The national health objectives for the year 2000 target the reduction of behaviors that place adolescents at risk for human immunodeficiency virus (HIV) infection and other sexually transmitted diseases, unintended pregnancies, and other health problems (1). Although clinical preventive services are an important component of health-promotion and disease-prevention programs required to achieve these objectives (2), adolescents and young adults are less likely to have access to health care than younger and older persons (2,3). To characterize comprehensive health-service programs for adolescents (i.e., persons aged 13-19 years) and whether such programs provide targeted services to adolescents at risk for HIV infection or infected with HIV, the Center for Health Promotion and Disease Prevention at the University of North Carolina at Chapel Hill conducted a national survey of such programs in 1991. This report summarizes the results of this survey.

Programs providing comprehensive health services to adolescents were identified through a review of publications, mailing lists, adolescent health experts, provider organizations, state and local maternal and child health directors, foundations, and other sources (3). A total of 664 such programs were identified nationwide; at least one program was identified in each state except Montana, Nebraska, North Dakota, South Dakota, Vermont, and Wyoming. To assess the validity of the census, local experts reviewed the lists of identified programs in a sample of four states (Kentucky, Maryland, Mississippi, and Washington) and one large metropolitan area (San Francisco); in each area, 85%-90% of all programs had been identified.

A questionnaire was mailed to the director of each of the 664 programs. Of the 435 (66%) programs that responded, 195 (45%) were based in schools, 96 (22%) in hospitals, 48 (11%) in health centers, 39 (9%) in community centers, 35 (8%) in public health departments, and 22 (5%) in other sites. Nonrespondents were equally distributed among geographic regions of the United States. Programs in rural counties were more likely to respond than programs in metropolitan statistical areas (MSAs) (78% versus 67% {p less than 0.01}).

The highest proportion (201 {30%}) of all 664 programs was located in nine northeastern states. Of the 278 programs in urban communities, 83 (30%) were hospital-based programs; 110 (40%), school-based programs; and 10 (4%), health department programs. Of the 115 responding programs in rural communities, 64 (56%) were school-based programs, and 21 (18%) were health department programs.

In 1990, the 435 programs served 605,185 adolescents (median: 720 adolescents per program; range: 13-40,000 adolescents) -- approximately 2.5% of the 1990 U.S. adolescent population (24,336,100). These programs reported 2,175,561 patient encounters, for an average of 3.6 visits per adolescent. The ratio of adolescent health programs to the population of adolescents in each state varied widely (Figure 1) (3).

A total of 313 (72%) of the programs received federal funding from different sources, including Medicaid, Title V (Maternal and Child Health), Title X (Family Planning), and Title XX (Family Life Programs). In addition, 326 (75%) received state or local government funding, 109 (25%) received state or local health department funding, and 17 (4%) received state education agency funding; 129 (30%) of the programs received private foundation funding.

Almost all programs provided primary health care (396 {91%}), health education (405 {93%}), and HIV-prevention education (409 {94%}); 200 (46%) provided services during evenings, and 91 (21%) provided services during the weekend. Although 187 (43%) programs targeted sexual risk behavior among adolescents, these programs were no more likely than other programs to provide family-planning services (77% versus 70% {p=0.14}), contraceptives (62% versus 57% {p=0.28}), or HIV-antibody testing (50% versus 43% {p=0.16}) on site. Sixty-four (15%) programs targeted services to adolescents infected with HIV; these programs were more likely to provide HIV testing (67% versus 43% {p less than 0.01}) and contraceptives on site (75% versus 56% {p=0.006}) than other programs. Programs in health or community centers were more likely to target sexual risk behaviors and adolescents infected with HIV than were programs in other locations.

Although all identified programs had been considered initially to be comprehensive, only 262 (60%) reported that they provided comprehensive services on site. School-based programs were the least likely to provide contraceptive services, hospital-based programs were the least likely to provide outreach programs, and health center programs were the least likely to provide mental health services. Programs that considered their services comprehensive were no more likely to provide case management or to have greater coordination of services than were programs that did not consider their services to be comprehensive. Comprehensive programs were more likely to have larger budgets and to receive private foundation funding than were other programs.

Reported by: JD Klein, MD, Div of Adolescent Medicine, Univ of Rochester School of Medicine, New York. SA Starnes, MPH, School of Medicine; M Kotelchuck, PhD, Dept of Maternal and Child Health; GH DeFriese, PhD, Cecil G. Sheps Center for Health Svcs Research; FA Loda, MD, Center for Early Adolescence; JA Earp, ScD, Dept of Health Behavior and Health Education, Center for Health Promotion and Disease Prevention, Univ of North Carolina at Chapel Hill. Div of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Considerations that are unique to the planning and organization of health services for adolescents include psychosocial development, the need for visible and convenient but confidential services, and the lack of insurance coverage for recommended preventive care (4). A variety of model programs have been implemented to meet the comprehensive health needs of adolescents (2); however, only a small proportion of all adolescents are served by these programs and systematic evaluation of such programs has been limited (2,3).

The findings in this report indicate that most programs depend on multiple sources of funding, reflecting the categorical nature of funding for adolescent health services. Access to specific services also varies substantially; for example, many programs identified as comprehensive do not provide comprehensive services on site.

Most adolescent health problems, including HIV infection and other sexually transmitted diseases, are preventable (2). Preventive service guidelines for adolescents * recommend that confidential health guidance, condoms, and other reproductive- health services be available to youth (5); however, the findings in this report indicate that many comprehensive programs, especially school-based programs, do not provide reproductive-health services. Guidelines that address the range of health services that should be provided are needed for programs seeking to deliver comprehensive, coordinated care to adolescents.** More service-delivery programs, stable funding, and better integration of funding and administrative relations among health, education, and other service sectors are also needed if more U.S. adolescents are to have access to appropriate health services.

References

1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

2. Office of Technology Assessment. Adolescent health: summary and policy options. Vol 1. Washington, DC: United States Congress, 1991.

3. Klein JD, Starnes SA, Kotelchuck M, Earp JA, DeFriese GH, Loda FA. Comprehensive adolescent health services in the United States, 1990. Chapel Hill, North Carolina: University of North Carolina at Chapel Hill, 1992.

4. Klein JD, Slap GB, Elster B, Schonberg SK. Access to health care for adolescents: a position paper of the Society for Adolescent Medicine. J Adolesc Health Care 1992;24:162-70.

5. Department of Adolescent Health, American Medical Association. Guidelines for adolescent preventive services. Chicago: American Medical Association, 1992.

• Single copies of Guidelines for Adolescent Preventive Services are available without charge from the American Medical Association, Department of Adolescent Health, 515 N. State Street, Chicago, IL 60610; telephone (312) 464-5570. ** Copies of Comprehensive Adolescent Health Services in the United States, 1990 are available from the Center for Early Adolescence, University of North Carolina at Chapel Hill, CB #8130, Carr Mill Mall, Carrboro, NC 27510; telephone (919) 966-1148; price: $15.50.

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