Family Practice Advance Access published March 14, 2015 Family Practice, 2015, 1–6 doi:10.1093/fampra/cmu090
Health Service Research
Psychosocial problems in adolescents associate with frequent health care use Downloaded from http://fampra.oxfordjournals.org/ at University of California, San Francisco on April 19, 2015
Virve K Kekkonena,*, Petri Kivimäkib, Hannu Valtonenc, Tommi Tolmunena,b, Soili M Lehtob,d, Jukka Hintikkae,f and Eila Laukkanena,b Department of Adolescent Psychiatry, Kuopio University Hospital, PO Box 100, FI-70029 Kuopio, bDepartment of Psychiatry, Institute of Clinical Medicine and cDepartment of Health and Social Management, University of Eastern Finland, PO Box 1627, FI-70211 Kuopio, dDepartment of Psychiatry, Kuopio University Hospital, PO Box 100, FI-70029 Kuopio, eDepartment of Psychiatry, Päijät-Häme Central Hospital, Keskussairaalankatu 7, FI-15850 Lahti and fSchool of Medicine, University of Tampere, FI-33014 University of Tampere, Finland. a
*Correspondence to Virve Kekkonen, Department of Adolescent Psychiatry, Kuopio University Hospital, PO Box 100, FI-70029 Kuopio, Finland; E-mail: [email protected]
Abstract Background. The prevalence of somatic, mental and behavioural problems increases in puberty. Nevertheless, compared to adults, health service utilization by adolescents, and associated factors such as risky health behaviours, have been poorly explored. In order to improve health care services, there is a need for further research on adolescents frequently using primary health care. Objectives. We aimed to investigate adolescents who seek help for health issues, and examine whether particular socio-economic or psychological factors predict frequent primary health care use. Methods. Finnish adolescents aged 13–18 years (N = 793) attending comprehensive, upper secondary and vocational schools participated in the study in 2005. Data were collected using a questionnaire that included the Youth Self Report (YSR), as well as questions on the psychosocial background of the adolescents and substance use. Data regarding the frequency of use of health services were gathered from medical records of the local public health care services. Results. Altogether, 288 in the sample had used primary health care services making a combined total of 1411 health care visits. Female gender associated with frequent primary health care use. Furthermore, a high level of alcohol consumption and mental health symptoms in girls, and increased self-reported somatic complaints in the YSR in boys were associated with frequent primary health care use. Attending upper secondary school was related to less frequent primary health care use. Conclusion. Few adolescents frequently use primary health care, but they account for a considerable proportion of all adolescent health care visits. There are higher levels of alcohol consumption, as well as socio-economic, educational and gender differences among adolescent frequent primary health care users. Key words. Adolescent, epidemiology, general practice, general practitioner, primary health care, utilization.
Introduction During puberty, healthy adolescents become more vulnerable to transient health concerns. Of these somatic symptoms, headaches and musculoskeletal pains are the most common (1). Rapid
alterations in mood, behaviour and health complaints in adolescence are considered to be strongly related to hormonal pubertal changes and bodily maturation (2). Of the more serious health concerns, the rates of mental health problems such as depression, panic disorder,
© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
1
Family Practice, 2015, Vol. 00, No. 00
2
Aims of the study Data on frequent primary health care use by adolescents are scarce, especially with regard to psychosocial risk factors (e.g., substance use). We investigated the contribution of psychosocial background factors such as school performance, mental health problems, smoking and alcohol use among frequent and non-frequent primary health care users, with a specific focus on differences between girls and boys.
