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JANUARY / FEBRUARY 2015 :: 76(1)
Rural Health in North Carolina

This issue of the NCMJ discusses factors that influence the well-being of residents in rural communities in North Carolina. These include factors related to health care, such as physician recruitment and retention, the effects of hospital closures, and the need for behavioral health services, and factors beyond the health care sphere, such as child care, health behaviors, economic development, and access to health services.


World Peace, To Be a Millionaire, and Hoop Dreams: Adolescent Wishes on Health Screening Surveys

Josh P. Boyd, Michael J. Steiner, Asheley Cockrell Skinner, Tamera Coyne-Beasley, Eliana M. Perrin

N C Med J. 2015;76(1):9-12.PDF | TABLE OF CONTENTS

Objective This study sought to learn the wishes of young adolescents via an open-ended survey question and to determine the association of these wishes with sociodemographic variables.

Methods We performed a cross-sectional study of consecutive adolescents aged 11–14 years who had a well-child visit at a clinic with a diverse patient population, who completed a Guidelines for Adolescent Preventive Services (GAPS) previsit health questionnaire, and who answered the question, “If you could have three wishes come true, what would they be?” Responses to this question were double-coded according to thematic content and whether wishes were for self, others, or both.

Results Among 96 respondents, wishes for others were listed more frequently by girls than by boys (54% versus 31%; P = .02). Girls also had more family-oriented wish themes (27% versus 10%; P = .04). Boys were more likely to wish for success (17% versus 4%; P = .05). Among respondents with private insurance, 45% wished for the good for the world, with responses such as “world peace”; only 12% of respondents with Medicaid wished for the good of the world (P = .01). No statistically significant differences were identified by race/ethnicity or age. Positive future orientation themes such as career were not as prioritized as previously suggested in the literature.

Limitations The sample population derives from a single university-based clinic in North Carolina; while diverse, this population may not be representative of larger groups.

Conclusions Many wishes seemed predictable (ie, for wealth, athleticism), but occasionally wishes were poignant and original (“to have papers for my parents to pass the border”); this finding reinforces the value of listening to adolescents’ wishes. Both sex and insurance status were related to wish themes. Further research should determine how knowledge of adolescents’ wishes can be used to best direct individual care.

A positive future orientation has been shown to be associated with decreased health-risk behaviors and greater socioemotional well-being in adolescents [1, 2]. In young adolescents, specifically, hopeful aspirations may be related to improved self-regulation and positive youth development [3]. Additionally, there may be therapeutic value in having adolescents discuss wishes or ideal states, similar to the value provided by the “miracle question” employed in solution-focused brief therapy [4].

Social and health-risk behaviors are the primary causes of morbidity and mortality in the adolescent population [5]. The Guidelines for Adolescent Preventive Services (GAPS) previsit health screening questionnaires were developed 2 decades ago to facilitate identification of these health-risk behaviors [5-7]. In addition to inventorying health-risk behaviors by querying respondents through a series of closed-ended questions, GAPS questionnaires also include a section not seen in many other adolescent health surveys. Specifically, the GAPS survey includes open-ended questions such as, “If you could have three wishes come true, what would they be?”

Answers to these questions may provide clues as to how adolescents view their personal and social situations, as well as their aspirations, concerns, and future orientation [8]. These responses also provide important psychosocial information, which may have clinical implications [9]. Previous studies have assessed adolescents’ future orientation by using open-ended questions that asked adolescents to list their wishes for the future [10]. Previous research has also looked at using closed-ended screening questions to identify risky behaviors [6] and the career aspirations of older adolescents [11], but to our knowledge no studies have specifically examined younger adolescents’ wishes as solicited by GAPS surveys.

We sought to describe responses to the “3 wishes” question from a sample of young adolescents of diverse backgrounds and to examine variations in their wishes. Based on the clinical experience of 3 pediatricians on the study team (one of whom has expertise in adolescent medicine) as well as commonly recognized adolescent interests, we hypothesized that adolescents would wish for material goods, athletic success, and changes in appearance. We also believed wishes would vary in association with sex, race/ethnicity, and insurance status [12, 13].

