality. In the first stage, we carried out a logistic regression analysis of the log odds of having demanded dental services during the last year. In the second stage, we carried out a multiple regression analysis of expenditure for dental treatment for those who had been to the dentist during the last year.

RESULTS

Altogether, 80% of the respondents had been to the dentist during the last year. Demand during the last year varied most according to dental status. There was little difference between men and women. The results of the logistic regression showed that the probability of having been to the dentist was 0.82 for those with a household income of €25 000 and 0.85 for those with a household income of €100 000. Mean expenditure for dental treatment was €355. There was no statistically significant relationship between household income and expenditure for dental treatment.

CONCLUSIONS

Differences in demand for dental services according to household income are small, and there are no differences in utilization according to income. The findings are interesting, because in a population in which people have to pay almost all the costs for dental treatment themselves, one would expect the income differences in demand and utilization to be greater.

Childhood disability and socio-economic circumstances in low and middle income countries: systematic review

BACKGROUND

The majority of children with disability live in low and middle income (LAMI) countries. Although a number of important reviews of childhood disability in LAMI countries have been published, these have not, to our knowledge, addressed the association between childhood disability and the home socio-economic circumstances (SEC). The objective of this study is to establish the current state of knowledge on the SECs of children with disability and their households in LAMI countries through a systematic review and quality assessment of existing research.

METHODS

Electronic databases (MEDLINE; EMBASE; PUBMED; Web of Knowledge; PsycInfo; ASSIA; Virtual Health Library; POPLINE; Google scholar) were searched using terms specific to childhood disability and SECs in LAMI countries. Publications from organisations including the World Bank, UNICEF, International Monetary Fund were searched for. Primary studies and reviews from 1990 onwards were included. Studies were assessed for inclusion, categorisation and quality by 2 researchers.

RESULTS

24 primary studies and 13 reviews were identified. Evidence from the available literature on the association between childhood disability and SECs was inconsistent and inconclusive. Potential mechanisms by which poverty and low household SEC may be both a cause and consequence of disability are outlined in the reviews and the qualitative studies. The association of poor SECs with learning disability and behaviour problems was the most consistent finding and these studies had low/medium risk of bias. Where overall disability was the outcome of interest, findings were divergent and many studies had a high/medium risk of bias. Qualitative studies were methodologically weak.

CONCLUSIONS

This review indicates that, despite socially and biologically plausible mechanisms underlying the association of low household SEC with childhood disability in LAMI countries, the empirical evidence from quantitative studies is inconsistent and contradictory. There is evidence for a bidirectional association of low household SEC and disability and longitudinal data is needed to clarify the nature of this association.

Receipt of health care transition counseling in the national survey of adult transition and health

OBJECTIVE

The goal of this study was to examine factors associated with receiving health care transition counseling services as reported by young adults.

METHODS

We analyzed data from the 2007 Survey of Adult Transition and Health, a nationwide survey of young adults aged 19 to 23 years conducted by the National Center for Health Statistics, to explore self-reported receipt of services to support transition from pediatric to adult health care. Multivariate logistic regression was used to identify whether sociodemographic characteristics, health status, or markers of provider-youth health communication were associated with the receipt of 3 key transition counseling services.

RESULTS

Among the 1865 Survey of Adult Transition and Health respondents, 55% reported that their physicians or other health care providers had discussed how their needs would change with age, 53% reported that their physicians or other health care providers had discussed how to obtain health insurance as an adult, and 62% reported having participated in a transition plan in school. Only 24% reported receiving all 3 transition counseling services. In multivariate logistic regression analyses, although gender, age, and race were not associated with increased receipt of the transition-related outcomes, markers of strong communication with the health system were associated with increased rates of receiving transition guidance.

CONCLUSIONS

Many young adults reported not having received health care transition counseling. Provider-youth communication was associated with increased health care transition guidance, and suggests that a medical home model that promotes anticipatory guidance for health care transition could promote improvements in the transition process.

Urban and rural immigrant Latino youths' and adults' knowledge and beliefs about mental health resources

Immigrant Latino youth experience mental health problems in the U.S. Cultural beliefs and knowledge may influence help-seeking behaviors. Two hundred thirty-four immigrant Latino respondents between 12 and 44 years of age completed a questionnaire assessing knowledge of and cultural beliefs regarding mental health resources for adolescents, symptoms, and help-seeking. Multivariate analyses showed that rural respondents were significantly less likely to know of mental health resources than urban-based immigrant Latinos. Knowledge and belief outcomes were also affected by age, gender, and length of time living in the community. Immigrant Latinos appear willing to seek professional help for mental health problems but may not know how to access this type of care, or may lack available services. Future research to inform interventions that increase awareness of accessible mental health services is suggested. Findings support systems-level changes including increased availability of culturally-specific mental health services, especially in rural areas.

Why are Low-Income Teens More Likely to Lack Health Insurance Than Their Younger Peers?

