Adolescents in primary care
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《英国医生杂志》
Introduction
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.
Reasons that teenagers visit their general practitioner. Data from Churchill et al. Br J Gen Pract 2000;50: 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.
Aspects of primary care identified as most important to young people. Data from Donovan C et al. Br J Gen Pract 1997;47: 715-8
Barriers to primary care perceived by adolescents
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.
Communicating with young people
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.
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.
Is your practice "user friendly" for young people?
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.
Doing a needs assessment
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.
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.
Issues in setting up a young persons clinic
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.
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
Further reading
? McPherson A, Macfarlane A, Allen J. What do young people want from their GP? Br J Gen Pract 1996;46: 627.
? Kari J, Donovan C, Li J, Taylor B. Adolescents' attitudes to general practice in north London. Br J Gen Pract 1997;47: 109-10.
? Gregg R, Freeth D, Blackie C. Teenage health and the practice nurse: choice and opportunity for both? Br J Gen Pract 1998;48: 909-10.
? Jacobson L, Mellanby A, Donovan C, Taylor B, Tripp J, members of the Adolescent Working Party, Royal College of General Practitioners. Teenagers' views on general practice consultations and other medical advice. Fam Pract 2000;17: 156-8.
? Sanci L, Coffey C, Veit F, Carr-Gregg M, Patton G, Day N, Bowes G. Evaluation of an educational intervention for general practitioners in adolescent health care: randomised controlled trial. BMJ 2000;320: 224-2.
? Clueless and Trust—Training videos (10 minutes long) about teenagers and primary healthcare services for use in general practice to prompt discussion on how to improve primary healthcare services for young people. Available from the Royal College of General Practitioners (tel 020 7581 3232; sales@rcgp.org.uk), price ￡7 each.
This is the fourth in a series of 12 articles
The photograph of a young person with his doctor is published with permission from CC Studio/SPL; and the photograph of the pregnant girl is with permission from Clare Marsh/John Birdsall Library.
The ABC of adolescence is edited by Russell Viner, consultant in adolescent medicine at University College London Hospitals NHS Foundation Trust and Great Ormond Street Hospital NHS Trust (rviner@ich.ucl.ac.uk). The series will be published as a book in summer 2005.(Ann McPherson)
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.
Reasons that teenagers visit their general practitioner. Data from Churchill et al. Br J Gen Pract 2000;50: 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.
Aspects of primary care identified as most important to young people. Data from Donovan C et al. Br J Gen Pract 1997;47: 715-8
Barriers to primary care perceived by adolescents
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.
Communicating with young people
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.
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.
Is your practice "user friendly" for young people?
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.
Doing a needs assessment
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.
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.
Issues in setting up a young persons clinic
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.
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
Further reading
? McPherson A, Macfarlane A, Allen J. What do young people want from their GP? Br J Gen Pract 1996;46: 627.
? Kari J, Donovan C, Li J, Taylor B. Adolescents' attitudes to general practice in north London. Br J Gen Pract 1997;47: 109-10.
? Gregg R, Freeth D, Blackie C. Teenage health and the practice nurse: choice and opportunity for both? Br J Gen Pract 1998;48: 909-10.
? Jacobson L, Mellanby A, Donovan C, Taylor B, Tripp J, members of the Adolescent Working Party, Royal College of General Practitioners. Teenagers' views on general practice consultations and other medical advice. Fam Pract 2000;17: 156-8.
? Sanci L, Coffey C, Veit F, Carr-Gregg M, Patton G, Day N, Bowes G. Evaluation of an educational intervention for general practitioners in adolescent health care: randomised controlled trial. BMJ 2000;320: 224-2.
? Clueless and Trust—Training videos (10 minutes long) about teenagers and primary healthcare services for use in general practice to prompt discussion on how to improve primary healthcare services for young people. Available from the Royal College of General Practitioners (tel 020 7581 3232; sales@rcgp.org.uk), price ￡7 each.
This is the fourth in a series of 12 articles
The photograph of a young person with his doctor is published with permission from CC Studio/SPL; and the photograph of the pregnant girl is with permission from Clare Marsh/John Birdsall Library.
The ABC of adolescence is edited by Russell Viner, consultant in adolescent medicine at University College London Hospitals NHS Foundation Trust and Great Ormond Street Hospital NHS Trust (rviner@ich.ucl.ac.uk). The series will be published as a book in summer 2005.(Ann McPherson)