ARTICLE
Rural Adolescents’ Access to Adolescent Friendly Health Services Molly A. Secor-Turner, PhD, RN, Brandy A. Randall, PhD, Alison L. Brennan, BA, Melinda K. Anderson, DNP, FNP-C, & Dean A. Gross, PhD, FNP
ABSTRACT Introduction: The purpose of this study was to assess rural North Dakota adolescents’ experiences in accessing adolescent-friendly health services and to examine the relationship between rural adolescents’ communication with health care providers and risk behaviors. Methods: Data are from the Rural Adolescent Health Survey (RAHS), an anonymous survey of 14- to 19-year-olds
Molly A. Secor-Turner, Assistant Professor, Departments of Nursing and Public Health, North Dakota State University, Fargo, ND. Brandy A. Randall, Associate Professor and Associate Dean, Graduate School, Department of Human Development and Family Science, North Dakota State University, Fargo, ND. Alison L. Brennan, Graduate Student, Department of Human Development and Family Science, North Dakota State University, Fargo, ND. Melinda K. Anderson, Doctor of Nurse Practitioners and Family Nurse Practitioner, Sanford Health, Perham, MN. Dean A. Gross, Assistant Professor, Department of Nursing, North Dakota State University, Fargo, ND. This study was funded by North Dakota State University Department of Nursing Faculty Development Funds (Secor-Turner, primary investigator). Conflicts of interest: None to report. Correspondence: Molly A. Secor-Turner, PhD, RN, Departments of Nursing and Public Health, North Dakota State University, Dept. 2670, PO Box 6050, Fargo, ND 58108; e-mail: molly.secor-turner@ ndsu.edu. 0891-5245/$36.00 Copyright Q 2014 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. Published online July 10, 2014. http://dx.doi.org/10.1016/j.pedhc.2014.05.004
534
Volume 28 Number 6
(n = 322) attending secondary schools in four frontier counties of North Dakota. Descriptive statistics were used to assess participants’ access to adolescent-friendly health services characterized as accessible, acceptable, and appropriate. Logistic regressions were used to examine whether participant-reported risk behaviors predicted communication with health care providers about individual health risk behaviors. Results: Rural adolescents reported high access to acceptable primary health care services but low levels of effective health care services. Participant report of engaging in high-risk behaviors was associated with having received information from health care providers about the leading causes of morbidity and mortality. Discussions: These findings reveal missed opportunities for primary care providers in rural settings to provide fundamental health promotion to adolescents. J Pediatr Health Care. (2014) 28, 534-540.
KEY WORDS Adolescent, health services, rural
Positive health practices established during adolescence set the stage for a healthy entry into adulthood. Yet accumulating research evidence suggests that rural adolescents may face elevated risk compared with urban adolescents, given their propensity to engage in higher rates of some risk behaviors. For example, rural youth have higher rates of drinking, binge drinking, and driving under the influence, and rural areas account for more fatal crashes than do urban areas (Gale, Lendardson, Lambert, & Hartley, 2012; United States Department of Transportation, 2013). Dunkley (2004) suggests that rural areas can be considered ‘‘risky geographies’’ for teens. Compounding this risk, adolescents living in rural, frontier areas may face substantial barriers to accessing quality preventive health services Journal of Pediatric Health Care
that are developmentally appropriate (Curtis, Water, & Brindis, 2010; Elliott & Larson, 2004). Adolescents in general report barriers to seeking health care related to lack of knowledge, lack of insurance, transportation challenges, fear, and confidentiality concerns (Ginsburg et al., 1995; Klein, McNulty, & Flatau, 1998; Zimmer-Gembeck, Alexander, & Nystom, 1997). Adolescents in rural communities in particular have reported anxiety, access, self-reliance, nonsupportive parents, and helplessness as reasons for not accessing care (Elliott & Larson, 2004). Other concerns about seeking health care discussed by rural adolescents include mental health stigma, confidentiality, parental control, and preference for seeing coaches or athletic trainers for health care (Elliott & Larson, 2004). Confidentiality concerns are amplified in rural settings where there are fewer health care providers and anonymity is difficult to attain and maintain. Further, access to specialty care, such as mental health or reproductive health, is limited by geographic distance and lack of public transportation (Elliott & Larson, 2004). Recent recommendations from the Institutes of Medicine guided by the World Health Organization (WHO) framework describe adolescent-friendly health services as accessible (with broadly accessible services); acceptable (considering the culture and climate of engagement); appropriate (fulfilling the needs of young people); equitable (not restricting the provision of and eligibility for services); and effective (reflecting evidence-based standards of care; Lawrence, Gootman, & Sim, 2009; WHO, 2002). A review of health services in the United States compared with these guidelines suggests that primary care services are available to many adolescents but services are not available to those who are uninsured or underinsured, are not offered in settings that foster open communication about sensitive topics, are not provided by developmentally appropriate providers, and are not effective at fostering health promotion and risk reduction (Lawrence et al., 2009). Evidence-based clinical practice recommendations, such as Bright Futures, provide specific guidance for risk evaluation and health promotion topics during adolescent well-child examinations to address the key priority issues of physical growth and development, social and academic competence, emotional well-being, risk reduction, and violence and injury prevention (Hagan, Shaw, & Duncan, 2008). These guidelines address the leading causes of adolescent morbidity and mortality, including risk behaviors related to alcohol use, sexual activity, mental health, smoking, violence, and guns (Blum & Qureshi, 2011). Although these psychosocial issues are the biggest contributors to the health burden of adolescents, very few adolescents seek health care services to address these complex needs (Sawyer, Proimos, & Towns, 2010). Instead, adowww.jpedhc.org
lescents primarily seek health care services for respiratory or dermatologic concerns (Sawyer et al., 2010). In addition to clinical practice recommendations, a body of research supports the use of healthy youth development approaches that simultaneously reduce risk and promote health among adolescents (Bernat & Resnick, 2006). The effective implementation of healthy youth development strategies into practice includes a primary prevention focus to prevent problems before they occur and employs secondary prevention when necessary by reducing health risk factors and fostering health protective factors (Bernat & Resnick, 2006). These approaches have demonstrated success in the prevention and reduction of multiple adolescent health risk behaviors. Despite the gap between services that adolescents seek and the health burdens they experience, adolescents report a willingness to talk with and trust providers about preventive counseling topics including contraception, substance use, and sexually transmitted infection (Bethell, Klein, & Peck, 2001; Tylee, Haller, Graham, Churchill, & Sanci, 2007). Yet rates of screening and counseling on key topics including alcohol, depression, sexual activity, smoking, injury