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Abstract
A descriptive survey regarding adolescents’ knowledge and use of local health related services and service providers was undertaken using a two stage probability sample. Two hundred and fifty three adolescents aged 14 and 15 years, attending eight of the 16 mainstream secondary schools in Stoke-on-Trent, England, were randomly selected. They were interviewed confidentially, using a semistructured questionnaire. They had used various service providers; knowledge of some local health services was poor. The preferred service provider varied with the nature of the problem. Adolescents had clear views regarding the nature of services they would like to see provided. Factors the adolescents associated with confidentiality were identified. Adolescents need information about local services. Issues they associate with lack of confidentiality should be addressed. Their preferences for care must be taken into account in developing future services.
- adolescent health
- confidentiality
- health services
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We ‘have been slow to give adolescence the same concentrated care that has gone into the study of the baby and the young child’. ‘If as a society we are to understand our adolescents instead of being estranged from them, we have to catch up fast on our ignorance of what life means to adolescents today, and what the world looks like through their eyes’. James Hemming1
Young people’s right of access to health related services, and to express opinions about them is enshrined in the United Nations Convention on the Rights of the Child.2 Recent reports add to the growing concern about the health of young people today and the future health of nations.3-7
According to the World Health Organisation (1980),8service provider may refer to an individual, a team, parents, peers, doctors, teachers, professionals, and non-professionals. The service provided may be advice, education, counselling, testing, medical, or others.
Adolescents may turn to informal service providers for advice on health related issues,9 10 yet may not know where to go with a health problem, or have difficulty getting health related help or information.11 Additionally, adolescents may forgo health care in some situations where confidentiality is not assured12; little is known about how to overcome this major barrier. Surveys frequently focus on specific service providers10 or settings,13 14 while the wider range of services available to adolescents is not addressed. The purpose of this study was thus to explore services and service provision for adolescents within its broadest context, and from the perspective of the adolescents.
This study was conducted in Stoke-on-Trent, where in common with other areas in England, a wide variety of both formal and informal services and service providers exist. Young people may seek health advice through formal services such as primary health care, school or hospital based services, or young persons’ advice centres. Other sources such as family, peer group, teachers, social workers, alternative practitioners, and the media may also be consulted.
Methods
We carried out a descriptive study using a two stage probability sample. Ethical approval was obtained. A questionnaire, developed for the purpose of data collection by interview, was pretested in a pilot study. Where possible we included questions validated by other surveys.11 12 Three questions were repeated as a check of reliability. We designed an evaluation sheet to obtain the adolescents’ opinions about the interview. Provision was made in the study design for teenagers identified during the course of their interview as requiring help. Eight of the 16 mainstream secondary schools in the city of Stoke-on-Trent were randomly selected. One school declined to participate so one further school was randomly selected. We identified pupils aged 14 and 15 years between 1 April and 30 June 1994 from computerised class lists and randomly selected 25%.
Parental and individual consent was sought after highlighting the confidential and voluntary nature of the project. Reminder letters were sent to those who did not return their forms by the required date. Non-respondents at one school were contacted by phone and subsequently interviewed. Each adolescent was interviewed in private at school by one of three female doctors, all of whom had previous experience of adolescent research. The first interview session was used as a training session and to ensure uniformity of procedures.
Responses to open ended questions were recorded verbatim and coding categories subsequently developed. At least three call backs were made to each school, in an attempt to minimise exclusions. Participants were invited to complete an evaluation form after their interview.
DATA HANDLING AND ANALYSIS
Epi-Info version 5, a statistical system for microcomputers was used for analysis. The data were double entered as two independent files and compared for discrepancies, which were traced back to the original questionnaires and corrected. The χ2 test for comparing proportions was used with Yates’s continuity correction. Differences are reported as statistically significant where p<0.05.
Results
Four hundred and ninety nine pupils were eligible for inclusion. Seventy two per cent (362), returned their parental consent forms, and 75% of these parents (272), gave consent. No adolescent in this group declined consent. Nineteen subjects were not interviewed due to repeated absences (14), being off sick (3), or having left the school (2). The original and final samples had a similar distribution of subjects by school. No significant differences were found for three repeated questions using McNemar’s test (p>0.05, p>0.1, p>0.1).
