bs_bs_banner
doi:10.1111/jpc.12424
VIEWPOINT
The promise of primary health reform for youth health Ann Dadich,1 Carmen Jarrett,2 Lena Sanci,5 Melissa Kang3 and David Bennett2,4 1 School of Business, University of Western Sydney, Parramatta, 2Youth Health and Wellbeing, NSW Kids and Families, North Sydney, 3Sydney Medical School, University of Sydney, 4The Children’s Hospital at Westmead and University of Sydney, Westmead, New South Wales and 5Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
As in other nations,1,2 the Australian primary care sector represents the first port of call for most young people aged 12 to 24 years seeking health care.3 Australian young people are more likely to consult general practitioners (GPs) for support and counsel than other clinicians.4 This is especially the case for sensitive matters, like mental health issues.5 Seventy to ninety per cent of young people access primary care at least once a year, primarily for respiratory or dermatological concerns.6 GPs are therefore well-placed to promote youth health. As part of the primary care sector, GPs are responsible for promoting and reinforcing prevention, early intervention and connected care.7 In some Western nations, like the UK and Australia, they serve as the conduit to secondary and tertiary care, and thus moderate patient-flow within the health system. Furthermore, the developmental phase of young people provides an opportune period for prevention and early intervention.6 Attending to youth health represents a sound investment. This is recognised by a number of governments that endeavour to facilitate youth access to general practice. For instance, the Department of Health in the UK has released criteria to promote youth access to health care, which include the availability of appointment times that are accessible to young people, confidentiality, and staff training in youth health.8 Similarly, the Australian federal government entitles young people to hold their own Medicare card from the age of 15 years and thus access primary care services independently.9 Despite government support for primary care and young people’s seeming acceptance of GPs, youth access to primary care remains limited. Recent research on GP activity throughout Australia suggests that patients aged 15 to 24 years account for approximately 8.6 percent of all encounters10 – yet young people represent 13.6 percent of the Australian population.11 At a state level, NSW data suggest that youth access to GPs is largely in decline, particularly among young males.12 Although this research indicates that over two-thirds of NSW young people access a GP within a given 12-month period, this means Correspondence: Professor David Bennett, Youth Health and Wellbeing, NSW Kids and Families, LMB 961, North Sydney, NSW 2059, Australia. Fax: +61 02 9424 5888; email: [email protected] Conflict of interest: Dr Ann Dadich, Dr Carmen Jarrett, A/Professor Lena Sanci, and Professor David Bennett are all affiliated with the Young and Well Cooperative Research Centre. A/Professor Lena Sanci is a member of the headspace Evaluation Technical Advisory Group and Professor David Bennett is a member of the headspace Evaluation Executive Committee with the Department of Health and Ageing. Accepted for publication 1 September 2013.
that one-third do not, representing close to 300 000 young people.11 Furthermore, research would suggest that these young people may be less likely to seek help in the future.13 Even when young people access primary care services, research suggests some receive suboptimal care. A national study of general practice in Australia revealed that GPs do not embrace opportunities to target problematic lifestyle choices with patients, including alcohol and tobacco use.14 This reflects international research findings. For instance, in a North American study involving approximately four-hundred young people aged 15 to 25 years, 76% screened positive for at least one major health-related social problem – yet only 3% reported comprehensive screening by any clinician within the last 12 months, and 33% had not been screened at all.15 These examples might partly explain why young people have been described as a ‘forgotten group caught between bureaucratic barriers and professional spheres of influence’.16 Limited youth access to timely and appropriate health care can have personal, social and economic implications. At the personal level, many Australian young people experience chronic health and/or mental health issues.17 At a social level, chronic health and/or mental health issues can exacerbate the oft-cited burden of care among family members;18,19 these issues can also limit educational opportunities20 and employment prospects.21 At an economic level, lack of well-being is likely to require more services, more hospitalisation, more treatment, more medication, and continued access to clinicians and other practitioners. Furthermore, lack of well-being foreshadows reduced employability and perhaps increased reliance on government benefits. Given there are almost 3 million young people in Australia,11 ‘adolescent health [represents] an opportunity not to be missed’.22 To harness this opportunity and enhance youth health, innovative, systemic change is required. This includes (but is not limited to) changing the types of primary care services delivered to young people, how they are delivered and how these services are supported. In this epoch of health reform, there is arguably no better time for such change. Like many other nations,23–25 Australia is witnessing ‘the single biggest health reform in a quarter of a century’,26 the essence of which is health care that is ‘funded nationally . . . and run locally’.27 Given mounting evidence on what works in youth health care,28,29 current health reforms represent a window of opportunity to promote youth health. This article reveals how recent policy developments and growing research on evidence-based youth health care provide a strong platform on which to promote youth health. This is achieved through a narrative review of recent Australian health
Journal of Paediatrics and Child Health 49 (2013) 887–890 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
887
Health reform for youth health
A Dadich et al.
reforms and empirical research. Following this review, the article concludes with a discussion of implications for policymakers, clinicians and other practitioners, as well as researchers.
