Preventive Medicine 41 (2005) 118 – 125 www.elsevier.com/locate/ypmed

Adolescents’ health beliefs are critical in their intentions to seek physician care Arik V. Marcell, M.D., M.P.H.a,*, Bonnie L. Halpern-Felsher, Ph.D.b a

Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Maryland School of Medicine, 120 Penn Street, Baltimore, MD 21201, USA b Division of Adolescent Medicine, Department of Pediatrics, University of California, San Francisco, USA Available online 26 November 2004

Abstract Background. The examination of predictors of adolescent’s intentions to use health care for different types of health issues has received little attention. This study examined adolescents’ health beliefs and how they relate to intentions to seek physician care across different types of health problems. Methods. Two hundred ten high school students (54% females; 76.6% participation rate) completed a self-administered survey of four separate age- and gender-specific health case scenarios: an adolescent who has symptoms of pneumonia; smokes five cigarettes daily; plans to initiate sex; and has symptoms of depression. For each health scenario, participants rated the seriousness of the health problem, physician effectiveness, and intentions to seek physician care. Results. Most adolescents believed all health problems were serious except for planning to initiate sex (P b 0.001). Adolescents believed that physicians were most effective in diagnosis and treatment for pneumonia, followed by cigarette use, depression, and sex, respectively (P’s b 0.001). Adolescents’ intentions to seek physician care were greatest for physical as compared to risk behavior or mental health problems (P b 0.001). Multiple regression analyses revealed that adolescents had greater intentions to seek physician care for cigarette, sex, and depression when they believed physicians were effective and they perceived these as health problems after controlling for age and gender (all P’s b 0.001). Health beliefs explained 12% to 49% of the variance in intentions to seek care (all P’s b 0.001). Conclusions. Adolescents’ health beliefs are important when understanding intentions to seek physician care. Health care use may be improved by increasing adolescents’ beliefs that physicians are effective in areas other than physical health, including risk behaviors and mental health. D 2004 Elsevier Inc. All rights reserved. Keywords: Preventive services; Adolescents; Risk behavior; Health care seeking

Background The provision of quality health care services is one important way to reduce adolescents’ morbidity and mortality. As such, clinical practice guidelines regarding clinical preventive services have been set up to address the significant risk-taking behaviors that can result in high rates of morbidity and mortality during adolescence [1,2]. However, studies find that national rates of adolescents’ health care use are low [3–6]. Moreover, certain populations, including males, older * Corresponding author. Fax: +1 410 706 0131. E-mail address: [email protected] (A.V. Marcell). 0091-7435/$ - see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2004.10.016

adolescents, and runaway and homeless youth, use health services less than others [7–10]. It is therefore critical that we understand adolescents’ beliefs regarding their use of the health care system and whether such beliefs vary by the types of problems for which they might seek care. Models of health care use, such as Andersen’s Behavioral Model of Health Services Use (BMHSU), can help to understand factors that are related to an individual’s use of health care. This model conceptualizes that health care use is influenced by individual and contextual characteristics. The model classifies three types of variables as being critical in one seeking health care: predisposing variables that provide the motivation to seek care, enabling variables that

