Using the Social-Ecological Model to Improve Access to Care for Adolescents and Young Adults

See Related Article on p. 667Spencer 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]Spener D. McManus M. Call K.T. 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: 667-673Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar]. 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]Nemiary D. Shim R. Mattox G. Holden K. The relationship between obesity and depression among adolescents.Psychiatr Ann. 2012; 42: 305-308Crossref PubMed Scopus (58) Google Scholar]. 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 [3Cuffe K.M. Newton-Levinson A. Gift T.L. et al.Sexually transmitted infection testing among adolescents and young adults in the United States.J Adolesc Health. 2016; 58: 512-519Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 4Shain B. Suicide and suicide attempts in adolescents.Pediatrics. 2016; : e20161420Crossref PubMed Scopus (221) Google Scholar]. Across these outcomes, improving access to and utilization of health services is a critical component of prevention efforts. See Related Article on p. 667 However, Spencer et al.'s results suggest that increasing insurance coverage is necessary but insufficient for improving quality care between childhood and adulthood [[4]Shain B. Suicide and suicide attempts in adolescents.Pediatrics. 2016; : e20161420Crossref PubMed Scopus (221) Google Scholar]. 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. Existing frameworks describe the multiple factors that impact health-care utilization and highlight opportunities for intervention [[5]Levesque J.F. Harris M.F. Russell G. Patient-centred access to health care: Conceptualising access at the interface of health systems and populations.Int J Equity Health. 2013; 12: 18Crossref PubMed Scopus (1108) Google Scholar]. Although these frameworks vary, many reflect principles of the social-ecological model, a simple yet seminal public health framework [[6]McLeroy K.R. Bibeau D. Steckler A. Glanz K. An ecological perspective on health promotion programs.Health Educ Q. 1988; 15: 351-377Crossref PubMed Scopus (4433) Google Scholar]. 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]Frieden T.R. A framework for public health action: The health impact pyramid.Am J Public Health. 2010; 100: 590-595Crossref PubMed Scopus (952) Google Scholar]. Yet the social-ecological model posits that a multilevel approach is more likely to be effective and sustained. 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]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: 36-43Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar]. 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 [9Tylee A. Haller D.M. Graham T. et al.Youth-friendly primary-care services: How are we doing and what more needs to be done?.Lancet. 2007; 369: 1565-1573Abstract Full Text Full Text PDF PubMed Scopus (471) Google Scholar, 10Riley M. Patterson V. Lane J.C. et al.The adolescent champion model: Primary care becomes adolescent-centered via targeted quality improvement.J Pediatr. 2018; 193: 229-236Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 11Committee on Adolescence American Academy of Pediatrics Achieving quality health services for adolescents.Pediatrics. 2008; 121: 1263Crossref PubMed Scopus (95) Google Scholar]. 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]Ford C.A. Davenport A.F. Meier A. McRee A.L. Partnerships between parents and health care professionals to improve adolescent health.J Adolesc Health. 2011; 49: 53-57Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar]. 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]Knopf J.A. Finnie R.K. Peng Y. et al.School-based health centers to advance health equity: A community guide systematic review.Am J Prev Med. 2016; 51: 114-126Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar]. 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]Bauermeister J.A. Pingel E.S. 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: 1860-1874Crossref PubMed Scopus (92) Google Scholar]. A benefit of these interventions is that they reach youth in settings where they are already engaged. 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. Health Care Coverage and Access Among Children, Adolescents, and Young Adults, 2010–2016: Implications for Future Health ReformsJournal of Adolescent HealthVol. 62Issue 6PreviewWe examine changes to health insurance coverage and access to health care among children, adolescents, and young adults since the implementation of the Affordable Care Act. Full-Text PDF