218An opportunity for teenage health promotion in general practice: an assessment of current provision and needs

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DOI: 10.1177/001789699905800303

1999 58: 218Health Education JournalZoe AK Walker, Joy L Townsend, Janet Bell and Sally Marshall

assessment of current provision and needsAn opportunity for teenage health promotion in general practice: an

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An opportunity for teenage health promotion ingeneral practice: an assessment of currentprovision and needs

ZoeAKWalker, Joy L Townsend, Janet Bell, Sally Marshall

ZoeAK Walker, Research Fellow, Joy L Townsend, Professor of Primary Health Care, Centre forResearch in Primary and Community Care, University of Hertfordshire, Hatfield, HertsAL10 9AB.E-mail: [email protected], Janet Bell, Nurse Practitioner, The Maltings Surgery, StAlbans.Sally Marshall, Practice Nurse, Bennetts End Surgery, Hemel Hempstead. Correspondence to MsZoe AK Walker.

ABSTRACT

Survey and group work was carried out to inform a trial of teenage healthpromotion consultations in general practice and identify current provisionin general practice of health promotion for teenagers, and their needs andpreferences.Although 83 per cent of general practitioners. thought primarycare an appropriate setting for health promotion, only 17 per cent currentlyprovided services specifically for teenagers. Ninety-five per cent of the teenagersreported that they would like to receive health behaviour advice from theirgeneral practice doctor or nurse, Results of teenage group meetings held todiscuss how best to develop a consultation service are reported.

Keywords: general practice, young people, health promotionconsultations, primary care

INTRODUCTION

Despite the prevalence of health-related risk behaviour in their age group. teenagersare rarely offered health promotion advice by their doctors. Where provided in

primary care, teenage screening and systematic health checks have been wellreceived by both health professionals and p~itleiltsl*2 but such consultations havenot been evaluated in terms of behaviour change or health outcomes A. This paperreports surveys and group work carried out to identify current health promotionprovision for teenagers within genera) practice. and the perceived needs and pref-erences of teenagers in Hertfordshire. These have been carried out to inform the

development of a trial which will evaluate the effectiveness of teenage healthpromotion consultations in genera) practice.

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Health problems among teenagers

The rising incidence of smoking, drug and alcohol usc, pregnancy and the highlevels of psychological disturbance are cause for serious concern about teenagehealth. The governments public health Green Paper, Our Hoalthior Nation focuses

on prevention in four areas (heart diseasc and stroke. accidents, cancer and 171C171~11health) and specifies targets for the next 12 years to cut heart disease and stroke

by a third, accidents by a fifth, cancer deaths by a fifth and suicide by a sixt]15.

Teenagers exhibit high levels of risk factors associated with each of these areas,such as substance use (tobacco, alcohol, drugs), inadequate diet and little exercise,and poor lllCllt~ll health.

In 1996, 13 per cent of I I -1 5-year-olds reported that they smoked. with 2S percent of boys and 33 per cent of girls aged 15 being regular smokersh. The White

Paper. ,SlJ1(J~CIlICJ Kills has set a target to reduce smoking among children to 9 pcrcent or less by ?010 with a fall to 1 per cent by the year 200S7. Over 40 per centof boys and girls aged 16 reported weekly alcohol consumption at a111 average of3.4 units per boy (7.9 per drinker), and 1.6 per girl (3.8 per dllI7kC1)~; 9 per cent of

12-13-year-olds said they had taken illegal drugs or solvents, rising to 30 per centof 14-I S-year-olds and 37 per cent of I S-16-year-olds.Few 16-24-year-olds eat the recommendcd daily amount of fruit or ve~etublcs&dquo;.