Low-income teenagers are more likely to lack health insurance than younger children. Using data from the 2006, 2007, and 2008 rounds of the National Health Interview Survey, we examine whether differences between teens and younger children in socioeconomic factors, public health insurance eligibility, and observable family characteristics explain this apparent age-related coverage gap. Somewhat surprisingly, they do not. We find a highly robust age-coverage gradient among poor and near-poor children. Our results suggest the need to examine teen-specific insurance enrollment dynamics, particularly in families with no younger siblings, to optimize the effect of the newly enacted Patient Protection and Affordable Care Act on teens' insurance coverage.

How do adolescents view health? Implications for state health policy

OBJECTIVES

Policy-makers rarely consult adolescents during development of health policies. However, perspectives of adolescents on health can inform public health policies and programs. As part of the development of an Indiana state plan for adolescent health, we used qualitative methods to describe adolescents' "emic" views of health, and discuss implications for a state health policy for youth.

PATIENTS AND METHODS

We conducted eight adolescent focus groups in geographically and culturally diverse regions of Indiana. Each group was audio-recorded, transcribed, and analyzed using qualitative methods.

RESULTS

Participants described health as a shared responsibility between adolescents and adults in their lives. They identified a key role for supportive adults in initiating and maintaining health behaviors. Physical, financial, and informational environments could support or hinder healthy behaviors and outcomes. Although adolescents' descriptions of physical health and risk behaviors were similar to adult formulations, they described mental health as "stress and fatigue," an interaction between the adolescent and their environment, rather than depression and anxiety which are considered to be individual pathologies. Respect for decision-making capacity, seeking adolescent input, and providing harm reduction messages were identified as particularly important.

CONCLUSIONS

Adolescent's perception of health can inform policies and programs, and should be sought before the development of health policies.

Social disparities in the receipt of contraceptive services among sexually experienced adolescent females

Social disparities in the receipt of contraceptive services were assessed among a sample of 2,031 sexually experienced adolescent females 15 to 18 years of age using secondary data from the National Longitudinal Study of Adolescent Health (Add Health). Findings revealed no social disparities in receipt of contraceptive services; rather, adolescent females who had a parent with less than a high school degree were more likely to receive contraceptive services. Adolescents' individual characteristics, including perceptions of maternal disapproval of sexual activity and use of contraceptives, barriers in access to and use of birth control, health needs, and enabling resources were significantly associated with their receipt of contraceptive services. Neighborhood characteristics were not significantly associated with adolescents' receipt of services in this study.

Adherence to scheduled appointments among HIV-infected female youth in five U.S. cities

OBJECTIVE

Identify factors associated with appointment-keeping among HIV-infected adolescents and young adults.

METHODS

HIV-infected adolescent and young adult females in five U.S. cities were followed for a period of 18 months to examine adherence to scheduled clinic visits with their HIV care provider. Psychosocial and behavioral factors that have been shown in other populations to influence appointment adherence were measured at baseline and follow-up visits using an audio computer-assisted self-interview questionnaire. These factors included mood disorder, depressive symptoms, social network support, healthcare satisfaction, disease acceptance, HIV stigma, alcohol use, and marijuana use. CD4 count and prescription of antiretroviral therapy medication were also monitored to understand the influence of health status on appointment- keeping.

RESULTS

Participants included 178 youth with a mean age of 20.6 years. Forty-two percent had clinically significant depressive symptoms, 10% had a diagnosable mood disorder, 37% reported marijuana use in the last 90 days, and 47% reported alcohol use. Overall, participants attended 67.3% of their scheduled visits. Controlling for age and health status, marijuana use was the only variable that was associated with appointment-keeping behavior.

CONCLUSIONS

Considering the importance of appointment-keeping for maintaining personal health and preventing further transmission, screening HIV-infected adolescents for marijuana use could help alert providers of this specific barrier to visit compliance.

Subjective unmet need and utilization of health care services in Canada: what are the equity implications?

This study aimed to evaluate whether subjective assessments of unmet need may complement conventional methods of measuring socioeconomic inequity in health care utilization. This study draws on the 2003 Canadian Community Health Survey to develop a conceptual framework for understanding how unmet need arises, to empirically assess the association between utilization and the different types of unmet need (due to waiting times, barriers and personal reasons), and to investigate the effect of adjusting for unmet need on estimates of income-related inequity. The study's findings suggest that a disaggregated approach to analyzing unmet need is required, since the three different subgroups of unmet need that we identify in Canada have different associations with utilization, along with different equity implications. People who report unmet need due to waiting times use more health services than would be expected based on their observable characteristics. However, there is no consistent pattern of utilization among people who report unmet need due to access barriers, or for reasons related to personal choice. Estimates of inequity remain unchanged when we incorporate information on unmet need in the analysis. Subjective assessments of unmet need, namely those that relate to barriers to access, provide additional policy-relevant information that can be used to complement conventional methods of measuring inequity, to better understand inequity, and to guide policy action.

