Chapter 105 The Epidemiology of Adolescent Health Problems

Circumstances impacting adolescent lives vary across the globe. In countries at war, adolescents may be serving as soldiers. In countries deeply affected by AIDS, youth may be at the demographic epicenter of the epidemic and/or assuming the role as primary provider for younger siblings in the aftermath of parent death. In low income nations, youth may be laboring long hours in rural fields near their homes or in distant cities as urban migrants, while in middle and high income nations, they are more likely to be in school. Health promoting behaviors also vary; among youth ages 11, 13, and 15 yr from 29 countries, 54% of U.S. females and 74% of U.S. males exercise on 2 or more occasions per week. Among the remaining 28 countries, rates of exercise twice a week for males range from 90% in Northern Ireland to 60% in Greenland, and for females, rates range from 66% in Germany and the Czech Republic to a low of 37% in Greenland. Among females in all 29 countries, there is a decline in this proportion with age; this trend is not seen among males.

Health outcomes also vary. About 16 million women aged 15-19 yr old give birth annually, accounting for 10% of births worldwide. The average adolescent birthrate in low-income countries is 5-fold that of high-income countries. Complications from pregnancy and childbirth are the leading cause of death among adolescents in developing countries; death as an outcome of pregnancy is rare in developed countries. Perceptions of feeling healthy also vary greatly by country as shown in Figure 105-1; those who do not feel healthy increases proportionately with age.

Figure 105-1 Proportion of 15 yr old youth from 28 nations who report not feeling healthy.

(From Health Resources and Services Administration, Maternal and Child Health Bureau: U.S. teens in our world. Understanding the health of U.S. youth in comparison to youth in other countries (website). www.mchb.hrsa.gov/mchirc/_pubs/us_teens/main_pages/ch_1.htm. Accessed April 16, 2010.)

Despite these variations by geographic region and level of economic development, there are many similarities in adolescent health issues. In all nations, adolescence is a time of immense biologic, psychologic, and social change (Chapter 104). Many of the psychologic changes have a biologic substrate in the development and eventual maturation of the central nervous system, particularly the frontal lobe areas responsible for executive functioning (Fig. 105-2). In addition to cognitive development, there are both risk and protective factors for adverse adolescent health behaviors that are dependent on the social environment as well as the mental health of an adolescent (Table 105-1).

Figure 105-2 It has been speculated that the impact of puberty on arousal and motivation occurs before the maturation of the frontal lobes is complete. This gap may create a period of heightened vulnerability to problems in the regulation of affect and behavior, which might help to explain the increased potential in adolescence for risk taking, recklessness, and the onset of emotional and behavioral problems.

(From Steinberg L: Cognitive and affective development in adolescence, Trends Cogn Sci 9:69–74, 2005.)

Table 105-1 IDENTIFIED RISK AND PROTECTIVE FACTORS FOR ADOLESCENT HEALTH BEHAVIORS

Adapted from Mclntosh N, Helms P, Smyth R, editors: Forfar and Arneil’s textbook of paediatrics, ed 6, Edinburgh, 2003, Churchill Livingstone, pp 1757–1768; and Viner R, Macfarlane A: Health promotion, Br Med J 330:527–529, 2005.

Geographic similarities are reflected in many adolescent health outcomes. Suicide is the 3rd leading cause of death among adolescents worldwide. In the USA, an estimated 13.8% of high school students seriously considered attempting suicide, and 6.3% had actually attempted suicide in the previous 12 mo. Experimentation with new behaviors leads to an increase in risky behaviors among adolescents in the USA (Fig. 105-3) and globally. The Global Youth Tobacco Survey, initiated by the World Health Organization (WHO) in 1999, reveals that tobacco use is a major problem among adolescents ages 13-15 yr in all 6 regions of the globe (Africa, Americas, Eastern Mediterranean, Europe, Southeast Asia, and Western Pacific), averaging 17% globally, with a low of 11% in the Western Pacific region and a high of 22% in the Americas. Alcohol and illicit drugs are a major cause of concern in high-income countries and have also been estimated by the WHO to contribute 4% of the disease burden in adolescents and young adults in low- and middle-income countries. Adolescents and young adults worldwide have high rates of most common sexually transmitted infections in their countries. Persons in this age group in the USA have been estimated to account for nearly half of all incidents of sexually transmitted infections, although they represent only 25% of the sexually active population. A study of 9 developed countries revealed a similar pattern in many of the nations: >50% of cases of syphilis occurred among youth 15-24 yr in Romania and the Russian Federation; >50% of cases of gonorrhea occurred in this age group in Romania, the Russian Federation, the Slovak Republic, Canada, England and Wales, and the USA; and in 6 countries, youth this age were responsible for >50% of annually reported chlamydia cases.

Figure 105-3 Selected health risk behaviors among 12th grade high school students.