prevention, physical activity, and diet are consistently below levels recommended by established guidelines (Bethell et al., 2001; Ozer et al., 2005). Current trends in preventable adolescent morbidity and mortality underscore the importance of screening and preventive counseling. Although the majority of adolescents in the United States report a visit to a health care provider at least annually that could provide an important opportunity to incorporate preventive services, as previously noted, other studies suggest that rural youth access services at lower rates (Ozer et al., 2005). The objective of this study was to describe rural adolescents’ experiences with accessing adolescentfriendly health services inclusive of health-promoting information. METHODS Data Source This study uses data from the Rural Adolescent Health Survey (RAHS), an anonymous survey of 9th- to 12thgrade students (n = 322) attending secondary schools in four frontier counties of North Dakota between January and April of 2012. Frontier counties are defined as sparsely populated rural areas with population densities of seven or fewer people per square mile (Center for Rural Health, 2010). Students were recruited from participating schools (n = 4) using a convenience sampling technique. Within each school, all eligible students—that is, those in grades 9 through 12 who were present on the day of the survey—were invited to participate in the survey. Across schools, 98% of total eligible students were available and provided written assent to participate on the day of the survey. November/December 2014
535
Parent/guardian consent was obtained using passive consent procedures similar to the state’s process for obtaining parental consent for the Youth Risk Behavioral Surveillance Survey. Prior to survey administration, introduction and consent information were sent by mail and with students to the home of each student in grades 9 through 12 at participating schools. The introduction letter described the purpose of the study, what participants would be asked to do, the date of survey administration, and contact information for the research team. Parents/guardians were instructed to contact the school or research team by telephone or e-mail if they did not want their child to participate in the study. All study procedures were approved by the North Dakota State University Institutional Review Board. Measures The RAHS uses a battery of individual items from multiple previously established and validated adolescent health surveys to assess rural adolescents’ access to (a) preventive health services, (b) health promoting information, and (c) health and risk behaviors. For the current analyses, all items are from the Young Adult Health Care Survey (YAHCS; The Child and Adolescent Health Measurement Initiative, 2010). Adolescent-Friendly Health Services Access to adolescent health services was derived from two yes/no items: ‘‘Have you been to see a doctor, nurse, or other health provider in the last 12 months?’’ and ‘‘Has there been any time over the last 12 months when you thought you should get medical care but did not?’’ Acceptability was derived from four items that assessed how often providers listened carefully, explained things, showed respect, and spent enough time with adolescents in the past 12 months (a = 0.78; Bethell et al., 2001). For example, a question on the survey was, ‘‘In the last 12 months, how often did doctors, nurses, or other health providers show respect for what you had to say?’’ Response options were never, sometimes, usually or always. Appropriateness of health services was assessed by asking participants if a doctor, nurse, or other health provider discussed 20 preventative health topics (Bethell et al., 2001). Items included a measure of preventive screening and counseling on risky behaviors, sexual activity and sexually transmitted infections, weight, healthy diet and exercise, emotional health, and relationship issues. Response options for each topic were yes or no. The topics were reflective of the evidence-based Bright Futures Guidelines for anticipatory guidance with adolescents (Hagan et al., 2008). Health Risk Behaviors Five items assessed health risk behaviors associated with leading causes of adolescent morbidity and mor536
Volume 28 Number 6
tality and included seat belt use, feeling sad or hopeless, cigarette use, alcohol use, binge drinking, and sexual activity. For each item, response options were dichotomized to indicate risk. Participants were asked, ‘‘How often do you wear a seatbelt when riding or driving in a car?’’ Response options were dichotomized as never, rarely, sometimes, and most of the times versus always. Feeling sad or hopeless was assessed by asking participants, ‘‘During the last 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?’’ Response options were yes or no. Substance use was assessed using three items that asked participants how many days they smoked, had at least one drink of alcohol, or binge drank in the past 30 days. For example, binge drinking was assessed by asking participants, ‘‘During the last 30 days, on how many days did you have five or more drinks of alcohol in a row, that is, within a couple of hours?’’ Response options were dichotomized as 0 days versus 1 or more days. Sexual activity was assessed using the question, ‘‘Have you ever had sex?’’ Response options were yes or no. Statistical Analysis To characterize participants’ experiences in accessing adolescent-friendly health services, the distribution of reported access, acceptability, and appropriateness of health services was examined as previously described. Next, binomial logistic regression models examined associations between communication with a health care provider about health risk behaviors and participantreported risk behaviors. All analyses were completed using SPSS version 21 (SPSS Inc., Chicago, IL) and were conducted in 2013. RESULTS Participant Descriptors Reflective of the demographic profile of North Dakota, the majority of participants were White. Participants ranged in age from 14 to 19 years. There were slightly more boys than girls and slightly fewer participants in 9th grade compared with other grades. Nearly half of participants lived outside of town (Table 1). Adolescent-Friendly Health Services Overall, rural adolescents reported high access to primary health care services. Ninety-four percent (n = 303) of participants reported having seen a primary care provider in the past 12 months. However, one third of participants reported that it was usually/always a problem to get care when they believed it was necessary (Table 2). Most rural adolescents reported that their primary care providers listened carefully to them (80%), explained things in a way they could understand (86%), showed respect for what they had to say (85%), and spent enough time with them (80%), indicating high Journal of Pediatric Health Care
year compared with participants who reported using seat belts usually or always.
TABLE 1. Participant demographics Descriptor Race/ethnicity (check all that apply) American Indian/Native American Black, African, or African American White Other Age range (mean) Grade in school 9th 10th 11th 12th Received free or reduced-price lunch Yes No Don’t know Residence In town On farm or ranch Out of town, not farm or ranch
% (n) 4.7 (15) 1.6 (5) 90.7 (292) 6.5 (21) 14-19 (16.5) 21.4 (69) 26.1 (84) 25.8 (83) 24.8 (80) 18.9 (61) 53.7 (173) 26.1 (84) 53.1 (171) 34.2 (110) 10.2 (33)
