Adolescent Health Concerns, Problems, and Patterns of Utilization in a Triethnic Urban Population

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Adolescent

Health

Concerns,

Problems,

and Patterns

of

Utilization

in a Triethnic

Urban

Population

Guy S. Parcel, Ph.D., Philip R. Nader, M.D., and Michael P. Meyer, MS.

From the School Health Programs, Department of Pediatrics, University of Texas Medical Branch, Galveston

ABSTRACT. All aspects of health (concerns, perceived adequacy of knowledge, problems, sources of care, and utilization of health care resources) were significantly influenced by the ethnic background, grade level, or sex of the 3,255 high school students surveyed in an urban tnethnic community of 65,000. Variation in needs was not consistent for any one ethnic group, sex, or age group.

The highest ranked concerns and problems were school, drugs, sex, getting along with parents and adults, acne, depression, and overweight. Ninety-one percent reported they often or sometimes worry about their health. Sources of medical care were family physician (56.8%) and hospital emergency room (15.9%). Reported visits in the past year

were none (27.5%); one (24.1%); two to three (32.2%); and four or more (14.7%).

In analyzing responses according to sex, grade, and ethnic background, several implications are apparent: (1) many of the concerns and problems identified require educational as

well as health care services; (2) the diverse perceived health needs of an entire high school population indicate that the

traditional one-semester general health course for all is grossly inadequate; and (3) students’ concerns and problems are not limited to the areas of drugs, venereal disease, and

unwanted pregnancy.

The study is presented as a model for the needs assessment

phase of planning and delivering adolescent health care and health education services for a community. Pediatrics

60:157-164, 1977, ADOLESCENT HEALTh, HEALTh SURVEY,

nxu.m NEEDS, NEEDS ASSESSMENT, HEALTH EDUCATION.

document a much broader range of needs, but is

infrequently carried out.35 A method of deter-mining the perceived needs of the population should be a prerequisite for closer examination of the adequacy of existing resources in providing

care and health education services.68 The

purpose of this article is to provide information and to suggest an approach for planning

adoles-cent health care and education services in a

community. The article presents the results of a structured survey designed to reflect existing health resources in the urban triethnic commu-nity of Galveston, Texas. The results indicate that

differences among ethnic, age, or sex groups in

health concerns, problems, and utilization of

services exist. These differences demand

specif-icity in planning and delivering services.

METHODS

The data were collected by self-administered, anonymous, precoded questionnaires (copies available on request). The instrument included selected questions from previously published questionnaires as well as questions designed specifically to reflect local community resources

Health care resources and health education programs for adolescents are often underutilized

or poorly received because they are based on

characteristics, needs, or problems of adolescents

attributed to them by the adults who plan such

programs.’2 It is frequently assumed that major problems include drug abuse, venereal disease, and unwanted pregnancy. Direct assessment can

Received December 6, 1976; revision accepted for publica-tion February 14, 1977.

Supported in part by a grant from the Robert Wood Johnson

Foundation.

Presented in part before the American Public Health Asso-ciation, Miami, October 21, 1976.

ADDRESS FOR REPRINTS: (G.S.P.) School Health Pro-grams, Department of Pediatrics, 1202 Market Street,

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TABLE I

ETHNICITY BY SOCIOECONOMIC STATUS OF RESPONDENTS#{176}

Socioeconomic Status

Black, No.

(%)

Anglo, No. ‘%)

Mexican-American, No. (%)

Other, No. (‘%)

Total, No.

(%)

Upper 42 (5.1) 184 (17.2) 7 (1.8) 21 (17.8) 254 (10.6)

Upper-middle 84 (10.3) 175 (16.3) 17 (4.3) 18 (15.3) 294 (12.2) Middle 167 (20.4) 266 (24.8) 45 (11.4) 23 (19.5) 501 (20.8) Lower-middle 374 (45.7) 341 (31.8) 131 (33.2) 37 (31.4) 883 (36.7)

Lower 152 (18.6) 106 (9.9) 195 (49.4) 19 (16.1) 472 (19.6)

Total 819 (34.1) 1,072 (44.6) 395 (16.4) 118 (4.9) 2,404

‘Missing data

=

851.

and characteristics.38 School approval was

obtained by working with the principals and

making a formal presentation to the school board. The questionnaire was pretested for comprehen-sion and clarity by students, teachers, and health providers. The revised instrument was adminis-tered at the two high schools by teachers follow-ing standardized directions. The administration took place during one class period on one of three consecutive days.