Health Reforms In response to the rising rates of non-communicable diseases, the rising costs of hospital care and the ageing population, the Australian government is leading considerable health reform to alleviate the pressure on Australian health services.30 This includes working with state and territorial governments to fortify the primary care sector as the linchpin of the health system.31,32 A key part of these reforms is establishing Medicare Locals – independent primary care organisations with a mandate to provide locally responsive, planned and coordinated primary care services. More specifically, they aim to improve the patient journey by developing integrated and coordinated services, support clinicians and other practitioners in improving patient care, address local health needs, ensure the effective implementation of primary care initiatives, and ensure efficiency and accountability.33 These activities in turn are expected to reduce a hospitalcentric health system by broadening the remit of the primary care sector and ensuring that health promotion, prevention and early intervention are provided in tandem with treatment and disease management. It is envisaged that a widened scope of service delivery and population-based planning will increase the effectiveness and efficiency of the health system in meeting local needs and improving health outcomes. Despite the potential value of these reforms, their capacity to meet the complex needs of Australian young people remains to be seen. For instance, given the breadth of their remit, can Medicare Locals be sufficiently youth-friendly to appeal to young people and respond appropriately to their needs and preferences? Given the infancy of these reforms, the answer remains to be seen – however, as the following section suggests, there is a growing body of youth health research that offers constructive guidance on the establishment, operation and benefits associated with youth-friendly primary care services.
Youth Health Research There have been three decades of programmatic academic work in Australia to improve the accessibility of general practice for young people, which has centred on capacity building within the workforce and developing guidelines for service reorientation. Working with education departments on curricula to inform young people of their rights to confidential health care and improve their knowledge of how to access primary health care have been important outcomes of this research. Efforts to lobby for policy change at state and/or national government levels to improve access have paralleled these activities. This programme of research, capacity building within the sector and policy development follows an increased understanding of the issues that young people experience and recognition of the factors that shape youth access to primary care. The evidence to date shows that Australian young people aged 11 to 19 years access primary care for acute and chronic physical health conditions, such as respiratory infections, asthma, musculoskeletal injuries and acne.34 Among young 888
women aged 15–19 years, there is an increase in presentations to general practice for family planning concerns, and contraceptive management represents a small but substantial proportion of general practice encounters within this age group. Presentations about and the management of mental health issues, including depression and anxiety, are also seen in general practice in the older adolescent age group, but these rates fall far short of the estimated rates of mental health disorders in this population.35,36 General practice is also the appropriate setting for chlamydia screening in sexually active young people, but rates of testing are low.37 Youth access to primary care is hindered by several barriers – some of these are organisational, while others pertain to misapprehension. The former include service location, which can be inaccessible when transportation is limited; hours of operation; and prohibitive service costs. The latter include young people’s misconceptions about the services offered by primary care clinicians, fears of confidentiality breaches and fears of judgement with regard to sensitive issues.38 To address some of these barriers, efforts to date include educating Australian young people and clinicians and other practitioners, as well as advocating for inexpensive, if not free, health care. Although these efforts have furthered the cause of promoting youth health in Australia, considerable challenges remain. These include engaging with clinicians and other practitioners who are not youth-health-savvy, who are uncomfortable about delivering youth health care and/or who have limited access to resources to support their clinical role. Despite these challenges, the programmatic work to date in youth health collectively highlights the importance of a developmentally appropriate, patient-centred service with an orientation towards prevention and early intervention. These lessons have been used to shape a conceptual framework for a youth-friendly health service. More specifically, the epidemiology of young people’s major burden of disease reveals the role of risk-taking behaviours (e.g. unprotected sex; the use of tobacco, alcohol and other drugs; and unsafe road behaviour). It also indicates that many experience mental health issues for which they are reluctant to seek support.39,40 Young people are more likely to seek counsel from family members or friends, and they may not advise clinicians or other practitioners of their risk-taking behaviours unless asked.6 Addressing these tendencies forms the core elements of the youth-friendly service, which are echoed by international bodies like the World Health Organization (WHO). The WHO has summarised the key components of the youthfriendly service.41–43 A youth-friendly service is said to be: • available • easily accessible to young people (e.g. affordable, open at convenient times and geographically convenient) • equitable (e.g. non-judgemental; open for all young people regardless of gender, culture, marital status, socio-economic status, etc.) • acceptable to young people (e.g. clear policies about confidential and patient-centred care, using developmentally and culturally appropriate communication) • appropriate (e.g. staffed by clinicians and other practitioners who are skilled and confident in working with young people, and who have access to the resources required to deliver evidence-based care)
Journal of Paediatrics and Child Health 49 (2013) 887–890 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
A Dadich et al.
Reflecting the United Nations Convention on the Rights of the Child,44 the WHO also highlights the importance of youth participation in both the development and evaluation of health services. Youth-friendly primary care can be delivered in a range of contexts to maximise coverage and choice.6 For instance, there are youth-specific clinics that deliver enhanced primary care for a narrow range of health issues, but with strong links to other services for comorbid conditions. An Australian example is headspace,45 a federally funded health service established in 2006 ‘to improve young people’s mental, social, and emotional wellbeing through the provision of high quality, integrated services when and where they are needed’.46 In addition to youthspecific clinics there are generalist community-based health centres and private practices. These are staffed by generalist clinicians, like GPs or nurses, who can provide primary care across a range of issues. Generalist youth-specific services may integrate health care with a range of legal and welfare services and/or provide outreach clinical visits to at-risk young people, like those who are homeless. Youth-friendly primary care is also delivered within the education sector. As places where some young people spend considerable time, high schools and universities represent another opportunity to meet the health needs of young people. Some educational institutions have thus opened their doors to colocated clinics. The aforesaid Australian examples illustrate the different contexts in which youth-friendly primary care can be delivered – however, international initiatives demonstrate the value of broadening conventional understandings of primary care to encompass other disciplines, like dentistry, allied health and pharmacy. For instance, pharmacists have been promoted to young people in the UK as a youth-friendly health resource.47 The campaign, known as ‘Think Pharmacy’, encompasses online and audiovisual media to inform young people of the services that pharmacists offer and their locations – these include a music video clip and interviews with pharmacists, which are posted on YouTube. As indicated by ‘Think Pharmacy’, technology is emerging as a key player in youth-friendly primary care. A further sign of its potential is found in the work of the Young and Well Cooperative Research Centre – an Australian initiative to understand ‘the role of technology in young people’s lives, and how technology can be used to improve the mental health and wellbeing of young people aged 12 to 25’.48 Findings from its recent research suggest that moderate video game play can contribute to: reduced emotional disturbances, positive mental well-being and reduced depressed affect.49 The challenge now is to empirically determine how technology might be used within primary care to promote positive health outcomes among young people.
