Assessing the Knowledge and Comfort Level of US Family Medicine Residents Regarding Consenting and Confidentiality in Adolescent Health Care

OBJECTIVES

Organizations recommend providing confidential adolescent health care to reduce the consequences of high-risk health behaviors such as substance use, unhealthy eating patterns, and high-risk sexual behaviors. Family physicians are uniquely positioned to provide confidential counseling and care to this vulnerable population but must be trained to provide such care. This study describes the impact of formal and informal training on the knowledge of and comfort level in providing confidential adolescent healthcare among a sample of US Family Medicine residents.

METHODS

Electronic surveys were distributed to all Family Medicine residents throughout the United States. We used descriptive statistics and χ2 analysis where appropriate to determine the association between resident-reported receipt of training, confidence, and frequency in providing confidential adolescent health care.

RESULTS

A total of 714 Family Medicine residents completed the survey. The majority reported no formal training in residency (50.3%). The receipt of formal and informal training in both medical school and residency was associated with a greater degree of comfort in providing confidential adolescent care and a higher likelihood of providing confidential time alone. Those reporting formal training were more likely to always provide confidential care (P = 0.001).

CONCLUSIONS

Training focused on confidential adolescent health care in medical school or residency was associated with a greater degree of comfort and a higher likelihood of providing confidential adolescent health care.

Demographic and epidemiological transitions and burden of adolescent healthcare in sub-Saharan Africa: A review

This review's main objective is to discuss how demographic and epidemiological transitions relate to the burden of adolescent healthcare in sub-Saharan Africa (SSA). The review explicitly discussed the burden of adolescent healthcare, the current African policies on adolescent healthcare, and gaps in the African policies compared with Europe and North America. We also examined how adolescent healthcare policies evolve and documented the recommended essential part of the policy for enhancing its sustainability. The burden of adolescent health is high in SSA with diseases and reproductive health-related problems prevailing among adolescents. However, variations exist in the burden of adolescent healthcare across countries in the region. While some SSA countries are currently undergoing demographic and epidemiological transition processes concerning adolescent health care, the majority are either at an early stage of the transition or yet to commence the process. Policy-makers should consider effective ways to improve adolescents' health in SSA through preventive mechanisms and a multi-dimensional approach.

A comparison of contraceptive services for adolescents at school-based versus community health centers in Oregon

OBJECTIVE

To compare Oregon school-based health centers (SBHCs) with community health centers (CHCs) as sources of adolescent contraceptive services.

DATA SOURCES

Oregon electronic health record data, 2012-2016.

STUDY DESIGN

We compared clinic-level counseling rates and long-acting reversible contraception (LARC) provision, adolescent populations served, and visit-level LARC provision time trends. We evaluated adjusted associations between LARC provision and Title X participation by clinic type.

DATA COLLECTION/EXTRACTION METHODS

We used diagnosis and procedure codes to identify contraceptive counseling and provision visits, excluding visits for adolescents not at risk of pregnancy.

PRINCIPAL FINDINGS

CHCs were more likely to provide LARC on-site than SBHCs (67.2% vs. 36.4%, respectively). LARC provision increased more at SBHCs (5.8-fold) than CHCs (2-fold) over time. SBHCs provided more counseling visits per clinic (255 vs. 142) and served more young and non-White adolescents than CHCs. The adjusted probability of LARC provision at Title X SBHCs was higher than non-Title X SBHCs (4.4% [3.9-4.9] vs. 1.7% [1.4-2.0]), but there was no significant association at CHCs.

CONCLUSIONS

In Oregon, CHCs and SBHCs are both important sources of adolescent contraceptive services, and Title X plays a crucial role in SBHCs. Compared with CHCs, SBHCs provided more counseling, showed a larger increase in LARC provision over time, and served more younger and non-White adolescents.

Predicting Child-to-Adult Community Mental Health Service Continuation

Serious mental health conditions peak in prevalence and incidence during the transition to adulthood (approximately ages 16-25). Young adults are at high risk for discontinuation of care when no longer eligible for child mental health services. This study uses state administrative data to examine service continuation among those aging out of child system services in Texas (N = 3135). Most (63.5%) did not enroll in adult services following their 18th birthday. Binary logistic regression analyses found that significant predictors of child-to-adult service continuation included (1) a serious primary mental health diagnosis (i.e., schizophrenia, bipolar disorder, major depressive disorder), (2) risks to self and others, and (3) number of prior-year mental health services received. These findings suggest that historical mental health policies and practices may contribute to service disconnection at age 18 in Texas. Implications for mental health policy and system reform locally and nationally are discussed.

Parent-adolescent communication on sexual and reproductive health and the utilization of adolescent-friendly health services in Kailali, Nepal

Background

Adolescents are vulnerable to various sexual and reproductive health (SRH) problems such as unintended pregnancy, HIV or other sexually transmitted infections (STIs), and unsafe abortion. Adolescent-friendly health services offer SRH services such as SRH counseling, contraceptive services, STI and HIV services, and abortion-related services, which may help prevent these risks. Parent–adolescent communication about SRH prevents adolescents from adopting unhealthy SRH practices. However, its association with the utilization of SRH services is less known. Therefore, this study examined the association between parent–adolescent communication on SRH issues and the utilization of adolescent-friendly health services in Nepal.

Methods

This was a school-based, cross-sectional study conducted in Kailali district, Nepal, among students aged 15–19 years in Grade 11 and 12 from seven schools. We used multivariable logistic regression analysis to examine the association between parent–adolescent communication and service utilization.

Results

We analyzed the data from 594 students. Students with a higher score of parent–adolescent communication on SRH were significantly more likely to use adolescent-friendly health services (adjusted odds ratio, AOR: 1.70, 95% Confidence Interval, CI: 1.29–2.23, p<0.001). Those who reported having engaged in sexual intercourse in the past year were more likely to use services than those who did not (AOR: 29.11, 95% CI: 13.65–62.08, p<0.001). Those who belonged to the Janajati ethnic group were more likely to use these services than those from the Brahmin/Chhetri ethnic group (AOR: 2.86, 95% CI: 1.28–6.42, p = 0.01). Those living alone were less likely to use services than those living with both parents (AOR: 0.12, 95% CI: 0.02–0.66, p = 0.01).

Conclusion

Students with a higher score on parent–adolescent communication on SRH were more likely to use adolescent-friendly health services. Thus, parental involvement in SRH communication could contribute to the use of adolescent-friendly health services and ultimately prevent negative SRH outcomes among students in late adolescence.

Evaluating the success of Slovenia's policy on the health of children and adolescents: results of an audit

OBJECTIVES

The aims of this audit were twofold: (1) to demonstrate the contribution of the auditing process in evaluating the success of child and adolescent health policy in Slovenia between 2012 and 2019, and (2) to expand on the commentary published in the International Journal of Public Health in 2019 to demonstrate the benefits of auditing in improving public health policy in general.

METHODS

The audit followed health, safety and environmental approaches as per the standards of public health policy.

RESULTS

Due to poor intersectoral coordination and weak associations between environmental and health indicators, no clear evidence could be established that child and adolescent health policy contributed to positive changes in child and adolescent health from 2012 to 2019.

CONCLUSIONS

Auditing should become an essential component of measuring the success of public health policies. Attention should also be paid to the following issues affecting youth health: sleeping and eating habits, economic migration, poverty, etc.

[COVID-19 and mental health services in Europe]

The area of mental health is directly affected by the pandemic and its consequences, for various reasons: 1-the pandemic triggered a global lockdown, with dramatic socioeconomic and therefore psychosocial implications; 2-mental health services, which treat by definition a fragile population from the psychological, biological and social points of view, have a complex organizational frame, and it was expected that this would be affected (or overwhelmed) by the pandemic; 3-mental health services should, at least in theory, be able to help guide public health policies when these involve a significant modification of individual behaviour. It was conducted a narrative review of the publications produced by European researchers in the period February-June 2020 and indexed in PubMed. A total of 34 papers were analyzed, which document the profound clinical, organizational and procedural changes introduced in mental health services following this exceptional and largely unforeseen planetary event.Among the main innovations recorded everywhere, the strong push towards the use of telemedicine techniques should be mentioned: however, these require an adequate critical evaluation, which highlights their possibilities, limits, advantages and disadvantages instead of simple triumphalist judgments. Furthermore, should be emphasized the scarcity of quantitative studies conducted in this period and the absence of studies aimed, for example, at exploring the consequences of prolonged and forced face-to-face contact between patients and family members with a high index of "expressed emotions".

