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Male adolescents frequently become disconnected from health care, especially as they get older, which limits physicians’ abilities to address their health needs and results in missed opportunities to connect them to the health care system as they enter adulthood. In this study we tested the ability of modifiable (beliefs about masculinity, parental communication, sex education, and health insurance) and nonmodifiable (age, race/ethnicity, and region of residence) factors to prospectively predict health care use by male adolescents.
We conducted a prospective analysis of data from 1677 male participants aged 15 to 19 years who completed the National Survey of Adolescent Males, a household probability survey conducted throughout the United States in 1988 (wave 1, participation rate: 74%) and in 1990–1991 (wave 2, follow-up rate: 89%). We present percentages and adjusted relative risks of the factors that predict male adolescents’ self-report of a physical examination by a regular provider in the past year measured at wave 2.
On average, 1067 (66%) of 1677 male adolescents at wave 2 reported having a physical examination within the last year. Factors associated with a lower likelihood of a physical examination included living in the South, Midwest, and West; being older in age; and holding more traditional masculine beliefs. Factors associated with a higher likelihood of a physical examination included communicating about reproductive health with both parents and being insured. Male adolescents who were sexually active or engaged in ≥2 other risk behaviors had neither a higher nor lower likelihood of a physical examination.
Efforts to enhance male adolescents’ health through health care should include work to modify masculine stereotypes, improve mothers’ and fathers’ communication about health with their sons, expand health insurance coverage, and identify interventions to connect male adolescents at increased risk for health problems with health care.
Most causes of adolescent male morbidity and mortality are preventable.1,2 This is the basis for practice guidelines that recommend clinical preventive services for all adolescents as part of annual or tailored visits.3-7 Two adolescent clinical preventive services supported by research include that physicians provide reproductive health services (eg, sexually transmitted infection [STI]/HIV screening, counseling, and testing) to male patients between 11 and 21 years of age and age-appropriate immunizations.3-8 Whether physicians are able to provide preventive health services to adolescent male patients depends on this populations’ involvement in the health care system.
Male adolescents frequently become disconnected from health care, especially as they get older.9,10 A better understanding of modifiable factors that influence adolescent male health care use would improve our ability to develop interventions to increase adolescent male connections to health care. The Andersen’s Behavioral Model of Health Services Use has been used to examine factors that influence health care use and proposes that use is influenced by enabling factors that provide resources, predisposing factors that provide motivation, and health needs that provide actual stimulus to engage in care.11 Previous studies show that enabling factors that represent adolescent barriers to care include lower socioeconomic status,12 lack of health insurance,13,14 and lack of a regular source of care,15 whereas factors that promote adolescent male access to care include the availability of confidential services,16,17 gender of the provider,18 assistance with appointment making,19,20 and school-based health clinics.9 Predisposing factors associated with the lower use of health care by male adolescents include being older in age,9 being of minority race/ethnicity,21 and lacking knowledge/sources of health care information.22 Few studies have examined how adolescent male health needs23 and. in particular. needs related to reproductive health, influence their health care use.
Two modifiable factors that may influence adolescent male health care use have been largely ignored in the research literature. First, although parent-teen communication has been shown to be an important contributor to adolescent health, the relationship between parental communication and access to care for sons has received little attention. Second, the way in which men are socialized in the United States (eg, to be tough, competitive, and inexpressive), defined as beliefs about masculinity, has been shown to influence adult men’s health care use24-26 but has not been examined in adolescence.
The National Survey of Adolescent Males (NSAM) provides a unique opportunity to address gaps in our knowledge. The main objective of this prospective study is to test the combined influence of modifiable and non-modifiable factors, organized around Andersen’s Behavioral Model of Health Services Use framework, to predict the report of health care use by male adolescents. We also specifically focus on the relationship among beliefs about masculinity, parental communication, and health care use while controlling for other factors.
