vulnerable in an unstable job market, frequently the first fired or working in temporary jobs with no employer-based insurance coverage.

Access to health care can include concerns beyond mere financial issues. Transportation, convenience, and cultural sensitivity are also factors. In addition, parental support and encouragement, as well as understanding the importance of health care and how to approach the system, influence students' access to health care.

Even with access to health care, young people may not be receiving the attention they need. When adolescents with access to physicians are asked what they want to discuss and what they actually discuss with the physician, the percentage drops on virtually every topic from nutrition, to sex, to drug use (Marks et al., 1983). Even those adolescents with insurance and family doctors do not seek help from health care professionals for problems of greatest importance for their high-risk behaviors. In fact, doctors themselves do not feel qualified to discuss most adolescent health behaviors—only 38 percent feel they have adequate training in alcohol and drug abuse, and a mere 11 percent feel qualified to discuss depression with a youth (Beringer, 1990). Studies have shown that an initial history and physical examination for a new adolescent patient should require 30 to 45 minutes. Although 23 percent of adolescent physician visits are first encounters, half of all visits last 10 minutes or less, 30 percent last 11 to 15 minutes, and only 4 percent are 30 minutes or longer (Klein et al., 1993).

THE COMPREHENSIVE SCHOOL HEALTH PROGRAM

The comprehensive school health program is seen as a new paradigm needed to deal with the problems of today's children and families. It became clear to the IOM committee at the onset of its study that although a variety of conceptions and models exist, coordinated comprehensive programs are still essentially an unrealized ideal in most communities. The committee members themselves came into the study with a range of backgrounds and experiences, and the committee determined that it needed to establish its own working definition of the term "comprehensive school health program," which would guide further work. This definition was published and distributed in the committee's interim statement in the spring of 1995, along with additional background information and an outline of issues the committee planned to address in its study. The definition of a CSHP, as well as various program models and essential components, is further discussed in Chapter 2 of this report.



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