Availability, accessibility, and quality of adolescent Sexual and Reproductive Health (SRH) services in urban health facilities of Rwanda: a survey among social and healthcare providers

BACKGROUND

Adolescents are still getting pregnant and contracting Human Immunodeficiency Virus (HIV) and Sexually Transmitted Infections (STIs) in Rwanda as elsewhere. Quality and comprehensive SRH services and information for adolescents is valuable for adolescents' wellbeing. This study aimed at understanding SRH services providers' viewpoints on accessibility, availability, and quality of SRH services provided to adolescents in selected cities of Rwanda.

METHOD

The study was a descriptive cross-sectional survey conducted between May 2018 and May 2019 in six selected cities of Rwanda using a mixed-methods approach. A checklist was used to collect data from 159 conveniently selected SRH services providers. The survey tool was validated. SPSS version 20 was used to describe quantitative data and ATLAS TI version 5.2 was used to code and analyze the qualitative data thematically.

RESULTS

Qualitatively, health care providers reported that the availability of adolescent SRHS are satisfactory with access to accurate SRH information, contraceptive methods, prevention and management of STIs and HIV services, and counselling. However, the accessibility of some services remains limited. According to respondents, some products such as female condoms are less in demand and often expire before they can be distributed. One nurse clarified that they render services at a low price if an adolescent has insurance medical coverture. Religious leaders and family members may hinder adolescents from health-seeking behavior by promoting abstinence and discouraging use of protective means. Quantitatively, we found that 94.3% of health facilities provide information to adolescents on SRH services that were available and 51.6% affirmed delivering services at a low cost. Only 57.2% of respondents mentioned that adolescents are involved in designing the feedback mechanisms at their facilities.

CONCLUSION

SRH services in Rwanda are available for the general population and are not specifically designed for adolescents. These SRH services seem to be fairly accessible to adolescents with insufficient quality as adolescents themselves do not get to be fully involved in service provision among other aspects of quality SRH as stated by the World Health Organization (WHO). Therefore, there is a need to improve the present quality of these services to meet adolescents' needs in an urban setting.

National Trends in Mental Health Care for US Adolescents

Importance

The prevalence of adolescent depression and other internalizing mental health problems has increased in recent years, whereas the prevalence of externalizing behaviors has decreased. The association of these changes with the use of mental health services has not been previously examined.

Objective

To examine national trends in the care of different mental health problems and in different treatment settings among adolescents.

Design, Setting, and Participants

Data for this survey study were drawn from the National Survey on Drug Use and Health, an annual cross-sectional survey of the US general population. This study focused on adolescent participants aged 12 to 17 years interviewed from January 1, 2005, to December 31, 2018. Data were reported as weighted percentages and adjusted odds ratios (aORs) and analyzed from July 20 to December 1, 2019.

Main Outcomes and Measures

Time trends in 12-month prevalence of any mental health treatment or counseling in a wide range of settings were examined overall and for different sociodemographic groups, types of mental health problems (internalizing, externalizing, relationship, and school related), and treatment settings (inpatient mental health, outpatient mental health, general medical, and school counseling). Trends in the number of visits and nights in inpatient settings were also examined.

Results

A total of 47 090 of the 230 070 adolescents across survey years (19.7%) received mental health care. Of these, 57.5% were female; 31.3%, aged 12 to 13 years; 35.8%, aged 14 to 15 years; and 32.9%, aged 16 to 17 years. The overall prevalence of mental health care did not change appreciably over time. However, mental health care increased among girls (from 22.8% in 2005-2006 to 25.4% in 2017-2018; aOR, 1.11; 95% CI, 1.04-1.19; P = .001), non-Hispanic white adolescents (from 20.4% in 2005-2006 to 22.7% in 2017-2018; aOR, 1.08; 95% CI, 1.03-1.14; P = .004), and those with private insurance (from 19.4% in 2005-2006 to 21.2% in 2017-2018; aOR, 1.11; 95% CI, 1.04-1.18; P = .002). Internalizing problems, including suicidal ideation and depressive symptoms, accounted for an increasing proportion of care (from 48.3% in 2005-2006 to 57.8% in 2017-2018; aOR, 1.52; 95% CI, 1.39-1.66; P < .001), whereas externalizing problems (from 31.9% in 2005-2006 to 23.7% in 2017-2018; aOR, 0.67; 95% CI, 0.62-0.73; P < .001) and relationship problems (from 30.4% in 2005-2006 to 26.9% in 2017-2018; aOR, 0.75; 95% CI, 0.69-0.82; P < .001) accounted for decreasing proportions. During this period, use of outpatient mental health services increased from 58.1% in 2005-2006 to 67.3% in 2017-2018 (aOR, 1.47; 95% CI, 1.35-1.59; P < .001), although use of school counseling decreased from 49.1% in 2005-2006 to 45.4% in 2017-2018 (aOR, 0.86; 95% CI, 0.79-0.93; P < .001). Outpatient mental health visits (eg, private mental health clinicians, from 7.2 in 2005-2006 to 9.0 in 2017-2018; incidence rate ratio, 1.30; 95% CI, 1.23-1.37; P < .001) and overnight stays in inpatient mental health settings (from 4.0 nights in 2005-2006 to 5.4 nights in 2017-2018; incidence rate ratio, 1.18; 95% CI, 1.02-1.37; P = .03) increased.

Conclusions and Relevance

This study's findings suggest that the growing number of adolescents who receive care for internalizing mental health problems and the increasing share who receive care in specialty outpatient settings are placing new demands on specialty adolescent mental health treatment resources.

The use of mental health services by Australian adolescents with mental disorders and suicidality: Findings from a nationwide cross-sectional survey

OBJECTIVES

Mental disorders and suicidality among adolescents have been identified as a major public health concern worldwide; however, they often do not get the necessary attention from parents, school and health professional, and therefore are left untreated. This study aimed to investigate the factors associated with the use of mental health services among Australian adolescents aged 13-17 with mental disorders and/or suicidality.

METHODS

Adolescents aged 13-17 (n = 2134) from Young Minds Matter (YMM): the Second Australian Child and Adolescent Survey of Mental Health and Wellbeing were included in this study. The YMM is a cross-sectional nationwide survey, in which information was collected from both parents and adolescents (aged 13-17 years). Both bivariate and multivariate analyses were conducted to identify the factors that have an impact on the use of mental health services (outcome variable) in two subsamples: (1) adolescents with mental disorder and (2) adolescents with suicidality.

RESULTS

Overall, 740 (34.7%) and 168 (7.9%) adolescents reported a mental disorder and/or suicidality, respectively. The incidence of seeking any service was higher among adolescents with suicidality (approximately 50%) compared to those with a mental disorder (about 30%). Girls, older age-group (15-17), adolescents living with disadvantaged families (lower-income, less educated and unemployed parents), those who had multiple mental disorders and history of substance use were most likely to use mental health services regardless of mental disorder and suicidality. Health services and online services were the most popular type of mental health service among adolescents aged 13-17 across two subgroups, while, school and telephone services were less utilized.

CONCLUSIONS

Many adolescents with mental disorders and/or suicidality do not use mental health services. The findings indicate differences in factors associated with the use of mental health services among adolescents with mental disorder and suicidality. Further research is needed to address the specific barriers that limit the use of the services.

"Objectively terrifying": a qualitative study of youth's experiences of transitions out of child and adolescent mental health services at age 18

BACKGROUND

Mental health issues presenting in childhood often persist into adulthood, usually requiring youth to transition from child and adolescent mental health services to adult mental health services at 18 years. Discontinuity of care during this transition period is well-documented and can leave youth vulnerable to adverse mental health outcomes. There is growing recognition of the need to improve transition-related care for youth leaving the child and adolescent mental health system. However, the perspectives and experiences of youth have not always been forefront in these discussions, and in particular, the perspectives of youth in the pre-transition period. This study qualitatively explores transition-related knowledge and experiences of youth both prior-to and after transition.

METHODS

A purposive sample of youth aged 16-19 years was recruited from two child and adolescent mental health programs. Youth were enrolled as part of a longitudinal follow-up study and had the opportunity to opt into this study. Interviews were transcribed and coded using NVivo11 software. Main themes were distilled through descriptive analysis following the principles of directed content analysis. The study followed the principles of participatory action research, engaging youth with lived experience navigating transitions in each stage of the study.

RESULTS

In-depth, semi-structured interviews were conducted with 14 pre-transition and 8 post-transition youth. All youth reported having either a mood and/or anxiety disorder for which the majority were receiving treatment at the time of the interview. The participants' experiences were distilled into six major themes. Youth advocated for being considered partners in transition planning and to have increased control over transition-related decisions. Youth also made specific recommendations on how to improve continuity of care during the transition process.

