Adolescent Health in America: Transforming Care to Better Serve Young People

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00:04 Leanne: I'm Leanne, I'm from Ypsi and I go EMU right now. I am a Women and Gender studies major, with a minor in Human Sexuality. I got pregnant at 15 and had my son at 16, so I had a lot of problems because I went to a pediatrician, I had never been to a gynecologist before. And then I continued to see a pediatrician after, so they didn't have a lot of the resources that I need.

00:27 Leanne: Like when I found out I was pregnant, it was at a pediatrician, but then they couldn't not tell my parents that I got a pregnancy test. They offered me Plan B, but I couldn't do that without my parents seeing it on their insurance and whatever. And then the gynecologist that I went to wasn't very inclusive of the fact that I was a teenager, he was more focused on trying to make it into a bad situation rather than a celebration, which I feel is a bad narrative that a lot of teen parents have. And then, a lot of my post-natal care, I went back to a pediatrician, so my son and I had the same doctor. But I wasn't old enough to go to a different doctor, so I was stuck at a pediatrician, but they didn't have the lactation consultant that I needed. A lot of the things I would go in for, they'd be like, "Okay, well, you've had a baby, so we don't really know what to do with this information." But then I'd try to go to a different doctor and they'd be like, "Okay, but you're a child, so we don't know what to do with you." So there wasn't a lot of middle ground where I could be an adolescent and be a mom and get the resources I needed for both.

01:41 Speaker 2: Growing up is hard to do. For American adolescents like Leanne, nearly 20% of the US population, managing their changing health and learning the skills they'll need to navigate the healthcare system for the rest of their lives is a daunting task, especially when that system is not set up with their needs in mind. In this episode of Population Healthy, we'll talk to University of Michigan School of Public Health experts and teens themselves to learn about issues facing adolescents in the US, and to explore how providers, parents and peers can help empower them to live healthier lives. Hello, and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important public health topics, stuff that affects the health of all of us at a population level. From the microscopic to the macroeconomic, the social to the environmental, from neighborhoods to cities, states to countries, and around the world.

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02:47 S2: The technical definition of adolescence for health professionals is the ages 12 to 24. But to really understand the issues facing young adults in that age group, Michigan Public Health professor Cleo Caldwell, says we have to start by acknowledging that adolescence is much more than a number.

03:04 Cleo Caldwell: I'm Cleo Caldwell and I'm the chair of the Department of Health Behavior and Health Education here at the School of Public Health. I'm also a professor in the department and I've been here for a long time. I'm someone who really has a strong interest in adolescence as a stage of development specifically, and I also oversee a number of research projects that involve adolescence. I'm a psychologist by training and I came into the School of Public Health because I was particularly interested in doing community-based work, and I came in with the responsibility of teaching the adolescent health class. One of the things that I noticed in looking at a lot of intervention programs that were designed for adolescents, oftentimes, they didn't consider the developmental aspect of what was happening during the adolescent stage of development. So, my approach to that class was really to begin thinking about how can I teach it from a developmental perspective. We were interested in all of the typical youth risk behaviors that we try to prevent, particularly in my department, HBHE, is a department that focuses a lot on intervention and prevention is a part of that process.

04:09 CC: But in terms of really meeting youth where they are, that became an important part of this whole process. So my approach to the work that I do, thinks about adolescence in terms of where they are from a developmental perspective, what they're trying to accomplish, and what their needs are because they have a number of psychosocial needs that aren't being addressed during this time of development. Social identities are really critical for adolescents because the developmental stage where they are, their main task is to develop an identity. And that means developing a sense of "Who am I and what can I be?" And so, social identities then becomes extremely important as they try to figure out who they are from a youth's perspective. Adolescents don't grow up in isolation. When they are figuring out who they are, they are influenced by families, they're influenced by schools, they're influenced by communities, they're influenced by the social media. So there are a lot of influences in terms of helping them figure out who they are.