Data for these analyses come from the first and second waves of the NSAM. NSAM used an area probability sampling frame based on census data that provides a racially and ethnically representative household sample of noninstitutionalized never-married US male adolescents ages 15 to 19.27 NSAM wave 1 was conducted in 1988 (response rate: 74%; N = 1880). NSAM wave 2 was conducted 2 years later in 1990–1991 (follow-up rate: 89%; N = 1677). Temple University and Brandeis University human subjects review boards approved NSAM procedures. Adult participants provided verbal consent; parental consent and verbal assent was obtained for minors. Survey administration consisted of a 1-hour in-person interview followed by a self-administered paper-and-pencil questionnaire to collect more sensitive information.
Anderson’s Behavioral Model of Health Services Use,11 coupled with variables known to be associated with adolescent male health care use, guided variable selection for this analysis. Unless specified, variables were assessed by self-report at wave 1.
Demographics included participant’s age and race/ethnicity coded as non-Hispanic white, non-Hispanic black, Hispanic, or other race. Region of residence, measured by census tract information, was coded categorically as Northeast, South, Midwest, or West. Urbanicity, measured by census tract information, was coded categorically as urban or nonurban. Family composition at age 14 years was coded as living in a single- or 2-parent household.
Parental communication about reproductive health was measured by asking whether participants communicated with parents or people who raised them about any of 6 reproductive health topics (eg, pregnancy, STIs, contraception, HIV/AIDS, menstruation, and what happens if he got a girl pregnant) with responses coded categorically as no communication with parent(s), communication about ≥1 topic with only 1 parent, or communication about ≥1 topic with both parents (together or separately). Hours of sex education ever received in school or an organized program was coded as <5 hours or ≥6 hours.
Beliefs about masculinity were assessed using a 12-item scale that is conceptualized as beliefs in the importance that men adhere to culturally defined standards for male behavior.28 Scale items were introduced by the question, “How much do you agree or disagree with the following statements?” Item examples included “men are always ready for sex,” “it is essential for a guy to get respect from others,” and “I could be friends with a gay person.” Responses were coded on a 4-point Likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree; Cronbach α = .67). For these analyses, using cut points of 1 SD below and above the mean, scale scores were classified as representing less, neutral, and more traditional beliefs about masculinity, respectively.
Mother’s education level was measured by highest schooling level completed and coded as an ordered categorical variable. Annual family income was coded as an ordered categorical variable (with $10 000 increments up to $50 000 or more).
Insurance status during the past 12 months was measured at wave 2 and coded as insured (any type) or uninsured (no insurance).
School performance was measured by participants’ response to “how well they did in school” with responses coded on a 5-point Likert-type scale ranging from 1 (well below average) to 5 (well above average).
Wave 1 measures for risk of health problems were “have you ever had sex?” and “have you ever had any STI including gonorrhea, syphilis, herpes, warts and HIV/AIDS?” Measure also include sum composite comorbidity risk score developed from responses to involvement in 5 risk behaviors23: “Have you ever drunk alcohol?”; “…used tobacco?”; “…used cocaine?”; “…been picked up by the police for doing something wrong?”; and “…tricked or forced someone to have sex?” This score was coded categorically on the basis of responses indicating involvement in 0 to 1 vs ≥2 risk behaviors. At wave 2, participants were also asked “have you had a serious illness or injury since the last interview?”
Health care use was measured by response to, “When was the last time you saw your regular care provider for a physical examination?” with responses coded as >12 months or ≤12 months.
The University of Maryland’s human subjects review board provided approval to perform secondary data analysis. Data were prepared and analyzed using SPSS 12.0 (SPSS Inc, Chicago, IL) and Stata 9.0 (Stata Corp, College Station, TX), respectively. Descriptive analyses reported for the full sample are weighted. Sample weights were calculated as the product of the basic sampling rate that takes into account sampling framework, screening nonresponse rate, interview nonresponse rate, and attrition.27,29
Unweighted univariate logistic regression analyses were first conducted to examine relationships between predictor variables and health care use. A P value of <.10 determined variables to include in the final model. Two nonsignificant yet conceptually important health needs (eg, sexual activity and engaging in other high-risk behaviors) were included in the final model, because male adolescents involved in these behaviors are at risk for experiencing negative health outcomes.
