Charles E. Irwin

Worldwide application of prevention science in adolescent health

The burden of morbidity and mortality from non-communicable disease has risen worldwide and is accelerating in low-income and middle-income countries, whereas the burden from infectious diseases has declined. Since this transition, the prevention of non-communicable disease as well as communicable disease causes of adolescent mortality has risen in importance. Problem behaviours that increase the short-term or long-term likelihood of morbidity and mortality, including alcohol, tobacco, and other drug misuse, mental health problems, unsafe sex, risky and unsafe driving, and violence are largely preventable. In the past 30 years new discoveries have led to prevention science being established as a discipline designed to mitigate these problem behaviours. Longitudinal studies have provided an understanding of risk and protective factors across the life course for many of these problem behaviours. Risks cluster across development to produce early accumulation of risk in childhood and more pervasive risk in adolescence. This understanding has led to the construction of developmentally appropriate prevention policies and programmes that have shown short-term and long-term reductions in these adolescent problem behaviours. We describe the principles of prevention science, provide examples of efficacious preventive interventions, describe challenges and potential solutions to take efficacious prevention policies and programmes to scale, and conclude with recommendations to reduce the burden of adolescent mortality and morbidity worldwide through preventive intervention.

Trends in Adolescent and Young Adult Health in the United States

This review presents a national health profile of adolescents and young adults (ages 10-24). The data presented include trends on demographics, mortality, health-related behaviors, and healthcare access and utilization, as well as the most significant gender and racial/ethnic disparities. Although the data show some improvement, many concerns remain. Encouraging trends-such as decreases in rates of homicide, suicide, and some measures of reproductive health-appear to be leveling off or, in some cases, reversing (e.g., birth and gonorrhea rates). Large disparities, particularly by race/ethnicity and gender, persist in many areas. Access to quality healthcare services remains a challenge, especially during young adulthood. Policy and research recommendations to improve health during these critical periods in the lifespan are outlined.

Sexually active adolescents and condoms: changes over one year in knowledge, attitudes and use.

Over a year when public health information regarding AIDS intensified, changes in perceptions and use of condoms in a sample of sexually active adolescents in San Francisco were examined. Although perceptions that condoms prevent sexually transmitted diseases (STDs) and the value and importance placed on avoiding STDs remained high, these were neither reflected in increased intentions to use condoms nor in increased use.

Preventive Care for Adolescents: Few Get Visits and Fewer Get Services

OBJECTIVE. Professional guidelines for adolescents recommend annual preventive visits with screening and anticipatory guidance for health-related behaviors. The objective of this study was to examine receipt of preventive services, including disparities in services received, by using a nationally representative sample of adolescents. METHODS. Using data from the 2001–2004 Medical Expenditure Panel Survey (ages 10–17; N = 8464), we examined receipt of preventive care visits and several measures of the content of care, based on caregivers reports, among adolescents who received a preventive care visit during the past 12 months. Content of care outcomes included physical parameters measurement (height, weight, and blood pressure); receipt of anticipatory guidance (dental care, seat belts, helmets, exercise, healthy eating, and secondhand smoke exposure); and, for 12- to 17-year-olds, whether adolescents had time alone with their provider during their most recent visit, a proxy for confidential services. We conducted logistic regression analyses to test for disparities in the outcomes on the basis of race/ethnicity, income, and insurance status. RESULTS. Thirty-eight percent of adolescents had a preventive care visit in the previous 12 months. Low-income and full-year uninsured status were associated with higher risk for not receiving this visit. Most adolescents had height (87%), weight (89%), and blood pressure (78%) assessed. Rates for height and weight were lower in poor and uninsured adolescents. Anticipatory guidance rates were much lower, ranging from 31% for seat belts, helmets, and secondhand smoke to 49% for healthy eating. Only 10% had all 6 areas addressed. Multivariate analyses yielded few disparities in receipt of anticipatory guidance. Forty percent had time alone with their providers. Hispanic and the lowest-income adolescents were the least likely to have time alone. CONCLUSIONS. Few adolescents received a preventive visit; among those who received this visit, provision of recommended anticipatory guidance was very low. Strategies are required to improve delivery of recommended preventive services to adolescents.

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

DATA COLLECTION/EXTRACTION METHODS National household survey. DATA SOURCES/STUDY SETTING We analyzed data on 12,434 adolescents (10 through 18 years old) included in the 1999 and 2000 editions of the National Health Interview Survey. STUDY DESIGN We assessed the presence of income gradients using four income groups. Outcome variables included health status, health insurance coverage, access to and satisfaction with care, utilization, and unmet health needs. PRINCIPAL FINDINGS After adjustment for confounding variables using multivariate analysis, statistically significant disparities were found between poor adolescents and their counterparts in middle- and higher-income families for three of four health status measures, six of eight measures of access to and satisfaction with care, and for six of nine indicators of access to and use of medical care, dental care, and mental health care. CONCLUSION Our analyses indicate adolescents in low-income families remain at a disadvantage despite expansions of the Medicaid program and the comparatively new State Childrens Health Insurance Program (SCHIP). Additional efforts are needed to ensure eligible adolescents are enrolled in these programs. Nonfinancial barriers to care must also be addressed to reduce inequities.

