Increasing national attention is being focused upon the escalating morbidity and mortality of this nation's youth. In April 1986, the importance of this issue was underscored by a national conference which convened a group of researchers, educators, and service providers in the field of adolescence. These experts made recommendations concerning issues which will impact upon the health of adolescents over the next decade, one of which was to improve the quality of education in adolescent health care (Youth 2000, 1986; Bearinger & Gephart, 1987). Recognition of this growing problem is not new, however. Addressing the need for adequate preparation of health providers, the Division of Maternal and Child Health (DMCH) of the Department of Health and Human Services established postgraduate training grants in adolescent medicine in 1968. By 1977, DMCH expanded the focus of these grants to provide specialized interdisciplinary education in adolescent health care, and included nursing as one of the targeted disciplines. The authors represent the nursing faculty of the six current interdisciplinary training programs funded by DMCH and the nurse consultant of that agency. The collective experience of this group with graduate nursing student trainees participating in these projects contributed to a concern that nurses are poorly prepared to meet the complex challenges which adolescents present to the healthcare system. Indeed, in a national study of practicing health professionals, nurses reported having limited competencies with which to address major adolescent health concerns, and cited insufficient training as the major barrier to adequately caring for an adolescent patient (Blum, 1986). This paper addresses the need for nursing educators to emphasize adolescent content and clinical experiences in both undergraduate and graduate nursing programs in order to promote nursing leadership in establishing service, research, and policy priorities which will address the needs of this country's young people.
Adolescents - Growing Health Problems
The mortality rate for youth, 15 to 24 years of age, is 95.8 per 100,000. A staggering 75% of these deaths can be attributed to accidents, homicides, and suicides (Irwin & Mill stein, 1986). Motor vehicle accidents alone account for more than a third of these deaths and are higher for adolescents than for any other age group (Health United States, 1984). Many of these accidents can be attributed to another major health problem of adolescents - alcohol use and abuse. In 1982, 16- to 24-year-old males accounted for more than one third of all alcoholrelated fatalities (Health United States, 1984). The use of alcohol among high school students is widespread. It has been estimated that 90% of high school seniors have used alcohol at least once (Johnston, Bachman & O'Malley, 1980) and that teens typically have their first drink at age 13 (Healthy People, 1979). While some use of both alcohol and drugs reflects the normal behavioral experimentation common to this stage of life, limitations in the adolescent's ability to project ahead to possible consequences of present behavior, and feelings of invincibility make even infrequent use of mind-altering substances a potentially lethal experience.
Indeed, many of the health problems of youth can be directly attributable to the negative consequences of their behaviors. The repercussions of the sexual behaviors of adolescents further illustrates this point. Forty-seven percent of 15- to 19-year-old unmarried women and 70% of 17- to 21year-old men have engaged in sexual activity (Pratt, Mosher, Bachrach, & Horn, 1984; Zelnik & Shah, 1983). While some progress has been made in promoting the use of contraceptives among sexually active youth, adolescents remain notoriously inconsistent users of effective methods of birth control (Furstenberg, Shea, Allison, Herceg-Baron, & Webb, 1983).
Thus, in 1983, there were approximately 10,000 live births to teens less than 15 years of age and 173,000 live births to teens between the ages of 15 and 17 (Kovar, 1986). The consequences of such births to teens are now well documented. The very young adolescent has an increased risk of delivering a baby who is low birthweight, which itself is associated with high rates of infant morbidity and mortality (Testa & Wulezyn, 1980). For the teen mother, herself, poor prospects exist with respect to educational and occupational attainment, divorce, reliance upon public assistance, and rapid repeat pregnancies (Burden & Klerman, 1984; Burt, 1986; Card & Wise, 1978; McCarthy & Menken, 1979; Mott, 1986). The abortion rate for this age group is also high. Approximately one third of women aged 15 to 19 end their pregnancies in abortion (Zelnik & Kantner, 1980).
