Toward youth friendly services: a survey of young people in primary care

Adolescent Healthcare Access: A Qualitative Study of Provider Perspectives

INTRODUCTION

Adolescent access to quality healthcare is key to prevention and early intervention for health risk behaviors. This paper provides a healthcare provider perspective on barriers and facilitators to youth accessing care.

METHODS

Five focus groups were conducted from November to December 2020 with providers from a variety of healthcare settings. Participants were asked to describe their respective adolescent patient populations, adolescent-specific health concerns, and organizational accommodations specific for youth services. Transcripts were analyzed using Inductive Thematic Analysis and themes were grouped using a social-ecological framework.

RESULTS

At an individual level, providers noted that an adolescent's knowledge and ability to navigate services varied greatly across settings. Providers identified provider trust and parent/guardian support as key interpersonal factors that support adolescents' access to services. Organizational factors included bureaucratic barriers and the clinic's reputation among youth. Community factors centered on mistrust within healthcare systems and stigmatization of seeking certain types of services. Participants also described how state-level policies influence parent/guardian consent requirements, which can limit adolescents' access to care.

CONCLUSION

Adolescent access to and utilization of healthcare in the United States is a complex problem requiring systems-level change. Healthcare organizations and providers have the opportunity and capacity to positively influence adolescents' healthcare access and experiences, however a lack of standardized, clinic-level priorities and guidelines can limit adolescent-centered care.

Reasons for Encounters and Comorbidities in Adolescents with Intellectual Disability in General Practice: A Retrospective Analysis of Data from the Ask Study

Adolescents with intellectual disability have substantial health needs. This retrospective analysis of data from the Ask Study describes reasons for primary care encounters and the prevalence and incidence of chronic physical and mental conditions among a cohort of community-dwelling adolescents with intellectual disability. Participants attended secondary schools in southern Queensland, Australia. Primary care data were extracted from primary care records. Demographic and health information was collected using carer-completed questionnaires. Reasons for primary care encounters, disease prevalence at age 16 years, and disease incidence through adolescence were reported. Data were obtained for 432 adolescents with intellectual disability (median follow-up: 4.1 years). Skin problems (29.4 per 100 encounters) were the most common reason patients presented for primary care, followed by psychological and behavioural problems (14.4 per 100 encounters) and musculoskeletal problems (13.8 per 100 encounters). Conditions with the highest prevalence were autism spectrum disorder (18.6%) and asthma (18.1%). The prevalence of epilepsy, visual impairment, and cerebral palsy were 14.7, 11.1, and 8.0%, respectively. Gastroesophageal reflux had the highest incidence (9.4 cases per 1000 person-years). Adolescents with intellectual disability have significant healthcare needs, which general practitioners need to be aware of and address. Study findings should inform the development of training programs for general practitioners.

Young People Awareness of Sexually Transmitted Diseases and Contraception: A Portuguese Population-Based Cross-Sectional Study

Adolescents and young adults are an important target concerning reducing health-risk behavior adoption, including sexual health. Studying their knowledge concerning sexuality and their main counsellors, can be an important step in targeting an updated health promotion approach. This study characterized adolescents and young adults' knowledge and attitudes about sexually transmitted diseases (STDs), and contraception, prospecting for their main trusted counseling sources. We conducted a cross-sectional, population-based, self-report survey of 746 individuals aged between 14 and 24 years from Paredes, Portugal. The questionnaire included many dimensions, as demographic characteristics, youth behavior, currently sexually active status, main counselors concerning health topics, awareness, and knowledge about STDs and contraception. Mean age of the participants was 18.3 years, 50.5% of them had started their sexual activity. Males present themselves as more sexually active, starting earlier, and have more sexual partners than females. Participants reported an adequate knowledge perception about STDs and contraception methods, however we found different patterns on specific STDs and contraceptive methods, according to gender, age, and sexually active status. Our results help design specific interventions to reach youth, community, and healthcare providers, pointing out the value of bringing people to the center of health policies.

'Demystifying' the encounter with adolescent patients: a qualitative study on medical students' experiences and perspectives during training with adolescent simulated patients

Training with adolescent simulated patients (ASP) is increasingly recognized as an effective form of teaching interviewing skills with adolescent patients. Beyond the acknowledged effectiveness and satisfaction of training with ASP, little is known on medical students' actual experience and specific learning needs related to simulated encounters with ASP, as well as factors influencing their learning experience.The aim of this study was an in-depth exploration of medical students' perspectives about training with ASP.Using a qualitative design with grounded theory methods, we conducted in-field observation of training sessions with ASP and individual interviews with eighteen fourth-year medical students participating in training.When provided with an actual experience in a simulated setting, students go through a process of anticipating then modulating the challenge of the encounter with an adolescent patient. This challenge is influenced and modulated within 3 main dimensions: preconceptions about adolescents, level of experience with adolescent patients and professional distance. This process is also influenced by how students perceive and cope with the educational setting.Training with ASP, as a first concrete experience of an adolescent consultation, is an opportunity to address important aspects of students' attitudes towards adolescent patients such as students' preconceptions, personal experiences and feelings that could influence the doctor-patient relationship later on. Training should focus on ways to reflect upon and handle such attitudes and the emotional resonance experienced by medical students.

