Adolescent Health

Goal

Improve the healthy development, health, safety, and well-being of adolescents and young adults.

Overview

Adolescents (ages 10 to 19) and young adults (ages 20 to 24) make up 21 percent of the population of the United States. The behavioral patterns established during these developmental periods help determine young people's current health status and their risk for developing chronic diseases in adulthood.

Although adolescence and young adulthood are generally healthy times of life, several important public health and social problems either peak or start during these years. Examples include:

• Homicide
• Suicide
• Motor vehicle crashes, including those caused by drinking and driving
• Substance use and abuse
• Smoking
• Sexually transmitted infections, including human immunodeficiency virus (HIV)
• Teen and unplanned pregnancies
• Homelessness

Because they are in developmental transition, adolescents and young adults are particularly sensitive to environmental—that is, contextual or surrounding—influences. Environmental factors, including family, peer group, school, neighborhood, policies, and societal cues, can either support or challenge young people’s health and well-being. Addressing the positive development of young people facilitates their adoption of healthy behaviors and helps to ensure a healthy and productive future adult population.

Why Is Adolescent Health Important?

Adolescence is a critical transitional period that includes the biological changes of puberty and the need to negotiate key developmental tasks, such as increasing independence and normative experimentation.

There are many examples of effective policies and programs that address adolescent health issues. They include:

• State graduated driver licensing programs
• Teen pregnancy prevention programs
• Violence prevention programs
• Delinquency prevention programs
• Mental health and substance abuse interventions
• HIV prevention interventions

The financial burdens of preventable health problems in adolescence are large and include the long-term costs of chronic diseases that are a result of behaviors begun during adolescence. For example, the annual adult health-related financial burden of cigarette smoking, which usually starts by age 18, is $193 billion.

There are significant disparities in outcomes among racial and ethnic groups. In general, adolescents and young adults who are African American, American Indian, or Hispanic, especially those who are living in poverty, experience worse outcomes in a variety of areas (examples include obesity, teen pregnancy,tooth decay, and educational achievement) compared to adolescents and young adults who are white.

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Understanding Adolescent Health

The leading causes of illness and death among adolescents and young adults are largely preventable.3 Health outcomes for adolescents and young adults are grounded in their social environments and are frequently mediated by their behaviors. Behaviors of young people are influenced at the individual, peer, family, school, community, and societal levels.

As illustrated by the following examples of research findings, health outcomes are linked to multiple environmental factors.

Family

• Adolescents who perceive that they have good communication and are bonded with an adult are less likely to engage in risky behaviors.
• Parents who provide supervision and are involved with their adolescents' activities are promoting a safe environment in which to explore opportunities.
• The children of families living in poverty are more likely to have health conditions and poorer health status, as well as less access to and utilization of health care.

School

• Academic success and achievement are strong predictors of overall adult health outcomes. Proficient academic skills are associated with lower rates of risky behaviors and higher rates of healthy behaviors.
• High school graduation leads to lower rates of health problems and risk for incarceration,as well as enhanced financial stability during adulthood.
• The school social environment affects students' attendance,academic achievement, and behavior.A safe and healthy school environment promotes student engagement and protects against risky behaviors and dropping out.

Neighborhoods

Adolescents growing up in distressed neighborhoods characterized by concentrated poverty are at risk for a variety of negative outcomes, including poor physical and mental health, delinquency, and risky sexual behavior.

Media Exposure

Adolescents who are exposed to media portrayals of violence, sexual content, smoking, and drinking are at risk for adopting these behaviors.