Subject responses were transferred to data

processing cards and the data were analyzed

using the StatLitical Package for the Social

Sciences.

The data were analyzed according to the percentage of students indicating a particular response to each question. Cross-tabulations were run and the

x2

statistic was calculated to judge the significance of differences in the proportion of

students responding according to sex, grade in

school, and ethnicity. The large number of

respondents and variables prohibited the report-ing of all statistically significant differences.

Attempts were made to report the most

mean-ingful differences. All differences reported here are statistically significant at the .05 level or less.

SUBJECTS

At the time of questionnaire administration there was a high school population of 3,874 in the

two Galveston high schools (school A

=

3,524;

school B

=

350). Approximately 84% (3,255) of

the students completed the questionnaire (school A

=

2,937; school B 318). These 3,255 stu-dents represent 71% of the adolescents, ages 15 to 18, in Galveston (1970 census). Ethnic distribu-tion of those completing the questionnaire did not differ significantly from that of the entire school population. Black-Americans and

Anglo-Amen-cans each account for approximately the same

percentage of the respondents (38%).

Mexican-Americans were 16%, and 5% belong to “other”

ethnic groups. There were slightly more females (1,641) than males (1,548). The distribution of students by grade was 9th, 22.56%; 10th, 27.74%; 11th, 23.41%; arid 12th, 21.41%.

The Hol1ingsead technique was used to

clas-sify respondents into socioeconomic groups. This

technique requires knowing the education and

occupation of head of the household. One fourth of students (828) were either unable or unwilling to provide this information; therefore, analysis

according to socioeconomic status is limited to

the respondents providing sufficient information. A cross-tabulation of ethnicity and socioeconomic status is presented in Table I.

RESULTS

Results are presented for three main health areas: (1) knowledge and information; (2)

concerns and problems; and (3) health care

utilization. A larger number of students expressed a need for information, fewer students identified

concerns, and a smaller number indicated that

they would like to have help with selected health problem areas.

Knowledge and Information

Five questions were asked to determine

students’ perceptions of the adequacy of their

knowledge concerning birth control, information about health, where to get health services, drugs, and sex (Table II). Almost three fourths of the students thought young people did not know

enough about birth control. Approximately two

thirds of the students also thought that young

people did not know enough about drugs, where

to get health services, and information about

health. Nearly one half of the students indicated

that young people did not know enough about

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TABLE III

AVAILABILITY OF INFORMATION AND RESOURCES

All Respondents, No. (%)

DRUGS

SEX EDUCATION

VENEREAL DISEASE

BIRTH CONTROL ALCOHOL

GETTING ALONG WITH PARENTS

CHILD ABUSE

LEGAL ADVICE

SUICIDE PREVENTION

GETTING ALONG WITH ADULTS

GETTING ALONG WITH FRIENDS

OTHER

N

2,175

I8 I

-

I

7IO I

[629 j

t347

₁

I

N203

₁

1119#{176}

.

I

1ipo

111939

1

[839 -1

I 255

I I I I I 1

FIG. 1. Number and percent of respondents who indicated information that should be provided

in teenage clinic.

TABLE II

ADEQUACY OF KNOWLEDGE CONCERNING SELECTED HEALTH CONTENT AREAS FOR Au

RESPONDENTS AND ACCORDING TO EmNICrn

Thought Young People Did Not Know Enough About

Black No. (%)

Anglo, No. (%)

Mexican-American,

No.

(%)

All Respondents, No. (%)

Birth control 846 (78.8) 926 (77.7) 397 (81.9) 2,329 (71.6)

Information about

health

847 (77.6) 886 (74.7) 379 (77.3) 2,270 (69.7)

Where to get

health services

707 (66.1) 875 (73.8) 343 (70.0)

.

