Appointment-keeping behavior in adolescents: factors associated with follow-up appointment-keeping.

STUDY OBJECTIVES: To identify the sociodemographic and Health Belief Model predictors of follow-up appointment-keeping behavior. DESIGN: Prospective observational study. SETTINGS: General adolescent medical clinic. PATIENTS AND MEASUREMENTS: Sequential sample of 166 adolescents (aged 12 to 20 years, mean = 15.9 years) enrolled in the clinic. The population was 75% female; the racial-ethnic distribution of the sample was 37.9% black, 29.8% white, 11.2% Asian, 14.3% Hispanic, and 6.8% "other" background. Subjects' social class was primarily lower-middle (60.5%) and middle class (28.6%). A subsample was randomly assigned to be interviewed about their beliefs concerning their follow-up appointment and the constructs of the Health Belief Model. RESULTS: Forty-eight percent of the total sample failed to keep their follow-up appointment. There was a significant positive correlation between social class and appointment keeping (F = 5.07; df = 5,110; P = .026). Neither race-ethnicity nor who made the appointment were found to be associated with follow-up appointment-keeping. The only construct of the Health Belief Model found to be significantly associated with appointment keeping was the number of potential negative outcomes resulting from noncompliance perceived by the subject (F = 6.85; df = 1.74; P = .011). CONCLUSIONS: Clinicians must work with adolescents to improve their understanding of the potential negative outcomes associated with noncompliance to improve appointment-keeping behavior.

Conceptions of illness in young adolescents.

This study examined conceptions of illness in young adolescents. A group of 77 urban junior high school students aged 11 to 15 years were asked for their definitions of illness. Themes occurring in definitions of illness were identified and coded according to a previously developed coding scheme. Evidence in support of a developmental process underlying conceptions of illness was found by examining adolescents' definitions and comparing them with child and adult norms established in prior research. Results for adolescents showed the frequency of use of specific themes to fall between child and adult norms. The strongest evidence in support of a developmental trend was seen in definitions of illness pertaining to changes in daily activities. However, the relative frequency of adolescents' definitions was more like that of children than adults, indicating that whereas adolescents used a greater frequency of adult-like themes, they did so within a framework more descriptive of children. Qualitative aspects of definitions of illness showed age-linked differences with adolescents generating more adult-like, conceptually sophisticated definitions than children. In addition to developmental differences, similarities in definitions of illness were also found; among all age groups the most common delineators of illness were physical symptoms. Psychosocial themes were less frequently mentioned. Clinicians who discuss with their adolescent patients the ways in which illness affects social interaction may be communicating more effectively than practitioners who focus solely on signs and symptoms of physical disease.

Health-risk behaviors and health concerns among young adolescents.

This study examined the health concerns and behaviors of 563 adolescents (aged 11 through 14) from a variety of social, racial, and ethnic backgrounds. Behaviors associated with adolescent morbidity and mortality were examined, including sexual behavior, substance use, and injury-related behaviors. Although young adolescents are often viewed as unlikely participants in these risk behaviors, the results of this study suggest that greater attention should be paid to this younger group and their health-risk behaviors. A majority of the sample had tried alcohol and tobacco, and almost a third had used marijuana. Twenty-one percent were sexually active. Prevalence rates varied by social class, race-ethnicity, gender, and age. More than 75% of the sample had visited a physician during the prior year, suggesting an important role physicians may serve as sources of information and positive role models for these young adolescents. The results suggest that we stop viewing young adolescents as naive children and begin to view them as observers of and participants in a changing social environment that has important implications for their current and future health status. Without a realistic appraisal of the young adolescent, we can expect to have little overall effect on the status of adolescent health in the United States.

Delivery of confidentiality assurances to adolescents by primary care physicians.