CONCLUSIONS

Transition planning should be individualized for each youth based on their developmental needs, transition readiness and ongoing mental health needs. Transition pathways, co-designed with youth and caregivers, should be developed to guide providers in transition best practices. Obtaining both the pre- and post-transition experiences of youth is crucial for developing a more complete of understanding of youth perspectives and implementing guidelines that improve transition quality and experiences.

Intensive home treatment for adolescents in psychiatric crisis

BACKGROUND

Adolescents with acute psychiatric disorders are typically treated with long-term clinical admission. However, long term admission may be associated with a variety of negative outcomes. This pilot study presents a new model of care, that is, the combined application of intensive home treatment and the possibility of short term stay at a psychiatric high & intensive care.

METHODS

In total 112 referred adolescents with mixed diagnoses participated in this longitudinal observational design. Clinical outcome was measured by the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) which measures the severity of multiple mental health problems. The HoNOSCA was clinician-rated at intake, after two months and after four months at discharge. Change in HoNOSCA total score was analysed with paired t-tests. Outcome moderators were gender, age, primary diagnosis, clinical admission, home treatment-time, medication and additional therapies. Follow up data were completed for 62 patients after two months and for 53 after four months.

RESULTS

Participants aged between 11 and 18 years (M = 14.8 years, SD = 0.3; 52% female). Mean HoNOSCA total score at intake was 18.8 (SD = 5.2), after two months 13.0 (SD = 5.0); after four months resulting in a score of 9.3 (SD = 5.2). None of the moderators tested showed a significant effect on HoNOSCA scores. However, a control group could not be used because of the severe psychopathology and high risk for suicidality and the lack of an effective treatment intervention for a comparable study group.

CONCLUSION

With a symptom decrease of over 50% within four months as measured by the HoNOSCA, including less risk for hospitalization, this new model appears promising and of clinical relevance. Nevertheless, further research regarding stability of treatment outcome is warranted and evaluation of long-term effects of this model in follow-up studies is needed.

Early life adversity, contact with children's social care services and educational outcomes at age 16 years: UK birth cohort study with linkage to national administrative records

OBJECTIVES

To use record linkage of birth cohort and administrative data to study educational outcomes of children who are looked-after (in public care) and in need (social services involvement), and examine the role of early life factors.

SETTING, DESIGN

Prospective observational study of children from the Avon Longitudinal Study of Parents and Children (ALSPAC), which recruited pregnant women in and around Bristol, UK in the early 1990s. ALSPAC was linked to the annual Children Looked-After (CLA) Data Return and Children In Need (CIN) Census. Educational outcomes at 16 years were obtained through linkage to the National Pupil Database (NPD). These included passing 5+ good GCSEs (grades A*-C, including English and Maths). Covariates included early life adversity and social position.

PARTICIPANTS

12 868 ALSPAC participants were linked to the NPD. The sample for the main educational outcomes analyses comprised 9545 children from the ALSPAC core sample who had complete education data.

RESULTS

Overall, of the 12 868 ALSPAC participants linked to NPD data, 137 had a CLA record and a further 209 a CIN record during adolescence. These children were more disadvantaged than their peers and had little active study participation beyond infancy. In the main educational outcomes analyses, achievement of 5+ good GCSEs was low in the CLA (OR 0.14, 95% CI 0.05 to 0.35) and CIN (0.11, 0.05 to 0.27) groups relative to their peers. Measured early life factors explained little of this difference.

CONCLUSIONS

Data linkage enabled the study of educational outcomes in children with social services contact. These children had substantially worse educational outcomes relative to their peers, for reasons likely to be multifactorial.

How to measure the need for transition to adult services among young people with Attention Deficit Hyperactivity Disorder (ADHD): a comparison of surveillance versus case note review methods

BACKGROUND

Health services have not provided adequate support for young people with long term health conditions to transfer from child to adult services. National Institute of Health and Care (NICE) guidance on transition has been issued to address these gaps. However, data are often sparse about the number of young adults who might need to transition. Using Attention Deficit Hyperactivity Disorder (ADHD) as an exemplar, this study used an existing surveillance system and a case note review to capture the incidence of the transition process, and compared and contrasted the findings.

METHODS

The Child and Adolescent Psychiatry Surveillance System (CAPSS) was used to estimate the incident transition of young people with Attention Deficit Hyperactivity Disorder (ADHD) from child to adult services. This involves consultant child and adolescent psychiatrists from the United Kingdom (UK) and Republic of Ireland (ROI) reporting relevant young people as they are seen in clinics. In parallel, a case note review was conducted using the Maudsley Biomedical Research Centre (BRC) Clinical Records Interactive Search (CRIS). The study period ran for twelve months with a nine month follow up to see how the transition proceeded.

RESULTS

CRIS identified 76 cases in the study period, compared to 18 identified using surveillance via CAPSS. Methodological issues were experienced using both methods. Surveillance issues; eligibility criteria confusion, reporting errors, incomplete questionnaires, difficulties contacting clinicians, and surveillance systems do not cover non-doctors and psychiatrists who are not consultants. Case note review issues using CRIS included the need for researchers to interpret clinical notes, the availability and completeness of data in the notes, and data limited to the catchment of one particular mental health trust.

CONCLUSIONS

Both methods demonstrate strengths and weaknesses; the combination of both methods in the absence of strong routinely collected data, allowed a more robust estimate of the level of need for service planning and commissioning.

Mobile sexual health services for adolescents: investigating the acceptability of youth-directed mobile clinic services in Cape Town, South Africa

BACKGROUND

The Human Immunodeficiency Virus (HIV) epidemic is growing rapidly among South African adolescents and young adults (AYA). Although HIV counselling and testing, HIV prevention and treatment options are widely available, many AYA delay health-seeking until illness occurs, demonstrating a need for youth responsive, integrated sexual and reproductive health services (SRHS). While feasibility and cost-effectiveness have been evaluated, acceptability of mobile clinics among AYA has yet to be established. The objective of this study was to investigate patient acceptability of mobile AYA SRHS and compare mobile clinic usage and HIV outcomes with nearby conventional clinics.

METHODS

Patients presenting to a mobile clinic in Cape Town were invited to participate in an acceptability study of a mobile clinic after using the service. A trained researcher administered an acceptability questionnaire. Mobile clinic medical records during the study period were compared with the records of AYA attending four clinics in the same community.

RESULTS

Three hundred three enrolled participants (16-24 years, 246 (81.2%) female) rated mobile AYA SRHS acceptability highly (median = 4,6 out of 5), with 90% rating their experience as better or much better than conventional clinics. The mobile clinic, compared to conventional clinics, attracted more men (26% v 13%, p < 0,000), younger patients (18 v 19 years, p < 0,000), and yielded more HIV diagnoses (4% v 2%, p < 0,000).

CONCLUSIONS

Given the high ratings of acceptability, and the preference for mobile clinics over conventional primary health clinics, the scalability of mobile clinics should be investigated as part of a multipronged approach to improve the uptake of SRHS diagnostic, prevention and treatment options for AYA.

Utilization and Perceptions of Drop-in Center Services Among Youth Experiencing Homelessness

Drop-in centers offer a range of services to assist unaccompanied youth experiencing homelessness, but little is known about their perceptions of drop-in centers or use of different services. A random sample of 273 youth experiencing homelessness in the Los Angeles area who had ever used a drop-in center was surveyed. Most youth heard about local drop-in centers from peers (65.1%). They generally reported positive perceptions of the drop-in center environment, staff, and clients; overall, 57.8% were "very" or "extremely" satisfied with the services they had received. Nearly all youth cited basic services (e.g., food, showers, clothes) as a reason they went to drop-in centers; far fewer reported going to obtain higher-level services (e.g., case management). Perceptions and utilization did not differ by sexual orientation; however, non-white youth were more likely than Whites to use drop-in centers for certain higher-level services. Strategies for engaging youth in drop-in center services are discussed.

Assessing the social determinants of health care costs for Medicaid-enrolled adolescents in Washington State using administrative data

OBJECTIVE

The study used administrative data to identify the social determinants that have the greatest impact on Medicaid expenditures in adolescence.

DATA SOURCES

Data were compiled using the Washington State Department of Social and Health Services Integrated Client Databases, which link data from state systems including Medicaid claims and social services receipt.

STUDY DESIGN

Medical system and behavioral health service costs of over 180 000 Medicaid-enrolled adolescents aged 12-17 were measured using integrated administrative data from Washington State. Social determinants of health, including child maltreatment and parent risk factors, were also measured. Two-stage regression models were used to identify factors associated with increased health care utilization and costs.

PRINCIPAL FINDINGS

Regression models revealed that the factors most predictive of higher health care costs were child abuse, child neglect, and instability in out-of-home placements related to foster care. Other social determinants of health, such as parent risk factors, were not associated with health care costs. Child maltreatment and placement instability impacted health care costs primarily through large increases in behavioral health utilization and costs.