2,073 (63.7)

Drugs 771 (69.7) 770 (64.7) 332 (66.9) 2,004 (61.6)

Sex 646 (56.3) 537 (45.2) 268 (53.2) 1,552 (47.7)

birth control. Blacks had the highest proportion

indicating not enough is known about where to

get health services.

Table III shows students’ responses concerning availability of information about resources for dealing with problems. Only 8.3% indicated that

they did not know where to go with a health

problem, yet 36.1% indicated that they have had trouble trying to get help or information about a

probeim. About one third of the students have

had health questions that did not get answered because there was no one to ask. There were only small differences according to ethnicity except

that Mexican-American respondents had the

highest proportion (43.6%) that indicated they did not get answers to questions about health because no one was available to ask.

Students selected those topics they would like information about if a clinic were set up espe-cially for teenagers (Fig. 1). The highest ranked

Did not know where to go with a health problem

Found difficulty getting help or informa-tion about a problem

271 (8.3)

1,176 (36.1)

Did not get answers to questions about health because no one was available to

1,181 (36.3)

ask

(

50%

to 60% of respondents) were drugs, sex

education, venereal disease, birth control, and alcohol. Getting along with parents, child abuse,

legal advice, and suicide prevention were

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10 20 30 40 50 N

SCHOOL

DRUGS

SEX

PARENTS OR FAMILY

GETTING ALONG WITH ADULTS

BIRTH CONTROL

VENEREAL DiSEASE PREGNANCY

MENSTRUAL PERIODS

I

1,431

1

L 1,279

1 I

I,243

I

I 1,145

1

I 967

I

873 1

I 767 1

I 728

J

I 384 I

PERCENTAGE 0

FIG. 2. Number and percent of respondents who indicated about.

students indicating a desire for information for all listed topic areas except child abuse. The

propor-tion of respondents needing information about

child abuse was similar for all ethnic groups. More females than males checked sex education

and birth control. Interest in birth control

increased with grade (39.4% in the 9th grade to

64.6%

in the 12th grade). Interest in suicide and legal advice also tended to increase with grade.

Concerns and Problems

Health concerns included nine areas that are

frequently associated with adolescent health

shown in Figure 2. The purpose was to determine the relative proportions of students who would

indicate concerns with each of these areas.

“School” was the most frequently reported concern. In order, other closely ranked concerns included “drugs,” “sex,” and “parents or family.” In addition, nearly one fourth of the students also

expressed concern about “getting along with

adults,” “birth control,” “venereal disease,” and “pregnancy.” If the concerns are ranked

separate-ly by grade level or ethnic background of the

students, very little difference in rank order is

noted. More girls than boys indicate having

concerns about “parents or family,” “menstrua-lion,” “pregnancy,” and “birth control.” More boys indicate concern about “drugs,” “school,” and “sex.”

A list of health problems was presented and

students checked those for which they would like to have help. Figure 3 presents the frequency and

percentage of students checking each of the

problems. One fourth to a third of all students

areas they have some concern

checked “acne” and “how far to go with sex.”

More girls than boys checked these problems.

Desire for help with both of these common

problems had the greatest number of students

checking them at the tenth-grade level.

“Feelings of depression, sadness” was the next

most frequently checked problem. More girls

(30.7%) than boys (15.8%) had this need. Fewer

9th-graders (18.6%) than 12th-graders (28%)

expressed this problem. More Anglo students

(27.4%) than the other ethnic groups (black

19.9%, Mexican-American 21.8%) checked this

problem area.

“Overweight” was considered a health

prob-lem by 22.8% of students. This is contrasted to

12.7% who wanted help for being “underweight.”

Nearly one third of the girls wanted help with

being “overweight” compared to 14.1% of the

boys. This trend was reversed for being “under-weight,” with only 9.1% of girls indicating this need compared to 16.7% of boys.

The next most frequently checked needs for all

students were “getting along with parents,”

“worries about your health,” and “dental.” For the first two, no significant effects of sex or grade

level were detected. Ethnic background of

students did not affect checking “getting along with parents.” However, black (27.4%) and

Mexi-can-American (26.2%) students had more

“wor-ries about health” for which they wanted help

than did Anglos (6.7%). For “dental” problems,

there were only slight differences among sex,

grade, or ethnic background of students.

