In the last few lectures, we've talked about the broader ways in which family, peers, and community can support young people's healthy development. We've considered how laws, taxation, marketing, and social media shape healthy and unhealthy ideas about what it is to be young, healthy, happy, and successful. Outmoded notions of adolescence as the healthiest stage of life have also inadvertently been associated with beliefs about health services. If young people are healthy, we don't need to think about health services for them, do we? But, having outlined the range of health issues experienced by young people across the globe, I hope it's pretty clear that young people, just like infants, adults, and older folk, also benefit from health services. The increasing global attention now being given to universal health coverage has strong resonance with adolescents, whose health needs have arguably been most neglected by health services. The next few lectures will focus on health services, and the role they can play in responding to young people's comprehensive health needs, rather than their role to simply respond to what young people present with. One important consideration about health services is quality. What comes to mind when you think about quality health services for adolescents? Clearly, one aspect is that health services need to understand the burden of disease experienced by young people in order to be able to respond. Health services also need to appreciate what adolescents seek help for, and what they don't seek help for. And understand the barriers that prevent adolescents from seeking health care more widely. Understanding provider attitudes, knowledge, and skills is also a critical consideration in planning quality healthcare services for the young, in order that teaching and training can help obviate these. The most common reasons that adolescents present to primary healthcare are for acute healthcare needs, such as accidents and injuries, infections, including upper respiratory tract infections, coughs and colds, and skin conditions. So, how does this sit with our knowledge of the burden of disease that young people experience, that I've attempted to describe in this schema here? Clearly, there is a gap. Young people less commonly seek health services for the conditions that have the greatest impact on their burden of disease, both now, as well as in the future. One example of this is mental disorders. This figure depicts the burden of mental disorder in Australia by age as measured by DALYs. We can appreciate that if health services do not have a strong understanding of adolescence as the time of the greatest upswing in the incidence of mental disorder, they will be less able to deliver quality healthcare to the young. Why? Because the majority of young people with mental disorders do not present to health services with explicit mental health conditions. These conditions will commonly remain hidden, unless clinicians have the skills to identify them when young people present with other health concerns. So what issues do adolescents experience? And what do they seek help for? In this study in India, the author surveyed a group of high school students who had a mean age of about 15 and a half years. Two-thirds of both boys and girls reported their health to be good or very good. But still, 81% reported having had a health problem in the previous months that the authors categorized into the following five groups, as outlined here. The leading psychological problems reported by young people were tensions about future careers, concerns about physical appearance, difficulty concentrating, and masturbation. The most common behavioral problems were the inability to express feelings, feeling hypersensitive, feeling lonely, misunderstanding parents, and lack of confidence. Now, I find it hard to differentiate the content of what these authors have placed within the psychological from the behavioral category. The issues in the top box, to me, feel very similar to the issues in the bottom box. Were we to combine these two categories, we can see that two-thirds of respondents had concerns around what are broadly called a psychosocial domain. When we then look at what constitutes medical and general health concerns, we are faced with a similar challenge. I would also tend to combine these two categories. And, again, if we do that, then around a third of young people also had health issues within the physical health domain. So, did these young Indian students seek help for their problems? And if so, from whom did they seek help? We can see that boys were most likely to seek help from their friends and their families. While girls were most likely to seek help from their mothers, friends, and also female family members. We don't know how well these sources of help addressed the problem. Hopefully they did. What we do know is that only a minority have seen a health professional. In this case, a doctor was the only named option for a health professional in their survey. I was surprised by the proportion who had been accompanied to the doctor by a family member, expecting it would be higher, for boys, but particularly for girls. This same study wet out to explore whether there were differences in the rate of seeking help at two different types of clinic. A school-based clinic and a community-based clinic, both run by the same health professionals at no cost to students. Convenience seems to matter, with over double the number of students seeing a health professional at the school-based clinic than at the community-based clinic. What was pleasing to see, not shown here, is that it is not just older adolescents who were able to access these services. About 60% of students attending the school-based clinic were aged between 13 and 15 years. There was, however, a very different pattern of health issues that students presented to each clinic with. The community-based clinic saw young people primarily for medical concerns, physical health issues. In comparison to a more balanced presentation at the school-based clinic. It'd be interesting to think about why this might be the case. What do you think might explain this? Young people experience many barriers to accessing healthcare that are common to both genders and across all socioeconomic groups. Prominent barriers include lack of knowledge of services, fears about confidentiality, and embarrassment about discussing particular health concerns. Accessibility is not just about just the physical aspects of being able to get to a clinic in terms of its particular geographic location. A health service that is youth-friendly must be accessible geographically, but also physically in terms of disabled access, particularly culturally, and in all of its procedures, including financial and administrative arrangements. On a practical level, a most important consideration for young people is the access to free or minimal-cost healthcare. And, this needs to consider not only the costs of the consultation, but also diagnostic testing and, where possible, treatments, such as drug costs and other treatment costs. Most clinicians receive little training in working with adolescents and young adults. We should, therefore, not be surprised that many clinicians report that adolescents are the age group that they are least confident consulting. Specifically, health professionals, including general practitioners, report that consultations with young people take more time. That young people are challenging to work with in terms of communication difficulties. And the doctors are uncertain about the medical legal status of treating those under 18 years. And are uncertain also about how they manage consultations, with parents present, or indeed, when parents aren't present? The good news is that training in adolescent and young adult medicine positively improves the clinical performance of undergraduates and experienced healthcare providers alike from all health disciplines. The gap between the burden of disease experienced by the young, and their help-seeking behavior, is one that the healthcare system, and the community, is responsible for reducing, rather than young people. A decade ago, the World Health Organization coined the term Adolescent Friendly Health Services, as shorthand for quality healthcare for adolescents. The notion of Adolescent Friendly Health Care does not refer to standalone health services, but rather denotes that quality health services provide care to adolescents that meets their needs. That responds to the burden of disease that young people are experiencing now, including health-related behaviors. And that also provides comprehensive, preventable healthcare and anticipatory guidance. In almost all settings, adolescents access healthcare through the same services that provide healthcare to the general population, together with some specific opportunities, such as school-based services. The principles of adolescent friendly healthcare echo those of quality health systems for all ages within a population. Namely, healthcare that is accessible, acceptable, appropriate, effective, equitable, namely, being able to be reached by all, and healthcare that is safe will also provide quality healthcare to adolescents. It is how these aspects are implemented and experienced by the young that differentiates the delivery of healthcare to young people and their families, and it's these issues that we will address in the following lectures.