levels of acceptability. Conversely, rural adolescents reported low levels of appropriate or effective health care services compared with Bright Futures recommendations (Table 2). For example, the most frequently talked about health promotion/risk screening topic reported was physical activity or exercise (45%), followed by smoking and alcohol use (44% and 43%). Other key risk topics were talked about less frequently, such as condom use (30%) and birth control (23%), suicide (20%), and helmet use (16%). Gun safety and other weapons were talked about least frequently (7%). Associations Between Health Care Experiences and Health Risk Behaviors In general, participant reports of engaging in a risk behavior were associated with significantly higher odds of having talked with a health care provider about that risk behavior in the past 12 months (Table 3). Participants who reported feeling sad or hopeless in the past year were more than three and a half times more likely to have talked with a health care provider about suicide compared with participants who did not report feeling sad or hopeless. Participants who reported smoking or binge drinking were also significantly more likely to have talked with a primary care provider about smoking and drinking compared with participants who did not report engaging in these behaviors (odds ratio [OR] = 3.52, 2.04, respectively). Likewise, participants who reported ever having sex had significantly higher odds of having talked with a health care provider about condom use and birth control in the past year compared with participants who reported never having sex (OR = 2.12, 3.59, respectively). Conversely, participants who reported not using seat belts were half as likely to report having talked with a health care provider about seat belt use in the past www.jpedhc.org
DISCUSSION Findings from this study suggest that rural adolescents may have high rates of access to acceptable health care services, yet the services they are accessing may not include important preventive health information and anticipatory guidance. Similar to other national samples of adolescents, the rural adolescents in this sample report very low rates of receiving anticipatory guidance consistent with professional recommendations, including Bright Futures (Irwin, Adams, Park, & Newacheck, 2009). Findings from this Anticipatory guidance ranged from a low of study suggest that 6.5% of participants rural adolescents receiving information may have high rates about guns or weapons to 45.3% of access to receiving information acceptable health about physical activity care services, yet and exercise. In only two categories did the services they nearly half of particiare accessing may pants report receiving not include anticipatory guidance: physical activity important (45.3%) and cigarettes, preventive health tobacco, or smoking information and (44.4%). Findings from this study also highanticipatory light disparities beguidance. tween this rural sample and national samples. For example, 15.8% of rural adolescents reported receiving information about wearing a helmet from a health care provider compared with 31.3% of a national sample (Irwin et al., 2009). Among a national sample of youth ages 12 to 17 years, only 40% report spending time alone with a health care provider, suggesting relatively low rates of counseling on sensitive topics (Irwin et al., 2009). Fewer than one third of the rural adolescents in this sample reported communicating with a health care provider about sensitive topics such as sexually transmitted infections (32.3%), condoms (30.1%), and sexual orientation (13.7%). Rural health care providers may be providing risk-based services that focus on secondary prevention to address risk behaviors that have already occurred rather than focusing on primary prevention. Health care providers in rural settings may be missing important opportunities to provide fundamental risk assessment and health promotion to adolescents. Ideally, all visits in a primary care center, including nonpreventive visits, should be used to provide developmentally appropriate anticipatory November/December 2014
537
TABLE 2. Participant-reported health care experiences and risk behaviors
Health care experiences Saw a doctor, nurse, or other health provider in the past 12 months Thought you should get medical care but did not in the past 12 months Doctors, nurses, or health care providers did the following in the past 12 months Listened carefully to you Explained things in a way you could understand Showed respect for what you had to say Spent enough time with you In the past 12 months, did a doctor, nurse, or other health provider talk with you about any of the following? Guns or weapons Sexual orientation Wearing a helmet Physical or sexual abuse Suicide Friends Birth control Drunk driving School Weight Condoms Sexually transmitted infections Healthy eating Wearing a seat belt Chewing tobacco Emotions/mood Drug use Alcohol Cigarettes, tobacco, or smoking Physical activity or exercise Health risk behaviors Seat belt use when riding or driving in a car Felt sad or hopeless in the past 12 months Cigarette use in the past 30 days 0 days 1 or more days Alcohol use in the past 30 days 0 days 1 or more days Binge drinking in the past 30 days 0 days 1 or more days Ever had sex
Yes % (n)
No % (n)
94.1 (303)
5.9 (19)
30.7 (99)
67.7 (218)
6.5 (21) 13.7 (44) 15.8 (51) 16.5 (53) 20.2 (65) 21.4 (69) 23 (74) 26.1 (84) 27 (87) 27.6 (89) 30.1 (97) 32.3 (104) 33.5 (108) 35.1 (113) 37.3 (120) 38.2 (123) 40.7 (131) 42.5 (137) 44.4 (143) 45.3 (146)
19.3 (62)
Usually/ always % (n)
Never/ sometimes % (n)
78.6 (253) 81.1 (261)
21.1 (68) 18.6 (60)
84.1 (271)
15.5 (50)
77.9 (251)
21.7 (70)
Always % (n)
Never/rarely/ sometimes/most of the time % (n)
27.6 (89)
70.2 (226)
87 (280) 80.1 (258) 77.3 (249) 77.3 (249) 72.7 (234) 71.7 (231) 73.9 (238) 67.7 (218) 66.5 (214) 66.1 (213) 68.3 (220) 61.5 (198) 59.3 (191) 58.7 (189) 57.1 (184) 55 (177) 57.1 (171) 55.6 (179) 54 (174) 48.8 (157)
79.8 (257)
78.3 (252) 21.2 (68) 50.6 (163) 48.8 (157) 68.9 (219) 30.7 (99) 46 (148)
51.2 (165)
Note. Because of missing data, totals do not always equal 100%. Missing data varies from 0.3% (n = 1) to 7.1% (n = 23). Total N = 322.
guidance for adolescents using evidence-based guidelines (Irwin et al., 2009). Similar to other studies, rural adolescents in this study reported at least annual encounters with primary health care providers (Elliott & Larson, 2004; Irwin et al., 2009). It is well established that unhealthy or risky behaviors are the 538
Volume 28 Number 6
leading causes of mortality and morbidity among adolescents (Elliott & Larson, 2004). However, fewer than half of rural adolescents in this sample reported receiving information from their primary care providers about leading causes of adolescent morbidity (e.g., substance use, condom and contraceptive use, Journal of Pediatric Health Care
TABLE 3. Effects of selected predictors on communication with health care provider in the past 12 months
Talked with health care provider about seat belt use Never, sometimes, usually wear seat belt Always wear seat belt Talked with health care provider about suicide Felt sad or hopeless 2 or more weeks in a row Did not feel sad or hopeless for 2 or more weeks in a row Talked with health care provider about cigarettes, tobacco, or smoking Cigarette use, past 30 days No cigarette use, past 30 days Talked with health care provider about alcohol use Alcohol use, past 30 days No alcohol use, past 30 days Talked with health care provider about binge drinking Binge drinking, past 30 days No binge drinking, past 30 days Talked with health care provider about condom use Ever had sex Never had sex Talked with health care provider about birth control Ever had sex Never had sex
Odds ratio
Confidence interval
.58*
.33-.92
1.00
3.64** 1.00
—
1.95-6.81 —
3.52** 1.00
1.98-6.25 —
1.55 1.00
.99-2.42 —
2.04** 1.00
1.25-3.13 —
2.12 1.00
1.30-3.47 —
3.59** 1.00
2.04-6.32 —
*p < .05. **p < .01.