Discussion Given the current state of youth health, the growing research on what works in youth health care, and well-motivated health reforms championed by Australian governments, the time has never been better to promote youth health in Australia. This is largely because the research to date and the health reforms both position the primary care sector as the linchpin of the health
Health reform for youth health
system. This sector attracts the highest proportion of young people seeking health care. Furthermore, it is responsible for promoting and reinforcing prevention, early intervention and connected care.7 New governance arrangements, like those epitomised by Medicare Locals, have the potential to strengthen service connections within and beyond the primary care sector and improve service coordination. Given the complex psychosocial issues that many experience, Australian young people are likely to benefit from these new arrangements. If Medical Locals operate as planned and are guided by evidence-based research, young people are likely to experience an improved journey as they navigate different services that represent different sectors. Under the auspices of Medicare Locals, primary care clinicians potentially will be better supported and able to function more effectively, with a broader remit, in the context of their local communities. And if other aspirations in this epoch of change are met, in addition to improved patient care, greater attention will be given to population health issues, contributing to more sensible health service planning. The growing evidence base on youth health and the current epoch of health reform suggest there is much opportunity to promote and sustain youth health, particularly in the context of primary care. However, this will require political will, strong leadership and further research to help operationalise systemic change that is both effective and efficient. Together, these elements will help to harness the current window of opportunity.
Acknowledgements The authors received no additional funding for this research.
References 1 Baltag V, Mathieson A, eds. Youth-friendly health policies and services in the European region: Sharing experiences. Copenhagen: World Health Organization, 2010. 2 Healy D, Naqvi S, Meagher D, Cullen W, Dunne C. Primary care support for youth mental health: a preliminary evidence base for Ireland’s Mid-West. Ir. J. Med. Sci. 2013; 182: 237–43. 3 NSW Health. NSW youth health policy 2011–2016: healthy bodies, healthy minds, vibrant futures. Sydney: NSW Health, 2010. 4 Booth M, Bernard D, Quine S et al. Access to health care among NSW adolescents: phase 1. Sydney: NSW Health, 2002. 5 Rickwood DJ, Deane FP, Wilson CJ. When and how do young people seek professional help for mental health problems? Med. J. Aust. 2007; 187 (Suppl. 187): S35–9. 6 Tylee A, Haller DM, Graham T, Churchill R, Sanci LA. Youth-friendly primary-care services: how are we doing and what more needs to be done? Lancet 2007; 369: 1565–73. 7 National Health and Hospitals Reform Commission. A healthier future for all Australians: final report. Canberra: Commonwealth of Australia; 2009 Jun. 8 Department of Health, UK. You’re Welcome quality criteria: making health services young people friendly. London: Department of Health, 2005. 9 Department of Health and Ageing. Youth health: a summary of youth health related initiatives [Website]. Canberra: DHA (Department of Health and Ageing); 2010 [updated 31st Aug.]. Available from: http://
Journal of Paediatrics and Child Health 49 (2013) 887–890 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
889
Health reform for youth health
10
11
12 13 14
15
16
17
18
19
20
21
22 23 24 25
26
27
28
A Dadich et al.
www.health.gov.au/internet/main/publishing.nsf/Content/healthpubhlth-strateg-youth-programs.htm [accessed 12 February 2012]. Britt H, Miller GC, Charles J et al. General practice activity in Australia 2009–2010. Canberra: Australian Institute of Health and Welfare, 2010 Dec. Report No. GEP 27. Australian Bureau of Statistics. 2006 Census quickstats: New South Wales [Website]. Canberra: Australian Bureau of Statistics; 2007 [updated 10th Feb. 2008]. Available from: http://www.censusdata .abs.gov.au/ABSNavigation/prenav/ProductSelect?newproducttype =QuickStats&btnSelectProduct=View+QuickStats+%3E&collection =Census&period=2006&areacode=1&geography=&method =&productlabel=&producttype=&topic=&navmapdisplayed=true &javascript=true&breadcrumb=LP&topholder=0&leftholder=0 ¤taction=201&action=401&textversion=false [accessed 24 February 2009]. Centre for Epidemiology and Research. 