Armstrongll studied patterns of physical activity among British school children

aged 1 1-16 years, and reported that boys were more active than girls, but that allhad low levels of exercise and very few undertook the recommended amount of

physical activity during the school week.It is estimated that 15 per cent of teenagers experience psychiatric disturh-

anceX.12 . There are about 400 cases of completed suicide in the age range IS- 24in England and Wales each yearl2: most are mate. Every year one in 100 girls aged15-ls attempts suicideBl, and tllC incidence of repeat para-suicide is as high as 10

per centl2, The UKranks first among European countries for teenage pIC~II~lIICy,with 9 per thousand women conceiving bCf01C age 16 years in England and Wales1996&dquo;.A 1993 survey investigated health related behaviours in 12-15-year-old shoolchildren in Hertfordshire&dquo;.A third of the girls and ? per cent of the boys aged 15were smokers: 78 per cent of the girls who smoked wished to give up. Forty-threeper cent of 14-15-year-olds had been offered or encouraged to try some form of

drug. Twenty-one per cent had loBv self-esteem.

Teenagers in general practice

Teenagers attend their general practice on average two to three times a year&dquo;.The commonest reasons for 13-16-year-olds to attend one practice in London were

upper-rcspiratory-tract infections, asthma, genera) check-ups, injuries and acne.Frequent attenders (four or more V1511S in one year) had significantly more psy-chiatric and bchavioural COIIIPILIIIItS2.

It is reported that teenagers consider their doctors surgeries to be the most

appropriate place to receive health care and trust their doctor for health-relatedinformation22. In .Iacobsen and colleagues survey of 14-] 8-year-olds. 75 per cent

said they would accept more advice about hfcstyte issues if offered in an appropriateway; 81 per cent fell that GPS should know more about their age group and said



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they would welcolne more patient-centred services 21 . The most common criticismwas lack of time to discuss health issues with the GP. Jacobsen also reported thatGPs actually did give less time per consultation to teenagers (agcd 1 1-19 ycars)than to any other age cyi-oup2. McPherson and colleagues surveyed 17-year-oldsto

identifywhat they rated as

importantin primary health care facilities, and

reported the most important criteria to be: first, confidentiality; second, anonymousaccess to advice via the telephone; and third, good written information25.2(,. The

presence of a parent at the consultation may mean that the adolescents views are

not elicited or fully taken into account, since discussion tends to take place betweenthe doctor and parcnt23.27.

Epstein and collcugues questioned 13- I 5-year-olds in inner-city London abouttheir health concerns and health-related behaviours.Although ncarly three-quar-ters of them had seen a GP recently, few had discussed their health concerns, but

reportedthat

theywould most like to talk with a health

professional about sexuallytransmitted disease (STD), contraception. menstruation (girls only), nutrition,acne, and fear of cancer-. Jones and colleagues reported that school pupils aged1 1-19 years would most like to discuss sex, stress, relationships, diet, and generalhealth29.

In 1984, Bewley;&dquo; reported that the majority of teenagers who had left schoolstill had contact with the health services; for young single parents or unemployedschool leavers, clinic services are one of the more accessible resources for personaladvice and education on health matters. However, a school survey of 12-18-year-

olds suggested that adolescents did not know how to make optimum use of primarycare services; 61 per cent did not know how to register with a GP when they lefthome, and although 60 per cent knew what was meant by emergency contraception,only a third knew they were entitled to ask a GP for it&dquo; .

Reviews of the literature identified few published papers on teenage screening or

systematic health checks in primary care 3- but those that have been reported werewell received by both health professionals and p~itleiitsl*2. However, the impact onhealth and health behaviour of such consultations has not been evaluated.A

controlled trial informed by the results reported here is planned to evaluate the

effectiveness of general practice consultations with hcalth behaviour advice andappropriate follow-up care.

METHODS

In order to ensure that a primary care service to be developed for teenagers wouldmeet their needs, two postal surveys were carried out. The first was sent to generalpractices to identify health promotion services provided for teenagers by primarycare teams.A second was sent to

teenagersthemselves to find out what information

they would like to receive and what they had received from general practice in the

previous year. The results of these surveys were then discussed in teenage focus

groups held at two practices in order to develop a pilot intervention.

