Adolescents' preventive care experiences before entry into the State Children's Health Insurance Program (SCHIP)

Adolescence has traditionally been thought of as a time of good health. However, adolescents comprise an important group with unique needs among State Children's Health Insurance Program (SCHIP) enrollees. Throughout the 1990s, there was increasing evidence of unacceptably high morbidity and mortality among adolescents from injuries, suicide, sexually transmitted diseases, substance abuse, and other conditions associated with risk behaviors. The establishment of relationships with the health care system can ensure prompt treatment and help promote healthy behaviors, assuming that the adolescent feels comfortable seeking help for his or her health-related concerns. However, health care systems typically are not designed to ensure that adolescents receive the primary and preventive care that might ameliorate the negative consequences of health-damaging behaviors.

The purpose of this study was to examine the following hypotheses. 1) Adolescents with special health care needs, those engaging in risk behaviors, and those who were insured before program enrollment would be more likely than those who were healthy and those not engaging in risk behaviors to have a preventive care visit in the year preceding the interview. No differences would be observed in the odds of preventive care visits based on age, race/ethnicity, and gender. 2) No differences would be observed in the receipt of risk-behavior counseling for those with a preventive care visit based on the adolescents' sociodemographic and health characteristics. 3) Adolescents who were older would be more likely to engage in risk behaviors than younger adolescents. There would be no differences in reports of risk behaviors based on gender, race/ethnicity, and children with special health care needs status.

Adolescents 12 to 19 years old and newly enrolled in SCHIP were eligible for the study. Telephone interviews were conducted within 3 months after enrollment with parents of adolescents to obtain sociodemographic information and information about the adolescents' health by using the Children with Special Health Care Needs screener. Interviews also were conducted with the adolescents themselves to obtain information about the adolescents' risk behaviors and experiences with preventive care before SCHIP enrollment.

Interviews were completed with 1872 parents. In addition, a total of 918 interviews were completed with adolescents. Approximately 73% of adolescents reported engaging in at least one risk behavior. Approximately 69% reported having a primary care visit during the last year with 46% of those reporting that the visit was private. Of those reporting a primary care visit, between 41% and 53% reported receiving counseling along 1 of the 5 content dimensions of anticipatory guidance. Older adolescents were more likely to engage in risk behaviors than younger adolescents. Hispanic adolescents were approximately 30% less likely than white non-Hispanic adolescents to report engaging in risk behaviors. In terms of having a preventive care visit, adolescents with a special need were twice as likely to have a visit when compared with their healthy counterparts. Hispanics and black non-Hispanics were half as likely to have a preventive care visit (odds ratios of 0.59 and 0.54, respectively) than white non-Hispanics. Those engaging in risk behaviors were almost 50% less likely to report private preventive care visits than those reporting no risk behaviors. Privacy during the preventive care visit was associated with a greater odds of receiving counseling for risk behaviors in general, sexual activity, and emotional health and relationships. Depending on the type of counseling, those with private preventive care visits were 2 to 3 times more likely to receive the counseling than those whose visits were not private. In addition, those engaging in risk behaviors were 1.45 to almost 2 times more likely to receive counseling than those not engaging in any risk behaviors.

Based on our findings, health plans health plans and providers involved in SCHIP are likely to serve adolescents who have had limited opportunities for private preventive care visits and counseling during such visits. The most underserved are likely to be black and Hispanic adolescents who may have had no preventive care at all compared with their white non-Hispanic counterparts. State agencies, health plans, and providers need to follow established guidelines for adolescent health care that emphasize the provision of counseling for risk behaviors for all adolescents, not just those engaging in risk behaviors or those with special health care needs. Moreover, providers need to seek opportunities to ensure privacy for the adolescents during their preventive care visits so that much-needed counseling can be provided. Particular attention needs to be given to adolescents from minority groups to encourage them to seek preventive care.