05:09 CC: My work is particularly focused on the role of the adolescents within families. Adolescents don't grow up in isolation, we know that they're an important part of the family system. And when we think about healthcare, one of the things that we know is that families are an important part of that process in terms of managing the health of the adolescents. One of the challenges I think we face as a society is really trying to figure out, "When does that adolescent become independent enough to make their own choices and their own decisions?" In the healthcare system, it was fascinating to me for a long time. Adolescents went to pediatricians as their physicians. Now, we have, thank goodness, specialty in adolescent medicine, where we have physicians who really do take into consideration where adolescents are developed mentally. Typically, going to a pediatrician, that pediatrician may talk with the family about the adolescent's health, without engaging the adolescent's input in that process. That becomes challenging because one of the things that we know during adolescence, one of those psychosocial needs that they have is this idea of autonomy, that they can have some decision in what happens to them.

06:14 CC: With the healthcare system that's now prepared to address adolescents' needs a bit more, I think this is an advancement that's really important for us to recognize. Because youth who still continue to go to healthcare specialists who don't understand adolescence as a stage of development, oftentimes treat them as little adults. And that doesn't get us where we need to be in terms of helping them transition into adulthood, with this full sense of confidence that they know who they are and that they can advocate for themselves.

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06:51 S2: Lauren Ranalli is an alumni of the University of Michigan School of Public Health and has built her career on improving the health of adolescents. Her roles have included being the Director of the Adolescent Health Initiative at Michigan Medicine. For this next segment, we asked her about the issues that are unique to adolescent health and how practitioners can address them. And you will also hear from some Michigan-based teenagers about their experiences managing their own health.

07:14 Lauren Ranalli: In general, adolescence is a pretty healthy time of life, a pretty healthy stage of life but there are a number of health concerns that can either start or peak during this time and that can be anything from mental health disorders that present during adolescence, patterns of substance use or initiation of sexual activity. Mental health is a huge concern for this age group and this population. According to 2017 Youth Risk Behavior survey data which is a national survey of high school students between grades nine through 12, over 32% of young people have experienced symptoms of depression in the past year, so that means feeling so sad or hopeless almost every single day for one or more weeks in a row that they stopped doing some of their usual activities. Almost a third of young people surveyed nationally felt this way, and that's really significant. And we know from the CDC and from Healthy People 2020 that suicide is a leading cause of death in adolescents and young adults, so certainly, access to adolescent centers and mental health services and support is really crucial.

08:22 LR: CDC data also shows that adolescents make up the majority of new sexually transmitted infections in the US and according to the Youth Risk Behavior Survey again, 29% of 9th through 12th graders are currently sexually active, and only 54% of them used a condom during their last sexual intercourse. So while teen pregnancy rates are on the decline, STI rates continue to increase. In addition to mental health and STIs, I think clearly, substance use is a significant public health issue that impacts teens and young adults. Between vaping and opioids and other substance, it's also just a rapidly changing landscape. But I think what ties all of these together are this idea of risk behavior. And again, adolescence is... It's developmentally normal to be taking risk and kind of exploring during this time period, but as health professionals, we need to remain really committed to screening young people for potential risk.

09:25 Speaker 5: Hi, am [09:26] ____ and I am 18 years old from the West Michigan area. I go to Davenport University, getting my master's in business, looking to do organizational and leadership in the future. I'm transgender, my pronouns are she/her. So as a 18-year-old, I've had a completely different experience. Since before then, I've been labeled as a minor in health context, a lot of things kind of block you off for access-wise as what you can get. A lot of times, I would ask for something from my doctors and they would say, "Well, we're gonna have to bring your parents in for that." A lot of that shut down anything I really wanted to do. So then I kinda just waited around until I was 18 when I knew I could actually get things. Instead of fighting a really hard fight, I kinda just waited till my health issues could be addressed when I was older and I had my own independence with it. But that has obviously caused a lot of delay in things I needed attention of and I've paid the price for that. So it would have been really nice if I could have felt comfortable enough to have my parents involved or had more anonymity with having my own health and having my own rights with dealing with my own health issues. The difference is just an immense feeling of freedom, going to my own doctors, choosing my own doctors and organizing them myself. I'm seeing multiple doctors for things I've just wanted to address my entire life.

