Adolescent health care: improving access by school-based service

Participants in this discussion of the potential of school-based health care services for adolescents included family medicine physicians, school health coordinators, a school nurse, and a community worker. It was noted that health care for adolescents tends to be either inaccessible or underutilized, largely because of a lack of sensitivity to adolescent culture and values. An ideal service for adolescents would offer immediate services for crises, strict confidentiality, ready access to prescribed medications, a sliding-scale scheme, and a staff that is tolerant of divergent values and life-styles. School-based pilot adolescent clinics have been established by the University of New Mexico's Department of Family, Community, and Emergency Medicine to test the community-oriented health care model. On-site clinics provide urgent medical care, family planning, pregnancy testing, psychological counseling, alcohol and drug counseling, and classroom health education. Experience with these programs has demonstrated the necessity for an alliance among the health team and the school administration, parents, and students. Financial, ethical, and political factors can serve as constraints to school-based programs. In some cases, school administrators have been resistant to the provision of contraception to students on school grounds and parents have been unwilling to accept the adolescent's right to confidentiality. These problems in part stem from having 2 separate systems, each with its own values, orientation, and responsibilities, housed in 1 facility. In addition, there have been problems generating awareness of the school-based clinic among students. Health education theater groups, peer counseling, and student-run community services have been effective, however, in increasing student participation. It has been helpful to mold clinic services to meet the needs identified by teenagers themselves. There is an interest not only in curative services, but in services focused on depression and feelings of uncertainty about the future.     

Managed Care Organizations and Public Health: Exploring Collaboration on Adolescent Immunizations

ABSTRACT: Managed care organizations (MCOs) joined local and state public health agencies in a pilot effort to improve hepatitis B immunization rates of adolescents in an urban and a suburban/rural school district. The pilot also explored issues inherent in public and private collaboration on population health improvement.
Local public health agencies provided links to schools in their communities, took the lead in implementing school-based immunization programs, and provided health education materials. MCOs contributed financial support necessary for the project. The final cost per fully vaccinated student, not taking into account the work group's planning and coordination time, was little more than the catalog price of the vaccine alone.
Managed care organizations face challenges that complicate their participation and funding of school-based vaccinations: 1) Limited data on health plans of participating students complicate allocation of costs to each MCO; 2) Double-paying occurs for MCOs paying clinics a monthly, per-member rate that already includes adolescent immunizations; 3) When schools provide adolescent immunizations, MCOs lose the "hook" that draws adolescents to clinics for comprehensive health services.
When self-consenting is permitted, schools can achieve a high consent and completion rates for multi-dose adolescent immunizations such as hepatitis B. At the same time, MCOs have the responsibility to provide members with comprehensive care and should continue to examine both internal modifications and external partnerships as opportunities to improve their services to adolescents.     

Different Setting, Different Care: Integrating Prevention and Clinical Care in School-Based Health Centers

School-based health centers (SBHCs) are widely credited with increasing students’ access to care by making health services affordable and convenient.SBHCs can also provide a qualitatively different type of health care for children and adolescents than that delivered by community providers. Health services offered in a school setting can integrate clinical care with public health interventions and environmental change strategies. This ability to reach outside the walls of the exam room makes SBHCs uniquely positioned to address the multiple determinants of health.We describe innovative California SBHC programs focusing on obesity prevention, asthma, mental health, and oral health that represent new models of health care for children and adolescents.Although insuring the 8.1 million uninsured children in the United States is a critical first step, improving children''s and adolescents’ health requires going beyond insurance coverage and providing better access and preventive services. Obesity, adolescent pregnancy, dental disease, uncontrolled asthma, and many mental health conditions are serious child and adolescent health concerns whose amelioration requires a combination of clinical services and preventive strategies. The pediatric health care system falls far short in the delivery of preventive care.^1,2 A recent study examined pediatric medical records for 175 indicators of quality care defined by an expert panel of physicians. Adherence to these quality standards was 67.6% for acute care but only 40.7% for preventive care, dropping to 34.5% when only adolescents were considered.³Many authors have highlighted the need to tackle the multiple determinants of children''s health. The resiliency paradigm emphasizes the importance of supportive environments and psychosocial skill development as protective factors mediating both adolescent risk behaviors and health outcomes.⁴ The life course health development framework points to the importance of biological, behavioral, social, and economic determinants of health status that require integrated health interventions.⁵ Most recently, with the growing obesity epidemic, we are seeing increasing attention to environmental determinants of health such as opportunities for physical activity and access to produce. A successful system for children''s health requires a multisector approach that integrates medical, public health, educational, and social services—sectors that today remain an uncoordinated patchwork of categorical programs.⁶The ability of school-based health centers (SBHCs) to increase access to health care has been well documented.^7–9 SBHCs, which deliver primary medical and mental health care, increase access and utilization by providing health care in a location that is convenient for students and their families. Less well recognized, however, is that health care services can be qualitatively different in an SBHC than they are in a community provider''s office. Because of their unique location, SBHCs have the potential to implement health care models for children and adolescents that fully integrate prevention—primary, secondary, and tertiary—into clinical care and that address biological, behavioral, social, and economic determinants of health. We describe 4 school-based programs that exemplify this integration of clinical and preventive care and discuss opportunities for expanding these innovative models.     

