First Advisor

Julia Goodman

Term of Graduation

Spring 2025

Date of Publication

6-10-2025

Document Type

Dissertation

Degree Name

Doctor of Philosophy (Ph.D.) in Health Systems and Policy

Department

Health Systems and Policy

Language

English

Subjects

adolescents, geography, Medicaid, primary care, race-ethnicity, telehealth

Physical Description

1 online resource (xvii, 393 pages)

Abstract

Adolescents are a developmentally distinctive population with unique primary health care needs; they comprise about 10% of Oregon's population and more than half are covered by the Oregon Health Plan (OHP). This dissertation investigated significant declines in preventive care utilization (well visits and HPV immunizations) among adolescents enrolled in OHP during the COVID-19 pandemic and the relationship between the decline in utilization and the rise in telehealth availability. The study focused specifically on the role of race/ethnicity, geography, and access to health systems in mitigating or exacerbating decreases in preventive care. A mixed methods approach was employed to understand not only how Oregon adolescents' utilization changed from pre-COVID (2019) to post-COVID (2022), but also how this utilization may have been shaped by youth attitudes towards preventive care and telehealth use. The Andersen Model of Health Care Access was used to identify environmental, systemic, and demographic factors relevant to adolescent preventive care utilization and telehealth use.

This dissertation was designed to answer the following research question: How has the increase in telehealth availability during the COVID-19 pandemic affected primary care outcomes for Oregon Medicaid-enrolled adolescents overall, and what impact has it had on inequities for youth of color and rural youth? The research question was addressed through three aims:

  1. Assess youth perceptions of telehealth as a primary care access point, and how these perceptions relate to adolescents' understanding of their own health;
  2. Describe the changes in select primary care outcomes between 2019 and 2022 among Oregon Medicaid-enrolled adolescents and assess differential impacts on youth of color and rural youth; and
  3. Investigate the relationship between telehealth primary care access and adolescent preventive care outcomes among OHP-enrolled adolescents in 2022, as well as the role of telehealth primary care access in observed declines in preventive care between 2019 and 2022.

Youth focus groups were used for Aim 1; results found that youth opinions and decisions on whether and how to access primary care focused on privacy, sense of connection, flexibility, and acuity of need. Aims 2 and 3 relied on comprehensive OHP claims data from 2019 and 2022; multivariate logistic regression, generalized estimating equations, and post-estimation marginal effects were utilized the analyses. Between 2019 and 2022, adjusted HPV immunization rates declined by 28% and well visit rates declined by 29%. Youth experienced very similar rates of decline in preventive care between 2019 and 2022 regardless of race/ethnicity. Results by geography varied by outcome. Youth in frontier areas experienced a much steeper decline in adjusted HPV immunizations between 2019 and 2022 compared to youth in urban and rural areas. However, while adjusted well visit rates declined by about 30% for youth in rural and urban areas between 2019 and 2022, they increased slightly among youth in frontier areas. Access to a School-Based Health Center was associated with a less steep decline in adjusted HPV immunization rates and an increased likelihood of receiving a well visit in both 2019 and 2022.

Of adolescents with a primary care visit in 2022, 13.7% used telehealth for at least one visit. Youth in urban areas were far more likely to utilize telehealth for primary care (16%) than those in rural (10%) and frontier (5%) areas. There was no meaningful relationship between telehealth intensity and either HPV immunizations or well visits in 2022.

Synthesized findings from across the three aims contribute to an overall picture of youth preventive care in Oregon and the role of telehealth that emerged in three themes. First, it was clear that the significant decline in adolescent preventive care rates caused by the pandemic has affected nearly all populations of OHP youth, across race, ethnicity, geography, and access to health systems. Secondly, emotional and physical disconnection from health care resources are important factors in why youth do not receive preventive care or utilize telehealth. And lastly, youth views on telehealth are nuanced and involve tradeoffs; telehealth may be part of a solution for improving access to care for youth but it cannot entirely address preventive care deficits.

The findings from this research highlight potential actions across health policy and practices that could improve the health of Oregon's adolescents. Policy and practice recommendations focus on centering youth privacy, investing in accessible and adolescent-friendly health care resources, and more clearly supporting youth in the most sparsely populated parts of Oregon to improve preventive care utilization. Given the change in federal policy and political priorities after the 2024 election, it is imperative that the Oregon Health Authority and its partners consider ways to implement these recommendations to prevent further declines in adolescent preventive care.

Rights

In Copyright. URI: http://rightsstatements.org/vocab/InC/1.0/ This Item is protected by copyright and/or related rights. You are free to use this Item in any way that is permitted by the copyright and related rights legislation that applies to your use. For other uses you need to obtain permission from the rights-holder(s).

Persistent Identifier

https://archives.pdx.edu/ds/psu/43881

Download

Available for download on Wednesday, June 10, 2026

Share

COinS