Young peoples' perspectives about care in a youth-friendly general practice

INTRODUCTION Youth health outcomes are poor in New Zealand and have a life-long impact on individuals, whānau (family) and society. Little is known about how young people view their experiences of general practice care despite it being the most common place to access health care. AIM This study sought to explore young peoples' experiences of care in a selected, youth-friendly general practice. METHODS In-depth individual interviews with six young people. RESULTS Four themes were identified from young peoples' narratives in relation to their experiences of general practice care: going to the doctor is not easy for a young person; the attributes of staff make all the difference; specific youth-friendly consultation practices help young people; and a youth-friendly physical environment can help young people access services and feel safe. DISCUSSION Even though the study general practice had explicitly instituted youth-friendly initiatives, including offering no-charge consultations and specialist staff members, young people still described considerable barriers to attendance. Many barriers are practice-based and could be modified by staff training, provision of further youth care staff roles and consideration of environmental changes. Other barriers such as waiving prescription costs need government funding.

Results of a National Text Message Poll of Youth: Perspectives on Primary Care

PURPOSE

There is a significant interest in improving adolescent access to primary care, yet limited attempts to incorporate youth feedback within these efforts. The purpose of this study was to describe the experiences related to primary care among a large national sample of adolescents to improve patient-centered care.

METHODS

Youth were sent open-ended text message prompts via an ongoing study of 14- to 24-year-olds in the U.S. Text responses were analyzed using qualitative thematic analysis, including descriptive coding, consensus building, and theme development. Secondary quantitative analyses were conducted to determine differences by demographics.

RESULTS

Of 1,123 eligible participants, 789 (70.2%) responded to at least one prompt. Four themes were developed: (1) youth recognized the importance of primary care, but barriers exist that limited their utilization; (2) youth felt that improving convenience would increase the use of primary care; (3) youth were unsure how to transition between primary care settings; and (4) feeling respected was essential to youth having positive experiences in a primary care health care setting. Older youth and those identifying as female, nonbinary, or transgender were more likely to report previous bad experiences with primary care.

CONCLUSIONS

Our findings describe barriers and possible solutions to primary care among youth. Because attitudes toward health and health care are established during adolescence, a transformation is needed to create more patient-centered care that aligns with young people's values and experiences. Thus, primary care providers have the opportunity to positively impact the health of young people today and the adults of the future.

Adolescents' experiences of fluctuating pain in musculoskeletal disorders: a qualitative systematic review and thematic synthesis

BACKGROUND

Adolescents with chronic musculoskeletal pain experience daily fluctuations in pain. Although not all fluctuations are bothersome, pain flares are a distinct type of symptom fluctuation with greater impact. Since literature on the experience of pain flares is non-existent, the aim of this review was to (i) synthesise the qualitative literature on adolescents' experiences of fluctuating pain in musculoskeletal disorders in order to (ii) identify knowledge gaps to inform future research on pain flares.

METHODS

Electronic databases (CINAHL, MEDLINE, EMBASE, PsycINFO), grey literature and reference lists were searched from inception to June 2018 for qualitative studies reporting adolescents' experiences of pain. Comprehensiveness of reporting was assessed using the Consolidated Criteria for Reporting Qualitative Health Research. Studies were analysed using thematic synthesis.

RESULTS

Of the 3787 records identified, 32 studies (n = 536) were included. Principal findings were synthesised under three key themes: 1) symptom experience, 2) disruption and loss, and 3) regaining control. The first theme (symptom experience) describes adolescent's perception and interpretation of pain fluctuations. The second theme (disruption and loss) describes the physical, social and emotional constraints faced as a result of changes in pain. The third theme (regaining control) describes coping strategies used to resist and accommodate unpredictable phases of pain. Each theme was experienced differently depending on adolescents' characteristics such as their developmental status, pain condition, and the duration of the pain experience.

CONCLUSIONS

Adolescents with chronic musculoskeletal pain live with a daily background level of symptoms which frequently fluctuate and are associated with functional and emotional difficulties. It was not clear whether these symptoms and challenges were experienced as part of 'typical' fluctuations in pain, or whether they reflect symptom exacerbations classified as 'flares'. Further research is needed to explore the frequency and characteristics of pain flares, and how they differ from their typical fluctuations in pain. The review also highlights areas relating to the pain experience, symptom management and health service provision that require further exploration to support more personalised, tailored care for adolescents with chronic musculoskeletal pain.

Characterizing pain flares in adolescent inflammatory and non-inflammatory musculoskeletal disorders: A qualitative study using an interpretative phenomenological approach

BACKGROUND

Adolescents with musculoskeletal disorders experience acute exacerbations in pain, colloquially called "pain flares" in adult literature. This study aimed to explore adolescents' lived experience of pain flares, including what pain flares are, why they occur, how they are managed and what lasting effects they have on adolescents.

METHODS

A sample of 10 adolescents diagnosed with juvenile idiopathic arthritis or chronic idiopathic pain syndrome were recruited from a tertiary hospital in the UK. Data were collected using semi-structured interviews and visual aids, and analysed using interpretative phenomenological analysis.

RESULTS

Four broad themes were identified which describe as a journey of change from participants: (a) daily life with pain, where adolescents report a level of pain that is "normal" for them which they can tolerate and continue their daily routines around; (b) pre-flare period, where adolescents begin to notice pain increasing beyond normal levels and employ preventative strategies to reduce the risk of symptoms developing into a flare; (c) flare period, where adolescents describe the symptoms, frequency, duration, impact and their attempts to manage flares; to their (d) post-flare period, where symptoms begin to return to baseline levels and adolescents take actions to regain the level of normality experienced in daily life.

CONCLUSION

This study has identified a number of components of the pain flare experience. Findings show that pain flares are more than an increase in pain intensity; they are multi-layered and require other features to change. These findings help to differentiate pain flares from typical fluctuations in pain.