CONCLUSIONS

Prevention and early interventions for children and families to decrease child maltreatment and increase foster care placement stability could reduce overall health care costs.

Assessment of Inequalities in Coverage of Essential Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions in Kenya

IMPORTANCE

Previous work has underscored subnational inequalities that could impede additional health gains in Kenya.

OBJECTIVE

To provide a comprehensive assessment of the burden, distribution, and change in inequalities in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) interventions in Kenya from 2003 to 2014.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study used data from the 2003, 2008, and 2014 Kenya Demographic and Health Surveys. The study included women of reproductive age (ages 15-49 years) and children younger than years, with national, regional, county, and subcounty level representation. Data analysis was conducted from April 2018 to November 2018.

EXPOSURES

Socioeconomic position that was derived from asset indices and presented as wealth quintiles. Urban and rural residence and regions of Kenya were also considered.

MAIN OUTCOMES AND MEASURES

Absolute and relative measures of inequality in coverage of RMNCAH interventions.

RESULTS

For this analysis, representative samples of 31 380 women of reproductive age and 29 743 children younger than 5 years from across Kenya were included. The RMNCAH interventions examined demonstrated pro-rich and bottom inequality patterns. The most inequitable interventions were skilled birth attendance, family planning needs satisfied, and 4 or more antenatal care visits, whereby the absolute difference in coverage between the wealthiest (quintile 5) and poorest quintiles (quintile 1) was 61.6% (95% CI, 60.1%-63.1%), 33.4% (95% CI, 31.9%-34.9%), and 31.0% (95% CI, 30.5%-31.6%), respectively. The most equitable intervention was early initiation of breastfeeding, with an absolute difference (quintile 5 minus quintile 1) of -7.9% (95% CI, -11.1% to -4.8%), although antenatal care (1 visit) and diphtheria-tetanus-pertussis immunization (3 doses) demonstrated the best combination of high coverage and low inequalities. Our geospatial analysis revealed significant socioeconomic disparities in the northern and eastern regions of Kenya that have translated to suboptimal intervention coverage. A significant gap remains for rural, disadvantaged populations.

CONCLUSIONS AND RELEVANCE

Coverage of RMNCAH interventions has improved over time, but wealth and geospatial inequalities in Kenya are persistent. Policy and programming efforts should place more emphasis on improving the accessibility of health facility-based interventions, which generally demonstrate poor coverage and high inequalities, and focus on integrated approaches to maternal health service delivery at the community level when access is poor. Scaling up of health services for the urban and, in particular, rural poor areas and those residing in Kenya's former north eastern province will contribute toward achievement of universal health coverage.

Diminished Trust of Healthcare Providers, Risky Lifestyle Behaviors, and Low Use of Health Services: A Descriptive Study of Rural Adolescents

The purpose of our study was to determine the extent to which individual characteristic variables predict trust of healthcare provider (HCP), lifestyle behaviors, and use of health services among adolescents attending public high school in rural Indiana. The sample included 224 individuals surveyed in 9th grade or 12th grade required courses. Trust of HCP and lifestyle behaviors were predicted using hierarchical multiple regression; number of HCP visits and emergency department (ED) visits in the past 12 months were predicted using negative binomial regression. This sample of adolescents living in a rural area reported riskier lifestyle behaviors than another sample of adolescents, lower trust of HCP than adults in general, and fewer HCP and ED visits than adolescents in general. Our study supports the need for school-based health services in rural areas and the opportunity for school nurses to act as care coordinators for marginalized youth.

Global Development Assistance for Adolescent Health From 2003 to 2015

IMPORTANCE

Growth in financing has underpinned progress in most areas of health. Adolescent health has recently become a global priority, with inclusion in the Global Strategy for Women's, Children's and Adolescents' Health, but little is known about patterns of financing and development assistance for adolescent health (DAAH).

OBJECTIVE

To provide estimates of DAAH at global, regional, and country levels.

DESIGN, SETTING, AND PARTICIPANTS

In this quality improvement study, data from the Creditor Reporting System were used to estimate flows of total DAAH and per-adolescent DAAH and to assess its distribution by donors, regions, and countries and the leading causes of burden of disease (ie, disability-adjusted life-years) in 132 developing countries between January 1, 2003, and December 31, 2015. Through use of a key word search and various funding allocation methods, 2 sets of estimates were produced: adolescent-targeted DAAH that included disbursements to projects with a primary adolescent health target and adolescent-inclusive DAAH that included disbursements to projects with either a primary or partial adolescent health target, as well as projects that could benefit adolescent health but did not include age-related key words.

MAIN OUTCOMES AND MEASURES

Estimates of DAAH distinguishing between adolescent-targeted and adolescent-inclusive DAAH.

RESULTS

There were 19 921 projects in 132 countries in the adolescent-targeted estimation between 2003 and 2015, with a total funding amount of $3634.6 million, accounting for 1.6% of total development assistance for health. The top 5 donors (Global Fund to Fight AIDS, Tuberculosis and Malaria, $806.8 million; United Nations Population Fund, $401.3 million; United States, $389.9 million; United Kingdom, $251.8 million; and International Development Association, $218.6 million) together provided 56.9% of all adolescent-targeted DAAH. Sub-Saharan Africa received the largest cumulative DAAH per adolescent ($5.37) during the period. In 2015, among the 10 leading causes of disability-adjusted life-years, HIV and AIDS received the largest DAAH, followed by interpersonal violence, tuberculosis, and diarrheal diseases. Other leading causes, including road injuries and depressive disorders, received few disbursements, especially among the low-income countries.

CONCLUSIONS AND RELEVANCE

Despite an increasing rate, DAAH composed a small proportion of total development assistance for health, suggesting that adolescent health has gained little donor attention. Moreover, recent allocations of DAAH have not aligned well with either the burden of disease or the areas where the benefits of investment are likely to be high.

Pediatricians' Knowledge and Practices Related to Long-Acting Reversible Contraceptives for Adolescent Girls

STUDY OBJECTIVE

A 2014 American Academy of Pediatrics (AAP) policy statement identified long-acting reversible contraceptives (LARCs) as first-line choices for adolescents, but pediatricians' current knowledge and practices about intrauterine devices (IUDs) and subdermal contraceptive implants (Implants) is unknown. We aimed to characterize pediatricians' knowledge and practices about LARCs for adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional online survey emailed to a convenience sample of AAP member pediatricians in New York, Utah, Illinois, and Kansas in 2015 and 2016. The study included 561 practicing pediatricians.

MAIN OUTCOME MEASURES

We measured knowledge about the suitability of IUDs and Implants for adolescents using two 7-item scales; a score of 7 indicates all correct. We dichotomized participants' scores as high and low knowledge if they scored ≥85% correct or <85%, respectively.

RESULTS

Mean age was 47.4 (±11) years; 73% were female; and 72% general pediatricians. Almost all, 88%, counsel about contraception; 64% counsel about IUDs, and Implants, but only 4.1% insert them; 72% prescribe short-acting hormonal contraceptives; 44% had read the AAP policy statement. Mean score on the knowledge scale was lower for IUDs than for Implants (4.2 vs 5.1, respectively; P < .001). Multivariable regression analysis indicated that female pediatricians, adolescent medicine subspecialists, agreeing that pregnancy is a serious problem for adolescents in their practice, and having read the AAP policy statement predicted high knowledge about IUDs as well as Implants for adolescents.

CONCLUSION

Most pediatrician respondents provided reproductive health care for adolescents and counseled about LARCs, but few inserted the devices. We identified knowledge deficits about suitability of IUDs for adolescents.

Examining Time to Treatment and the Role of School-Based Health Centers in a School-Based Sexually Transmitted Infection Program

BACKGROUND

Barriers to health care service utilization contribute to the spread of sexually transmitted infections (STIs) among teens. School-based STI screening programs reach adolescents outside of the clinic-based health care model and schools with school-based health centers (SBHCs) may expedite treatment because of their proximity to the population. This study examined whether students who tested positive for STIs in a school-based screening program had differing times to treatment based on treatment location.

METHODS

All positive cases of chlamydia and gonorrhea from the 2012-2013 school year in a Chicago Department of Public Health (CDPH) and Chicago Public Schools school-based STI screening program were reviewed. Median time to treatment was compared for those treated at an SBHC versus those treated elsewhere (CDPH STI clinic, community health center, private physician).