Next, the final set of covariates was assessed for multicollinearity, and none was found. Unweighted multivariate analyses were then performed. A Poisson model was applied in the multivariate analyses to calculate the relative risk (RR),30 because odds ratios overestimate RR when main outcomes are common (>10%) and, thus, lead to inaccurate estimates of health care use.31 All of the predictor variables were entered simultaneously into the regression model to produce adjusted incidence rate ratios.30 Thus, RR represents the association of each predictor variable with the dependent variable after accounting for the influence of all of the other variables.
For multivariate analyses, participants who had missing data for mother’s education (n = 170 [10%]) and family income (n = 104 [6.2%]) were replaced with the sample’s mean for that variable. Dummy variables were created for each of these variables to represent missing data and were included in the final model.32 Multivariate analyses were performed with and without mean replacement for missing data, and findings were not significantly different; because 10% of participants had missing data for mother’s education, multivariate analyses presented here use mean replacement.
Participants had a mean (±SD) age of 16.9 (±1.4) years and were predominantly non-Hispanic white (73.2%). Approximately one third lived in the South, two thirds in urban settings, and one fifth in single-parent households. Approximately three quarters communicated about reproductive health with 1 or both parents, and approximately half reported they had received ≥6 hours of sex education in school or an organized program. The participant mean (±SD) beliefs about masculinity score was 2.6 (±0.4); that is, on average, male adolescents had neutral masculine beliefs (Table 1).
Participants’ mean (±SD) mother’s education level was 12.9 (±2.6) years. There was equal representation from all of the family income levels. During the 12 months preceding the second interview, 85.4% of participants were insured. Behaviors associated with health needs were reported by many: 59.6% ever had sex, 3.6% ever had an STI, 16.3% had a serious illness or injury, and 20.3% engaged in ≥2 risk behaviors (Table 2).
Approximately two thirds of the participants (66%) reported that the last time they saw their regular care provider for a physical examination was within the last year (Table 1).
Bivariate analyses revealed that male adolescents who were less likely to have a physical examination in the past year were Hispanic versus non-Hispanic white (53.8% vs 68.6%; Table 1); lived in the South (60.9%) and West (63.8%) versus Northeast (74.4%); lived in the South versus Midwest (60.9% vs 69.8%); were age 19 vs 15 (62.1% vs 72.3%); lived in single-parent versus 2-parent households (55.9% vs 68.9%); and held more traditional masculine beliefs (51.3%) versus neutral (66.9%) or less traditional beliefs (68.8%). Male adolescents who communicated about reproductive health with both parents (73.7%) were more likely to have a physical examination than male adolescents who had no communication with either parent (55.6%) or who communicated with only 1 parent (59.8%).
Bivariate analyses revealed that male adolescents who were more likely to have a physical examination in the past year had mothers with higher educational versus mothers with lower educational levels; were from higher versus lower income families; and were insured versus uninsured (Table 2).
Male adolescents who were sexually active or engaged in ≥2 risk behaviors were neither more nor less likely to have a physical examination than male adolescents who were not sexually active or engaged in less risk behavior (Table 2).
Multivariate analyses showed that region of residence, age, parental communication about reproductive health, beliefs about masculinity, and insurance prospectively predicted having a visit to a regular care provider for a physical examination in the last year while controlling for all other factors (Table 3). Male adolescents who were less likely to have a physical examination in the past year lived in the South, Midwest, and West versus Northeast (RR [95% confidence interval (CI)]: 0.81 [0.74–0.89], 0.89 [0.80–0.98], and 0.87 [0.77–0.97], respectively); were age 19 vs 15 years (0.86 [0.75–0.98]); and held more traditional masculine beliefs versus neutral beliefs (0.86 [0.77–0.96]). Male adolescents who were more likely to have a physical examination within the past year communicated about reproductive health with both parents versus no communication with either parent (1.14 [1.04–1.26]) and were insured versus uninsured (1.62 [1.40–1.87]). The other significant bivariate relationships did not persist in multivariate analyses.