SAMPLE CHARACTERISTICS
There were 111 males and 142 females in the sample. Due to protraction of the data collection period, three pupils had turned 16 years by the time they were interviewed. The majority of the sample were white British (87%), and had no religion (60%). The distribution of these variables by sex was broadly similar (see table 1). Twenty nine per cent of the sample said they had a health problem, while 65% said they had a health worry. A wide variety of health related problems and worries relating to lifestyle and risk taking behaviour, sexual and reproductive health, emotional and related problems, and biological problems were identified. Seventy per cent of the sample had used tobacco, alcohol or drugs, either alone or in combination.
Sample characteristics by sex: age, religion, racial group, and socioeconomic status by father’s occupation (results expressed in percentages)
Use of health services in the preceeding 12 months (results expressed in percentages)
Sources of advice preferred by adolescents for various health related problems (results expressed in percentages)
Reasons given for preferred service provider for different health related problems (results expressed in percentages)
KNOWLEDGE OF LOCAL SERVICES AND SERVICE PROVIDERS
The majority knew their general practitioner by name and or sight (92%). Fewer knew their school nurse (54%) or their school doctor (6%). Knowledge of the school nurse was higher among those living in areas of high (60%, n=136) or moderate deprivation (59%, n=73) (by Jarman score) compared with those in areas of low deprivation (29%, n=38). (Jarman score not known for six subjects.)
More females (37%) than males (23%) had heard of two local contraceptive services for young people (p=0.03). These females were twice as likely to have heard about the contraceptive service from a friend (67%), compared with the males (31%).
Only nine females and one male (4% of sample) knew the location and opening times of the centres.
USE OF HEALTH RELATED SERVICES (TABLE 2)
In the preceding 12 months, more males (37%) had used the accident and emergency unit than females (25%), p=0.04. There was no statistically significant difference by sex for the other health services used.
The school health service was predominantly used for medical reviews, screening and immunisation, hospital services for injuries, and investigations such as chest radiographs and blood tests, and the general practitioner was consulted with a wide variety of physical problems including chest and skin complaints. Oral and dental problems were seen by ‘other’ doctors. Sources of advice ‘ever used’ included family members, a homoeopath, phone lines, chemists, teenage magazines, the school nurse, social workers, and hospital staff.
The girls were significantly more likely than the boys to say they had consulted an adult family member (p=0.01) or their peers/siblings (p=0.01) for health related advice.
PREFERENCES FOR HEALTH RELATED CARE (TABLES 3 AND 4)
The preferred service provider, and reasons for choosing them, varied with the nature of the problem. For example, adult family members were the preferred source of advice for a sore throat (90%) and for substance abuse (37%). However reasons for this choice were different; for the complaint of sore throat, family members were primarily consulted because they were readily available, and would try and sort the problem out. However their choice regarding substance abuse was because family members were perceived as having knowledge and understanding of the problem.
Peers/siblings were the preferred source of advice for relationship problems (52%), due to the perception they had had a similar experience/problem or had the knowledge and understanding to help, but confidentiality was the most important reason why they were consulted about contraception.
CONFIDENTIALITY
Confidentiality was an important issue for this group of adolescents. Seventy per cent felt their general practitioner would keep something confidential compared with 56% for the school nurse, 40% for school doctor, and 59% for other doctor/clinic.
Factors considered to influence confidentiality includedproximity of service provider to adolescent’s familiar environment, previous experience, attendance with a parent,relationship between service provider and others, for example adolescent, adolescent’s parents, and other context, for example school, legal obligation of service provider, andseverity of the condition (referred to as PPARLS).
Eighty four per cent felt comfortable going to see their general practitioner (always or sometimes), compared with 64% for their school nurse, and 34% for their school doctor. Significantly more of the girls (74%) felt comfortable going to see the school nurse, compared with the boys (50%) (p=0.0006). The reasons given included approachability, and confidentiality (table 5). A third of the girls felt embarrassed, shy, scared, or nervous about seeing their general practitioner.
Reasons given for feeling comfortable or uncomfortable with general practitioner, school nurse, and school doctor, by male and female adolescents (results expressed in percentages)
PREFERRED SERVICES
The majority (85%), felt that there should be health related services specifically for young people. Reasons given included teenagers have a lot of problems, a specialist is needed who understands young people, afraid or apprehensive about using existing services, prevention/education needed, existing facilities are inaccessible or insufficient, and contraceptive services are inadequate.
