Abstract
Objectives: This study examines the receipt of health care transition (HCT) preparation and anticipatory guidance by whether the teen had time alone with a health care professional using self-reported data collected from a nationally representative sample of teens aged 12 to 17 years.
Methods: Data from the National Health Interview Survey—Teen (NHIS—Teen) a follow-back survey to the National Health Interview Survey (NHIS) were used (n = 1635). Prevalence estimates of teens’ receipt of time alone with a health care professional, HCT preparation (eg, understanding the changes in health care that happen at age 18) and anticipatory guidance discussions (eg, use of tobacco products) were examined. Logistic regression models tested for associations between receipt of time alone and each measure; analyses were adjusted for selected teen and family level sociodemographic characteristics.
Results: Only 47.1% of teens with a medical care visit in the past 12 months had time alone with a health care professional. Approximately 25% of teens discussed changes in health care and 43.2% discussed gaining skills to manage their own health. In addition, 46.0% of teens discussed puberty and sexual health, 55.5% discussed use of tobacco products and 66.5% discussed mental or emotional health. Teens that had time alone with a health care professional were significantly more likely to receive HCT preparation and anticipatory guidance.
Conclusions: Teen self-reported receipt of HCT preparation and anticipatory guidance was low. Having time alone with a health care professional was associated with increased receipt of HCT preparation and anticipatory guidance.
- Adolescence
- Adolescent Health
- Child Health
- Cross-Sectional Studies
- Health Promotion
- National Health Interview Survey
- Patient-Centered Care
- Pediatrics
- Population Health
- Preventive Medicine
- Primary Health Care
- Public Health
- Quality of Care
- Screening
- Self Care
- Self Report
- Surveys and Questionnaires
Introduction
Adolescence is a developmental stage of life marked by rapid changes in physical, psychological, sexual, moral and cognitive growth.1 It is also during this time, generally beginning at age 12,2 where it is appropriate that adolescents begin receiving health care transition (HCT) preparation3,4 and confidential care5–7 as affirmed in a collective clinical recommendation from the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP)3 with scheduled visits outlined in AAP’s Bright Futures schedule.8 One key aspect of these services is having time alone with their clinician.8,9 Adolescents should also begin to receive anticipatory guidance from the clinician, such as information about positive lifestyle choices to prevent disease and injury.8
Health care transition is the purposeful movement from pediatric to adult-oriented systems of care. This is a process that involves coordination between clinicians, families and youth themselves to assess readiness, plan, implement and document.10–12 Annual preventive visits are recommended for all adolescents, as they are a time to deliver clinical preventive services, including age appropriate preventive counseling and anticipatory guidance.8 Time alone with a health care provider has been shown to facilitate opportunities for youth to disclose sensitive health concerns.13
Many recent studies that focus on these health care experiences and quality among adolescents are based on parental-report. Therefore, much of the knowledge base assumes parents are fully aware of the services provided and the content of the visit for their adolescents; this has been noted as a limitation in previous work.14–20 Recent parent-reported data on this topic shows that less than 1 in 5 adolescents (18.4%) received all services needed for transition to adult health care21 while 2 in 5 (42%) received time alone at their last medical care visit.21 Previous research has also noted that fewer than 50% of adolescents have received anticipatory guidance on topics related to health promotion and risky behaviors during preventive visits,22 and there are similar rates for provision of such counseling during outpatient visits.23,24 Despite this, there is a strong association between receipt of a preventive visit and increased likelihood for receipt of anticipatory guidance.14 Less is known about adolescent self-reported health care experiences.
To address this research gap, this study uses a nationally representative sample of adolescents aged 12 to 17 to examine 1) the prevalence of self-reported receipt of time alone with a health care provider, selected HCT preparation components, and receipt of selected anticipatory guidance measures; and 2) the associations of time alone with HCT and anticipatory guidance received.
