PEDIATRICS Vol. 106 No. 5 November 2000, pp. 1065-1069

Using a Health Concerns Checklist as a Bridge From Reason for Encounter to Diagnosis of Girls Attending an Adolescent Health Service

Rachel Wilf-Miron, MD, MPH^*, , Saralee Glasser, MA, Fabienne Sikron, MA, and Vita Barell, BA

From the ^* Pediatric Division and  Health Services Research Unit, Chaim Sheba Medical Center, Tel Hashomer, Israel.

	ABSTRACT

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Objective.  We assessed the extent to which a health concerns checklist (HCC) helps bridge the gap between the reason for encounter (RFE) described by girls entering an adolescent health service and the ultimate diagnosis.

Methods.  The sample, 547 consecutive 12- to 18-year-old girls visiting an adolescent health service, first underwent a structured intake procedure, including a self-administered form on which they described their RFEs and other health concerns, as well as a psychosocial interview and medical evaluation performed by staff members. The RFEs, HCC items, and diagnoses, grouped into somatic, sexuality-related, and psychosocial categories, were then compared.

Results.  Among the 399 girls expressing specific RFEs on entering the clinic, one-third were diagnosed with psychosocial disorders and one-fifth with sexuality-related concerns. Of the patients receiving a sexuality-related diagnosis, 57% presented with a sexuality-related request; another 26% noted it on the checklist. For those diagnosed with psychosocial problems, 22% stated this as the RFE, and another 50% indicated it on the HCC. The contribution of the HCC to the diagnosis was higher among adolescents not stating a specific RFE.

Conclusion.  The findings highlight the HCC's contribution in identifying health problems, especially among adolescents who find it difficult to verbalize sensitive issues.  Key words:  adolescent, reason for encounter, psychosocial, sexuality-related health concerns.

Health-related habits often are acquired during adolescence and have significant health consequences. Particularly problematic are the risk behaviors that have become leading causes of adolescent morbidity and mortality over the last few decades. Injury-related mortality (accidents, homicide, and suicide) accounted for 76% of deaths among 15- to 24-year-olds in the United States in 1995.¹ A national survey conducted in 1997 among US high school students found that 36% had smoked cigarettes and 51% had consumed alcohol in the 30 days before the survey.² Of those who were sexually active, 43% reported not using a condom during their last sexual encounter, and 83% reported not using birth control pills. One-fifth had seriously contemplated suicide during the 12 months before the survey.

Adolescents often are troubled about their health. More than a quarter of the 11- to 14-year-old US students asked about their health reported being bothered by feelings of anger, depression, and nervousness.³ Fatigue has been reported as a problem by a similar proportion of 11- to 17-year-old Israeli students.⁴ Other major areas of concern among Israeli students are school, weight, and coping with aggression.⁵ Although teenagers may seek medical advice for health problems that they define as somatic, they tend to avoid seeking care for emotional problems or stress despite the fact that many indicate that they would have liked help in these matters.⁶ From another perspective, health care providers often underestimate the severity of adolescent psychological and social health concerns,⁷ a factor impeding the provision of adequate health services.

Despite their engagement in health risk behaviors and their health-related concerns, adolescents in both the United States and Israel have the lowest rate of health service use of any age group, especially among male patients.^8,9 Time constraints during routine medical encounters generally leave little opportunity for professional screening for health risk behaviors or for discussing psychosocial issues. In addition, providers of adolescent health care express low levels of perceived competency in areas such as eating disorders, alcohol and drug abuse, and school-related problems.¹⁰ A survey conducted among physicians revealed that during their encounters with adolescents, fewer than half the pediatricians provide anticipatory guidance about sexuality and only 14% report questioning patients about depression.¹¹

This combination of unique health problems and low use of services, as well as perceived low competency among medical care providers, has created a gap between adolescents' needs and providers' responses. To address this gap, we developed and tested a structured comprehensive intake procedure for assessing the health concerns and problems of adolescents in the context of a community clinic. The procedure involves completing a self-administered intake form on which adolescents are asked to note the reason for the visit or encounter (RFE) and a 64-item health concerns checklist (HCC), as well as a semistructured psychosocial interview and medical evaluation leading to designation of a diagnosis.