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provide the resources to do so, and health need variables that represent perceptions and evaluations of need to seek care [11,12]. In Andersen’s BMHSU, examples of predisposing variables include a person’s knowledge about health, potentially changeable health attitudes and beliefs, and nonchangeable demographics such as age and race/ethnicity. Examples of enabling factors include personal or family resources, such as health insurance, having a regular place one goes for health care (or regular source of health care), and access to care. Finally, health need variables include external evaluations of health needs based typically on the judgment of a health professional and individuals’ own perceptions of health needs based on how an individual views his or her own health status. Research that examines adolescents’ access to care has historically focused on enabling factors, such as the lack of confidential services [13,14] or health insurance [8,15], and need factors, such as the fact that a minority of adolescents in the US who have been judged by health professionals to have significant health needs are least likely to use health care [16,17]. Although the absence of enabling factors can explain some of adolescents’ low health care use rates [13,15], health care use does not necessarily increase when these factors are present [18]. There is a dearth of research that examines the role that predisposing variables plays in adolescent health care use, including the role health beliefs play in adolescents’ intentions to use health care. This study will examine such health beliefs, including beliefs regarding the seriousness of the health problem and whether physicians are effective at treating these problems. We will also determine the relationship between these beliefs and adolescents’ intentions to seek health care for each health problem. Adolescence represents a unique transition during which teenagers take on new responsibilities of taking care of themselves and seeking health care. This population may not be socialized into the health care system and/or may have incorrect beliefs that influence their view of the role of the physician. Although a number of studies examine adolescents’ health beliefs [19–22] and care seeking beliefs [14,21,23–29], none of these studies examine the relationship between adolescents’ beliefs and health care use or intentions to use health care. For example, one qualitative study found that adolescents have an overall antipathy towards seeking general medical services [30]. In this study, adolescents described that they were more likely to use health care when services were viewed as bbeing appropriate,Q such as for either medical or personal concerns, with higher priority being placed on personal concerns, such as issues related to sexuality, drugs, alcohol, and relationships. Another study found that adolescents’ perceptions of provider characteristics were among the most salient issues when making decisions to seek health services, including general provider competence, provider and patient interactions, cleanliness of the site and the physician, provision of confidential services, cost of service, and HIV status of the provider [14]. Moreover, it may be that the factors that influence health

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care use for adolescents are dependent on the type of health care problem studied. For example, many adolescents tend to forego seeking health care because they think the problem will go away [31] or is not very serious [8]. Leading reasons why adolescents are seen in ambulatory care settings include the need for a general examination, and for respiratory, dermatological, and musculoskeletal complaints [3]. Adolescent women are also much more likely to use clinics for reproductive health care needs than adolescent men [32]. The main goal of this paper is to examine the relationship between adolescents’ health beliefs and their intentions to use health care for different types of health issues, including pneumonia, cigarette use, sexual behavior, and depression. This paper examines (1) the extent to which adolescents believe these health issues are serious health problems and that physicians are effective, trustworthy, and confident in diagnosing and treating these health problems; (2) whether adolescents’ beliefs regarding the seriousness of the health problem and physician effectiveness vary as a function of the type of health problem; and (3) whether adolescents’ health beliefs are related to intentions to use health care across these four different health problems. The contribution of age and gender to any observed differences in the relationship between adolescent health beliefs and intentions to seek care is also examined.

Methods Participants Participants were 221 adolescents recruited from all eight mandatory bSocial IssuesQ classrooms for 9th graders and three bSocial StudiesQ classrooms for 12th graders in one suburban high school in Northern California (54% female), and ranged in age from 13 to 19 (mean age = 15.4, SD = 1.8). Participants were 75% White, 2.5% African-American, 3.5% Hispanic/Latino, 6% Asian, and 13% other/mixed race (Table 1). A majority of participants’ mothers and fathers completed college or a professional and/or graduate degree, reflecting, in part, this sample’s higher socioeconomic background. Participants reported on average being in generally good health (mean = 4.3 [SD = 0.7]; 5 = very good). The majority (73%) of adolescents’ last routine physical exam occurred within the past 12 months. The only difference between the two grades was that 9th graders were more likely to have had a recent routine physical exam than 12th graders (v 2 = 12.3, df = 3, P = 0.007). Procedures Study participants were recruited from all eight mandatory bSocial IssuesQ classrooms for 9th graders and three bSocial StudiesQ classrooms for 12th graders in one suburban high school in Northern California. The classes included 173 9th grade students and 101 12th grade

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Table 1 Participant demographics Question

All mean (SD) or %

9th graders mean (SD) or %

12th graders mean (SD) or %

Mean age (SD) (n = 201) Gender (n = 210) Female Male Race/ethnicity (n = 201) White Black Hispanic/Latino Asian Other or mixed race In general, how is your health? (Mean [SD], n = 177) When was your last routine physical exam? (n = 175) Never Past 12 months 1–2 years ago N2 years ago Highest level of education mother completed? (n = 201) High School or less Some or 2-year college 4-year college and/or some school after college Professional/graduate degree Don’t know Highest level of education father completed? (n = 200) High school or less Some or 2-year college 4-year college and/or some school after college Professional/graduate degree Don’t know