Methods
Data Source
Data are from the National Health Interview Survey—Teen (NHIS—Teen), a cross-sectional survey of adolescents aged 12 to 17 years (subsequently, teens) collected between July 2021 and December 2023. NHIS-Teen is a follow-back survey of the National Health Interview Survey (NHIS). NHIS is an annual household survey of the noninstitutionalized civilian population conducted by the National Center for Health Statistics (NCHS). For NHIS, one randomly selected adult and child are subjects of an interviewer-administered health survey (Sample Adult interview and Sample Child interview, respectively). Parents provide responses for the Sample Child in NHIS. Teens selected for the NHIS-Teen sample are those whose parents or guardians have completed the Sample Child interview and have given permission for their child to participate in NHIS—Teen. Teens are then invited to participate in a self-administered survey; nonrespondents receive multiple reminders via mail, text message, and e-mail to participate. Invitations and reminders were addressed to the teen (mail), sent to the teens phone number or e-mail address (text/e-mail).
The total NHIS—Teen sample size included 1958 teens, however given the focus to explore what HCT or anticipatory guidance topics teens receive during doctor visits, analyses for this study were limited to respondents with medical care visits in the past 12 months (n = 1658). Respondents with missing responses for all HCT or anticipatory guidance measures were excluded (n = 23), resulting in an analytic sample of 1635 teens. The parent permission rate for NHIS-Teen was 60.4%, the teen participation rate was 46.2%, resulting in an overall NHIS-Teen interview rate of 27.9%. Sampling weights were used to adjust for nonresponse and reduce the bias, additional information regarding NHIS-Teen sampling weights construction and how bias has been reduced can be found elsewhere.25 More detailed survey methodology have also been previously published.26 Data collection was approved by the NCHS Ethics Review Board. This study used secondary data analysis of deidentified data and therefore did not require institutional review. Data used in this analysis are available via the NCHS Research Data Center (https://www.cdc.gov/rdc/index.htm).
Measures
Measures of time alone with a health care professional, HCT and anticipatory guidance topics were collected as part of the NHIS—Teen survey only and are based on self-report. Time alone with a health care professional (subsequently, time alone) was based on teen responses to survey questions about their experiences speaking with a doctor or other health professional privately, without a parent or guardian in the room, during either 1) their last medical care visit in the past 12 months, or 2) a wellness, physical or general-purpose checkup (ie, wellness visits) in the past 12 months. Teens with affirmative responses to either survey item were considered to have received time alone; thus, this composite measure includes preventive and nonpreventive visits.
HCT and anticipatory guidance questions were based on separate questions that identified whether teens had discussed HCT components of 1) understanding the changes in health care that happen at age 18 years (subsequently, health care changes) or 2) gaining skills to manage their own health and health care (subsequently, health management skills) during any of the medical care visits in the past 12 months. In addition, teens were asked whether they had discussions with health care providers about anticipatory guidance topics on 1) use of tobacco products, 2) mental or emotional health or 3) puberty and sex during any of the medical care visits in the past 12 months (Appendix Table 1). Each item was asked as yes or no and analyzed dichotomously. These items were selected to align with measures identified within national performance measures framework for maternal and child health27,28 and Bright Futures8 guidelines for adolescents. Although these items do not encompass all elements of HCT nor all the Bright Futures anticipatory guidance guidelines, they shed light on a meaningful cross-section of experiences youth are having with their health care provider.
Teen sociodemographic characteristics were collected as part of the NHIS Sample Child interview, and therefore are based on parent-report. Characteristics selected were based on previous literature15,17 and included: sex, age, race and ethnicity, health insurance type, and family income as a percentage of the federal poverty level (FPL). FPL was calculated as the ratio of total family income and the family poverty threshold; NHIS imputed income files were used to account for missing family income.29–31 In addition based on parent-report, whether the teenager had a health professional they considered to be their personal doctor or nurse, and disability status, based on the Washington Group Child Functioning Module,32 were also assessed.
Statistical Analysis
Descriptive statistics (percentages and standard errors (S.E.)) weighted to the national population were calculated. χ2 tests were used to determine significant differences in sociodemographic and selected health measures by receipt of time alone with a health care provider. Prevalence of each HCT component and anticipatory guidance topic, stratified by receipt of time alone, were calculated. t test were used to test for significant differences.
Multivariate logistic regression analyses were used to examine the odds of receiving each HCT component and anticipatory guidance topic by receipt of time alone, adjusted for sex, age-group, race and ethnicity, health insurance type, family income, having a personal doctor or nurse, and disability status. All analyses were conducted by using SAS-Callable SUDAAN and all estimates presented meet NCHS data presentation standards for proportions.33
Results
Overall, less than half (47.1%) of teens who had a medical care visit in the past 12 months received time alone with a health care professional in the past 12 months (Table 1). Receipt of time alone varied by sex, age, family income and whether teens had a personal doctor or nurse.