Emerging Issues in Adolescent Health

Two important issues influence how adolescent health will be approached in the coming decade. First, the adolescent population is becoming more ethnically diverse, with rapid increases in the numbers of Hispanic and Asian American youth. The growing ethnic diversity will require cultural responsiveness to health care needs and sharpened attention to disparate health and academic outcomes, which are correlated with poverty, especially among adolescents from minority racial and ethnic groups.2, 46

The second emerging issue is the increased focus on the use of positive youth development interventions for preventing adolescent health risk behaviors.47, 48 Youth development interventions can be briefly defined as the intentional process of providing all youth with the support, relationships, experiences, resources, and opportunities needed to become successful and competent adults.49 There is growing empirical evidence that well-designed youth development interventions can lead to positive outcomes. Ongoing, rigorous evaluation will determine what works, why it works, and how successful interventions can be applied.49

References

1U.S. Census Bureau. 2008 population estimates: National characteristics, national sex, age, race and Hispanic origin. Washington: 2008. Available from:http://www.census.gov/popest/national/asrh/NC-EST2008-asrh.html

2National Research Council and Institute of Medicine. Committee on Adolescent Health Care Services and Models of Care for Treatment, Prevention, and Healthy Development. Adolescent health services: Missing opportunities. Lawrence RS, Gootman JA, Sim LJ, editors. Washington: National Academies Press, 2009. Available from:http://books.nap.edu/openbook.php?record_id=12063&page=1 

3Mulye TP, Park MJ, Nelson CD, et al. Trends in adolescent and young adult health in the United States. J Adolesc Health. 2009;45(1):8-24. Available from: http://download.journals.elsevierhealth.com/pdfs/journals/1054-139X/PIIS1054139X09001244.pdf 

4National Research Council, Panel on High-Risk Youth, Commission on Behavioral and Social Sciences and Education. Losing generations: Adolescents in high-risk settings. Washington: National Academies Press; 1993. Available from: http://www.nap.edu/openbook.php?record_id=2113&page=1 

5McNeely C, Blanchard J. The teen years explained: A guide to healthy adolescent development. Baltimore: Johns Hopkins Bloomberg School of Public Health, Center for Adolescent Health; 2009. Available from: http://www.jhsph.edu/adolescenthealth 

6Halfon N, Hochstein M. Life course health development: An integrated framework for developing health, policy and research. Milbank Q. 2002;80(3):433-79. Available from: http://www.milbank.org/quarterly/8003feat.html 

7National Research Council, Institute of Medicine, and Transportation Research Board; Committee for a Workshop on Contributions from the Behavioral and Social Sciences in Reducing and Preventing Teen Motor Crashes. Preventing teen motor crashes: Contributions from the behavioral and social sciences, workshop report. Washington: National Academies Press; 2007. Available from:http://www.nap.edu/openbook.php?record_id=11814&page=1 

8Department of Health and Human Services (HHS), Office of Public Health and Science, Office of Adolescent Health. Overview of the teen pregnancy prevention research evidence review. Washington: HHS; 2010. Available from:http://www.hhs.gov/ash/oah/prevention/research/index.html

9National Campaign to Prevent Teen and Unplanned Pregnancy. Effective program research [Internet]. Washington: National Campaign to Prevent Teen and Unplanned Pregnancy; 2010. Available from: http://www.thenationalcampaign.org/resources/effective_programs.aspx 

10Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control [Internet]. Best practices of youth violence prevention: A sourcebook for community action. Atlanta: CDC; 2002. Available from:http://www.cdc.gov/violenceprevention/pub/YV_bestpractices.html

11Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. STRYVE: Striving to reduce youth violence everywhere [homepage on the Internet]. Atlanta: CDC. Available from: http://www.safeyouth.gov 

12University of Colorado, Institute of Behavioral Science, Center for the Study and Prevention of Violence. Blueprints for violence prevention [homepage on the Internet]. Boulder, CO: University of Colorado; 1996–2010. Available from:http://www.colorado.edu/cspv/blueprints/index.html 

13Centers for Disease Control and Prevention. The effectiveness of universal school-based programs for the prevention of violent and aggressive behavior: A report on recommendations of the Task Force on Community Preventive Services. MMWR. 2007;56(RR-7):1-12. Available from: http://www.cdc.gov/mmwr/PDF/rr/rr5607.pdf

14Interagency Working Group on Youth Programs. Evidence-based program directory [Internet]. Washington: Interagency Working Group on Youth Programs; 2008. Available from: http://www.findyouthinfo.gov/ProgramSearch.aspx 