and factors related to obesity), and fewer than one fourth reported receiving information about leading causes of mortality (e.g., unintentional injury, such as gun safety, and suicide). Because adolescents are typically physically healthy in general, providing clinical services that reduce risk and promote health by addressing these preventable causes of morbidity and mortality can help adolescents maintain health and develop a strong foundation for healthy adulthood (Elliott & Larson, 2004). Capitalizing on primary care clinical encounters may be especially beneficial in rural settings where access to services can be particularly challenging (Gamm, Hutchison, & Bellamy, 2002). As previous literature suggests, rural adolescents may face additional barriers to risk reduction and health promotion about sensitive topics, such as sexuality, because of elevated concerns about privacy and confidentiality (Elliott & Larson, 2004). Clinical encounters with adolescents that emphasize risk screening without simultaneously providing health www.jpedhc.org
promotion are contrary to effective healthy youth development strategies that deliberately provide all youth with support to prevent or reduce adolescent risk behavior, yet these data suggest that this is the approach being taken in rural communities (Bernat & Resnick, 2006). Given the higher rates of risk behaviors previously documented for rural compared with urban youth, shifting to a health promotion model has the potential to substantially reduce the negative health outcomes that rural youth experience. Utilizing primary prevention approaches to prevent adolescent risk behavior is also congruent with current shifts in health care that emphasize moving from treatment to prevention in response to high rates of preventable causes of morbidity and mortality among the U.S. population (Hellerstedt & Oberg, 2013). For example, the Affordable Care Act (ACA) has several provisions that have the potential to increase the number of rural adolescents in the United States who will be able to access preventive health services through expanded health insurance coverage and increased payment to rural health care providers (English & Park, 2012; Hellerstedt & Oberg, 2013). The expanded access to health insurance underscores the importance of capitalizing on the opportunity to improve health outcomes for rural adolescents and into young adulthood through acceptable and appropriate preventive health services. STRENGTHS AND LIMITATIONS This study has several limitations. These data are from a rural school-based survey, and therefore findings cannot be generalized to adolescents in other settings or those not attending school. However, by focusing on a rural sample from frontier counties, the present findings make a contribution to the limited amount of data that focus on rural adolescents (Brandy A. Randall, PhD, unpublished observations, 2012). Second, the RAHS utilizes a cross-sectional design; therefore any temporal relationships between experiences accessing adolescent-friendly health services and health risk behaviors cannot be examined. Third, this study used measures of adolescent-friendly health services derived from participant recall that do not include any objective measures, such as chart reviews. Therefore several possible scenarios may have impaired participants’ recall and reporting. For example, participants could have completed a prescreening questionnaire prior to their visit and only received information about topics that revealed elevated risk, or participants may not remember discussing certain topics with their provider. Finally, limitations of the survey instrument did not allow for analysis that included the purpose of the participants’ health care visits. IMPLICATIONS Adolescents in rural settings report high levels of trust and access to rural health care providers. It is imperative November/December 2014
539
that health care providers capitalize on all encounters with adolescents to identify areas for risk reeducation and health promotion. Several factors may It is imperative that inhibit providers’ abilhealth care ity to provide comprehensive care that providers capitalize integrates screening on all encounters and routine preventive with adolescents to counseling into clinic visits with adolescents. identify areas for For example, limited risk reeducation time may not allow and health providers to conduct time-consuming risk promotion. screening. In addition, many adolescents seek care for somatic, rather than psychosocial, complaints. Billing and coding reimbursement limitations may complicate the integration of health promotion into such visits. Future research to address the health promotion needs of rural adolescents should examine adolescents’ preferences for the delivery of information and other potential sources of receiving health promotion information, such as at home or at school. In addition, the content of discussions between providers and adolescents should be explored. Finally, the integration of screening and health promotion into clinic visit protocols should be delivered through multiple modes of communication, including one-on-one counseling, written information, and electronic communication. REFERENCES Bernat, D. H., & Resnick, M. D. (2006). Health youth development: Science and strategies. Journal of Public Health Management Practice, 10, S10-S16. Bethell, C., Klein, J., & Peck, C. (2001). Assessing health system provision of adolescent preventive services: The young adult health care survey. Medical Care, 39, 478-490. Blum, R. W., & Qureshi, F. (2011). Morbidity and mortality among adolescents and young adults in the United States: AstraZeneca fact sheet 2011. Retrieved from John Hopkins Bloomberg School of Public Health website: www.jhsph.edu/research/ centers-and-institutes/center-for-adolescent-health/az/_images/ US%20Fact%20Sheet_FINAL.pdf Center for Rural Health, The University of North Dakota School of Medicine & Health Sciences. (2010). North Dakota frontier counties. Retrieved from www.ruralhealth.und.edu/maps/ mapfiles/frontier.png Curtis, A. C., Water, C. M., & Brindis, C. (2010). Rural adolescent health: The importance of prevention services in the rural community. Journal of Rural Health, 27, 60-71. Dunkley, C. M. (2004). Risky geographies: Teens, gender, and rural landscape in North America. Gender Place & Culture: A Journal of Feminist Geography, 11, 559-579.
540
Volume 28 Number 6
Elliott, B. A., & Larson, J. T. (2004). Adolescents in mid-sized rural communities: Foregone care, perceived barriers, and risk factors. Journal of Adolescent Health, 35, 303-309. English, A., & Park, M. J. (2012). The Supreme Court ACA decision: What happens now for adolescents and young adults? Retrieved from http://nahic.ucsf.edu/wp-content/uploads/ 2012/11/Supreme_Court_ACA_Decision_Nov29.pdf Gale, J. A., Lendardson, J. D., Lambert, D., & Hartley, D. (2012). Adolescent alcohol use: Do risk and protective factors explain rural-urban differences? (Working paper No. 48.). Portland, ME: Maine Rural Health Research Center. Gamm, L., Hutchison, L., & Bellamy, G. (2002). Rural healthy people 2010: Identifying rural health priorities and models for practice. The Journal of Rural Health, 18, 9-14. Ginsburg, K. R., Slap, G. B., Cnaan, A., Forke, C. M., Balseley, C. M., & Rouselle, D. M. (1995). Adolescents’ perceptions of factors affecting their decisions to seek health care. JAMA: Journal of the American Medical Association, 273, 1913-1918. Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2008). Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, Illinois: American Academy of Pediatrics. Hellerstedt, W. L., & Oberg, C. N. (2013). The Affordable Care Act: Goals and mechanisms. Implications of the Affordable Care Act on MCH populations and public health services. Retrieved from University of Minnesota Board of Regents website: http://www.epi.umn.edu/mch/wp-content/uploads/2012/05/ HG_Fall20132.pdf Irwin, C., Jr., Adams, S. H., Park, M. J., & Newacheck, P. W. (2009). Preventive care for adolescents: Few get visits and fewer get services. Pediatrics, 123, e565-e572. Klein, J. D., McNulty, M., & Flatau, C. N. (1998). Adolescents’ access to care: Teenagers’ self-reported use of services and perceived access to confidential care. Archives of Pediatric and Adolescent Medicine, 152, 676-682. Lawrence, R. S., Gootman, J. A., & Sim, L. J. (2009). Adolescent health services: Missing opportunities. Washington, DC: The National Academies Press. Ozer, E. M., Adams, S. H., Lustig, J. L., Gee, S., Garber, A. K., Gardner, L. R., . Irwin, C. E. (2005). Increasing the screening and counseling of adolescents for risky health behaviors: A primary care intervention. Pediatrics, 115, 960-968. Sawyer, S. M., Proimos, J., & Towns, S. J. (2010). Adolescentfriendly health services: What have children’s hospitals got to do with it? Journal of Paediatrics & Child Health, 46, 214-216. The Child and Adolescent Health Measurement Initiative. (2010). Young Adult Health Care Survey (YACHS). Retrieved from http://cahmi.org/ViewDocument.aspx?DocumentID=56 Tylee, A., Haller, D. M., Graham, T., Churchill, R., & Sanci, L. A. (2007). Youth-friendly primary-care services: How are we doing and what more needs to be done? Lancet, 369, 1565-1573. United States Department of Transportation, National Highway Traffic Safety Administration. (2013). Traffic safety facts 2011 data: Rural/urban comparison. Retrieved from http://wwwnrd.nhtsa.dot.gov/Pubs/811821.pdf World Health Organization. (2002). Adolescent friendly health services: An agenda for change. Geneva, Switzerland: World Health Organization. Zimmer-Gembeck, M. J., Alexander, T., & Nystom, R. J. (1997). Adolescents report their need for and use of health care services. Journal of Adolescent Health, 21, 388-399.