The first aim of this study was to clarify the extent to which the diagnosis was related to the RFE. The second aim was to quantitatively assess the value of the HCC in achieving a final diagnosis.

	METHODS

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Setting

A community-based adolescent health service, located in an Israeli Jewish urban area, offers diagnosis and short-term intervention to the adolescent population of the region. These services were provided by a multidisciplinary team composed of a pediatrician trained in adolescent medicine, a psychiatrist, a gynecologist, and a social worker.¹²

Participants

The study sample included 547 12- to 18-year-old girls who visited the service consecutively. Boys constituted only 19% of the patient population during the study period and differed from the girls in various demographic and health characteristics: younger age (the average age of male and female patients was 14.6 and 15.6, respectively), a higher proportion who had dropped out of school (7% and 3%, respectively), and a lower rate of request not to be contacted at home (12% and 23%, respectively). The proportion of psychosocial RFEs was 24% and 6% among male and female patients, respectively; 75% of the boys were given psychosocial diagnoses, compared with 35% of the girls. These differences opposed the joint analysis of both sexes. Therefore, boys were excluded from the present study.

Instruments

Each participant's health concerns were assessed using an HCC, a condensed version of the Palti questionnaire.⁵ The HCC, based on Brown and Henderson's work,¹³ is a self-administered questionnaire containing 64 medical, sexuality-related, and psychosocial items, such as looking young for one's age, conflict with parents, social isolation, pressure to have sex, weight problems, fear of pregnancy, and suicidal ideations. The patient is asked to check each item about which she is concerned or would like to receive information. It takes about 5 minutes to review the list. Adolescents with reading difficulties or language problems need more time (about 10 minutes) and the assistance of the medical secretary to complete the form.

Procedure

At their initial visit, each patient filled out a questionnaire that included requests for demographic data and RFE, the latter in a free text format, as well as a 64-item HCC. After the HCC items checked by the patient were reviewed, a semistructured psychosocial interview was conducted, based on the Home, Education, Activities, Drugs, Sexuality, Suicide/Depression potential (HEADSS) format.¹⁴ The psychosocial interview was conducted by the attending pediatrician, gynecologist, or social worker (depending on the nature of the patient's RFE) and took about 20 minutes to complete. This was followed by a medical evaluation and determination of diagnoses, based on the International Classification in Primary Care (ICPC).¹⁵ The service's medical director reviewed all files and confirmed the diagnoses.

Analysis

HCCs were grouped into the following categories: somatic concerns (eg, headaches, acne, weight concern), sexuality-related issues (suspected pregnancy, sexual relations, and birth control), and psychosocial concerns (eg, depression, anxiety, social isolation, school difficulties). The rationale for this categorization is derived from the five primary areas affecting adolescents' health as defined by Brown and Henderson¹³: physical health, romance, home, school or work, and peers. Somatic concerns and sexuality-related issues parallel the physical health and the romance category, respectively. Psychosocial concerns represent the combination of home, peers, and school. The internal validity between all the items included in the HCC psychosocial category, as measured by Cronbach's , was .77. RFEs were grouped into similar categories, plus a nonspecific complaint category that includes general statements (eg, "request for advice") or no answer at all. Diagnoses were similarly grouped according to somatic, sexual, and psychosocial categories.

Statistical analyses were performed using the SAS (SAS, Cary, NC) program. Contingency tables were constructed and ² tests were performed to assess the statistical significance of the findings; P < .05 was considered significant.

	RESULTS

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Sociodemographic Characteristics

The average age of the female participants was 15.6 years (median = 16 years). Ninety-three percent reported attending school, and 13% were born outside the country, mainly in the former Soviet Union. Median parental education was 11 years of school, compared with the national median of 12.0 years.

