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Measuring Unmet Needs for Anticipatory Guidance Among Adolescents at School-Based Health Centers
Journal of Adolescent Health xxx (2017) 1e7
www.jahonline.org Original article
Measuring Unmet Needs for Anticipatory Guidance Among Adolescents at School-Based Health Centers Mary M. Ramos, M.D., M.P.H. a, *, Rachel A. Sebastian, M.A. b,1, Scott P. Stumbo, M.A. c, Jane McGrath, M.D. a, and Gerry Fairbrother, Ph.D. d, 2 a
Department of Pediatrics, Envision New Mexico, University of New Mexico School of Medicine, Albuquerque, New Mexico Child Policy and Population Health, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio c Department of Population, Family, and Reproductive Health, Child and Adolescent Health Measurement Initiative, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland d AcademyHealth, Washington, D.C. b
Article history: Received September 19, 2016; Accepted December 22, 2016 Keywords: Adolescent health care; Anticipatory guidance; Preventive counseling; Quality; Depression; Immigrant; Minority
A B S T R A C T
Purpose: Our previously validated Youth Engagement with Health Services survey measures adolescent health care quality. The survey response format allows adolescents to indicate whether their needs for anticipatory guidance were met. Here, we describe the unmet needs for anticipatory guidance reported by adolescents and identify adolescent characteristics related to unmet needs for guidance. Methods: We administered the survey in 2013e2014 to 540 adolescents who used school-based health centers in Colorado and New Mexico. A participant was considered to have unmet needs for anticipatory guidance if they indicated that guidance was needed on a given topic but not received or guidance was received that did not meet their needs. We calculated proportions of students with unmet needs for guidance and examined associations between unmet needs for guidance and participant characteristics using the chi-square test and logistic regression. Results: Among participants, 47.4% reported at least one unmet need for guidance from a health care provider in the past year. Topics with the highest proportions of adolescents reporting unmet needs included healthy diet (19.5%), stress (18.0%), and body image (17.0%). In logistic regression modeling, adolescents at risk for depression and those with minority or immigrant status had increased unmet needs for guidance. Adolescents reporting receipt of patient-centered care were less likely to report unmet needs for guidance. Conclusions: The Youth Engagement with Health Services survey provides needs-based measurement of anticipatory guidance received that may support targeted improvements in the delivery of adolescent preventive counseling. Interventions to improve patient-centered care and preventive counseling for vulnerable youth populations may be warranted. Ó 2017 Society for Adolescent Health and Medicine. All rights reserved.
Conflicts of Interest: The authors have no conflicts of interest to disclose. * Address correspondence to: Mary M. Ramos, M.D., M.P.H., Envision New Mexico, University of New Mexico Department of Pediatrics, 625 Silver Avenue Southwest, Suite 324, Albuquerque, NM 87012. E-mail address: [email protected] (M.M. Ramos). 1 Present address: Rachel Sebastian Research Consulting, 124 Basswood Circle, Fort Wright, KY 41011. 2 Present address: Fairbrother Associates, 1564 Corte la Canada, Santa Fe, NM 87501. 1054-139X/Ó 2017 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2016.12.021
IMPLICATIONS AND CONTRIBUTION
This article presents continued research developing a survey instrument that measures the quality of adolescent health care. This survey provides a needs-based measurement of anticipatory guidance received by adolescents. Findings document the unmet needs for anticipatory guidance reported by adolescents and identify adolescent characteristics related to unmet needs for guidance.
The impact of physician screening and counseling on adolescent health behaviors has been well documented; clinician-provided counseling can both reduce risky behaviors and promote healthy behaviors [1]. Behaviors initiated in adolescence can have serious health implications long into adulthood. Appropriate counseling can impact many adolescent health behaviors, including tobacco use, alcohol use, substance
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use, seat belt and bicycle helmet use, sexual behaviors, violencerelated behaviors, healthy eating and exercise, and oral health care [1e4]. The American Academy of Pediatrics (AAP), American Medical Association, American Academy of Family Physicians, Society for Adolescent Health and Medicine, and Maternal and Child Health Bureau all recommend periodic screening and counseling for adolescents [5e8]. The AAP Bright Futures: Guidelines for Health Supervision has identified priority anticipatory guidance topics for discussions during adolescent health care visits [5]. However, in the United States, the actual provision of anticipatory guidance to adolescents is noted to be quite low. Many adolescents do not receive preventive care visits in a typical year [9]. Even when they do, they often do not receive the full recommended package of preventive services at visits including anticipatory guidance on priority health topics [10,11]. Many reasons explain this lack of preventive counseling. Many adolescents do not have opportunities for confidential or private care with their providers and are reluctant to discuss certain topics with parents or guardians present [12]. Providers, for their part, may be reluctant to discuss sensitive adolescent health topics with their patients or may feel ill-equipped to do so [13e16]. Many providers are simply short on time [17,18] and may have to contend with their own sense of competing priorities for their time or what they believe adolescents are interested in talking about. In addition, pediatric clinics are often more suited to younger patients and may not be conducive to adolescent health care visits. National efforts to improve the quality of health care and reduce health care costs are ongoing and embrace the importance of patient-centered care, that is, care that meets the needs of patients [19e21]. Nevertheless, efforts to measure and improve the quality of adolescent health care rarely use adolescents’ own reports of their experiences with health care [22e24]. Evaluations of the quality of adolescent health care tend to rely on clinical records or parental or clinician report, and not on reports from the adolescent patients themselves, with few exceptions [21,25,26]. We developed the Youth Engagement with Health Services (YEHS!) survey to measure adolescent health care quality [25]. The adolescent survey includes measures of risk behaviors and health care experiences including health care utilization, receipt of anticipatory guidance, and receipt of patient-centered care. Unlike previous instruments that simply measure whether adolescents have received guidance on a given topic, our survey response format goes further and allows adolescents to indicate whether their needs for guidance on a particular topic were met. The purposes of this study are twofold: (1) to describe the levels of unmet needs for anticipatory guidance reported by adolescents using this newly developed needs-based response format and (2) to identify adolescent characteristics associated with unmet needs for guidance from health care providers.
Methods Ethical review This study protocol was approved by the Human Research Protections Office of the University of New Mexico Health Sciences Center and the Cincinnati Children’s Hospital Medical Center.