1997–2007 report on young adults. Sydney: NSW Health, 2008. Wilson C, Deane F. Predicting adolescents’ future intentions to seek help for mental health problems. Youth Stud. Aust. 2011; 30: 27–33. Degenhardt L, Knox S, Barker B, Britt H, Shakeshaft A. The management of alcohol, tobacco and illicit drug use problems by general practitioners in Australia. Drug Alcohol Rev. 2005; 24: 499–506. Hassan A, Blood EA, Pikcilingis A et al. Youths’ health-related social problems: concerns often overlooked during the medical visit. J. Adolesc. Health 2013; 53: 265–71. Kennedy I. Getting it right for children and young people: overcoming cultural barriers in the NHS so as to meet their needs. London: Department of Health, 2010. Australian Institute of Health and Welfare. Young Australians: their health and wellbeing. Canberra: Australian Institute of Health and Welfare, 2011 PHE 140. Bobinac A, van Exel NJA, Rutten FFH, Brouwer WBF. Health effects in significant others: separating family and care-giving effects. Med. Decis. Making 2011; 31: 292–8. Maji KR, Sood M, Sagar R, Khandelwal SK. A follow-up study of family burden in patients with bipolar affective disorder. Int. J. Soc. Psychiatry 2011; 58: 217–23. Kalist D, Molinari N-A. The effects of mental illness on schooling. Paper presented at Economics of Population Health: Inaugural Conference of the American Society of Health Economists; 4 June 2006, Madison, WI, USA. Killackey EJ, Jackson HJ, Gleeson J, Hickie IB, McGorry PD. Exciting career opportunity beckons! Early intervention and vocational rehabilitation in first-episode psychosis: employing cautious optimism. Aust. N. Z. J. Psychiatry 2006; 40: 951–62. Kleinert S. Adolescent health: an opportunity not to be missed. Lancet 2007; 369: 1057–8. Boselie P. High performance work practices in the health care sector: a Dutch case study. Int. J. Manpow. 2010; 31: 42–58. Warwick P. Back to the future in NHS reform. J. Health Organ. Manag. 2007; 21: 194–204. Pettersen IJ, Nyland K. Reforms and clinical managers’ responses: a study in Norwegian hospitals. J. Health Organ. Manag. 2012; 26: 15–31. Rudd K, Roxon N. New directions for Australian health. Taking responsibility: labor’s plan for ending the blame game on health and hospital care. Canberra: Australian Labor Party, 2007 Aug. Contract No.: 9. Department of Health and Ageing. A national health and hospitals network for Australia’s future: delivering the reforms. Canberra: Department of Health and Ageing, 2010. Dadich A, Jarrett C, Robards F, Bennett C. Enhancing youth health in primary care: lessons learned from general practitioners. Health Commun. in press.
890
29 Jarrett C, Dadich A, Robards F, Bennett D. ‘Adolescence is difficult, some kids are difficult’: general practitioner perceptions of working with young people. Aust. J. Primary Health 2011; 17: 54–9. 30 Department of Health and Ageing. About national health reform [Website]. Canberra: Department of Health and Ageing; 2010 [updated 27th Jun.] Available from: http://www.yourhealth.gov.au/ internet/yourhealth/publishing.nsf/Content/health-reform-overview [accessed 15 May 2012]. 31 Department of Health and Ageing. Building a 21st century primary health care system: Australia’s first national primary health care strategy. Canberra: Department of Health and Ageing, 2010. 32 Standing Council on Health. National primary health care strategic framework. Canberra: Department of Health and Ageing, 2013 Apr. 33 Department of Health and Ageing. Medicare Locals operational guidelines. Canberra: Department of Health and Ageing, 2012 Sep. 34 Britt H, Miller GC, Henderson J et al. General Practice Activity in Australia 2011–2012. Sydney: University of Sydney, 2012 GEP 31. 35 Scott EM, Hermens DF, Glozier N, Naismith SL, Guastella AJ, Hickie IB. Delivering youth-specific mental health services: the advantages of a collaborative, multi-disciplinary system. Med. J. Aust. 2012; 196: 136–40. 36 Scott EM, Hermens DF, Glozier N, Naismith SL, Guastella AJ, Hickie IB. Targeted primary care-based mental health services for young Australians. Med. J. Aust. 2012; 196: 136–40. 37 Kong FYS, Guy RJ, Hocking JS et al. Australian general practitioner chlamydia testing rates among young people. Med. J. Aust. 2011; 194: 249–52. 38 Booth ML, Knox S, Kang M. Encounters between adolescents and general practice in Australia. J. Paediatr. Child Health 2008; 44: 699–705. 39 Kramer T, Garralda ME. Excellence through evidence: the what, when, and where of clinical autonomy. Br. J. Psychiatry 1998; 173: 508–13. 40 Reavley NJ, Jorm AF. Recognition of mental disorders and beliefs about treatment and outcome: findings from an Australian national survey of mental health literacy and stigma. Aust. N. Z. J. Psychiatry 2011; 45: 947–56. 41 World Health Organization. Programming for adolescent health and development: report of a WHO/UNFPA/UNICEF study group on programming for adolescent health. Geneva: World Health Organization, 1999. 42 World Health Organization. Global consultation on adolescent health services: a consensus statement. Geneva: World Health Organization, 2001. 43 Dehne K, Riedner G. Sexually transmitted infections among young people: the need for adequate health services. Geneva: World Health Organization, 2005. 44 United Nations. Convention on the Rights of the Child. Geneva: Office of the High Commissioner for Human Rights; 1989 Nov. 45 McGorry PD, Tanti C, Stokes R et al. headspace: Australia’s national youth mental health foundation – where young minds come first. Med. J. Aust. 2007; 187: S68–70. 46 Headspace. Headspace strategic plan 2012–2015. Melbourne: Headspace, 2012. 47 National Health Service, UK. Think ‘pharmacy’ [Website]. London: National Health Service; 2011. Available from: http://www .thinkpharmacy.info/ [accessed 20 July 2013]. 48 Young and Well Cooperative Research Centre. Understanding the Young and Well Cooperative Research Centre [Website]. Melbourne: Young and Well Cooperative Research Centre; 2012. Available from: http://www.yawcrc.org.au/about/young-and-well [accessed 2 January 2013]. 49 Johnson D, Jones C, Scholes L, Carras M. Videogames and wellbeing. Melbourne: Young and Well Cooperative Research Centre, 2013.