We conducted an exploratory posthoc analysis to determine whether the impact of different sources of parental communication on health care use varied according to age, family composition, and beliefs about masculinity while controlling for factors described in the previous multivariate analysis. For these analyses we ran separate multivariate models stratified by age (15–17 and 18–19 years), family composition (single- and 2-parent households), and masculine beliefs (less traditional, neutral, and more traditional).
Sources of parental communication on health care use were found to vary by age, family composition, and masculine beliefs (Table 4). Analyses by age found that communication about reproductive health with both parents predicted increased health care use in the last year for younger and older male adolescents, although the importance of talking with both parents together varied by age. Analyses by family composition found that, among male adolescents who live in 2-parent households, those who communicate with both parents separately are more likely to have a physical examination than male adolescents who do not communicate with either parent (1.15 [1.01–1.30]). Parental communication did not influence the use of health care among male adolescents in single-parent households. Analyses by masculine beliefs found that, among male adolescents with more traditional beliefs, those who communicated with their father only or both parents together were more likely to have a physical examination than male adolescents who did not communicate with either parent (RR [95% CI]: 1.61 [1.13–2.29] and 1.55 [1.09–2.20], respectively). As shown in Table 4, a nearly identical pattern was found for male adolescents with less traditional masculine beliefs.
Three modifiable factors (masculine beliefs, parent-teen communication, and insurance status) prospectively influence health care use among male adolescents in the United States. These findings can be used to inform interventions to improve adolescent male health through increased use of health care.
To our knowledge, this is the first report linking adolescents’ beliefs about masculinity and male roles to health care use behaviors. Our findings that male adolescents with more traditional masculine beliefs are less likely to get health care is consistent with research focused on adult men.26 Our findings demonstrate that such attitudes may hinder adolescent male use of health care and may be consistent with Courtenay’s33 suggestion that boys’ lack of help seeking can itself be considered a risk behavior. Within this context, additional research is needed to better understand how masculine beliefs influence adolescent male care-seeking behaviors. Programs that promote health and gender equity among boys are currently under evaluation.34,35 These programs are designed, in part, to target mythology that suggests that care-seeking is a sign of weakness and to promote the belief that care seeking can be consistent with the male role and seen as a sign of strength. An alternative strategy that warrants investigation among male youth populations may be to promote health and target services in a manner that is more congruent with traditional male gender roles.36,37
Parent-teen communication has long been accepted as an important contributor to adolescent health.22,38,39 Studies that examine parent-teen communication about sex have reported gender-specific issues (that mothers are more likely than fathers to talk with their children about sex and that mothers talk more to daughters than to sons).40,41 Also, the influence of mothers has been shown to outweigh that of fathers as it relates to the sexual behaviors of their teenage sons and daughters.38 Our findings provide new insight into the relationship between parent-son communication about reproductive health and health care use and highlight the unique importance of father-son communication. In this study, communication with both mothers and fathers predicted increased health care use for male adolescents regardless of age and for sons with either more or less traditional masculine beliefs. For adolescent sons with either more or less traditional beliefs, talking with fathers about reproductive health issues seems to be particularly important. Isolated mother-son communication did not predict health care use in our study. Future research is needed to examine the content and quality of parent-son communication as it relates to male use of health care and to further explore parental communication within the context of single-parent households.
Consistent with existing literature, insurance plays a major role in whether male adolescents get health care. The proportion of male adolescents in our study who reported that they were uninsured (14.6%) is similar to that of more recent national samples (F. L. Sonenstein, PhD, written communication, 2006 [data from the National Survey of Family Growth]).13 Newacheck et al13 recently reported that adolescents who reside in regions outside the Northeast are more likely to be uninsured. Our study shows that regional variation in health care use persists after controlling for insurance status. Strategies to reduce adolescent male barriers to care may, thus, include extending insurance coverage to all adolescents and young adults, developing equitable insurance plans for male adolescents and young adults that are comparable to reproductive health care services available for female adolescents and young adults (eg, family planning) and improving access to care in all of the US regions.