Providing Medical Services Through School-Based Health Programs

ABSTRACT: Resolution 162, which was adopted at the 1987 Annual Meeting by the Board of Trustees, called on the American Medical Association to study the efficacy of school-based health clinics. Recent data show that a significant number of school-aged youth are in need of an adequate source of health care. School-based health programs constitute a promising avenue for providing health services to adolescents, particularly in medically underserved areas. Although there are insufficient data to support universal establishment of school-based health programs, small-scale studies suggest that such programs are a viable means to increase access to health care for youth.     

The AMA Residency Training in Adolescent Preventive Services Project: report of the working group. The American Medical Association.

PURPOSE: To improve resident education in provision of adolescent preventive health care. The American Medical Association (AMA) Residency Training in Adolescent Preventive Services Project Working Group convened to identify specific goals and objectives (G&Os) for pediatric and family medicine resident education in adolescent clinical preventive services and recommend strategies to achieve these G&Os. METHODS: Iterative review process involving members of the working group, nine experienced teaching faculty and 16 resident physicians from family medicine and pediatric training programs, and an advisory board. RESULTS: We achieved consensus on appropriate G&Os for pediatric and family medicine residency education in adolescent clinical preventive services. Faculty and residents expressed concerns about achieving G&Os because of challenges to implementing effective training and evaluation strategies. Suggestions for achieving G&Os included development of an adolescent clinical preventive services curriculum and evaluation program that could be adapted for use in a variety of training program structures. Faculty and residents anticipated the success of a training curriculum would be influenced by: (a) availability of adequate numbers of skilled teaching faculty; (b) availability of time and support for faculty development and teaching efforts; and (c) exposure of residents to adequate numbers of adolescent patients in settings where there are clear expectations for delivery of comprehensive preventive services. CONCLUSIONS: The AMA Residency Training in Adolescent Preventive Services Project Working Group presents G&Os for organizing training experiences in adolescent clinical preventive services in family medicine and pediatric residency training programs and recommends strategies to achieve these G&Os.     

School-Based Prenatal and Postpartum Care: Strategies for Meeting the Medical and Educational Needs of Pregnant and Parenting Students

Adolescent pregnancy is not a new phenomenon, but it is a source of concern to U.S. educators because of the many young women choosing to become parents and the profound effect early childbearing has on the educational and vocational careers of many young Americans. Strategies for addressing the unique medical, educational, and psychosocial needs of pregnant and parenting students will be examined. Documented physical and psychosocial risks associated with adolescent childbearing will be reviewed, and data related to the effect of young maternal age on pregnancy outcome and the effect of pregnancy on the life course development of adolescents will be emphasized. Specific elements of comprehensive, adolescent-oriented prenatal and postnatal care will be discussed, as well as the effectiveness of existing prenatal and postnatal programs at preventing the most serious sequelae of adolescent childbearing. The role of school-based services will be examined, and ways will be discussed for educators and health care providers to collaborate in providing medical, educational, and social services for adolescent parents and their children. In addition, topics for future research will be suggested.     

Coordinating the delivery of vaccinations and other preventive health care recommendations for adolescents

Although recommendations for annual preventive care for adolescents have been in place for decades, the need to bring adolescents to the medical setting for newly recommended vaccines has placed this issue in the public health spotlight. Aggressive efforts have been ongoing to increase adolescent adherence to new vaccine recommendations--a measured outcome variable, and the hope has been that enhanced adherence to comprehensive health care visits will follow. Evidence indicates that the implementation of more comprehensive preventive health care elements among adolescents may be improving; however, a passive approach to bringing more adolescents to preventive health visits using vaccine as an incentive may not be effective for all youth. This paper reviews the history of recommendations for new vaccines as well as comprehensive health care visit recommendations for adolescents, how these recommendations may synergistically improve preventive care for adolescents, and how we may need to continue to think creatively to further access all youth for preventive health care using vaccination implementation as a model for reaching out beyond the providers' office walls.     