Excessive substance use screening to encourage behaviour change among young people in primary care: Pilot study in preparation for a randomized trial

INTRODUCTION

Alcohol, cannabis and other substance use affects young people's health. Primary care physicians are encouraged to screen and provide brief interventions for substance use in this population, but implementation is often limited. Pre-consultation self-administered screening may decrease at-risk substance use and could have population-level benefits. A randomized controlled trial is planned to test this hypothesis. The present pilot study's objective was to assess the feasibility of methods for the future trial.

METHODS

The parallel-group randomized controlled pilot trial was undertaken in 6 primary care practices in Geneva, Switzerland, over 2 months. 29 patients aged 15-24 years consulting for any reason were randomly assigned to intervention (substance use screening, n = 14) or control (physical activity questionnaire, n = 15) using computer-generated random number tables. Outcomes were assessed one month later by telephone questionnaire. Physicians, practice staff and outcome assessors were blinded to allocation. The primary outcomes were feasibility of procedures and acceptability to participants, primary care physicians and practice staff.

RESULTS

Of 16 participants reached at follow-up, 3 reported excessive substance use. Methods were acceptable to all participants, especially regarding confidentiality. Three participants were lost due to technical difficulties with the consent form. No major problems with study methods were reported in the practices. 4 practices did not meet recruitment targets.

CONCLUSION

The study procedures proved to be feasible in primary care practices and acceptable to young people who were readily available to participate. The main challenge for the future full-sized trial will be to ensure that recruitment targets can be met.

GP follow-up after first diagnosing psychological problems among adolescents: a nationwide register-based study

BACKGROUND

Psychological problems are common among adolescents. Many GPs consider these problems challenging, even after diagnosis.

AIM

To explore how Norwegian GPs follow-up patients after a first diagnosis of a psychological problem at age 15-16 years.

DESIGN AND SETTING

Nationwide longitudinal, register-based study using claims data for all GPs in the national list patient system, and for adolescents born in 1993 and 1994 (n = 129 499).

METHOD

National databases and registers were used to determine how many adolescents received a first diagnosis of a psychological problem in a GP consultation at age 15 or 16 years. Further consultations, collaborative contacts in primary care, and referrals to secondary care during the year after diagnosis were then identified and used as outcomes in regression analyses to investigate associations with initial diagnosis, parental education, and GP characteristics.

RESULTS

In total, 6809 (5.3%) adolescents received a first diagnosis of a psychological problem in a GP consultation at age 15 or 16 years. Internalising problems constituted 50.5% of initial diagnoses among females and 28.8% among males. Behaviour and attention problems accounted for 21.3% for females and 45.0% for males. In total, 46.6% of females and 39.9% of males had ≥1 follow-up consultation, and 32.8% of females and 27.0% of males were referred to secondary care. GPs reported primary care collaboration for 22.1% of females and 19.1% of males. GPs with larger patient lists had higher referral rates, but collaborated less within primary care. Males with a male GP had more follow-up consultations than males with a female GP.

CONCLUSION

GP follow-up after diagnosing psychological problems among adolescents is limited, but predominantly comprised referrals and some multidisciplinary cooperation. GP follow-up consultations should be studied more thoroughly, and the role of GPs warrants further policy discussions.

GP-diagnosed internalizing and externalizing problems and dropout from secondary school: a cross-sectional study

Background

Dropout from secondary education is a major concern in many Western countries because it is associated with later adverse consequences at the individual and societal level. Efforts have thus been made to identify precursors for dropout. The aim of the study was to examine the risk for not finishing secondary education by age 20 when mental health problems were diagnosed during general practitioner (GP) consultations.

Methods

National registries were linked to assess the association between GP-diagnosed internalizing and externalizing problems from the ages of 15-20 years and school dropout in a sample of 63 970 Norwegians, adjusting for health and social background factors. Relative risks (RR) were estimated by Poisson regression.

Results

Dropout was bivariately related to both internalizing (RR = 2.2 among girls and 1.7 among boys) and externalizing problems (RR = 2.7 for girls and 2.0 for boys), though the associations were somewhat attenuated in the adjusted analyses. After controlling for somatic comorbidity and parent education level, the absolute risk for not fulfilling secondary education by age 20 was 43% among girls and 60% among boys with internalizing problems and approximately 15% points higher with externalizing problems. The highest absolute risk for dropout was found for boys and girls who have both externalizing and internalizing problems. However, with some overlap in the confidence intervals, the added impact of internalizing problems when added to externalizing problems is uncertain.

Conclusions

Intervention for mental health problems by a GP could benefit adolescent education outcomes and mental well-being.

Caring for Lesbian, Gay, Bisexual, Transgender, and Questioning Youth in Inclusive and Affirmative Environments

Lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ) youth may experience interpersonal and structural stigma within the health care environment. This article begins by reviewing special considerations for the care of LGBTQ youth, then turns to systems-level principles underlying inclusive and affirming care. It then examines specific strategies that individual providers can use to provide more patient-centered care, and concludes with a discussion of how clinics and health systems can tailor clinical services to the needs of LGBTQ youth.

Study protocol: Determining what young people with rheumatic disease consider important to research (the Young People's Opinions Underpinning Rheumatology Research - YOURR project)

PLAIN ENGLISH SUMMARY

Involving young people in research about their health is increasingly recognized as being important to make sure that research is focused more on the needs of young people. However, at present, ideas about what should be researched and found out mainly come from researchers and health professionals like doctors and nurses rather than young people. Therefore, in the past, young people's ideas about what should be researched in terms of rheumatic problems have not been explored. In this study, we will talk with groups of young people with rheumatic problems across the UK to explore what they think research into their health should focus on. We will also discuss with young people, if and how, they would like to be involved in shaping research into rheumatic problems. The findings from this work will help make sure that the views of young people with rheumatic problems influence the work of a group of researchers and health professionals who concentrate on rheumatology research. This group is called the Barbara Ansell National Network for Adolescent Rheumatology (BANNAR). A national young person's advisory group will be set up to make sure that the beliefs and ideas of young people with rheumatic disease inform the work of the BANNAR.

