Editorials

Primary health care and adolescence

What do adolescents, aged between 10 and 18, need that can be supplied by primary health care? What do adolescents want from primary health care? How do adolescents use primary health care? What is in adolescent health for primary health care? The reasons for the present paucity of literature on these subjects include "labelling" of adolescents by health professionals as low users of primary health care services, confusion during the shift of responsibility for health care from parents to adolescents, the perception of doctors and nurses (shared by many parents) that adolescents are hard to understand and talk to, and a fear of unnecessarily overmedicalising adolescents' lives.

A cross sectional study found that adolescents reported coughs and colds (13%), hay fever (5%), skin problems (5%), and asthma (4%).¹ The commonest reasons for this age group to consult a general practitioner are respiratory illness, infective and parasitic diseases, diseases of the nervous system, and skin disease.² The main reasons for admission to hospital at the age of 16 are termination of pregnancy and childbirth for females and trauma for males.³ In both sexes the main cause of death is injury, followed by neoplasms and diseases of the nervous system.⁴

Recent research indicates that the main requirements of one group of adolescents from the primary health care services are confidentiality, the ability to telephone the practice without giving their names, and well written information designed specifically for them (A McPherson et al, unpublished findings). Sexually transmitted diseases, contraception, nutrition, acne, weight problems, and exercise were the subjects that they most frequently expressed an interest in discussing with a doctor or nurse.⁵

How do young people use the primary health care services? Surveys show that adolescents visit their general practitioner on average two to three times a year.^{6 7} They start making decisions about attending for health care by themselves at around the age of 15, and over 50% of boys and just under 60% of girls attend by themselves at the age of 15.⁷ Another feature is that general practitioners' consulting time with adolescents tends to be shorter than that spent with patients of other age groups--eight minutes rather than 10.⁸ It remains uncertain whether this is appropriate for the kind of illnesses being seen or means that adolescents are being short changed.

These data provide evidence for concrete action. Firstly, the characteristics of the practice populations' 10-18 year olds should be defined (for example, the local unemployment rate, number of single mothers, and number of students). Secondly, it should be positively advertised to 16 year olds on the practice register that they can register with a general practitioner who is not the same one as their parents' and that everything they discuss with practice members will be treated with absolute confidentiality. Details of specific services provided by practices--for example, emergency contraception--should be provided, especially given young people's difficulty in gaining access to emergency contraception, even when they know all about it.^{9 10} Teenagers, especially those under 16, may find specialist family planning clinics more accessible than services currently offered by general practitioners.¹¹ Thirdly, adolescents should be involved in making practices more user friendly--for example, what do they think are suitable posters, leaflets, and magazines? Fourthly, practice staff need training to be responsive to what adolescents want--they should be able to ring practices for advice without giving their names and receive a friendly response. Lastly, information cards about the practice should be available in a form that is oriented towards adolescents.¹²

What's in it for primary health care? The first question is whether health promotion by primary health care teams prevents illness and therefore decreases work in the long run. The effectiveness of any health promotion to adolescents is as contentious as that to adults¹³ and is further complicated by the fact that teenagers' beliefs do not necessarily influence their behaviours.¹⁴ However, one preliminary study has shown that adolescents were at least willing to enter into a health promotion contract to give up smoking, even if no final outcome has yet been published.¹⁵ A second benefit is the personal one of increasing the satisfaction of dealing with a patient group more effectively; training resources in adolescent health may be better directed towards primary health care than to hospital specialists in adolescence.¹⁶ One further reward could be a realistic payment for reregistration of a practice's 16 year olds. This would recognise the primary health care team's specific contribution in advertising its wares and enabling young people to access them.

However, to achieve its goals of ensuring better health for this age group, members of the primary health care team need also to remember responsibilities that lie outside their direct clinical practice: the most effective interventions in improving the health of adolescents are made by governments--improving education, reducing unemployment, and equalising the distribution of the gross national product.

Director National Adolescent and Student Health Unit, Anglia and Oxford Regional Health Authority, Oxford OX3 7LF

General practitioner Oxford OX1 2NA

Aidan Macfarlane, Ann McPherson 

1. Macfarlane A, McPherson A, McPherson K, Ahmed L. Teenagers and their health. Arch Dis Child 1987;62:1125-9. [Abstract]
2. Office of Population Censuses and Surveys. Morbidity statistics from general practice 1991-92. London:HMSO, 1995.
3. Henderson J, Goldacre M, Yeates D. Use of hospital in patient care in adolescence. Arch Dis Child 1993;169:559-63.
4. On the state of the public health 1993: the annual report of the chief medical officer of the Department of Health for the year 1993. London: HMSO, 1994.
5. Epstein R, Rice P, Wallace P. Teenagers' health concerns: implications for primary health care professionals. J R Coll Gen Pract 1989;39:247-9. [Medline]
6. Department of Health. General household survey. London: HMSO, 1992.
7. Balding J. Young people in 1993. Exeter: HEA Schools Health Education Unit. University of Exeter, 1994.
8. Jacobson L, Wilkinson C, Owen P. Is the potential of teenage consultations being missed? A study of consultation times in primary care. Fam Pract 1994;11:196-99.
9. Wareham V, Drummond N. Contraception use among teenagers seeking abortion--a survey from Grampian. The British Journal of Family Planning 1994;20:76-8.
10. Pearson VAH, Owen MR, Phillips DR, Pereira Gray DJ, Marshall MN. Pregnant teenagers' knowledge and use of emergency contraception. BMJ 1995;310:1644. [Free Full Text]
11. Allaby M. Contraceptive services for teenagers: do we need family planning clinics. BMJ 1995;310:1641-3. [Abstract/Free Full Text]
12. McPherson A. Pulse 1995;55:50.
13. Oakley A, Fullerton D, Hollland J, Arnold S, France-Dawson M, Kelley P, et al. Sexual health education interventions for young people: a methodological review. BMJ 1995;310:158-62. [Abstract/Free Full Text]
14. Sissons Joshi M, Beckett K, Macfarlane A. Cycle helmet wearing in teenagers--do health beliefs influence behaviour? Arch Dis Child 1994;71:536-9.
15. Townsend J, Wilkes H, Haines A, Jarvis M. Adolescent smokers seen in general practice: health, lifestyle, physical measurements, and response to anti-smoking advice. BMJ 1991;303:947-50.
16. Maturing dangers [editorial]. Lancet 1995;345:997-8. [Medline]