Instruments and measures The survey instrument used in this study was created for use in school-based health centers (SBHCs) as part of a federally funded quality improvement project. The initial survey development and validation, described elsewhere [25], included a review of existing literature on adolescent health care, subjectmatter expert opinion, and focus groups with youth to assess face and content validity. The questionnaire format for measuring receipt of anticipatory guidance was cognitively tested with 28 adolescents aged 14e18 years in New Mexico. Survey items measuring youth report on anticipatory guidance received from health care providers were adapted from the AAP Bright Futures priority topics for adolescent health [5]. We organized the anticipatory guidance questions around four topical areas that were the focus of the quality improvement initiative: physical growth and development, social and academic competence, emotional well-being, and sexual health risk reduction. Each domain included four to five specific anticipatory guidance topics. For each anticipatory guidance topic, youths were asked, “In the last 12 months, did a doctor or other health care provider talk with you about (the topic, e.g., ‘healthy eating or diet’)?” This question applied to care received anywhere in the prior 12 months. Youths were asked to choose from among the following four responses: “Yes, and I got what I needed,” “Yes, but I did NOT get what I needed,” “No, but I needed to talk about that,” or “No, I did not need to talk about that.” Those responding “Yes, but I did NOT get what I needed” or “No, but I needed to talk about that” were considered to have an unmet need for anticipatory guidance on that topic. Health risk behavior information from the youth participants included the question, “Have you ever had sex (including oral sex)?”and a question about depression risk from the Youth Risk Behavior Survey [27] from the Centers for Disease Control and Prevention: “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?” For each of these questions, possible responses were “yes” or “no.” An additional question from the Youth Risk Behavior Survey asked about grades, “During the last 12 months, how would you describe your grades in school?” Response options included: “Mostly A’s,” “Mostly B’s,” “Mostly C’s,” “Mostly D’s,” “Mostly F’s,” “None of these grades,” and “Not sure.” Those indicating “Mostly D’s” or “Mostly F’s” were considered to be at risk for school failure. Demographic questions included questions about age, gender, race and Hispanic ethnicity, sexual orientation, and birth in the United States. We also included a four-item Family Affluence Scale, previously validated and described elsewhere [28] as an adolescent measure of socioeconomic status. To measure patient-centered care, we included five items from the PatientCentered Care Scale (also known as the Experiences of Care Scale), developed for the Consumer Assessment of Healthcare Providers and Systems survey and previously described elsewhere [29]. These five items include a common stem: “In the last 12 months, how often did doctors or other health care providers listen carefully to you?”; “.how often did you have a hard time speaking with or understanding your doctor or other health care provider because you spoke different languages?”; “. how often did doctors or other health care providers explain things in a way that you could understand?”; “.how often did doctors or other health care providers show respect for what you had to say?”; and “.how often did doctors or other health care
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Table 1 Respondent characteristics by unmet needs for guidance, 2013e2014
Demographics Age (average years) Female White, non-Hispanic Immigrant Home language non-English LGBQ Family Affluence Scale Low Mid High Health care utilization Insured Had a checkup within past year Health risk behaviors Ever had sex At risk for depression within past year At risk for school failure Quality of care Patient-centered care (scale of 1e4)
pa
All respondents
No unmet needs
At least one unmet need for guidance
N ¼ 540
%/mean
n ¼ 284
%/mean
n ¼ 256
%/mean
540 350 141 81 147 64
16.1 65.3% 25.8% 15.4% 27.2% 11.9%
284 185 91 33 77 22
16.2 65.6% 31.2% 11.9% 27.0% 7.7%
256 165 50 48 70 42
16.1 65.0% 19.6% 19.2% 27.5% 16.6%
.165 .876 .002 .021 .910 .001
91 258 191
16.9% 47.8% 35.4%
41 130 114
14.4% 45.6% 40.0%
50 128 77
19.6% 50.2% 30.2%
.106 .288 .017
371 422
68.6% 76.7%
206 231
72.3% 78.6%
165 191
64.5% 74.6%
.050 .274
335 182 41
62.0% 33.6% 8.2%
173 72 13
60.7% 25.2% 4.9%
162 110 28
63.5% 43.1% 12.1%
.500 .000 .003
537
3.31
281
3.47
256
3.13
.000
Bold indicates p < 0.05. LGBQ ¼ lesbian, gay, bisexual, or questioning. a Compared to those with no unmet needs for guidance, chi-square analysis.
providers spend enough time with you?” Questions about health care utilization included questions about having insurance and having had a checkup in the past year. Setting The YEHS! survey was administered from August 2013 through May 2014 at 12 SBHCs (six in Colorado and six in New Mexico) participating in the SBHC improvement project. All these SBHCs followed an integrated care model, common to SBHCs [30], that provides both primary care and behavioral health services. Most SBHCs were open 2e4 days per week. SBHCs typically augment and complement the health care services received by adolescents in their medical homes in their communities; less commonly, SBHCs are the main health care sites for adolescents [30]. Survey administration The survey was administered on a tablet by SBHC staff members to all patients as an anonymous postclinic visit survey. Quality improvement coaches working with the sites provided guidance on survey administration, including recruitment, ensuring eligibility (limited to those high school students who had used the SBHC within the past year), tracking survey completion, and providing incentives ($5 gift cards as compensation for students’ time). Youth were provided a private space within the SBHC to complete the survey. Surveys were anonymous and collected no identifying information. Youth were informed that survey data would not be linked to their medical records and that only aggregate deidentified data would be shared with providers. Written documentation of informed consent and parental permission were both waived in the interest of protecting the privacy of students receiving services at SBHCs, some of whom receive confidential services.
Data analysis We performed descriptive analyses including means and standard deviations for linear variables and frequencies and percentages for categorical variables. We performed the chi-square test or t test and logistic regression analyses to look for expected associations between sociodemographic characteristics and unmet needs for anticipatory guidance. We ran separate logistic regression models for each topic area of anticipatory guidance (physical growth and development; social and academic competence; emotional well-being; and sexual health risk reduction) and one for all categories of anticipatory guidance. The dependent variable was whether students reported at least one unmet need for guidance in that topic area (or in any topic area for the model including all topic areas), and we included predictors thought to influence having unmet needs for guidance based on our bivariate analyses. The predictors included demographic characteristics of the student (age, sex, race/ethnicity, immigrant status, home language, sexual orientation, and family affluence); health care utilization (having insurance and having had a checkup within the past year); health risks (having had sex and being at risk for depression or school failure); and quality of care, which was based on the PatientCentered Care Scale. Results Characteristics of sample During the 2013e2014 school year, 540 surveys were completed from a diverse population of 1,850 high school students who used the participating SBHCs in Colorado and New Mexico (Table 1). The mean age of the respondents was 16.1 years. Most survey respondents were female (65.3%) and Hispanics (60.9%, data not shown), consistent with the demographics of the patient populations at these SBHCs.
