Global adolescent health: is there a role for general practice?

Young people are a nation’s greatest asset for growth, prosperity, innovation, and current and future workforce and social support: it makes sense to invest in their health. The 21st century heralds the largest global population of young people ever previously known with a total of 1.8 billion individuals aged 10–24 years, 90% of whom live in low-income countries.¹ Young people represent more than one-third of the population in low-income countries, and one-sixth to one-fifth of the population in high-income countries such as the UK. Yet, until recently the health needs of young people have been poorly understood and marginalised. The first WHO/UNFPA/UNICEF report on programming for adolescent health and development was issued less than 20 years ago.¹

The need for a global focus on young people’s health is evidenced by a landmark study of 50-year global mortality trends showing that mortality in young people aged 15–24 years is now higher than in children aged 1–4 years, with mortality of young males in this age group, two- to threefold higher than in the first decade of life.² Furthermore, the major causes of morbidity and mortality in adolescence are largely preventable such as transport injuries, violence, suicide, rising rates of mental health issues, substance abuse, sexually transmitted infections including HIV, and precancerous lesions. Prevention and early intervention have thus dominated the recommended healthcare responses to these health risks.

The World Health Organization definition of adolescence refers to young people between the ages of 10 and 19 years. However, in this article we define adolescence to be synonymous with young people, encompassing the ages of 10–24 years, because the biological, psychological, and social role transitions of adolescence affect the health of young people throughout this age range. Many of the risk factors for disease in adulthood begin in adolescence; for example, initiation of tobacco and substance use, unprotected sex, and first episodes of mental health disorders.

A FRAMEWORK FOR ACTION

The recently published second Lancet series on global adolescent health highlights the burden of disease in this age group and proposes a framework for action.^3,4–7 A key theme is centre-staging adolescence within a ‘life-course approach,’ as a foundation for future health.³ Early development, social determinants of health and risk, and protective factors, which translate into health-related behaviours, are key elements in the conceptual framework of adolescence, articulated by Sawyer and colleagues.³

The neural plasticity of the adolescent brain from early puberty, and the emerging autonomy of adolescence, also highlight potential for the health promoting interventions in this period of life.

The process of adolescence remains acutely sensitive to sociocultural norms and to the local context. WHO defines these social determinants of health as the conditions in which people are born, grow, live, work, and age. For young people they translate into the families (or institutions) in which they are raised, the communities in which they live, and the opportunities for study, work, and recreation which are available; against the backdrop of the national stage shaped by the decisions governments make.

WHAT ROLE FOR GENERAL PRACTICE?

Caring for and promoting the health of individuals across their life course is a key characteristic of primary care and also recently found to be a critical element in shaping the degree of engagement by a GP with adolescent patients.⁸

If distress, disease, and death are preventable in this age group then primary care is best placed to respond to this need. Barbara Starfield (and others) have demonstrated that a strong primary care infrastructure and the provision of ‘a medical home’ offer the best assurance for equitable and quality care with improved health outcomes.⁹ The approach taken is under-pinned by generalism, the cornerstone to good general practice which supports a holistic, biographical–biological approach to medicine and eschews a vertical-disease orientated approach, whereby healthcare problems are compartmentalised into silos based on the body systems. Young people’s health problems usually co-occur with, and are impacted by, their social and emotional needs, hence validating the generalist perspective as best supporting good adolescent health care.

GPs can play an important role in addressing social determinants of health through advocacy and in calling for structural changes that promote social justice and address inequities. Tudor-Hart is a luminary example of what can be achieved¹⁰ and his legacy is evident in the important work currently being undertaken in Scotland by the ‘GPs at the Deep End’; recently collated in a report examining the impact of austerity on patients and practices in deeply disadvantaged areas.¹¹

YOUNG PEOPLES’ ENGAGEMENT WITH GENERAL PRACTICE

It is a common myth that young people are reluctant users of general practice. Data from a variety of high income countries show that young people are regular users of healthcare services. The UK QResearch® database provides consistent data that young people consult at a minimum of 2 consultations per annum with an increase to an average of 4.5 per annum by young women (15–19 years), and a further increase to 5.5 per annum among 20–24 year olds.¹² A recent UK school-based study found that around half of year 10 pupils (14–15 years) had consulted their GP in the previous 3 months. Data from international sources supports a base line minimum of at least 1 consultation per annum, including for young people who engage in health compromising behaviours such as drug use or delinquency.