ABSTRACT

Background The involvement of people of all ages (including young people) in health-related research is now widely advocated but research priorities are still largely driven by professional agendas, with evidence from the adult literature reporting a mismatch between researcher and patient generated lists of research topics. To date, there have been no studies exploring the research priorities of young people with long term conditions including rheumatic disease. In this study, we will explore young people's beliefs about their research priorities for rheumatic conditions and whether and how young people would like to become involved in the research process. Methods/Design We will hold up to 16 focus group discussions with young people (11-24 years) across England, Northern Ireland, Scotland and Wales. Two age groups will be recruited to the study, 11-15 year olds to represent early and mid-adolescence and 16-24 year olds to reflect late adolescence and emerging adulthood. Focus groups will be as interactive and engaging as possible, using a mixture of statement sorting and a research prioritization exercise to stimulate the discussion. Young people will be recruited via members of the Barbara Ansell National Network for Adolescent Rheumatology (BANNAR) and relevant national charities. Focus groups will be audiotaped and transcribed for analysis. Discussion This project will help ensure full representation from young people with rheumatic diseases in the development of a research strategy for BANNAR and will ultimately inform a young person's led involvement strategy to facilitate the future ethical and meaningful involvement of young people in BANNAR members' future research programmes. In addition, a national young persons' advisory group will be established, the constitution and format of which will be determined by the young people themselves.

Reasons for encounter in young people consulting a family doctor in the French speaking part of Switzerland: a cross sectional study

Background

Knowledge of patient’s reasons for encounter is useful to inform health service planning and health professional education. Our aim was to describe reasons for encounter as stated by an unselected group of young people attending primary care practices in the French-speaking part of Switzerland.

Methods

Consecutive patients aged between 15 and 24 years were recruited as part of the PRISM-Ado trial (n = 594). They completed an anonymous questionnaire in the waiting room, including their main reason for encounter (free text). Reasons for encounter were coded using ICPC-2 classification and analyzed according to sex, age and living in a rural or urban area.

Results

95 % of questionnaires contained valid data about reasons for encounter (n = 567). General and unspecific (A) reasons were the most common in boys (44 %) and girls (42 %), followed by respiratory, musculoskeletal, dermatological and psychological reasons. Psychological reasons were more frequent in girls attending urban practices; musculoskeletal and dermatological reasons were more frequent in rural areas. Sexually transmitted infections or substance use were very rarely stated as a reason for encounter.

Conclusions

This is the first study describing reasons for encounter as stated by young people themselves in primary care in Switzerland. These findings provide useful guidance for family doctors training and health service planning in Europe.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12608000432314.

University students' point of views to facilitators and barriers to sexual and reproductive health services

AIM

The right to health is a universal human right, and this includes sexual and reproductive health services. The aim of this study is to explore the opinions of Iranian university students toward facilitators and barriers to sexual and reproductive health services.

MATERIALS AND METHODS

In 2012, a random sample of 548 university students completed anonymous, self-administered questionnaires. Topics covered the participants' attitudes towards facilitators and barriers to sexual and reproductive health services in personal, interpersonal, and structural domains.

RESULTS

Mean age of participants was 21.57 years and 57.82% were female. The maximum score of facilitators and barriers to sexual and reproductive health services was related to "Young people's participation in sexual and reproductive health services provision" and "Fear of stigmatization", respectively. The results showed that among female university students, the mean score of personal and structural facilitators was significantly higher than the mean score of interpersonal ones (F=12.23, p<0.001). This difference was also reported in barrier factors (F=5.51, p=0.004).

CONCLUSION

Results highlight the roles of policy makers and health service providers in improving accessibility to provided services for young people through the enforcement of facilitators and reduction of barriers, particularly in the areas of personal and structural facilitators focusing on female services.

Increasing access to sexual health care for rural and regional young people: Similarities and differences in the views of young people and service providers

OBJECTIVE

This study aims to describe the views of sexual health service providers on access issues for young people and consider them together with the views of young people themselves.

DESIGN

A cross-sectional mixed-methods study design involving semi-structured interviews with health service providers and an electronic survey with young people.

SETTING

Four towns in rural and regional Queensland, Australia.

PARTICIPANTS

A total of 32 service providers: 9 sexual health nurses, 8 general practitioners, 6 school-based youth health nurses, 5 sexual health educators, 2 Australian Aboriginal health workers and 2 youth workers. There were 391 young people who participated in the Young People's Survey.

MAIN OUTCOME MEASURES

Themes generated from interviews with service providers and quantitative data from young people addressing access to sexual and reproductive health (SRH) services for rural and regional young people.

RESULTS

Service providers frequently identified structural barriers, confidentiality and lack of awareness of SRH services as barriers for young people seeking SRH care. Young people also reported that structural factors such as transport, cost and service operating hours were important; however, they placed greater value on personal attributes of service providers, particularly welcoming and non-judgemental attitudes.

CONCLUSION

Health service policy and training focused on attitudinal qualities of individual service providers may improve access to SRH services for young people. Selective staff recruitment and professional development are important to increase sensitivity to youth issues. Promotion of non-judgemental and confidential care may also improve access for youth.

Development and evaluation of an educational intervention in youth mental health for primary care practitioners

OBJECTIVES

Irish adolescents have one of the highest rates of suicide and self-harm in the European Union. Although primary care has been identified as an opportune environment in which to detect and treat mental health problems in adolescents, lack of training among primary care professionals (PCPs) is a barrier to optimum identification and treatment. We describe the development and evaluation of an educational intervention on youth mental health and substance misuse for PCPs.