OBJECTIVE: To investigate physicians' practices in assuring confidentiality to adolescent patients. DESIGN: Mail survey. SETTING: California. PARTICIPANTS: Seven hundred eighty-six board-certified physicians in family practice, internal medicine, obstetrics and gynecology, or pediatrics (response rate, 65%). MAIN OUTCOME MEASURES: Physicians were asked the percentage of adolescent patients (15 to 18 years old) with whom they discuss confidentiality during routine visits and the content of their assurances of confidentiality. A clinical vignette assessed physicians' knowledge of legal guidelines for confidential treatment of adolescents. RESULTS: Physicians reported discussing confidentiality with 53% (on average) of their adolescent patients. Eleven percent of physicians did not discuss confidentiality with any adolescent patients. Hierarchical linear regression used to control for other physician demographic and practice factors showed that female physicians were more likely to discuss confidentiality than were male physicians (R2 change = 0.03, P < .001). There was also an association between specialty and discussing confidentiality (R2 change = .04, P < .001); obstetricians and gynecologists were more likely to discuss confidentiality than were other primary care physicians (beta = .21, P < .001). Among physicians who discussed confidentiality, 64% assured unconditional confidentiality and 36% assured conditional confidentiality. When asked about legal guidelines for managing a 15-year-old patient with a sexually transmitted disease, 63% of physicians responded correctly, 5% responded incorrectly, and 31% were unsure of management guidelines. CONCLUSIONS: Physicians do not consistently discuss confidentiality with their adolescent patients. Most of the physicians who discuss confidentiality, with adolescents assure unconditional confidentiality, which is inconsistent with professional guidelines or the legal limitations of confidentiality.

Features of sexually transmitted disease services important to African American adolescents.

OBJECTIVE: To determine the relative importance of various features of health clinics when African American adolescents consider seeking care for sexually transmitted diseases (STDs). DESIGN: Confidential interviewer-administered telephone survey. SETTING: A predominantly low-income, African American neighborhood in San Francisco, Calif. PARTICIPANTS: Random sample of African American adolescents aged 12 to 17 years; 302 (76.6%) of 394 identified eligible adolescents participated. MAIN OUTCOME MEASURES: Items and scales measuring adolescents' sense of the importance of the attributes of the provider (alpha = .58), availability of services (alpha = .61), and perceived confidentiality of health services from family (alpha = . 72) when deciding where to seek care for possible STDs. RESULTS: More than 90% (90.4%) of subjects rated items relating to provider attributes as being highly important when they consider where they would seek care for an STD; between 62.5% and 82.7% rated availability items as being highly important; and between 38.6% and 60.8% rated items pertaining to confidentiality as being highly important. Greater importance was placed on provider attributes and confidentiality by female than male adolescents. The importance placed on provider attributes and confidentiality increased as adolescents aged. CONCLUSIONS: Low-income, African American adolescents place great importance on provider attributes, less importance on availability, and even less importance on confidentiality when deciding where to seek health care for a possible STD. Health care providers and organizations need to be aware of these adolescent preferences to better promote screening and treatment of STDs in this population.

Preventive services in a health maintenance organization: how well do pediatricians screen and educate adolescent patients?

OBJECTIVE: To determine whether pediatricians in managed care settings adhere to national guidelines concerning the provision of clinical preventive services. DESIGN: Surveys were mailed between September 1996 and April 1997 to all pediatricians practicing in a California group-model health maintenance organization. The survey asked pediatricians about their screening and education practices on 34 recommended services and the actions taken with adolescent patients who have engaged in risk behavior. RESULTS: The response rate was 66.2% (N = 366). Pediatricians, on average, screened 92% of their adolescent patients for immunization status and blood pressure; 85% for school performance; 60% to 80% for obesity, sexual intercourse, cigarette use, alcohol use, drug use, and seat belt and helmet use; 30% to 47% for access to handguns, suicide, eating disorders, depression, and driving after drinking alcohol; fewer than 20% for use of smokeless tobacco, sexual orientation, sexual and physical abuse, and riding a bike or swimming after drinking alcohol; and 26% to 41% for close friends' engagement in risk behavior. Pediatricians' assessment and education with adolescent patients who screened positive for risk behavior was particularly low. Female physicians, physicians who saw a greater proportion of older adolescents, and recent medical school graduates were more likely to provide preventive services. CONCLUSIONS: Pediatricians in this health maintenance organization provide preventive services to adolescent patients at rates below recommendations but at rates greater than physicians in other practice settings. Improvement is especially needed in the areas that contribute most to adolescent mortality and for patients who screen positive for a risk behavior.