We performed a cross-sectional, mixed-methods study of adolescent patients aged 11–14 years who received well-child care during a 4-month period at a resident continuity clinic associated with a children’s hospital. Consecutive patients privately completed the GAPS survey at the start of their well-child visit as part of the clinic’s standard protocol. After the visit, questionnaires were collected and analyzed. Sex, race/ethnicity, and insurance status (used as a proxy for socioeconomic status) were obtained from patients’ medical records. The study protocol, which included a patient waiver and parental consent, was approved by the Biomedical Institutional Review Board of the University of North Carolina (#10-1303).

Two of us (E.M.P. and M.J.S.) generated an a priori coding index for the types of wishes anticipated in the adolescent responses. To our knowledge, no previous studies had developed such an index, so components were devised based on prior clinical experience and general study foci. The index consisted of 2 groupings: whom adolescents wished for (subject), and what they wished for (themes). Subsequent to development of the coding index, each wish response was coded according to the subject of the wish, and wishes were categorized as being for self (eg, “I want to be a good basketball player”), for others (eg, “for my friends to be happy”), or for both self and others (eg, “for my sister and I to get into good colleges”). Each wish response was then coded according to its thematic content, such as a wish for material possessions (eg, “a car”) or academic success (eg, “better grades”). A third investigator (T.C.B.) resolved discrepancies to finalize the coding.

All quantitative analyses were performed at the level of the adolescent (eg, percentage of adolescents who wished for something for themselves). For subjects, we categorized adolescents according to whether all 3 wishes were for themselves, all 3 wishes were for others, or the 3 wishes were for both themselves and others. For themes, we examined the number of adolescents reporting a particular theme in at least 1 of their 3 wishes. Chi-squared tests were used to determine associations of wish subjects and themes with sex, race/ethnicity, insurance status, and age.

A total of 119 consecutive adolescents aged 11–14 years completed GAPS questionnaires during the specified study period. Of these, 96 adolescents provided at least 1 answer to the question, “If you could have three wishes come true, what would they be?” There were no differences in the demographic characteristics of adolescents who answered this question versus those who did not. The sample was sociodemographically diverse; less than half (42%) of the study participants were white, 28% were black, and 24% were Hispanic (See Table 1). Over two-thirds (69%) of study participants had Medicaid insurance, 18% had no insurance at the time of the study, 3% had Tricare (military) insurance, and 10% had private insurance.

A total of 269 wishes were provided: 83 adolescents shared 3 wishes each, 7 adolescents shared 2 wishes each, and 6 adolescents shared 1 wish each. Over half of study participants (57%) expressed wishes only for themselves; 5% expressed wishes only for others; and 34% expressed wishes for both themselves and others. Almost twice as many female as male respondents wished for something for others (54% versus 31%; P = .02). No significant association was found between respondent age and wish theme.

Table 2 lists the most common wish themes and specific examples of each theme. Adolescents most often wished for money or other material goods; wishes for the world, wishes for family, and wishes for athletic or school success were also common. Girls were more likely than boys to have family-oriented wish themes (27% versus 10%; P = .04), and girls trended toward more emotion-oriented wishes (15% versus 4%; P = .08). Boys were more likely to wish for success (17% versus 4%; P = .05). Almost half (45%) of adolescents with private insurance wished for something good for the world, such as “world peace,” compared with only 12% of those with Medicaid (P = .01). No other statistically significant differences were identified for race/ethnicity, age, or insurance type.

Wishes varied considerably across the sample and even across the 3 wishes provided by a single respondent. Wishes ranged from predictable and hypothesized desires, such as wealth and athleticism, to more poignant wishes, such as “to have papers for my parents to pass the border.” The variation and insightful responses that adolescents provided reinforce the value of open-ended questionnaires in health care. Some of the answers to the “3 wishes” question have direct connection to the health encounter (eg, “to not have asthma,” “weren’t depressed”), and many other responses demonstrated personal depth and insight that have the potential to contribute to a more well-rounded and individualized assessment of the patient when such information is integrated with clinical history and other data. For example, the wish “to be skinny” could be the beginning of a motivational interviewing session about a healthier lifestyle, or it could be the first clue to an eating disorder. Although closed-ended questions on GAPS surveys have been shown to increase detection of health-risk behaviors, open-ended questions that give adolescents the opportunity to communicate about their socioemotional health may yield information that could not be obtained otherwise. The results of this study demonstrate that adolescence is a dynamic phase of life that is often best explained by adolescents in their own words [14].