METHODS

Thirty general practitioners and other PCPs working in the Mid-West region participated in an educational session on youth-friendly consultations, and identification and treatment of mental ill-health and substance use. Learning objectives were addressed through a presentation, video demonstration, small group discussions, role play, question-and-answer sessions with clinical experts, and an information pack. Following the session, participants completed an evaluation form assessing knowledge gain and usefulness of different components of the session.

RESULTS

A total of 71% of participants were involved in the provision of care to young people and 55% had no previous training in youth mental health or substance abuse. Participants rated knowledge gains as highest with regard to understanding the importance of early intervention, and primary care, in youth mental health. The components rated as most useful were case studies/small group discussion, the 'question-and-answer session' with clinical experts, and peer interaction.

CONCLUSIONS

The educational session outlined in this pilot was feasible and acceptable and may represent an effective way to train professionals to help tackle the current crisis in youth mental health.

Development of youth friendly family medicine services in Bosnia and Herzegovina: protocol for a cluster randomized controlled trial

Background

Young people face many barriers in accessing health services that are responsive to their needs. The World Health Organization has led a call to develop services that address these barriers, i.e. youth-friendly health services. Addressing the needs of young people is one of the priorities of Foundation fami, an organisation working in collaboration with the Swiss Federal Department of Development and Cooperation and Geneva University Hospitals to develop quality family medicine services in Bosnia and Herzegovina. This paper describes the design of a trial to assess the effectiveness of a multifaceted intervention involving family medicine teams (primary care doctors and nurses) to improve the youth-friendliness of family medicine services in Bosnia and Herzegovina.

Methods/Design

This is a stratified cluster randomised trial with a repeated cross-sectional design involving 59 health services in 10 municipalities of the canton of Zenica in Bosnia and Herzegovina. Municipalities were the unit of randomisation: five municipalities were randomised to the intervention arm and five to a wait-list control arm. Family medicine teams in the intervention arm were invited to participate in an interactive training program about youth-friendly service principles and change processes within their service. The primary outcome was the youth-friendliness of the primary care service measured using the YFHS-WHO + questionnaire, a validated tool which young people aged 15 to 24 years complete following a family medicine consultation.

A total of 600 young people aged 15 to 24 years were invited to participate and complete the YFHS-WHO + questionnaire: 300 (30 per municipality) at baseline, and 300 at follow-up, three to five months after the training program.

Discussion

The results of this trial should provide much awaited evidence about the development of youth-friendly primary care services and inform their further development both in Bosnia and Herzegovina and worldwide.

Trial registration

Australian New Zealand Clinical Trials Registry_ ACTRN12610000142033

Primary care and youth mental health in Ireland: qualitative study in deprived urban areas

Background

Mental disorders account for six of the 20 leading causes of disability worldwide with a very high prevalence of psychiatric morbidity in youth aged 15–24 years. However, healthcare professionals are faced with many challenges in the identification and treatment of mental and substance use disorders in young people (e.g. young people’s unwillingness to seek help from healthcare professionals, lack of training, limited resources etc.) The challenge of youth mental health for primary care is especially evident in urban deprived areas, where rates of and risk factors for mental health problems are especially common. There is an emerging consensus that primary care is well placed to address mental and substance use disorders in young people especially in deprived urban areas. This study aims to describe healthcare professionals’ experience and attitudes towards screening and early intervention for mental and substance use disorders among young people (16–25 years) in primary care in deprived urban settings in Ireland.

Methods

The chosen method for this qualitative study was inductive thematic analysis which involved semi-structured interviews with 37 healthcare professionals from primary care, secondary care and community agencies at two deprived urban centres.

Results

We identified three themes in respect of interventions to increase screening and treatment: (1) Identification is optimised by a range of strategies, including raising awareness, training, more systematic and formalised assessment, and youth-friendly practices (e.g. communication skills, ensuring confidentiality); (2) Treatment is enhanced by closer inter-agency collaboration and training for all healthcare professionals working in primary care; (3) Ongoing engagement is enhanced by motivational work with young people, setting achievable treatment goals, supporting transition between child and adult mental health services and recognising primary care’s longitudinal nature as a key asset in promoting treatment engagement.

Conclusions

Especially in deprived areas, primary care is central to early intervention for youth mental health. Identification, treatment and continuing engagement are likely to be enhanced by a range of strategies with young people, healthcare professionals and systems. Further research on youth mental health and primary care, including qualitative accounts of young people’s experience and developing complex interventions that promote early intervention are priorities. (350 words)

Enhancing youth health in primary care: lessons learned from general practitioners

Primary care represents a fundamental component of the health system, particularly for young people. However, youth access to primary care is less than ideal. To optimize clinician capacity to promote youth health, an interactive training module was developed and tailored to the needs of general practitioners. As part of an exploratory study, 11 participants were interviewed to determine the perceived capacity of the module to promote youth-friendly primary care. Findings suggest the module can enhance clinician skills, knowledge, and confidence to promote youth health; however, it has a limited ability to inform how organizational capacity might be bolstered-this includes the development of interagency networks. In this epoch of primary care reform, these findings are important for two key reasons. First, they reveal the need to bolster clinicians' perceived ability to use youth healthcare skills; second, they highlight the complementary importance of organizational support to ensure and sustain youth-friendly practices. The article concludes with a discussion of key implications for policymakers, practitioners, and researchers.

Assessment of youth-friendly health care: a systematic review of indicators drawn from young people's perspectives

PURPOSE

To review the literature on young people's perspectives on health care with a view to defining domains and indicators of youth-friendly care.