15.4 (1.8)

14.2 (0.52)

17.8 (0.53)*

54.3 45.7

50.3 49.7

62.7 37.3

75.1 2.5 3.5 6.0 12.9 4.3 (0.71)

74.8 3.7 3.7 3.7 14.1 4.3 (0.72)

75.8

2.9 72.6 19.4 5.1

2.6 78.1 12.3 7.0

3.3** 62.3 32.8 1.6

10.0 20.5 30.5 31.5 7.5

10.5 20.8 28.6 30.8 11.3

9.0 23.8 34.4 32.8

6.5 16.0 23.5 46.5 7.5

6.8 14.3 18.8 48.9 11.3

6.0 19.4 32.9 41.8

3.0 10.6 10.6 4.1 (0.69)

SD = standard deviation. * P b 0.001, Student’s t test (t = 45.6). ** P = 0.007, chi-square test (v 2 = 12.3, df = 3).

students. A total of 221 students and their parents consented to participate according to guidelines approved by the University of California, San Francisco’s Institutional Review Board (80.7%; 151 9th and 70 12th graders). There were 11 students absent on the day of the survey administration (5.0% absence rate; eight 9th and three 12th graders), yielding a final participation rate of 76.6% (N = 210; 143 9th and 67 12th graders). All students were asked to complete a confidential, self-administered written survey. Instructions were read aloud by the investigators during a regularly scheduled 50-min class.

adolescent who smokes five cigarettes daily and an adolescent who is planning to initiate sex); and (3) mental health (a scenario of an adolescent who has symptoms of depression). Scenarios were created to represent the type of behaviors that are relevant to and commonly represent adolescent health issues. The adolescents’ gender and age as depicted in the four scenarios were matched with the participant: (1)

Study measures Demographics Sociodemographic information elicited from participants included age, gender, race/ethnicity, past health care utilization experience, health status, and parental education. Measures Case scenarios were used as a means to examine intentions to use health care for three health areas: (1) physical health (a scenario of an adolescent with symptoms of pneumonia); (2) two risk behaviors (two scenarios: an

(2)

(3)

Pneumonia scenario—Paul is a 14-year-old teenager who has had a bad cough for 3 days now. Since his cough began, he had a high fever of 1038 Fahrenheit. During the past 24 h, he has been having harder time breathing and is having some chest pain. He has been real tired during this illness and has not been able to go to school at all. Cigarette scenario—Clint is a 14-year-old teenager who has been smoking about five cigarettes a day for the past 2 years. Most of his friends are real heavy smokers. His parents do not know he smokes. Sex scenario—Steve is a 14-year-old teenager who just started dating. He has been out with the same person three times now. They’ve kissed and hugged, and started some touching and fondling (feeling up). Steve is planning to have sex soon.

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(4)

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problem?, (iii) be able to help Paul with this problem?; and (2) Do you think Paul should. . . (iv) trust a doctor to figure out what’s wrong with him?, (v) trust a doctor to help him feel better in this situation?, (vi) have confidence that a doctor will figure out what’s wrong with him?, and (vii) have confidence that a doctor can help him feel better in this situation? All but the sex scenario included an additional item: hscenario included an additional item: How much do you think the doctor will be able to make the problem better? Possible responses for all items and the final physician effectiveness scale ranged from 1 to 5, with 5 being the higher value.

Depression scenario—David is a 14-year-old teenager who’s been feeling sad recently. He’s been having problems sleeping and eating. His schoolwork is suffering because he cannot concentrate well in class and in doing his homework. He would rather be alone most of the time. His friends have a hard time cheering him up.

