Issues in Adolescent Health

1. Issues in Adolescent Health Kathleen Rounds, Ph.D. Maria Gallo, MSW/MPH Jenny Nicholson, MSW StudentUniversity of North Carolina, Chapel Hill

2. Health Status Overview According to the US Census Bureau, there are about 39.3 million adolescents living in the US. Adolescence (ages 10-19) is the transitional stage between childhood and adult life. As one of the most dynamic stages of human development, adolescence is a time of profound physical, cognitive, emotional and social changes.

3. Poverty Statistics Poverty is the most influential factor affecting adolescent health (Klein, Slap, Elster, and Schonberg, 1992). According to the Children�s Defense Fund, 16.9% of children under 18 are poor.

4. Poverty and Race US poverty rates vary according to race and ethnicity: 13.1% of white children are poor. 33.1% of black children are poor. 30.3% of Hispanic children are poor. 11.8% of Asian/Pacific Islander children are poor. Children�s Defense Fund

5. Health Insurance According to the 1996 Medical Expenditure Panel Survey, conducted by the Agency for Health Care Policy and Research: 63.9% of children had private health insurance. 20.8% had public coverage. 15.4% of American children had no insurance.

6. Health Insurance (cont.) An estimated 20% of adolescents (10-18) have no health insurance. Maternal and Child Health Bureau, 1998. 90% of uninsured children live in households with a working adult. Medical Expenditure Panel Survey, 1996. Adolescents from low-income families (<$35,000/year) are nearly seven times as likely to be in fair or poor health than those from higher-income families. Singer & Hussey, 1995.

7. Health Insurance and Race The Medical Expenditure Panel Survey also found that insurance coverage varied according to race and ethnicity: 27.7% of Hispanic children were uninsured. 17.6% of black children were uninsured. 12.3% of white children were uninsured.

8. Adolescents&Sexual Behavior

9. Trends in Sexual Behaviors The 1999 CDC Youth Risk Behavior Surveillance Survey (YRBSS) found that 49.9% of high school students reported having sexual intercourse: 38.6% of 9th graders 64.9% of 12th graders 52.2% of males (down from 57.4% in 1991). 47.7% of females (down from 50.8% in 1991)

10. Adolescents and Safe Sex The 1999 YRBSS also indicated that 42% of sexually active high school students had not used a condom during their last incident of sexual intercourse.

11. Adolescent Pregnancy

12. Trends in Teen Pregnancy More than 1 million US adolescent females become pregnant each year, which is the highest rate among developed nations. Maternal and Child Health Bureau, 1998. According to a 1998 Children�s Defense Fund report, 1 in 8 babies is born to an adolescent mother. US adolescent birth rates declined 1/4th, from 39 to 29 births per 1000, between 1991 and 1999. The 1999 rate is a record low for the US. America�s Children, 2001.

13. Conditions Associated with Adolescent Childbearing Having economically disadvantaged families and communities Performing poorly in school and holding low aspirations for their own educational achievement Having dysfunctional families Having substance abuse and behavioral problems. KIDS COUNT Data Book, 2001.

14. Adolescent Pregnancy and Poverty �A child born to an unmarried, teenage high school dropout is 10 times as likely to be living in poverty as a child born to a mother with none of these characteristics.� KIDS COUNT Data Book, 2001

15. Sexually Transmitted Infections&HIV

16. Trends About 3 million adolescents contract an STI each year. YRBSS, 1999. Each year, young people (ages 5-24) account for 25% of new HIV cases and 25% of the new cases of STIs. CDC Adolescent &School Health Data. Among youth (5-24), HIV infection accounted for 2% of all deaths in 1998. YRBSS. 1999. HIV infection was the 6th leading cause of death in young adults (15-24) in 1997. Health & Human Services Press Release.

17. Substance Use and Abuse

18. Cigarette Use According to the 2000 �Monitoring the Future� survey, 31.4% of 12th graders and 14.6% of 8th graders reported smoking during the previous month. Daily smoking rates varied by ethnicity: 26% of whites 16% of Hispanics 8% of blacks

19. Cigarette Use and Drugs The 1999 National Household Survey on Drug Abuse (NHSDA) found that, among youths aged 12 to 17 years, 41.1% of past month smokers reported past month use of an illicit drug, compared to only 5.6% of adolescent non-smokers.