Utility of the theories of reasoned action and planned behavior for predicting physician behavior: a prospective analysis.

The utility of the theory of reasoned action (TRA) and the theory of planned behavior (TPB) for prospectively predicting physicians' delivery of preventive services was compared. Primary care physicians (N = 765) completed 2 mail surveys at periods 6 months apart. The addition of perceived behavioral control to the TRA model significantly increased the variance accounted for in behavioral intention and subsequent behavior (p < .001). TPB constructs were related to physicians' intentions to educate adolescents about sexually transmitted disease transmission (R = .52, p < .001) and to their subsequent delivery of this service (R = .63, p < .001). Perceived behavioral control had direct effects on behavior and interacted with social norms and behavioral intentions. Applications of models such as the TRA or TPB have focused primarily on predicting the behavioral intentions and behaviors of patients. Results suggest that these models have relevance for studying the behavior of health care providers as well.

Concepts of health and illness: different constructs or variations on a theme?

Although health and illness concepts are thought to be important mediators of health and illness behaviors, little work has been done examining health concepts, and no research has examined the two conceptual structures simultaneously. This study examined concepts of health and illness in 218 adolescents between the ages of 11 and 18 years. Results were consistent with the hypothesis that concepts of health and illness are not opposite ends of a single health dimension, but reflect different and overlapping constructs. The degree of overlap varied as a function of age, with health concepts showing less emphasis on "the absence of illness" with greater maturity. The results suggest that models of health behavior that focus on illness avoidance neglect many components of health salient to lay persons.

Autonomy, relatedness, and the initiation of health risk behaviors in early adolescence.

This study examined the relationships among sociodemographic characteristics, family processes, and the initiation of health risk behaviors in early adolescence. Subjects were 189 6th and 7th graders from a public middle school. A path-analytic model was used to analyze data. Results showed that students who received autonomy support from parents were less likely to initiate sexual intercourse. Students who were emotionally detached from their parents were more likely to fight and use substances. Those who were emotionally detached tended to come from families with low levels of cohesion and acceptance. Sociodemographic variables, such as family structure, gender, and ethnicity, had both direct and indirect effects on health risk behaviors, but the indirect effects were quite small.

The role of behavioral experience in judging risks.

This study used conditional risk assessments to examine the role of behavioral experiences in risk judgments. Adolescents and young adults (ages 10-30; N = 577) were surveyed on their risk judgments for natural hazards and behavior-linked risks, including their personal experiences with these events. Results indicated that participants who had experienced a natural disaster or engaged in a particular risk behavior estimated their chance of experiencing a negative outcome resulting from that event or behavior as less likely than individuals without such experience. These findings challenge the notion that risk judgments motivate behavior and instead suggest that risk judgments may be reflective of behavioral experiences. The results have implications for health education and risk communication.

Initiation of substance use in early adolescence: the roles of pubertal timing and emotional distress.

Two hypotheses regarding the effects of pubertal timing on substance use were tested in a prospective study of 221 young adolescents. A maturational-deviance hypothesis predicted that early-maturing girls and late-maturing boys would experience heightened emotional distress, which in turn would influence initiation and use of substances. Alternatively, an early-maturation hypothesis predicted that early-maturing girls would engage in more substance use than all other groups, independent of emotional distress. Early-maturing adolescents reported more substance use within 1 year. Adolescents experiencing elevated levels of negative affect also reported greater substance use within the next year. However, pubertal timing was not related to emotional distress. Results support the early-maturation hypothesis for girls and suggest its extension to boys.

Adolescent health. Challenges for behavioral scientists.

Clearly, the role of behavioral scientists in adolescent health is not limited to service delivery. They also have a role to play via their contributions to basic knowledge of adolescent health and development, their involvement with the design and evaluation of health systems, their efforts to design and evaluate interventions to reduce adolescent morbidity and mortality, and their contributions to adolescent health policy. The once popular view of adolescence as a period of inevitable storm and stress has been replaced by one that emphasizes the potential of this developmental stage for constructive adaptation and maturation. Behavioral scientists have an important role to play in assuring that the potential of this life stage is reached for future generations of youth.