RESULTS

Overall, 540 students had positive results. The median age was 17 years, 427 had chlamydia (79.1%), 59 had gonorrhea (10.9%), and 54 had dual infections (10.0%); 144 were tested in a school with a SBHC on site (26.7%). Of the 483 students who received treatment (89.4%), those treated at a SBHC had a faster time to treatment compared to CDPH STI clinics (median 17 days versus 28 days, respectively, p < .001).

CONCLUSIONS

For students testing positive in the Chicago school-based STI program, time to treatment is accelerated in locations with SBHCs.

Male adolescents' role in pregnancy prevention and unintended pregnancy in rural Victoria: health care Professional's and educators' perspectives

BACKGROUND

While there has been a steady decline in adolescent pregnancies worldwide and in Australia over the last three decades, Australian rates still rank third highest among developed countries. Adolescent pregnancies are defined as those that occur to girls between the ages of 15 and 19. The current pregnancy rate of 15 to 19 year old females rural Victoria is 21.19%, this is more than double the Victorian state rate of 8.2% and almost double the national Australian rate at 13.1% The aim of this study was to explore Health Care Professionals and Educator perspectives on these high adolescent pregnancy rates, with particular focus on the role of adolescent males, in a rural region in Victoria, Australia.

METHODS

A qualitative descriptive study using focus group discussion was undertaken with Health Care Providers and Educators (N = 8) in 2016. Data was analysed using thematic analysis.

RESULTS

Four themes emerged from analysis. The first, 'Gender Stereotyping' focused on the acceptance of traditional masculinities; the second 'Adolescent males as health consumers' was based on the consensus that adolescent males are poor consumers of health and 'invisible'; the third 'Complexity of Issues' identified that, particularly in a rural region, contributing issues are varied and complex; and the fourth 'Focus on Fatherhood', saw the participants diverge from the discussion about pregnancy prevention and the adolescent males' role in unintended pregnancy, and focus on the role adolescent males may have as unintended fathers.

CONCLUSIONS

Participants did not consider young males to be of importance in the prevention of adolescent pregnancy. There is a need to further explore the role of young males in pregnancy prevention, including what role traditional gender stereotyping, from health professionals' and young males' perspectives, plays in provision of adolescent sexual health services.

A survey of staffing levels in paediatric diabetes services throughout the UK

AIMS

To assess staffing levels of healthcare professionals involved in the care of children and young people with diabetes in the UK.

METHODS

A web-based questionnaire was distributed to lead consultant paediatricians from all paediatric diabetes services in the UK between October and December 2014. Data on staffing levels and other aspects of diabetes services were collected and differences between the four nations of the UK and across the 10 English diabetes networks were explored.

RESULTS

Some 175 services (93%) caring for 29 711 children and young people aged ≤ 24 years with diabetes participated in the survey. Northern Ireland and Wales had the lowest ratio of total staff to patient population. Nursing caseloads per one whole-time equivalent (WTE) nurse ranged from 71 patients in England to 110 patients in Northern Ireland with only 52% of the UK services meeting the Royal College of Nursing recommended nurse-to-patient ratio of > 1 : 70. Scotland and Northern Ireland had the highest ratio of consultants and fully trained doctors per 1000 patients (3.5 WTE). Overall, 17% of consultants had a Certificate of Completion of Training in Endocrinology and Diabetes. Some 44% of dietitians were able to adjust insulin dose. Only 43% of services provided 24-h access to advice from the diabetes team and 82% of services had access to a psychologist. Staffing levels adjusted for volume were not directly related to glycaemic performance of services in England and Wales.

CONCLUSIONS

Wide variations in staffing levels existed across the four nations of the UK and important gaps were present in key areas.

Association Between Adolescent Preventive Care and the Role of the Affordable Care Act

Importance

Despite decades of adolescent preventive well visit and services promotion (Guidelines for Adolescent Preventive Services and Bright Futures), rates are below recommended levels and little is known of the effect of the Patient Protection and Affordable Care Act (ACA) implementation on these care rates.

Objectives

To use Medical Expenditure Panel Survey data to determine (1) whether adolescent well visit rates increased from the pre-ACA period to post-ACA period, and (2) whether caregivers' reports of past-year preventive services delivery increased from the pre- to post-ACA period among adolescents with any past-year health care visit.

Design, Setting, and Participants

Secondary data analysis of 2007-2009 (before ACA implementation) and 2012-2014 (after ACA implementation) Medical Expenditure Panel Survey data on the differences in well visits and preventive services. Data were collected through computer-assisted personal interviews of caregivers of a nationally representative sample of a noninstitutionalized US population (n = 25 695 10- to 17-year-old adolescents).

Main Outcomes and Measures

For objective 1, pre- to post-ACA period differences in past-year well visits: (1) stratified bivariable logistic regressions identifying subgroup rate differences and (2) multivariable analyses controlling for demographic factors. For objective 2, pre- to post-ACA period differences in caregiver reports of preventive services receipt, including time alone with clinician: (1) bivariable (year differences) and (2) multivariable logistic regressions controlling for demographic variables.

Results

A total of 6279 (50.9%) and 6730 (50.8%) participating adolescents in the pre- and post-ACA period data were male, respectively. Under objective 1, we found that well-visit rates increased from 41% to 48% post-ACA implementation (odds ratio, 1.3; 95% CI, 1.2-1.5); minority and low-income groups had the greatest increases. Under objective 2, we found that among those with any past-year visit, most preventive services rates (8 of 9) increased post-ACA implementation (range, 2%-9%, absolute), with little or no change when controlling for demographic variables. Time alone with clinicians increased 1%, significant only when covariates were controlled (adjusted odds ratio, 1.2; 95% CI, 1.0-1.3).

Conclusions and Relevance

Despite modest to moderate increases, with greatest gains for underserved youth, adolescent preventive care rates remain low, highlighting the need for increased efforts to bring adolescents into well care and improve clinician delivery of preventive care within their practices.

Use of Mental Health Services by Adolescents After Traumatic Brain Injury: A Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Mental health problems are common after pediatric traumatic brain injury (TBI). Many patients in need of mental health services do not receive them, but studies have not consistently used prospective and objective methods or followed samples for more than 1 year.

OBJECTIVE

To examine adolescents' use of mental health services after TBI.

DESIGN

Secondary analysis from multicenter prospective randomized controlled trial.

SETTING

Five level 1 U.S. trauma centers.

PARTICIPANTS

Adolescents aged 12-17 years with moderate-to-severe TBI were recruited for a randomized clinical trial (n = 132 at baseline, 124 at 6 months, 113 at 12 months, and 101 at 18 months).

METHODS

Participants were randomly assigned to counselor-assisted problem-solving or Internet resource comparison. Follow-up assessments were completed at 6, 12, and 18 months after baseline. Generalized estimating equations with a logit link were used to examine use of mental health services. Treatment group and participant impairment were examined as predictors of use.

MAIN OUTCOME MEASUREMENTS

Mental health care use was measured with the Service Assessment for Children and Adolescents; daily functioning and clinical outcome with the Child and Adolescent Functional Assessment Scale; behavioral and emotional functioning with the Child Behavior Checklist; and executive dysfunction with the Behavior Rating Inventory of Executive Function.

RESULTS

Use of mental health services ranged from 22% to 31% in the 2 years post-TBI. Participants with impairments were about 3 times more likely than those without impairments to receive services (odds ratio 4.61; 95% confidence interval 2.61-8.14; P < .001). However, 50%-68% of patients identified as impaired had unmet mental health care needs.

CONCLUSIONS

Less than one half of adolescents with behavioral health needs after TBI received mental health services. Future studies are needed to examine barriers associated with seeking services after TBI and psychoeducation as preventive care for this population.

LEVEL OF EVIDENCE

II.

Chlamydia testing in practice - requisitioners and patients

BACKGROUND

Optimising the diagnostic work-up and treatment of genital chlamydia infection requires knowledge of the sampling patterns of those who order chlamydia tests. We wished to determine which groups of doctors collect specimens for chlamydia testing, and to examine the sex and age distribution of patients tested, and the proportion of positive tests, from general practitioners, gynaecologists in private practice, and youth health services.

MATERIAL AND METHOD

The study includes 43 465 specimens analysed for genital infection with Chlamydia trachomatis at Vestfold Hospital Trust over the period 1 January 2007 to 31 December 2011. Data from the laboratory information system were used to classify the test requisitioners.

RESULTS

General practitioners requisitioned 60 % of all chlamydia tests and 63 % of all positive tests. Youth health services requisitioned 13 % of all tests and 22 % of positive tests; gynaecologists in private practice, 12 % of all tests and 5 % of positive tests. Overall, 26 % of specimens were from women over the age of 30 with 2.2 % testing positive, and 82 % of these specimens were submitted by general practitioners or gynaecologists in private practice. Twenty-three per cent of specimens were from men, and 78 % of these were collected in general practice.