Time Alone with Health Care Professional by Selected Sociodemographic Characteristics Among Teens Aged 12–17 Years with Medical Care Visits in the Past 12 Months (n = 1,635)
Receipt of HCT Preparation and Anticipatory Guidance
Table 2 presents the percentage of teens that had HCT or anticipatory guidance discussions among those who had a medical care visit in the past 12 months. Approximately one quarter (25.4%) had discussions with their health care provider about health care changes and less than half (43.2%) had discussions about health management skills. The percentage of teens that had discussions about health care changes was significantly higher among those that had time alone with their health care provider (35.0% vs 16.8% P < .001) as was discussions about health management skills (48.9% vs 38.0% P < 0. 001).
Receipt of Health Care Transition Discussions or Anticipatory Guidance by Time Alone with Health Care Professional, Among Teens Aged 12–17 Years with Medical Care Visits in the Past 12 Months
Just over half of teens who had a medical care visit in the past 12 months discussed tobacco products (55.5%), approximately 66% discussed mental or emotional health (66.5%), while fewer (46.0%) discussed puberty and sexual health. Teens that had time alone were more likely to have received guidance discussions about tobacco products (71.3% vs 41.4% P < .001), mental or emotional health (81.2% vs 53.3% P < .001), and puberty and sexual health (64.3% vs 29.5% P < .001) compared with teens that did not have time alone.
Association of Time Alone with HCT Preparation and Anticipatory Guidance
Teens who had time alone were more likely to have had discussions about health care changes and health management skills. For example, teen that had time alone were more likely to have discussions about changes in health care (Table 3, Odds ratio [OR]: 2.67, 95% confidence interval [CI]: 1.96-3.62), and more likely to discuss health management skills (OR: 1.56, 95% CI: 1.21-2.01). These associations remained significant after adjustment for covariates.
Time Alone with Health Care Professional as a Predictor for Receipt of Health Care Transition Preparation and Anticipatory Guidance Among Teens Aged 12–17 Years with Medical Care Visits in the Past 12 Months
In addition, teenagers that had time alone were more likely to have discussions about tobacco products (OR: 3.50, 95% CI: 2.71-4.53), and mental or emotional health (OR: 3.79, 95% CI: 2.86-5.03). Teens that had time alone were also more likely to have discussions about puberty and sexual health (OR: 4.29, 95% CI: 3.32-5.55). These associations remained significant when adjusted for covariates.
Discussion
Results from this study are consistent with previously published research using parent-reported data. Many teens lack time alone with a health care professional,15,17,34,35 receipt of HCT preparation,16–18,35 or discussions with health care providers, as recommended by AAP anticipatory guidance.23,24 Based on self-report, just over 47% of teens with medical care visits in the past 12 months had time alone with a health care professional. Even fewer had discussions with health care providers regarding health care changes that happen at age 18 years and skills to manage their own health, key components of health care transition preparation for youth. Despite this, discussions were more likely to occur among teens that had time alone with a health care professional. Previous work has established that time alone with a health care provider is associated with improved health care experiences, including positive attitudes about their providers and comfort with discussing sensitive topics.13 Adolescents that have discussions with their health care provider about confidentiality have been shown to be more likely to go on and discuss sensitive topics,36,37 and engage in future health care utilization.37
To our knowledge, the present study is one of the first to provide population-based estimates of HCT preparation components as reported by teens themselves. Much of the literature available on this topic has been limited to parent report and assumes that parents are fully aware of the content of care that was delivered, especially when the adolescent met with the clinician. The present study had comparable estimates for time alone,16 however teen report of discussions about health care changes and health management skills were lower than other parent-reported estimates.21 Given this discrepancy, findings from this study shed light on the importance of measuring self-reported receipt of HCT and anticipatory guidance to gauge young adults’ progress preparedness in managing their own health and health care.
