ADVOCATES FOR YOUTH

Transitions
Volume 15, No. 3, January 2004

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Barriers to Health Care for Youth of Color

By Tamarah Moss, MSW, MPH, Program Manager, Teen Pregnancy Prevention Initiative

All adolescents, but especially youth of color, need comprehensive and culturally competent sexual and reproductive health care. Unfortunately, adolescents and young adults have less access to health care than any other age group.^1,2 Teens and young adults, especially those of color, face serious barriers related to sexual and reproductive health care—barriers that may severely limit their ability to avoid pregnancy and STIs, including HIV.³ Committed communities, organizations, and providers can address these barriers and assist youth in overcoming them.

Adolescents Face Service Related Barriers.

Uninsured and underinsured adolescents in the United States are more likely than their insured peers to forego needed health care. Among youth who have health insurance, the current shift from fee-for-service to managed care provides challenges as well as opportunities. Managed care provides more opportunities to monitor and measure the quality of care provided to adolescents and to provide them with preventive services.^4,5,6,7,8,9 Primary care providers, as gate keepers, can give teens access to specialized care (such as substance abuse or mental health treatment) and the opportunity to identify particular providers with whom youth are comfortable.¹⁰ In meeting the needs of adolescents, managed care can lead to continuity of care and appropriate referral.

On the other hand, adolescents face serious challenges in seeking services from managed care systems. These challenges include limits on services and benefits, a shortage of providers trained in adolescent health, financial and administrative systems that obstruct teens' access to needed services and that sometimes breach teens' confidentiality, and services that focus on adults or children, overlooking the particular needs of teens. Other service related barriers may include waiting rooms where adolescents feel uncomfortable or unwelcome, appointment times that conflict with school schedules, and clinic policies that prohibit walk-in appointments. These barriers contribute to the problems of youth of color, who experience greater difficulty than their white peers in getting early treatment for acute and chronic illnesses as well as appropriate preventive care.^11,12,13

Adolescents Face Social, Cultural, and Economic Barriers.

For youth of color in the United States, social, cultural, and economic factors form substantial obstacles to sexual and reproductive health services.

Cultural Barriers—

• Acculturation—For youth of color who are first and second generation Americans, acculturation—the degree to which they assimilate the values, beliefs, and behaviors of the host culture¹⁴—is a major factor in health care decisions and use of preventive services. These young people may face language barriers and fear meeting with cultural insensitivity. When youth and providers speak different languages, or rely on a different idiom for the same language, misunderstandings occur, and youth can be made to feel that the misunderstanding is their fault, thus creating a serious emotional barrier to youth's continued use of health care services.¹⁵
• Communication patterns—Communication about health and sexuality often differs by ethnicity, age, socioeconomic status, geographic location, and sexual orientation. Communication patterns can form serious obstacles to care. Patterns of speech that presuppose that all youth are heterosexual, share a cultural background, or operate from a single gender role perspective, create instantaneous barriers to care for many young people.
• Inaccurate assumptions or generalizations—Any assumption that a single program will meet the needs of all—or even several different—communities of a particular racial/ethnic group in the United States is wildly inaccurate. For example, Native Americans/American Indians possess individual languages, differing customs, and unique cultures and histories. Attitudes toward health and illness, sexuality, and wholeness differ widely. HIV/STI and teen pregnancy prevention programs must be individually tailored to each culture.¹⁶
• Differing history and community memory—Because groups within an ethnic community have different histories and differing community memories, a single program will not meet the needs of everyone in the larger community. For example, many African Americans—remembering the infamous Tuskegee syphilis study—are suspicious of government agencies, fearing that genocidal intentions underlay HIV/STI and pregnancy prevention efforts. As a result, they may be unwilling to use condoms and/or to be tested or treated for HIV/AIDS.¹⁶ At the same time, some black Americans, such as those with a Caribbean background, may not share this particular history of governmental abuse. Thus, programs must be tailored to address different cultures.
• Lack of culturally appropriate materials—Materials appropriate for one group of clients may simply lack the ability to convey important concepts to another group of clients. For example, many HIV prevention materials that are appropriate for use with some groups of Native Americans/American Indians could be inappropriate for use with Navajo people. Within traditional Navajo culture, speaking about disease is believed to bring it into existence.¹⁷
• Inadequate language resources— English-language materials and those translated into a single other language may simply be inadequate. For example, Asian and Pacific Islanders include over 60 ethnic groups, speaking more than 100 languages, and each ethnic and language group needs materials in its own language (and script) as well as culturally appropriate services.¹⁶ At the same time, Latinos may speak English, Spanish, Portuguese, and/or one of many indigenous (Native American) languages. Moreover, the more than 100 different Spanish dialects each have distinctive idioms, usage, and meanings, especially for words related to sexuality. Thus, a program designed by and for first or second generation Puerto Rican youth living in a minority community in an urban, Northeastern region may be totally inappropriate for use with Latinos whose families have lived as landowners in the Southwest for several centuries and whose culture is highly valued in the region.

