Research In Practice Blog

Adolescence is a pivotal stage of development characterized by significant physical and social changes. During this period, young people experience increased independence, make personal decisions, rely more on peer relationships, and may engage in risk-taking behaviors. This critical phase is often marked by the emergence of substance use, initiation of sexual activity, a rise in depression rates, and increased access to firearms. Adolescents face numerous health vulnerabilities that can impact their well-being and long-term health. This blog post highlights a recently published study that sheds light on the intersection of health vulnerabilities among adolescents and the role of neighborhood opportunity and age. While a third of adolescents reported at least one health vulnerability, older adolescents and adolescents from lower-opportunity neighborhoods were more likely to report two or more health vulnerabilities.

The Prevalence of Health Vulnerabilities among Adolescents

According to the Centers for Disease Control and Prevention (CDC), a significant proportion of adolescents in the United States engage in risky behaviors. Approximately 25% of adolescents report having used tobacco, 29% have experimented with alcohol, and 37% have used marijuana. Additionally, by age 18, about 55% of adolescents have had sexual intercourse, and 12% have experienced at least one major depressive episode. Alarmingly, firearm ownership in households with children has also increased, making it important to consider its impact on adolescent health.

Understanding the Interconnected Nature of Health Vulnerabilities

Prior research has shown that adolescents who engage in substance use are at an increased risk of developing depression or suicidality. Likewise, adolescents with depression or depressive symptoms often have a higher prevalence of early sexual debut, e-cigarette and tobacco use, and marijuana use. These findings emphasize the need to recognize that health vulnerabilities often intersect and influence each other. Addressing one issue may require acknowledging the presence of another, such as anxiety and depression or alcohol and marijuana co-use. This approach, known as a trans-diagnostic approach, is crucial for developing effective interventions that target overlapping health vulnerabilities.  

The Role of Neighborhood Opportunity

The neighborhood environment plays a significant role in shaping the health outcomes of adolescents. The Childhood Opportunity Index (COI) is a metric that assesses neighborhood characteristics relevant to child well-being, including educational resources, health-related environmental features, and social and economic context. The COI has been associated with various health outcomes, such as emergency department utilization, obesity, and cardiometabolic risk. However, little is known about the intersection of COI and adolescent health vulnerabilities, such as tobacco use, alcohol and other substance use, sexual activity, firearm access, lack of condom use, or depression, and the extent to which these vulnerabilities co-occur.

Study Objective

This study leveraged publicly available COI data and electronic medical record data from a large, diverse pediatric primary care network to examine the prevalence of health vulnerabilities among adolescents and determine whether there were differences in the co-occurrence of vulnerabilities based on age and neighborhood opportunity level.

Study Design

We performed a cross-sectional analysis of electronic health record (EHR) data for over 40,000 adolescents aged 13-18 who visited the Children's Hospital of Philadelphia (CHOP) Care Network between September 2021 and September 2022. We looked at data for five health vulnerabilities (tobacco use, alcohol and/or marijuana use, firearm access, condomless intercourse, and depressive symptoms) extracted from the Adolescent Health Questionnaire and Patient-Health Questionnaire Modified for Teens (PHQ-9M).  

Neighborhood opportunity was assessed using the Child Opportunity Index 2.0. COI scores were categorized into quintiles, representing very low to very high opportunity neighborhoods. Multivariable logistic regression models were used to assess the association between neighborhood COI and reporting two or more health vulnerabilities.  

Models were progressively adjusted for patient demographics, including age, sex assigned at birth, race/ethnicity, and insurance payor. Race/ethnicity and insurance were considered potential confounders due to their links to structural racism and socioeconomic disparities.

Key Findings

1. Nearly one-third of adolescents reported at least one health vulnerability, with 7.9% reporting two or more vulnerabilities.
2. Older adolescents (16-18 years old) were more likely to report co-occurring health vulnerabilities compared to younger adolescents (13-15 years old).
3. Adolescents living in neighborhoods with lower COI scores (indicating lower opportunity) were more likely to report health vulnerabilities compared to those in higher opportunity neighborhoods.
4. Adolescents living in neighborhoods with lower COI scores were at a higher risk of having multiple health vulnerabilities, even after adjusting for individual demographics.
5. Specific health vulnerabilities varied by neighborhood opportunity. For instance, adolescents in high COI neighborhoods were more likely to report alcohol use, while those in low COI neighborhoods reported higher rates of tobacco and marijuana use, condomless intercourse, and depressive symptoms.  
6. There was no difference in the COI quintile when examining teens with both firearm access and depressive symptoms. This demonstrates the importance of universal firearm screening and safe storage counseling for all adolescents and their caregivers.

Implications and Conclusion

These findings underscore the impact of neighborhood opportunity on adolescent health. Adolescents living in neighborhoods with limited opportunities face higher risks of experiencing health vulnerabilities, and healthcare systems need to tailor their services to address these unique challenges.

Preventive care visits offer an opportunity to identify and support adolescents with multiple health vulnerabilities. Health systems should consider implementing trans-diagnostic care approaches that account for the co-occurrence of health vulnerabilities. Furthermore, policy interventions aimed at improving neighborhood conditions and reducing poverty can play a crucial role in promoting adolescent health and well-being.

This study highlights the importance of recognizing that a complex interplay of individual behaviors, social determinants, and neighborhood environments influences the health and well-being of adolescents. By understanding these dynamics, healthcare providers and policymakers can take targeted actions to improve the lives of adolescents in their communities.

Clinical Futures author(s): Gabrielle DiFiore, MPH; Sarah Wood, MD, MSHP; Brian P. Jenssen, MD, MSHP; Alexander G. Fiks, MD, MSCE; Stephanie L. Mayne, PhD, MHS

Citation: DiFiore G, Wood S, Jenssen BP, Fiks AG, Mayne SL. Cumulative Health Vulnerabilities among Adolescents by Age and Neighborhood Opportunity. Pediatrics. 2023;152(6). doi: 10.1542/peds.2023-062657

Practice Change / Clinical Policy Change Statement: Older adolescents and adolescents from lower-opportunity neighborhoods were more likely to report two or more health vulnerabilities compared to younger adolescents and those from high-opportunity neighborhoods. These findings are integral to understanding the intersection between health vulnerabilities and environmental influences because using a trans-diagnostic care approach can truly help transform adolescent care.