Adolescents in primary care

The specific health needs of young people are often neglected by primary care as it is believed that adolescents are on the whole a healthy group who rarely present to their general practitioner (GP). “Out of sight” has been “out of mind,” especially given the ever increasing pressures on primary care from other client groups.

The new GP contract in England and Wales has done nothing to mitigate this. Change is needed, however, as teenagers (a) have many health concerns, though they do not always tell their GP about them, and (b) do visit their GPs, on average two to three times a year (with about 70% of all teenagers visiting their GP in any one year). These visits provide opportunities to deal with their health concerns.

Surveys have shown that adolescents are usually happy to discuss health issues with their GP, but 40% say that they find it difficult to see their GP. Over 60% said that they would not know how to register with a GP when they left home, and 71% did not know how to register as a temporary resident. Young people identify confidentiality and access as the most important aspects of primary care for them.

Figure 1.

Reasons that teenagers visit their general practitioner. Data from Churchill et al. Br J Gen Pract 200050: 953-7

A survey of all general practices in Oxfordshire showed that only about 30% of practices had tackled the issue of confidentiality and “user friendly” services for adolescents. These are the issues perceived by teenagers as the greatest barriers to accessing primary care.

Figure 2.

Aspects of primary care identified as most important to young people. Data from Donovan C et al. Br J Gen Pract 199747: 715-8

Table 1.

Barriers to primary care perceived by adolescents

• Concerns about confidentiality

• Geographical barriers (such as difficult to get to by public transport)

• Lack of information about services

• Appointments and opening times unsuitable for young people

• Parental consent not obtainable

• Unfriendly environment and staff

• Language barriers (staff use jargon or overly “adult” language)

Communication with young people

Effective communication is an essential part of any clinical interaction. Yet adolescents and doctors in primary care often feel that communication between these two groups is often highly problematic. Special skills are needed for effective clinical communication with adolescents—skills that require an understanding of cognitive and social development in adolescence and an ability to understand that the social contexts of health behaviours in adolescents can be very different from the contexts for children and adults.

Table 2.

Communicating with young people

• Be clear that you will respect their privacy and confidentiality

• See young people by themselves (time consuming and perhaps difficult to arrange but essential for providing enough confidential space for discussion)

• Be patient (teenagers may need further consultations before they trust you enough)

• Ask open ended questions to draw out information

• Listen more than you talk

• Use terms the adolescent will understand

• Do not be judgmental about their values and opinions unless these place them at clear risk

Particular issues for younger teenagers

• Use concrete language and expect concrete questions and answers

• As teenagers get older and their developmental capacities change, you may need to repeat information provided earlier

• Remember that teenagers often feel a conflict between a desire to be independent and a need to remain dependent on their parents

One of the reasons that health professionals find communication with young people difficult is that this is the only time in clinical practice that they are not dealing direct with adults. When seeing adult patients, health workers communicate with other adults, who share largely similar social values and norms about health, even taking account of cultural differences. When seeing children, they negotiate treatment decisions with the parents, with children's participation being obtained by explanation and parental authority. In contrast, in consultations with adolescents, health professionals are faced with the challenge of communicating with a personality undergoing rapid psychological and social changes who may not share an adult's understanding of society or adult cognitive abilities to decide between treatments in the light of future risks to health.

Randomised controlled trials show, however, that training can improve GPs' communication skills and interactions with young people (Sanci et al, see “Further reading” box). But do not be tempted to seem too “hip” or “cool” in interactions with teenagers. Young people want you to be their doctor, not their friend.

Figure 3.

Improving primary care services

The following ideas show how primary care services for adolescents can be improved. Many of the suggestions can be implemented without a lot of time and resources.

Improve friendliness of the practice

Young people rate friendliness as a high priority for a general practice, so organise a meeting for all practice staff (including the secretaries and receptionists) to look at ways of making the practice more friendly for teenagers. Use role play to identify the issues that might arise for the young person in the practice. Audit what your practice currently provides for young people.

Table 3.

Is your practice “user friendly” for young people?

• Are there posters and leaflets in the waiting room (or toilets) directed at young people?

• Are the leaflets user friendly—glossy, lots of pictures, suitable language?

• Do you provide appropriate information on counselling services (such as Childline) or drug services?