After reading each scenario, participants were queried about the extent to which they believed the issue depicted in the scenario was a health problem; believed physicians were effective, trustworthy, and confident in diagnosing and treating the specific health problem; and were willing to seek physician care for that type of problem. Participants were also queried about issues related to confidentiality and cost of service as barriers to care seeking for each of the scenarios studied. Beliefs about the Seriousness of the Health Problem included three items: an evaluation of whether the issue presented in the scenario represents a health problem, the issue’s seriousness, and the importance to get help from someone for the problem: (1) Does Paul have a health problem? [response: 0 = no, 1 = yes]; (2) How serious do you think Paul’s situation is? [response: 1–5, 5 = high]; (3) How important is it for Paul to get help from someone for this situation? [response: 1–5, 5 = high]. For analyses, the seriousness and importance items were transformed from a 1 to 5 scale to a 1 to 2 scale in order to be of like scaling with the evaluation of the health problem item. This was done by converting the response range for these items to the same interval (i.e., 1, 1.25, 1.5, 1.75, and 2 rather than 1, 2, 3, 4, and 5). These three items were significantly correlated with each other for each case-scenario (Table 2). Beliefs about Physician Effectiveness included eight items for all but the sex scenario, which included seven items (Crohnbach’s alpha = 0.83, 0.89, 0.89, and 0.94 for the pneumonia, cigarette, sex, and depression scenarios, respectively). The following items were asked after each scenario: (1) How much do you think the doctor will. . . (i) be capable of identifying Paul’s problem?, (ii) figure out that Paul has a

Intentions to seek physician care. For each scenario, participants indicated their willingness to go to a physician and the degree to which the physician is the right person to go to for each specific health problem: (1) Imagine that you were in the situation like Paul’s, would you go to a doctor? [response: 0 = no, 1 = yes]; (2) How much do you think the doctor is the right person for Paul to deal with this problem? [response: 1–5, 5 = highest]. For analyses, this latter item was transformed from a 1 to 5 scale to a 1 to 2 scale in order to be of like scaling with the former item. The same procedure described for the perceived seriousness of the health problem was employed here. These two items were also significantly correlated with each other for each case-scenario (Table 2). Data analysis Analyses were first conducted for all participants and then separately by age and gender. In order to examine whether adolescents’ beliefs and intentions to seek care varied by type of health problem, we performed repeated measures ANOVA using health scenario (4 levels) to determine the main effects of the scenario on adolescents’ beliefs. Paired two-tailed t tests were employed as follow-up to significant main effects. In order to minimize Type 1 error for these analyses, comparisons with associated probabilities less than or equal to 0.001 were considered statistically significant. In order to examine gender and age differences in participants’ health beliefs and intentions to seek care,

Table 2 Correlations and descriptive statistics for individual items of the beliefs about the seriousness of the health problem and intentions to seek physician care scores ITEMS

Pneumonia symptoms a

Cigarette use 1

2

1

2

1a

2b

Beliefs about seriousness of health problem (1) % Consider scenario a health problem (2) Seriousness of problem (3) Importance to get help from someone

– 0.30** 0.23**

– 0.58**

– 0.20* 0.23**

– 0.80**

– 0.18* 0.22*

– 0.69**

– 0.31** 0.37**

– 0.68**

Intentions to seek care (1) % willing to go to doctor (2) Doctor is the right person to go to

– 0.17*

–

– 0.50**

–

– 0.49**

–

– 0.59**

–

Spearman correlations. Pearson correlations. * P V 0.01. ** P V 0.001.

b

a

Depression symptoms

2

b

a

Sex initiation

1

a

b

b

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ANOVA with post hoc analyses using Bonferroni corrections were performed. Hierarchical regression analyses, controlling for age and gender, were performed to examine the relationship between adolescent health beliefs and intentions to seek care. For these analyses, a level of P V 0.01 was used for determination of statistical significance.

