Health care services utilization among adolescents (I-II)

After puberty, personal growth and development highlights individual differences in health behavior, health care services needs and utilization. It is well known that psychosocial difficulties are closely related to an increased rate of health complaints among adolescents.

Nevertheless, there is less knowledge of the increased utilization of health care services and associated factors.

2.2.1 Health care services and utilization Health care services are divided into primary, secondary, and tertiary health care. Here, focus is on primary health care, which refers to the municipally arranged monitoring of the health of the population with various services. Primary health care services are provided at municipal health centers (STM, Terveyskeskukset 2014). In addition, emergency room services offer walk-in medical treatment for patients with acute unexpected health complaints. Adolescents account for a notable proportion of patients in primary health care (Mölläri and Saukkonen 2014). Furthermore, the utilization of emergency room increases in adolescence and young adulthood (Callahan and Cooper 2010; Gnani et al. 2014).

It is well known that the utilization of health care services is determined by both demand (such as health problems, but also socio-demographic and psychological factors) and supply factors (availability and organization of various health services). Furthermore, the differences in the utilization of health care services are associated with demand side factors such as individual characteristics, health needs, and socio-demographic factors.

Frequent health care attenders account for a large proportion of contacts with primary health care. It has been suggested that the top 10% of individuals with frequent health care utilization account for up to 50% of all health care visits (Vedsted and Christensen 2005).

There is no standard definition for frequent health care utilization. For example, an integer threshold from 2 to 24 contacts in 12 to 24 months has often used to describe frequent attendance (Vedsted and Christensen 2005). Frequent attenders in primary health care more often suffer from somatic, psychiatric, and social problems compared to non-frequent health care attenders (Smits et al. 2009).

There are gender differences in health, health behavior, and health care utilization. In general, women are healthier than men, but they use a higher proportion of health care resources (Nguyen et al. 2011). Mortality is higher among males than females (Nguyen et al. 2011), and gender differences in mortality increase in adolescence (Gissler et al. 2006). In childhood, boys have more health problems and health care services utilization compared to girls (Gissler et al. 2006). After puberty, the utilization rate of health care services increases among adolescent girls (Gissler et al. 2006; Nguyen et al. 2011), and remains higher through life among women compared to men (Nguyen et al. 2011). Higher rates of utilization of health care services among females can be partly explained by gynecological reasons (Gissler et al 2006). Furthermore, there might be social differences and differences in behavioral style between genders in the utilization of health care.

Socioeconomic inequalities are strongly related to health care utilization in the Finnish population. People with a high income use more occupational health and private practice services, while visits to municipal health care services are more common among people with a low income (Manderbacka et al. 2007).

There are also individual patterns in health behavior and the utilization of health care services. Individual health behaviors are a more complicated issue than only defining the assortment of individual characteristics. The differences between individuals can be seen as variation in an individual’s behavior over time and variation in behavior between individuals (Gunasekara et al. 2014). Here, the concept of individual patterns refers to differences between individuals, or behavioral patterns that cannot be explained by known background characteristics (i.e., represent “unobserved heterogeneity”). Individuals may differ in their personal load of stress, adaptive regulation, physiological state, and external disturbances (Yashin et al. 2008). The non-medical reasons affecting care-seeking behavior can be divided in two groups: Firstly, there are differences between population groups in their care-seeking behavior, e.g. between males and females or persons of different ages.

These differences are observable in the same sense that they can be statistically explained by gender and age, reflecting e.g. cultural differences between population groups. Secondly, there are differences between individuals that cannot be statistically explained in a given dataset (“unobserved heterogeneity”). People with the same gender and age might have an individual pattern of behavior, and the existence and degree of this heterogeneity can be observed in panel data analysis, but not the factors behind it. For example, hidden heterogeneity in age-related characteristics may cause incorrect causal conclusions concerning the associated factors (Yashin et al. 2008).

2.2.2 Frequent primary health care services utilization among adolescents Among adolescents, the most common medical reasons for attending primary health care include respiratory tract problems, gastrointestinal problems, and signs or symptoms of diseases such as a poor appetite, aches, and pains (Vila et al. 2012). Psychosocial difficulties are related to an increased rate of somatic symptoms such as headache, stomach ache, and sleeping problems among adolescents in comprehensive school (Luntamo, Sourander and Aromaa 2015). Among frequent health care using adolescents, typical health complaints include upper respiratory tract infections, asthma, injuries, and acne (Kramer et al. 1997).

