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Adolescent Health: So Many Teens; So Little CareAlthough teenagers usually appear to have healthy bodies adults envy, adolescents are not immune to health problems. They may have unrecognized eating disorders, substance abuse problems, and mental health disorders. They may be experimenting with potentially risky behaviors including smoking and sexual activity. Additionally, health habits such as healthful eating, exercise, and self-care begin in adolescence as teens prepare for their future independence. Teenage weight gain, lack of exercise, and excessive TV time have become very common problems and their effects can last a lifetime. So, while teens may not need to see a doctor for aches, pains, or fevers, they desperately need the surveillance and education that regular medical care provides.
The American Academy of Pediatrics, the American Medical Association, and the American Academy of Family Practice all recommend yearly check-ups for all adolescents until their 21st birthday. Such visits would include a full history and examination, and age specific counseling about healthful habits and potentially risky behaviors. Optimally, at least part of the visit would be conducted without the presence of the parent, to provide an opportunity for open discussion of drug and alcohol use, sexuality and sexual activity, smoking and other sensitive topics. Additionally, recent changes in immunization policy have made some newer vaccines available to adolescents including the human papilloma vaccine and the meningococcal vaccine. Anecdotally, it appears that adolescents do not visit their doctors every year, possibly because they assume the sports physical at their school is an adequate visit, they don't have health insurance, and they feel and appear healthy and therefore do not seek medical care.
A recent study published in the April issue of Pediatrics assessed whether adolescents were actually getting the recommended medical care, both in frequency of annual visits, and in the nature of the visits themselves. These studies confirmed informal observations: In fact, teens are not seeing their doctors nearly often enough and those that are often don't receive all the recommended components of the visit.
The researchers investigated the frequency and the kind of care of a group of 10-17 year olds received from 2001 to 2004. They obtained their information on the number of adolescent visits from a medical expenditure survey performed by an organization that estimates health care use, insurance coverage and medical expenses for the US population. They then interviewed the teens' caregivers to find out the nature and content of the visits. Specific physical exam items included measurement of height, weight, and blood pressure. Specific counseling items included discussion of dental care, seat belt and sports helmet use, healthy eating and exercise, and second hand smoke exposure. The researchers asked whether the teens, ages 12-17, had had any time alone with the health care provider during the visit. They also looked for differences in services provided to different ethnicities and income groups, and to patients with public, private or no health insurance.
The initial study group of 8464 teens was used to determine the frequency of health care visits. This group yielded 3038 teens that had had primary care visits that could then be evaluated for their content. Their finding supported their concerns. The study revealed that that only 38% of the adolescents had had a preventive care visit in the preceding 12 months. In the initial study group of 8464, 35% percent of the African Americans, 31% of the Hispanics, and 41% of the white adolescents had preventive care visits. Low income and being uninsured decreased the likelihood of having a medical visit.
Evaluation of the content of the visit revealed that 87% had height, 89% had weight and 78% had blood pressure measured. Height and weight measurements were lowest in the low income and uninsured groups and in the Hispanic patients. Questions on counseling practices revealed that 31% of visits included discussions of seatbelt, helmet use and second hand smoke, 49% included healthy eating and in only 10% of visits were all six recommended areas discussed. Hispanic patients were more likely to be counseled on all six topics. Forty percent of patients had time alone with their health care provider and the groups least likely to obtain this privacy were the Hispanic and low income adolescents. The investigators also explored whether the ethnicity of the care provider influenced their exam and counseling practices and found that African American, Hispanic, and white caregivers were all similar in their adolescent visit content.
The researchers did not speculate on the reasons for their findings. However, the results may reflect the type of practice where the patient is seen. Lower income and uninsured patients are often seen in busy health centers with little time allotted to each patient. Lack of translators often limits counseling and conversation with patients and parents. Walk-in facilities are sites in which the clinicians are busy and don't have a longitudinal relationships with their patients, which limits their ability to effectively counsel patients, and limits the teenagers' willingness to confide in them. Patients often arrive late for appointments, decreasing their time with the doctor. Parents who accompany teens often question the doctor about issues relating to other family members, distracting the physician and intruding on the teen's visit time.
The researchers concluded that being poor, and not having continuous health insurance coverage are critical barriers to the access of preventive care by adolescents. They found that race or ethnicity had little or no influence, when separated from income and insurance. They found the low rate of measurement of weight and height in the lowest income groups worrisome because this population is at high risk for overweight and obesity and lifelong health problems.
The important message to parents is that teens, even those who appear healthy, need routine medical visits on at least a yearly basis and that they can play a role in improving the quality of their teenager's health care. The visits should include alone time with the teen and their doctor, and the parents should consider excusing themselves from the exam room, if the doctor doesn't initiate some private time. Parents should be aware that the teen's visit should be only about that child, and not intrude with questions about themselves or other family members. Parents may want to actively request that the doctor talk to their children about safety, diet, smoking, sexuality and other topics critical to adolescent safety. Parents with low incomes or no health insurance should check with the local health departments for information about low cost clinics, with sliding scales to accommodate different income levels.
Doctors also have a role in improving teenage use of the health care system. Issues about confidentiality of the visit and about information discussed privately between the doctor and patient should be clarified for the patient and parent. Parents should be advised that seeing the same doctor for routine health care is an important part of building the doctor-patient relationship that will increase the physician's ability to elicit important information from the teen and to positively influence them. Physician practices should send reminders to parents of teens who haven't been seen for an annual visit and should alert them to the availability of new vaccines. Doctors should also provide adolescents with written information or informative and reliable websites about safe health practices that they can refer to after the visit.
July 13, 2009
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