In terms of wish subjects and themes, the most notable differences were between boys and girls. This finding was consistent with our hypothesis that respondents’ wishes would demonstrate a sex-based association. Boys were approximately twice as likely to wish for themselves, and they demonstrated objectives that were more oriented toward overall success. In contrast, girls more frequently expressed wishes for others, and they also prioritized family and demonstrated a trend toward emotional wishes. These findings may result from the pressure adolescents feel to conform to the gender roles traditionally expected of them [15], and they match previous findings that showed significant sex-associated differences in core domain prioritization, particularly in terms of career future orientation [12].

Our data supported the hypothesis that respondents’ wishes would be associated with insurance status; specifically, we found that those with private insurance were more likely to wish for something good for the world. This may be explained by Mullen’s theory that those with more privilege have the luxury of thinking about others [13]. It is noteworthy that the 3rd most common wish theme was for something good for the world. Despite the challenges that individual adolescents encounter, many still express altruistic wishes, such as “to end global warming.” Seginer’s 3 core prospective domains for future orientation—higher education, work and career, and marriage and family—did not correspond with the 3 wish themes or domains that were most common in our study [8]. In fact, career or professional wishes were the 8th most common wish theme among respondents in our study. This may be due in part to the more abstract conceptualization elicited by the wording “any wish” in the GAPS question, or it may be attributed to the younger age of respondents.

Our data did not support the hypothesis that respondents’ wishes would be associated with race/ethnicity. Similarly, our data did not support the hypothesis that many wishes would be related to personal appearance. Only 4% of study participants wished for weight-related changes in appearance, and another 5% of adolescents wished for appearance changes that were not related to weight.

An obvious limitation of our study is that our adolescents derive from only 1 university-based clinic. While our patient population was sociodemographically diverse, further investigation of more respondents at multiple sites with broader geographic distribution could yield more generalizable results. Another limitation is that this study did not determine whether older adolescents might have different wish themes or subjects, because older adolescents are not asked the same questions on the GAPS survey. Lastly, we were unable to assess how adolescents’ wishes relate to health or social outcomes. Future research should examine the utility of the “3 wishes” question as a way to identify specific risks for poor outcomes or as a mechanism to identify adolescent resiliency and aspirations.

Our findings demonstrate that there are important differences in the wishes of adolescents based on sex and insurance status. Understanding these different future orientations may provide additional guidance when assessing adolescents’ socioemotional health and may help health care providers to develop behavior interventions. Additionally, adolescents’ wishes can be a valuable but overlooked resource for providers to get to know patients and to determine where solution-based approaches to care and counseling may begin. These findings individualize and further stratify GAPS health-risk behavior assessments and enhance our understanding of how contemporary adolescents perceive themselves and their futures.


We would like to acknowledge the Scientific Collaboration of Overweight and Obesity Prevention and Treatment (SCOOPT) for their help throughout this project.

Financial support. A.C.S was supported in her work on this article by a Building Interdisciplinary Research Careers in Women’s Health career development award (K12 HD01441). The work was also supported by the University of North Carolina’s Clinical and Translational Sciences Award (UL1RR025747).

Potential conflicts of interest. All authors have no relevant conflicts of interest.

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Josh P. Boyd, MD resident in emergency medicine, Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
Michael J. Steiner, MD, MPH associate professor of pediatrics, Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Asheley Cockrell Skinner, PhD associate professor, Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, UNC School of Medicine, University of North Carolina at Chapel Hill; associate professor, Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Tamera Coyne-Beasley, MD, MPH professor of pediatrics, Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, UNC School of Medicine, University of North Carolina at Chapel Hill; professor of medicine, Department of Internal Medicine, Division of General Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Eliana M. Perrin, MD, MPH professor of pediatrics, Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Address correspondence to Dr. Eliana M. Perrin, UNC School of Medicine, 231 MacNider Bldg, 333 S Columbia St, CB #7225, Chapel Hill, NC 27599 (