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Table 2 Responses to anticipatory guidance items and the identification of unmet needs In the last 12 months, did a health care provider talk to you about the following topics? Physical growth and development Oral health Weight Health eating or diet Physical activity or exercise Body image Social and academic competence Your family Your friends Your school performance or grades Your future plans Emotional well-being Your emotions or moods Suicide How you deal with stress Sleep Sexual orientation or gender identity Sexual health risk reduction Sexually transmitted diseases Condoms Choosing not to have sex Birth control At least one unmet need for guidance on any topic
(a) Yes, and I got what I needed (%)
(b) Yes, but I did not get what I needed (%)
(c) No, but I needed to talk about that (%)
(d) No, but I did not need to talk about that (%)
62.6 44.9 44.0 51.7 38.0
5.5 8.7 9.2 7.8 7.6
6.0 7.8 10.3 6.3 9.4
25.8 38.6 36.5 34.3 45.0
47.2 41.2 42.9 48.4
6.2 6.5 10.7 9.9
4.2 4.6 5.0 4.7
42.5 47.8 41.5 37.0
46.1 30.7 42.9 45.6 31.6
7.1 5.7 8.5 8.0 3.4
6.9 4.4 9.5 8.3 4.8
39.9 59.2 39.1 38.1 60.2
53.0 57.3 51.1 56.5
2.5 3.4 1.9 3.0
3.0 2.6 2.7 2.7
41.5 36.7 44.3 37.8
Unmet needs for guidance on topic ¼ (b) þ (c) (%) 31.5 11.5 16.5 19.5 14.0 17.0 22.5 10.4 11.0 15.6 14.6 28.0 14.0 10.1 18.0 16.3 8.2 10.2 5.5 6.0 4.5 5.7 47.4
Bold indicates proportion of respondents indicating an unmet need for guidance in at least one topic within the domain.
A majority of respondents reported having health insurance and having had a private visit with a provider in the past year. With respect to health risk behaviors, a majority reported ever having had sex (Table 1). Among respondents, the majority (52.6%) reported no unmet needs for anticipatory guidance in the previous year. The remaining 47.4% of respondents reported at least one unmet need as follows: 11.3% reported one unmet need; 5.2% reported two unmet needs; 6.7% reported three unmet needs; and 24.2% of respondents reported four or more unmet needs for anticipatory guidance in the previous year. Bivariate associations between adolescent characteristics and unmet needs for anticipatory guidance Table 1 shows the bivariate associations between adolescent characteristics and reported unmet needs for anticipatory guidance. Age and gender were not associated with unmet needs for guidance. Respondents who were white, non-Hispanic, and those with relatively high affluence were less likely to have unmet needs for guidance than their respective peers, p < .01 and p < .05, respectively. Those with higher Patient-Centered Care Scale scores were also less likely to report unmet needs for guidance, p < .001. Self-identifying as lesbian, gay, bisexual, or questioning (p < .01), being an immigrant (p < .05), being at risk for depression (p < .001), and being at risk for school failure (p < .01) were each associated with having at least one unmet need for anticipatory guidance in comparison with respective peers. Anticipatory guidance Table 2 lists the results for specific anticipatory guidance items. Respondents reported having received guidance within
the past 12 months on many topics. The proportion of students with unmet need for anticipatory guidance ranged from 4.5% to 19.5%, depending on the topic. Topics with the highest proportions of students reporting unmet needs included healthy eating or diet (19.5%), dealing with stress (18.0%), body image (17.0%), weight (16.5%), and sleep (16.3%; Table 2). Overall, 47.4% of respondents reported at least one unmet need for guidance from a health care provider on at least one priority health topic within the past year. Almost one third of respondents (31.5%) reported an unmet need to discuss a physical growth and development topic with a health care provider in the past year. For the domains of social and academic competence, emotional well-being, and sexual health risk reduction, the corresponding percentages were 22.5%, 28.0%, and 10.2% of respondents, respectively, with at least one unmet need for guidance (Table 2). Multivariate associations between adolescent characteristics and unmet needs for anticipatory guidance Table 3 shows the results of logistic regression analysis. In our models, those reporting higher levels of patient-centered care were less likely to report any unmet needs for anticipatory guidance for each topic area. Respondents who were at risk for depression, and those reporting minority or immigrant status, were more likely to have unmet needs for anticipatory guidance. Discussion To our knowledge, this is the first report of a survey instrument that quantifies the unmet needs of adolescents for anticipatory guidance on priority health topics. In our two-state sample, we administered the previously validated YEHS! survey at SBHCs and found that adolescents reported substantial levels of unmet needs for guidance. Almost half of adolescents reported
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Table 3 Logistic regression model of predictors of having at least one unmet need for guidance by topical area, N ¼ 540, 2013e2014
Demographics Age Female White, non-Hispanic Immigrant Home language Non-English > ½ time LGBQ Family Affluence Scale Mid High Health care utilization Insured Had a checkup within past year Health risks Ever had sex At risk for depression At risk for school failure Quality of care Patient-centered care
Any topic area
Physical growth and development
Social and academic competence
Emotional well-being
Sexual health risk reduction
Odds
Sig.
Odds
Sig.
Odds
Sig.
Odds
Sig.
Odds
Sig.
.870 .894 .447 2.824
.115 .610 .001 .003
.935 1.036 .351 2.054
.462 .878 .000 .033
.832 .786 .514 3.602
.079 .344 .030 .001
.912 1.501 .801 2.610
.341 .098 .416 .006
1.004 .672 .485 1.727
.980 .256 .103 .312
.769 1.824
.003 .070
.659 1.667
.098 .108
.652 1.400
.140 .337
1.208 1.401
.461 .314
.796 .754
.559 .580
1.147 .918
.650 .794
1.080 .979
.800 .949
2.157 1.899
.037 .109
.962 .818
.902 .563
.536 .353
.123 .030
1.057 .997
.823 .990
.939 .839
.808 .495
1.171 .941
.597 .832
1.034 1.087
.902 .758
1.723 1.023
.204 .952
1.348 1.899 1.444
.190 .005 .348
.979 1.433 .857
.929 .127 .683
1.163 1.947 2.065
.572 .011 .059
1.341 2.340 1.788
.245 .000 .121
1.704 2.833 1.714
.182 .004 .253
.400
.000
.570
.001
.374
.000
.440
.000
.330
.000
Bold indicates p < 0.05. LGBQ ¼ lesbian, gay, bisexual, or questioning.
