The problems and difficulties of approaching teenagers with offers of help and advice on health care problems are well known.
VOL: 101, ISSUE: 38, PAGE NO: 36
Elizabeth Green, BSc, RGN, NP, Dip FP, is nurse practitioner
J. Larcombe, MB, ChB, FRCGP, is GP;I. Horbury, MSc, DipCouns, is research facilitator; all at Dr Jones and Partners, Stockton-on-Tees
The problems and difficulties of approaching teenagers with offers of help and advice on health care problems are well known.
Using a combination of evidence from the literature and that collected locally from young people themselves, a service for the teenagers of Sedgefield (Sedgefield PCT, south west Durham) was introduced in 2001.
The initial reason for developing a service specifically for teenagers as an identifiable group had three dimensions:
- Government policy - The Health of the Nation (Department of Health 1992) and the subsequent paper Our Healthier Nation (DoH, 1999) both identified young people as a special group;
- Health gain can be demonstrated;
- Teenagers have service needs specific to their age group, which need to be addressed.
A number of authors found a decline in the health of young people despite the recognition of the value of health promotion in the 1970s (Parrish, 1996). Adolescent diets have been deteriorating since 1985 (Riley et al, 1995; Office for National Statistics, 1997), smoking among teenagers has been escalating (Hanson, 1999) and young people have been consuming increasing amounts of alcohol (ONS, 1997) leading to negative psychological, social and physical effects (Campbell, 1995).
Although more recent data suggests these figures may have stabilised since 2001 (DoH, 2004a), the problems have by no means disappeared. In addition, accidental death and suicide have their highest rates among teenagers (Campbell and Glasper, 2001). And the rate of conception in 15-19 year olds in the UK is far higher than in other European and developed countries (Brook Advisory Centres, 2004) - despite the fact that the trend of teenage pregnancy is finally falling. Furthermore, the incidence of sexually transmitted disease is also increasing in young people (Health Protection Agency, 2004).
These are worrying trends but research has indicated that education in lifestyle and health choice targeted at young people prior to experimentation and development of independence may actually provide benefits for future health and well-being (Little, 1997; Social Exclusion Unit, 1999). Also, a programme of care designed to meet the specific needs of teenagers can also provide benefits to health (Jacobson and Wilkinson, 1994).
The national teenage pregnancy strategy based its foundations on a report to the government outlining recommendations to assist health care workers in reducing the teenage conception rate (Social Exclusion Unit, 1999) and, more recently, the government has extended the national chlamydia screening programme into more areas with the aim of reducing the incidence of this disease by 2008 (DoH, 2004b). However, while these points illustrate that there is a requirement - and arguably a duty - to provide health care to young people, there are many seemingly insurmountable obstacles deterring teenagers from accessing the services available to them.
In primary care specifically there appear to be a number of barriers that prevent young people from visiting their GP. Perhaps the most fundamental of these is a lack of trust towards health care professionals, especially relating to the issues of confidentiality (Stephenson, 2000) and anonymity (Smart, 1997).
However, there are also issues about the attitude of health centre staff and the use of inappropriate language and terminology (Hadley, 1998), as well as the stigma identified in relation to mental illness (James, 1999). Such findings have led to recommendations for tailor-made, ‘teenage-friendly’ youth services in primary care settings (Royal College of General Practitioners, 2002).
Little (1997) recommended direct involvement of young people in assessing their projected requirements, so a survey was conducted within the local youth community. Accordingly, a questionnaire was devised to establish whether a local service just for teenagers was desirable and, if so, what preferences there were for time and place and what type of provision it should be - general health, contraceptive services or both.
At this stage, the school nurse’s interest in the project was unequivocal. Her involvement and support from this point proved invaluable and her knowledge and relationships with the children at school provided the backbone to the new service.
As it is a semi-rural area, the local comprehensive school catered for the majority of young people but also admitted many students from outlying villages. As a result, it was not unusual for the practice to consult teenagers who were registered elsewhere but who visited the surgery while in the village attending school. This meant that using the local school as a target for the questionnaire would allow a useful representation of the young people to whom the service would in due course be offered. Involvement of the school meant consideration of extraneous influences, including the school’s other commitments, but also benefited from the full support of a new head teacher.
The questionnaire included sections relating to venue, time, type of health care wanted, approach and attitude of health centre staff and the issue of confidentiality. In the main, it was formatted into simple tick boxes with closed questions allowing for ease of analysis. However, limited space was also provided for further open-ended questions to seek opinions and suggestions from the young people completing the survey. Prior to distribution a copy was sent to the local community health council for approval, with particular reference given to any ethical issues that may have arisen in consulting adolescents under 16 about contraceptives, drugs, smoking and alcohol.
There were 50 copies of the questionnaire printed and distributed as arranged through the school. A surprising 58 questionnaires were returned (additional copies having been made in school) and provided an agreeable response rate of 100 per cent. The results were overwhelmingly in favour of opening a clinic, with 91 per cent of respondents believing the service would be useful. Valuable feedback relating to poor attitudes and concerns regarding confidentiality was also received (Box 1).
During the early stages of planning some questions were raised by colleagues about the moral, ethical and religious issues surrounding the scheme and there were also doubts as to whether the teenagers themselves would use the service. However, the high take-up rate of the questionnaire overwhelmingly demonstrated the need for the project. Furthermore, the young people who completed the questionnaire expressed fewer concerns about the service being provided at the surgery, contrary to the experiences and opinions of others (Smart, 1997).