15Substance Abuse and Mental Health Services Administration (SAMHSA). National registry of evidence-based programs and practices [homepage on the Internet]. Rockville, MD: SAMHSA; 2010. Available from: http://www.nrepp.samhsa.gov/

16National Research Council and Institute of Medicine, Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. Preventing mental, emotional and behavioral disorders among young people—Progress and possibilities. O'Connell ME, Boat T, Warner KE, editors. Washington: National Academies Press; 2009. Available from: http://books.nap.edu/catalog.php?record_id=12480 

17Centers for Disease Control and Prevention (CDC), National Center for HIV, STD, and TB Prevention, HIV/AIDS Prevention Research Synthesis Project. Compendium of HIV prevention interventions with evidence of effectiveness. Atlanta: 2001. Available from:http://www.cdc.gov/hiv/resources/reports/hiv_compendium/pdf/HIVcompendium.pdf

18National HIV/AIDS Strategy. Washington: The White House; 2010. Available from: http://aids.gov/federal-resources/policies/national-hiv-aids-strategy/nhas.pdf

19Schoenborn CA, Vickerie JL, Barnes PM. Cigarette smoking behavior of adults: United States, 1997–98. Advance Data from Vital and Health Statistics, Number 331; 2003 Feb 7. Hyattsville, MD: National Center for Health Statistics. Available from:http://www.cdc.gov/nchs/data/ad/ad331.pdf

20SAMHSA, Office of Applied Studies. Results from the 2007 National Survey on Drug Use and Health: National findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343), Rockville, MD: Substance Abuse and Mental Health Administration; 2008. Chapter 5: Initiation of Substance Use. Available from: http://www.oas.samhsa.gov/nsduh/2k7nsduh/2k7results.cfm

21Adhikari B, Kahende J, Malarcher A, et al. Smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 2000–2004. MMWR. 2008;57(45):1226-8. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.htm

22Ogden, CL, Carroll MD, Curtin, LR, et al. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA. 2010;303(93):242-9. Available from: http://jama.ama-assn.org/cgi/reprint/303/3/242 

23Robert Wood Johnson Foundation (RWJF), Leadership for Healthy Communities. Overweight and obesity among American Indian and Alaska Native youths [fact sheet]. Princeton, NJ: RWJF; 2010. Available from: http://www.rwjf.org/files/research/20100512lhcamerindian.pdf 

24Centers for Disease Control and Prevention (CDC), Division of Reproductive Health. Preventing teen pregnancy 2010-2015. Atlanta: CDC; 2010. Available from: http://www.cdc.gov/TeenPregnancy/PDF/TeenPregnancy_AAG.pdf

25Centers for Disease Control and Prevention (CDC), Division of Oral Health. Disparities in oral health. Atlanta: CDC; 2009. Available from:http://www.cdc.gov/oralhealth/oral_health_disparities.htm

26Freudenberg N, Ruglis J. Reframing school dropout as a public health issue. Prev Chronic Dis. 2007;4(4):1-11. Available from:http://www.cdc.gov/pcd/issues/2007/oct/pdf/07_0063.pdf

27Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health. JAMA. 1997;278(10):823-32. Available from: http://jama.ama-assn.org/cgi/reprint/278/10/823 

28Aufseeser D, Jekielek S, Brown B. The family environment and adolescent well-being: Exposure to positive and negative family influences. Washington: Child Trends; and San Francisco: National Adolescent Health Information Center, University of California, San Francisco; 2006. Available from: http://www.childtrends.org/Files/Child_Trends-2006_06_01_FR_FamilyEnvironmen.pdf 

29Larson K, Halfon, N. Family income gradients in the health and health care access of US children. Matern Child Health J. 2010;14(3):332-42. Available from: http://www.springerlink.com/content/g1g387152516738r/fulltext.pdf 

30Marin P, Brown B. The school environment and adolescent well-being: Beyond academics. [Research Brief]. Washington, DC: Child Trends; 2008 (publication #2008-26). Available from: http://www.childtrends.org/Files/Child_Trends-2008_11_14_RB_SchoolEnviron.pdf 