METHODS

Three bibliographic databases were searched to identify studies that purportedly measured young people's perspectives on health care. Each study was assessed to identify the constructs, domains, and indicators of adolescent-friendly health care.

RESULTS

Twenty-two studies were identified: 15 used quantitative methods, six used qualitative methods and one used mixed methodology. Eight domains stood out as central to young people's positive experience of care. These were: accessibility of health care; staff attitude; communication; medical competency; guideline-driven care; age appropriate environments; youth involvement in health care; and health outcomes. Staff attitudes, which included notions of respect and friendliness, appeared universally applicable, whereas other domains, such as an appropriate environment including cleanliness, were more specific to particular contexts.

CONCLUSION

These eight domains provide a practical framework for assessing how well services are engaging young people. Measures of youth-friendly health care should address universally applicable indicators of youth-friendly care and may benefit from additional questions that are specific to the local health setting.

Feasibility and acceptability of nurse-led youth clinics in Australian general practice

Internationally, youth access to primary health care is problematic due to documented barriers such as cost, concerns about confidentiality, and knowledge about when to attend and available services. The treatment of health problems earlier in life together with engagement in prevention and health education can optimise youth health and maximise the potential of future wellbeing. This study investigated the feasibility, acceptability and cost of establishing nurse-led youth clinics in Victoria, Australia. Three general practices in rural and regional areas of Victoria implemented the nurse-led youth health clinics. The clinics were poorly attended by young people. Practice nurses identified several barriers to the clinic attendance including the short timeframe of the study, set times of the clinics and a lack of support for the clinics by some GPs and external youth health clinics, resulting in few referrals. The clinics cost from $5912 to $8557 to establish, which included training the practice nurses. Benefits of the clinics included increased staff knowledge about youth health issues and improved relationships within the general practice staff teams. The implementation of youth health clinics is not feasible in a short timeframe and to maximise use of the clinics, all members of the general practice team need to find the clinics acceptable.

Can general practice help address youth mental health? A retrospective cross-sectional study in Dublin's south inner city

AIMS

With general practice potentially having an important role in early intervention of mental and substance use disorders among young people, we aim to explore this issue by determining the prevalence of psychological problems and general practice/health service utilization among young people attending general practice.

METHODS

A retrospective cross-sectional study of patients attending three general practices in Dublin city.

RESULTS

Among a sample of young people (mostly women, 44% general medical services (GMS) eligible), we observed considerable contact with general practice, both lifetime and for the 2 years of the study. The mean consultation rate was 3.9 consultations in 2 years and psychosocial issues (most commonly stress/anxiety and depression) were documented in 35% of cases. Identification of psychosocial issues was associated with GMS eligibility, three or more doctor consultations, and documentation of smoking and drinking status.

CONCLUSIONS

Psychosocial issues are common among young people attending general practice and more work on their epidemiology and further identification in general practice are advocated.

Perceived Facilitators and Barriers to Interventions Aimed at Reducing Unintended Pregnancies among Adolescents in Low and Middle Income (Developing) Countries: a Systematic Review of Qualitative Evidence

BACKGROUND

Adolescent pregnancies are most often the result of sexual risk taking. Such pregnancies are in themselves "risks" perpetuating other adverse social outcomes on the adolescents who go through such pregnancies. Of the close to 14 million births among adolescents each year, between one-third and two-thirds are unplanned. Unplanned pregnancies coupled with societal restrictions result in adolescents opting for abortions under unsafe conditions.

OBJECTIVES

The objective of this review is to present the best available evidence on perceived facilitators and barriers to successful outcomes of programs aimed at reducing pregnancies among adolescents in low and middle income countries.

INCLUSION CRITERIA

Persons aged between 10 and 19 years residing in low and middle income countries, but during the review process, those up to 25 years, adults and opinion leaders were included.Perceived facilitators and barriers to interventions aimed at reducing pregnancies among adolescents in developing countries.The review considered studies that used qualitative study designs, including but not limited to: phenomenology, grounded theory, action research, narrative studies, descriptive studies, ethnographies, cultural studies, behavioural studies, case studies and feminist research.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished studies in English over the period of January, 1960 to December, 2010.

METHODOLOGICAL QUALITY

Critical appraisal of papers was conducted using standardized tools from the Joanna Briggs Institute by two independent reviewers.

DATA COLLECTION

Data was extracted using standardized tools from the Joanna Briggs Institute.

DATA SYNTHESIS

Findings were synthesized on the basis of similarity of meaning using software from the Joanna Briggs Institute.

RESULTS

Fourteen studies were included in the review which generated 103 findings, grouped into 22 categories and then further grouped into 11 synthesized findings, based on similarity of meaning. Seventeen categories (eight synthesized findings) described perceived barriers and five categories (three synthesized findings) described perceived facilitators.

CONCLUSIONS

Synthesized findings on both the barriers and facilitators encompassed adolescent, parental, community, health facility, care providers, school environment and societal contributing factors.

IMPLICATIONS FOR PRACTICE

IMPLICATIONS FOR RESEARCH: Further research should be conducted into the following.

What is the role of general practice in addressing youth mental health? A discussion paper

BACKGROUND

Mental and substance use disorders are a leading cause of morbidity among young people. Policy and clinical services in Ireland are endeavouring to address these twin issues.

AIMS

To review the emerging literature on the role of general practice in addressing youth mental health and to discuss the implications of this literature for further research, education and service delivery.

METHODS

We conducted a review of 'PubMed' and a web search of relevant national/international primary/mental healthcare agencies and professional bodies.