“Nervousness” to the point of wanting help for

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PERCENTAGE 0 10 20 30

Health

Care Utilization

N ACNE OR PIMPLES

HOW FAR TO GO WITH SEX

DEPRESSION, SADNESS

OVERWEIGHT

GETTING ALONG WITH PARENTS

WORRIES ABOUT YOUR HEALTH

DENTAL

NERVOUSNESS

MAKING FRIENDS

OFTEN TIRED

BIRTH CONTROL

FREQUENT HEADACHES

UNDERWEIGHT

DRUG USE

DRINKING PREGNANCY

VENEREAL DISEASE

FREQUENT STOMACH PAINS

RACIAL DISCRIMINATION

MENSTRUATION

COUGHING A LOT

____________

TROUBLE URINATING

_____

OTHER

FIG. 3. Number and percent

students. Ethnic background did not appreciably influence this choice, but more girls (25.7%) than boys (15.1%) indicated this need, and the need

increased from 9th grade (17.4%) to 12th

(23.5%).

Fewer students checked the following

prob-lems: “birth control,” “pregnancy,” “drug use,” “drinking,” and “VD.” Some variation in the percentage of students indicating these needs was noted when students’ sex, grade level, and ethnic

background were considered. For example, more

boys than girls and more ninth-graders than any other grade level wanted help with “drinking.” A

similar ninth-grade predominance was noted for

“drug use,” although no differences were

observed due to the sex of the students.

The need for “birth control” help was listed by more girls (22.2%) than boys (6.8%) and increased as grade level progressed (9th grade 11.8%, 12th grade 18.5%). Girls indicating a need of help for

“pregnancy” remained a consistent 9% to 10%

across all grade levels. Fewer Anglos (7.9%)

expressed this need than other ethnic groups

(blacks 15.1%, Mexican-Americans 12.6%). Help

for “VD” was desired by slightly more blacks

(12.6%) than other ethnic background groups

(Mexican-Americans 9.9%, Anglos 6.8%). In addition to concerns and problems, students were asked to give an indication of self-rating of their health. Twenty-nine percent of the students

F976

I9 -Il

757 1

742

1

724

1

714

I

:!OO

I

662

539

I

512

1

_v5

I

-4

I

412

1

397 1

8I

1378

[318

I

[304

1

[263

1

24O I

1224 I

1102 I

1234

1

of total respondents who indicated they wanted help with particular problems.

rated their health as very good, 51.3% as pretty

good, 17.6% as fair, and 1.3% as poor. Males

(33.7%) more than females (24.5%) rated their

health as very good. Mexican-Americans had the

lowest proportion (17.1%) rating their health as

very good compared to 29.2% for Anglos and

33.2% for blacks. Comparing their health to their friends, 23.4% viewed themselves as healthier,

61% about the same, and 13.9% not as healthy as

others. As with the ratings of health, males

(27.4%) more than females (20.1%) felt they were

healthier than their friends. There were also

ethnic differences in the proportions of students reporting that they felt they were healthier than

their friends: blacks 26.9%, Anglos 22.8%, and

Mexican-Americans 17.7%. Students were also asked to report how often they think about their

health: 44.3% often, 46.9% sometimes, and 7.9%

hardly ever or never. The proportion of respon-dents often thinking about their health increased with grade (9th grade 37%, 10th grade 42%, 11th grade 49.6%, 12th grade 51.1%). There were also ethnic differences: 52% of the blacks, 41.8% of the

Anglos, and 34% of the Mexican-Americans

mdi-cated that they often think about their health.

Major reported sources of health care were the

family physician (1,802 or 56.8%) and the

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I

80

70

60

Ui

50

Ui

40

30

20

0

UPPER UPPER MIDDLE MIDDLE LOWER MIDDLE LOWER

FIG. 4. Ethnicity and socioeconomic status for respondents who reported use of family physician.

ANGLO

MEX.-AMER

I

73 96

7 /

29

7. /

86

42 147 212

BLACK

15.9%) and clinics (471 or 14.9%). About 10%

(336) indicated they go to public health clinics or other sources of health care. Only 57 students

(1.8%) named the high school clinic as a usual

source of health care.

