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© 2003 American Public Health Association
EDITORIAL |
Amy Bleakley is with the Center for Applied Public Health and Jennifer A. Ellis is with the Harlem Health Promotion Center, Mailman School of Public Health, Columbia University, New York, NY. Jennifer A. Ellis is also technical deputy editor of the Journal.
Correspondence: Request for reprints should be sent to Amy Bleakley, MPhil, MPH, Center for Applied Public Health, 722 West 168th St, 12th Floor, New York, NY, 10032 (e-mail: ab443{at}columbia.edu).
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INTRODUCTION |
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 TOP INTRODUCTION ACCESS TO AND QUALITY...ABSTINENCE EDUCATIONALTERNATIVES TO OSMOSISReferences |
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Policy directed at influencing social and environmental determinants of health is an increasingly important component of successful community-based health promotion. A challenge in crafting effective policy is to achieve a balance between sound science and political pragmatism that meets the needs of populations throughout the life course. Policies directed at adolescents may be particularly effective, as factors outside the home become increasingly important at this stage of development in shaping behaviors known to affect health, including smoking, eating, and sexual practices. Translating applied research into appropriate and effective policies has the potential to improve the health and lives of entire cohorts of adolescents and may carry over into later stages of their lives. Unfortunately, limited time, funding, and training can relegate policy implications and development to little more than an afterthought in most public health research.
While the evaluation and research results featured in this month’s forum on adolescent health are significant contributions, notably absent are meaningful policy papers that highlight the inadequacies of current adolescent policy, present information that is useful to policymakers, and advance the scientific awareness of policy development. Many aspects of adolescent health call for policy discussion. Access to health care and abstinence education are 2 areas in particular in which consistent empirical and programmatic findings ought to be better reflected in policy.
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ACCESS TO AND QUALITY OF CARE |
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TOPINTRODUCTIONACCESS TO AND QUALITY...ABSTINENCE EDUCATIONALTERNATIVES TO OSMOSISReferences |
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Adolescents are more likely than younger children to be uninsured. Uninsured adolescents are 5 times as likely to lack a usual source of care and 4 times as likely to have unmet health needs as their peers with insurance.1 Some progress has been made in addressing these disparities. Since 1997, the number of states providing Medicaid and State Children’s Health Insurance Program (SCHIP) coverage to poor adolescents has doubled, and a subsequent increase in the number of adolescents enrolled in Medicaid and SCHIP has been demonstrated.2
Ensuring quality health care for adolescents extends beyond providing them with insurance coverage. We still have a long way to go in meeting their particular care needs, the development of preventive care guidelines for adolescents notwithstanding. A recent national survey of school health programs and policies found that smoking cessation services, identification of and counseling for eating disorders, HIV testing and counseling, and identification or treatment of sexually transmitted infections (STIs) were provided by schools in fewer than 15% of states.3 Klein et al4 have successfully improved quality of adolescent care through community-based health promotion initiatives and provider education programs. These initial efforts need to be broadened if access to and quality of care for adolescents are to be further advanced through state and local level policy initiatives.
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ABSTINENCE EDUCATION |
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TOPINTRODUCTIONACCESS TO AND QUALITY...ABSTINENCE EDUCATIONALTERNATIVES TO OSMOSISReferences |
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The risk of acquiring an STI is highest during adolescence, and about half of all new HIV infections occur among individuals younger than 25 years. As recently as July 2003, more than $15 million was awarded to communities for the development and implementation of abstinence education programs.5 Moreover, $50 million appears in President Bush’s fiscal year 2003 budget for mandatory funding of abstinence education grants to 59 states and jurisdictions,6 despite strong scientific evidence that abstinence-only education is ineffective in delaying or changing sexual behavior among adolescents.7,8 This gap between science and policy needs to be bridged, as valuable resources are being wasted and STIs, HIV, and unintended pregnancies continue to burden adolescents.
Despite state mandates on content requirements, the power to create and implement sexual education policies is largely at the local level.9 The current political climate, promulgated in part by conservative values in many US communities, contributes to supporting abstinence-only educational policies that are driven by ideology rather than science.
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ALTERNATIVES TO OSMOSIS |
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TOPINTRODUCTIONACCESS TO AND QUALITY...ABSTINENCE EDUCATIONALTERNATIVES TO OSMOSISReferences |
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According to English and Wilcox, "the science communities seem to adopt a ‘trickle-down theory’ of influence in which they assume that their findings, once published in journals, will find their way into a policy process through some process of osmosis."10(p293) This reliance on "osmosis" is problematic. Research initiatives and dissemination of results need to extend beyond technology transfer and peer-review publications to a more concerted attempt to realize and shape relevant policy. Adolescent health researchers can work toward this goal in at least 3 ways.
