Family Practice Vol. 17, No. 4, 305-308
© Oxford University Press 2000
Health services can be cool: partnership with adolescents in primary care
Health Services Research Group, Faculty of Health and Social Care, The Robert Gordon University, Kepplestone, Queens Road, Aberdeen AB15 4PH, UK.
Rosemary Chesson, Health Services Research Group, Faculty of Health and Social Care, The Robert Gordon University, Kepplestone, Queens Road, Aberdeen AB15 4PH, UK.
Milne AC and Chesson R. Health services can be cool: partnership with adolescents in primary care. Family Practice 2000; 17: 305–308.
Received 13 August 1999; Revised 17 January 2000; Accepted 13 March 2000.
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Abstract |
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 Top Abstract IntroductionAdolescent health needsHealth services for adolescentsThe views of young...Strategies for developing a...Developing a co-ordinated multi...ConclusionReferences |
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Young people's health is giving rise to increasing concern. However, despite recent government emphasis on patient involvement and partnership, little discussion has occurred concerning how this may be achieved with younger age groups in primary care. Here we outline issues relating to adolescents' health and characteristics of current provision. These are considered in the context of innovative services that have incorporated adolescents' views. Finally, we discuss the challenge of establishing a partnership with adolescents and propose strategies for achieving this.
Keywords. Adolescents, ambulatory services, communication, doctor-patient relationship, health care, participation.
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Introduction |
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TopAbstractIntroductionAdolescent health needsHealth services for adolescentsThe views of young...Strategies for developing a...Developing a co-ordinated multi...ConclusionReferences |
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Few health care professionals would dispute the need for partnership with patients. ‘Partnership’, however, includes patients' involvement in health care planning, policy and priority setting as well as participation in decision making about their own treatment in the surgery. Neither is easily achieved. Yet there has been little discussion of partnership with adolescents in primary care, even though their health gives rise to growing concern, and there is under-use of services. Recent government emphasis on patient involvement and choice highlights the need to work with young people. Clearly, contact at this stage is crucial, in terms of both helping to establish patterns of healthy living and appropriate service use.
Here we discuss adolescent health needs, current trends in young people's use of services, teenagers' involvement in the planning of provision and strategies for developing a partnership with adolescents. Finally, we examine the desirability of a co-ordinated health strategy for adolescents, which builds on alliances between health, education and social work.
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Adolescent health needs |
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TopAbstractIntroductionAdolescent health needsHealth services for adolescentsThe views of young...Strategies for developing a...Developing a co-ordinated multi...ConclusionReferences |
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The need to improve adolescent physical and mental health is widely acknowledged. There is a rising incidence of diabetes and asthma, and mortality rates as a result of accident and injury are on the increase. Emotional disorders may be present in 20% of adolescents, and an estimated 2–8% of young people experience major depression in mid-adolescence.1 The suicide rate for young men has nearly doubled since 1975.2 Teenage sexual health deteriorated in England and Wales between 1995 and 1996, with a substantial rise in sexually transmitted diseases among 16–19 year olds. During the same period in England and Wales, terminations increased by 14.5% for the under 16s and 12.5% among 16–19 year olds. High rates of teenager pregnancy not only persist, but there was a 6.7% increase in births among young women in their sixteenth year.3
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Health services for adolescents |
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TopAbstractIntroductionAdolescent health needsHealth services for adolescentsThe views of young...Strategies for developing a...Developing a co-ordinated multi...ConclusionReferences |
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In the provision of services, a balance must be found between providing clinical services and health promotion activities. Although considerable attention has been paid to the provision of contraception and sexual health services, long-term care of patients with chronic conditions such as asthma and diabetes must not be neglected. Indeed, problems with teenage adherence have been highlighted and coping strategies have been found to differ among young men and women with chronic illness.4
For many years, the Royal College of General Practitioners (RCGP) has recognized that adolescents have needs which are not being met adequately within primary care. A survey of 
4000 young people aged 15–16 years found that 53% reported problems with GP consultations. These included embarrassment, difficulty getting a ‘quick’ appointment and an unsympathetic doctor.5 A recent study of practice nurses found that they were relatively uncomfortable discussing issues of a psychosocial nature such as bullying, depression, safe sex and drug use.6 Teenage clinics have been developed within some practices, but attendance rates range between 77 and 60%8 and may be lower in more deprived areas.7 However, service usage by teenagers tends to be fragmented and can occur outside of general practice, for instance in family planning clinics, schools and student health centres, so that it may be difficult to obtain a comprehensive picture of service usage.