31SAMHSA Office of Applied Studies. The NSDUH Report: Youth activities, substance use, and family income. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2007. Available from: http://oas.samhsa.gov/2k7/youthActs/youthActs.htm

32Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Healthy youth! Student health and academic achievement. Atlanta: CDC; 2010. Available from:http://www.cdc.gov/HealthyYouth/health_and_academics/index.htm#2

33Wong MD, Shapiro MF, Boscardin W, et al. Contribution of major diseases to disparities in mortality. N Engl J Med. 2002;347(20):1585-92. Available from: http://www.nejm.org/doi/pdf/10.1056/NEJMsa012979 

34Muennig P, Woolf SH. Health and economic benefits of reducing the number of students per classroom in US primary schools. Am J Public Health. 2007;97(11):2020-7. Available from: http://ajph.aphapublications.org/cgi/reprint/97/11/2020 

35Muennig P. The economic value of health gains associated with education interventions. [Paper prepared for the Equity Symposium on "The Social Costs of Inadequate Education" at Teachers College, October 24–25]. New York: Columbia University; 2005. Available from:http://www.schoolfunding.info/news/policy/Muennig%20-%20Health%20and%20Education.pdf 

36Lochner L. Education policy and crime. Working Paper 15894. Cambridge, MA: National Bureau of Economic Research; 2010. Available from: http://economics.uwo.ca/faculty/lochner/papers/educationpolicycrime_mar10.pdf  or http://www.nber.org/papers/w15894 

37Sum A, Khatiwada I, McLaughlin J. The consequences of dropping out of high school: Joblessness and jailing for high school dropouts and the high cost for taxpayers. Boston: Center for Labor Market Studies, Northeastern University; 2009. Available from:http://www.americaspromise.org/~/media/Files/Resources/Consequences_of_Dropping_Out_of_High_School.ashx 

38Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2009. Surveillance summaries, June 4, 2010. MMWR. 59(SS-5):8. Available from: http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf

39Sellstrom E, Bremberg S. Is there a "school effect" on pupil outcomes? A review of multilevel studies. J Epidemiol Community Health. 2006;60(2):149-55. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2566146/pdf/149.pdf

40Blum RW, McNeely C, Nonnemaker J. Vulnerability, risk and protection. In: Adolescent risk and vulnerability: Concepts and measures. Fischhoff B, Nightingale EO, Iannotta JG, editors. Board on Children, Youth and Families, National Research Council and Institute of Medicine. Washington: The National Academies Press; 2001. Available from: http://www.nap.edu/catalog.php?record_id=10209 

41Bontempo DE, D'Augelli AR. Effects of at-school victimization and sexual orientation on lesbian, gay, or bisexual youths' health risk behavior. J Adolesc Health. 2002;30(5):364-74. Available from: http://download.journals.elsevierhealth.com/pdfs/journals/1054-139X/PIIS1054139X01004153.pdf 

42Henderson M, Ecob R, Wight D, et al. What explains between-school differences in rates of smoking? BMC Public Health. 2008;8:218. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442834/pdf/1471-2458-8-218.pdf or http://www.biomedcentral.com/1471-2458/8/218 

43Aveyard P, Markham WA, Lancashire E, et al. The influence of school culture on smoking among pupils [abstract]. Soc Sci Med. 2004;58(9):1767-80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14990377

44Leventhal T, Brooks-Gunn J. Diversity in developmental trajectories across adolescence: Neighborhood influences. Chapter 15 in Handbook of Adolescent Psychology (pp 451-86), 2nd ed. Lerner RM, Steinberg L, editors. Hoboken, NJ: John Wiley & Sons, Inc.; 2004.

45Roberts DF, Henriksen L, Foehr UG. Adolescents and media. Chapter 16 in Handbook of Adolescent Psychology (pp 487-521), 2nd ed. Lerner RM, Steinberg L, editors. Hoboken, NJ: John Wiley & Sons, Inc.; 2004.