Adolescent immunization delivery in school-based health centers: a national survey

PURPOSE

Vaccinating adolescents in a variety of settings may be needed to achieve high vaccination coverage. School-based health centers (SBHCs) provide a wide range of health services, but little is known about immunization delivery in SBHCs. The objective of this investigation was to assess, in a national random sample of SBHCs, adolescent immunization practices and perceived barriers to vaccination.

METHODS

One thousand SBHCs were randomly selected from a national database. Surveys were conducted between November 2007 and March 2008 by Internet and standard mail.

RESULTS

Of 815 survey-eligible SBHCs, 521 (64%) responded. Of the SBHCs, 84% reported vaccinating adolescents, with most offering tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and human papillomavirus vaccines. Among SBHCs that vaccinated adolescents, 96% vaccinated Medicaid-insured and 98% vaccinated uninsured students. Although 93% of vaccinating SBHCs participated in the Vaccines for Children program, only 39% billed private insurance for vaccines given. A total of 69% used an electronic database or registry to track vaccines given, and 83% sent reminders to adolescents and/or their parents if immunizations were needed. For SBHCs that did not offer vaccines, difficulty billing private insurance was the most frequently cited barrier to vaccination.

CONCLUSIONS

Most SBHCs appear to be fully involved in immunization delivery to adolescents, offering newly recommended vaccines and performing interventions such as reminder/recall to improve immunization rates. Although the number of SBHCs is relatively small, with roughly 2000 nationally, SBHCs appear to be an important vaccination resource, particularly for low income and uninsured adolescents who may have more limited access to vaccination elsewhere.

Differences in risk factors for children with special health care needs (CSHCN) receiving needed specialty care by Socioeconomic Status

BACKGROUND

The purpose of this study is to identify factors affecting CSHCN's receiving needed specialty care among different socioeconomic levels. Previous literature has shown that Socioeconomic Status (SES) is a significant factor in CHSHCN receiving access to healthcare. Other literature has shown that factors of insurance, family size, race/ethnicity and sex also have effects on these children's receipt of care. However, this literature does not address whether other factors such as maternal education, geographic location, age, insurance type, severity of condition, or race/ethnicity have different effects on receiving needed specialty care for children in each SES level.

METHODS

Data were obtained from the National Survey of Children with Special Health Care Needs, 2000-2002. The study analyzed the survey which studies whether CHSCN who needed specialty care received it. The analysis included demographic characteristics, geographical location of household, severity of condition, and social factors. Multiple logistic regression models were constructed for SES levels defined by federal poverty level: < 199%; 200-299%; >or= 300%.

RESULTS

For the poorest children (,199% FPL) being uninsured had a strong negative effect on receiving all needed specialty care. Being Hispanic was a protective factor. Having more than one adult in the household had a positive impact on receipt of needed specialty care but a larger number of children in the family had a negative impact. For the middle income group of children (200-299% of FPL severity of condition had a strong negative association with receipt of needed specialty care. Children in highest income group (> 300% FPL) were positively impacted by living in the Midwest and were negatively impacted by the mother having only some college compared to a four-year degree.

CONCLUSION

Factors affecting CSHCN receiving all needed specialty care differed among socioeconomic groups. These differences should be addressed in policy and practice. Future research should explore the CSHCN population by income groups to better serve this population.

Adolescent health care use: investigating related determinants in Greece

The frequency of health care use is crucial for adolescent well-being and health systems. The present study was the first to test a set of variables in a representative sample of Greek adolescents in order to identify factors that predict health care use and contribute to improving health service planning. Questionnaires were administered to a random sample of adolescents (N=1 194) aged 11-18 years and their parents (N=973) in 2003. Data from 894 participants with full data were analyzed. Parents' education, adolescents' chronic health needs, physical well-being and emotional/behavioural problems as well as parent-child relationship were independent predictors of health care use, although some factors, such as gender, age, type of residence, family affluence, social support and parental health status that previous research identified as predictors were not confirmed. Beyond the need of health care, other factors also play an important role in the utilization of health services by adolescents and their families.

Racial/ethnic disparities and culturally competent health care among youth and young men

Racial/ethnic disparities in health and health care are receiving increasing national attention from the fields of public health and medicine. Efforts to reduce disparities should adopt a life-span approach and recognize the role of gender. During adolescence, young people make increasingly independent decisions about health-related behavior and health care, while developing gender identity. Little is known about how cultural context shapes gender identity and gender identity's influence on health-related behavior and health care utilization. The authors review disparities in health status and health care among adolescents, especially young men, by reviewing health care access, clinical services, and issues related to culture, identity, and acculturation. Significant differences in health status by gender exist in adolescence, with young men faring worse on many health markers. This article discusses gaps in research and offers recommendations for improving health care quality and strengthening the research base on gender and disparities during adolescence.