Adolescents may consult less frequently than older children and younger adults.9 It has been reported recently that 9.1% of physician visits in the USA are made by adolescents, although this age group (11–21 years) represents 15.4% of the population.10 Also found was a notable decline in male visits between middle and late adolescence.
In the UK, when adolescents do use services, Jacobson et al. have shown that GPs spend ~20% less time with them.11 Primary care physicians in the USA have noted consistently that inadequate time is a deterrent to the provision of preventive services, particularly concerning adolescents.12 This may also relate to poor understanding of their special problems, language and sub-culture. Melville suggests that teenagers often have a hidden agenda behind apparently physical symptoms.13 In one study, 81% of teenagers felt that GPs should know more about their age group in general terms.14 GP attitude has also been identified as adversely affecting decisions about obtaining contraceptives.15
Defining the most appropriate extent of parental involvement in adolescent health care is one of the most difficult and challenging issues for GPs. Sixty percent of 16 year olds consult with a parent,16 and in general most teenagers turn initially to parents for advice on health. Teenagers consistently report anxiety regarding confidentiality, and 25–50% continue to believe that doctors have to tell parents about requests for contraception,17 despite the Gillick judgement which established that children under 16 years could give legally effective consent to medical treatment independently of their parents' wishes, provided they had sufficient understanding and intelligence. However, it must be acknowledged that different levels of maturity and willingness to accept responsibility occur even within young people of the same chronological age, and gender differences are also important.18
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The views of young people |
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Only recently have teenagers' views on health care in general, and contraceptive services in particular, been obtained by talking to them. The Children Act (1989), however, established the need to seek their opinions. The School Health Service has, in planning services, only recently placed an emphasis on working more closely with young people and report that they express a desire to run their own projects and want to become more involved. In particular, participation has been highlighted as important to teenagers in relation to sex education and sexual health education.19
Schemes were initiated in the 1990s which demonstrate that adolescents can and are willing to participate in developing services. An example is the Angus Young People's Project20 where young people led discussions on the issues and difficulties they faced accessing family planning services. This resulted in drop-in clinics, run by community nurses and supported by GPs, being provided. The appointment of a project worker allowed pupils to develop other initiatives including a ‘Young People's Charter’ and the evaluation of available health services. A further example is The Flower Estate Project based on a Sheffield estate, with high levels of poverty. An initial survey revealed that 59% of those under 16 years old worried about their health. In response, workshops were facilitated by health care professionals. Topics suggested by young people were diverse and included healthy eating, stress management and first-aid.21
Although peer-led initiatives are more common in the USA, there are recent examples in the UK relating to the need to address the problems of drug use, bullying, teenage pregnancy and sexually transmitted diseases. It is widely believed that peer-led teaching may be more effective in term of changing behaviour than traditional didactic methods.22
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Strategies for developing a partnership |
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TopAbstractIntroductionAdolescent health needsHealth services for adolescentsThe views of young...Strategies for developing a...Developing a co-ordinated multi...ConclusionReferences |
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Listening and engaging teenagers
Efforts to listen to and consult teenagers need to be extended. Young people may not welcome unsolicited health advice, and means need to be developed which enable and support teenagers to identify their needs and seek appropriate help at the appropriate time. The special needs of some adolescents, such as young carers, ‘looked after children’ and those with chronic illness, will only be met if there is awareness of their perceptions of their health and health-promoting behaviour, and the acceptability of interventions. This can only be known through dialogue. Adolescents can be involved in identifying gaps in service provision, and in the development of services, standards and evaluations.
Encouraging adolescents to accept responsibility for their own health
Adolescence is a developmental stage with unique biological and social characteristics. It has been argued that the behavioural problems which peak in the teenage years often involve ‘exaggerated and unresolved versions of the ordinary trials and tribulations of adolescence’.23 The fact that during adolescence there is a shift from accepting externally imposed rules and boundaries to their being self-set has significant implications for health-promoting behaviour as well as health care.
