Statistics from Altmetric.com
While many governments, non governmental organisations (NGOs) and United Nations (UN) agencies have focused in the past on the health of mothers, infants and young children, there is now growing evidence that the healthcare system should also address the well-being and problems of adolescents, defined by WHO as individuals aged 10–19 years. They represent 1.2 billion individuals in the global population and between 10% and 25% of the population in European countries.1 In September 2015, the UN Secretary-General announced that the ‘Every Woman, Every Child’ agenda would move forward to 2030 as a Global Strategy for Women’s, Children’s and Adolescents’ Health. In 2017, WHO responded to the large number of health problems affecting adolescents by launching a state-of-the-art review of programmes and interventions targeting the health burden of adolescents around the world, the AA-HA initiative (‘Accelerated Action for the Health of Adolescents’). Adolescents’ morbidities such as sexually transmitted infections or unplanned pregnancies, intentional and unintentional injuries, substance abuse and chronic disorders, especially mental disorders and metabolic diseases, constitute major causes of adolescent ill-health and have both short-term and long-term consequences.2 Among the many stakeholders who need to address the issues of adolescent health (eg, policy makers, professionals in charge of environmental measures or preventive interventions in the school and the community), healthcare professionals have an important role to play. For several decades, countries such as the USA, Canada and Australia have recognised the specific needs of adolescents and have thus developed dedicated healthcare structures and a specific area of training in the field,3–5 while Europe is still lagging behind.6 7 From the viewpoint of international standards, the quality of healthcare currently delivered to adolescents in Europe is less than optimal. The objective of this paper is to examine options for improving the quality of care delivered to adolescents, with a focus on the role of the paediatric community.
WHO recently published a document on quality of care in the field of paediatrics,1 which points out how European countries can improve child and adolescent health with regard to several parameters such as effectiveness, equity, accessibility, appropriateness and acceptability of care. Two other documents focus on specific aspects of adolescent healthcare8 9 and emphasise the importance of a series of conditions that encourage healthcare institutions to adapt to the needs of this population. The present paper calls for systematic integration of human rights into actions aimed at improving health across policy and in service delivery, the provision of adequate packages of care delivered by competent staff in an age-appropriate environment, and the promotion of health literacy among adolescents as well as the encouragement of adolescents’ participation in decisions for their own care and in evaluating the quality of services delivered. The paper thus reflects a recent movement from the concept of adolescent-friendly health services towards adolescent-responsive healthcare systems that promote a holistic multilevel approach.1 8–11
Adolescents’ rights, their health literacy and participation in decision-making and evaluation processes
Since the 1978 declaration of Alma-Ata, it has been recognised that members of a community have a right to participate in all decisions regarding their health and primary care.12 This statement applies to adolescents even before they reach adulthood. How does this translate in practice? Adolescents need to be educated on what their rights are and informed on how to access holistic healthcare, thus fostering their autonomy from their parents and guardians. This particularly concerns adolescents who have dropped out of the school or those who spend their lives on the street. Ways to improve access to health structures for these adolescents include support from street social workers who know their environment and accompany them to the consultation, or the use of the internet and e-health initiatives, both of which lower the barrier to health information and interventions.13 14 Many countries have developed policies to improve equal access to healthcare, including full financial coverage of healthcare.15 Inequalities in access to healthcare too often persist for various minorities such as migrants, refugees or lesbian, gay, bisexual, and transgender persons; policies and professionals should ensure equity of access and quality of care for all adolescents, irrespective of their gender, cultural background or socioeconomic status. The school sector has a role to play in improving the health literacy of pupils. As part of the guidance provided in the network of health-promoting schools, several educational institutions in Europe have developed policies such as liaising with the primary care system or informing adolescents on how to access health services by themselves. Younger adolescents, as long as they can be considered competent, should have the right to make decisions regarding their health, and to have confidentiality assured, as long as their life is not in danger and they have not been victims of violence or abuse.16 Also, according to the Convention on the Rights of the Child,17 adolescents should be given the opportunity to express their opinions on the quality of the healthcare they receive: this can be done with surveys or youth councils based in hospitals or clinics.10 In Moldova, adolescents have been involved in the development and assessment of the ‘Neovita’ Moldovan network of adolescent-friendly services. These adolescents have then been able to spread the information among their peers, with a clear impact on attendance: from 2005 to 2008, the rate of consultations within the network has increased from around 15 000 to 70 000 a year.18