Receipt of time alone and HCT preparation have been associated with a well-functioning system of care and specifically receipt of care in a medical home.19 Key components of the medical home include having a usual source of care, a personal doctor or nurse, referral access, receipt of care coordination, and receipt of family-centered care.38 It is estimated that less than half of adolescents have access to a medical home39,40 despite AAP recommendations that all children and youth receive care in a medical home.38 Future work could address how these systems of care are perceived by adolescents and what gaps exist in the delivery of health services as they transition to adult systems of care. Unfortunately, except for having a personal doctor or nurse, the NHIS—Teen did not include questions on these system components.
Adolescence is a time when clinicians should access teen’s readiness to manage their own health, which may include talking about skills that adolescents currently have.8 Certain health management skills may warrant privacy during the health care visit. For example, discussing medication adherence or challenges with medications, addressing sensitive topics, and assessing comprehension may be areas that clinicians may find more appropriate in settings without the presence of the parent. Furthermore, the time alone may promote the teens confidence, build a relationship with their clinician and provide opportunities to practice self-advocacy.
The prevalence of mental health conditions, suicide ideation and mental health care utilization have increased in recent years,41–45 and improving youth mental health is a public health priority area in the United States.46 In 2021, updates to AAP recommendations for preventive pediatric care included the addition of suicide risk as an element of universal depression screening for those 12 and older.47 Results from the present study found that the most prevalent discussions between teens and a medical care provider were about mental or emotional health. Teens that had time alone with their health care provider had over 4 times the odds of having discussions about their mental or emotional health compared with those that did not have time alone.
Recommendations specify that early adolescence is the appropriate time for clinicians to provide anticipatory guidance related to topics such as risk reduction for pregnancy, sexually transmitted infections, tobacco (including e-cigarettes).8 Discussion of sensitive topics may have a positive effect on youth perception of care and their ability to take an active role in their own health.48 Findings from this study add to the existing literature by providing teen-reported prevalence estimates for specific anticipatory guidance conversation topics. Results indicate that these discussions were more likely to occur among teens that had time alone with their health care provider. These findings are in line with previous research that has found sexual health and risk behaviors like smoking, drugs and alcohol use were more likely to be discussed when the visit was confidential.49
NHIS—Teen is a nationally representative sample of teens that is useful for understanding health care experiences from the teens’ point of view. However, data are cross-sectional, therefore directionality of correlations cannot be assessed. It is worth noting that these data are not directly comparable to National Survey of Children's Health (NSCH) composite measures of HCT, because NHIS—Teen does not have survey items that ascertain the type of health care professional that youth see (eg, pediatrician, family medicine) and if conversations about a shift to an adult provider would be needed. In addition, findings are representative among teens that have had a medical care visit in the past 12 months. For this reason, findings may overestimate the receipt of HCT preparation and anticipatory guidance among all teens. In addition, because findings represent teens experiences within both preventive and nonpreventive visits and did not differentiate between the type of provider (eg, pediatrician, family physician, specialist), future work may be useful to understand if the context of the visit or clinician’s specialty impacts the likelihood of a teen receiving HCT preparation or anticipatory guidance. Further, NHIS-Teen did not explore details about the teens’ experiences; such information may be helpful in understanding barriers to receiving HCT preparation and anticipatory guidance. Despite this, estimates from NHIS-Teen enhance our understanding of national prevalence of HCT preparation using the perspectives of the youths themselves.
Conclusions
Consistent with previous literature, the receipt of HCT preparation remains low among teens. However, AAP’s guidelines recommend that all teens receive HCT preparation and anticipatory guidance.8 Importantly, this study is based on teen-report, highlighting teens’ own perspectives of their health care experiences. Based on teen-report, having time alone with a health care professional is associated with receipt of discussions important for HCT preparation and anticipatory guidance topics. A unique and nationally representative data source, NHIS—Teen can help address key research questions regarding health care experiences of teens from their own point of view.
Acknowledgments
We would like to acknowledge Jeannine Schiller, Anjel Vahratian, and Amy Branum for their guidance on this analysis.
Appendix
Survey Items Used to Measure Receipt of Time Alone, Health Care Transition and Anticipatory Guidance
Notes
This article was externally peer reviewed.
Funding: None. This work was conducted under Federal government employment and did not include any external funding.
Conflict of interest: None.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the National Center for Health Statistics, Centers for Disease Control and Prevention (CDC).
- Received for publication March 13, 2025.
- Revision received July 11, 2025.
- Accepted for publication July 28, 2025.
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