Spencer et al.’s analysis of National Health Interview Survey data between 2010 and 2016 highlights promising reductions in the number of uninsured adolescents and young adults, with pronounced declines in coverage over the course of adolescent development [1]. Insurance coverage is critically important for young people who need preventive services or face serious health issues. Recent Centers for Disease Control and Prevention data indicate that 17% of children and 21% of adolescents are obese, which is linked to chronic health effects such as diabetes, heart disease, and depression [2]. Individuals aged 15–24 account for nearly half of incident sexually transmitted infections annually, and suicide is a leading cause of death among children and adolescents [3,4]. Across these outcomes, improving access to and utilization of health services is a critical component of prevention efforts.
However, Spencer et al.’s results suggest that increasing insurance coverage is necessary but insufficient for improving quality care between childhood and adulthood [4]. Specifically, their results demonstrate that measures of access to and use of care continue to worsen between childhood and early adulthood; 86% of children had a provider visit in the past year compared with 56% of young adults, and 96% of children had a regular source of care compared with 75% of young adults. These findings suggest that increases in insurance coverage may need to be coupled with interventions to address more proximal factors that influence access to and utilization of care.
The Social-Ecological Model
Existing frameworks describe the multiple factors that impact health-care utilization and highlight opportunities for intervention [5]. Although these frameworks vary, many reflect principles of the social-ecological model, a simple yet seminal public health framework [6]. This model underscores how characteristics of the environment influence individual health behavior and outcomes. The model conceptualizes individuals as nested within multiple levels of influence, organized hierarchically. Relationships (e.g., with parents and providers) are most proximal to individuals, followed by community/organizations (e.g., schools and clinics), and then society more broadly (e.g., health-care policy and media). Health-care policy yielding increases in insurance coverage is an example of a societal-level intervention, with potential for high impact [7]. Yet the social-ecological model posits that a multilevel approach is more likely to be effective and sustained.
Provider- and Clinic-Focused Interventions
A substantial body of literature has considered provider- and clinic-level barriers and facilitators to accessing care. For example, young people report concerns about confidentiality as reasons for not seeking health services. Of note, these concerns are more pronounced among young people covered by parents’ private insurance, as opposed to Medicaid [8]. Such research has informed an emphasis on “youth-friendly” services, which encompass both provider and clinic practices that remove barriers to care (e.g., providing confidentiality assurances and having flexible hours). Recent empirical evidence supports recommendations from the American Academy of Pediatrics, for targeted quality improvement initiatives to increase youth-friendly primary care [9–11].
Innovative Approaches to Increase Access
In addition to addressing providers and clinics, the social-ecological model points to potentially effective interventions in several domains not traditionally associated with healthcare. At the relationship-level, there is growing attention to the positive impact of parents in helping young people access services even while confidentiality remains a cornerstone of care. For example, parents can encourage their adolescents to seek routine preventive care encourage time alone between adolescents and providers [12]. At the organizational level, research on school-based health centers, youth-serving organizations, school referral programs for health services, and school nurses has shown that providing health services in the school setting is a cost-effective way to increase access [13]. Finally, at the societal level, there is emerging evidence that social media can be used to improve access and utilization of care for adolescents. For example, a prospective intervention study of young men aged 15–24 who have sex with men found that a web-based marketing intervention increased HIV/sexually transmitted infection testing [14]. A benefit of these interventions is that they reach youth in settings where they are already engaged.
Toward a Multilevel Approach
Although policy interventions can improve access to care for adolescents, we cannot ignore interventions in other domains that improve preventive health behaviors and outcomes. The social-ecological model can inform a comprehensive approach to increasing health-care access through interventions at multiple levels. Important work remains in moving toward a multilevel approach, increasing youth-friendly providers and clinics while engaging parents, schools, and social media to improve health-care access and utilization. Public health and clinical efforts would benefit from understanding how interventions at different levels of the model might interact to yield greater access to quality of care for our nation’s young people.
Footnotes
Disclaimer: The findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Contributor Information
Christopher R. Harper, Division of Adolescent and School Health
Riley J. Steiner, Division of Adolescent and School Health
Kathryn A. Brookmeyer, Division of Sexual Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
References
- [1].Spener D, McManus M, Call KT, et al. Health care coverage and access among children, adolescents, and young adults, 2010–2016: Implications for future health reforms. J Adolesc Health 2018;62:667–73. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [2].Nemiary D, Shim R, Mattox G, Holden K. The relationship between obesity and depression among adolescents. Psychiatr Ann 2012;42:305–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Cuffe KM, Newton-Levinson A, Gift TL, et al. Sexually transmitted infection testing among adolescents and young adults in the United States. J Adolesc Health 2016;58:512–9. [DOI] [PubMed] [Google Scholar]
- [4].Shain B. Suicide and suicide attempts in adolescents. Pediatrics 2016;e20161420. [DOI] [PubMed] [Google Scholar]
- [5].Levesque JF, Harris MF, Russell G. Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. Int J Equity Health 2013;12:18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [6].McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q 1988;15:351–77. [DOI] [PubMed] [Google Scholar]
- [7].Frieden TR. A framework for public health action: The health impact pyramid. Am J Public Health 2010;100:590–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [8].Fuentes L, Ingerick M, Jones R, Lindberg L. Adolescents’ and young adults’ reports of barriers to confidential health care and receipt of contraceptive services. J Adolesc Health 2018;62:36–43. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [9].Tylee A, Haller DM, Graham T, et al. Youth-friendly primary-care services: How are we doing and what more needs to be done? Lancet 2007;369:1565–73. [DOI] [PubMed] [Google Scholar]
- [10].Riley M, Patterson V, Lane JC, et al. The adolescent champion model: Primary care becomes adolescent-centered via targeted quality improvement. J Pediatr 2018;193:229–36. [DOI] [PubMed] [Google Scholar]
- [11].Committee on Adolescence American Academy of Pediatrics. Achieving quality health services for adolescents. Pediatrics 2008;121:1263. [DOI] [PubMed] [Google Scholar]
- [12].Ford CA, Davenport AF, Meier A, McRee AL. Partnerships between parents and health care professionals to improve adolescent health. J Adolesc Health 2011;49:53–7. [DOI] [PubMed] [Google Scholar]
- [13].Knopf JA, Finnie RK, Peng Y, et al. School-based health centers to advance health equity: A community guide systematic review. Am J Prev Med 2016;51:114–26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [14].Bauermeister JA, Pingel ES, Jadwin-Cakmak L, et al. Acceptability and preliminary efficacy of a tailored online HIV/STI testing intervention for young men who have sex with men: The Get Connected! program. AIDS Behav 2015;19:1860–74. [DOI] [PMC free article] [PubMed] [Google Scholar]