Survey 1: general practice

Apostal questionnaire was sent to the senior partner of 156 practices identified

using the Modicnl Directory CD-ROM Winter 1996/97. The one-page questionnaire



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asked about current, past and future plans for services for teenagers within the

practice and in the local community, and sought views on the appropriateness of

primary care as a setting for health checks and health promotion for the teenagegroup. Respondents were asked to indicate ~11S0 whether they: thought they hadthe necessary expertise for this within the practice; would be interested in receivingtraining if available; and would be interested in participating in research in thisarea.A prepaid envelopc was provided and non-respondents were sent remindersafter one month.

Survey 2: teenagers

A postal questionnaire was sent to a random sample of 100 girls and 100 boys aged14-15 years identified from the age/sex registers of two Hertfordshire town-based

general practices. Questionnaires were returned to the researcher in a prepaid

envelope. Two reminders were spent. The one-page questionnaire was designed withthc hclp of two GPs and two practice nurses (J B, SM ). The introduction cmphasisedthat the researchers were seeking tllC teenagers views in order to make sure theservice met their needs, and that all information would be treated confidentially.

Teenagers were asked to indicate which three topics they would most like toreceive information about from their general practice and the source of health.information previously received. They were asked to Circle suggested topics orwrite in their own ideas. Topics listed in the questionnaire were based on thoseidentified in previous research-~-&dquo;: acne, contraception, depression, diet, drinkingalcohol, drug use, family problems, exercise, school problems, sexually transmitteddisease, smoking, stress. They were also asked about their preferred timing forconsultations.

Group meetings

Teenagers receiving the postal questionnaires were invited to join a group to hclpset up a service for teenagers at their local general practice surgery. Thcy were

encouraged to invite fricnds along. and pOSLCIS were displayed in practice waitingareas. Those who indicated interest in participating were sent a lettei- with infor-mation for their parents and a sllp to return to confirm parental consent. One

group met at each of the two practices for an hour and a half after school. Groupswere led by a researcher (ZW) and a practice nurse (JB/SM) who explained the

practice code of confidentiality. The teenagers discussed the implications of the

survey results, issues of confidentiality. health education and practice leaflets, andhow best to provide suitable services for their age group. The teenagers wrote downcomments about the leatlets and the researcher took notes during the discussion:

meetings were not tape-recorded. Each teenager received a music voucher for their

time and input to the project.

RESULTS

Eighty-seven questionnaires (56 per cent) were returned from general! practices.Nine were not from practising NHS GPs in Hertfordshire and were excluded; suchinaccuracies in the database suggest that the response rate may be an underestimate.



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Fifty-nine girls and 53 boys returned questionnaires: and 13 were returned asaddressee unknown (2 girl, 1 1 boys), giving an overall response rate of 60 per ccnt( I 12/187).

Thirteen practices ( 17 per cent) reported that they currently provided services

specifically for teenagers: a TeenScreen drop-in clinic (five practices); contraceptiveSC1VICes (four practices): a group SCSS1O11 one afternoon a week, an invitation toschool teavers to visit the practice to discuss health concerns: and open access tonurse counsellors and a visiting psychiatrist on u bi-weekly basis. Onc practicereported services but did not specify what they were. Four practices had dis-continued p1cBIOLISI) provided serviccs; two reported that tllls was due to poorattendance. Sixteen planned to provide services ill the future.

Only 41 per cent of girls and 23 per cent of boys reported having received advicefrom their GP or practice nurse (TCll7/( J), although most had received informationon health topics from some source (Tahlo ?). School was the most

frequentlycited

altcrnative source of information (Tah/e 3). For those who did receive informationfrom their practice nurse or doctor, the most common topics discussed were acne.diet and contraception.Most genera) practice respondents thought primary care an appropriate setting

for health promotion and health checks. Two respondents thought schools a moreappropriate setting, and the issue of confidentiality was raised by rural practiceswhere teenagers may be unwitting to attend thc village surgery for fear of beingseen.