Family income gradients in the health and health care access of US children

This study sought to examine the shape and magnitude of family income gradients in US children's health, access to care, and use of services. We analyzed cross-sectional data from the 2003 National Survey of Children's Health, a telephone survey of 102,353 parents of children aged 0-17 years. Associations between family income [Below 100% Federal Poverty Level (FPL), 100-199% FPL, 200-299% FPL, 300-399% FPL, 400% FPL or Greater] and a set of 32 health and health care indicators were examined using linear polynomial testing and multivariate logistic regression. The percentage of children in better health increased with family income for 15 health outcomes. In multivariate logistic regression models that controlled for health insurance coverage and socio-demographic confounders, odds ratios >2 comparing the lowest to the highest income groups were noted for health conditions across both physical and developmental domains (diabetes, headaches, ear infections, learning disabilities, behavior/conduct problems, speech problems). Parent-reported global child health status, activity limitation, and oral health status showed steeper gradients than specific chronic and acute conditions. Ten measures of health care access and utilization were associated with family income in multivariate logistic regression models. Income gradients are pervasive across many health indicators at an early age. Social and health policy interventions are needed to address the multitude of factors that can affect children's health and initiate disparities in development.

Detecting, preventing, and treating sexually transmitted diseases among adolescent arrestees: an unmet public health need

Studies of detained and incarcerated adolescent offenders in the United States indicate that these juveniles have an elevated risk of sexually transmitted diseases (STDs). However, many more arrestees enter the "front end" of the juvenile justice system than are detained or incarcerated, and research into the STD risk profiles and service needs of this larger group is lacking. An expansion of STD testing (including of asymptomatic youths), prevention, and treatment is needed, as is improved knowledge about gender- and race-specific services. A pilot program in Florida has shown that juvenile justice and public health systems can collaborate to implement STD testing among new arrestees. With integrated linkages to treatment and prevention after release, this model could greatly reduce the STD burden in this underserved, high-risk population.

Adolescent preventive services: rates and disparities in preventive health topics covered during routine medical care in a California sample

PURPOSE

The objective was to examine rates and disparities in preventive health topics covered during routine medical care for adolescents, using a California sample.

METHODS

Utilizing 2003 California Health Interview Survey data, the sample included 2192 adolescents attending a physical exam within the past 6 months. Adolescents reported whether nine health topics: tobacco, alcohol, drugs, seatbelts, helmets, violence, exercise, nutrition, and sexually transmitted diseases (STDs) were discussed during their most recent physical exam. Outcomes were rates of health topics discussed and disparities in rates based on age, gender, race/ethnicity, income level, and insurance status.

RESULTS

Rates ranged from 15% (violence) to 76% (nutrition, exercise). Compared to older teens, younger teens reported discussing safety more, but substances, nutrition, and STDs less. Compared to males, females reported discussing tobacco and helmets less, but exercise and STDs more. Compared to white youths, Hispanic youths reported more discussion of most topics, black youths reported more discussion of nutrition and less of violence, and Asian youths reported more discussion of seatbelts and helmets. Lower income and uninsured groups reported more discussion of health topics compared to higher income and insured groups.

CONCLUSIONS

Rates of coverage of health topics are below recommended levels. Contrary to expectations, minority, uninsured, and lower income groups reported higher rates of discussing health topics. Strategies to increase the coverage of preventive health topics during routine medical care should address these findings.

Health-related Quality of Life and Its Relationship to Patient Disease Course in Childhood-onset Systemic Lupus Erythematosus

Objective.

To (1) estimate the health-related quality of life (HRQOL) of children with childhood-onset systemic lupus erythematosus (cSLE) and compare it to that of normative cohorts; (2) assess the relationship of HRQOL with cSLE disease activity and damage; and (3) determine the effects of changes of disease activity on HRQOL.

Methods.

Patients with cSLE (n = 98) followed every 3 months completed HRQOL measures, the Pediatric Quality of Life Inventory Generic Core scale (PedsQL-GC), the Rheumatology Module (PedsQL-RM), and the Child Health Questionnaire (CHQ). The British Isles Lupus Activity Group Index (BILAG) was used to measure organ-system-specific disease activity. Physicians rated the course of cSLE between visits.

Results.

At baseline, mean (standard deviation, SD) score [parent report] of the PedsQL-GC and the PedsQL-RM was 75 (17) and 79 (14), respectively; the mean (SD) of the CHQ physical summary score (CHQ-PHS) was 49 (7) and that of the CHQ psychological summary score was 42 (12). Higher BILAG scores, especially in the general, musculoskeletal, neurological, and vascular, but not the mucocutaneous, renal, cardiovascular, or hematological BILAG domains, were associated with a significantly lower HRQOL. Patients with damage had lower HRQOL than those without damage. All HRQOL measures included were at most modestly responsive to clinically important changes with cSLE.