The variety of services the adolescents wanted to see provided, shown in fig 1, reflected their wide range of needs. Almost a third listed information/advice centres covering topics such as substance abuse prevention and treatment, healthy eating, sexuality, and puberty. Sports and recreation facilities were mentioned more frequently by boys, and the need for contraceptive services was raised mainly by girls. The other category included various suggestions such as condom machines in the girls’ toilets in school, a mobile clinic to go round the schools, and the use of school drama huts for discussion groups.
Health related services that adolescents would like to see provided for young people in their area.
Discussion
THE SURVEY
Staff at three of the schools had explained that response rates to previous surveys in this deprived inner city area were generally very low, around 30%. The overall response rate, (51%, n=499), though low, was thus higher than had been predicted. It is possible that responders may differ from non-responders and may not be representative of the whole cohort. An attempt was made to evaluate whether or not responders differed significantly from non-responders. The results of the group of non-responders who were phoned to obtain consent and subsequently interviewed did not differ in any significant way from the original group of responders.
The use of trained, experienced interviewers allowed a verbatim record of the richness of detail expressed in response to the open ended questions.
FINDINGS
The high level of knowledge and use of general practitioners, and perception of their service as generally confidential, and comfortable to visit suggests adolescents would be open to initiatives from general practitioners.15 16 However a third of the girls were not comfortable about seeing their general practitioner and specific efforts should be directed to clarifying the reasons for this. Additionally the adolescents had mainly consulted their general practitioners with physical problems, and not the variety of other health related problems they faced.
The significantly higher knowledge of the school nurse in areas of highest deprivation was consistent with the additional input of nurses in schools serving a deprived population. The poor knowledge of the school doctor may be a reflection of their high turnover, as some were on six monthly appointments, as well as their relatively infrequent visits to each school.
Some adolescents expressed a need for contraceptive services, yet many lacked awareness of two local contraceptive clinics for young people. This emphasises the importance of ensuring that adolescents have accurate knowledge about local services. Unless adolescents know about services, they cannot advise their peers when consulted, and will not know where to turn if they require help.
The larger proportion of girls consulting peers for health related advice is developmentally consistent with the difference in friendship patterns of adolescent girls who share confidences about deepest feelings and personal decisions with close friends.17 This has implications for peer education programmes which might be expected to have a greater impact on girls.
EVALUATION OF QUESTIONNAIRE
Altogether 92% of the sample completed an evaluation sheet. They generally found the questionnaire interesting, felt comfortable answering the questions, and enjoyed the chance to air their views. Unexpectedly some subjects also felt they had learnt something!
CONCLUSIONS
Efforts must be directed to ensuring that adolescents know about their local health related services. Some factors adolescents associate with confidentiality (PPARLS) have been identified in this study. These factors could be used by various service providers as the basis of discussions with adolescents regarding their rights to confidential care. Adolescents consult a variety of service providers, and their preferred source of advice varies with the nature of the problem. Adolescents have important contributions to make regarding the nature of health related services that they wish to see provided. Purchasers and providers must take adolescents’ preferences into account when planning services.
We hope these results will contribute to further understanding of adolescents’ needs and preferences for health related services, and will be translated into positive changes so that as one of the adolescents wrote on the evaluation sheet, ‘at least you can put your views across and perhaps things can get a little better’.
Acknowledgments
The views expressed are those of the authors. No external funding was obtained for this study. The authors gratefully acknowledge the support and encouragement of family and colleagues, in particular Dr M Plant, Dr M Jones, Dr G Smith, Ms J Banks, Ms J Mannion, Professor D S Southall, and Dr L Odiseng. Access to local photocopying facilities was appreciated. Our thanks also to the school nurses, the schools, the adolescents, and their families.
The questionnaire used in this study is available from Dr A C K Oppong-Odiseng on receipt of a stamped, addressed envelope.
We ‘have been slow to give adolescence the same concentrated care that has gone into the study of the baby and the young child’. ‘If as a society we are to understand our adolescents instead of being estranged from them, we have to catch up fast on our ignorance of what life means to adolescents today, and what the world looks like through their eyes’. James Hemming1