TABLE 1 Information or advice from the general practice doctor or nurse



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TABLE 2 Number of respondents receiving information or advice from sourcesother than general practice in the last year

When the teenagers were asked to indicate up to thrcc topics they would like toreceive information ol advice about from their doctor or nursc, diet. stress, exercise

and contraception were the most common topics chosen by girls, and exercise, diet.stress and acne by bovs (see Tahfe l).Of genera) practice respondents. 56 (73 per cent) thought they had sumcient

expertise within their practice to carry out teenage health promotion and checks.

although 52 (68 pcr cent) indicated an interest ill training were it available. Forty-three (54 per cent) indicated interest in collaborating in research in this area.Whcn asked to indicate their

prclcrcnccsfor thc

lcngthof

general practiceconsultations (10, !5. ?(), or 25 minutes). 70 her cent of teenagers said that aconsultation lasting up to I S minutes would alloBv them to discuss their hcalth andllC~lflll-1~.l~lll:d concerns; very few (5 pcr cent) said they would need more than 20minutes. TIIO most popular time at which to have an appointment was after schools

TABLE 3 Sources of information other than general practice



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(68 per cent), or during school holidays (32 per ceiit). Fewer than 15 per centsuggested other times such as on Saturday or during school hours.

Group meetings

Twenty-seven teenagers expressed an interest in helping to develop a service forteenagers at their practice but not everyone could come on the same day, five girlsattended the first iiiectiiig and eight the second (three boys expressed interest injoining the group but did not attend). The teenagers said that the results of thesurvey reflected their experience, that they would prefer appointments held afterschool with some flexibility in the appointment system for those with after-schoolactivities such as sport. Saturday morning was unpopular as it was seen as a timeto lie in and relax on a non-school day.The groups were shown a selection of practice leaflets, some designed for general

use and some specifically for teenagers. They said that a specific leaflet, providingfocused information appropriate for their age group, was a good idea. The preferredformat was credit-card-sized, in a small book. Glossy paper or bright colours wcrcsuggested for the cover to attract attention and took interesting. Quality wasimportant; poor photocopies with cramped. poorly )aid-out information wereunanimously criticised. The consensus on priority for teaftct content was an cxpla-nation of the policy on confidentiality. information on about how to make acomplaint or comment about the practice without having to ask at reception, briefadvice about how to deal with common

problemssuch as headaches, information

about practice and local services, and help-lines available. Too much detail wasperceived as too heavy and would not be read. whereas too little information leftthem feeling unsure about whether it would be appropriate to call the numberssuggested.A pop-out card with key telephone numbers was requested so that itcould be detached from the leaflet and kept in a purse or wallet.The groups also discussed a selection of leaflets. aimed at the teen age range,

which addressed various topics including: diet and exercise, substance use (alcohol,drugs, tobacco), sexual health, and mental health. Thcy approved of most of theleaflets but there were clcar

preferences.Positive comments about

thecontent:

&dquo;good information - but not too much&dquo;, &dquo;good mixture of information&dquo;. &dquo;rc,>cal-

ing&dquo;. &dquo;it is good and to the point&dquo;, &dquo;funny&dquo;. In contrast. criticisms included: &dquo;toomuch warning&dquo;. &dquo;not much information&dquo;. &dquo;not realistic - no one would do a lotof the stuff&dquo;, &dquo;not aimed at our age group&dquo;, &dquo;need more humour&dquo;. They alsoexpressed strong opinions about the appearance of the teanets. Criticisms included&dquo;bad packaging&dquo;, &dquo;too big and foldy&dquo;, &dquo;dated&dquo;, &dquo;looks really boring from thecover&dquo;. In contrast they were clear about what they did like: &dquo;eye-catching&dquo;,&dquo;handy, easy to pick it up&dquo;, &dquo;lots of pictures&dquo;, &dquo;sophisticated&dquo;, &dquo;up to date&dquo;, &dquo;this

has a really good layout which makes youwanna

read it&dquo;.In one practice, an existing drop-in teen clinic was available on two cvcnings a

w~eek. Those who had used this service reported that it worked well, although theywould have preferred a daily clinic.Although they felt it was not necessary to inviteteenagers in for a consultation, an invitation for those who had not accessed theservice might prompt them to do so. The group at the practice without a teen clinicthought that inviting teenagers in to discuss health issues was a good idea, andthat they would not come unless given a specific appointment, as they would feel



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it inappropriate to call to make an appointment unless they were actually unwell.They felt that receiving an invitation to a consultation would ease the issue ofconfidentiality by providing their parents with an acceptable explanation of whythey were visiting thc surgery, but would prefer to receive pcrsonal letters ratherthan being contacted via their parents.