20. Alcohol Use The 2000 �Monitoring the Future� survey found that 73.2% of high school seniors reported the use of alcohol within the past year. The study also found that 8.3% of 8th graders and 23.5% of 10th graders (the highest level since 1991) reported having been drunk within the last month. Youth who start to drink before the age of 15 are 4 times as likely to develop alcohol dependence as people who began drinking at 21 National Longitudinal Alcohol Epidemiological Survey (NLAES)

21. Alcohol Use, Race, and Gender The federal government�s 2001 �America�s Children� report indicates that heavy drinking varies according to ethnicity and gender. For example, among 12th graders: 35% of whites 31% of Hispanics 12% of blacks 37% of males 24% of females

22. Adolescent Drug Use In the 1999 NHSDA, 10.9% of youth ages 12-17 reported illicit drug use in the past month. In the same study, 7.7% reported marijuana use within the past month. The 2000 �Monitoring the Future� survey found that 5% of 12th graders reported using cocaine at least once. 1.1% of 8th and 1.5% of 12th graders reported having used heroin in the past month.

23. Drugs: Perceived Behavior Risk 31% of youth (12-17) surveyed in the 1999 NHSDA consider the use of marijuana once a month to be a great risk. 50% of these surveyed youth consider the use of cocaine once a month to be a great risk. This is a decrease from 72% in 1990.

24. Access to Controlled Substances In the US Justice Dept�s 1993 National Household Education survey, 29% of the students reported easy access to beer, wine, or marijuana at school. 26% reported easy access to liquor. 22% reported easy access to other drugs. The students who reported easy access to controlled substances at school were more likely than others to know of violence at school.

25. Adolescents and Violence

26. Homicides According to the CDC National Vital Statistics System, in 1998 the firearm homicide rate for adolescents (ages 15-19) was 9.6/100,000 deaths, making homicide the 2nd leading cause of death. This rate does represent a decrease from the 1995 rate of 15.4/100,000 deaths. Among young people (ages 5-24), homicide cause 20% of all deaths.

27. Homicides, Race, and Gender The 1995 firearm homicide rate varied according to race and gender: White males � 3.4 per 100,000 deaths Black males � 63.5 per 100,000 deaths White females � 1.0 per 100,000 deaths Black females � 6.7 per 100,000 deaths. �America�s Children,� 2001

28. Adolescent Suicide Between 1991 and 1999, the percentage of teens who had seriously considered attempting suicide declined from 29% to 19.3%. 1999 YRBSS 1,450 youth (less than 20 years old) died in firearm suicides in 1995. Children�s Defense Fund

29. Suicide, Race & Gender The 1999 YRBSS found that the percentage of teens who had seriously considered attempting suicide during the previous year varied by race and gender: Male � 13.7% Female � 24.9% White � 17.6% Black � 15.3% Hispanic � 19.9%

30. Suicide, Race & Gender (cont.) The percentage of adolescents who had actually attempted suicide during the previous year also varied according to race and gender: Male � 5.7% Female � 10.9% White � 6.7% Black � 7.3% Hispanic � 17.7% 1999 YRBSS

31. Juvenile Violent Crime Rate The rate of juveniles arrested for violent crimes decreased from 503 arrests per 100,000 juveniles in 1993 to 394 per 100,000 in 1998. 2001 KIDS COUNT Profile for the US According to the 1999 YRBSS, 11% of male and 2.8% of female students (grades 9-12) reported carrying a weapon (razor, knife, club or firearm) at least once during the previous month.

