This study extends current research on services by describing rates of preventive services and disparities utilizing an adolescent-report perspective. These findings, from state-level data, represent the status of discussions of preventive health topics for approximately 1.75 million adolescents throughout California.
Our finding of low rates of preventive discussions for most topics, as reported by adolescents, is consistent with research based on provider records of counseling delivered and parental recall.10,12,13,18
Discussion of prevention topics during regular physical exams varied widely across risk topics. At least four out of five adolescents did not discuss helmet use, violence issues, or seatbelt use at their last physical exam visit. The latter is of particular concern, given that automobile crashes are the leading cause of death in this age group. More than two thirds of adolescents did not discuss substance use or STDs, and one quarter did not discuss nutrition or physical activity. Overall, adolescents were most likely to talk with their providers about nutrition and exercise, a finding consistent with other research,12
and least likely to talk about violence prevention.
Our analyses indicated that the presence of significant disparities in rates of health topics covered varied depending on the topic area. Our findings that younger adolescents were more likely to have discussions about safety and that older adolescents were more likely to discuss substance use and STD topics suggests that the content covered during the physical exam was influenced by adolescent age. While this may make intuitive sense in terms of which adolescents are more likely to be engaging in particular behaviors, discussing health behaviors with adolescents before they initiate risky behaviors is an important component of preventive services.
We had expected that minority adolescents and those in lower-income or uninsured groups would be less likely to report health discussions during routine visits. While we found disparities in several topics, in all but one instance the disparities were in the opposite direction of what we had anticipated. Hispanic adolescents reported significantly higher levels of discussing health topics than white adolescents in five of nine content areas including seatbelt, helmet, violence, nutrition, and STD screening, although only violence remained significant when we controlled for confounding factors. Asian adolescents were more likely to discuss seatbelt and helmet use in the unadjusted analyses, but these differences were no longer significant in the adjusted analyses.
Similar to findings from Rand et al.,12
black adolescents in our study reported preventive discussion rates that were either not significantly different from or were higher than rates for white adolescents in eight of nine content areas. In the cases where minority adolescents had higher health discussion rates than their white counterparts, we suggest that it is likely that clinicians may think that minority families require greater screening, either because of perceived elevated risk levels in families or communities, or because of perceptions that minority families may have reduced access to alternative resources for preventive health services. By contrast, black adolescents reported lower rates of discussing violence compared to their white counterparts. Further research regarding violence prevention in primary care settings is required to gain an adequate understanding of this finding.
Also contrary to our expectations, adolescents in the lowest income group were more likely to discuss five of nine the topics during health visits, including seatbelts, helmets, violence, nutrition, and STDs, compared to their highest income counterparts. Those who lacked insurance received higher levels of screening in seatbelt, helmet, violence, and STD topics compared to those with insurance. It is possible that providers perceived that lower income and uninsured youth had greater exposure to risk factors thus they made a point to cover more topic areas. It is also possible that insured adolescents and those in higher income groups were seen more frequently for physical exams and some health discussions took place at earlier visits.
There are limitations to the data set that require mentioning. The present assessment of health topics covered in routine visits allows us to quantify the breadth of preventive topics were covered during routine visits. However, we are unable to discern detail of the discussions and whether they included screening and/or counseling. Because the wording of the items asked whether the adolescent and their provider had talked about topics, we cannot identify who initiated the discussions. While we assume that it is primarily providers who initiate discussions about health topics, it is possible that adolescents may have initiated topics by raising a concern. Nevertheless, the pattern of rates that we found was similar to those found in previous research that specifically assessed provider behaviors, suggesting that there is correspondence between this measure and measures of provider screening. 26
As necessitated by large surveys, the wording of the screening question topics (e.g., nutrition, violence or violence prevention) was brief. It is possible that adolescents may have talked about aspects of the topics with providers at their exams, but did not identify that discussion as fitting into one particular topic. More in depth research focusing on adolescent perception of preventive services during physical exams including clear identification of who initiates discussions would help improve our understanding of what adolescents experience during their physical exam visits.
While the presence of disparities is noteworthy, it is important to keep in mind that regardless of age, gender, race/ethnicity, income and insurance levels, the delivery of preventive services were distressingly low for all topics except nutrition and physical activity. This is of concern, given the wide promotion of the new Bright Futures
a consensus document that promotes preventive care for pediatric populations, and the evidence that training and tools in clinical practice can increase the delivery of preventive services.28-30
Increased investment and effort are required to improve of the delivery of preventive services, so that all adolescents may benefit from adequate knowledge about the importance of healthy behaviors across the lifespan.