at least one unmet need for a discussion with a health care provider in the previous year, and a quarter of adolescents reported high levels of unmet needs for discussions with a provider. The topical areas with the highest levels of reported unmet needs were largely in the physical growth and development and emotional well-being domains. Specific topics for which there were the highest levels of reported unmet needs for counseling included healthy eating or diet, how to deal with stress, body image, weight, sleep, and school performance or grades. In contrast, there were low levels of reported unmet needs for counseling on topics in the sexual and reproductive health domain. This latter finding may reflect a particular strength of the SBHC setting in that confidential reproductive and sexual health counseling services tend to be available at these sites [30]. However, the relatively high levels of reported unmet needs for counseling in other topical areas underscores a need for SBHC providers to more adequately discuss fundamental health topics including diet, healthy weight, sleep, stress, and so forth. We found that adolescents reporting higher levels of patientcentered care were less likely to have an unmet need for anticipatory guidance. This finding contributes to an emerging body of literature suggesting that effective provider-patient communication enhances the quality of adolescent health care [17,18,31,32]. Previous studies have shown that adolescents who report that well visits were helpful are more likely to recall having received anticipatory guidance [18]. The use of open-ended questions and solicitation of adolescent patients’ concerns has been associated with greater receipt of anticipatory guidance and shorter visits [17]. Shared decision-making between providers and adolescent patients has been shown to improve outcomes for adolescents with certain chronic conditions, such as asthma and mental disorders [32]. Additional measures to increase the quality of adolescent anticipatory guidance have been described by researchers and professional societies. These include time with provider, private and confidential time with provider, patient-completed
questionnaires, use of technology, and the routine provision of anticipatory guidance at all visits, not just at well visits [5e8,33e36]. We identified specific adolescent populations with greater unmet needs for anticipatory guidance. Among these are immigrants, racial and ethnic minorities, and sexual minorities; these populations have been previously identified as having particular and often unmet health care needs [37e39]. SBHC providers and other adolescent health care providers may want to consider that adolescents from among these populations could have heightened needs for counseling and anticipatory guidance. The YEHS! survey, with its needs-based measurement of anticipatory guidance received, may be a useful tool in adolescent health disparities research. In addition, we identified those at risk for depression as being more likely to have unmet needs for anticipatory guidance. Given the prevalence of depression among adolescents [40], youth should be routinely screened for depression and those who screen positive should be evaluated for depression and other comorbidities. Our finding underscores the potential for additional health concerns of these adolescent patients. SBHCs and other health care agencies serving adolescents may want to assess the quality of the anticipatory guidance being delivered to their panel of adolescent patients. The YEHS! survey is designed to be administered anonymously as a tablet-based postclinic visit survey. Routine administration of a survey such as the YEHS! provides clinic-level data to identify the topical areas for discussion most needed by adolescent patients and the adolescent groups showing highest levels of unmet needs for guidance. These data could inform trainings or quality improvement work to optimize the anticipatory guidance being delivered to adolescent patients. It should be noted that our findings reflect the reports of adolescents who had access to care through SBHCs that each offered an integrated care model. As such, respondents had access to both primary and behavioral health care providers in their school setting and still, almost half reported at least one
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unmet need for anticipatory guidance within the past year. Most, but not all, students who use SBHCs also receive services through community health providers [30]. Future areas of research may include exploring correlations between health care access and utilization patterns and adolescents’ reports of unmet needs for preventive counseling. Finally, the importance of patient-centered care for reducing unmet needs for anticipatory guidance was striking in this study. Patient-centered care has been endorsed by the Institute of Medicine and many professional societies as one of the central aspects of quality health care [19]. Patient-centered care is recommended for children, adolescents, and adults to reduce health care costs and improve efficiencies and outcomes [21]. This study showed an additional specific benefit of patientcentered care; those adolescents who report receiving it are more likely to have their needs for anticipatory guidance met. This study thus underscores the importance of patient-centered care in adolescent health care settings such as SBHCs. Limitations This study has several important limitations. Our findings may not be generalizable to other populations as this study was conducted in SBHC settings in Colorado and New Mexico. This sample had higher proportions of Hispanic and immigrant youth than the nation as a whole. Future studies with the YEHS! survey should be conducted with other and diverse adolescent populations. Our data were cross-sectional; and thus, we can identify associations but not causality. We collected survey responses from adolescents after SBHC clinic visits; these respondents consisted of one third of the adolescents who used the SBHCs during the school year and may not be a representative of the entire population of SBHC users at those sites. We do not have data to compare survey respondents with nonrespondents. Finally, the federally funded quality improvement work for which this survey was created did not focus on either substance use risk reduction or violence and injury prevention; as such, these two important anticipatory guidance domains were omitted from the YEHS! survey version used in this study. Despite limitations, this study introduces a novel and advanced approach to quantifying the anticipatory guidance received by adolescents. Rather than merely asking adolescents which priority topics were covered, we asked adolescents about the anticipatory guidance they received in relation to their individual needs. Through this approach, we were able to document substantial levels of previously undetected unmet needs for guidance. We believe that this needs-based measurement of anticipatory guidance received may allow for targeted improvements in the delivery of adolescent preventive counseling, not just in SBHCs but in other settings serving adolescents as well. Furthermore, the YEHS! survey may have both direct clinical and research applications. Finally, we demonstrated that patient-centered care was protective for adolescent patients; students receiving this type of care were less likely to have an unmet need for guidance than students who did not receive this type of care. Acknowledgments The authors thank the participating school-based health centers in New Mexico and Colorado and the patients who participated in this study.
Funding Sources This project was supported in part by CMS Grant Award number: 1Z0C30559-01-00, Colorado Department of Healthcare Policy and Financing. This CMS grant was part of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) Program.
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M.M. Ramos et al. / Journal of Adolescent Health xxx (2017) 1e7 [24] McCormick MC, Flores G, Freed GL, et al. Challenge to child health services research: Report from the Committee on Pediatric Health and Health Care Quality Measures. Acad Pediatr 2011;11:257e9. [25] Sebastian RA, Ramos MM, Stumbo S, et al. Measuring youth health engagement: Development of the youth engagement with health services survey. J Adolesc Health 2014;55:334e40. [26] Klein JD, Handwerker L, Sesselberg TS, et al. Measuring quality of adolescent preventive services of health plan enrollees and school-based health center users. J Adolesc Health 2007;41:153e60. [27] Kann L, Kinchen S, Shanlkin SL, et al. Youth risk behavior surveillanceeUnited States, 2013. MMWR Suppl 2014;63:1e168. [28] Currie C, Molcho M, Boyce W, et al. Researching health inequalities in adolescents: The development of the Health Behaviour in School-Aged Children (HBSC)Family Affluence Scale. Social Sci Med 2008;66:e1429e36. [29] Hays RD, Shaul JA, Williams VS, et al. Psychometric properties of the CAHPS 1.0 survey measures. Consumer assessment of health plans study. Med Care 1999;37(Suppl. 3):MS22e31. [30] School-Based Health Alliance. 2013-2014 Digit Census Report. Available at: http://censusreport.sbh4all.org/. Accessed on September 4, 2016. [31] Pollack KI, Alexander SC, Ostbye T, et al. Primary care physicians’ discussions of weight-related topics with overweight and obese adolescents: Results from the teen CHAT pilot study. J Adolesc Health 2009; 45:205e7. [32] Fiks AG, Localio AR, Alessandrinia EA, et al. Shared decision-making in pediatrics: A national perspective. Pediatrics 2010;126:306e14.