INTERPRETATION

Knowledge of who requisitions chlamydia testing and of whom is important for planning and improving chlamydia diagnosis, treatment and contact tracing. In this study from Norway, we found that doctors in general practice play a key role in diagnosing and treating chlamydia. The testing of women over the age of 30 by general practitioners and gynaecologists in private practice probably leads to unnecessary use of resources and should be reduced.

Help and Care Seeking for Sexually Transmitted Infections Among Youth in Low- and Middle-Income Countries

BACKGROUND

The ability to seek help or medical care for sexually transmitted infections (STIs) is vital for sexually active youth; yet, their needs are often unmet.

METHODS

We conducted a qualitative systematic review of studies to assess youth and provider views about the behaviors of young people in help seeking and care seeking for STI services in low- and middle-income countries. We searched peer-reviewed literature for studies published between 2001 and 2014 with a study population of youth (age, 10-24 years) and/or health service providers. Eighteen studies were identified for inclusion from 18 countries. Thematic analyses identified key themes across the studies.

RESULTS

The majority of studies included discussion of youth not seeking treatment, resorting to self-treatment, or waiting to access care, suggesting that many youth still do not seek timely care for STIs. Youth desired more information on sexual health and cited barriers related to fear or taboos in obtaining help or information, especially from providers or parents. Many did not recognize symptoms or waited until symptoms worsened. However, many youth were able to identify a number of sources for STI related care including public and private clinics, pharmacies, alternative healers, and nongovernmental organizations. Youth's help seeking and care seeking preferences were frequently influenced by desires for confidentiality, friendliness, and cost.

CONCLUSIONS

Youth in low- and middle-income countries experience significant barriers in help seeking for STIs and often do not seek or postpone medical care. Improving uptake may require efforts to address clinic systems, provider attitudes, confidentiality, and cultural norms related to youth sexuality.

A Facebook-Based Obesity Prevention Program for Korean American Adolescents: Usability Evaluation

INTRODUCTION

Adolescent obesity is one of the most serious global public health challenges. Social networking sites are currently popular among adolescents. Therefore, the obesity prevention program for Korean American adolescents was developed on the most popular social networking site, Facebook. The purpose of this study was to evaluate the usability of a culturally tailored Facebook-based obesity prevention program for Korean American adolescents (Healthy Teens).

METHOD

An explorative descriptive design of usability testing was used. Usability testing employing one-on-one observation, the think-aloud method, audio taping, screen activity capture, and surveys was performed. Twenty participants were recruited from two Korean language schools (mean age, 15.40 ± 1.50 years). Recruitment and user testing was performed between February and April 2014. Content analysis, using the inductive coding approach, was performed by three coders to analyze transcriptions. Descriptive statistics were used to analyze quantitative data including demographic characteristics, perceived usability, eHealth literacy, and health behaviors.

RESULTS

Testing revealed several usability issues in content, appearance, and navigation. Participants' comments regarding content were positive. Although the Facebook platform provided limited flexibility with respect to building the site, participants described the program's appearance as appropriate. Most participants did not experience difficulty in navigating the program.

DISCUSSION

Our preliminary findings indicated that participants perceived the Healthy Teens program as usable and useful. This program could be used as a robust platform for the delivery of health education to adolescents. Further research is required to assess the effects of Facebook-based programs on adolescent obesity prevention.

Intervention recommendations and subsequent access to services following clinical assessment for fetal alcohol spectrum disorders

BACKGROUND

Children with fetal alcohol spectrum disorders (FASD) and prenatal alcohol exposure (PAE) experience multiple difficulties requiring various interventions. Researchers have called for investigation into service use with respect to clinically recommended interventions.

AIMS

To examine intervention recommendations for children with FASD/PAE and subsequent access to these recommended interventions.

METHODS AND PROCEDURES

Intervention recommendations following FASD assessment were examined for children (1-17 years). Recommendations were compared according to diagnostic status and demographic and environmental variables. Subsequent access to several interventions was examined for 45 participants.

OUTCOMES AND RESULTS

A variety of recommendations were given. Children with FASD received more recommendations overall and received more education, anticipatory guidance, family support, and safety recommendations than undiagnosed children with PAE. Undiagnosed children received more mental health and reassessment recommendations. Older children received fewer family support and developmental therapy recommendations but more mental health recommendations than younger age groups. Many families accessed modified school programming, developmental therapy, psychiatry, child counseling, and parent support as recommended.

CONCLUSIONS AND IMPLICATIONS

Children with FASD and PAE have extensive needs and should receive individualized recommendations. An assessment is valuable even without an FASD diagnosis. Areas of high/low service access may provide insight into accessibility and perceived importance of interventions.

WHAT THIS PAPER ADDS

This study responds to important research questions regarding the intervention needs of individuals with FASD. It is novel in its exploration of intervention recommendations given to children prenatally exposed to alcohol without an FASD diagnosis (rather than only children with FASD) and in its examination of post-assessment service use patterns specifically in relation to clinical recommendations.

The Relationship Between the Use of Health Clinics in Rural Mississippi Schools and the CHIP-AE Adolescent Health Profile

School health clinics are one way to meet the objectives in Healthy People 2010 for adolescent health. To determine the relationship between adolescent health status and use of the school health clinics in four Mississippi high schools, the Child Health and Illness Profile–Adolescent Edition (CHIP-AE) was used. The CHIP-AE identifies health status, giving scores on resilience, comfort, risks, and satisfaction, resulting in health profiles. One hundred seventy-one 9th-graders participated in this descriptive study. Students with the highest discomfort and risk scores had no use of the school health clinic. Students with fair health profiles were the highest users of the school health clinic when compared to all other profiles. Of those students with very poor health status, 60% reported the school health clinic was their only source of health care. In this study, the term school health clinic refers to the health office staffed by a nurse without an advanced degree.

Patterns of Child Mental Health Service Delivery in a Public System: Rural Children and the Role of Rural Residence

This study uses existing data from Hawaii's public mental health system for children and youth as an example of a state-level examination of service use patterns and health care disparities. The purpose of this study was to compare differences in mental health service utilization between rural and non-rural children, especially use of residential services. This study used a performance measure approach to conduct multi-level modeling on existing administrative data to examine the impact of community factors on service utilization. Rural children were found to have the most serious levels of mental health problems at intake, more likely to be placed in out-of-home care, more likely to receive only out-of-home care, more likely to in stay out-of-home longer, and less likely to receive follow-up care than their non-rural counterparts. Practice, policy, and research implications are discussed.

The Effect of Parents' Insurance Coverage on Access to Care for Low-Income Children

This study examines the effects of having an uninsured parent on access to health care for low-income children. Using data from the 1999 National Survey of America's Families, we find that having an uninsured parent decreases the likelihood that a child will have any medical provider visit by 6.5 percentage points, and decreases the likelihood of a well-child visit by 6.7 percentage points. Estimates for low-income children who have insurance but have an uninsured parent indicate a 4.1 percentage-point reduction in the probability of having any medical provider visit, and a similar 4.2 percentage-point reduction in the probability of having a well-child visit relative to those with insured parents. The effects of having an uninsured parent are smaller in magnitude than the effects of a child being uninsured. Efforts to increase insurance coverage of parents, either by extending eligibility for public insurance or through other policy interventions, will have positive spillover effects on access to care for children. Although the magnitude of these effects is small relative to the direct effect of providing insurance to either the child or parent, they should be considered in analyses of costs and benefits of proposed policies.

The Impact of Medicaid Primary Care Case Management on Office-Based Physician Supply in Alabama and Georgia

The success of the “primary care case management (PCCM)” form of managed care implemented in many state Medicaid programs over the past several years depends in part on the expanded availability of primary care physician sites to substitute for hospital-based outpatient care and to provide a medical home for enrollees. However, the PCCM requirement for physicians to accept assignment of a caseload of patients and to provide all of their primary care likely conflicts with the approach of limited Medicaid participation favored by many Medicaid physician participants. This study examines the early impact of PCCM implementation, in the absence of physician reimbursement level increases, on the patterns of Medicaid participation by physicians in communities in Georgia and Alabama. We find that the implementation of PCCM under these conditions often was associated with reductions in the proportion of physicians participating in Medicaid, reductions in the number of very small Medicaid practices, and declines in Medicaid visit volumes across all participating physicians. We also find evidence of an overall reduction in the number of primary care visits per Medicaid enrollee, but an increase in the proportion of these visits that were for preventive care services associated with initial PCCM implementation.

Child and Adolescent Mental Health Care in Iran: Current Status and Future Directions

BACKGROUND

The need for mental health care among children and adolescents in Iran, as in other low and middle income countries (LAMIC) remains mostly unmet. In this paper, we sought to provide an overview of the extent of unmet need and mental health services in Iran. We also aimed to propose approaches to address this gap.