Sexually-transmitted disease in female adolescents: effects of psychosocial factors and high risk behaviors.

BACKGROUND: Although previous studies have reported behavioral correlates of sexually-transmitted diseases (STDs) and psychosocial correlates of risky behavior, research has not examined the linkages between psychosocial attributes, behavioral patterns, and actual STD acquisition within the same adolescent sample. We examined the effects of five psychosocial factors on risky sexual behavior and substance use, and their direct and indirect effects on STD acquisition. METHODS: A multiethnic sample of 571 sexually-active female adolescents (ages 13-19 years) was recruited from family planning clinics. Subjects completed questionnaires prior to their gynecologic examination and STD testing. RESULTS: A multiethnic sample of 571 sexually-active female adolescents (ages 13-19 years) was recruited from family planning clinics. Subjects completed questionnaires prior to their gynecologic examination and STD testing. RESULTS: Female adolescents who were heavy substance users, who felt little control over their sexual behavior, and had a greater number of friends who engaged in risky sexual behavior were themselves more likely to engage in risky sexual behavior. Risky sexual behavior was associated with positive STD status. Subjects who used psychoactive substances during sex reported higher numbers of sexual partners and were more likely to have an STD. CONCLUSIONS: This research has identified possible causal paths by which psychosocial factors may influence specific behaviors that are predictive of STDs in adolescent females.

Delivery of STD/HIV preventive services to adolescents by primary care physicians.

PURPOSE: To document the rates of STD/HIV preventive services delivered to adolescents by primary care physicians in California, and to identify variation owing to physician and practice-related factors. METHODS: A stratified random sample of California internists, family physicians, obstetricians-gynecologists, and pediatricians was drawn from the AMA Masterfile and surveyed by mail about their practices with regard to STD/HIV prevention for 15-18-year-old adolescent patients. Sixty percent of eligible physicians responded; the final sample was 1217 physicians. RESULTS: Results showed that 40% of physicians reported screening all of their adolescent patients for sexual activity and 31% reported educating all of their adolescent patients about STD/HIV transmission. For their sexually active adolescent patients, 36% of physicians always provided STD/HIV education, 17% always screened for number of previous sexual partners; 12% always screened for sexual orientation; and 10% always screened for frequency of casual sex. Four percent of the physicians reported that they always provided condoms for their sexually active adolescent patients; 81% never provided condoms. Higher levels of preventive services delivery were associated with female physician gender, specialization in obstetrics-gynecology, and more recent date of medical school graduation. Physicians practicing in health maintenance organizations reported providing significantly higher rates of preventive services to sexually active adolescents than did physicians in private practice. CONCLUSIONS: Primary care physicians provide STD/HIV preventive services to adolescents at rates far below those recommended by current guidelines. Areas where additional research would be informative are highlighted.

Relationship of alcohol use and risky sexual behavior: a review and analysis of findings.

In this review article, three methodologic approaches that have been used to examine the association between adolescents' alcohol use and their involvement in risky sex are discussed: global correlation studies, situational covariation studies, and event analyses. The strengths and limitations of each of these research methods are discussed. An extensive review of the most rigorous studies, which used event analysis to examine the alcohol-risky sex link, reveals positive results for first-time sexual events but equivocal findings for other types of sexual relationships. It is argued that differences in the types of sexual relationships studied have been confounded, limiting our ability to evaluate the extent to which alcohol has a causal influence on adolescents' condom use. It is suggested that future investigations consider the nature of the sexual relationship, and go beyond studying the length or status of the relationship to explore how variation in relationship dimensions such as trust and intimacy affect adolescents' sexual behavior.