Conclusion.

HRQOL with cSLE is significantly lower than that reported in healthy populations. Organ-specific involvement with cSLE has a differential effect on HRQOL. Higher disease activity and damage are associated with significantly lower HRQOL as measured by the PedsQL-RM and the CHQ-PHS, and worsening of cSLE leads to a further decline.

Exploring Women’s Perceptions About Their Role in Supporting Partners’ and Sons’ Reproductive Health Care

Women serve as important health information sources for young men. No previous study has explored women’s perceptions about this role related to young men’s sexual and reproductive health (SRH) care. Twenty African American women recruited from two clinics participated in three focus groups to explore perceptions to engage young men in SRH care. Themes were identified that may facilitate and/or hinder women to engage young men in SRH care: 1) communication/actions to provide support; 2) challenges in providing support; 3) traditional gender role perceptions and other access barriers; and 4) motivation, influence and control. Participants were interested and willing to support young men’s SRH including sharing information about clinics (95%), making appointments (90%), going to visits together (90%), and having joint appointments (67%). Findings provide a foundation for programs interested to engage women as health promotion agents to improve young men’s SRH care access. Future efforts should explore the generalizability of study findings.

Educating youth about health and science using a partnership between an academic medical center and community-based science museum

Declining student interest and scholastic abilities in the sciences are concerns for the health professions. Additionally, the National Institutes of Health is committed to promoting more research on health behaviors among US youth, where one of the most striking contemporary issues is obesity. This paper reports findings on the impact of a partnership between Oregon Health and Science University (OHSU) and the Oregon Museum of Science and Industry linked to a 17-week exhibition of BodyWorlds3 and designed to inform rural underserved youth about science and health research. Self-administered survey measures included health knowledge, attitudes, intended health behaviors, and interest in the health professions. Four hundred four surveys (88% of participants) were included in analyses. Ninety percent or more found both the BodyWorlds (n = 404) and OHSU (n = 239) exhibits interesting. Dental care habits showed the highest level of intended behavior change (Dental = 45%, Exercise = 34%, Eating = 30%). Overall, females and middle school students were more likely than male and high school students, respectively, to state an intention to change exercise, eating and dental care habits. Females and high school students were more likely to have considered a career in health or science prior to their exhibit visit and, following the exhibit, were more likely to report that this intention had been reinforced. About 6% of those who had not previously considered a career in health or science (n = 225) reported being more likely to do so after viewing the exhibits. In conclusion, high quality experiential learning best created by community-academic partnerships appears to have the ability to stimulate interest and influence intentions to change health behaviors among middle and high school students.

Preventive care for adolescents: few get visits and fewer get services

OBJECTIVE

Professional guidelines for adolescents recommend annual preventive visits with screening and anticipatory guidance for health-related behaviors. The objective of this study was to examine receipt of preventive services, including disparities in services received, by using a nationally representative sample of adolescents.

METHODS

Using data from the 2001-2004 Medical Expenditure Panel Survey (ages 10-17; N = 8464), we examined receipt of preventive care visits and several measures of the content of care, based on caregiver's reports, among adolescents who received a preventive care visit during the past 12 months. Content of care outcomes included physical parameters measurement (height, weight, and blood pressure); receipt of anticipatory guidance (dental care, seat belts, helmets, exercise, healthy eating, and secondhand smoke exposure); and, for 12- to 17-year-olds, whether adolescents had time alone with their provider during their most recent visit, a proxy for confidential services. We conducted logistic regression analyses to test for disparities in the outcomes on the basis of race/ethnicity, income, and insurance status.

RESULTS

Thirty-eight percent of adolescents had a preventive care visit in the previous 12 months. Low-income and full-year uninsured status were associated with higher risk for not receiving this visit. Most adolescents had height (87%), weight (89%), and blood pressure (78%) assessed. Rates for height and weight were lower in poor and uninsured adolescents. Anticipatory guidance rates were much lower, ranging from 31% for seat belts, helmets, and secondhand smoke to 49% for healthy eating. Only 10% had all 6 areas addressed. Multivariate analyses yielded few disparities in receipt of anticipatory guidance. Forty percent had time alone with their providers. Hispanic and the lowest-income adolescents were the least likely to have time alone.

CONCLUSIONS

Few adolescents received a preventive visit; among those who received this visit, provision of recommended anticipatory guidance was very low. Strategies are required to improve delivery of recommended preventive services to adolescents.

The pediatric nurse practitioner's role in reducing oral health disparities in homeless children

Dental caries is the most common infectious disease of children. The majority of children in the United States who experience dental decay are from low-income, minority families. Many low- income, minority families are at risk for homelessness and, indeed, mothers with children are the fastest growing homeless group. Once homeless, families end up in shelters. Shelters are a unique source for the provision of health care; however, the provision of dental care to mothers and children in shelters is limited. At a shelter-based clinic, of a total number of children assessed in a 24-month period (n = 264), 22.7% (n = 60) had obvious gross dental cavities. The school-aged children (6-12 years) (n = 41) had the highest prevalence of dental cavities (34%). Consistent with the literature, dental caries was the most prevalent condition of homeless children and the most difficult for which to obtain treatment. Follow-up was difficult because of the transient nature of homeless families.