Our intention was to advocate an in-house service with the aim of minimising costs, maintaining a simplicity of provision and introducing the young people to health care services. A local family planning nurse recommended using a Monday surgery to cater for common weekend ‘accidents’ of unprotected intercourse, thus allowing access to emergency oral contraception within the stipulated 72 hours (Mehta, 2005).
There were normally two nurses on duty during a Monday afternoon, so this scheme allowed one nurse to continue a normal surgery for general patients, freeing up other nursing time for a teenage health clinic.
The majority of young people indicated that the preferred time of day was directly following school at 3.30pm so no extra opening hours for the surgery would be necessary. Also, at this time of day there would normally be a doctor on duty so that should any requirements for prescriptions or other GP services arise, access would be possible.
The needs identified in the survey were already within the remit of both the practice nurse and the school nurse, so no additional training was deemed necessary at this stage. There was a lunchtime training/discussion session for reception staff to assist in alleviating concerns regarding confidentiality and any concerns the staff had about admission of young people under the age of 16.
Finally, the PCT had at this time extended a free condom distribution service to the surgery in Sedgefield. This meant condoms and - subject to protocol - sensitive pregnancy tests could be ordered and provided free of charge.
Information from the experiences of other authors offered useful advice. Much of this was of enormous value in avoiding the pitfalls of other attempts at initiating a service for adolescents within a GP practice. Ideas included:
- Ensuring that the young people were able to wait in a separate area to other patients at the surgery to preserve their anonymity (Smart, 1997).
- A side entrance, normally used only as a fire exit, was suggested as an alternative for the use of clinic attendees but regretfully this idea had to be abandoned for health and safety reasons.
- To avoid some adults feeling the clinic was a means of promoting sexual activity among young people (Smart, 1997), marketing of the scheme portrayed the important message that the clinic would be for the purpose of all general health needs and not just for contraceptive purposes.
- Approaching a representative of a pharmaceutical company that manufactured oral contraceptives for assistance with advertising costs.
- Agreement by a doctor to reserve one or two appointments during clinic hours for ad hoc use of attendees as a useful additional service.
Implementing the service
We provided final versions of posters to the school, to local shops where teenagers were known to gather and to other groups within the community who worked closely with young people. Local organisations, such as Connexions (information and advice for young people available on the www.connexions.gov.uk website) and youth outreach workers were informed of the service. The school also assisted by running a series of announcements in their weekly bulletin to all pupils via the assembly forum.
We set a start date in the early part of the autumn term of 2001 and systems were put into place for the launch of the new ‘teenage health clinic’. Despite careful preparations the first day came and went without a single visitor. The uptake of service was slow throughout the whole of the first term, possibly because the regular school nurse was unable to attend the clinic during this term.
When the school nurse returned in the spring term, numbers rose. It was agreed to extend the service until the end of the summer term before an evaluation took place to ascertain its success.
The evaluation was a simple statistical analysis of the number of attendees, the gender of attendees and the reason for attending the clinic (Table 1, p37). These figures were not only encouraging for the future of the service, but also provided evidence to support the school nurse’s invaluable link between the surgery and the students at school.
In summer 2002 a follow-up questionnaire was conducted. Another 50 questionnaires were distributed and 41 (82 per cent) returned (Table 2).
None of those who attended the clinic identified any problems with:
- The venue;
- The waiting room;
- The drop-in system;
- The help they received.
Of those who knew the clinic but had not attended, none identified a problem with the staff. Some of the reasons for non-attendance included:
- Problems with transport;
- Not being allowed by parents to attend;
- In one case, being uncomfortable about contraception being available at the clinic.
Suggestions for improvements included:
- Introducing music (a radio) in the waiting area;
- Providing a map to enable the surgery to be found more easily;
- Distributing more posters around the village;
- Adding posters to newspaper deliveries;
- Providing bus passes for travelling home outside school hours;
- Adding different and additional opening times and venues.
A further survey was conducted in summer 2004 in order to determine satisfaction levels and marketing gaps (Table 3). Again 50 copies were allocated to the school and distributed between year nine and ten students.
It is interesting to note that year ten pupils appeared more informed than year nine pupils. As most of all respondents identified school as the main source of information, it was suggested that because year ten pupils were in attendance in secondary school during the initial launch they had received more input during this time.
This implies that future marketing strategies may benefit from a boost of information at more frequent intervals than occurs at present.
Suggestions for improved marketing:
- Posters - a competition has been organised within school for a new design;
- An updated leaflet is being designed;
- More information at school via assembly;
- TV, radio and internet advertising.
Setting up a specialist primary care service is useful and need not be costly or difficult to achieve. Arguably, there is some cost in nursing time if the number of patients normally consulted in one-and-a-half hours of surgery is compared with the numbers consulted in the teenage clinic. Accordingly, further research into the benefit of longer consultations with teenagers may be useful to determine true cost-effectiveness of this type of service.
Advertising of the clinic is clearly an important issue, highlighted by the latest questionnaire, which suggested that marketing has lapsed. Again, in response to this problem, a boost in advertising at regular intervals is intended.
- This article has been double-blind peer-reviewed.
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