Adolescent health spending and measures in state Title V Maternal and Child Health Programs.

This study examines how state public health agencies report using Title V Maternal and Child Health Block Grant funds to improve the health of adolescents. The Title V Information System was analyzed to identify state level expenditures allocated to pediatric primary and preventive care and to identify measures that monitor adolescents' primary and preventive health care as defined by adolescent clinical preventive guidelines such as Bright Futures and Guidelines for Adolescent Preventive Services. Most states do not report expending 30 percent or more on primary and preventive care, nor do they report measuring adolescents' receipt of primary or preventive health services.     

Male adolescent use of health care services: where are the boys?

PURPOSE: To describe patterns of health care use by adolescent males in the United States and clinical practice characteristics associated with their use of adolescent-specific programs. METHODS: Secondary analysis of three national data sets to determine health care use by male adolescents: the National Ambulatory Medical Care Survey [NAMCS (1994): pediatric, family physician, internal medicine, and obstetric/gynecologic outpatient visits]; National Hospital Ambulatory Medical Care Survey [NHAMCS (1994): outpatient department (OPD) and emergency department (ED) visits]; and Comprehensive Adolescent Health Services Survey [CAHSS (1995)]. Both NAMCS and NHAMCS are representative national probability samples. Total visit estimates by adolescents in 1994 to NAMCS sites were 387,076,630, to OPD sites were 6,511,244, and to ED sites were 13,161,824. For CAHSS, 468 programs (60% of eligible) participated. Data analyses were performed using two-tailed Student's t-tests and correlation testing. RESULTS: Older male adolescents, aged 16-20 years, account for a lower percentage of total visits to NAMCS sites combined compared to younger males, aged 11-15 years (15.8% vs. 25.1%, p <.001), mainly owing to a significant decline in visits to pediatricians (3.2% vs. 14.9%, p <.001), despite significant increases in female health care use during the same time period. Younger males were seen at similar rates compared to females at NAMCS, NHAMCS-OPD and NHAMCS-ED sites, but older males account for a significantly lower percentage of total visits than females to all NAMCS sites combined (15.8% vs. 34.7%, p <.001), the NHAMCS-ED (26.4% vs. 31.5%, p <.05), and the NHAMCS-OPD (15.0% vs. 41.2%, p =.001). Among specialized adolescent sites (CAHSS), 13-19-year-old males account for fewer visits than females to all programs types: schools (40% vs. 60%), hospitals (33% vs. 67%), and community/health departments (25% vs. 75%) (all p's < or =.001). Clinical practice characteristics correlated with having a greater proportion of male adolescent visit varied depending on the types of adolescent program examined. CONCLUSIONS: Younger male adolescents make health care visits in relatively equal proportions to females at all NAMCS and NHAMCS locations and visits by older males are significantly reduced. Male adolescent visits are lower than females at all adolescent-specific programs; school-based clinics see the highest proportion of males. Greater understanding of male adolescents' transition between providers from adolescence to adulthood is needed to improve care to male adolescents who under-use health services.     

Health access and status of adolescents and young adults using youth employment and training programs in an urban environment.

PURPOSE: To describe the health status and access to healthcare of adolescents and young adults disconnected from traditional education and work settings. The health status of these disconnected youth is largely unknown, although it is suspected to be quite poor. Most information about the health of youth in the United States relies on school-based samples. METHOD: In-person interviews with 1037 adolescents and young adults (aged 16-24 years) enrolled in an employment and training program in Baltimore were used to measure access to health services and health status in four domains: violent behavior, mental health, substance use, and reproductive health. Differences in healthcare access and health status by age and gender were examined. In addition, youth in the employment and training sample are compared with Baltimore youth in school and of comparable ages, as measured by the Youth Risk Behavior Surveillance System. RESULTS: Nearly 50% of young adults in the employment and training program were found to lack health insurance, and about 20% reported a time when they needed medical care but did not receive it. Youth in the program exhibited notable health status concerns, often exceeding the risk prevalence of students in school. In particular, adolescents and young adults disconnected from traditional employment and work settings were more likely to be in physical fights, to smoke cigarettes, and to use marijuana than their in-school counterparts. In-school youth were more likely to have considered harming themselves and to have made a suicide plan in the last year. CONCLUSIONS: Given high levels of health risk among youth disconnected from traditional education and work settings, adolescent health providers must increasingly pay attention to integrating health promotion and disease prevention strategies into youth employment and training programs, where sizable numbers of these youth can be reached.     