46Ozer EM, Park MJ, Paul T, et al. America's adolescents: Are they healthy? San Francisco: University of California-SF, National Adolescent Health Information Center; 2003. Available from: http://staff.imsa.edu/wellness/AA_2003.pdf 

47Birkhead GS, Riser MH, Mesler K, et al. Youth development is a public health approach. J Public Health Manag Pract. 2006;12(suppl 6):S1-S3. Available from: http://journals.lww.com/jphmp/Fulltext/2006/11001/Youth_Development_Is_a_Public_Health_Approach.1.aspx 

48Centers for Disease Control and Prevention. Positive youth development promoting adolescent sexual and reproductive health: A review of observational and intervention research. J Adolesc Health. 2010 Mar;46(3 suppl). Available from: http://jahonline.org/issues/contents?issue_key=S1054-139X(10)X0003-9 

49Bernat DH, Resnick MD. Healthy youth development: Science and strategies. J Public Health Manag Pract. 2006;12(suppl 6):S10-S16. Available from: http://journals.lww.com/jphmp/Fulltext/2006/11001/Healthy_Youth_Development__Science_and_Strategies.4.aspx 

Access to Health Services

Goal

Improve access to comprehensive, quality health care services.

Overview

Access to comprehensive, quality health care services is important for the achievement of health equity and for increasing the quality of a healthy life for everyone. This topic area focuses on four components of access to care: coverage, services, timeliness, and workforce.

Why Is Access to Health Services Important?

Access to health services means the timely use of personal health services to achieve the best health outcomes.1 It requires 3 distinct steps:

1. Gaining entry into the health care system.
2. Accessing a health care location where needed services are provided.
3. Finding a health care provider with whom the patient can communicate and trust.2

Access to health care impacts:

• Overall physical, social, and mental health status
• Prevention of disease and disability
• Detection and treatment of health conditions
• Quality of life
• Preventable death
• Life expectancy

Disparities in access to health services affect individuals and society. Limited access to health care impacts people's ability to reach their full potential, negatively affecting their quality of life. Barriers to services include:

• Lack of availability
• High cost
• Lack of insurance coverage

These barriers to accessing health services lead to:

• Unmet health needs
• Delays in receiving appropriate care
• Inability to get preventive services
• Hospitalizations that could have been prevented 3

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Understanding Access to Health Services

Access to health services encompasses four components: coverage, services, timeliness, and workforce.

Coverage

Health insurance coverage helps patients get into the health care system. Uninsured people are:

• Less likely to receive medical care
• More likely to die early
• More likely to have poor health status

Lack of adequate coverage makes it difficult for people to get the health care they need and, when they do get care, burdens them with large medical bills. Current policy efforts focus on the provision of insurance coverage as the principal means of ensuring access to health care among the general population. Other factors, described below, may be equally important to removing barriers to access and utilization of services.

Services

Improving health care services depends in part on ensuring that people have a usual and ongoing source of care. People with a usual source of care have better health outcomes and fewer disparities and costs.

Having a primary care provider (PCP) as the usual source of care is especially important. PCPs can develop meaningful and sustained relationships with patients and provide integrated services while practicing in the context of family and community.Having a usual PCP is associated with:

• Greater patient trust in the provider
• Good patient-provider communication
• Increased likelihood that patients will receive appropriate care

Improving health care services includes increasing access to and use of evidence-based preventive services. Clinical preventive services are services that:

• Prevent illness by detecting early warning signs or symptoms before they develop into a disease (primary prevention).
• Detect a disease at an earlier, and often more treatable, stage (secondary prevention).15

In addition to primary care and preventive services, emergency medical services (EMS) are a crucial link in the chain of care. EMS include basic and advanced life support.16 Within the last several years, complex problems facing the emergency care system have emerged.17 Ensuring that all persons have access to rapidly responding, prehospital EMS is an important goal in improving the health of the population.