PIP: Research on the association between alcohol use and high-risk sexual practices among US adolescents has been compromised by methodological flaws. Global correlation studies, situational covariate studies, and event-history analyses have examined the impact of alcohol on adolescents' condom use. Although the correlation studies have found an association between alcohol consumption and risky sexual behavior, they can not identify potential causal effects. Situational covariate studies have examined effects from the use of alcohol during sexual events, but they also obscure the important temporal relationship between variables. Both global correlation and situational covariation studies fail to address the possibility that alcohol use and risky sexual behavior are caused by a third factor such as a general tolerance for deviance or a predisposition to risk taking. Critical incident or event analyses are limited by the recall bias inherent in retrospective data. Support for an alcohol-risky sex association emerges most consistently from studies that examined first-time sexual intercourse events, but this finding may not generalize to later experiences with new partners. Recent studies have recognized the importance of examining how sexual relationships themselves influence condom use. It is possible that alcohol will affect condom use only at specific points in the relationship. To control for the potentially confounding effects of the partner relationship on the alcohol-risky sex link, the natural history of these behaviors over the course of a relationship should be examined. The use of diaries is likely to yield more reliable information than retrospective questioning.

Puberty questions asked by early adolescents: what do they want to know?

OBJECTIVE: We undertook the following study to document questions asked by early adolescents regarding pubertal development. METHODS: As part of a health education program, 159 sixth-grade students (mean = 12.1 years) were surveyed to obtain their questions about puberty and their self-assessed pubertal stage. Questions were coded for content and gender specificity. RESULTS: Of 159 initial subjects, 111 generated a total of 200 questions. A majority of the questions reflected biological topics (88%), such as genital physiology (26%) and sexuality and reproduction (26%). Only 6% addressed psychosocial questions. Both females and Asians (compared with other ethnic or racial groups) expressed greater interest in the differences between male and female development (P < .05). Prepubertal males were more concerned about general puberty than were boys in later Tanner stages (P < .05). Earlier maturing males focused on genital anatomy (P < .05). CONCLUSIONS: We found that biological questions concerning puberty predominated over psychosocial topics, and that the gender, race or ethnicity, and stage of development determined the kinds of questions that early adolescents have about pubertal development. Health educators and clinicians may need to focus on physiologic areas to provide more meaningful information about development to early adolescents.

Adolescent sexual strategies.

PURPOSE: The aim of this study has been to survey adolescents' strategies to promote sexual encounters and to compare those used by males and females. We examined the predictions that sexual strategies of young adolescents are fewer and less adult-like and that those of male adolescents are more coercive. We also examined the predictions from evolutionary psychology that suggest in sexual strategies, males communicate emotional involvement, long-term interest, and resource investment, whereas females communicate sexual availability and fertility. METHODS: The sample consisted of 153 African-American, white, Chinese-American, and Mexican-American adolescents. A strategy inventory was developed and mention of strategies by males and females were compared. RESULTS: Significant gender differences in mention of strategies were found. Males mentioned a higher percentage of coercive strategies such as pressuring and raping as well as a higher percentage of strategies such as lying and getting a partner drunk or high. Males and females both mentioned a higher percentage of strategies communicating commitment and investment. Females mentioned more strategies which signaled sexual availability. Adolescent strategies were fewer than those reported by adults and less focused on appearance enhancement and the intricacies of dating. CONCLUSIONS: Findings suggest the need for special targeting of coercive situations, use of sexual strategies as a prompt for counterstrategies aimed at abstinence, use of sexual strategies as a context for condom use promotion, and reinforcement of female preparatory strategies.

PIP: 153 sexually active 11th and 12th graders attending two inner-city high schools in San Francisco participated in a study of strategies adolescents use to secure sexual intercourse with a partner. The study sample comprised 20 male and 16 female African-Americans, 21 male and 22 female Caucasians, 17 male and 18 female Chinese-Americans, and 19 male and 20 female Mexican-Americans aged 14-19 years (mean age, 16.96 years). Non-English-speaking and special education students were excluded from study. Relative to females, males reported using a higher degree of pressure, rape, lying, and getting a partner drunk or high to encourage sexual involvement. Both sexes reported suggesting interest in developing commitment and a relationship with the intended sex partner to achieve the goal of intercourse. Females mentioned more strategies than males which signaled sexual availability. Relative to adults, the study participants reported fewer strategies and were less focused upon appearance enhancement and the intricacies of dating.