Journal of Pediatric Health Care
Rural Adolescents’ Access to Adolescent Friendly Health Services Molly A. Secor-Turner, PhD, RN, Brandy A. Randall, PhD, Alison L. Brennan, BA, Melinda K. Anderson, DNP, FNP-C, & Dean A. Gross, PhD, FNP
ABSTRACT Introduction: The purpose of this study was to assess rural North Dakota adolescents’ experiences in accessing adolescent-friendly health services and to examine the relationship between rural adolescents’ communication with health care providers and risk behaviors. Methods: Data are from the Rural Adolescent Health Survey (RAHS), an anonymous survey of 14- to 19-year-olds
Molly A. Secor-Turner, Assistant Professor, Departments of Nursing and Public Health, North Dakota State University, Fargo, ND. Brandy A. Randall, Associate Professor and Associate Dean, Graduate School, Department of Human Development and Family Science, North Dakota State University, Fargo, ND. Alison L. Brennan, Graduate Student, Department of Human Development and Family Science, North Dakota State University, Fargo, ND. Melinda K. Anderson, Doctor of Nurse Practitioners and Family Nurse Practitioner, Sanford Health, Perham, MN. Dean A. Gross, Assistant Professor, Department of Nursing, North Dakota State University, Fargo, ND. This study was funded by North Dakota State University Department of Nursing Faculty Development Funds (Secor-Turner, primary investigator). Conflicts of interest: None to report. Correspondence: Molly A. Secor-Turner, PhD, RN, Departments of Nursing and Public Health, North Dakota State University, Dept. 2670, PO Box 6050, Fargo, ND 58108; e-mail: molly.secor-turner@ ndsu.edu. 0891-5245/$36.00 Copyright Q 2014 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. Published online July 10, 2014. http://dx.doi.org/10.1016/j.pedhc.2014.05.004
534
Volume 28 Number 6
(n = 322) attending secondary schools in four frontier counties of North Dakota. Descriptive statistics were used to assess participants’ access to adolescent-friendly health services characterized as accessible, acceptable, and appropriate. Logistic regressions were used to examine whether participant-reported risk behaviors predicted communication with health care providers about individual health risk behaviors. Results: Rural adolescents reported high access to acceptable primary health care services but low levels of effective health care services. Participant report of engaging in high-risk behaviors was associated with having received information from health care providers about the leading causes of morbidity and mortality. Discussions: These findings reveal missed opportunities for primary care providers in rural settings to provide fundamental health promotion to adolescents. J Pediatr Health Care. (2014) 28, 534-540.
KEY WORDS Adolescent, health services, rural
Positive health practices established during adolescence set the stage for a healthy entry into adulthood. Yet accumulating research evidence suggests that rural adolescents may face elevated risk compared with urban adolescents, given their propensity to engage in higher rates of some risk behaviors. For example, rural youth have higher rates of drinking, binge drinking, and driving under the influence, and rural areas account for more fatal crashes than do urban areas (Gale, Lendardson, Lambert, & Hartley, 2012; United States Department of Transportation, 2013). Dunkley (2004) suggests that rural areas can be considered ‘‘risky geographies’’ for teens. Compounding this risk, adolescents living in rural, frontier areas may face substantial barriers to accessing quality preventive health services Journal of Pediatric Health Care
that are developmentally appropriate (Curtis, Water, & Brindis, 2010; Elliott & Larson, 2004). Adolescents in general report barriers to seeking health care related to lack of knowledge, lack of insurance, transportation challenges, fear, and confidentiality concerns (Ginsburg et al., 1995; Klein, McNulty, & Flatau, 1998; Zimmer-Gembeck, Alexander, & Nystom, 1997). Adolescents in rural communities in particular have reported anxiety, access, self-reliance, nonsupportive parents, and helplessness as reasons for not accessing care (Elliott & Larson, 2004). Other concerns about seeking health care discussed by rural adolescents include mental health stigma, confidentiality, parental control, and preference for seeing coaches or athletic trainers for health care (Elliott & Larson, 2004). Confidentiality concerns are amplified in rural settings where there are fewer health care providers and anonymity is difficult to attain and maintain. Further, access to specialty care, such as mental health or reproductive health, is limited by geographic distance and lack of public transportation (Elliott & Larson, 2004). Recent recommendations from the Institutes of Medicine guided by the World Health Organization (WHO) framework describe adolescent-friendly health services as accessible (with broadly accessible services); acceptable (considering the culture and climate of engagement); appropriate (fulfilling the needs of young people); equitable (not restricting the provision of and eligibility for services); and effective (reflecting evidence-based standards of care; Lawrence, Gootman, & Sim, 2009; WHO, 2002). A review of health services in the United States compared with these guidelines suggests that primary care services are available to many adolescents but services are not available to those who are uninsured or underinsured, are not offered in settings that foster open communication about sensitive topics, are not provided by developmentally appropriate providers, and are not effective at fostering health promotion and risk reduction (Lawrence et al., 2009). Evidence-based clinical practice recommendations, such as Bright Futures, provide specific guidance for risk evaluation and health promotion topics during adolescent well-child examinations to address the key priority issues of physical growth and development, social and academic competence, emotional well-being, risk reduction, and violence and injury prevention (Hagan, Shaw, & Duncan, 2008). These guidelines address the leading causes of adolescent morbidity and mortality, including risk behaviors related to alcohol use, sexual activity, mental health, smoking, violence, and guns (Blum & Qureshi, 2011). Although these psychosocial issues are the biggest contributors to the health burden of adolescents, very few adolescents seek health care services to address these complex needs (Sawyer, Proimos, & Towns, 2010). Instead, adowww.jpedhc.org
lescents primarily seek health care services for respiratory or dermatologic concerns (Sawyer et al., 2010). In addition to clinical practice recommendations, a body of research supports the use of healthy youth development approaches that simultaneously reduce risk and promote health among adolescents (Bernat & Resnick, 2006). The effective implementation of healthy youth development strategies into practice includes a primary prevention focus to prevent problems before they occur and employs secondary prevention when necessary by reducing health risk factors and fostering health protective factors (Bernat & Resnick, 2006). These approaches have demonstrated success in the prevention and reduction of multiple adolescent health risk behaviors. Despite the gap between services that adolescents seek and the health burdens they experience, adolescents report a willingness to talk with and trust providers about preventive counseling topics including contraception, substance use, and sexually transmitted infection (Bethell, Klein, & Peck, 2001; Tylee, Haller, Graham, Churchill, & Sanci, 2007). Yet rates of screening and counseling on key topics including alcohol, depression, sexual