DISCUSSION

The response rate of 56 per cent was flirly typical of postal surveys in generalpractice. It seems likely that those who were most interested in the subject willhavc replied, and therefore thc Icvcl of service may be over-estimatcd. Neverthelessthe results indicate that the level of service provision is low; fewer than 20 per cent01~ responding practices provided services for teenagers. Only 16 practices stated

that they were aware of any local health promotion schemes aimed at teenagers,which suggested that the need was not being met elsewhere in the community.Over half of the teenagers responded to the questionnaires and gave a clear

message about what they would like from general practice. The most common

topics the teenagers chose were diet, exercise and stress, over a third of both boysand ~~ll1S choosing these topics. However, all the options given were taken up bysomeone, indicating that a broad service rather than an intervention focused on a

particular risk behaviour would be appropriate. The practitioners thought primarycare an appropriate setting for hcalth promotion and health checks and wereinterested in research and further training. The topics identified by the teenagersare also areas which concern health professionals, and this suggests an opportunityto address an 11n111Ct need.

In light of these findings, the group meetings WC1C held to 111VO1VC local teenagersin the development of a general practice consultation service, to ensure it wouldbe appropriate and meet their needs. Feedback from those who attended the

groups indicated the importance teenagers attach to being consulted about services

planned for them. The teenagers had many areas thcy wished to discuss with healtll

professionals, but also valued written information if it was presented in a teen-

friendly manner. By being asked to help plan services and design leaflets, teenagersare likcly to have a greater sense of ownership and the service is more likely toreflect their needs and preferences.As in previous studies. confidentiality andinformation tailored to the age group were highlighted as key issues in providingservices for teenagcrs25.26.

~

CONCLUSION

The earlier survey of Hertfordshire school children&dquo; had indicated a high preva-lence of health-related risk behaviour, however less than half of the girls and evenfewer boys in our sample had received information or advice from their generalpractice during the last year. Practitioners need to be aware of the inverse care

law; those most at risk are least likely to seek or want advice on their lifestylc22;although the vast majority of psychiatric, ncurological and psychosomatic com-

plaints are reported to occur in frequent attenders21.While many teenagers do havc health concerns they would like to discuss with



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a hcalth hlOlCS510I1a11. the groups lcli it unlikely that a teenager BB.C111C1 take the lirsi

step in making an appointment to discuss health issues unless they were actuallyill. inviting teenagers to the surgery for a hCallth consultation BB


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the 72 to 15Age Group in N.W. Herts. StAlbans: North West Hertfordshire Health

Authority, 1993.19 Balding J. Young People in 1994. Exeter: Schools Health Education Unit, University of

Exeter, 1995.20 Office of Population Censuses and Surveys. General Household Survey. London: HMSO,

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21 Kramer T, Iliffe S, Murray E, Waterman S. Which adolescents attend the GP? BritishJournal of General Practice 1997:47(418): 327.

22 Jacobson LD, Wilkinson CE. Review of teenage health: time for a new direction. British

Journal of General Practice 1994:44(386): 420-4.23 Jacobsen LD, Wilkinson C, Pill R, Hackett P. Communication between teenagers and

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Adolescent Health in Your Practice. Exeter: Royal College of General Practitioners,1996,55-61.

26 McPhersonA, MacfarlaneA,Allen J. What do young people want from their GP?British Journal ofGeneral Prcrclice 1996:46(411): 627.

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218An opportunity for teenage health promotion in general practice: an assessment of current provision and needs