The proportion who reported using a family

physician increased with grade (59.7% in 9th

grade to 73.8% of 12th-graders); however, the

proportion indicating the emergency room

remained about the same for all grade levels.

Ethnic background of students influenced their

indicated source of health care as shown in Figure 4. Family physicians were named as their primary source of health care by 89% of Anglo students,

69.5% of Mexican-American students, but only

39.8% of black students. When analyzed by

socioeconomic status, a higher proportion of

Anglo students than black for each socioeconomic level utilized a family physician. Even for the

small number of Mexican-American students on

whom socioeconomic data are available, the

proportion of middle, lower middle, and lower

socioeconomic students utilizing a family physi-cian is almost double that for black students. Utilization of the emergency room as a source of

primary care by black students was similar

(343%) to the proportion using a family

physi-cian. Emergency room services were listed as the

primary health care resource by 20.4% of

Mexi-can-American students and 5.4% of Anglo

students.

During the past year, 27.3% of the responding students had no visits to a physician. About one

fourth had one visit and one third had two or

three visits. Four or more visits to a physician

were made by 14.7% of the students. Sex and

grade of the students did not influence the

number of visits. Anglo-Americans were most

likely to seek services of a physician, as only 21.3% responded that they did not see a physician at all in the past year as compared to 32.4% for blacks and 33.6% for Mexican-Americans.

In order to assess the knowledge and indicated

selection of specific school and community

re-sources, a series of seven problem situations was posed, with each respondent asked to select one of several plausible alternative sources of help in

this community. As can be seen in Table IV,

respondents often selected their parents, family

physician, or community resources well known

for dealing with specific problems. School-based resources were much less frequently chosen.

Summary of Results

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socioeco-TABLE IV

SUGGESTIONS ON WHERE TO Go ORCALL FOR INFORMATION OR HEu FOR Dzmasr SITUATIONS STUDENTS MAY ENCOUNTER#{176}

1. Suppose a friend was worried that he had VD.

Family physician 27.4% (893)

Free clinic 22.1% (718)

Hot Line 17.5% (568)

Health department clinic 13.1% (426)

School nurse practitioner 6.4% (207)

2. A friend is very depressed about personal matters, and you are worried that he is thinking about suicide.

Parents 33.6% (1,093)

Hot Line 11.2% (364)

Adolescent psychiatry 9.2% (298)

Teacher 8.6% (279)

Clergyman 6.4% (209)

School social worker 3.2% (105)

3. A good friend isusing what seems to be too much alcohol and feels he needs help.

Alcoholics Anonymous 52.6% (1,711)

Parents 14.0% (456)

Community Action 3.5% (113)

Clergyman 1.5% (50)

4. A friend tells you that he/the is thinking about having sexual intercourse and is worried about the possibility of pregnancy.

Family Planning 34.3% (1,116)

Parents 9.8% (318)

#{176}Percentages based on total number of respondents (3,255). The options, “do nothing,” “other,” or no response.

nomic status, black students relied more on public

health facilities while Anglos tended to go to

private physicians. Although Mexican-American students had the highest proportion in the lowest socioeconomic levels, they were less likely to use public health facilities. Mexican-American stu-dents gave less consideration to health matters

than did the other two ethnic groups. They had

lower proportions reporting a need for

informa-tion, identifying problems requiring help, and

thinking often about their health. However, they had the lowest proportion rating their health as very good and the highest reporting that they did not get answers to questions about health because no one was available to ask.

Females were more likely than males to iden-tify problems requiring assistance. Information or assistance with sexually related problems was expressed as more of a need for females than for

males. As students became older they were more

likely to identify the need for assistance with health problems. The younger students either had less problems or were less likely to be aware of

their needs with regard to some problem areas.