Journal of Paediatrics and Child Health 49 (2013) 887–890 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
doi:10.1111/jpc.12424
VIEWPOINT
The promise of primary health reform for youth health Ann Dadich,1 Carmen Jarrett,2 Lena Sanci,5 Melissa Kang3 and David Bennett2,4 1 School of Business, University of Western Sydney, Parramatta, 2Youth Health and Wellbeing, NSW Kids and Families, North Sydney, 3Sydney Medical School, University of Sydney, 4The Children’s Hospital at Westmead and University of Sydney, Westmead, New South Wales and 5Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
As in other nations,1,2 the Australian primary care sector represents the first port of call for most young people aged 12 to 24 years seeking health care.3 Australian young people are more likely to consult general practitioners (GPs) for support and counsel than other clinicians.4 This is especially the case for sensitive matters, like mental health issues.5 Seventy to ninety per cent of young people access primary care at least once a year, primarily for respiratory or dermatological concerns.6 GPs are therefore well-placed to promote youth health. As part of the primary care sector, GPs are responsible for promoting and reinforcing prevention, early intervention and connected care.7 In some Western nations, like the UK and Australia, they serve as the conduit to secondary and tertiary care, and thus moderate patient-flow within the health system. Furthermore, the developmental phase of young people provides an opportune period for prevention and early intervention.6 Attending to youth health represents a sound investment. This is recognised by a number of governments that endeavour to facilitate youth access to general practice. For instance, the Department of Health in the UK has released criteria to promote youth access to health care, which include the availability of appointment times that are accessible to young people, confidentiality, and staff training in youth health.8 Similarly, the Australian federal government entitles young people to hold their own Medicare card from the age of 15 years and thus access primary care services independently.9 Despite government support for primary care and young people’s seeming acceptance of GPs, youth access to primary care remains limited. Recent research on GP activity throughout Australia suggests that patients aged 15 to 24 years account for approximately 8.6 percent of all encounters10 – yet young people represent 13.6 percent of the Australian population.11 At a state level, NSW data suggest that youth access to GPs is largely in decline, particularly among young males.12 Although this research indicates that over two-thirds of NSW young people access a GP within a given 12-month period, this means Correspondence: Professor David Bennett, Youth Health and Wellbeing, NSW Kids and Families, LMB 961, North Sydney, NSW 2059, Australia. Fax: +61 02 9424 5888; email: [email protected] Conflict of interest: Dr Ann Dadich, Dr Carmen Jarrett, A/Professor Lena Sanci, and Professor David Bennett are all affiliated with the Young and Well Cooperative Research Centre. A/Professor Lena Sanci is a member of the headspace Evaluation Technical Advisory Group and Professor David Bennett is a member of the headspace Evaluation Executive Committee with the Department of Health and Ageing. Accepted for publication 1 September 2013.
that one-third do not, representing close to 300 000 young people.11 Furthermore, research would suggest that these young people may be less likely to seek help in the future.13 Even when young people access primary care services, research suggests some receive suboptimal care. A national study of general practice in Australia revealed that GPs do not embrace opportunities to target problematic lifestyle choices with patients, including alcohol and tobacco use.14 This reflects international research findings. For instance, in a North American study involving approximately four-hundred young people aged 15 to 25 years, 76% screened positive for at least one major health-related social problem – yet only 3% reported comprehensive screening by any clinician within the last 12 months, and 33% had not been screened at all.15 These examples might partly explain why young people have been described as a ‘forgotten group caught between bureaucratic barriers and professional spheres of influence’.16 Limited youth access to timely and appropriate health care can have personal, social and economic implications. At the personal level, many Australian young people experience chronic health and/or mental health issues.17 At a social level, chronic health and/or mental health issues can exacerbate the oft-cited burden of care among family members;18,19 these issues can also limit educational opportunities20 and employment prospects.21 At an economic level, lack of well-being is likely to require more services, more hospitalisation, more treatment, more medication, and continued access to clinicians and other practitioners. Furthermore, lack of well-being foreshadows reduced employability and perhaps increased reliance on government benefits. Given there are almost 3 million young people in Australia,11 ‘adolescent health [represents] an opportunity not to be missed’.22 To harness this opportunity and enhance youth health, innovative, systemic change is required. This includes (but is not limited to) changing the types of primary care services delivered to young people, how they are delivered and how these services are supported. In this epoch of health reform, there is arguably no better time for such change. Like many other nations,23–25 Australia is witnessing ‘the single biggest health reform in a quarter of a century’,26 the essence of which is health care that is ‘funded nationally . . . and run locally’.27 Given mounting evidence on what works in youth health care,28,29 current health reforms represent a window of opportunity to promote youth health. This article reveals how recent policy developments and growing research on evidence-based youth health care provide a strong platform on which to promote youth health. This is achieved through a narrative review of recent Australian health
Journal of Paediatrics and Child Health 49 (2013) 887–890 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
887
Health reform for youth health
A Dadich et al.
reforms and empirical research. Following this review, the article concludes with a discussion of implications for policymakers, clinicians and other practitioners, as well as researchers.