Correlates of use of health care services by children and adolescents from 11 European countries

OBJECTIVE

To examine the association between use of health care services and health status, sociodemographic, and health care system characteristics in children and adolescents from 11 European countries.

RESEARCH DESIGN

Cross-sectional surveys in representative samples included using phone or school-based sampling.

SUBJECTS

Children and adolescents aged 8-18 years and their parents. Questionnaires were administered in households or at schools in Austria, Czech Republic, France, Germany, Greece, Hungary, Poland, Spain, Switzerland, the Netherlands, and the United Kingdom.

MAIN OUTCOME MEASURES

Any visit to ("access") and number of visits ("intensity of use") to health care professionals during the previous 12 months.

RESULTS

The study included 16,210 parent-child pairs. In a multivariate analysis, variables statistically associated with access included the following: health status (more disability days, more chronic conditions), sociodemographic characteristics (being younger, being female, having a higher socioeconomic status, or higher parental educational level), and health system variables (higher percentage of public health expenditure, widespread private health care coverage, pediatrician-led system). The strongest association was with disability days [odds ratio (OR) = 6.92; 95% confidence interval (CI) = 5.24-9.14 for 5-15 days]. In the "intensity of use" model, sociodemographic (being younger, strong social support) and health status (chronic conditions, disability days, psychiatric disorders, psychosomatic complaints, poor health-related quality of life) characteristics were associated with greater intensity of use. Health system variables were not significant in this model.

CONCLUSIONS

The likelihood of contacting the health services is a function of health status, socioeconomic factors, and health system characteristics. Intensity of use among those having made contact is associated with health status and sociodemographic characteristics but not with health system characteristics.

Parents' perspectives on access to rehabilitation services for their children with special healthcare needs

PURPOSE

This study examined parents' (caregivers') perspectives on problems related to access to therapy services for their children with special healthcare needs (CSHCN) as predicted by child, family, and health insurance characteristics.

METHODS

Secondary data analysis was conducted using the Family Partners Project database. A subsample of 1027 parents of CSHCN who received rehabilitation services in the year before the study were the participants.

RESULTS

Child, family, and insurance characteristics explained 19.1% of problems related to access to rehabilitation services with family characteristics being the strongest predictor (10.8%). Odds ratios are reported for these characteristics.

CONCLUSION

Family financial hardship, the child's age, and managed care practices in health insurance plans may be the primary factors contributing to problems related to access to therapy services for CSHCN. Therapists may need a better understanding of family challenges with access to services to be more effective advocates.

Opportunities for prevention in primary care in a country with universal insurance coverage

Data from studies in the United States suggest that young people engaging in health-compromising behaviors have lower access to health care. Using data from a Swiss national survey we tested the hypothesis that in a country with universal insurance coverage, adolescents engaging in health-compromising behaviors access primary care to the same extent as those who do not engage in these behaviors.

Exploring perceptions of health needs among young African American men

Recent recommendations advocate involving young men in reproductive health programs. We know little about how young men perceive their reproductive health needs. For this study, 47 African American young men (mean age, 17.9 years) recruited from four community-based organizations completed a brief survey to explore life priorities and perceptions of health needs across 12 to 14, 15 to 19, and 20 to 25-year-olds. Participants' life priorities varied by age group with overall top categories, including education, economics, and family members. Health was listed as a salient life priority among older participants aged 15 to 25 years, though it was not highly ranked. Participants' top health concerns included sexually transmitted infections and HIV/AIDS, with limited mention of other reproductive health concerns. Understanding where young men start from when thinking about reproductive health can better help us meet their needs. Future studies warrant examining how health needs change over time among a larger and more diverse sample of young men.

Predictors of adolescent health care utilization

This study, using Andersen's health care utilization model, examined how predisposing characteristics, enabling resources, need, personal health practices, and psychological factors influence health care utilization using a nationally representative, longitudinal sample of Canadian adolescents. Second, this study examined whether this process varies across physicians, non-physicians, and dentists. The results indicate that need and psychological factors were strong determinants of utilization. Predisposing factors were associated with utilization, although there were few enabling resources. Differences were found for utilization of different services. Females, adolescents who were older, from single parent families, with lower self-rated health, lower health status, higher disability, higher distress and involved in health compromizing practices were more likely to visit physicians and non-physicians. Higher dentist utilization was related to higher income, single parent status, being younger, having lower health status, and higher disability. Predisposing and enabling factors were not mediators of utilization. The findings suggest that health care providers could be an important source of counselling on psychological, lifestyle issues, and physical concerns.