Female adolescents at high, moderate, and low risk of exposure to HIV: differences in knowledge, beliefs, and behavior.

PURPOSE: To examine differences in the beliefs and behaviors of female adolescents at varying degrees of probable risk for HIV transmission. METHODS: A clinically-based, ethnically diverse sample of 696 sexually active female adolescents was recruited from urban and suburban general adolescent, family planning, and public health clinics. Subjects were categorized into four risk status groups on the basis of their history of IV drug use, sexually transmitted disease (STD), and probable risk of contact with an infected individual (living in a high-risk geographic location, sexual promiscuity, sex with male homo/bisexuals). RESULTS: Females in the highest risk group showed high rates of substance use, anal intercourse, and intentions to have future risky sexual partners. A second high-risk group reported high rates of STDs, inconsistent condom use, and less AIDS knowledge. CONCLUSION: Different subsets of higher risk adolescents may require different intervention strategies.

Primary care physicians' screening of adolescent patients: a survey of California physicians.

PURPOSE: To determine how often primary care physicians screen adolescents for important risk factors and to determine how rates of screening vary by physicians' specialty and practice setting, patients' age, and type of risk factor. METHODS: A stratified random sample of 343 California physicians who are Board certified in pediatrics, family practice, or internal medicine, and physicians in these specialties who specialized in adolescent medicine were surveyed about their screening practices using a mailed questionnaire. Subjects were asked the percentage of routine comprehensive physical examination during which they personally queried or screened each age group of adolescents (11-14 years old and 15-18 years old) for each of the following risk factors: high blood pressure, alcohol use, cigarette use, sexual activity, and drug use. RESULTS: The frequency with which primary care physicians reported actually screening younger and older adolescents for the various risks were approximately: 93% and 96% for high blood pressure, 70% and 84% for alcohol use, 74% and 82% for drug use, 67% and 83% for sexual activity, and 76% and 86% for smoking, respectively. For all risk factors, providers screened older adolescents more frequently than younger adolescents (p < 0.01). Finally, screening rates varied by specialty (p < 0.01) but not by practice setting. CONCLUSIONS: This study found that California physicians frequently screen adolescents for a variety of risk factors. However, the reported rates may not be consistent with published guidelines. Interventions may need to be developed which focus on improving primary care physicians' adolescent-specific screening practices.

Utilization of ambulatory health services by urban adolescents.

PURPOSE: To describe adolescents' utilization of ambulatory health services and its association with sociodemographic and health status characteristics. METHODS: Adolescents (N = 199) were selected from a larger group of urban middle and high school students who had previously participated in a health risk survey. Subjects were surveyed about their health status and use of ambulatory medical services. Subjects' parents/guardians were also surveyed about sociodemographic information. Bivariate and multivariate analyses using Chisquare statistics and logistic regression techniques assessed the contribution of hypothesized variables to use of routine medical, illness-related medical, and dental services. RESULTS: Most adolescents reported having seen a physician (70%) or a dentist (79%) within the past year. Subjects reported using a wide variety of practitioners and settings, with family/general practitioners (29%), and the private office setting (23%) most commonly reported. Subjects having a regular source of care and those perceiving their health as "excellent" or "very good" were 2.4 and 3.4 times more likely to have used routine medical services than those without a regular source of care and those reporting their health as "fair" or "poor." In contrast, the strongest predictors of having received illness-related care in the past year were the presence of a current medical problem and an age by gender interaction factor. Those reporting a current medical problem were twice as likely as those not reporting a problem and older females were 6.6 times as likely as younger males to have received illness-related care within the past year. The only significant predictor of recent dental care was having private insurance. CONCLUSION: For adolescents enabling variables, such as having a regular source of care and health insurance, are stronger predictors of routine use of medical and dental care, whereas medical need and sociodemographic factors, such as age and gender, are more important in predicting use of illness-related care. These results support, in part, models that have been previously developed to explain use of ambulatory health services.