Health Reforms In response to the rising rates of non-communicable diseases, the rising costs of hospital care and the ageing population, the Australian government is leading considerable health reform to alleviate the pressure on Australian health services.30 This includes working with state and territorial governments to fortify the primary care sector as the linchpin of the health system.31,32 A key part of these reforms is establishing Medicare Locals – independent primary care organisations with a mandate to provide locally responsive, planned and coordinated primary care services. More specifically, they aim to improve the patient journey by developing integrated and coordinated services, support clinicians and other practitioners in improving patient care, address local health needs, ensure the effective implementation of primary care initiatives, and ensure efficiency and accountability.33 These activities in turn are expected to reduce a hospitalcentric health system by broadening the remit of the primary care sector and ensuring that health promotion, prevention and early intervention are provided in tandem with treatment and disease management. It is envisaged that a widened scope of service delivery and population-based planning will increase the effectiveness and efficiency of the health system in meeting local needs and improving health outcomes. Despite the potential value of these reforms, their capacity to meet the complex needs of Australian young people remains to be seen. For instance, given the breadth of their remit, can Medicare Locals be sufficiently youth-friendly to appeal to young people and respond appropriately to their needs and preferences? Given the infancy of these reforms, the answer remains to be seen – however, as the following section suggests, there is a growing body of youth health research that offers constructive guidance on the establishment, operation and benefits associated with youth-friendly primary care services.
Youth Health Research There have been three decades of programmatic academic work in Australia to improve the accessibility of general practice for young people, which has centred on capacity building within the workforce and developing guidelines for service reorientation. Working with education departments on curricula to inform young people of their rights to confidential health care and improve their knowledge of how to access primary health care have been important outcomes of this research. Efforts to lobby for policy change at state and/or national government levels to improve access have paralleled these activities. This programme of research, capacity building within the sector and policy development follows an increased understanding of the issues that young people experience and recognition of the factors that shape youth access to primary care. The evidence to date shows that Australian young people aged 11 to 19 years access primary care for acute and chronic physical health conditions, such as respiratory infections, asthma, musculoskeletal injuries and acne.34 Among young 888
women aged 15–19 years, there is an increase in presentations to general practice for family planning concerns, and contraceptive management represents a small but substantial proportion of general practice encounters within this age group. Presentations about and the management of mental health issues, including depression and anxiety, are also seen in general practice in the older adolescent age group, but these rates fall far short of the estimated rates of mental health disorders in this population.35,36 General practice is also the appropriate setting for chlamydia screening in sexually active young people, but rates of testing are low.37 Youth access to primary care is hindered by several barriers – some of these are organisational, while others pertain to misapprehension. The former include service location, which can be inaccessible when transportation is limited; hours of operation; and prohibitive service costs. The latter include young people’s misconceptions about the services offered by primary care clinicians, fears of confidentiality breaches and fears of judgement with regard to sensitive issues.38 To address some of these barriers, efforts to date include educating Australian young people and clinicians and other practitioners, as well as advocating for inexpensive, if not free, health care. Although these efforts have furthered the cause of promoting youth health in Australia, considerable challenges remain. These include engaging with clinicians and other practitioners who are not youth-health-savvy, who are uncomfortable about delivering youth health care and/or who have limited access to resources to support their clinical role. Despite these challenges, the programmatic work to date in youth health collectively highlights the importance of a developmentally appropriate, patient-centred service with an orientation towards prevention and early intervention. These lessons have been used to shape a conceptual framework for a youth-friendly health service. More specifically, the epidemiology of young people’s major burden of disease reveals the role of risk-taking behaviours (e.g. unprotected sex; the use of tobacco, alcohol and other drugs; and unsafe road behaviour). It also indicates that many experience mental health issues for which they are reluctant to seek support.39,40 Young people are more likely to seek counsel from family members or friends, and they may not advise clinicians or other practitioners of their risk-taking behaviours unless asked.6 Addressing these tendencies forms the core elements of the youth-friendly service, which are echoed by international bodies like the World Health Organization (WHO). The WHO has summarised the key components of the youthfriendly service.41–43 A youth-friendly service is said to be: • available • easily accessible to young people (e.g. affordable, open at convenient times and geographically convenient) • equitable (e.g. non-judgemental; open for all young people regardless of gender, culture, marital status, socio-economic status, etc.) • acceptable to young people (e.g. clear policies about confidential and patient-centred care, using developmentally and culturally appropriate communication) • appropriate (e.g. staffed by clinicians and other practitioners who are skilled and confident in working with young people, and who have access to the resources required to deliver evidence-based care)
Journal of Paediatrics and Child Health 49 (2013) 887–890 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
A Dadich et al.
Reflecting the United Nations Convention on the Rights of the Child,44 the WHO also highlights the importance of youth participation in both the development and evaluation of health services. Youth-friendly primary care can be delivered in a range of contexts to maximise coverage and choice.6 For instance, there are youth-specific clinics that deliver enhanced primary care for a narrow range of health issues, but with strong links to other services for comorbid conditions. An Australian example is headspace,45 a federally funded health service established in 2006 ‘to improve young people’s mental, social, and emotional wellbeing through the provision of high quality, integrated services when and where they are needed’.46 In addition to youthspecific clinics there are generalist community-based health centres and private practices. These are staffed by generalist clinicians, like GPs or nurses, who can provide primary care across a range of issues. Generalist youth-specific services may integrate health care with a range of legal and welfare services and/or provide outreach clinical visits to at-risk young people, like those who are homeless. Youth-friendly primary care is also delivered within the education sector. As places where some young people spend considerable time, high schools and universities represent another opportunity to meet the health needs of young people. Some educational institutions have thus opened their doors to colocated clinics. The aforesaid Australian examples illustrate the different contexts in which youth-friendly primary care can be delivered – however, international initiatives demonstrate the value of broadening conventional understandings of primary care to encompass other disciplines, like dentistry, allied health and pharmacy. For instance, pharmacists have been promoted to young people in the UK as a youth-friendly health resource.47 The campaign, known as ‘Think Pharmacy’, encompasses online and audiovisual media to inform young people of the services that pharmacists offer and their locations – these include a music video clip and interviews with pharmacists, which are posted on YouTube. As indicated by ‘Think Pharmacy’, technology is emerging as a key player in youth-friendly primary care. A further sign of its potential is found in the work of the Young and Well Cooperative Research Centre – an Australian initiative to understand ‘the role of technology in young people’s lives, and how technology can be used to improve the mental health and wellbeing of young people aged 12 to 25’.48 Findings from its recent research suggest that moderate video game play can contribute to: reduced emotional disturbances, positive mental well-being and reduced depressed affect.49 The challenge now is to empirically determine how technology might be used within primary care to promote positive health outcomes among young people.