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[33] Rand CM, Blumkin A, Szilagyi PG. Electronic health record use and preventive counseling for US children and adolescents. J Am Med Inform Assoc 2014;21(e1):e152e6. [34] Shenkman E, Youngblade L, Nackashi J. Adolescents’ preventive care experiences before entry into the State Children’s Health Insurance Program (SCHIP). Pediatrics 2003 Dec;112(6 Pt 2):e533. [35] Thomspon LA, Wegman M, Muller K, et al. Improving adolescent health risk assessment: A multi-method pilot study. Matern Child Health J 2016; 20:2483e93. [36] Duncan P, Frankowski B, Carey P, et al. Improvement in adolescent screening and counseling rates for risk behaviors and developmental tasks. Pediatrics 2012;130:e1345e51. [37] Mendoza FS. Health disparities and children in immigrant families: A research agenda. Pediatrics 2009;124:S187e95. [38] Alegria M, Green JG, McLaughlin KA. Disparities in child and adolescent mental health and mental health services in the U.S.William T. Grant Foundation. 2015. Available at: http://www.mamh.org/Portals/0/Uploads/ Documents/Public/Disparities%20in%20Child%20and%20Adolescent%20 Mental%20Health.pdf. Accessed September 4, 2016. [39] Kann L, Olsen EO, McManus T, et al. Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9-12-United States and selected sites, 2015. MMWR Surveill Summ 2016;65:1e202. [40] Avenevoli S, Swendsen J, Jian-Ping H, et al. Major depression in the National Comorbidity Surveyeadolescent Supplement: Prevalence, Correlates, and treatment. J Am Acad Child Adolesc Psychiatry 2015;54:37e44.
www.jahonline.org Original article
Measuring Unmet Needs for Anticipatory Guidance Among Adolescents at School-Based Health Centers Mary M. Ramos, M.D., M.P.H. a, *, Rachel A. Sebastian, M.A. b,1, Scott P. Stumbo, M.A. c, Jane McGrath, M.D. a, and Gerry Fairbrother, Ph.D. d, 2 a
Department of Pediatrics, Envision New Mexico, University of New Mexico School of Medicine, Albuquerque, New Mexico Child Policy and Population Health, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio c Department of Population, Family, and Reproductive Health, Child and Adolescent Health Measurement Initiative, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland d AcademyHealth, Washington, D.C. b
Article history: Received September 19, 2016; Accepted December 22, 2016 Keywords: Adolescent health care; Anticipatory guidance; Preventive counseling; Quality; Depression; Immigrant; Minority
A B S T R A C T
Purpose: Our previously validated Youth Engagement with Health Services survey measures adolescent health care quality. The survey response format allows adolescents to indicate whether their needs for anticipatory guidance were met. Here, we describe the unmet needs for anticipatory guidance reported by adolescents and identify adolescent characteristics related to unmet needs for guidance. Methods: We administered the survey in 2013e2014 to 540 adolescents who used school-based health centers in Colorado and New Mexico. A participant was considered to have unmet needs for anticipatory guidance if they indicated that guidance was needed on a given topic but not received or guidance was received that did not meet their needs. We calculated proportions of students with unmet needs for guidance and examined associations between unmet needs for guidance and participant characteristics using the chi-square test and logistic regression. Results: Among participants, 47.4% reported at least one unmet need for guidance from a health care provider in the past year. Topics with the highest proportions of adolescents reporting unmet needs included healthy diet (19.5%), stress (18.0%), and body image (17.0%). In logistic regression modeling, adolescents at risk for depression and those with minority or immigrant status had increased unmet needs for guidance. Adolescents reporting receipt of patient-centered care were less likely to report unmet needs for guidance. Conclusions: The Youth Engagement with Health Services survey provides needs-based measurement of anticipatory guidance received that may support targeted improvements in the delivery of adolescent preventive counseling. Interventions to improve patient-centered care and preventive counseling for vulnerable youth populations may be warranted. Ó 2017 Society for Adolescent Health and Medicine. All rights reserved.
Conflicts of Interest: The authors have no conflicts of interest to disclose. * Address correspondence to: Mary M. Ramos, M.D., M.P.H., Envision New Mexico, University of New Mexico Department of Pediatrics, 625 Silver Avenue Southwest, Suite 324, Albuquerque, NM 87012. E-mail address: [email protected] (M.M. Ramos). 1 Present address: Rachel Sebastian Research Consulting, 124 Basswood Circle, Fort Wright, KY 41011. 2 Present address: Fairbrother Associates, 1564 Corte la Canada, Santa Fe, NM 87501. 1054-139X/Ó 2017 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2016.12.021
IMPLICATIONS AND CONTRIBUTION
This article presents continued research developing a survey instrument that measures the quality of adolescent health care. This survey provides a needs-based measurement of anticipatory guidance received by adolescents. Findings document the unmet needs for anticipatory guidance reported by adolescents and identify adolescent characteristics related to unmet needs for guidance.
The impact of physician screening and counseling on adolescent health behaviors has been well documented; clinician-provided counseling can both reduce risky behaviors and promote healthy behaviors [1]. Behaviors initiated in adolescence can have serious health implications long into adulthood. Appropriate counseling can impact many adolescent health behaviors, including tobacco use, alcohol use, substance
2
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use, seat belt and bicycle helmet use, sexual behaviors, violencerelated behaviors, healthy eating and exercise, and oral health care [1e4]. The American Academy of Pediatrics (AAP), American Medical Association, American Academy of Family Physicians, Society for Adolescent Health and Medicine, and Maternal and Child Health Bureau all recommend periodic screening and counseling for adolescents [5e8]. The AAP Bright Futures: Guidelines for Health Supervision has identified priority anticipatory guidance topics for discussions during adolescent health care visits [5]. However, in the United States, the actual provision of anticipatory guidance to adolescents is noted to be quite low. Many adolescents do not receive preventive care visits in a typical year [9]. Even when they do, they often do not receive the full recommended package of preventive services at visits including anticipatory guidance on priority health topics [10,11]. Many reasons explain this lack of preventive counseling. Many adolescents do not have opportunities for confidential or private care with their providers and are reluctant to discuss certain topics with parents or guardians present [12]. Providers, for their part, may be reluctant to discuss sensitive adolescent health topics with their patients or may feel ill-equipped to do so [13e16]. Many providers are simply short on time [17,18] and may have to contend with their own sense of competing priorities for their time or what they believe adolescents are interested in talking about. In addition, pediatric clinics are often more suited to younger patients and may not be conducive to adolescent health care visits. National efforts to improve the quality of health care and reduce health care costs are ongoing and embrace the importance of patient-centered care, that is, care that meets the needs of patients [19e21]. Nevertheless, efforts to measure and improve the quality of adolescent health care rarely use adolescents’ own reports of their experiences with health care [22e24]. Evaluations of the quality of adolescent health care tend to rely on clinical records or parental or clinician report, and not on reports from the adolescent patients themselves, with few exceptions [21,25,26]. We developed the Youth Engagement with Health Services (YEHS!) survey to measure adolescent health care quality [25]. The adolescent survey includes measures of risk behaviors and health care experiences including health care utilization, receipt of anticipatory guidance, and receipt of patient-centered care. Unlike previous instruments that simply measure whether adolescents have received guidance on a given topic, our survey response format goes further and allows adolescents to indicate whether their needs for guidance on a particular topic were met. The purposes of this study are twofold: (1) to describe the levels of unmet needs for anticipatory guidance reported by adolescents using this newly developed needs-based response format and (2) to identify adolescent characteristics associated with unmet needs for guidance from health care providers.