activity, smoking, injury prevention, physical activity, and diet are consistently below levels recommended by established guidelines (Bethell et al., 2001; Ozer et al., 2005). Current trends in preventable adolescent morbidity and mortality underscore the importance of screening and preventive counseling. Although the majority of adolescents in the United States report a visit to a health care provider at least annually that could provide an important opportunity to incorporate preventive services, as previously noted, other studies suggest that rural youth access services at lower rates (Ozer et al., 2005). The objective of this study was to describe rural adolescents’ experiences with accessing adolescentfriendly health services inclusive of health-promoting information. METHODS Data Source This study uses data from the Rural Adolescent Health Survey (RAHS), an anonymous survey of 9th- to 12thgrade students (n = 322) attending secondary schools in four frontier counties of North Dakota between January and April of 2012. Frontier counties are defined as sparsely populated rural areas with population densities of seven or fewer people per square mile (Center for Rural Health, 2010). Students were recruited from participating schools (n = 4) using a convenience sampling technique. Within each school, all eligible students—that is, those in grades 9 through 12 who were present on the day of the survey—were invited to participate in the survey. Across schools, 98% of total eligible students were available and provided written assent to participate on the day of the survey. November/December 2014
535
Parent/guardian consent was obtained using passive consent procedures similar to the state’s process for obtaining parental consent for the Youth Risk Behavioral Surveillance Survey. Prior to survey administration, introduction and consent information were sent by mail and with students to the home of each student in grades 9 through 12 at participating schools. The introduction letter described the purpose of the study, what participants would be asked to do, the date of survey administration, and contact information for the research team. Parents/guardians were instructed to contact the school or research team by telephone or e-mail if they did not want their child to participate in the study. All study procedures were approved by the North Dakota State University Institutional Review Board. Measures The RAHS uses a battery of individual items from multiple previously established and validated adolescent health surveys to assess rural adolescents’ access to (a) preventive health services, (b) health promoting information, and (c) health and risk behaviors. For the current analyses, all items are from the Young Adult Health Care Survey (YAHCS; The Child and Adolescent Health Measurement Initiative, 2010). Adolescent-Friendly Health Services Access to adolescent health services was derived from two yes/no items: ‘‘Have you been to see a doctor, nurse, or other health provider in the last 12 months?’’ and ‘‘Has there been any time over the last 12 months when you thought you should get medical care but did not?’’ Acceptability was derived from four items that assessed how often providers listened carefully, explained things, showed respect, and spent enough time with adolescents in the past 12 months (a = 0.78; Bethell et al., 2001). For example, a question on the survey was, ‘‘In the last 12 months, how often did doctors, nurses, or other health providers show respect for what you had to say?’’ Response options were never, sometimes, usually or always. Appropriateness of health services was assessed by asking participants if a doctor, nurse, or other health provider discussed 20 preventative health topics (Bethell et al., 2001). Items included a measure of preventive screening and counseling on risky behaviors, sexual activity and sexually transmitted infections, weight, healthy diet and exercise, emotional health, and relationship issues. Response options for each topic were yes or no. The topics were reflective of the evidence-based Bright Futures Guidelines for anticipatory guidance with adolescents (Hagan et al., 2008). Health Risk Behaviors Five items assessed health risk behaviors associated with leading causes of adolescent morbidity and mor536
Volume 28 Number 6
tality and included seat belt use, feeling sad or hopeless, cigarette use, alcohol use, binge drinking, and sexual activity. For each item, response options were dichotomized to indicate risk. Participants were asked, ‘‘How often do you wear a seatbelt when riding or driving in a car?’’ Response options were dichotomized as never, rarely, sometimes, and most of the times versus always. Feeling sad or hopeless was assessed by asking participants, ‘‘During the last 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?’’ Response options were yes or no. Substance use was assessed using three items that asked participants how many days they smoked, had at least one drink of alcohol, or binge drank in the past 30 days. For example, binge drinking was assessed by asking participants, ‘‘During the last 30 days, on how many days did you have five or more drinks of alcohol in a row, that is, within a couple of hours?’’ Response options were dichotomized as 0 days versus 1 or more days. Sexual activity was assessed using the question, ‘‘Have you ever had sex?’’ Response options were yes or no. Statistical Analysis To characterize participants’ experiences in accessing adolescent-friendly health services, the distribution of reported access, acceptability, and appropriateness of health services was examined as previously described. Next, binomial logistic regression models examined associations between communication with a health care provider about health risk behaviors and participantreported risk behaviors. All analyses were completed using SPSS version 21 (SPSS Inc., Chicago, IL) and were conducted in 2013. RESULTS Participant Descriptors Reflective of the demographic profile of North Dakota, the majority of participants were White. Participants ranged in age from 14 to 19 years. There were slightly more boys than girls and slightly fewer participants in 9th grade compared with other grades. Nearly half of participants lived outside of town (Table 1). Adolescent-Friendly Health Services Overall, rural adolescents reported high access to primary health care services. Ninety-four percent (n = 303) of participants reported having seen a primary care provider in the past 12 months. However, one third of participants reported that it was usually/always a problem to get care when they believed it was necessary (Table 2). Most rural adolescents reported that their primary care providers listened carefully to them (80%), explained things in a way they could understand (86%), showed respect for what they had to say (85%), and spent enough time with them (80%), indicating high Journal of Pediatric Health Care
year compared with participants who reported using seat belts usually or always.
TABLE 1. Participant demographics Descriptor Race/ethnicity (check all that apply) American Indian/Native American Black, African, or African American White Other Age range (mean) Grade in school 9th 10th 11th 12th Received free or reduced-price lunch Yes No Don’t know Residence In town On farm or ranch Out of town, not farm or ranch
% (n) 4.7 (15) 1.6 (5) 90.7 (292) 6.5 (21) 14-19 (16.5) 21.4 (69) 26.1 (84) 25.8 (83) 24.8 (80) 18.9 (61) 53.7 (173) 26.1 (84) 53.1 (171) 34.2 (110) 10.2 (33)