Data and methods Participants The participants were follow-up study cohorts of adolescents aged 13–18 years from comprehensive, upper secondary and vocational schools in Kuopio, which is a city in Eastern Finland with approximately 100 000 inhabitants. Methodological aspects of the baseline study setting have previously been described in detail by Laukkanen et al. (11). The original target population comprised 6421 adolescents aged 11–21 years in 2005. The response rate was 65.5%, leading to a sample of 4214 adolescents. Altogether, 43 questionnaires were excluded due to an age of 12 or younger or 19 or older, leading to a final sample of 4171 adolescents. From this population, 1827 (43.8%) provided consent to be contacted for a follow-up study. A younger age, female gender and a higher number of hobbies were associated with providing consent. Only those who provided consent to research their medical records in the follow-up phase and whose municipality of residence was Kuopio in 2005 were included, giving a sample of 793 (43.4%) participants. Visits to a primary health care center in our data involved visits to a physician (55.8%) or other health care professional such as a nurse due a perceived health problem. Routine check-ups (510 visits) were excluded from the data. Of the individuals in the sample, 288 (36.3%) attended primary health care in 2005. Frequent health care visits were defined as five or more visits during the year 2005. Based on this definition, 112 (14.1%) participants in our sample frequently utilized health care services. In our study setting, the supply of services was constant, comprising the health service supply of one city. Primary health care data were collected from Kuopio city public health care center. Primary health care comprises GPs and nursing services in polyclinics, school
and student health care units and emergency rooms. In addition, primary health care includes low threshold mental health services (12) targeted at adolescents with mild to moderate mental health problems. For all primary health care visits, (i) the number and reasons for the visits, (ii) the training of the health care professional providing the service (physician/other) and (iii) the visit location were gathered from the medical records of each individual. For each visit to primary health care, the main reason for the visit was determined from the medical records and classified according to the International Classification of Primary Care [ICPC (13)]. The Research Ethics Committee of Kuopio University Hospital approved the study design. Access to medical records was authorized by the National Institute for Health and Welfare, and the primary care management was based on a followed study plan, including a description of data protection procedures. Before the study, written informed consent was obtained from all participants and from the parents of those aged below 15 years. All participants had the possibility to withdraw from the study without any explanation.
Measurements The data included the sex, age and educational level of the study participants. The parental occupations were classified into three groups: (i) ‘white collar worker’, such as a ‘higher employee’ or ‘self-employed’, (ii) ‘blue collar worker’, such as a ‘worker’, ‘lower employee’ or ‘other’, and (iii) ‘not known’. Here, ‘other’ included unemployed and deceased parents, and those who for other reasons were not employed. Participants were asked if they studied in a ‘comprehensive’, ‘upper secondary’ or ‘vocational’ school. School performance was self-rated separately for Finnish (i.e. native language and grammar) and mathematics, with a grading of ‘poor/below average’ or ‘average/good’. Symptoms of internalizing and externalizing problems were assessed with the Youth Self-Report (YSR) of the Achenbach System of Empirically Based Assessment [ASEBA (14)], which has been found to be reliable and valid in several studies [e.g. Achenbach et al. (15)]. It has been designed for adolescents aged 11−18 years. The questionnaire includes eight empirically based syndrome scales designated as follows: anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, delinquent behaviour and aggressive behaviours. The internalizing problems scale consists of anxious/depressed, withdrawn/depressed and somatic complaints subscales, while the externalizing problems scale consists of delinquent behaviour and aggressive behaviour subscales (14). The Alcohol Use Disorders Identification Test [AUDIT (16)] was originally designed for screening risky alcohol consumption in adults, but it is also sensitive in measuring problematic drinking behaviour in adolescents (17). We used the recommended AUDIT cut-off of three for identifying alcohol abuse or dependence (17). The use of tobacco was determined with a questionnaire previously applied by Laukkanen et al. (11) , and classified as ‘yes’ or ‘no’.
Statistics The chi-squared test was used to analyse group differences in categorical variables such as sex, parental occupations, school performance and the risky health behaviours variable. Age and scores in the YSR subscale of attention problems were normally distributed, but the distributions of all other continuous variables were non-normal. The non-parametric Mann–Whitney U-test was consequently used in comparisons of continuous variables such as age, YSR subscale scores and the AUDIT score. For regression analyses, standard scores were derived from YSR subscales by converting raw scores to Z-scores (14).
Downloaded from http://fampra.oxfordjournals.org/ at University of California, San Francisco on April 19, 2015
agoraphobia and substance use increase in puberty (3). Alcohol use increases in adolescence, and drinking is associated with a number of health risks and social problems (4). Among adult patients, chronic diseases, mental health problems and social problems have been associated with frequent primary health care visits (5,6). According to a Finnish health survey of young adults, mental symptoms such as depression increased the use of health care services, and health care use was more prevalent among young women compared to men (7). Nevertheless, few studies have investigated frequent health care use by adolescents. Among British secondary school pupils of a young age, frequent primary care use associated with having been admitted to hospital, absence from school, current medical illness and a previous need for psychiatric consultation (8). Moreover, in a study of Norwegian students (aged 15–16 years), dropping out of school was associated with frequent student health care use and referrals to mental health care (9). There is some evidence of typical health complaints among adolescents frequently using health care (10). To our knowledge, however, there have been no studies on adolescent substance use or risky health behaviors in relation to frequent primary health care use.