10:38 LR: I don't wanna speak directly for adolescents, but I can say that the literature and our experience working with teens has shown that they cite confidentiality or real or perceived lack of confidentiality as one of their biggest barriers to receiving care. So if you live in a small community and the nurse at the health center is your neighbor or the provider that you see goes to your place of worship or any number of things, how likely are you to disclose information about the fact that you've started vaping or you're concerned that you have an STI or reporting that you're in an abusive relationship or fill a prescription for birth control if you know the pharmacist? But even in larger communities where proximity isn't really the main concern for confidentiality, young people are still not likely to open up or ask questions or disclose information if they feel judged, if they feel that their identity isn't affirmed or validated, adolescents aren't that different from adults. If as an adult, I go into my healthcare visit and I'm feeling judged, I'm much less likely to bring up my actual concerns. Giving people the tools and the time and the space to ask questions in the right way, have that confidential time alone, can really profoundly impact the interactions that you have with your patients.

11:57 Sakina: I'm Sakina or you can call me Saki or S, I go to school at MU. My biggest issues that I would say that I've experienced when accessing healthcare is essentially not knowing my resources. And because of that, I did not always experience the best or adequate healthcare that I could have as a youth just simply because I didn't know what my health clinic or healthcare facility offered me or what they have for people in my situation. I've had positive experiences but not through me. I am a part of taking my little sister to the hospital, and my little sister is 10. I was so happy to witness the doctor speaking to my little sister. She didn't really ask the adults in the room questions. She directly looked at my 10-year-old sister, gave her eye contact, and spoke to her about her and her healthcare. And if my little sister didn't know, that's when we took the liberty of interjecting while also respecting her space to answer her own questions. But yeah, that was a positive experience. I was really happy that she spoke to the patient and not to us.

12:57 LR: Every adolescent is different, but generally speaking, around age 11 or 12, adolescents should be informed of their healthcare rights. They should start learning their personal and their family medical history. If they take medication, they should know the names of their meds, and also what schedule they're supposed to follow. And they should talk directly with their healthcare provider at the visit, right? It shouldn't be the parent kind of speaking to the provider on behalf of the young person. And that honestly should start way younger than 11 or 12. By age 13, we recommend that they have confidential time alone with their provider at every visit, and that they should go and check in for their own appointments. When you arrive, you go in, you check in, you give your name, you can fill out some information. By age 15 or 16, we think that adolescents should be encouraged to actually call and make their own appointments, call the pharmacy to fill their prescriptions, and learn about their current insurance coverage or what their options are. And then, by 17 or 18, teens should know what their healthcare rights are going to be and how they change when they turn 18, and starting to put together a plan for if they're moving away from home, or transitioning to a new provider and receiving care elsewhere.

14:06 LR: Providers here at University of Michigan Health Services say that so many incoming freshmen have never set up their own appointments, they've really never had visits, they've never had to navigate a referral. And navigating a referral is not always intuitive. You're not always sure what you're supposed to do. And they don't know their family or their personal health history. And so, really just giving young people the tools that they're gonna need to be successful. But I think on top of that, you can be as savvy or as successful as you want, but if you walk into a healthcare space and you have a really bad experience, you're just not likely to go back. And so, making sure that when we do capture young people, we do get them in the door, that they're having the types of positive experiences that make them feel like this is a place where I can come when I have concerns, and making sure that we're creating those spaces so that young people can continue to invest and value their health.

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15:04 S2: Michigan Public Health alumna, Taryn Gal, is the director of the Michigan Organization on Adolescent Sexual Health, or MOASH. Her organization partners directly with adolescents in high impact work that touches policy, practice, and more. MOASH's formal mission is to mobilize youth voices, engage community partners, and inform decision-makers to advance sexual health identities and rights.

15:26 Taryn Gal: My elevator pitch, what I usually tell people, is that we do anything we can to ensure that young people have access to sexual health services and sexual health education that is high quality, according to best practice. So, sex ed and sexual services that's non-shaming, trauma-informed, survivor-centered, medically accurate, research-informed, youth-informed, inclusive and affirming of expectant and parenting youth, of LGBTQIA+ youth, of students of different intellectual and developmental abilities, their physical, mental, spiritual, and social well-being in relation to sexual health. Anything related. It's anatomy, bodies, body image, body positivity, puberty, reproduction, relationships, pleasure is often left out of the conversation, sexuality, porn, consent. Lots of different aspects to sexual health. Sexual health is related to physical health. We talk about our bodies, we talk about puberty, we talk about STIs, our mental health, our social health, our spiritual health. We do a lot of work to try to collaborate with others and realize how sexual health is related to the work that they do, so we can collaborate on funding and on programming, even things like oral health and talking about oral STIs, and mental health, such as PTSD from sexual violence, or spiritual health, like not being welcome at a place of worship because of your sexual orientation.