Unmet mental health needs in pediatric epilepsy: insights from providers

Eighteen pediatric neurologists and 18 pediatricians completed a 5-point Likert scale questionnaire on their knowledge of, attitudes toward, and management of the behavioral, cognitive, and psychosocial aspects of pediatric epilepsy, before and after a lecture on this topic. They also responded to questions about possible barriers to mental health care of children with epilepsy. The brief educational intervention modified the knowledge/attitudes of pediatricians compared with pediatric neurologists on the impact of epilepsy on behavior and cognition in children with epilepsy. However, there were no between-group differences in how providers perceived their competence to assess behavioral and cognitive comorbid conditions in pediatric epilepsy. Responses to open-ended questions suggested insufficient mental health coverage for and expertise on pediatric epilepsy, resistance of mental health clinicians to treat children with epilepsy, and the stigma of mental health as possible barriers to mental health care in children with epilepsy. In addition to the need for provider education about the behavioral and cognitive comorbid conditions of pediatric epilepsy, these findings emphasize the importance of examining alternative routes to increasing mental health care for children with epilepsy.

School-based health centers: improving access and quality of care for low-income adolescents

OBJECTIVES

We sought to compare visit rates, emergency care use, and markers of quality of care between adolescents who use school-based health centers and those who use other community centers within a safety-net health care system for low-income and uninsured patients.

PATIENTS AND METHODS

In this retrospective cohort study we used Denver Health electronic medical chart data, the Denver Health immunization registry, and Denver Public Schools enrollment data for the period from August 1, 2002, to July 31, 2003. The cohort included all 14- to 17-year-old Denver Public Schools high school enrollees who were active Denver Health patients and were either uninsured or insured by Medicaid or the State Children's Health Insurance Program. "School-based health center users" were those who had used a Denver Health school-based health center; "other users" were those who had used a Denver Health community clinic but not a school-based health center. Markers of quality included having a health maintenance visit and receipt of an influenza vaccine, tetanus booster, and hepatitis B vaccine if indicated. Multiple logistic regression analysis that controlled for gender, race/ethnicity, insurance status, chronic illness, and visit rate was used to compare school-based health center users to other users.

RESULTS

Although school-based health center users (n = 790) were less likely than other users (n = 925) to be insured (37% vs 73%), they were more likely to have made > or = 3 primary care visits (52% vs 34%), less likely to have used emergency care (17% vs 34%), and more likely to have received a health maintenance visit (47% vs 33%), an influenza vaccine (45% vs 18%), a tetanus booster (33% vs 21%), and a hepatitis B vaccine (46% vs 20%).

CONCLUSIONS

These findings suggest that, within a safety-net system, school-based health centers augment access to care and quality of care for underserved adolescents compared with traditional outpatient care sites.

Family perceptions of the usual source of care among children with asthma by race/ethnicity, language, and family income

A usual source of care (USC) can serve as the foundation for good primary health care and is critical for children living with a chronic health condition. This study applies national data to the following objectives: (1) describe family reports of the presence and characteristics of the USC for children with asthma; (2) examine evidence of systematic differences in the USC for these children with asthma by race/ethnicity, English language proficiency in Hispanic respondents, and family income; and (3) conduct multivariate analysis adjusting for possible confounding factors to examine independent effects of race/ethnicity, language, and income. Data from the 1996-2000 Medical Expenditure Panel Survey (MEPS) were analyzed. Overall, 95% of children with asthma had a USC, with Spanish-speaking Hispanics least likely to report a USC (89%). There were significant differences in USC attributes by race/ethnicity, language, and income, with the largest differences by type of provider and accessibility. Hispanics with poor English language proficiency had the greatest accessibility barriers.

Pediatrician perspectives on children's access to mental health services: consequences and potential solutions

This paper examines pediatricians' perspectives regarding access to children's mental health care. In response to a question about factors that help or hinder coordination of care 190 respondents voluminously wrote about mental health access barriers. Responses were qualitatively analyzed to understand pediatricians' perspectives. Four thematic areas emerged: Insurance issues; availability of mental health specialty providers; state mental health systems; and pediatricians' attempts to improve access to mental health services. Pediatricians' responses included educating themselves, using telemedicine, and hiring co-located mental health specialists. Recommendations are made to address pediatricians' treatment of children with mental illnesses and their access to treatment resources.

Masculine beliefs, parental communication, and male adolescents' health care use

OBJECTIVES

Male adolescents frequently become disconnected from health care, especially as they get older, which limits physicians' abilities to address their health needs and results in missed opportunities to connect them to the health care system as they enter adulthood. In this study we tested the ability of modifiable (beliefs about masculinity, parental communication, sex education, and health insurance) and nonmodifiable (age, race/ethnicity, and region of residence) factors to prospectively predict health care use by male adolescents.