Psychosocial problems in adolescents
Results Sample characteristics The number of visits, the most common reasons, and where primary health care visits took place are presented in Table 1. The 10% of the adolescent most frequently using primary health care accounted for 38.5% of all primary health care visits, and they all made 10 or more visits per year. Of the 793 participants, 560 (70.6%, P
Health Service Research
Psychosocial problems in adolescents associate with frequent health care use Downloaded from http://fampra.oxfordjournals.org/ at University of California, San Francisco on April 19, 2015
Virve K Kekkonena,*, Petri Kivimäkib, Hannu Valtonenc, Tommi Tolmunena,b, Soili M Lehtob,d, Jukka Hintikkae,f and Eila Laukkanena,b Department of Adolescent Psychiatry, Kuopio University Hospital, PO Box 100, FI-70029 Kuopio, bDepartment of Psychiatry, Institute of Clinical Medicine and cDepartment of Health and Social Management, University of Eastern Finland, PO Box 1627, FI-70211 Kuopio, dDepartment of Psychiatry, Kuopio University Hospital, PO Box 100, FI-70029 Kuopio, eDepartment of Psychiatry, Päijät-Häme Central Hospital, Keskussairaalankatu 7, FI-15850 Lahti and fSchool of Medicine, University of Tampere, FI-33014 University of Tampere, Finland. a
*Correspondence to Virve Kekkonen, Department of Adolescent Psychiatry, Kuopio University Hospital, PO Box 100, FI-70029 Kuopio, Finland; E-mail: [email protected]
Abstract Background. The prevalence of somatic, mental and behavioural problems increases in puberty. Nevertheless, compared to adults, health service utilization by adolescents, and associated factors such as risky health behaviours, have been poorly explored. In order to improve health care services, there is a need for further research on adolescents frequently using primary health care. Objectives. We aimed to investigate adolescents who seek help for health issues, and examine whether particular socio-economic or psychological factors predict frequent primary health care use. Methods. Finnish adolescents aged 13–18 years (N = 793) attending comprehensive, upper secondary and vocational schools participated in the study in 2005. Data were collected using a questionnaire that included the Youth Self Report (YSR), as well as questions on the psychosocial background of the adolescents and substance use. Data regarding the frequency of use of health services were gathered from medical records of the local public health care services. Results. Altogether, 288 in the sample had used primary health care services making a combined total of 1411 health care visits. Female gender associated with frequent primary health care use. Furthermore, a high level of alcohol consumption and mental health symptoms in girls, and increased self-reported somatic complaints in the YSR in boys were associated with frequent primary health care use. Attending upper secondary school was related to less frequent primary health care use. Conclusion. Few adolescents frequently use primary health care, but they account for a considerable proportion of all adolescent health care visits. There are higher levels of alcohol consumption, as well as socio-economic, educational and gender differences among adolescent frequent primary health care users. Key words. Adolescent, epidemiology, general practice, general practitioner, primary health care, utilization.
Introduction During puberty, healthy adolescents become more vulnerable to transient health concerns. Of these somatic symptoms, headaches and musculoskeletal pains are the most common (1). Rapid
alterations in mood, behaviour and health complaints in adolescence are considered to be strongly related to hormonal pubertal changes and bodily maturation (2). Of the more serious health concerns, the rates of mental health problems such as depression, panic disorder,
© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
1
Family Practice, 2015, Vol. 00, No. 00
2
Aims of the study Data on frequent primary health care use by adolescents are scarce, especially with regard to psychosocial risk factors (e.g., substance use). We investigated the contribution of psychosocial background factors such as school performance, mental health problems, smoking and alcohol use among frequent and non-frequent primary health care users, with a specific focus on differences between girls and boys.
Data and methods Participants The participants were follow-up study cohorts of adolescents aged 13–18 years from comprehensive, upper secondary and vocational schools in Kuopio, which is a city in Eastern Finland with approximately 100 000 inhabitants. Methodological aspects of the baseline study setting have previously been described in detail by Laukkanen et al. (11). The original target population comprised 6421 adolescents aged 11–21 years in 2005. The response rate was 65.5%, leading to a sample of 4214 adolescents. Altogether, 43 questionnaires were excluded due to an age of 12 or younger or 19 or older, leading to a final sample of 4171 adolescents. From this population, 1827 (43.8%) provided consent to be contacted for a follow-up study. A younger age, female gender and a higher number of hobbies were associated with providing consent. Only those who provided consent to research their medical records in the follow-up phase and whose municipality of residence was Kuopio in 2005 were included, giving a sample of 793 (43.4%) participants. Visits to a primary health care center in our data involved visits to a physician (55.8%) or other health care professional such as a nurse due a perceived health problem. Routine check-ups (510 visits) were excluded from the data. Of the individuals in the sample, 288 (36.3%) attended primary health care in 2005. Frequent health care visits were defined as five or more visits during the year 2005. Based on this definition, 112 (14.1%) participants in our sample frequently utilized health care services. In our study setting, the supply of services was constant, comprising the health service supply of one city. Primary health care data were collected from Kuopio city public health care center. Primary health care comprises GPs and nursing services in polyclinics, school
and student health care units and emergency rooms. In addition, primary health care includes low threshold mental health services (12) targeted at adolescents with mild to moderate mental health problems. For all primary health care visits, (i) the number and reasons for the visits, (ii) the training of the health care professional providing the service (physician/other) and (iii) the visit location were gathered from the medical records of each individual. For each visit to primary health care, the main reason for the visit was determined from the medical records and classified according to the International Classification of Primary Care [ICPC (13)]. The Research Ethics Committee of Kuopio University Hospital approved the study design. Access to medical records was authorized by the National Institute for Health and Welfare, and the primary care management was based on a followed study plan, including a description of data protection procedures. Before the study, written informed consent was obtained from all participants and from the parents of those aged below 15 years. All participants had the possibility to withdraw from the study without any explanation.