32. Adolescents&Unintentional Injury

33. Trends Unintentional injury is the leading cause of adolescent mortality and accounts for more deaths than all other causes combined. 2001 KIDS COUNT Data Book Among young people (ages 10-24), motor vehicle accidents cause 31% of all deaths. 1999 YRBSS Among young people (10-24) other injuries (falls, fires, drowning, etc.) cause 11% of all deaths. 1999 YRBSS

34. Safety Measures The 1999 YRBSS reported that 16.4% of the high school students surveyed rarely or never wore a seatbelt. In this same survey, 33.1% of students reported, during the previous month, riding with a driver who had been drinking alcohol. Half of the motor vehicle deaths among youth (5-24) are alcohol-related. CDC Adolescent & School Health Data. In the 1999 YRBSS, 85.3% of students who rode bicycles during the preceding year reported rarely or never wearing a bicycle helmet.

35. Access to Health Care

36. Recommendations A position paper by the Society for Adolescent Medicine identified 7 criteria for evaluating adolescents� access to health care: Availability Visibility Quality Confidentiality Affordability Flexibility Coordination

37. Availability: Recommendations Health care providers and age-appropriate services should be available in all communities. Clinic location and hours of operation should allow for adolescent attendance. Health care services should be available in a variety of settings: community health centers, school-based and school-linked health centers, family planning clinics, physicians� offices, etc.

38. Availability: Current Status The lack of available health care services and transportation are serious problems for rural youth (Klein, et al., 1992). Low physician participation in Medicaid can limit health care availability for adolescents enrolled in Medicaid. The �Healthy Schools, Healthy Communities� is a program designed to increase young people�s access to health care.

39. Visibility: Recommendations Health services should be convenient and recognizable � access should not require extensive planning by the adolescent. Health services should include outreach to educate adolescents both on the use of health services and about the importance of preventive health care. (Klein, et al., 1992)

40. Visibility: Current Status The Medical Expenditure Panel Survey of the Agency for Health Care Policy and Research estimates that more than one million children (age 13 or older) are eligible for Medicaid but are not enrolled in the program.

41. Quality: Recommendations Service providers should have a basic level of competence regarding adolescent health. Adolescents should be satisfied with the quality of care they receive.

42. Quality: Current Status There is a lack of providers trained in adolescent health care. Only 11 states mandate that insurance programs include preventive care for children. (Klein et al., 1992). 97.5% of children with a usual source of health care reported being �somewhat� or �very� satisfied with their care. Agency for Health Care Research and Quality Research Findings

43. Confidentiality: Recommendations Generally, adolescents should be encouraged to involve their families in their health concerns. Confidentiality, should, however, be assured to those adolescents who choose not to involve their family.

44. Confidentiality: Current Status Confidentiality issues can prevent insured adolescents from using their parents� insurance policies. The Society for Adolescent Medicine has developed a position paper on confidentiality and adolescent health care.

45. Affordability: Recommendations Insurance programs should include preventive services and should allow for additional time and intensity to meet adolescent-specific health care needs. Employer insurance companies should include adolescents as employees or as dependents.

46. Affordability: Current Status 60% of families who lack health care cite affordability as their primary barrier. 27% of uninsured children do not have a usual source of health care. Uninsured children are 9 times more likely to have no usual source of health care than insured children. The health insurance of many adolescents does not cover counseling, substance abuse treatment, or preventive care. Medicaid and the Children�s Health Insurance Program are both federal programs that provide insurance coverage for adolescents from low-income families. �America�s Children 2001�

47. Flexibility: Recommendations Cultural, ethnic, and social diversity factors should be considered when providing care to adolescents. Providers should assist in the transition between receiving pediatric and adult health care services.

48. Flexibility: Current Status The Institute of Medicine found that some adolescents enrolled in Medicaid cannot access health care because of barriers created by cultural, geographical, or racial differences. Klein et al, 1992

49. Coordination: Recommendations Service providers should ensure that comprehensive services (e.g., medical, mental health, and social services) are provided to adolescents. Service providers should coordinate services when adolescents have to access multiple service sites.

50. Coordination: Current Status Adolescent health care is often fragmented and office visits often problematic. 49% of adolescent visits with physicians are 10 minutes or less in duration. 30% of adolescent visits are 11-15 minutes in duration. The current patchwork system of services may delay or prevent adolescents from accessing care. But, by 1989, 50% of the state Maternal and Child Health offices had adolescent health coordinators. (Klein et al., 1992).