Methods Ethical review This study protocol was approved by the Human Research Protections Office of the University of New Mexico Health Sciences Center and the Cincinnati Children’s Hospital Medical Center.
Instruments and measures The survey instrument used in this study was created for use in school-based health centers (SBHCs) as part of a federally funded quality improvement project. The initial survey development and validation, described elsewhere [25], included a review of existing literature on adolescent health care, subjectmatter expert opinion, and focus groups with youth to assess face and content validity. The questionnaire format for measuring receipt of anticipatory guidance was cognitively tested with 28 adolescents aged 14e18 years in New Mexico. Survey items measuring youth report on anticipatory guidance received from health care providers were adapted from the AAP Bright Futures priority topics for adolescent health [5]. We organized the anticipatory guidance questions around four topical areas that were the focus of the quality improvement initiative: physical growth and development, social and academic competence, emotional well-being, and sexual health risk reduction. Each domain included four to five specific anticipatory guidance topics. For each anticipatory guidance topic, youths were asked, “In the last 12 months, did a doctor or other health care provider talk with you about (the topic, e.g., ‘healthy eating or diet’)?” This question applied to care received anywhere in the prior 12 months. Youths were asked to choose from among the following four responses: “Yes, and I got what I needed,” “Yes, but I did NOT get what I needed,” “No, but I needed to talk about that,” or “No, I did not need to talk about that.” Those responding “Yes, but I did NOT get what I needed” or “No, but I needed to talk about that” were considered to have an unmet need for anticipatory guidance on that topic. Health risk behavior information from the youth participants included the question, “Have you ever had sex (including oral sex)?”and a question about depression risk from the Youth Risk Behavior Survey [27] from the Centers for Disease Control and Prevention: “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?” For each of these questions, possible responses were “yes” or “no.” An additional question from the Youth Risk Behavior Survey asked about grades, “During the last 12 months, how would you describe your grades in school?” Response options included: “Mostly A’s,” “Mostly B’s,” “Mostly C’s,” “Mostly D’s,” “Mostly F’s,” “None of these grades,” and “Not sure.” Those indicating “Mostly D’s” or “Mostly F’s” were considered to be at risk for school failure. Demographic questions included questions about age, gender, race and Hispanic ethnicity, sexual orientation, and birth in the United States. We also included a four-item Family Affluence Scale, previously validated and described elsewhere [28] as an adolescent measure of socioeconomic status. To measure patient-centered care, we included five items from the PatientCentered Care Scale (also known as the Experiences of Care Scale), developed for the Consumer Assessment of Healthcare Providers and Systems survey and previously described elsewhere [29]. These five items include a common stem: “In the last 12 months, how often did doctors or other health care providers listen carefully to you?”; “.how often did you have a hard time speaking with or understanding your doctor or other health care provider because you spoke different languages?”; “. how often did doctors or other health care providers explain things in a way that you could understand?”; “.how often did doctors or other health care providers show respect for what you had to say?”; and “.how often did doctors or other health care
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3
Table 1 Respondent characteristics by unmet needs for guidance, 2013e2014
Demographics Age (average years) Female White, non-Hispanic Immigrant Home language non-English LGBQ Family Affluence Scale Low Mid High Health care utilization Insured Had a checkup within past year Health risk behaviors Ever had sex At risk for depression within past year At risk for school failure Quality of care Patient-centered care (scale of 1e4)
pa
All respondents
No unmet needs
At least one unmet need for guidance
N ¼ 540
%/mean
n ¼ 284
%/mean
n ¼ 256
%/mean
540 350 141 81 147 64
16.1 65.3% 25.8% 15.4% 27.2% 11.9%
284 185 91 33 77 22
16.2 65.6% 31.2% 11.9% 27.0% 7.7%
256 165 50 48 70 42
16.1 65.0% 19.6% 19.2% 27.5% 16.6%
.165 .876 .002 .021 .910 .001
91 258 191
16.9% 47.8% 35.4%
41 130 114
14.4% 45.6% 40.0%
50 128 77
19.6% 50.2% 30.2%
.106 .288 .017
371 422
68.6% 76.7%
206 231
72.3% 78.6%
165 191
64.5% 74.6%
.050 .274
335 182 41
62.0% 33.6% 8.2%
173 72 13
60.7% 25.2% 4.9%
162 110 28
63.5% 43.1% 12.1%
.500 .000 .003
537
3.31
281
3.47
256
3.13
.000
Bold indicates p < 0.05. LGBQ ¼ lesbian, gay, bisexual, or questioning. a Compared to those with no unmet needs for guidance, chi-square analysis.
providers spend enough time with you?” Questions about health care utilization included questions about having insurance and having had a checkup in the past year. Setting The YEHS! survey was administered from August 2013 through May 2014 at 12 SBHCs (six in Colorado and six in New Mexico) participating in the SBHC improvement project. All these SBHCs followed an integrated care model, common to SBHCs [30], that provides both primary care and behavioral health services. Most SBHCs were open 2e4 days per week. SBHCs typically augment and complement the health care services received by adolescents in their medical homes in their communities; less commonly, SBHCs are the main health care sites for adolescents [30]. Survey administration The survey was administered on a tablet by SBHC staff members to all patients as an anonymous postclinic visit survey. Quality improvement coaches working with the sites provided guidance on survey administration, including recruitment, ensuring eligibility (limited to those high school students who had used the SBHC within the past year), tracking survey completion, and providing incentives ($5 gift cards as compensation for students’ time). Youth were provided a private space within the SBHC to complete the survey. Surveys were anonymous and collected no identifying information. Youth were informed that survey data would not be linked to their medical records and that only aggregate deidentified data would be shared with providers. Written documentation of informed consent and parental permission were both waived in the interest of protecting the privacy of students receiving services at SBHCs, some of whom receive confidential services.