Theories of adolescent risk-taking behavior.

The study of adolescent risk-taking behavior gained prominence in the 1980s as it became increasingly evident that the majority of the morbidity and mortality during the second decade of life was behavioral in origin. The term risk-taking behavior has been used to link, conceptually, a number of potentially health-damaging behaviors including, among others, substance use, precocious or risky sexual behavior, reckless vehicle use, homicidal and suicidal behavior, eating disorders, and delinquency. The linkage of these behaviors under a single domain is theoretically useful because it allows for the investigation of particular behaviors in the context of other behaviors. The construct of risk-taking behavior also suggests a more parsimonious use of interventions, targeting groups of behaviors rather than applying multiple more narrowly targeted interventions.

Adolescent health insurance coverage: recent changes and access to care.

Objective. To assess the health insurance status of adolescents, the trends in adolescent health care coverage, the demographic and socioeconomic correlates of insurance coverage, and the role that insurance coverage plays in influencing access to and use of health care. Together, the results provide a current and comprehensive profile of adolescent health insurance coverage. Methods. We analyzed data on 14 252 adolescents, ages 10 to 18 years, included in the 1995 National Health Interview Survey. The survey obtained information on insurance coverage and several measures of access and utilization, including usual source of care, site of the usual source of care, indications of missed or delayed care, and use of ambulatory physician services by adolescents. We conducted multivariate analyses to assess the independent association of age, sex, race, poverty status, family structure, family size, region of residence, metropolitan resident status, and health status on the likelihood of insurance coverage. We conducted bivariate and multivariate analyses to ascertain how insurance coverage was related to each of the access and utilization measures obtained in the survey. We also examined trends in health insurance coverage using the 1984, 1989, and 1995 editions of the National Health Interview Survey. Results. An estimated 14.1% of adolescents were uninsured in 1995. Risk of being uninsured was higher for older adolescents, minorities, adolescents in low-income families, and adolescents in single parent households. Compared with their insured counterparts, uninsured adolescents were five times as likely to lack a usual source of care, four times as likely to have unmet health needs, and twice as likely to go without a physician contact during the course of a year. Between 1984 and 1995 the percentage of adolescents with some form of health insurance coverage remained essentially unchanged. During this period, the prevalence of private health insurance decreased, while the prevalence of public health insurance increased. Conclusions. This study demonstrates the critical importance of health insurance as a determinant of access to and use of health services among adolescents. It also shows that little progress has been made during the past 15 years in reducing the size of the uninsured adolescent population. The new State Childrens Health Insurance Program could lead to substantial improvements in access to care for adolescents, but only if states implement effective outreach and enrollment strategies for uninsured adolescents. adolescents, health insurance, access, Medicaid, SCHIP.

Initiation of substance use in early adolescence: the roles of pubertal timing and emotional distress.

Two hypotheses regarding the effects of pubertal timing on substance use were tested in a prospective study of 221 young adolescents. A maturational-deviance hypothesis predicted that early-maturing girls and late-maturing boys would experience heightened emotional distress, which in turn would influence initiation and use of substances. Alternatively, an early-maturation hypothesis predicted that early-maturing girls would engage in more substance use than all other groups, independent of emotional distress. Early-maturing adolescents reported more substance use within 1 year. Adolescents experiencing elevated levels of negative affect also reported greater substance use within the next year. However, pubertal timing was not related to emotional distress. Results support the early-maturation hypothesis for girls and suggest its extension to boys.

Validity of self-report of pubertal maturation in early adolescents

Abstract Self-report measures of sexual maturation continue to be used to classify pubertal development even though their reliability remains in question. This study examined the accuracy of self-report measures by early adolescents in two settings. Standardized figure drawings depicting Tanners sexual maturation scale (SMS) were shown to early adolescents at school (S 1 ) and again in a clinical sitting (S 2 ), and subjects were asked to rate their own pubertal development. Physical examination by a physician at S 2 was used to corroborate sexual maturation. Participating in the study were 46 males, age 11–14 years (mean, 12.4, SD, 1.9), and 37 females, age 11–14 years (mean, 12.7, SD, 0.7). Concordance rate between physical examination and self-report of pubic hair development (males) at S 1 was 58% (κ = 0.35, p 2 . Concordance rate of self-report of genital development at S 1 and S 2 was 27% (κ = − 0.06, p 1 and 72% (κ = 0.59, p 2 . Concordance rate for selfreport of pubic hair development in females was 58% at S 1 (κ = 0.42, p 2 (κ = 0.64, p

Autonomy, relatedness, and the initiation of health risk behaviors in early adolescence.

This study examined the relationships among sociodemographic characteristics, family processes, and the initiation of health risk behaviors in early adolescence. Subjects were 189 6th and 7th graders from a public middle school. A path-analytic model was used to analyze data. Results showed that students who received autonomy support from parents were less likely to initiate sexual intercourse. Students who were emotionally detached from their parents were more likely to fight and use substances. Those who were emotionally detached tended to come from families with low levels of cohesion and acceptance. Sociodemographic variables, such as family structure, gender, and ethnicity, had both direct and indirect effects on health risk behaviors, but the indirect effects were quite small.