It is important to highlight that male adolescents who are at higher risk of health problems on the basis of reported risk-related behaviors (eg, sexual intercourse, substance use, and truancy) are equally likely to have a physical examination in the last year when compared with lower-risk adolescents after controlling for serious illness or injury. This is unfortunate, because male adolescents engaging in risk-related behaviors may benefit the most from connections to the health care system. Strategies to identify and connect this population to care are needed and may involve collaboration with allied professionals (eg, teachers, counselors, and community leaders) and the juvenile justice system.23,42 These strategies will need to be linked to efforts to support physicians’ delivery of high-quality adolescent clinical preventive services, such as STI/HIV testing and age-appropriate immunizations.43-45
A major strength of this study is its prospective nature and the use of a racially and ethnically diverse national sample. This study also has several potential limitations. First, self-report measures have inherent limitations, although adolescent reports of their own health care behaviors are probably at least as accurate as those of parental report. Second, there are limitations with our main outcome variable. We are unable to determine the reason that respondents had a physical examination by their regular care provider, so we cannot distinguish acute from routine visits. Furthermore, we are unable to independently test the influence of having a regular source of care on health care use, because these variables were linked in the original survey instrument. This combined measure does decrease the risk of overestimation of adolescent male health care, because it described examinations linked to a regular source of care from examinations provided in group settings as part of sports clearance events.46 Third, bias based on attrition between waves is possible. The risk for bias is expected to be small, because previous analyses have shown no attrition bias in the areas of sexual or contraceptive behaviors47 or in any of the other the main study variables except for age (older boys were less likely to follow-up at wave 2; P < .04). Next, the internal reliability of the masculine beliefs scale is somewhat lower than that traditionally found for scales used in behavioral research. Although this scale may not fully capture masculine beliefs, it is able to prospectively differentiate adolescent male health care use, thus demonstrating construct validity. Finally, NSAM is an older data set, but we believe our findings are still relevant given the expected stability of our main study predictor and outcome variables. NSAM remains a seminal prospective data set to examine adolescent male reproductive health. This data set provides us a unique opportunity to examine prospectively whether modifiable factors, including masculine beliefs and parental communication, within the context of an organized framework are related to adolescent male health care use.
Our study suggests that efforts to enhance adolescent male health through health care should include work to modify masculine stereotypes, increase mothers’ and fathers’ communication about health with their sons, and expand health insurance coverage. Specific efforts to connect male adolescents at high risk of health problems to health care are needed. Primary care providers should encourage mothers and fathers to talk with their sons about general and reproductive health and the importance of connections with health services. Whether establishing better connections between male adolescents and health care can subsequently lead to better connections between adult men and health care (and improved men’s health) is an important area of future longitudinal research.
Support was provided by National Institute for Child Health and Human Development grant NIH 1 K23 HD47457-01 (to Dr Marcell), Centers for Disease Control and Prevention grant CDC 1 U48 DP000040-01 (to Dr Sonenstein), and Cooperative State Research, Education, and Extension Service, US Department of Agriculture project ILLU-45-0366 (to Dr Pleck). Funding for data collection was provided by National Institute of Child Health and Human Development grant RO1 HD30681, with additional funds from the Office of Population Affairs, the National Institute of Mental Health, and the Centers for Disease Control and Prevention. Funding for the work performed by the Data Archive on Adolescent Pregnancy and Pregnancy Prevention to prepare the data for public use was provided by the National Institute of Child Health and Human Development and the US Office of Population Affairs under contract N01-HD-9-3306 to Sociometrics Corporation.
The data used in this publication were made available by the Data Archive on Adolescent Pregnancy and Pregnancy Prevention, Sociometrics Corporation. The study titled “The National Survey of Adolescent Males, Old Cohort, Waves 1–3, 1988, 1990–91, 1995” was conducted by Freya L. Sonenstein, Joseph H. Pleck, Leighton Ku, and Charles F. Turner of the Urban Institute.
The original funding agency and Data Archive on Adolescent Pregnancy and Pregnancy Prevention are not responsible for the analyses or interpretations presented here.
The authors have indicated they have no financial relationships relevant to this article to disclose.
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/119/4/e966
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