levels of acceptability. Conversely, rural adolescents reported low levels of appropriate or effective health care services compared with Bright Futures recommendations (Table 2). For example, the most frequently talked about health promotion/risk screening topic reported was physical activity or exercise (45%), followed by smoking and alcohol use (44% and 43%). Other key risk topics were talked about less frequently, such as condom use (30%) and birth control (23%), suicide (20%), and helmet use (16%). Gun safety and other weapons were talked about least frequently (7%). Associations Between Health Care Experiences and Health Risk Behaviors In general, participant reports of engaging in a risk behavior were associated with significantly higher odds of having talked with a health care provider about that risk behavior in the past 12 months (Table 3). Participants who reported feeling sad or hopeless in the past year were more than three and a half times more likely to have talked with a health care provider about suicide compared with participants who did not report feeling sad or hopeless. Participants who reported smoking or binge drinking were also significantly more likely to have talked with a primary care provider about smoking and drinking compared with participants who did not report engaging in these behaviors (odds ratio [OR] = 3.52, 2.04, respectively). Likewise, participants who reported ever having sex had significantly higher odds of having talked with a health care provider about condom use and birth control in the past year compared with participants who reported never having sex (OR = 2.12, 3.59, respectively). Conversely, participants who reported not using seat belts were half as likely to report having talked with a health care provider about seat belt use in the past www.jpedhc.org
DISCUSSION Findings from this study suggest that rural adolescents may have high rates of access to acceptable health care services, yet the services they are accessing may not include important preventive health information and anticipatory guidance. Similar to other national samples of adolescents, the rural adolescents in this sample report very low rates of receiving anticipatory guidance consistent with professional recommendations, including Bright Futures (Irwin, Adams, Park, & Newacheck, 2009). Findings from this Anticipatory guidance ranged from a low of study suggest that 6.5% of participants rural adolescents receiving information may have high rates about guns or weapons to 45.3% of access to receiving information acceptable health about physical activity care services, yet and exercise. In only two categories did the services they nearly half of particiare accessing may pants report receiving not include anticipatory guidance: physical activity important (45.3%) and cigarettes, preventive health tobacco, or smoking information and (44.4%). Findings from this study also highanticipatory light disparities beguidance. tween this rural sample and national samples. For example, 15.8% of rural adolescents reported receiving information about wearing a helmet from a health care provider compared with 31.3% of a national sample (Irwin et al., 2009). Among a national sample of youth ages 12 to 17 years, only 40% report spending time alone with a health care provider, suggesting relatively low rates of counseling on sensitive topics (Irwin et al., 2009). Fewer than one third of the rural adolescents in this sample reported communicating with a health care provider about sensitive topics such as sexually transmitted infections (32.3%), condoms (30.1%), and sexual orientation (13.7%). Rural health care providers may be providing risk-based services that focus on secondary prevention to address risk behaviors that have already occurred rather than focusing on primary prevention. Health care providers in rural settings may be missing important opportunities to provide fundamental risk assessment and health promotion to adolescents. Ideally, all visits in a primary care center, including nonpreventive visits, should be used to provide developmentally appropriate anticipatory November/December 2014
537
TABLE 2. Participant-reported health care experiences and risk behaviors
Health care experiences Saw a doctor, nurse, or other health provider in the past 12 months Thought you should get medical care but did not in the past 12 months Doctors, nurses, or health care providers did the following in the past 12 months Listened carefully to you Explained things in a way you could understand Showed respect for what you had to say Spent enough time with you In the past 12 months, did a doctor, nurse, or other health provider talk with you about any of the following? Guns or weapons Sexual orientation Wearing a helmet Physical or sexual abuse Suicide Friends Birth control Drunk driving School Weight Condoms Sexually transmitted infections Healthy eating Wearing a seat belt Chewing tobacco Emotions/mood Drug use Alcohol Cigarettes, tobacco, or smoking Physical activity or exercise Health risk behaviors Seat belt use when riding or driving in a car Felt sad or hopeless in the past 12 months Cigarette use in the past 30 days 0 days 1 or more days Alcohol use in the past 30 days 0 days 1 or more days Binge drinking in the past 30 days 0 days 1 or more days Ever had sex
Yes % (n)
No % (n)
94.1 (303)
5.9 (19)
30.7 (99)
67.7 (218)
6.5 (21) 13.7 (44) 15.8 (51) 16.5 (53) 20.2 (65) 21.4 (69) 23 (74) 26.1 (84) 27 (87) 27.6 (89) 30.1 (97) 32.3 (104) 33.5 (108) 35.1 (113) 37.3 (120) 38.2 (123) 40.7 (131) 42.5 (137) 44.4 (143) 45.3 (146)
19.3 (62)
Usually/ always % (n)
Never/ sometimes % (n)
78.6 (253) 81.1 (261)
21.1 (68) 18.6 (60)
84.1 (271)
15.5 (50)
77.9 (251)
21.7 (70)
Always % (n)
Never/rarely/ sometimes/most of the time % (n)
27.6 (89)
70.2 (226)
87 (280) 80.1 (258) 77.3 (249) 77.3 (249) 72.7 (234) 71.7 (231) 73.9 (238) 67.7 (218) 66.5 (214) 66.1 (213) 68.3 (220) 61.5 (198) 59.3 (191) 58.7 (189) 57.1 (184) 55 (177) 57.1 (171) 55.6 (179) 54 (174) 48.8 (157)
79.8 (257)
78.3 (252) 21.2 (68) 50.6 (163) 48.8 (157) 68.9 (219) 30.7 (99) 46 (148)
51.2 (165)
Note. Because of missing data, totals do not always equal 100%. Missing data varies from 0.3% (n = 1) to 7.1% (n = 23). Total N = 322.
guidance for adolescents using evidence-based guidelines (Irwin et al., 2009). Similar to other studies, rural adolescents in this study reported at least annual encounters with primary health care providers (Elliott & Larson, 2004; Irwin et al., 2009). It is well established that unhealthy or risky behaviors are the 538
Volume 28 Number 6
leading causes of mortality and morbidity among adolescents (Elliott & Larson, 2004). However, fewer than half of rural adolescents in this sample reported receiving information from their primary care providers about leading causes of adolescent morbidity (e.g., substance use, condom and contraceptive use, Journal of Pediatric Health Care
TABLE 3. Effects of selected predictors on communication with health care provider in the past 12 months
Talked with health care provider about seat belt use Never, sometimes, usually wear seat belt Always wear seat belt Talked with health care provider about suicide Felt sad or hopeless 2 or more weeks in a row Did not feel sad or hopeless for 2 or more weeks in a row Talked with health care provider about cigarettes, tobacco, or smoking Cigarette use, past 30 days No cigarette use, past 30 days Talked with health care provider about alcohol use Alcohol use, past 30 days No alcohol use, past 30 days Talked with health care provider about binge drinking Binge drinking, past 30 days No binge drinking, past 30 days Talked with health care provider about condom use Ever had sex Never had sex Talked with health care provider about birth control Ever had sex Never had sex
Odds ratio
Confidence interval
.58*
.33-.92
1.00
3.64** 1.00
—
1.95-6.81 —
3.52** 1.00
1.98-6.25 —
1.55 1.00
.99-2.42 —
2.04** 1.00
1.25-3.13 —
2.12 1.00
1.30-3.47 —
3.59** 1.00
2.04-6.32 —
*p < .05. **p < .01.