Measurements The data included the sex, age and educational level of the study participants. The parental occupations were classified into three groups: (i) ‘white collar worker’, such as a ‘higher employee’ or ‘self-employed’, (ii) ‘blue collar worker’, such as a ‘worker’, ‘lower employee’ or ‘other’, and (iii) ‘not known’. Here, ‘other’ included unemployed and deceased parents, and those who for other reasons were not employed. Participants were asked if they studied in a ‘comprehensive’, ‘upper secondary’ or ‘vocational’ school. School performance was self-rated separately for Finnish (i.e. native language and grammar) and mathematics, with a grading of ‘poor/below average’ or ‘average/good’. Symptoms of internalizing and externalizing problems were assessed with the Youth Self-Report (YSR) of the Achenbach System of Empirically Based Assessment [ASEBA (14)], which has been found to be reliable and valid in several studies [e.g. Achenbach et al. (15)]. It has been designed for adolescents aged 11−18 years. The questionnaire includes eight empirically based syndrome scales designated as follows: anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, delinquent behaviour and aggressive behaviours. The internalizing problems scale consists of anxious/depressed, withdrawn/depressed and somatic complaints subscales, while the externalizing problems scale consists of delinquent behaviour and aggressive behaviour subscales (14). The Alcohol Use Disorders Identification Test [AUDIT (16)] was originally designed for screening risky alcohol consumption in adults, but it is also sensitive in measuring problematic drinking behaviour in adolescents (17). We used the recommended AUDIT cut-off of three for identifying alcohol abuse or dependence (17). The use of tobacco was determined with a questionnaire previously applied by Laukkanen et al. (11) , and classified as ‘yes’ or ‘no’.
Statistics The chi-squared test was used to analyse group differences in categorical variables such as sex, parental occupations, school performance and the risky health behaviours variable. Age and scores in the YSR subscale of attention problems were normally distributed, but the distributions of all other continuous variables were non-normal. The non-parametric Mann–Whitney U-test was consequently used in comparisons of continuous variables such as age, YSR subscale scores and the AUDIT score. For regression analyses, standard scores were derived from YSR subscales by converting raw scores to Z-scores (14).
Downloaded from http://fampra.oxfordjournals.org/ at University of California, San Francisco on April 19, 2015
agoraphobia and substance use increase in puberty (3). Alcohol use increases in adolescence, and drinking is associated with a number of health risks and social problems (4). Among adult patients, chronic diseases, mental health problems and social problems have been associated with frequent primary health care visits (5,6). According to a Finnish health survey of young adults, mental symptoms such as depression increased the use of health care services, and health care use was more prevalent among young women compared to men (7). Nevertheless, few studies have investigated frequent health care use by adolescents. Among British secondary school pupils of a young age, frequent primary care use associated with having been admitted to hospital, absence from school, current medical illness and a previous need for psychiatric consultation (8). Moreover, in a study of Norwegian students (aged 15–16 years), dropping out of school was associated with frequent student health care use and referrals to mental health care (9). There is some evidence of typical health complaints among adolescents frequently using health care (10). To our knowledge, however, there have been no studies on adolescent substance use or risky health behaviors in relation to frequent primary health care use.
Psychosocial problems in adolescents
Results Sample characteristics The number of visits, the most common reasons, and where primary health care visits took place are presented in Table 1. The 10% of the adolescent most frequently using primary health care accounted for 38.5% of all primary health care visits, and they all made 10 or more visits per year. Of the 793 participants, 560 (70.6%, P