RESULTS

Although general practice has an important role in addressing youth mental health, there are challenges in how young people seek help. Specifically, young people do not engage with healthcare agencies and many factors which act as barriers and enablers in this regard have been identified. The detection and treatment of mental and substance use disorders by GPs can be improved and implementing interventions to improve screening and early intervention are likely to be valuable.

CONCLUSIONS

General practice is a central agency in addressing youth mental health and complex multifaceted interventions (education, clinical guidelines, and promoting awareness) are likely to support its role. Further research exploring this issue is a priority.

Trust, autonomy and relationships: the help-seeking preferences of young people in secondary level schools in London (UK)

Help-seeking among young people is complicated, often determined vicariously by the ability of adults, family or professionals, to recognize, and respond to, their difficulties. We know very little about the complex concerns of teenage young people and how they impact on help-seeking preferences. We aimed to ascertain the help-seeking preferences for a range of mental health problems among adolescents attending schools in an inner-city area of London. In particular we sought to examine the relationship between such adolescents and their family doctor. Using a mixed methods approach we explored help-seeking attitudes of young people. Emotional and mental health problems are not seen by young people as the domain of General practitioners. Moreover, there is a worrying lack of confidence and trust placed in family doctor and other professionals by young people. Young people do not tend easily to trust adults to help them with emotional difficulties.

Primary care services provided to adolescents in detention: a cross-sectional study using ICPC-2

AIM

The aim of this study was to provide a detailed description of the health problems for which primary care services are provided to adolescents in a juvenile detention facility in Europe.

METHODS

We reviewed the medical files of all detainees in a juvenile detention centre in Switzerland in 2007. The health problems for which primary care services were provided were coded using the International Classification for Primary Care, version 2. Analysis was descriptive, stratified by gender.

RESULTS

A total of 314 adolescents (18% female) aged 11-19 years were included. Most (89%) had a health assessment and 195 (62%) had consultations with a primary care physician; 80% of the latter had a physical health problem, and 60% had a mental health problem. The most commonly managed problems were skin (49.7%), respiratory (23.6%), behavioural (22.6%) and gynaecological problems (females: 23.9%); 13% females (no males) had sexually transmitted infections (STI), and 8.7% were pregnant. Substance abuse was common (tobacco: 64.6%, alcohol: 26.2%, cannabis: 31.3%).

CONCLUSION

In addition to health problems known to be more prevalent among young offenders, such as mental health problems and STI, these adolescent detainees required care for a range of common primary care problems. These data should inform the development of comprehensive primary care services in all juvenile detention facilities in Europe.

Detecting emotional disorder in young people in primary care

PURPOSE OF REVIEW

Screening young people for emotional disorder in primary care has seemed sensible given most attend annually and most mental disorder is undetected. Yet evidence supporting screening has been scant. This review considers recent progress around conceptual frameworks, epidemiological findings, accuracy of available instruments and evidence for effectiveness of screening in reducing the burden of emotional disorders.

RECENT FINDINGS

Despite better evidence about the accuracy of screens in identifying adolescent depression and possible benefits of early intervention with current treatments, demonstration of improved health outcomes and cost-effectiveness is still lacking. Even when screening detects mental disorder other factors such as readiness for care and availability of effective treatments may affect responses. Best results are obtained when screening is linked to collaborative models of care. Evidence around harms from screening is scant but debate exists over potential harms of false-positives such as stigma and increased strain on healthcare resources.

SUMMARY

There is growing consensus that, if screening for emotional disorder is to be effective in primary care, facilitated access of identified young people to effective treatment options is necessary. Further research is required to demonstrate that routine screening will improve mental health outcomes and be cost-effective.

Young people and their GP: a register-based study of 1717 Norwegian GPs

BACKGROUND

Internationally, there has been a call to improve the youth-friendliness of health services. In surveys, 60-90% of young people report having contact with a GP at least once a year. Regular contact with the GP can be assumed to be an indicator of a youth-friendly health service. The aim of the current study was to identify associations between a high consultation rate with young people (15-24 years) on the one hand and GP characteristics, patient list characteristics and practice profiling factors on the other.

METHODS

A cross-sectional national register-based study from 2002-04 in Norwegian general practice. Data on 1717 GPs, their practice populations and a sample of 316 773 consultations with young people were used to estimate differences between GPs, using one-way analysis of variance and logistic regression.

RESULTS

The mean annual consultation rate with young people was 1.4 (95% confidence interval 1.4-1.5) and 2.2 (2.1-2.2) for the age groups 15-19 and 20-24, respectively. List characteristics indicating free capacity-a shorter patient list, a growing patient list and a high access for persons not on the patient list-were associated with a high youth consultation rate. Young age of the GP, low educational level among the list population and a high rate of interdisciplinary activity by the GP were also associated with a high youth consultation rate.

CONCLUSIONS

GPs seem to assign especially low priority to young people when workload is high or free capacity low. Increased awareness of these mechanisms and greater interdisciplinary cooperation could increase the youth-friendliness of general practice.

Text message communication in primary care research: a randomized controlled trial

BACKGROUND

Text message communication is increasingly used in clinical practice but rarely in research. Particularly in young people, this method of participation in primary care research appears both feasible and acceptable. However, previous experience shows that text messaging for research may lead to lower response rates. Aim. To test the hypothesis that text message communication in primary care research does not lead to lower response rates compared to a paper-based method.

METHODS

This randomized controlled trial took place in 26 randomly selected practices in Victoria, Australia. Consecutive patients aged 16-24 years attending general practice appointments were recruited as part of a larger study on patients' perspectives. Patients owning a mobile phone were randomized to receive a question about satisfaction with the consultation either by text message or on a card completed before leaving the practice. Logistic regression was used to estimate the effect on the response rate of using text message rather than the card method, adjusting for clustering within practices and for differences in baseline characteristics among participants.