- By including policy questions in research activities. By expanding research activities to include more focused policy questions, public health researchers can directly assess the impact of policy decisions. The integration of policy into evaluation research provides communities, advocates, and policymakers with more functional, explicit information to aid in decisionmaking. By investigating areas in adolescent health that could benefit from more critical policy studies—such as access to and quality of care—researchers are in a better position to set standards for the type and quality of scientific evidence used to inform policy.
- By working with communities to promote evidence-based policy and advocacy efforts. Increasingly, more areas of adolescent health policy are left to the discretion of local governments. One key to improving adolescent health outcomes may lie in strengthening the ability of communities to make informed policy decisions that meet the critical health needs of adolescents. By grassroots mobilization of local resources armed with reliable data, advocacy groups may assist in bringing about policy changes through citizen action. Simply presenting empirical evidence, however, will not be sufficient to engender community support. Researchers need to creatively frame potentially contentious issues—such as the failure of abstinence education—into messages that will win over both liberal and conservative constituencies. Collaborative partnerships, such as those modeled in community-based participatory research, offer a framework in which researchers can work with school boards, parents, and government agencies that have decisionmaking authority in areas related to adolescent health policy.
- By building relationships directly with policymakers. Though public health researchers often justify a lack of attention to policy by maintaining that policy is outside their area of training or expertise, researchers are uniquely equipped to translate findings into accessible tools for local policymakers. In addition to working through communities and advocates, researchers need to share in the responsibility of communicating with policymakers. Enhancing direct relationships between researchers and policymakers would be mutually beneficial. The subsequent provision of sound scientific evidence to policymakers would increase their familiarity with rigorous scientific processes and program evaluations; additionally, researchers would gain from a more explicit understanding of the nature of information needed to inform policy decisions.
Public health scientists have the potential to conduct studies with more relevance to policy development that will meaningfully affect the lives of adolescents. The physical, emotional, and social vulnerability of adolescence makes policy an especially crucial tool in shaping this phase of their life course. By incorporating policy into evaluation research and engaging communities and policymakers, researchers can provide a sound scientific basis from which policymakers can formulate more effective recommendations to achieve the goal of promoting healthy adolescent behaviors.
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Acknowledgments |
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The authors would like to thank Mary E. Northridge, PhD, MPH, and Emily Nishi, MPA, for their thoughtful comments on this editorial.
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References |
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TOPINTRODUCTIONACCESS TO AND QUALITY...ABSTINENCE EDUCATIONALTERNATIVES TO OSMOSISReferences |
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1. Newacheck PW, Brindis CD, Cart CU, et al. Adolescent health insurance coverage: recent changes and access to care. Pediatrics. 1999;104 (2 pt 1):195–202. As cited in: MacKay AP, Fingerhut LA, Duran CR. Adolescent Health Chartbook. Health, United States, 2000. Hyattsville, Md: National Center for Health Statistics; 2000:86.
2. Morreale MC, English A. Eligibility and enrollment of adolescents in Medicaid and SCHIP: recent progress, current challenges. J Adolesc Health.2003;32 (suppl 6):25–39.[Web of Science][Medline]
3. Brenner ND, Burstein GR, DuShaw ML, et al. Health services: results from the School Health Policies and Programs Study 2000. J Sch Health.2001;71:294–304.[Medline]
4. Klein JD, Sesselberg TS, Gawronski B, Handwerker L, Gesten F, Schettine A. Improving adolescent preventive services through state, managed care, and community partnerships. J Adolesc Health.2003;32(suppl 6):91–97.[Medline]
5. US Dept of Health and Human Services. HHS awards new grants to support abstinence education among nation’s teens. Available at: http://www.hhs.gov/news/press/2003pres/20030702.html. Accessed September 12, 2003.
6. Maternal and Child Health Bureau. Abstinence education. Available at: http://mchb.hrsa.gov/programs/adolescents/abstinence.htm. Accessed September 12, 2003.
7. Thomas MH. Abstinence-based programs for prevention of adolescent pregnancies: a review. J Adolesc Health.2000;26:5–17.[Web of Science][Medline]
8. Silva M. The effectiveness of school-based sex education programs in the promotion of abstinent behavior: a meta-analysis. Health Educ Res.2002;17:471–481.
9. Alan Guttmacher Institute. State Policies in Brief, as of July 1, 2003: Sexuality Education. Available at: http://www.agi-usa.org/pubs/spib_SE.pdf (PDF file). Accessed August 4, 2003.
10. English A, Wilcox B. Work Group VI: exploring the influence of law and public policy on adolescent health. J Adolesc Health. 2002;31:293–295.[Medline]
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