Results Beliefs about seriousness of the health problem Adolescents believed the pneumonia, cigarette, and depression scenarios were serious health problems (Table 3); whereas the sex scenario was not. Repeated measures ANOVA revealed significant differences regarding adolescents’ beliefs of the seriousness of the health problem across the four scenarios (F = 467.8, P b 0.001). Follow-up paired two-tailed t tests of the significant main effects found that adolescents believed the pneumonia scenario was significantly more serious than the sex scenario (paired t = 33.5, P b 0.001), and both the cigarette and depression scenarios were significantly more serious than the sex scenario (paired t’s = 33.9 and 29.8, respectively, all P’s b 0.001). No differences were found among adolescents’ beliefs of the seriousness of the pneumonia, cigarette and depression scenarios. Adolescents differed by age and gender in their beliefs about the seriousness of the cigarette and sex scenarios as health problems (ANOVA, F = 6.6 and 6.7, respectively, all P’s b 0.001). Younger males and females believed using cigarettes was more serious than older males (mean difference = 0.15, 95% CI = 0.05, 0.25 and mean difference = 0.13, 95% CI = 0.04, 0.23, respectively, all P’s V 0.002), and younger females believed planning to initiate sex was more serious than all other groups (older females, and younger and older males; mean difference = 0.10, 95% CI = 0.001, 0.20, P = 0.05, mean difference = 0.13, 95% CI = 0.03, 0.23, P = 0.006, and mean difference = 0.18, 95% CI = 0.06, 0.29, P b 0.001, respectively). Beliefs about physician effectiveness Adolescents believed physicians were most effective, trustworthy, and confident in diagnosing and treating the

pneumonia and cigarette scenarios (Table 3); and less effective for the depression and sex scenarios. Repeated measures ANOVA revealed significant differences regarding adolescents’ beliefs about physician effectiveness across the four scenarios (F = 144.5, P b 0.001). Follow-up paired two-tailed t tests of the significant main effects found that adolescents believed physicians were most effective in diagnosing and treating the pneumonia scenario, followed by the cigarette, depression, and sex scenarios, respectively (paired t’s ranged from 4.3 to 20.0, all P’s b 0.001). Beliefs about physician effectiveness were not found to vary by age or gender. Intentions to seek care Adolescents’ intention to seek care was highest for the pneumonia and lowest for the cigarette, depression, and sex scenarios (Table 3). Repeated measures ANOVA revealed significant differences regarding adolescents’ intentions to seek care across the four scenarios (F = 149.5, P b 0.001). Follow-up paired two-tailed t tests of the significant main effect found that adolescents’ intentions to seek care for the pneumonia scenario were significantly greater than for the cigarette, sex, and depression scenarios (paired t’s = 15, 18 and 17, respectively, all P’s b 0.001). No differences were found between adolescents’ perceptions regarding intentions to seek care for the cigarette, sex, and depression scenarios, respectively. Adolescents differed by age and gender in their intentions to seek care for the sex scenario (ANOVA, F = 6.4, P b 0.001), younger and older females had greater intentions to seek care for the sex scenario than younger males (mean difference = 0.24, 95% CI = 0.07, 0.41 and mean difference = 0.23, 95% CI = 0.05, 0.40, respectively, P’s V 0.004). Relationship between beliefs about seriousness of health problem and physician effectiveness with intentions to seek care Hierarchical regression analyses were performed separately for each scenario in order to examine the relationship between scenario-specific health beliefs and adolescents’ intentions to seek care. In the first step, age

Table 3 Adolescent health beliefs and intentions to seek care for each health scenario, means (standard deviations) and repeated measures ANOVA with t test follow-ups Variables

Pneumonia symptoms (P)

Cigarette use (C)

Sex initiation (S)

Depression symptoms (D)

Repeated measures ANOVA (F)

Paired t test Follow-upsc

Beliefs about seriousness of health problema Beliefs about physician effectivenessb Intentions to seek carea

1.9 (0.2) 4.2 (0.5) 1.9 (0.2)

1.9 (0.2) 3.5 (0.8) 1.5 (0.4)

1.3 (0.2) 2.6 (1.0) 1.5 (0.4)

1.8 (0.2) 3.0 (1.0) 1.4 (0.4)

467.8* 144.5* 149.5*

P=D=CNS PNCNDNS PNC=S=D

a

Responses ranged from 1 to 2; 2 = highest. Responses ranged from 1 to 5; 5 = highest. c All paired t tests significant at P b 0.001. * P b 0.001. b