RFE

The largest group of patients, nearly 60%, presented with RFEs of a primarily somatic nature, and the smallest group (6%) presented with psychosocial issues; 9% presented with sexuality-related needs. More than one-quarter (27%, n = 148) responded with nonspecific RFEs. The group with nonspecific RFEs was significantly different from the others in various personal and health characteristics: They were older, more of them asked not to be contacted at home, and more noted concerns about depression, suicide, death, and substance abuse on the HCC. Parental education and place of birth were not correlated with this effect (Table 1). The percentage of adolescents with diagnosed sexuality-related or psychosocial problems was significantly higher among those with nonspecific complaints. Therefore, this group was analyzed separately.

Participants With Specific RFEs

On completion of the intake procedure, 534 diagnoses were assigned to the 399 participants presenting with a specific RFE (mean = 1.3 diagnoses per participant). Somatic diagnoses comprised the largest single category, being assigned to 84% of the patients. Thirty percent were diagnosed with psychosocial problems and 20% with a sexuality-related problem (Table 2). RFE was significantly affected by place of birth. Adolescents born outside the country had a lower rate of sexuality-related RFEs than Israeli-born youth, 4% and 14%, respectively (² = 3.9; P < .05). Being born outside the country was also significantly correlated with more psychosocial concerns. Age and parental education did not affect the RFE or HCC. The proportion of adolescents assigned to the sexuality-related and psychosocial diagnostic categories changed considerably from the first step of the intake process (statement of RFE) to its culmination (diagnosis). The proportion of participants with psychosocial problems increased from 8% to 30%, and those identified with sexuality-related problems rose from 12% to 20%. In comparison, identification of somatic problems increased only slightly, from 80% to 84%.

A quarter of the adolescents who presented with a somatic RFE eventually received a combined diagnosis (somatic and psychosocial or sexuality-related diagnosis). Eight percent received a nonsomatic diagnosis. No correlation was found between any particular somatic RFE (eg, abdominal pain) and the resulting nonsomatic diagnosis.

Diagnosis was significantly affected by age but not by place of birth or parental schooling. Adolescents 16 years old or younger tended to receive more psychosocial diagnoses than older teens, 34% versus 24%, respectively (² = 3.9; P < .05).

To assess the contribution of the HCC in arriving at the diagnosis, the responses to the HCC were analyzed in relation to the RFE, the psychosocial interview, and the physician's diagnosis. Figure 1 indicates the progressive contribution of the HCC toward determination of the diagnosis. The majority of the somatic diagnoses (88%) were presented as somatic RFEs on the intake form. An additional 9% of the somatic diagnoses had not been stated as the RFE but were noted as a somatic issue on the HCC (ie, the contribution of the HCC). Another 3% of the somatic diagnoses were neither indicated as the RFE nor marked on the HCC. This probably represents the contribution of the interview and medical evaluation. The relative contribution of the HCC rose to 26% for sexuality-related diagnoses and even further, to 49%, for psychosocial diagnoses.

View larger version (38K): [in this window] [in a new window]   Fig. 1.   Relative contributions of HCC and psychosocial interview to diagnosis of female adolescents with specific RFE (n = 399; 534 diagnoses). * Each patient could receive >1 diagnosis.

Participants With Nonspecific RFEs

Of the 148 participants who did not specify a specific RFE, almost half were diagnosed with psychosocial problems, 84% of whom checked related items on the HCC (Table 1). About one-third were diagnosed with sexuality-related issues, and 91% of them had checked HCC items in this category.

	DISCUSSION

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Most of the patients at the community adolescent health center whose diagnosis was a somatic problem indeed stated such a problem as their RFE. This is in striking contrast to the findings regarding psychosocial and sexuality-related issues. Whereas fewer than 6% of the participants indicated a psychosocial issue as their RFE, 32% were diagnosed as having such a problem. Furthermore, although only 9% of the participants presented with sexuality-related RFEs, 23% were diagnosed as needing treatment or guidance on this issue. Several explanations may be posited for this disparity between presenting complaint and diagnosis. First, on the more personal or sensitive issues, it may represent masking behavior or a hidden agenda. In other words, the young person might have approached the clinic with a "neutral" complaint, such as abdominal pain (actual or not), as a cover for a more pressing problem, such as anxiety, depression, or a need for oral contraceptives, issues that she preferred not to state explicitly. This disparity may also result from a low expectation of such problems receiving attention in what is perceived as a medical setting. The adolescent turned to the clinic because she thought she could get help for a somatic problem such as headaches and found an open door: an interested and attentive professional from whom she could get advice or treatment for other issues of concern to her. Another reason for the disparity may result from the adolescents' difficulties in defining these problems even to themselves. It is likely that a combination of these explanations may be at work, emphasizing the particular challenge to this type of service.