16:48 S2: A persistent challenge facing adolescents is the ways in which stigma and shame can keep people from talking about sex and their sexual health.

16:57 TG: People don't talk about their experiences. We don't hear what others are experiencing. Stigma keeps folks from getting tested, it keeps folks from getting medical care, it keeps folks from talking with their partners about what they feel is safe, what they like, what they don't like. And the more that we talk about all of these things, the more we can normalize them, and the healthier that we can be. We find once we create a space where we are not shaming and we're not stigmatizing and we are being open and affirming to everyone's identities and lived experiences, that youth will totally talk to us and tell us what we need to know in order to provide them with additional information and access to services.

17:40 TG: So much of the work in sexual health has been around teen pregnancy prevention, and we're really starting to realize how shaming and stigmatizing even that phrasing can be. And going into it with that sort of intention of teen pregnancy is the worst possible thing that can happen, which, it's not. And so, we are really working to reframe the conversation around adolescent sexual health, not just teen pregnancy prevention, and really reframing it as unintended teen pregnancy prevention. And we do a lot of work with expectant and parenting youth, so pregnant and parenting teens. We're working, as usual, to get a youth advisory council of young parents who can inform our work, ensure that it is inclusive and affirming of young parents, things like even reframing pregnant parenting teens to expectant and parenting youth.

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18:28 TG: At MOASH, we have several buckets of work that we do, and one of the huge buckets is sexual orientation and gender identity and attractionalities. We find, not surprisingly, at least to us, that sexual orientation and gender identity intersects with every single thing that we do, every single program, every single issue, every single effort that we put our time and energy into. For example, sex ed is not inclusive of LGBTQIA+ youth. A lot of the sex ed that young people have, if they get any sex ed in school, that a lot of times, it's just about heterosexual, cisgender sex, penis-vagina sex. And we hear from young people that they just tune out, it doesn't apply to them, they're not learning how to go into healthy sexual relationships, protect themselves, protect their partners when none of this applies to them. So, really working to ensure that sex ed that's being recommended and reviewed by sex ed advisory boards across the state is inclusive and affirming of LGBTQIA+ youth.

18:55 TG: We know that it's all related, all intersects, but that LGBTQIA+ youth are more likely to have unintended teen pregnancies. A lot of that is because we're not getting the sex ed, we're not providing the information that's needed. I think a lot of it's doing education for educators around how to be inclusive of folks of all sexual orientations and gender identities and attractionalities, working with youth of all sexual orientations and gender identities to inform the materials that we provide to educators. I would say that we, as adults, need to step back and let young people tell us what they need and what their experiences are. And as adults, we need to provide the resources and the support. We all don't know what we don't know, so providing that information, but doing it in a way where young people can really say, "This aligns with my experience, this doesn't, this is what I need." And then, we need to actually listen to that and act on it, not just tokenize or be asking for input and then not actually putting that information to work.

20:33 Sakina: The biggest thing I would have to say is teaching us as young people, that we have ownership within our healthcare and that we could be independent while navigating through our healthcare with assistance from our parents, and then, but also encouraging us to recognize our own power in healthcare. And I think that the biggest thing is to start at a very young age.

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21:01 S2: Thanks for listening to this episode of Population Healthy, from the University of Michigan School of Public Health. We're glad you decided to join us, and we hope you learned something that will help improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, Apple Podcasts, Google Play, Stitcher, Spotify, or wherever you listen to podcasts. Be sure to follow us at UMICHSPH on Twitter, Instagram, and Facebook, so you can share your perspectives on the issues we discuss, learn more from Michigan public health experts, and share episodes of the podcast with your friends on social media. You can also check out the show notes on our website, publichealth.umich.edu/podcast for more resources about the topics discussed in today's episode. If you want to stay up to date with the latest research and expertise from Michigan public health, subscribe to our Population Healthy newsletter, at publichealth.umich.edu/news/newsletter. We hope you join us for next week's episode, where we'll dig further into public health topics that affect all of us at a population level.