Few studies have investigated frequent health care use in adolescents. Among British secondary school pupils, 30% of adolescents were frequent attenders of primary healthcare, and they had 4 or more visits per year (Vila et al. 2012). Having been admitted to hospital, absence from school, current medical illness, and a previous need for psychiatric consultation were associated with frequent primary care use among adolescents (Vila et al.

2012). Moreover, in a study on Norwegian students (aged 15–16 years), dropping out from school was associated with frequent student health care use and referrals to mental health care (Homlong, Rosvold and Haavet 2013).

To our knowledge, however, there have been no studies on adolescent substance use or risky health behaviors in relation to frequent primary health care use. According to a Finnish health survey of young adults, mental symptoms such as depression increased the use of

health care services, and health care use was more prevalent among young women compared to men (Kestilä et al. 2007). Furthermore, survey results suggested that several childhood and current adverse experiences and high alcohol consumption were associated with psychological distress. In addition, psychological distress was associated with frequent use of health care services, but only few of distressed young adults had sought professional help for a mental health problem (Kestilä et al. 2007). Among adult patients, chronic diseases, mental health problems, and social problems have been associated with frequent primary health care visits (Smits et al. 2009).

2.2.3 Frequent emergency room services utilization among adolescents

The utilization of emergency room services increases in adolescence and young adulthood (Callahan and Cooper 2010; Gnani et al. 2014). Common reasons leading to this increasing use in young people include musculoskeletal issues, injuries, and respiratory tract infections (Gnani et al. 2014). Concerning mental health issues, the most common conditions leading to the need for emergency room services are depression, conduct disorders, substance use, and unspecified neurotic disorders (Mahajan et al. 2009). Injury-related emergency visits increase in puberty (Downing and Rudge 2006). In a Finnish emergency room survey, up to two-thirds of underage patients attending emergency room due injuries were under the influence of alcohol (Karjalainen et al. 2013).

Recurrent emergency room visits by adolescents are associated with female gender, older age, mental health problems (Newton et al. 2010; Burnett-Zeigler et al. 2012), socioeconomic deprivation (Newton et al. 2010; Rudge et al. 2013), a poorer health status (Lau et al. 2014), and alcohol-related injuries (Linakis et al. 2009). In a pediatric emergency room study, positive responses to a suicide-screening questionnaire associated with repeated emergency room visits in children (aged 8–12 years), and psychiatric hospitalization in adolescents (aged 13–18 years) (Ballard et al. 2013). A few American studies have revealed a relationship between higher rates of emergency visits and a lack of private health care insurance among adolescents and young adults (Callahan and Cooper 2010; Lau et al. 2014). In a pediatric emergency room study, a higher proportion of emergency room visits compared to all other visits to health care services associated with lower educational and income levels in the family and public insurance (Kroner, Hoffmann and Brousseau 2010).

In comparison to adolescents, among adult patients, frequent emergency room visits have been associated with an older age, chronic illness, psychological distress and mental health problems, socioeconomic distress such as a low educational level and low income, and a high level of use of other health care resources (Sun, Burstin and Brennan 2003; Jelinek et al. 2008; Stockbridge, Wilson and Pagán 2014). In addition, among adults, problem drinking of alcohol and illicit drug use have been associated with emergency room use more often than with other primary health care use (Cherpitel and Ye 2008; Jelinek et al. 2008).

The immediacy of the objective need in a medical sense for medical care is expected to determine the decision to use health care services. However, factors other than those related to the medical condition influence the decision to seek help from health care services such as emergency room services. Health care utilization might be affected by unobserved measures or individual characteristics and personal factors (Woolridge 2002). It might also

be possible that the utilization of health care services could be predicted by individual past behavior. Published research on individual health behavioral patterns and associations with health care utilization and emergency room utilization in adolescence or young adulthood was not found.

2.3 REPRESENTATIVENESS AND ATTRITION OF ADOLESCENT MENTAL