METHOD

We reviewed the published epidemiologic studies of child and adolescent mental and behavioral health problems in Iran. We also examined the current status of child mental health services and the gaps between current needs and available services based on published literature that included papers published in scientific journals, as well as governmental and other administrative reports. The contextual issues relevant to child mental health care were also explored, as well as the possibilities to introduce new or scale up promising services.

RESULTS

Child and adolescent mental and behavioral health problems are highly prevalent in Iran. Different studies have estimated that 16.7% to 36.4% of children and adolescents suffer from one or more mental health problems. However, there is a serious scarcity of resources to meet this need. Available services are delivered by independent public organizations (e.g., Ministry of Health, Welfare Organization, and Ministry of Education) or private sector with inefficient communication and collaboration among them and no mandatory national mental health policy. Available specialized child and adolescent services are mostly confined to small inpatient units and university outpatient facilities in larger cities, and there is a scarce evidence for  the effectiveness of the available services.

CONCLUSIONS

Expansion of primary care's role in timely detection and management of child and adolescent mental health problems, implementation of task-shifting and -sharing initiatives, as well as improved collaboration among responsible governmental and non-governmental sectors are some of the most promising future venues to improve mental health care for the Iranian youth.

Analysis of health care claims during the peri-transfer stage of transition from pediatric to adult care among juvenile idiopathic arthritis patients

BACKGROUND

To investigate the utilization of health care services before and after transfer from pediatric to adult rheumatology care in clinical practice.

METHODS

Using US commercial claims data from January 2005 through August 2012, we identified individuals with a JIA diagnosis code from a pediatric rheumatologist followed by any diagnosis code from an adult rheumatologist. Individuals had 6 months observable time before the last pediatric visit and 6 months after the first adult visit. Medication, emergency room, physical therapy use, and diagnosis codes were compared between the pediatric and adult interval using McNemar's test. The proportion of days covered (PDC) of TNFi for the time between last pediatric and first adult visit was calculated.

RESULTS

We identified 58 individuals with JIA who transferred from pediatric to adult rheumatology care after the age of 14. The median age at the last pediatric rheumatology visit was 18.1 years old and the median transfer interval was 195 days. 29 % of patients received NSAIDs in the adult interval compared to 43 % in the pediatric interval (p = 0.06). In the pediatric interval, 71 % received a JRA and 0 % received an RA physician diagnosis code compared to 28 and 45 %, respectively, in the adult interval. The median PDC for patients receiving a TNFi was 0.75 during the transfer interval.

CONCLUSION

Individuals with JIA who transferred to adult care were more likely receive a diagnosis of RA instead of JRA and were less likely to receive NSAIDs, but had no significant immediate changes to other medication use.

Meet the school health pioneer

Nineteen years after becoming a school nurse I won the child health category in the RCNi Nurse Awards for creating and developing a website called Health Matters. Since becoming a school nurse in 1987, I have been challenged by how difficult it is to engage young people in health and well-being. Young people want a health service that is visible, accessible and confidential. But how can we achieve that with the resources we have?'

Teen Smoking Cessation Help Via the Internet: A Survey of Search Engines

The objective of this study was to assess Web sites related to teen smoking cessation on the Internet. Seven Internet search engines were searched using the keywords teen quit smoking. The top 20 hits from each search engine were reviewed and categorized. The keywords teen quit smoking produced between 35 and 400,000 hits depending on the search engine. Of 140 potential hits, 62% were active, unique sites; 85% were listed by only one search engine; and 40% focused on cessation. Findings suggest that legitimate on-line smoking cessation help for teens is constrained by search engine choice and the amount of time teens spend looking through potential sites. Resource listings should be updated regularly. Smoking cessation Web sites need to be picked up on multiple search engine searches. Further evaluation of smoking cessation Web sites need to be conducted to identify the most effective help for teens.

The Experiences and Perceptions of Street-Involved Youth Regarding Emergency Department Services

Street-involved (SI) youth comprise a substantial component of the urban homeless population. Despite being significant users of hospital emergency department (ED) services for acute and ongoing health needs, little is known about their experiences of ED care and the factors affecting their ED use. This study used a grounded theory and community-based approach to examine these issues. Focus groups and individual interviews were facilitated with 48 SI youth between ages 15 and 26 years, recruited in hospital or through community agencies serving SI youth in a major Western Canadian city. Results demonstrate that SI youth often perceived suboptimal care and experienced long waiting periods that led to many avoiding or prematurely exiting the ED. Service gaps appeared to have a negative bearing on their care and health outcomes. Findings invite a critical review of ED care processes, structures, and staff interactions in the aim of enhancing ED services to SI youth.

Access and Utilization of Selected Preventive Health Services Among Adolescents Aged 10-17

Data from the National Health Interview Survey •The percentages of adolescents aged 10-17 who did not have a usual place for preventive care, did not receive a well-child checkup in the past 12 months, or did not have a dental visit in the past 12 months decreased from 2008 to 2014. •In 2014, 2% of adolescents aged 10-17 did not have a usual place for preventive care, 21% did not receive a well-child checkup, and 12% did not have a dental visit in the past 12 months. •In 2014, the percentages of adolescents not having a usual place for preventive care, not receiving a well-child checkup, and not having a dental visit were higher for those aged 16-17 compared with those in younger age groups. These percentages also varied by race and ethnicity, poverty status, and insurance status.

Access to Care for Youth in a State Mental Health System: A Simulated Patient Approach

OBJECTIVE

To examine access to psychiatric care for adolescents with depression in outpatient specialty clinics within a state mental health system, using a simulated patient approach.

METHOD

Trained callers posed as the mother of a 14-year-old girl with depression, following a script. A stratified random sample (n = 264) of 340 state-licensed outpatient mental health clinics that serve youth was selected. Clinics were randomly assigned to season and insurance condition. We examined whether access varied by season, clinic characteristics, and caller insurance type. Weighted logistic and linear mixed effects regression models were fitted to examine associations with appointment availability and wait times.

RESULTS

Among clinics at which a treatment appointment could be scheduled, appointment availability differed by season. Clinics that had participated in state-sponsored trainings targeting access were more available. Wait times for treatment appointments varied by season and region. Wait times in New York City were shorter than in some other regions. Although callers were 4.1 times more likely to be able to schedule a psychiatry appointment in the spring, wait times for psychiatry appointments were significantly longer in the spring than in the summer (49.9 vs. 36.7 days). Wait times for therapy appointments were significantly shorter in community than in hospital clinics (19.1 days vs. 35.3 days).

CONCLUSION

Access to psychiatric care for youth with depression was found to be variable in a state system. State-sponsored trainings on strategies to reduce wait times appear to improve care access. The simulated patient approach has promise for monitoring the impact of health care policy reforms on care quality measures.

A Statewide Profile of Frequent Users of School-Based Health Centers: Implications for Adolescent Health Care

BACKGROUND

The purpose of this study is to describe patterns of care and service use among adolescent school-based health center (SBHC) users in New Mexico and contrast patterns and services between frequent and infrequent users.

METHODS

Medical claims/encounter data were analyzed from 59 SBHCs located in secondary schools in New Mexico during the 2011-2012 school year. We used Pearson's chi-square test to examine the differences between frequent (≥ 4 visits/year) and infrequent users in their patterns of SBHC care, and we conducted logistic regression to examine whether frequent use of the SBHC predicted receipt of behavioral, reproductive, and sexual health; checkup; or acute care services.

RESULTS

Most of the 26,379 adolescent SBHC visits in New Mexico were for behavioral health (42.4%) and reproductive and sexual health (22.9%). Frequent users have greater odds of receiving a behavioral, reproductive, and sexual health; and acute care visit than infrequent users (p < .001). American Indians, in particular, have higher odds of receiving behavioral health and checkup visits, compared with other races/ethnicities (p < .001).

CONCLUSIONS

SBHCs deliver core health care services to adolescents, including behavioral, reproductive, and checkup services, to high need populations. American-Indian youth, more than their peers, use SBHCs for behavioral health and checkups.

Privacy and Confidentiality Practices In Adolescent Family Planning Care At Federally Qualified Health Centers

CONTEXT

The confidentiality of family planning services remains a high priority to adolescents, but barriers to implementing confidentiality and privacy practices exist in settings designed for teenagers who are medically underserved, including federally qualified health centers (FQHCs).

METHODS

A sample of 423 FQHCs surveyed in 2011 provided information on their use of five selected privacy and confidentiality practices, which were examined separately and combined into an index. Regression modeling was used to assess whether various state policies and organizational characteristics were associated with FQHCs' scores on the index. In-depth case studies of six FQHCs were conducted to provide additional contextual information.