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and gender were entered in order to control for these variables. Next, scenario-specific adolescent health beliefs (beliefs about seriousness of the health problem and physician effectiveness) were entered into the second step. Overall, adolescent health beliefs were found to be significantly related to intentions to seek care for all scenarios after controlling for age and gender (Table 4; pneumonia: R 2 change = 0.12; cigarette: R 2 change = 0.35; sex: R 2 change = 0.34; and depression: R 2 change = 0.49, all P’s b 0.001). Specifically, beliefs about the seriousness of the health problem were related to greater adolescent intentions to seek care for cigarette use and planning to initiate sex (beta = 0.25 and beta = 0.22, all P’s b 0.001, respectively). That is, the more adolescents believed scenarios were serious health problems, the more likely they intended to seek care for these problems. No relationship was found between beliefs about the seriousness of the health problem for the pneumonia and depression scenarios and intentions to seek care. This was likely due to the limited variance in adolescents’ beliefs that these scenarios were health problems (88.1% and 78.6% of adolescents believed pneumonia and depression were serious health problems, respectively). Beliefs about physician effectiveness were related to greater adolescent intention to seek care for all scenarios (pneumonia: beta = 0.31; cigarette: beta = 0.49; sex: beta = 0.49; and depression: beta = 0.69, all P’s b 0.001). That is, adolescents who believed physicians were more effective,

Table 4 Results of hierarchical regression analyses predicting adolescent intentions to seek physician care for a variety of health issues, showing standardized regression coefficients Independent variables Step 1 Age Gender (0 = female) Adjusted R 2 df F Step 2 Age Gender (0 = female) Beliefs about seriousness of health problema Beliefs about physician effectivenessa R 2 change df F a

Pneumonia symptoms

Cigarette use

Sex initiation

Depression symptoms

0.10 0.01

0.13 0.02

0.01 0.29*

0.09 0.06

0.001 2,196 1.1

0.01 2,186 1.8

0.08 2,186 8.8*

0.001 2,184 1.1

0.09 0.03

0.04 0.003

0.01 0.22*

0.07 0.05

0.12

0.25*

0.22*

0.04

0.31*

0.49*

0.49*

0.69*

0.12 2,194 13.0*

0.35 2,184 51.8*

0.34 2,184 54.0*

0.49 2,182 89.6*

Transformed scales used for regression analyses. * P b 0.001.

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trustworthy, and confident in their diagnostic and treatment skills for each of the scenarios were more likely to intend to seek care for these issues. Results did not vary when analyses were separated by gender and age, or when controlled for health status, experience with scenariospecific health problems, report of health care experience for scenario-specific health problems and/or recency of last routine physical examination. Issues related to confidentiality and cost of service was also not consistently related to intention to seek care across the scenarios studied.

Discussion This is the first study to examine the relationship between adolescents’ health beliefs and their intentions to seek care for different types of health issues. The results of this study highlight the importance of understanding adolescents’ health beliefs in their intentions to seek care. Adolescents who believed physicians were more effective and health problems were more serious were more likely to intend to seek care. Adolescent health beliefs in this study explained 35% to 49% of the variance in their intentions to seek care for risk behavior and mental health issues. Adolescents’ health beliefs and intentions to seek physician care varied depending on the type of health problem studied. Adolescents believed physicians were most effective in managing problems related to physical health and less effective for mental health and issues related to having sex. Our findings are in contrast with past exploratory work that describe adolescents as more likely to use health care for medical and personal concerns, including issues related to sexuality, drugs, alcohol, and relationships [30]. A strength of this study is that the relationship between adolescent beliefs and intentions to seek health care is examined. Adolescents’ failure to recognize physicians as being effective in these areas may contribute to their foregone health care (i.e., care that is needed but not received) observed among adolescents [8,31,33]. Other studies have shown that adolescents who report not seeking health care or no recent care also report being less knowledgeable about available health care services, having negative attitudes toward health care, and being less likely to plan to seek care in the future [34]. In this study, when examining each health scenario separately, this type of relationship was not detected (e.g., a relationship between recent care use, or lack thereof, and health care use intentions). Perhaps in this study we were able to improve upon the specificity of participants’ responses to such health care use questions by the use of specific care seeking case scenarios. Additionally, a large proportion of study participants recently saw a physician but controlling for past care use behaviors did not alter study findings.