Discussion Given the current state of youth health, the growing research on what works in youth health care, and well-motivated health reforms championed by Australian governments, the time has never been better to promote youth health in Australia. This is largely because the research to date and the health reforms both position the primary care sector as the linchpin of the health
Health reform for youth health
system. This sector attracts the highest proportion of young people seeking health care. Furthermore, it is responsible for promoting and reinforcing prevention, early intervention and connected care.7 New governance arrangements, like those epitomised by Medicare Locals, have the potential to strengthen service connections within and beyond the primary care sector and improve service coordination. Given the complex psychosocial issues that many experience, Australian young people are likely to benefit from these new arrangements. If Medical Locals operate as planned and are guided by evidence-based research, young people are likely to experience an improved journey as they navigate different services that represent different sectors. Under the auspices of Medicare Locals, primary care clinicians potentially will be better supported and able to function more effectively, with a broader remit, in the context of their local communities. And if other aspirations in this epoch of change are met, in addition to improved patient care, greater attention will be given to population health issues, contributing to more sensible health service planning. The growing evidence base on youth health and the current epoch of health reform suggest there is much opportunity to promote and sustain youth health, particularly in the context of primary care. However, this will require political will, strong leadership and further research to help operationalise systemic change that is both effective and efficient. Together, these elements will help to harness the current window of opportunity.
Acknowledgements The authors received no additional funding for this research.
References 1 Baltag V, Mathieson A, eds. Youth-friendly health policies and services in the European region: Sharing experiences. Copenhagen: World Health Organization, 2010. 2 Healy D, Naqvi S, Meagher D, Cullen W, Dunne C. Primary care support for youth mental health: a preliminary evidence base for Ireland’s Mid-West. Ir. J. Med. Sci. 2013; 182: 237–43. 3 NSW Health. NSW youth health policy 2011–2016: healthy bodies, healthy minds, vibrant futures. Sydney: NSW Health, 2010. 4 Booth M, Bernard D, Quine S et al. Access to health care among NSW adolescents: phase 1. Sydney: NSW Health, 2002. 5 Rickwood DJ, Deane FP, Wilson CJ. When and how do young people seek professional help for mental health problems? Med. J. Aust. 2007; 187 (Suppl. 187): S35–9. 6 Tylee A, Haller DM, Graham T, Churchill R, Sanci LA. Youth-friendly primary-care services: how are we doing and what more needs to be done? Lancet 2007; 369: 1565–73. 7 National Health and Hospitals Reform Commission. A healthier future for all Australians: final report. Canberra: Commonwealth of Australia; 2009 Jun. 8 Department of Health, UK. You’re Welcome quality criteria: making health services young people friendly. London: Department of Health, 2005. 9 Department of Health and Ageing. Youth health: a summary of youth health related initiatives [Website]. Canberra: DHA (Department of Health and Ageing); 2010 [updated 31st Aug.]. Available from: http://
Journal of Paediatrics and Child Health 49 (2013) 887–890 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
889
Health reform for youth health
10
11
12 13 14
15
16
17
18
19
20
21
22 23 24 25
26
27
28
A Dadich et al.
www.health.gov.au/internet/main/publishing.nsf/Content/healthpubhlth-strateg-youth-programs.htm [accessed 12 February 2012]. Britt H, Miller GC, Charles J et al. General practice activity in Australia 2009–2010. Canberra: Australian Institute of Health and Welfare, 2010 Dec. Report No. GEP 27. Australian Bureau of Statistics. 2006 Census quickstats: New South Wales [Website]. Canberra: Australian Bureau of Statistics; 2007 [updated 10th Feb. 2008]. Available from: http://www.censusdata .abs.gov.au/ABSNavigation/prenav/ProductSelect?newproducttype =QuickStats&btnSelectProduct=View+QuickStats+%3E&collection =Census&period=2006&areacode=1&geography=&method =&productlabel=&producttype=&topic=&navmapdisplayed=true &javascript=true&breadcrumb=LP&topholder=0&leftholder=0 ¤taction=201&action=401&textversion=false [accessed 24 February 2009]. Centre for Epidemiology and Research. 1997–2007 report on young adults. Sydney: NSW Health, 2008. Wilson C, Deane F. Predicting adolescents’ future intentions to seek help for mental health problems. Youth Stud. Aust. 2011; 30: 27–33. Degenhardt L, Knox S, Barker B, Britt H, Shakeshaft A. The management of alcohol, tobacco and illicit drug use problems by general practitioners in Australia. Drug Alcohol Rev. 2005; 24: 499–506. Hassan A, Blood EA, Pikcilingis A et al. Youths’ health-related social problems: concerns often overlooked during the medical visit. J. Adolesc. Health 2013; 53: 265–71. Kennedy I. Getting it right for children and young people: overcoming cultural barriers in the NHS so as to meet their needs. London: Department of Health, 2010. Australian Institute of Health and Welfare. Young Australians: their health and wellbeing. Canberra: Australian Institute of