However, young peoples’ experiences of consulting with primary care practitioners are often mixed. Consultations tend to be shorter despite the complexity of consulting with young people, which may lead to dissatisfaction and a tendency to ask for advice from friends and family in equal measures with their GP.

Young people often describe a reluctance to confide psychological health problems in their GP and hold a belief that GPs are not interested or skilled in discussing emotional health. This situation creates a further barrier to appropriate care since those young people who do seek help in general practice often represent a sub-group with greater needs. Studies from the UK and Australia demonstrate that a higher proportion of young people who consult with their GP have emotional distress secondary to underlying psychological problems than in the general population. This tends only to be detected by the GP if severe, raised by the young person themselves, or associated with a previous history of mental health problems.

Identification by GPs is favoured by continuity of care, a feature often absent from the relationship young people have with healthcare services. Furthermore, young people whose health needs are greatest because of a history of being in care, being homeless, in the youth justice system, or coming from a cultural minority group often have more difficulty having their health needs recognised.

Concerns around the confidentiality of any health service, not only primary care, are a major barrier for young people who fear their intimate disclosures will be shared without their consent and relayed back to parents.

SUPPORT FOR YOUTH FRIENDLY PRIMARY CARE SERVICES

Efforts to remove the barriers young people face in accessing care have been investigated using a broad range of methodologies and summarised in a review.¹³ An increasing number of tools are available which support youth-friendly primary care and encourage GPs to make changes that seek to accommodate the developmental needs of young people. Ten years ago WHO produced An Agenda for Change which makes a compelling case for high quality health care while foregrounding friendliness in delivering care.¹⁴ A smiling, welcoming face on arrival can make all the difference to a young person accessing health care and will trump many other features.

The five key features articulated in‘ An Agenda for Change — accessibility, acceptability, equity, appropriateness, and effectiveness — have been translated into a UK tool-kit known as the ‘You’re welcome’ criteria¹⁵ which advise on eight areas of practice. The criteria were developed with input from the Royal College of General Practitioners (RCGP) Adolescent Health Group and are now available as a check list for practices wanting to rate the degree of youth-friendliness of their surgery. The RCGP also makes freely available a web-based resource informing GPs and practice staff about the issues associated with confidentiality and offers clinical scenarios to promote practice-based learning.¹⁶

Other UK GP-developed resources include a website, developed by Ann McPherson and Aiden Macfarlane, which young people can use to both find out information and pose questions anonymously (www.teenagehealthfreak.org); and the e-learning adolescent health project.¹⁷ The Association of Young People’s Health is a key partner with the RCGP Adolescent Health Group and both are focused on making general practice more youth friendly.

Small scale pilot studies conducted in general practice indicate that the use of mobile phone technology may be a welcome step forward in the management of young people with health conditions.

Elsewhere, colleagues in Australia have produced a GP resource kit¹⁸ which comprehensively addresses the developmental profile of adolescence and provides detailed guidance aimed at enhancing consulting skills and promoting systemic changes in practices to encourage young people to use their services. At the European level, the award winning EuTEACH programme, offers ‘a training package for professionals interested in improving adolescent health care in their countries’.¹⁹

EVIDENCE FOR THE ROLE OF GENERAL PRACTICE

It would be helpful, in the face of juxtaposing arguments for the role of general practice in addressing adolescent health burdens, to have some firm evidence of effectiveness. On the one hand the generalist model of general practice places it in a prime position to address the health needs of adolescents. On the other hand we have some clearly articulated barriers that many adolescents face in accessing primary care.