Data analysis We performed descriptive analyses including means and standard deviations for linear variables and frequencies and percentages for categorical variables. We performed the chi-square test or t test and logistic regression analyses to look for expected associations between sociodemographic characteristics and unmet needs for anticipatory guidance. We ran separate logistic regression models for each topic area of anticipatory guidance (physical growth and development; social and academic competence; emotional well-being; and sexual health risk reduction) and one for all categories of anticipatory guidance. The dependent variable was whether students reported at least one unmet need for guidance in that topic area (or in any topic area for the model including all topic areas), and we included predictors thought to influence having unmet needs for guidance based on our bivariate analyses. The predictors included demographic characteristics of the student (age, sex, race/ethnicity, immigrant status, home language, sexual orientation, and family affluence); health care utilization (having insurance and having had a checkup within the past year); health risks (having had sex and being at risk for depression or school failure); and quality of care, which was based on the PatientCentered Care Scale. Results Characteristics of sample During the 2013e2014 school year, 540 surveys were completed from a diverse population of 1,850 high school students who used the participating SBHCs in Colorado and New Mexico (Table 1). The mean age of the respondents was 16.1 years. Most survey respondents were female (65.3%) and Hispanics (60.9%, data not shown), consistent with the demographics of the patient populations at these SBHCs.
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Table 2 Responses to anticipatory guidance items and the identification of unmet needs In the last 12 months, did a health care provider talk to you about the following topics? Physical growth and development Oral health Weight Health eating or diet Physical activity or exercise Body image Social and academic competence Your family Your friends Your school performance or grades Your future plans Emotional well-being Your emotions or moods Suicide How you deal with stress Sleep Sexual orientation or gender identity Sexual health risk reduction Sexually transmitted diseases Condoms Choosing not to have sex Birth control At least one unmet need for guidance on any topic
(a) Yes, and I got what I needed (%)
(b) Yes, but I did not get what I needed (%)
(c) No, but I needed to talk about that (%)
(d) No, but I did not need to talk about that (%)
62.6 44.9 44.0 51.7 38.0
5.5 8.7 9.2 7.8 7.6
6.0 7.8 10.3 6.3 9.4
25.8 38.6 36.5 34.3 45.0
47.2 41.2 42.9 48.4
6.2 6.5 10.7 9.9
4.2 4.6 5.0 4.7
42.5 47.8 41.5 37.0
46.1 30.7 42.9 45.6 31.6
7.1 5.7 8.5 8.0 3.4
6.9 4.4 9.5 8.3 4.8
39.9 59.2 39.1 38.1 60.2
53.0 57.3 51.1 56.5
2.5 3.4 1.9 3.0
3.0 2.6 2.7 2.7
41.5 36.7 44.3 37.8
Unmet needs for guidance on topic ¼ (b) þ (c) (%) 31.5 11.5 16.5 19.5 14.0 17.0 22.5 10.4 11.0 15.6 14.6 28.0 14.0 10.1 18.0 16.3 8.2 10.2 5.5 6.0 4.5 5.7 47.4
Bold indicates proportion of respondents indicating an unmet need for guidance in at least one topic within the domain.
A majority of respondents reported having health insurance and having had a private visit with a provider in the past year. With respect to health risk behaviors, a majority reported ever having had sex (Table 1). Among respondents, the majority (52.6%) reported no unmet needs for anticipatory guidance in the previous year. The remaining 47.4% of respondents reported at least one unmet need as follows: 11.3% reported one unmet need; 5.2% reported two unmet needs; 6.7% reported three unmet needs; and 24.2% of respondents reported four or more unmet needs for anticipatory guidance in the previous year. Bivariate associations between adolescent characteristics and unmet needs for anticipatory guidance Table 1 shows the bivariate associations between adolescent characteristics and reported unmet needs for anticipatory guidance. Age and gender were not associated with unmet needs for guidance. Respondents who were white, non-Hispanic, and those with relatively high affluence were less likely to have unmet needs for guidance than their respective peers, p < .01 and p < .05, respectively. Those with higher Patient-Centered Care Scale scores were also less likely to report unmet needs for guidance, p < .001. Self-identifying as lesbian, gay, bisexual, or questioning (p < .01), being an immigrant (p < .05), being at risk for depression (p < .001), and being at risk for school failure (p < .01) were each associated with having at least one unmet need for anticipatory guidance in comparison with respective peers. Anticipatory guidance Table 2 lists the results for specific anticipatory guidance items. Respondents reported having received guidance within
the past 12 months on many topics. The proportion of students with unmet need for anticipatory guidance ranged from 4.5% to 19.5%, depending on the topic. Topics with the highest proportions of students reporting unmet needs included healthy eating or diet (19.5%), dealing with stress (18.0%), body image (17.0%), weight (16.5%), and sleep (16.3%; Table 2). Overall, 47.4% of respondents reported at least one unmet need for guidance from a health care provider on at least one priority health topic within the past year. Almost one third of respondents (31.5%) reported an unmet need to discuss a physical growth and development topic with a health care provider in the past year. For the domains of social and academic competence, emotional well-being, and sexual health risk reduction, the corresponding percentages were 22.5%, 28.0%, and 10.2% of respondents, respectively, with at least one unmet need for guidance (Table 2). Multivariate associations between adolescent characteristics and unmet needs for anticipatory guidance Table 3 shows the results of logistic regression analysis. In our models, those reporting higher levels of patient-centered care were less likely to report any unmet needs for anticipatory guidance for each topic area. Respondents who were at risk for depression, and those reporting minority or immigrant status, were more likely to have unmet needs for anticipatory guidance. Discussion To our knowledge, this is the first report of a survey instrument that quantifies the unmet needs of adolescents for anticipatory guidance on priority health topics. In our two-state sample, we administered the previously validated YEHS! survey at SBHCs and found that adolescents reported substantial levels of unmet needs for guidance. Almost half of adolescents reported
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5
Table 3 Logistic regression model of predictors of having at least one unmet need for guidance by topical area, N ¼ 540, 2013e2014
Demographics Age Female White, non-Hispanic Immigrant Home language Non-English > ½ time LGBQ Family Affluence Scale Mid High Health care utilization Insured Had a checkup within past year Health risks Ever had sex At risk for depression At risk for school failure Quality of care Patient-centered care
Any topic area
Physical growth and development
Social and academic competence
Emotional well-being
Sexual health risk reduction
Odds
Sig.
Odds
Sig.
Odds
Sig.
Odds
Sig.
Odds
Sig.