Even if pregnancy is avoided, however, the sequelae of sexual activity for adolescents exposes them to the risk of a sexually transmitted disease (STD). Chlamydia is the most common STD among teens, with gonorrhea being the second most common. It has been estimated that there are over 250,000 reported cases of gonorrhea in 15to 19-year-olds per year. This represents approximately 25% of all reported cases per year (Cohen, 1982). An STD can lead to further complications such as pelvic inflammatory disease (PID), and 15- to 19year-olds have been reported to have a rate of PlD second only to the 20- to 24-year-old age group (D'Angelo, 1986). With the increasing spread of AIDS among the sexually active heterosexual population, it will only be a matter of time before this, too, becomes a major problem for this nation's youth, unless significant changes occur in their sexual practices.
Despite the fact that adolescents do, indeed, have significant and complex health needs, it is alarming to confront evidence which indicates that they are underserved by the health-care system. The 1979 Surgeon General's report indicated that adolescents typically see a physician less often than both younger children and adults (Healthy People, 1979). A 1980-81 national ambulatory medical care survey reported that 11- to 20-year-olds have the lowest rate of office visits to physicians than any other age group and that, of these, 11- to 14-year-olds had a lower rate than 15to 20-year-olds (Cypress, 1984). If an adolescent is seen in an ambulatory care facility, however, it may be no indication that health-care needs have been adequately addressed since the average office visit for this age group lasts less than 11 minutes (Cypress, 1984). Unfortunately, adolescent utilization of services provided by nurses is not available on a systematic basis to complement the data pertinent to physicians.
The traditional organization of health services also contributes to the problem of inadequately meeting the needs of youth. Because of the nature of many of the health problems of teens, a broad array of services is often needed to optimally care for the adolescent, yet few health-care organizations are structured in such a way to facilitate access to what is needed. Health-care financing is also a problem for youth in this country. In a review of the financing problems affecting youth, Resnick (1986) cites data which reveal that many youth are underserved in terms of health insurance as exemplified by having only part-year coverage, and that 7% of youth lack insurance altogether. He further points out that while Medicaid is a major source of funding for health services to youth, there is a wide variation in coverage. Just over 20% of 16to 24-year-olds are not covered by any health insurance (Wetzel, 1987). While Medicaid is a major source of funding for health services to youth, there is a wide variation in coverage across states, and recent cuts in funding have led to loss of benefits by many families and children.
Implications for Nursing Education
Teens are at risk for a variety of health problems primarily because of behavior and activities which are the outgrowth of a complex interchange of developmental factors such as cognition, experimentation, emerging sexuality, and psychosocial growth. While adolescents present a challenge to health providers because of this, they also present opportunity. This is a stage of life where values and beliefs are still in flux, and so the opportunity to impact upon the development of healthpromoting values and subsequent behaviors may be great. This is clearly within the purview of nursing. Yet, adequate educational and clinical preparation is a necessary prerequisite in order for nurses to intervene with adolescents in a knowledgeable and effective manner. Further, advanced educational preparation in adolescent health care is necessary if nursing is to help shape the nature of such interventions through research, and impact upon care on a broader level through affecting public policy. As stated earlier, however, nurses report that their educational preparation has left them poorly prepared to adequately deal with the health-care needs of their adolescent clients (Blum, 1986). Indeed, there is a paucity of graduate nursing programs that have an emphasis in adolescent health care. In reviewing the 103 National League of Nursing accredited master's programs listed in the 1984 Directory of Degree Programs in Nursing (Anderson & Schmidt, 1984), only three cite adolescence as an area of clinical specialization. Nurses are needed who are well-grounded in the biological, psychological, and sociological aspects of development in order to develop effective healthcare interventions for this age group. In order for nursing to assume leadership in establishing service, research, and policy priorities in the field of adolescent health, our educational institutions must provide its students with the opportunity to develop expertise about the health needs and health-care system problems of this population. We urge the academic nursing community to begin a dialogue about this issue with the aim of generating ways in which nursing education can address this significant gap in its preparation of future clinicians and leaders of the profession.
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