Timeliness

Timeliness is the health care system's ability to provide health care quickly after a need is recognized. Measures of timeliness include:

• Time spent waiting in doctors' offices and emergency departments (EDs)
• Time between identifying a need for specific tests and treatments and actually receiving those services

Actual and perceived difficulties or delays in getting care when patients are ill or injured likely reflect significant barriers to care. Prolonged ED wait time:

• Decreases patient satisfaction.
• Increases the number of patients who leave before being seen.
• Is associated with clinically significant delays in care.

Causes for increased ED wait times include an increase in the number of patients going to EDs, with much of the increase due to visits by less acutely ill patients. At the same time, there is a decrease in the total number of EDs in the United States.

References

1Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Millman M, editor. Washington: National Academies Press; 1993.

2Bierman A, Magari ES, Jette AM, et al. Assessing access as a first step toward improving the quality of care for very old adults. J Ambul Care Manage. 1998 Jul;121(3):17-26.

3Agency for Healthcare Research and Quality (AHRQ). National healthcare disparities report 2008. Chapter 3, Access to healthcare. Washington: AHRQ; 2008. Available from: http://www.ahrq.gov/qual/nhdr08/Chap3.htm

4Hadley J. Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition. JAMA. 2007;297(10):1073-84.

5Insuring America's health: Principles and recommendations. Acad Emerg Med. 2004;11(4):418-22.

6Durham J, Owen P, Bender B, et al. Self-assessed health status and selected behavioral risk factors among persons with and without healthcare coverage—United States, 1994-1995. MMWR. 1998 Mar;13;47(9):176-80.

7Starfield B, Shi L. The medical home, access to care, and insurance. Pediatrics. 2004;113(5 suppl):1493-8.

8De Maeseneer JM, De Prins L, Gosset C, et al. Provider continuity in family medicine: Does it make a difference for total health care costs? Ann Fam Med. 2003;1:144-8.

9US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2010, 2nd ed. With understanding and improving health and objectives for improving health. 2 vols. Washington: Government Printing Office; Nov 2000, p.45. Available from: http://www.healthypeople.gov

10Institute of Medicine. Primary care: America's health in a new era. Donaldson MS, Yordy KD, Lohr KN, editors. Washington: National Academies Press; 1996.

11Mainous AG 3rd, Baker R, Love MM, et al. Continuity of care and trust in one's physician: Evidence from primary care in the United States and the United Kingdom. Fam Med. 2001 Jan;33(1):22-7.

12Starfield B. Primary care: Balancing health needs, services and technology. New York: Oxford University Press; 1998.

13National Commission on Prevention Priorities. Preventive care: A national profile on use, disparities, and health benefits. Washington, DC: Partnership for Prevention; Aug 2007.

14National Commission on Prevention Priorities. Data needed to assess use of high-value preventive care: A brief report from the National Commission on Prevention Priorities. Washington: Partnership for Prevention; Aug 2007.

15Rose DJ, Lantz PM, House JS, et al. Health care access and the use of clinical preventive services. Paper presented at: Annual Meeting of the American Sociological Association; 2006 Aug 10; Montreal, Quebec. Available from:http://www.uspreventiveservicestaskforce.org/uspstf08/methods/procmanual.htm 

16Massachusetts General Hospital (MGH), Department of Emergency Medicine. Prehospital care: Emergency medical service [Internet]. Boston: MGH; 2010. Available from: http://www.mgh.harvard.edu/emergencymedicine/services/treatmentprograms.aspx?id=1433 

17Institute of Medicine (IOM). Future of emergency care series: Emergency medical services: At the crossroads. Washington: IOM; 2006.

18Agency for Healthcare Research and Quality. National healthcare disparities report 2008 [Internet]. Washington: Agency for Healthcare Research and Quality; 2008. Chapter 3, Access to healthcare. (AHRQ publication; no. 09-0002). Available from:http://www.ahrq.gov/qual/nhdr08/Chap3.htm

19Hsai RY, Tabas JA. The increasing weight of increasing waits. Arch Intern Med. 2009 Nov 9;169(20):1826-1932.

20Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005: Trends in primary care specialties. JAMA. 2005 Sep 7;294(9):1075-82.