RESULTS

Among FQHCs reporting on confidentiality, most reported providing written or verbal information regarding adolescents' rights to confidential care (81%) and limiting access to family planning and medical records to protect adolescents' confidentiality (84%). Far fewer reported maintaining separate medical records for family planning (10%), using a security block on electronic medical records to prevent disclosures (43%) or using separate contact information for communications regarding family planning services (50%). Index scores were higher among FQHCs that received Title X funding than among those that did not (coefficient, 0.70) and among FQHCs with the largest patient volumes than among those with the smallest caseloads (0.43). Case studies highlighted how a lack of guidelines and providers' confusion over relevant laws present a challenge in offering confidential care to adolescents.

CONCLUSIONS

The organizational practices used to ensure adolescent family planning confidentiality in FQHCs are varied across organizations.

QUANTITATIVE ASSESSMENT OF SOME PREVENTIVE HEALTH SERVICES PROVIDED FOR ADOLESCENT INDIVIDUALS IN DUBAI

The United Arab Emirate (UAE) of Dubai, faces significant adolescent health problems. In 2009, evidence based clinical guidelines were developed for primary health care professionals in Dubai to help reduce adolescent health problems. This research study explores adolescents' self-reports about health education services received between 2008 and 2010. The sample consisted of 730 public high school students in grades 10 through 12 between the ages of 15 and 19. 357 (48.9%) of the sample were males and 373 (51.1%) were female. The major language spoken in the home was Arabic (77.4%). All students completed a 27-item survey in Arabic that was adapted from the Young Adult Health Care Survey (YAHCS). The YAHCS is a 56-item research instrument traditionally administered in English and Spanish. The sample reported they had received little or no health education from their health care providers. 94.2% reported receiving no information about using a helmet for bicycle and motorbike safety; 88.2% reported receiving no information about drug use; and 81.9% reported that they received no information about smoking. The instrument also explored the health education material students received within the last 12 months. 65.5% of the sample reported seeing and/or hearing safety tips; 84.9% reported hearing and/or seeing health information about healthy diet, physical activity and exercise; and 79.2% reported seeing and/or hearing information about the risks of smoking and substance abuse.

Inpatient Children and Adolescent Mental Health Services (CAMHS): outcomes of young people with and without intellectual disability

BACKGROUND

Little is known about the effectiveness of inpatient care for young people with co-morbid mental illness and intellectual disability (ID). This study aims to compare the demographics and outcome of young people with mental illness with or without ID admitted to psychiatric hospital. A secondary aim is to look into the outcome of those with ID admitted to general mental health young people's units.

METHOD

Data were collected on the outcome of young people's admissions to specialist ID and general adolescent mental health units as part of a larger quality improvement project run by the College Centre for Quality Improvement. Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) scores were completed by local clinical staff at admission and discharge on 38 young people with and 113 people without ID from 14 units.

RESULTS

Young people with mental disorders significantly improved clinically over the admission whether or not they had ID. There were no differences between the groups in age or use of the Mental Health Act but people admitted with ID were more likely to be male and had longer lengths of stay. Admission to a general adolescent unit was associated with clinical improvement for people with ID.

CONCLUSIONS

This study needs replication because of the small sample and incomplete data but it suggests that young people with ID and mental disorders significantly improve clinically when admitted to hospital as do their non-disabled peers.

Socioeconomic inequalities in adolescent health 2002-2010: a time-series analysis of 34 countries participating in the Health Behaviour in School-aged Children study

BACKGROUND

Information about trends in adolescent health inequalities is scarce, especially at an international level. We examined secular trends in socioeconomic inequality in five domains of adolescent health and the association of socioeconomic inequality with national wealth and income inequality.

METHODS

We undertook a time-series analysis of data from the Health Behaviour in School-aged Children study, in which cross-sectional surveys were done in 34 North American and European countries in 2002, 2006, and 2010 (pooled n 492,788). We used individual data for socioeconomic status (Health Behaviour in School-aged Children Family Affluence Scale) and health (days of physical activity per week, body-mass index Z score [zBMI], frequency of psychological and physical symptoms on 0-5 scale, and life satisfaction scored 0-10 on the Cantril ladder) to examine trends in health and socioeconomic inequalities in health. We also investigated whether international differences in health and health inequalities were associated with per person income and income inequality.

FINDINGS

From 2002 to 2010, average levels of physical activity (3·90 to 4·08 days per week; p<0·0001), body mass (zBMI -0·08 to 0·03; p<0·0001), and physical symptoms (3·06 to 3·20, p<0·0001), and life satisfaction (7·58 to 7·61; p=0·0034) slightly increased. Inequalities between socioeconomic groups increased in physical activity (-0·79 to -0·83 days per week difference between most and least affluent groups; p=0·0008), zBMI (0·15 to 0·18; p<0·0001), and psychological (0·58 to 0·67; p=0·0360) and physical (0·21 to 0·26; p=0·0018) symptoms. Only in life satisfaction did health inequality fall during this period (-0·98 to -0·95; p=0·0198). Internationally, the higher the per person income, the better and more equal health was in terms of physical activity (0·06 days per SD increase in income; p<0·0001), psychological symptoms (-0·09; p<0·0001), and life satisfaction (0·08; p<0·0001). However, higher income inequality uniquely related to fewer days of physical activity (-0·05 days; p=0·0295), higher zBMI (0·06; p<0·0001), more psychological (0·18; p<0·0001) and physical (0·16; p<0·0001) symptoms, and larger health inequalities between socioeconomic groups in psychological (0·13; p=0·0080) and physical (0·07; p=0·0022) symptoms, and life satisfaction (-0·10; p=0·0092).

INTERPRETATION

Socioeconomic inequality has increased in many domains of adolescent health. These trends coincide with unequal distribution of income between rich and poor people. Widening gaps in adolescent health could predict future inequalities in adult health and need urgent policy action.

FUNDING

Canadian Institutes of Health Research.

Treatment outcome for adolescents abusing alcohol and cannabis: how many 'reliably improve'?

Alcohol and cannabis are the primary substances contributing to referrals of adolescents to substance abuse treatment services. Their outcome has not been examined in Ireland. A three month follow-up was conducted in an outpatient adolescent treatment program. We followed up 35 high risk users of alcohol and 55 high risk users of cannabis. Although the high risk drinkers achieved a significant reduction in median number of days drinking (p = 0.004), only four (11 %) were abstinent at follow up. A further five (14%) achieved a reliable reduction in days of drinking. The high risk cannabis users demonstrated a significant drop in median days of use (p < 0.001), although only six (11%) were abstinent at follow up. A further 20 (36%) achieved a reliable reduction in days of use. Calculation of reliable change allows examination of outcomes which fall short of the elusive goal of abstinence.

Understanding sexual and reproductive health needs of adolescents: evidence from a formative evaluation in Wakiso district, Uganda

INTRODUCTION

Adolescents are frequently reluctant to seek sexual and reproductive health services (SRH). In Uganda, adolescent health and development is constrained by translation of the relevant policies to practice. Recent studies done in central Uganda have shown that there is need for a critical assessment of adolescent friendly services (AFS) to gain insights on current practice and inform future interventions. This study aimed to assess the sexual reproductive health needs of the adolescents and explored their attitudes towards current services available.

METHODS

A qualitative study was conducted in Wakiso district, central Uganda in September 2013.Twenty focus group discussions (FGDs) stratified by gender (10 out-of-school, and 10 in-school), were purposefully sampled. We used trained research assistants (moderator and note taker) who used a pretested FGD guide translated into the local language to collect data. All discussions were audio taped, and were transcribed verbatim before analysis. Thematic areas on; adolescent health problems, adolescent SRH needs, health seeking behaviour and attitudes towards services, and preferred services were explored. Data was analysed using atlas ti version 7 software.

RESULTS

Our results clearly show that adolescents have real SRH issues that need to be addressed. In and out-of-school adolescents had sexuality problems such as unwanted pregnancies, sexually transmitted infections (STIs), defilement, rape, substance abuse. Unique to the females was the issue of sexual advances by older men and adolescents. We further highlight RH needs which would be solved by establishing adolescent friendly clinics with standard recommended characteristics (sexuality information, friendly health providers, a range of good clinical services such as post abortion care etc.). With regard to health seeking behaviour, most adolescents do not take any action at first until disease severity increase.

CONCLUSIONS

Adolescents in Uganda have multiple sexual and reproductive health needs that require special focus through adolescent friendly services. This calls for resource support in terms of health provider training, information education and communication materials as well as involvement of key stakeholders that include parents, teachers and legislators.