Analysis of our data confirms the importance of using appropriate tools to assess the needs of adolescents seeking help from a medical service. Various approaches, such as HEADSS¹⁴ and the Guidelines for Adolescent Preventive Services,¹⁶ have been developed for evaluating adolescent health status and risk behavior. However, these instruments are time-consuming and require a professional experienced in interviewing adolescents and helping them overcome their discomfort in discussing sensitive issues.

The HCC appears to facilitate identifying the problems facing adolescents beyond those stated formally as RFEs. Its effectiveness is supported by the fact that many participants who did not indicate an RFE nonetheless checked items pertaining to sexuality-related and psychosocial problems on the HCC, problems that usually were confirmed by their diagnoses. The HCC's added value can be realized in 2 ways. First, it can serve as a point of reference for eliciting information about various aspects of the patient's life and well-being. The items marked allow the interviewer to ask leading questions to open up these issues, particularly if they have not been directly stated as the presenting complaint. Second, by presenting a list of issues, the HCC informs the patient that these are legitimate issues that can be addressed at the clinic. Even if she came for some other real or more pressing problem, she may now realize that she has found an avenue for dealing with or gaining information about other issues. Thus, even if the patient did not mark the item on the HCC, she may later raise the issue herself or respond more openly to the interviewer's inquiries during the psychosocial interview. Thus, the HCC allows patients to indicate their concerns without having to formulate them explicitly in the RFE.

The HCC emerges as a simple, time-saving diagnostic tool that can also be viewed as the health service's calling card. The HCC can be used in two different settings: in adolescent health services, as an intake instrument to be followed by a semistructured psychosocial interview and medical evaluation, and in the primary care clinic, as a follow-up device to be completed (after a brief introduction by a nurse or a medical secretary) by the adolescent attending the clinic for the first time and once a year thereafter. Based on the items the patient checks, the primary care physician can make targeted inquiries and evaluate the patient's need for further information, referral, or treatment. This is compatible with the yearly screening of adolescents for health risk behaviors recommended in the guidelines of the American Medical Association.¹⁶

The value of the HCC was particularly apparent among adolescents who had difficulty raising or defining their problems, indicated by their inability to offer a specific RFE. This group is an important target population for every health service. Members of this group approached the service to get help but were not able to write down the nature of their problem. The HCC may have been particularly beneficial for them, as indicated by the fact that the types of problems they checked usually were confirmed by the diagnosis.

One limitation of the current method is that the intake form left little space for writing the RFE. Some participants may have listed more than one complaint if more space had been provided. Another problem is the difficulty of assessing the independent contribution of the HCC to the diagnosis, given that the interviewer knew which concerns the patient checked in the HCC. However, because this may also occur in the actual settings where the HCC is to be used, this potential for bias may be less critical in the field than in the laboratory.

	CONCLUSION

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This study presents a method that has proven useful in clarifying sensitive issues and concerns typical of adolescents using community health services. Time and other constraints operating during the medical encounter increase the need for an efficient tool, such as the HCC, that can help primary care physicians and adolescent medical specialists approach the teenage patient and initiate productive communication. By doing so, the HCC may help bridge the gap between current medical care services and adolescents' needs with respect to sensitive health care issues.

	FOOTNOTES

Received for publication Jul 19, 1999; accepted Feb 22, 2000.

Reprint requests to (R.W.-M.) Health Services Research Unit, Chaim Sheba Medical Center, Tel Hashomer, 52621, Israel. E-mail: fabiennes{at}gertner.health.gov.il

	ABBREVIATIONS

RFE, reason for encounter; HCC, health concerns checklist; HEADSS, Home, Education, Activities, Drugs, Sexuality, Suicide/Depression potential; ICPC, International Classification in Primary Care.

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