Improving Receipt and Preventive Care Delivery for Adolescents and Young Adults: Initial Lessons from Top-Performing States

Purpose Provisions of the Patient Protection and Affordable Care Act (ACA) of 2010 hold promise for improving access to and receipt of preventive services for adolescents and young adults (AYAs). The Title V Block Grant transformation also includes a focus on improving adolescent preventive care. This brief report describes and discusses an inquiry of promising strategies for improving access and preventive care delivery identified in selected high-performing states. Methods Two data sources were used to identify top-performing states in insurance enrollment and preventive care delivery: National Survey of Children’s Health for adolescents (ages 12–17 years) and Behavioral Risk Factors Surveillance System for young adults (ages 18–25 years). Interviews were conducted with key stakeholders to identify promising strategies related to increasing AYAs’ insurance enrollment and receipt of preventive services. Results Seven top-performing states were selected: California, Colorado, Illinois, Iowa, Oregon, Vermont, and Texas; 27 stakeholders completed interviews. Four strategies were identified regarding insurance enrollment: use of partnerships; special populations outreach; leveraging laws and resources; and youth engagement. Four strategies were identified regarding quality preventive care: expand provider capacity to serve AYAs; adopt medical home policies; establish quality improvement projects; and enhance consumer awareness of well-visit. States focused more on adolescents than young adults and on increasing health insurance enrollment than the provision of preventive services. Conclusions This commentary identifies strategies and recommends areas for future action, as Title V programs and their partners focus on improving healthcare for AYAs as ACA implementation and the Title V transformation continues.     

Adolescent immunizations: A position paper of the Society for Adolescent Medicine

New vaccines are being targeted to help protect the adolescent population from disease. The Society for Adolescent Medicine strongly urges compliance with adolescent vaccination recommendations provided by the Advisory Committee on Immunization Practices. These vaccines will significantly impact the health and well-being of the adolescent population. To enhance vaccination compliance and access to prevention health care and promotion, the Society supports linking vaccination to the three distinct comprehensive preventive health care visits already recommended by multiple organizations during early, middle, and late adolescence. In addition, multiple provider strategies should be used to increase vaccination rates among adolescents.     

Outcomes of enhanced prenatal services for Medicaid-eligible women in public and private settings.

OBJECTIVE: With changes in Medicaid, more low-income women are receiving prenatal care in private practice settings. The authors sought to determine whether private settings can provide the enhanced prenatal support services for low-income women that have been offered for decades in public settings. METHODS: The authors analyzed birth outcomes of Medicaid-eligible women receiving care from public and private providers certified to deliver enhanced prenatal care services, which included assessments of nutritional, psychosocial, and health educational risks and individualized counseling along with clinical care. Birth outcomes were compared by type of provider setting using multivariate logistic regression models to adjust for differences in risks and use of care. RESULTS: Among settings certified to deliver enhanced perinatal support services, private physicians'' offices had the best risk-adjusted birth outcomes and public health department clinics the worst, while public hospital clinics had outcomes no different from private physicians'' offices. Adjusted for prenatal care use, outcomes were still better for women seen in private physicians'' offices than for women seen in public health department clinics, community clinics, or private hospital clinics. CONCLUSIONS: The findings suggest that given a certification process, private providers can provide enhanced support services as effectively as providers in public practice settings.     

School-based clinic use other factors affecting adolescent contraceptive behavior

Adolescent risk taking, preventive behavior, and contraceptive use were investigated using a self-administered questionnaire in a sample of 260 inner-city high school students targeted by a school-based health clinic. Multivariate models consisting of individual and environmental variables significantly predicted sexual activity and contraceptive use. Older age at first intercourse, higher number of welfare benefits received by the household (including Medicaid, food stamps, and free or reduced price lunch), and use of the school-based clinic were significant positive predictors of more frequent contraceptive use by adolescents.Results of our study suggest that programs may be having some success in encouraging and enabling sexually active adolescents to use contraception and to use it more consistently. Rigorous program evaluations should help program planners and policy makers design and refine adolescent pregnancy-prevention efforts.     