RESULTS

In total, 402 of 409 eligible young people agreed to participate and were randomized to either receive a text message (n = 193) or a card enquiry (n = 209). The response rate was 80.2% [95% confidence interval (CI): 73.3-87.1%] with text message and 85.6% (95% CI: 79.6-91.7%) with the card. The adjusted odds of responding (odds ratio: 0.62; 95% CI: 0.30-1.27) were not significantly lower in the group using text messaging compared to the group using the card response method.

CONCLUSION

These findings offer new perspectives for use of text message communication to gather information from patients in primary care research.

Handheld vs. laptop computers for electronic data collection in clinical research: a crossover randomized trial

OBJECTIVE

To compare users' speed, number of entry errors and satisfaction in using two current devices for electronic data collection in clinical research: handheld and laptop computers.

DESIGN

The authors performed a randomized cross-over trial using 160 different paper-based questionnaires and representing altogether 45,440 variables. Four data coders were instructed to record, according to a random predefined and equally balanced sequence, the content of these questionnaires either on a laptop or on a handheld computer. Instructions on the kind of device to be used were provided to data-coders in individual sealed and opaque envelopes. Study conditions were controlled and the data entry process performed in a quiet environment.

MEASUREMENTS

The authors compared the duration of the data recording process, the number of errors and users' satisfaction with the two devices. The authors divided errors into two separate categories, typing and missing data errors. The original paper-based questionnaire was used as a gold-standard.

RESULTS

The overall duration of the recording process was significantly reduced (2.0 versus 3.3 min) when data were recorded on the laptop computer (p < 0.001). Data accuracy also improved. There were 5.8 typing errors per 1,000 entries with the laptop compared to 8.4 per 1,000 with the handheld computer (p < 0.001). The difference was even more important for missing data which decreased from 22.8 to 2.9 per 1,000 entries when a laptop was used (p < 0.001). Users found the laptop easier, faster and more satisfying to use than the handheld computer.

CONCLUSIONS

Despite the increasing use of handheld computers for electronic data collection in clinical research, these devices should be used with caution. They double the duration of the data entry process and significantly increase the risk of typing errors and missing data. This may become a particularly crucial issue in studies where these devices are provided to patients or healthcare workers, unfamiliar with computer technologies, for self-reporting or research data collection processes.

Brief intervention addressing excessive cannabis use in young people consulting their GP: a pilot study

BACKGROUND

When excessive cannabis consumption occurs in adolescence, the adverse consequences extend into adulthood. Interventions by GPs are effective in preventing harm associated with alcohol use. Similar interventions have potential in addressing cannabis use.

AIM

To develop and pilot test a brief intervention targeting excessive cannabis use (defined as > or = 1x/week) in young people in primary care.

DESIGN OF THE STUDY

Pilot intervention trial.

SETTING

Seven family practices in Switzerland.

METHOD

The team collaborated with GPs and young people to develop the intervention. Seven GPs piloted its use in their consultations. Patients aged 15 to 24 years consulting for any health problem were recruited before the consultation. Cannabis use, other substance use, and their psychosocial correlates were assessed with a short confidential questionnaire administered before the consultation and 1 month later. GPs, staff, and patients were asked to comment on the study and its feasibility.

RESULTS

Of 81 young people invited to participate, 78 (70% female) agreed (participation rate: 96%). One in seven (13.2%, 95% confidence interval = 7.5% to 18.9%) used cannabis at least once a week. Data at 1 month were available for 42% who had provided email contact details and 91% of those who had provided their mobile phone number (63% overall). In most cases, the intervention lasted no more than 5 minutes. Comments from participants added favourable data towards the feasibility of the study.

CONCLUSION

This pilot study provides a solid base on which to build a randomised trial of a brief intervention addressing cannabis use in young people consulting in family practice.

The identification of young people's emotional distress: a study in primary care

BACKGROUND

Primary care is a key step in young people's pathway to mental health care. Despite the high prevalence of mental disorder in this age group, little is known about the factors that determine the identification of young people's mental disorder in primary care.

AIM

To provide a detailed description of the factors associated with both 'correct' and 'excessive' identification of youth mental disorder in primary care.

DESIGN OF THE STUDY

Cross-sectional study.

SETTING

Twenty-six randomly selected general practices in Victoria, Australia.

METHOD

Consecutive young people (16-24 years) were interviewed before their consultation, using a semi-structured interview. They completed Kessler's scale of emotional distress (K10). GPs completed a questionnaire after the consultation. Multinomial logistic regression was used to examine the factors associated with GP identification of mental disorder in those with high and low probability of disorder on the K10.

RESULTS

Altogether, 450/501 (90%) of approached young people participated; 36.1% (95% confidence interval [CI] = 32.3 to 40.2%) had high probability of mental disorder on the K10. Young people's perception that they had a mental illness was highly associated with GP identification (odds ratio [OR] = 62.6, 95% CI = 22.8 to 172.0). Other significantly associated factors were: patient fears (OR = 2.4, 95% CI = 1.1 to 5.1), frequent consultations (OR = 3.0, 95% CI = 1.0 to 8.4), days out of role (OR = 2.7, 95% CI = 1.2 to 5.7), and continuity of care (OR = 3.4, 95% CI = 1.6 to 6.9). The latter two were also associated with 'over-identification' of young people who had low probability of mental disorder. GP characteristics were not associated with identification.

CONCLUSION

These findings provide guidance for GPs in their clinical work and training. They should also inform the further development of mental health literacy programmes in the community.