Flekkoy and Kaufman24 suggest that in modern societies the goal of becoming a totally responsible and independent adult can be very unclear as many people are not economically or socially independent until their mid-twenties. Failure to engage young people in health care decision making has not been helpful in promoting responsibility. Nagel wrote in 1987 "The process of participation itself changes participants by developing in them new values, attitudes, skills, knowledge and beliefs . . . an enhanced sense of ones own individual worth and an intensified identification with ones own community"25 (our emphasis). However, currently adolescent health needs are defined by policy makers and providers, with little input from teenagers themselves.
Increasing awareness and training of health professionals
In general, little specific training has been provided for health professionals regarding adolescents at either the undergraduate or post-graduate level. For example, in a recent study, only a small proportion of nurses had received training in relation to teenage health care.6 In particular, health care professionals need to be: (i) more aware of the pressures on adolescents, for example regarding examinations, difficulties with parents and peer relationships, finance and employment; (ii) better at identifying teenagers' own agendas; (iii) more aware of the ‘at risk’ teenage population; (iv) more confident in dealing with adolescent health issues; and (v) more proactive in reaching out to adolescents. Disequilibrium regarding knowledge and status are obstacles regarding partnership with older patients,26 and these are thrown into even sharper relief with adolescents. Teenagers may underestimate the value of experience while adults may underestimate teenagers' ability to resolve their own problems.23
Including adolescent provision in the practice plan
The RCGP has recommended that practices should have a clear policy for adolescent care. Anecdotal evidence would suggest that this is seldom the case. Thought needs to be given to how waiting and consulting rooms may be made more teenage friendly through, for instance, designated areas. With the development of Primary Care Groups in England and Wales and Local Health Care Co-operatives in Scotland, an excellent opportunity exists for a practice team to develop teenage clinics, and to be trained in teenage health care. Specialist knowledge and resources could be exploited through outreach work in other practices and liaison with other agencies.
Developing guidelines
Recent guidelines for adolescent primary care in the USA such as Bright Futures27 offer a comprehensive and dynamic framework for the delivery of services, specifying different strategies at ages 11–14, 15–17 and 18–21 years. Important changes during the course of adolescence lead to differences in the health services required and sought. Ziv et al. in the USA advocate the design of service strategies that target age cohorts within adolescence.10 However, care may be needed as it is difficult to tailor services to the needs of adolescents since they are not a homogeneous group.
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Developing a co-ordinated multi-agency strategy |
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TopAbstractIntroductionAdolescent health needsHealth services for adolescentsThe views of young...Strategies for developing a...Developing a co-ordinated multi...ConclusionReferences |
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Although McKee recently has highlighted the poor record of the UK compared with the rest of Europe regarding sexual health, drug use, alcohol consumption and smoking rates, and emphasized the links between poverty, low educational achievement and health,28 there are few formal local initiatives which co-ordinate the work of different agencies regarding teenage health. However, inter-agency collaboration has been called for regarding children's health in general29 and, in particular, with respect to bullying.30
The boundaries between health, education and leisure (exercise was a second ranked target in Towards a Healthier Scotland31) need to be less rigid so that initiatives can be better co-ordinated. Health professionals need to consider working outside traditional settings, developing their roles as advocates or facilitators of community health projects and encouraging community involvement in health and well-being, for example through the development of healthy living centres. These, together with healthy schools, were seen in Our Healthier Nation as an important means of raising awareness on issues such as diet, smoking, drinking, drug misuse and physical activity. It is clear that new and radical initiatives are needed if the targets set in The Health of the Nation are to be achieved between the years 2000 and 2005. These include reductions in the pregnancy rate of under 16 year olds by 50%, lowering the overall suicide rate by 15% and lowering the smoking rates of 11–15 year olds by 33%. A multi-agency strategy with a clear policy for adolescent health care, therefore, is urgently needed.
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Conclusion |
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TopAbstractIntroductionAdolescent health needsHealth services for adolescentsThe views of young...Strategies for developing a...Developing a co-ordinated multi...ConclusionReferences |
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Despite the opportunities to improve the long-term health of the population which adolescent health care offers, the primary care team has failed to target this group at practice level. Given recent structural changes, it is timely to consider how general practice can address this neglect. This will require engaging with young people, imagination and a willingness to take risks!
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Acknowledgments |
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We are grateful to Drs Hart and Welsh for their helpful comments on an earlier draft of this paper.
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References |
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  A. Hine and P. Oakeshott Health services can be cool: partnership with adolescents in primary Care Fam. Pract., August 1, 2001; 18(4): 462 - 462. [Full Text] [PDF]
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