To date however, evidence for the impact of primary care approaches on adolescent health is only newly emerging. One problem lies in the aggregation of routinely collected local and national morbidity data. Data from 0–16 year olds (or 0–14 year olds) are aggregated in one group and 17–64 year olds (15–64 year olds) in another, hence rendering the health status or health care access measures for adolescents and young adults invisible.⁵ Furthermore, primary care access is not routinely measured in large national epidemiological surveys of young people’s health and wellbeing and, therefore, we have little data on the patterns of access globally nor the relationship of these patterns with other health indicators.⁵

Tylee et al concluded in 2007 that our understanding of the barriers and opportunities to providing youth-friendly primary care-based services had not been translated into practice and, as such, we lacked an evidence base to demonstrate the benefits on health of providing youth-friendly services.¹³ Five years on, promising, yet still insufficient, data have been added to the literature.

WHAT IS NEEDED TO ENSURE A STRONG GENERAL PRACTICE RESPONSE TO THE NEEDS OF YOUNG PEOPLE?

Tool-kits and guidelines offer a framework for all general practices to re-orientate services to better meet the health needs of young people but cannot act alone as a catalyst for change. If the current status quo, which can fail young people, is to be challenged we need to see strong leadership supporting a change in practice on a number of levels.

First we need to prepare future GPs around the world to respond confidently, compassionately, and effectively to young peoples’ health needs. The concept of adolescence, as presented through the life-course model,⁸ needs to be centre-staged in medical education and a cross-cutting agenda adopted which acknowledges the impact of the social determinants of health on adolescent development. This needs to begin within undergraduate and training programmes and be vertically integrated through vocational training and continuing professional development programmes (CPD) around the world. Many countries, such as Australia and Switzerland, already address this in medical school and specialist and general practice training programmes.

The recently published report of the Children and Young Peoples’ Health Outcomes Forum (England) offers a clear steer on the changes that need to be made at a national level including the recommendation that all GPs who care for children and young people should have training in children and young people’s health and appropriately validated CPD.²⁰ Enhanced education and training for other members of the practice team, such as receptionists and nurse practitioners, is also key to making general practice more youth-friendly.¹⁸

Second, these educational initiatives need to be buttressed by rigorous research which will inform on the most youth-friendly, effective, and cost-efficient models for designing and delivering care.

Third, collaborations between public health and primary care deserve to be strengthened, as GPs are ideally placed to reinforce and individualise health messages young people receive through the media and in school. Vulnerable adolescents would also benefit if the sectors including health, education, welfare, and justice were better linked in their response to address not only health issues but the other social determinants of health.

Changes at a policy level must facilitate this cross-sectoral linkage and also provide funding models which will support effective general practice for young people who often need longer times in consultation for the practitioner to better detect and deal with multiple problems of a biopsychosocial nature. Even in countries where youth specific primary care services exist, the need for routine generalist primary care services to be more youth-friendly and orientated more toward prevention, detection, and early intervention will not be removed because these services are more widespread. They are embedded in local community settings and will see the vast majority of young people over time. GPs remain in an ideal position for the early detection of, and intervention with health risk, with the appropriate training and support.

Finally, as recommended by the Report of the Children and Young People’s Health Outcome Forum, all data about children and young people should be presented in 5-year bands from 0–24 years to clarify the developmental transitions in childhood and adolescence and allow data to be compared internationally, mirroring data collection patterns as used by WHO.

YOUNG PEOPLES’ VOICE AND PARTICIPATION

Underpinning all proposed changes is the fundamental requirement to hear from young people themselves, and to actively incorporate their views and experiences to shape and inform the design and delivery of services. Adolescents can be powerful agents of personal change and community development³ and their inclusion in the education and training of healthcare professionals and the reform of services is essential. Through the increasing capacity of social media to initiate change, witnessed in the recent Arab Spring uprising, and in the use of digital mobile technology itself, young people have an immense potential to catalyse change and challenge the status quo. The primary care community needs to harness this energy and work with young people to develop services fit for purpose.

Today’s young people are the parents, healthcare providers, policy makers, and leaders of the future. Time spent in developing youth-friendly general practice is to everyone’s advantage and will promote social justice in an epoch which has ill-served young people for too long.

Provenance

Commissioned; peer reviewed.