Adapting the functions of health institutions to the needs and expectations of adolescents
Over the last 15 years, many documents and papers have been published on adolescent-friendly services and healthcare.8 19 They all underline the main ingredients for high-quality healthcare according to the views of adolescents, such as flexibility of appointments, an appealing environment with clear respect for privacy, a professional and friendly attitude as well as the technical expertise and communication skills of the staff and their capacity to involve adolescents in all decisions affecting their health. This applies to public and private primary care settings as well as school health services.11 Several European countries have implemented networks of centres and clinics that target adolescent health. For instance, since two decades, France has developed a network of ‘Maisons des Adolescents’, which provides psychosocial support to adolescents and their families who face mental health problems and conflicts.20 Also, for many years, Sweden has provided counselling and healthcare activities to adolescents in the field of sexual and reproductive health with a sustainable set of friendly clinics using a confidential and holistic approach.21 Another example is the already mentioned Moldavian ‘Neovita’ project supported by Unicef, which has contributed to tangible improvements in the quality of health service provision for adolescents.22 Finally, in some countries such as Russia, school health services are developing programmes to cover the health needs of pupils.23 By providing specific training of school health professionals as well as educating pupils and school staff in the area of health, (including how to respond to emergencies), these programmes improve direct and equal access to healthcare for all pupils. In other words, the adoption of the concept of friendly healthcare should not be limited to specialised centres, but progressively implemented in every institution providing healthcare to adolescents. Public health stakeholders, paediatrics associations and associations of family practitioners should establish national packages of adolescent health interventions at primary and referral levels, and improve the capacity to deliver such packages in an integrated manner.
Improving the training and skills of healthcare providers
Increasing competencies of professionals delivering services to adolescents is of clear relevance. If they are equipped with effective communication skills and appropriate counselling techniques, it will improve the trust of adolescents towards healthcare services and thus increase access to care for those who need it. Furthermore, a skilled workforce will also affect health outcomes. Paediatricians, general practitioners, gynaecologists, nurses and other allied professionals should be able to address the specific aspects of adolescent health problems such as growth and puberty, adolescent sexual and reproductive health, mental health, nutritional needs, eating dysfunctions and substance misuse, to cite but a few. Until now, Europe has had very few academic institutions that deal specifically with adolescent health, and few general internal medicine/family practice and paediatric programmes that provide comprehensive training in this field at undergraduate or postgraduate levels. However, the importance of providing educational guidance in adolescent health and medicine is progressively coming of age. For instance, the Adolescent Medicine Division of the Department of Paediatrics of the Faculty of Medicine of Lisbon provides training sessions to medical students and residents, and has set up a Master in adolescent medicine. In Lausanne, the Interprofessional Division for Adolescent Health of the university hospital delivers formal lectures and training sessions to medical students and residents, including small group meetings involving simulated adolescent patients. Also, several publications of WHO display comprehensive information and standards on this topic.9 11 24 25 Since several years, paediatric societies include topics tackling adolescent health more systematically in the programmes of their scientific meetings and the European Academy of Paediatrics has recently published an outline of the core competencies that paediatric residents should acquire during their postgraduate training.26 Another initiative is the EuTEACH programme (European training in effective adolescent care and health; www.euteach.com), developed 20 years ago, which has contributed to the training of hundreds of health professionals as well as to development of the field of adolescent health and medicine in several European countries such as UK, Sweden, Finland, Georgia, Kosovo or Greece. Finally, yet importantly, the European Chapter of the International Association for Adolescent Health (www.iaah.org) has organised regional conferences for 20 years; these represent another opportunity for health professionals to improve their knowledge and skills.
A recent paper published in The Lancet stresses the short-term and long-term benefits for any society to invest in adolescent health.27 We hope that the present contribution illustrates how in European countries, the quality of healthcare for adolescents could be scaled up: such a goal will need multilevel interventions from professional societies and health professionals, medical faculties and training institutions as well as an increased awareness on the part of policy makers, politicians and, of course, of adolescents themselves and their families.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests MWW is a WHO staff member. His opinions do not necessarily reflect the position and policies of WHO.
Provenance and peer review Not commissioned; externally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.