Differential use of adolescent reproductive health programs in Addis Ababa,Ethiopia

PurposeAdolescent reproductive health programs in Africa have largely remained as small-scale pilot programs, however, there is increasing interest in bringing programs to scale. Evaluations have focused on individual programs and few have gathered population-based information on the reach of program models and the profile of adolescents who utilize services, versus those who do not. This study examines the coverage and utilization of existing adolescent programs in Addis Ababa, Ethiopia.MethodsPopulation-based surveys were undertaken among over 1000 adolescents aged 10 to 19 years in slum areas of Addis Ababa, Ethiopia. An inventory of youth programs including youth centers and peer education programs was compiled in the study area.ResultsEight peer education programs and six youth centers were operating in the study area. Twenty percent of boys and only 7% of girls had visited a youth center in the last year; 27% of boys and 15% of girls had had contact with a peer educator. Older adolescents, especially boys, were more likely to utilize programs. Girls who work long hours and who are isolated are less likely to access and benefit from programs.ConclusionsGreater segmentation of the adolescent population is needed in the design and content of adolescent reproductive health programs. In addition, programmers should pay attention to the specific circumstances of young people in local settings, particularly vulnerable, hard-to-reach sub-groups of adolescents, including girls.     

The alcohol-related psychosocial and behavioral risks of a nationally representative sample of adolescents

This study, a secondary analysis of the National Longitudinal Study of Adolescent Health, used a representative sample of 7th-through 12th-grade students enrolled in US public schools between April and December 1995. Data were collected in respondents' homes using trained interviewers. A subset of 4,485 adolescents aged 12-17 were surveyed with regard to alcohol-use practices and related health-risk behavior, interpersonal problems, and demographic characteristics. Results showed adolescent males as significantly more likely to drink at high risk than adolescent females. Among those who drank one or more times in the past year, older adolescents were significantly more likely to report high-risk drinking than younger adolescents. Significantly more high-risk adolescents reported having a hangover, vomiting, regretting a behavior, having trouble with parents, regretting a sexual activity, having dating problems, fighting, having trouble with friends, and experiencing school trouble than did low-risk adolescents. These findings underscore the long-range significance of a coordinated school health program; in particular, school health services, school health instruction, and school health environment. Implications for school-based and community-based prevention and intervention programs are presented.     

School-based Prenatal Services

The purpose of this study is to evaluate whether enhancement of hospital-based prenatal care of adolescents results in pregnancy outcomes comparable to those found in adolescents receiving care at school-based clinics. An initial study comparing hospital clinic and school clinic programs administered by the St. Paul Maternal and Infant Care Project (MIC) from 1973–1976 indicated that delivered teens from the high school clinics had earlier and more frequent prenatal visits and fewer low birth weight babies than delivered adolescents who received care at hospital based clinics. After the initial study of 1976, MIC hospital based services for the adolescents were enhanced to include additional educational and support services.
A follow up study, (1976–1979) was subsequently conducted, using criteria similar to the previous study, to compare the results of hospital and school-based programs for pregnant teens. The follow up data demonstrated that the School Group initiated care much earlier and had significantly more prenatal visits than the Comparison Group, but the Comparison Group demonstrated a dramatic improvement in both areas when compared to the first study.
Rates of obstetrical complications and infant outcomes were more similar for both groups than in the initial study, supporting the premise that while the school provides a superior setting for provision of prenatal services, similar services at nonschool sites can be greatly enhanced and can demonstrate significant improvement in obstetrical outcomes.     

The role of the pediatrician in preventing suicide in adolescents with alcohol use disorders

Worldwide, suicide is among the top five causes of mortality in the 15- to 19- year age group. Pediatricians and primary care providers are in a distinctive position to help prevent suicide in adolescents. According to the Guidelines for Adolescent Preventive Services, all adolescents should have at least an annual preventive services visit, which should address both the biomedical and psychosocial aspects of health. Suicide prevention may best be accomplished by detection and management of specific risk factors, rather than by attempting to recognize those youth who are considered most likely to commit suicide. Alcohol use has been regarded as an important risk factor for adolescent suicidal behavior and the diagnosis of an alcohol use disorder indicates an elevated risk for adolescent suicide. Although the causal relationship between alcohol use and suicide remains unknown, a clear and strong relationship exists. Pediatricians and other health care providers should be skilled to recognize risk factors for adolescent suicide, including alcohol and drug misuse, depression, major loss, and recent suicides within a community. The relative frequency of suicidal behavior among adolescents suffering from alcohol use disorders and its distressing effects on individuals, families and society merits further research and development of prevention strategies in general pediatric settings.