.870 .894 .447 2.824
.115 .610 .001 .003
.935 1.036 .351 2.054
.462 .878 .000 .033
.832 .786 .514 3.602
.079 .344 .030 .001
.912 1.501 .801 2.610
.341 .098 .416 .006
1.004 .672 .485 1.727
.980 .256 .103 .312
.769 1.824
.003 .070
.659 1.667
.098 .108
.652 1.400
.140 .337
1.208 1.401
.461 .314
.796 .754
.559 .580
1.147 .918
.650 .794
1.080 .979
.800 .949
2.157 1.899
.037 .109
.962 .818
.902 .563
.536 .353
.123 .030
1.057 .997
.823 .990
.939 .839
.808 .495
1.171 .941
.597 .832
1.034 1.087
.902 .758
1.723 1.023
.204 .952
1.348 1.899 1.444
.190 .005 .348
.979 1.433 .857
.929 .127 .683
1.163 1.947 2.065
.572 .011 .059
1.341 2.340 1.788
.245 .000 .121
1.704 2.833 1.714
.182 .004 .253
.400
.000
.570
.001
.374
.000
.440
.000
.330
.000
Bold indicates p < 0.05. LGBQ ¼ lesbian, gay, bisexual, or questioning.
at least one unmet need for a discussion with a health care provider in the previous year, and a quarter of adolescents reported high levels of unmet needs for discussions with a provider. The topical areas with the highest levels of reported unmet needs were largely in the physical growth and development and emotional well-being domains. Specific topics for which there were the highest levels of reported unmet needs for counseling included healthy eating or diet, how to deal with stress, body image, weight, sleep, and school performance or grades. In contrast, there were low levels of reported unmet needs for counseling on topics in the sexual and reproductive health domain. This latter finding may reflect a particular strength of the SBHC setting in that confidential reproductive and sexual health counseling services tend to be available at these sites [30]. However, the relatively high levels of reported unmet needs for counseling in other topical areas underscores a need for SBHC providers to more adequately discuss fundamental health topics including diet, healthy weight, sleep, stress, and so forth. We found that adolescents reporting higher levels of patientcentered care were less likely to have an unmet need for anticipatory guidance. This finding contributes to an emerging body of literature suggesting that effective provider-patient communication enhances the quality of adolescent health care [17,18,31,32]. Previous studies have shown that adolescents who report that well visits were helpful are more likely to recall having received anticipatory guidance [18]. The use of open-ended questions and solicitation of adolescent patients’ concerns has been associated with greater receipt of anticipatory guidance and shorter visits [17]. Shared decision-making between providers and adolescent patients has been shown to improve outcomes for adolescents with certain chronic conditions, such as asthma and mental disorders [32]. Additional measures to increase the quality of adolescent anticipatory guidance have been described by researchers and professional societies. These include time with provider, private and confidential time with provider, patient-completed
questionnaires, use of technology, and the routine provision of anticipatory guidance at all visits, not just at well visits [5e8,33e36]. We identified specific adolescent populations with greater unmet needs for anticipatory guidance. Among these are immigrants, racial and ethnic minorities, and sexual minorities; these populations have been previously identified as having particular and often unmet health care needs [37e39]. SBHC providers and other adolescent health care providers may want to consider that adolescents from among these populations could have heightened needs for counseling and anticipatory guidance. The YEHS! survey, with its needs-based measurement of anticipatory guidance received, may be a useful tool in adolescent health disparities research. In addition, we identified those at risk for depression as being more likely to have unmet needs for anticipatory guidance. Given the prevalence of depression among adolescents [40], youth should be routinely screened for depression and those who screen positive should be evaluated for depression and other comorbidities. Our finding underscores the potential for additional health concerns of these adolescent patients. SBHCs and other health care agencies serving adolescents may want to assess the quality of the anticipatory guidance being delivered to their panel of adolescent patients. The YEHS! survey is designed to be administered anonymously as a tablet-based postclinic visit survey. Routine administration of a survey such as the YEHS! provides clinic-level data to identify the topical areas for discussion most needed by adolescent patients and the adolescent groups showing highest levels of unmet needs for guidance. These data could inform trainings or quality improvement work to optimize the anticipatory guidance being delivered to adolescent patients. It should be noted that our findings reflect the reports of adolescents who had access to care through SBHCs that each offered an integrated care model. As such, respondents had access to both primary and behavioral health care providers in their school setting and still, almost half reported at least one
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unmet need for anticipatory guidance within the past year. Most, but not all, students who use SBHCs also receive services through community health providers [30]. Future areas of research may include exploring correlations between health care access and utilization patterns and adolescents’ reports of unmet needs for preventive counseling. Finally, the importance of patient-centered care for reducing unmet needs for anticipatory guidance was striking in this study. Patient-centered care has been endorsed by the Institute of Medicine and many professional societies as one of the central aspects of quality health care [19]. Patient-centered care is recommended for children, adolescents, and adults to reduce health care costs and improve efficiencies and outcomes [21]. This study showed an additional specific benefit of patientcentered care; those adolescents who report receiving it are more likely to have their needs for anticipatory guidance met. This study thus underscores the importance of patient-centered care in adolescent health care settings such as SBHCs. Limitations This study has several important limitations. Our findings may not be generalizable to other populations as this study was conducted in SBHC settings in Colorado and New Mexico. This sample had higher proportions of Hispanic and immigrant youth than the nation as a whole. Future studies with the YEHS! survey should be conducted with other and diverse adolescent populations. Our data were cross-sectional; and thus, we can identify associations but not causality. We collected survey responses from adolescents after SBHC clinic visits; these respondents consisted of one third of the adolescents who used the SBHCs during the school year and may not be a representative of the entire population of SBHC users at those sites. We do not have data to compare survey respondents with nonrespondents. Finally, the federally funded quality improvement work for which this survey was created did not focus on either substance use risk reduction or violence and injury prevention; as such, these two important anticipatory guidance domains were omitted from the YEHS! survey version used in this study. Despite limitations, this study introduces a novel and advanced approach to quantifying the anticipatory guidance received by adolescents. Rather than merely asking adolescents which priority topics were covered, we asked adolescents about the anticipatory guidance they received in relation to their individual needs. Through this approach, we were able to document substantial levels of previously undetected unmet needs for guidance. We believe that this needs-based measurement of anticipatory guidance received may allow for targeted improvements in the delivery of adolescent preventive counseling, not just in SBHCs but in other settings serving adolescents as well. Furthermore, the YEHS! survey may have both direct clinical and research applications. Finally, we demonstrated that patient-centered care was protective for adolescent patients; students receiving this type of care were less likely to have an unmet need for guidance than students who did not receive this type of care. Acknowledgments The authors thank the participating school-based health centers in New Mexico and Colorado and the patients who participated in this study.
Funding Sources This project was supported in part by CMS Grant Award number: 1Z0C30559-01-00, Colorado Department of Healthcare Policy and Financing. This CMS grant was part of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) Program.
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