and factors related to obesity), and fewer than one fourth reported receiving information about leading causes of mortality (e.g., unintentional injury, such as gun safety, and suicide). Because adolescents are typically physically healthy in general, providing clinical services that reduce risk and promote health by addressing these preventable causes of morbidity and mortality can help adolescents maintain health and develop a strong foundation for healthy adulthood (Elliott & Larson, 2004). Capitalizing on primary care clinical encounters may be especially beneficial in rural settings where access to services can be particularly challenging (Gamm, Hutchison, & Bellamy, 2002). As previous literature suggests, rural adolescents may face additional barriers to risk reduction and health promotion about sensitive topics, such as sexuality, because of elevated concerns about privacy and confidentiality (Elliott & Larson, 2004). Clinical encounters with adolescents that emphasize risk screening without simultaneously providing health www.jpedhc.org
promotion are contrary to effective healthy youth development strategies that deliberately provide all youth with support to prevent or reduce adolescent risk behavior, yet these data suggest that this is the approach being taken in rural communities (Bernat & Resnick, 2006). Given the higher rates of risk behaviors previously documented for rural compared with urban youth, shifting to a health promotion model has the potential to substantially reduce the negative health outcomes that rural youth experience. Utilizing primary prevention approaches to prevent adolescent risk behavior is also congruent with current shifts in health care that emphasize moving from treatment to prevention in response to high rates of preventable causes of morbidity and mortality among the U.S. population (Hellerstedt & Oberg, 2013). For example, the Affordable Care Act (ACA) has several provisions that have the potential to increase the number of rural adolescents in the United States who will be able to access preventive health services through expanded health insurance coverage and increased payment to rural health care providers (English & Park, 2012; Hellerstedt & Oberg, 2013). The expanded access to health insurance underscores the importance of capitalizing on the opportunity to improve health outcomes for rural adolescents and into young adulthood through acceptable and appropriate preventive health services. STRENGTHS AND LIMITATIONS This study has several limitations. These data are from a rural school-based survey, and therefore findings cannot be generalized to adolescents in other settings or those not attending school. However, by focusing on a rural sample from frontier counties, the present findings make a contribution to the limited amount of data that focus on rural adolescents (Brandy A. Randall, PhD, unpublished observations, 2012). Second, the RAHS utilizes a cross-sectional design; therefore any temporal relationships between experiences accessing adolescent-friendly health services and health risk behaviors cannot be examined. Third, this study used measures of adolescent-friendly health services derived from participant recall that do not include any objective measures, such as chart reviews. Therefore several possible scenarios may have impaired participants’ recall and reporting. For example, participants could have completed a prescreening questionnaire prior to their visit and only received information about topics that revealed elevated risk, or participants may not remember discussing certain topics with their provider. Finally, limitations of the survey instrument did not allow for analysis that included the purpose of the participants’ health care visits. IMPLICATIONS Adolescents in rural settings report high levels of trust and access to rural health care providers. It is imperative November/December 2014
539
that health care providers capitalize on all encounters with adolescents to identify areas for risk reeducation and health promotion. Several factors may It is imperative that inhibit providers’ abilhealth care ity to provide comprehensive care that providers capitalize integrates screening on all encounters and routine preventive with adolescents to counseling into clinic visits with adolescents. identify areas for For example, limited risk reeducation time may not allow and health providers to conduct time-consuming risk promotion. screening. In addition, many adolescents seek care for somatic, rather than psychosocial, complaints. Billing and coding reimbursement limitations may complicate the integration of health promotion into such visits. Future research to address the health promotion needs of rural adolescents should examine adolescents’ preferences for the delivery of information and other potential sources of receiving health promotion information, such as at home or at school. In addition, the content of discussions between providers and adolescents should be explored. Finally, the integration of screening and health promotion into clinic visit protocols should be delivered through multiple modes of communication, including one-on-one counseling, written information, and electronic communication. REFERENCES Bernat, D. H., & Resnick, M. D. (2006). Health youth development: Science and strategies. Journal of Public Health Management Practice, 10, S10-S16. Bethell, C., Klein, J., & Peck, C. (2001). Assessing health system provision of adolescent preventive services: The young adult health care survey. Medical Care, 39, 478-490. Blum, R. W., & Qureshi, F. (2011). Morbidity and mortality among adolescents and young adults in the United States: AstraZeneca fact sheet 2011. Retrieved from John Hopkins Bloomberg School of Public Health website: www.jhsph.edu/research/ centers-and-institutes/center-for-adolescent-health/az/_images/ US%20Fact%20Sheet_FINAL.pdf Center for Rural Health, The University of North Dakota School of Medicine & Health Sciences. (2010). North Dakota frontier counties. Retrieved from www.ruralhealth.und.edu/maps/ mapfiles/frontier.png Curtis, A. C., Water, C. M., & Brindis, C. (2010). Rural adolescent health: The importance of prevention services in the rural community. Journal of Rural Health, 27, 60-71. Dunkley, C. M. (2004). Risky geographies: Teens, gender, and rural landscape in North America. Gender Place & Culture: A Journal of Feminist Geography, 11, 559-579.
540
Volume 28 Number 6
Elliott, B. A., & Larson, J. T. (2004). Adolescents in mid-sized rural communities: Foregone care, perceived barriers, and risk factors. Journal of Adolescent Health, 35, 303-309. English, A., & Park, M. J. (2012). The Supreme Court ACA decision: What happens now for adolescents and young adults? Retrieved from http://nahic.ucsf.edu/wp-content/uploads/ 2012/11/Supreme_Court_ACA_Decision_Nov29.pdf Gale, J. A., Lendardson, J. D., Lambert, D., & Hartley, D. (2012). Adolescent alcohol use: Do risk and protective factors explain rural-urban differences? (Working paper No. 48.). Portland, ME: Maine Rural Health Research Center. Gamm, L., Hutchison, L., & Bellamy, G. (2002). Rural healthy people 2010: Identifying rural health priorities and models for practice. The Journal of Rural Health, 18, 9-14. Ginsburg, K. R., Slap, G. B., Cnaan, A., Forke, C. M., Balseley, C. M., & Rouselle, D. M. (1995). Adolescents’ perceptions of factors affecting their decisions to seek health care. JAMA: Journal of the American Medical Association, 273, 1913-1918. Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2008). Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, Illinois: American Academy of Pediatrics. Hellerstedt, W. L., & Oberg, C. N. (2013). The Affordable Care Act: Goals and mechanisms. Implications of the Affordable Care Act on MCH populations and public health services. Retrieved from University of Minnesota Board of Regents website: http://www.epi.umn.edu/mch/wp-content/uploads/2012/05/ HG_Fall20132.pdf Irwin, C., Jr., Adams, S. H., Park, M. J., & Newacheck, P. W. (2009). Preventive care for adolescents: Few get visits and fewer get services. Pediatrics, 123, e565-e572. Klein, J. D., McNulty, M., & Flatau, C. N. (1998). Adolescents’ access to care: Teenagers’ self-reported use of services and perceived access to confidential care. Archives of Pediatric and Adolescent Medicine, 152, 676-682. Lawrence, R. S., Gootman, J. A., & Sim, L. J. (2009). Adolescent health services: Missing opportunities. Washington, DC: The National Academies Press. Ozer, E. M., Adams, S. H., Lustig, J. L., Gee, S., Garber, A. K., Gardner, L. R., . Irwin, C. E. (2005). Increasing the screening and counseling of adolescents for risky health behaviors: A primary care intervention. Pediatrics, 115, 960-968. Sawyer, S. M., Proimos, J., & Towns, S. J. (2010). Adolescentfriendly health services: What have children’s hospitals got to do with it? Journal of Paediatrics & Child Health, 46, 214-216. The Child and Adolescent Health Measurement Initiative. (2010). Young Adult Health Care Survey (YACHS). Retrieved from http://cahmi.org/ViewDocument.aspx?DocumentID=56 Tylee, A., Haller, D. M., Graham, T., Churchill, R., & Sanci, L. A. (2007). Youth-friendly primary-care services: How are we doing and what more needs to be done? Lancet, 369, 1565-1573. United States Department of Transportation, National Highway Traffic Safety Administration. (2013). Traffic safety facts 2011 data: Rural/urban comparison. Retrieved from http://wwwnrd.nhtsa.dot.gov/Pubs/811821.pdf World Health Organization. (2002). Adolescent friendly health services: An agenda for change. Geneva, Switzerland: World Health Organization. Zimmer-Gembeck, M. J., Alexander, T., & Nystom, R. J. (1997). Adolescents report their need for and use of health care services. Journal of Adolescent Health, 21, 388-399.
Journal of Pediatric Health Care