Clergyman 1.5% (50)

5. A close friend tells you that she is worried about being pregnant and doesn’t know what to do.

Pregnancy interruption clinic 27.9% (908)

Parents 21.4% (695)

Family planning 12.9% (421)

Free clinic 6.5% (212)

6. Suppose a friend tells you that he can no longer stand his parents and is planning to run away from home.

Parents 36.5% (1,189)

School counselor 13.7% (445)

Go ahead and do it 10.6% (346)

Clergy 4.2% (138)

7. Suppose a friend complains of many, bad stomach aches and cramps.

Family physician Parents

Health department clinic School nurse practitioner Pediatric (C&Y) clinic Free clinic 52.3% (1,703) 17.2% (561) 7.6% (246) 7.2% (233) 3.7% (119) 3.5% (115)

percentage necessary to make 100% is accounted for by the

There is an exception to this age trend with

drinking and drug use. The youngest students are more likely to express the need for assistance with

drinking and drug use and their need appears to

decrease with age.

Students appear to be able to select

appro-priate community sources for dealing with

specific problems. However, resources available

in the school were infrequently selected as a

source for dealing with specific problems.

IMPLICATIONS

The purpose of conducting the survey was to

obtain directly from the adolescents information

that could be used to plan and develop health

education and health services programs. The

results have the following implications for

program planning:

1. Students’ concerns and problems are not

limited to the frequently assumed major problems of drug abuse, venereal disease, and unwanted

pregnancy. A much wider range of physical

health needs as well as social-emotional needs was

(8)

results suggest a wide range of services and a

variety of helping professionals need to be

involved in both the planning and provision of health-related services.

2. The findings indicate a need for a more

coordinated effort for letting students know about the types of services as well as how to get access

to services in the school. Students showed a

willingness to use services and they identified numerous problems, yet the reported frequency of use of school services was low. School health services need to be made accessible and attractive to students. This includes working with school administrative and health personnel to develop an awareness that help for health problems involves psychosocial problems as well as physical illness. This may involve modification of school rules that will make time available for students to utilize school services. Students are often not involved in planning or evaluation of school health services. If

they could be involved, the services might be

more effective in meeting student-identified needs.

3. Since community services were selected

more frequently than services already available in the schools, there is also a need for structures that will lead to more cooperative efforts between school health services and community agencies.

This involvement may serve to improve both

school and community resources and make the

services more attractive to students.

4. Many of the concerns and problems identi-fled by the students require educational services as well as health care services. Therefore, a school health program at the high school level should be planned so that there is a close working

relation-ship between health educators and health care

personnel.

5. When examining the perceived health needs of an entire high school population, the diversity is too great to expect a single health education

course at a particular grade level to meet the

educational needs. Alternatives to the traditional

course approach must be sought to deal with

health education needs on a more individualized and ongoing basis. Planning for health education programs should include processes that will assist

students in identifying their own needs and

involve them in making plans to seek and utilize resources to meet needs.

6. Although the majority of students reported having a family physician, a large proportion of these urban students did not use a private physi-cian for their medical care. This was especially true for the black students. Therefore, the private physician model for preventive or curative ser-vices does not apply to some students. Alterna-tives to this model should be included in health services and educational activities. Students who rely on public health resources should receive assistance in how to obtain and effectively utilize these services.

REFERENCES

1. Simons B, Douns E: Ambulatory care for urban adoles-cents. NY State J Med 68:755, 1968.

2. The Report of the President’s Committee on Health Education. US Dept of Health, Education and Welfare, 1973.

3. Bnmswick A: Adolescent health in Harlem. Am JPublic Health (suppl):l, 1972.

4. Friedman SB, Weiner I: Special problems of adoles-cents, in Haggerty RJ, Roghmann KJ, Pless lB (eds): Child Health and the Community. New York, John Wiley & Sons, 1975, pp 107-110.

5. Newman I, Fuenning S: Adolescent health knowledge. Nebr Med J 58:411, 1973.

6. Brunswick A: Health needs of the adolescent: How the adolescent sees them. Am J Public Health 59:1730, 1969.

7. Deisher RW, Mills CA: The adolescent looks at his health and medical care. Ain J Public Health 53:1928, 1963.

8. Munan L, Sternlieb J: A survey of health problems, practices and needs of youth. Pediatrics 49:177,

1972.

ACKNOWLEDGMENT

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1977;60;157

Pediatrics

Guy S. Parcel, Philip R. Nader and Michael P. Meyer

Urban Population

Adolescent Health Concerns, Problems, and Patterns of Utilization in a Triethnic

Services

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