Identify needs of teenage patients

Doing a “needs assessment” of your practice is one of the first steps towards making a practice adolescent friendly. It is relatively easy to work out your practice's adolescent profile using the practice's age and sex register and the knowledge of individual team members.

Table 4.

Doing a needs assessment

• Determine the total number of young people aged 10-18 in the practice (with age bands, by sex)

• Determine the percentage of young people seen in the past year

• Determine the number seen for sensitive issues such as contraceptive advice

• Identify the practice staff who see young people

• Identify the practice staff with special skills or training in working with young people

• Ask your staff about areas of working with young people that they would like more training in

• Ask young people in your practice what improvements they want

Train staff appropriately

All practice staff need to be trained about their interaction with teenagers. In specific areas, such as contraception, staff need to be sensitive to young people's embarrassment—if staff respond inappropriately, teenagers may not return to the practice.

Advertise clearly in the waiting room, for example, that emergency contraception is available, and make sure that the receptionists do not ask embarrassing questions about emergency appointments. If a doctor is unwilling to give emergency contraception, make sure that the young person will be directed towards alternative sources of help without being made to feel guilty.

Inform about practice services

Posters about the services that the practice provides for young people are useful so that when they attend for one problem they know that they can get advice on other issues—for example, contraception, depression, and drugs.

Consider also compiling a “practice information” booklet for teenagers. It's also a good idea to write a “birthday letter” to all young people when they become 16 (or earlier), explaining about the practice and pointing out that they may register with their choice of GP when they become 16 and get contraceptive services from any GP willing to offer the service.

Prioritise confidentiality

Adolescents are used to the fact that much of what they say about themselves and the way they behave is not treated as confidential by their family, friends, peers, and teachers.

Contact with the primary healthcare team may be the first time that the concept of confidentiality will be raised. It is essential that the practice conveys a positive message about confidentiality.

Figure 4.

Reassure young people about confidentiality during face to face consultations

It is worth telling young people and their parents how they can a register as a temporary patient

• Use posters such “Here to listen not to tell” (available from Brook, a UK charity providing free and confidential sexual health advice and services for young people aged under 25; www.brook.org.uk)

• Consider displaying the booklet Private and Confidential—Talking to Doctors (available from Brook)

• Every member of the practice needs to understand the confidentiality “code of practice” and be familiar with the “confidentiality toolkit” (available from the Royal College of General Practitioners, tel 020 7581 3232; sales@rcgp.org.uk).

Organise a young persons clinic

These are successful in some practices and not in others, and how well they work usually depends on, for example, the personality of the person running them, the characteristics of the local teenage population, and whether other local general practices join in.

Table 5.

Issues in setting up a young persons clinic

• It takes time not only for teenagers to find out about them but also to have confidence in them

• The timing needs to be convenient for teenagers—that is, immediately after school

• Consider running the clinic with the school nurse in the school setting or in other less medical community settings

• Make the environment teenage friendly—ask teenagers how this can be done

Involve parents

During the teenage years parents still continue to be the main providers, carers, and sources of health information to teenagers. This contribution by parents needs to be supported and respected. Provide information for parents about the practice's facilities for teenagers and other resources (on, for example, depression, drugs, and eating disorders). Make sure that parents know how to tell their teenagers about contraception (including emergency contraception). Discuss with young people the advantages of involving their parents in sexually related decisions.

Figure 5.

Support the teenager, whatever decision she makes about her pregnancy

Support for pregnant teenagers

If a teenager gets pregnant, make sure that they are given support and help in coming to a decision on whether to continue with the pregnancy or have a termination—without indulging in moral attitudes.

If they want to continue with the pregnancy try to get them to involve their parents and put them in contact with supporting agencies, including the health visitor. If they decide to have a termination arrange for a rapid referral. If you are against a termination, ensure that the young person is not made to feel guilty and arrange for them to see another doctor immediately.

Advise young men, too

It is important to remember young men as well as women, so let them know they are also welcome at your practice. In advertising contraceptive services, direct the information at both boys and girls.

Consider providing free condoms and advising about emergency contraception and sexually transmitted infections. Try putting up posters in your waiting room that are aimed directly at young men. Run clinics specifically for young men, although these may work best in a community centre rather than in your clinic.

It is a good idea to advertise to adolescents what sources of help are available to them locally, outside the practice services. They need to know about, for example, young people's clinics (including Brook), family planning clinics, other general practices, accident and emergency departments, and condom machines in lavatories