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The finding that adolescents who believed a health issue was serious were more likely to intend to seek health care was not a surprise, especially given that studies of other populations, such as the homeless and adults, find a relationship between perceptions of health needs and health care use [35–38]. Results from this study indicate that if an adolescent does not view the physician as a potential source of help for a particular health issue, regardless of the extent to which it is identified as a health problem, he or she will be less likely to seek medical assistance. This is especially relevant for what adolescents may consider as non-traditional health issues, like getting help for risk behaviors and mental health issues. Gender also contributed to differences in intentions to seek care specifically as it related to reproductive health and is consistent with findings from other studies [32,39]. Adolescents’ beliefs about the seriousness of the health problems studied were not based on the severity of the health problem. In fact, fewer differences were found in adolescents’ beliefs about the seriousness of health problems across the four case scenarios. The pneumonia, depression and cigarette scenarios were believed, on average, to be equally serious problems. It may come as a surprise that adolescent study participants would believe such problems as equally serious. A number of factors may contribute to these findings. Study participants’ beliefs about what is a health problem may be based on their personal experiences (75% of study participants described experiencing depression at least once, about 50% described trying cigarettes, and 35% had smoked one cigarette more than once). Or their beliefs may be based on participants’ ability to do a better job in identifying health problems in other people despite their personal health histories [40]. Participants in this study may also have a reduced stigma associated with identifying mental health issues or cigarette smoking as health problems. Alternatively, study participants’ responses may reflect socially desired responses despite self-reported health histories. It may be that adolescents do not necessarily understand the role a physician can play in their health especially when it comes to managing problems other than for physical health, including risk behavior and mental health issues. Adolescents’ low use of health care nationally may in part reflect a failure in their ability to identify such issues as health problems and/or to understand the physicians’ role in managing such health problems. Of course, physicians need to be competent when it comes to screening, diagnosis, and treatment of adolescent risk behavior and mental health issues. Moreover, physicians need to be trained in how to outreach to adolescents, so that adolescents are aware that health care providers can be comfortable working with this population, and on more sensitive health issues. The results of this study demonstrate the need to increase messages to adolescents and their parents that physicians are competent in managing

health issues other than for physical health and are accessible to be seen for such issues. Prevention and interventions programs will be necessary to educate adolescents and their parents to recognize and acknowledge the role of the primary care provider in delivering appropriate services related to risk behaviors and mental health. Such efforts may result in subsequent increases in the use of health care by this population.

Limitations This study has several limitations. First, this study is not predictive in nature because of its cross-sectional design. Second, responses to case scenarios may differ from actual behaviors once participants are placed in real life situations. Scenarios used in this paper build upon previous work using case scenarios as a method to elicit adolescent beliefs about health behaviors [41–43]. As evidenced by these other studies, despite the fact that hypothetical scenarios are used, adolescents are responsive to such scenario-driven survey methodology. Next, intentions rather than direct observation of health care behaviors is examined. Fishbein [44] describe that intentions are predictive of subsequent behaviors. Finally, the generalizability of the study sample is limited due to the lack of ethnic/racial and socioeconomic diversity. Future studies are needed in order to validate our findings using prospective designs, more diverse sample populations and observation of adolescents’ actual physician-seeking behaviors rather than care-seeking intentions.

Summary Adolescent health care beliefs are important in their intentions to seek health care. Use of health services by adolescents may be improved by increasing beliefs that physicians are effective in areas other than physical health, and educating them regarding health problems that fall under the purview of physician care. More research is needed to determine others from whom adolescents should and do seek health care, and whether these patterns hold for other more diverse adolescent populations.

Acknowledgments We thank Michael Biehl for his assistance with the data analyses, as well as all of the teachers and students who helped make this study possible. This study was supported in part by a Faculty Development Award from the Academic Senate Committee on Equal Opportunity, University of California, San Francisco (Dr. Halpern-Felsher), the Norman Schlossberger Award through

A.V. Marcell, B.L. Halpern-Felsher / Preventive Medicine 41 (2005) 118–125

the UCSF Division of Adolescent Medicine (Dr. Marcell), and the Maternal and Child Health Bureau (MCHB) of the Department of Health and Human Services (2T71 MC00003) awarded to the UCSF Division of Adolescent Medicine.

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