(Data from Centers for Disease Control and Prevention: 2009 youth risk surveillance system (website). www.cdc.gov/HealthyYouth/yrbs/index.htm. Accessed February 20, 2011.)

In the USA, injuries cause more than twice as many deaths among adolescents as do natural causes; motor vehicle traffic–related injuries and firearm-related injuries are the 2 leading causes of injury death among adolescents 10-19 yr of age (Chapter 5). Although infectious diseases remain important causes of death for adolescents in some low-income countries, adolescents worldwide are increasingly exposed to risk-taking behavior including violence. Worldwide, motor vehicle accidents are the greatest cause of death and disability among men ages 15-19 yr. For all causes of mortality resulting from unintentional injury there is an inverse relationship between mortality rates and per capita income except for motor vehicle traffic among adolescents and young adults; for this category, mortality is higher in high-income countries compared to low-income countries. Though mortality due to motor vehicle injury is decreasing among adolescents in higher income countries, it is increasing in low-income countries.

Access to Health Care

Access to health care may be limited for adolescents regardless of the country of residence. Adolescents in low-income countries experience reduced access to health care compared to their counterparts in wealthier nations for a range of reasons, including lack of facilities, long distances to facilities, inadequate transportation, and insufficient time to travel to facilities. There are also cultural prohibitions, such as gender, poor education, and inadequate financing. Within countries, access is generally inversely related to socioeconomic status (Chapter 1).

Among middle- and high-income countries, adolescents often have reduced access compared to other age groups. Adolescents in the USA make fewer visits to physicians for ambulatory office visits than does any other age group; school-aged children and adolescents are more likely than younger children to have unmet health needs and delayed medical care. Adolescents and young adults are less likely to be insured than all other age groups. Young adults 18-24 yr are more likely to be uninsured because until the passage in 2010 of America’s Affordable Health Choices Act, many were no longer eligible to receive benefits from their parents’ health plans or public insurance programs. In addition, health insurance status differs based on income and race/ethnicity. Adolescents and young adults who are near poor (100-199% federal poverty level [FPL]) and poor (below 100% FPL) are less likely to have health insurance coverage than those with higher family incomes; and Hispanic and black adolescents and young adults are less likely to have health insurance coverage than their non-Hispanic white and Asian peers. Uninsured children and adolescents are less likely to receive preventive visits and have a regular source of care than the insured, and are more likely to go without treatment of symptoms.

Adolescents who actually receive preventive care may still not have access to time alone with their provider or discuss important confidential health issues, such as sexually transmitted infections, HIV, or pregnancy prevention. Less than half (40%) of adolescents have time alone with their health care provider during a preventive health care visit; sexually experienced teens report sexual health discussions more often than nonsexually experienced teens, but the frequency is still low at 64% and 33.5% for sexually experienced females and males, respectively.

In 2002-2004, adolescents 10-19 yr of age in the USA had about 13 million emergency department (ED) visits annually. ED visit rates increase with age for both male and female adolescents. Female ED visit rates more than double between ages 10-13 yr and 18-19 yr, in part because of pregnancy and sexual activity–related conditions. Among adolescents and young adults ages 15-24 yr in 2005, females and blacks had higher ED visit rates than their peers. Injuries are a major cause of ED visits. In 2002-2004, initial injury-related ED visits comprised 42% of all ED visits for 10-19 yr olds and were higher among male than female adolescents. Other principal ED diagnoses among adolescents 10-19 yr of age include asthma, upper respiratory conditions, and abdominal or gastrointestinal conditions. Among female adolescents, ED visits for symptomatic sexually transmitted infections, urinary tract infections, and pregnancy-related conditions are also high and increase substantially with age.

Adolescents are among the least likely of all age groups to be hospitalized. In 2004, childbirth was the leading cause of inpatient hospitalizations for adolescents and young adults ages 12-24 yr, followed by mental health disorders and trauma-related disorders, such as open wounds and fractures (Fig. 105-4).

Figure 105-4 Number of hospital inpatient stays by condition, ages 12-24 yr, 2004.

(Adapted from National Adolescent Health Information Center: 2008 fact sheet on health care access & utilization: adolescents & young adults, San Francisco, 2008, University of California, San Francisco. Source: Medical Expenditure Panel Survey, Household Component Summary Tables, 2007.)

The National Initiative to Improve Adolescent Health by the Year 2010 has identified 21 critical health objectives for adolescents and young adults as a strategy to focus state and community resources and health professionals on improving the health status of U.S. youths (Table 105-2). Progress to date includes significant improvement in incidence of teen pregnancy and tobacco use, small increments of improvement in some areas (i.e., physical fighting, weapon carrying, safety belt use), and worsening trends for others such as motor vehicle crashes, chlamydial infections, and obesity. These health objectives are applicable to adolescents throughout the world.

Table 105-2 TWENTY-ONE CRITICAL HEALTH OBJECTIVES FOR ADOLESCENTS AND YOUNG ADULTS

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