Economic Barriers—

Poverty, lack of insurance, and/or lack of Medicaid providers are additional barriers to adolescents' use of health care.^11,18,19 Teens may be unwilling to court humiliation by asking whether services are free or at reduced fees; they may instead fail to seek care.

Social Barriers—

Social barriers may include such factors as the attitudes of peers, family, and religious community as well as mass media influences. For example, peers may relate stories about unpleasant experiences—such as pelvic exams—that deter their friends from seeking health care. Parents and/or religious community may express disapproval of the use of family planning services, thus discouraging teens from seeking services that will help them avoid unwanted pregnancy. Music videos and the film industry present many images of sexualized behavior, but less frequently depict use of preventive health services or of contraception and/or condoms.

Improving Access to Health Care for Youth of Color—Recommendations

Solutions that may be critical in meeting the health care needs of adolescents, especially racial/ethnic minority youth and teens from low-income families, include the following.

1. Provide easy access—via free public transportation, redeemable tokens, or travel vouchers—to comprehensive, coordinated care in convenient locations.¹⁰
2. Ensure that financing mechanisms permit free or low-cost services for adolescents.¹⁰
3. Advertise the availability of free or reduced cost services for adolescents—using flyers, pamphlets, business cards, and posters prominently displayed in the reception area and waiting room(s).
4. Monitor and evaluate services to ensure that teens receive high quality care.^{10 11,18}
5. Establish and monitor mechanisms to ensure teens' confidentiality.^{10 11,18}
6. Publicize confidentiality policies in waiting rooms, advertisements, and handouts.^16,18
7. Create a youth-focused waiting room with appropriate décor and music and staff trained to treat youth respectfully and confidentially.¹⁶
8. Set aside special hours for appointments with young people, especially after school, evenings, and Saturdays.¹⁶
9. Leave room in the schedule for walk-in appointments.¹⁶
10. Offer comprehensive, culturally relevant, and age appropriate services (see previous articles in this issue).^16,18,19

References

1. Weinick RM et al. Access to Health Care: Sources and Barriers. Rockville, MD: Agency for Health Care Policy & Research, 1996.
2. Klein JD et al. Adolescents and Access to Care. New York: New York Academy of Medicine, 1993.
3. Melendez Salgado A, Cheetham, N. The Sexual and Reproductive Health of Youth: A Global Snapshot. [The Facts] Washington, DC: Advocates for Youth, 2003.
4. National Committee for Quality Assurance. Health Plan Employer Data and Information Set 2.0/2/5/ Washington, DC: The Committee, 1993.
5. National Committee for Quality Assurance. Book I HEDIS 3.0. Washington, DC: The Committee, 1997.
6. National Committee for Quality Assurance. Book II HEDIS 3.0. Washington, DC: The Committee, 1997.
7. _____ . Are HMOs the answer? Consumer Reports August 1992:519-530.
8. Hiramatsu S. Member satisfaction in a staff-model health maintenance organization. American Journal of Hospital Pharmacy 1990;47:2270-2273.
9. Sobczak C et al. Quality measurement and management in an HMO setting. Topics in Health Care Financing 1991;18:67-74.
10. English A et al. Meeting the health care needs of adolescents in managed care. Journal of Adolescent Health 1998; 22:278-292.
11. US Congress, Office of Technology Assessment. Adolescent Health, Vols. I & II. Washington, DC: USGPO, 1991.
12. Newacheck PW. Access to ambulatory care for poor persons. Health Services Research 1988;23:401-419.
13. Newacheck PW. Characteristics of children with high and low usage of physician services. Medical Care 1992;30:30-42.
14. Dana RH. Assessment of acculturation for Hispanic populations. Hispanic Journal Behavioral Sciences 1996;18:317-28.
15. Penn NE et al. Panel VI: ethnic minorities, health care systems, and behavior. Health Psychology 1996;14:641-6.
16. Gipson LM, Frazier A. Young Women of Color and Their Risk for HIV/STD Infection. [Issues at a Glance] Advocates for Youth. Washington, DC: 1998
17. Carese JA, Rhodes LA. Western bioethics on the Navajo reservation: benefit or harm? JAMA 1995;274:826-829.
18. Council on Scientific Affairs, AMA. Confidential health services for adolescents. JAMA 1993;269:1420-4.
19. Klein J et al. Access to health care for adolescents: a position paper for the Society for Adolescent Medicine. Journal of Adolescent Health 1992;13(2):162-70.

Transitions (ISSN 1097-1254) © 2004, is a quarterly publication of Advocates for Youth—Helping young people make safe and responsible decisions about sex. For permission to reprint, contact Transitions' editor at 202.419.3420.

Editor: Sue Alford

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