PATIENTS AND METHODS

We conducted a prospective analysis of data from 1677 male participants aged 15 to 19 years who completed the National Survey of Adolescent Males, a household probability survey conducted throughout the United States in 1988 (wave 1, participation rate: 74%) and in 1990-1991 (wave 2, follow-up rate: 89%). We present percentages and adjusted relative risks of the factors that predict male adolescents' self-report of a physical examination by a regular provider in the past year measured at wave 2.

RESULTS

On average, 1067 (66%) of 1677 male adolescents at wave 2 reported having a physical examination within the last year. Factors associated with a lower likelihood of a physical examination included living in the South, Midwest, and West; being older in age; and holding more traditional masculine beliefs. Factors associated with a higher likelihood of a physical examination included communicating about reproductive health with both parents and being insured. Male adolescents who were sexually active or engaged in > or = 2 other risk behaviors had neither a higher nor lower likelihood of a physical examination.

CONCLUSIONS

Efforts to enhance male adolescents' health through health care should include work to modify masculine stereotypes, improve mothers' and fathers' communication about health with their sons, expand health insurance coverage, and identify interventions to connect male adolescents at increased risk for health problems with health care.

What gets measured gets done: assessing data availability for adolescent populations

OBJECTIVES

To identify specific adolescent sub-populations; to evaluate the health data available regarding these populations related to 21 key national adolescent health objectives from Healthy People 2010; and to make recommendations for improving data capacity to further efforts to reduce health disparities among adolescents.

METHODS

Adolescent populations were identified through a consensus process. Academic and government literature was extensively reviewed using internet search techniques to identify available national data for each of these populations on each key national health objective.

RESULTS

18 adolescent subpopulations were identified. These populations fit into four overlapping categories defined by demography, legal status, chronic health condition, or other special characteristics. Overall, national, population-based data regarding these sub-populations were located for 36% of the 21 health objectives. Within the sub-populations, most data was available for ethnic/racial groups, with 57-81% of each of the objectives having data. Data regarding rural/urban groups were found for about one-half of the 21 objectives, and data were located on all other groups for one-fourth or fewer of the objectives. Within the objectives, substance abuse objectives were the most widely measured, with data available for 56-78% of the various populations. For some objectives, such as drug-or alcohol-related motor vehicle deaths depression among the developmentally disabled, no national data were found.

CONCLUSIONS

There are still too little data available regarding the specific health status or health objectives for different adolescent populations. A national adolescent data-priority agenda is needed to develop strategies to improve health data regarding adolescent sub-populations. Federal and state health monitoring agencies could create national health profiles of different populations, include more population markers in health studies, and develop tools for population-specific health assessment, particularly for those within the government's care, including incarcerated and foster care youth.

What Gets Measured Gets Done: Assessing Data Availability for Adolescent Populations

OBJECTIVES

To identify specific adolescent sub-populations; to evaluate the health data available regarding these populations related to 21 key national adolescent health objectives from Healthy People 2010; and to make recommendations for improving data capacity to further efforts to reduce health disparities among adolescents.

METHODS

Adolescent populations were identified through a consensus process. Academic and government literature was extensively reviewed using internet search techniques to identify available national data for each of these populations on each key national health objective.

RESULTS

18 adolescent subpopulations were identified. These populations fit into four overlapping categories defined by demography, legal status, chronic health condition, or other special characteristics. Overall, national, population-based data regarding these sub-populations were located for 36% of the 21 health objectives. Within the sub-populations, most data was available for ethnic/racial groups, with 57-81% of each of the objectives having data. Data regarding rural/urban groups were found for about one-half of the 21 objectives, and data were located on all other groups for one-fourth or fewer of the objectives. Within the objectives, substance abuse objectives were the most widely measured, with data available for 56-78% of the various populations. For some objectives, such as drug-or alcohol-related motor vehicle deaths depression among the developmentally disabled, no national data were found.

CONCLUSIONS

There are still too little data available regarding the specific health status or health objectives for different adolescent populations. A national adolescent data-priority agenda is needed to develop strategies to improve health data regarding adolescent sub-populations. Federal and state health monitoring agencies could create national health profiles of different populations, include more population markers in health studies, and develop tools for population-specific health assessment, particularly for those within the government's care, including incarcerated and foster care youth.

Racial disparities in mental health service use by adolescents who thought about or attempted suicide

Differences in rates and predictors of mental health service use among 2,226 Black, Hispanic, and White adolescents (aged 12-17) who reported recent suicidal thoughts or an attempt were examined. Black adolescents were 65% (OR = .65, p < .05), and Hispanic adolescents were 55% (OR = .55, p < .001), as likely as White adolescents to report service use, even when controlling for need for care and ability to secure services. Suicide attempt and psychiatric symptoms each interacted with race to increase the odds of service use uniquely for White adolescents. Results indicate that racial disparities characterize adolescents' mental health service use even when suicide risk increases.