Health and Welfare, 2011 PHE 140. Bobinac A, van Exel NJA, Rutten FFH, Brouwer WBF. Health effects in significant others: separating family and care-giving effects. Med. Decis. Making 2011; 31: 292–8. Maji KR, Sood M, Sagar R, Khandelwal SK. A follow-up study of family burden in patients with bipolar affective disorder. Int. J. Soc. Psychiatry 2011; 58: 217–23. Kalist D, Molinari N-A. The effects of mental illness on schooling. Paper presented at Economics of Population Health: Inaugural Conference of the American Society of Health Economists; 4 June 2006, Madison, WI, USA. Killackey EJ, Jackson HJ, Gleeson J, Hickie IB, McGorry PD. Exciting career opportunity beckons! Early intervention and vocational rehabilitation in first-episode psychosis: employing cautious optimism. Aust. N. Z. J. Psychiatry 2006; 40: 951–62. Kleinert S. Adolescent health: an opportunity not to be missed. Lancet 2007; 369: 1057–8. Boselie P. High performance work practices in the health care sector: a Dutch case study. Int. J. Manpow. 2010; 31: 42–58. Warwick P. Back to the future in NHS reform. J. Health Organ. Manag. 2007; 21: 194–204. Pettersen IJ, Nyland K. Reforms and clinical managers’ responses: a study in Norwegian hospitals. J. Health Organ. Manag. 2012; 26: 15–31. Rudd K, Roxon N. New directions for Australian health. Taking responsibility: labor’s plan for ending the blame game on health and hospital care. Canberra: Australian Labor Party, 2007 Aug. Contract No.: 9. Department of Health and Ageing. A national health and hospitals network for Australia’s future: delivering the reforms. Canberra: Department of Health and Ageing, 2010. Dadich A, Jarrett C, Robards F, Bennett C. Enhancing youth health in primary care: lessons learned from general practitioners. Health Commun. in press.
890
29 Jarrett C, Dadich A, Robards F, Bennett D. ‘Adolescence is difficult, some kids are difficult’: general practitioner perceptions of working with young people. Aust. J. Primary Health 2011; 17: 54–9. 30 Department of Health and Ageing. About national health reform [Website]. Canberra: Department of Health and Ageing; 2010 [updated 27th Jun.] Available from: http://www.yourhealth.gov.au/ internet/yourhealth/publishing.nsf/Content/health-reform-overview [accessed 15 May 2012]. 31 Department of Health and Ageing. Building a 21st century primary health care system: Australia’s first national primary health care strategy. Canberra: Department of Health and Ageing, 2010. 32 Standing Council on Health. National primary health care strategic framework. Canberra: Department of Health and Ageing, 2013 Apr. 33 Department of Health and Ageing. Medicare Locals operational guidelines. Canberra: Department of Health and Ageing, 2012 Sep. 34 Britt H, Miller GC, Henderson J et al. General Practice Activity in Australia 2011–2012. Sydney: University of Sydney, 2012 GEP 31. 35 Scott EM, Hermens DF, Glozier N, Naismith SL, Guastella AJ, Hickie IB. Delivering youth-specific mental health services: the advantages of a collaborative, multi-disciplinary system. Med. J. Aust. 2012; 196: 136–40. 36 Scott EM, Hermens DF, Glozier N, Naismith SL, Guastella AJ, Hickie IB. Targeted primary care-based mental health services for young Australians. Med. J. Aust. 2012; 196: 136–40. 37 Kong FYS, Guy RJ, Hocking JS et al. Australian general practitioner chlamydia testing rates among young people. Med. J. Aust. 2011; 194: 249–52. 38 Booth ML, Knox S, Kang M. Encounters between adolescents and general practice in Australia. J. Paediatr. Child Health 2008; 44: 699–705. 39 Kramer T, Garralda ME. Excellence through evidence: the what, when, and where of clinical autonomy. Br. J. Psychiatry 1998; 173: 508–13. 40 Reavley NJ, Jorm AF. Recognition of mental disorders and beliefs about treatment and outcome: findings from an Australian national survey of mental health literacy and stigma. Aust. N. Z. J. Psychiatry 2011; 45: 947–56. 41 World Health Organization. Programming for adolescent health and development: report of a WHO/UNFPA/UNICEF study group on programming for adolescent health. Geneva: World Health Organization, 1999. 42 World Health Organization. Global consultation on adolescent health services: a consensus statement. Geneva: World Health Organization, 2001. 43 Dehne K, Riedner G. Sexually transmitted infections among young people: the need for adequate health services. Geneva: World Health Organization, 2005. 44 United Nations. Convention on the Rights of the Child. Geneva: Office of the High Commissioner for Human Rights; 1989 Nov. 45 McGorry PD, Tanti C, Stokes R et al. headspace: Australia’s national youth mental health foundation – where young minds come first. Med. J. Aust. 2007; 187: S68–70. 46 Headspace. Headspace strategic plan 2012–2015. Melbourne: Headspace, 2012. 47 National Health Service, UK. Think ‘pharmacy’ [Website]. London: National Health Service; 2011. Available from: http://www .thinkpharmacy.info/ [accessed 20 July 2013]. 48 Young and Well Cooperative Research Centre. Understanding the Young and Well Cooperative Research Centre [Website]. Melbourne: Young and Well Cooperative Research Centre; 2012. Available from: http://www.yawcrc.org.au/about/young-and-well [accessed 2 January 2013]. 49 Johnson D, Jones C, Scholes L, Carras M. Videogames and wellbeing. Melbourne: Young and Well Cooperative Research Centre, 2013.
Journal of Paediatrics and Child Health 49 (2013) 887–890 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
