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Access to primary health care for Australian adolescents: How congruent are the perspectives of health service providers and young people, and does it matter?

Access to primary health care for Australian adolescents: How congruent are the perspectives of... Diana Bernard NSW Centre for the Advancement of Adolescent Health, The Children’s Hospital at Westmead, New South Wales Abstract Objective: To explore the extent of congruence between the views of service providers and young people (on adolescents’ health concerns, barriers to accessing health services and ideal service model) in order to improve and increase the appropriateness, quality and usage of primary health care ser vices. Methods: A qualitative data collection technique was used. During 2001/02, focus groups were conducted in urban and rural locations with adolescents (in and out of mainstream education), general practitioners, community health staff and youth health workers. Results: Service providers and young people identified a similar range of health concerns for young people, with young people adding additional issues of great importance to them that service providers felt were not in their ‘domain of treatment’. There was reasonable congruence in regard to ‘ideal service model’ with some differences relating to methods of information delivery. However, for ‘barriers to accessing services’ there were major discrepancies. Conclusions: While there is some common understanding between young people and service providers on certain aspects of health services, there are clearly areas where perceptions differ. This discrepancy matters because it may adversely affect the quality of provideradolescent interaction and the willingness of adolescents to access services. Implications: To deliver optimal health services to young people, the differences in understanding regarding services need to be addressed. Strategies could include promotion to, and encouragement of, young people to seek help, continuing professional education of providers and changes in remuneration policies. ( Aust N Z J Public Health 2004; 28: 487-92) Susan Quine School of Public Health, Univ ersity of Sydney, New South Wales Melissa Kang Department of General Practice, University of Sydney at Westmead Hospital, New South Wales Garth Alperstein Area Community Health Ser vices, Central Sydney Area Health, New South Wales Tim Usherwood Department of General Practice, University of Sydney at Westmead Hospital, New South Wales David Bennett Department of Adolescent Medicine, The Children’s Hospital at Westmead, New South Wales Michael Booth Centre for Research into Adolescents’ Health, University of Sydney, New South Wales mproved access to health care services by adolescents, both actual and perceived, can contrib ute significantly to their health and well-being. A number of studies have documented the health concerns most commonly e xperienced by young people and the reasons for their failure to access health care services.1-5 Other studies have discussed the variety of bar riers that young people f ace in accessing services or seeking help. These include: inadequate knowledge of available services and the processes required to access them; various concer ns regarding conf identiality and anonymity,6 embar rassment, and difficulty communicating intimate concer ns;7,8 and the percei ved attitudes of health ser vice providers, their personal characteristics, and style of consultation with young people.9-11 Studies of the provision of health care ser vices to y oung people from the perspectives of health care providers have consistently found that ser vice provider conf idence and competencies in adolescent Correspondence to: Ms Diana Bernard, School of Public Health A27, Univ ersity of Sydney, New South Wales 2006. Fax: (02) 9907 8207; e-mail: dianab@health.usyd.edu.au or dianabernard@ozemail.com.au Submitted: May 2003 Revision requested: November 2003 Accepted: May 2004 2004 VOL. 28 NO . 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Bernard et al. Article health are least strong in areas that present the greatest threats to adolescent health and well-being, such as mental health and drug and alcohol issues.12-15 Other studies have sought to describe health care provider perspectives on why young people f ail to access their ser vices. Barriers identified include lack of after hours care, long waiting times16 and cost.1,16 Most studies have examined barriers to health care from either the perspective of y oung people or the perspective of ser vice providers. Few studies have described both perspectives and none have discussed the congruence between them. The only study in the UK to examine both ser vice providers and young people’ vie ws on primary health care suggested that s ser vice providers were still inclined to stereotype adolescent clients as “indulging in risk behaviours” and that young people saw providers as authority f igures who communicated with them briskly. 17 The findings reported here for m part of the multi-phased ‘Access Study’ 18 designed to improve the quality of, and positively influence access to, primary health care for Australian adolescents. Our study suggests that young people do not attend as frequently as their health concerns warrant. We wanted to explore the views of the two groups (providers and young people) and identify the extent to which their views were congruent. It is important that the range of views of young people regarding their needs is understood by service providers in order that service provision be appropriate and of high quality. Otherwise, young people will choose not to attend or young people and service providers will continue to enter the consultation process negotiating from different perspectives, as well as different positions of power with young people feeling that their needs are not being met. The issue of congruence is not addressed in our other papers, which examined other aspects of our data: age, gender and socioeconomic differences in young people’s perceptions,19 rural/urban comparisons,20,21 and ser vice providers’ perspectives.22 interaction. It was important to have sufficient focus groups within these subgroups so that we could identify the range of differences. Sampling For the selection of study participants we used a combination, or mixed purposeful, sampling strate gy This involves using a . combination of strategies to achieve the most desirable sample relevant to the topic of interest.26 In conjunction with NSW Health, we selected 10 of the 17 Area Health Services (community health) to cover the range of locations (urban/rural/regional). In urban areas, we also stratif ied by socio-economic status. Within these same metropolitan and rural/regional communities, local GP Divisions and youth health workers were invited to participate. We sampled for diversity, 27 inviting two groups of adolescents to participate in the study: those who regularly attended school and out-of-school adolescents (those who did not attend school, attended sporadically or who had left mainstream education and attended alternative education programs). For young people in schools, we stratif ied by the characteristics (gender, age, socioeconomic status and geographic location) and recruited suf ficient students to fill the cell sizes (quota) for focus groups for each characteristic. This is a form of non-probability stratified purposive sampling25,28 used in qualitative research. Out-of-school young people were stratif ied by urban/rural place of residence (see Table 1). Recruitment Within each of the selected areas, quota sampling by required characteristics (location and socio-economic status) was used to select the high schools from which students were subsequently recruited. Out-of-school young people were recr uited through youth health ser vices in urban and rural areas and were paid for their participation. Their groups were equivalent to the Year 9/10 Method This exploratory study used a cross-sectional design to e xplore the views and experiences of young people and service providers regarding health concerns and health services. 23 A qualitative technique, focus g roups, was used to collect the data. Homogeneity in the composition of focus groups, putting participants with similar characteristics together, is recommended to encourage participants to interact freely.24 For young people, the characteristic common to all subgroups was that the y were adolescents living in New South Wales (NSW).25 For school students, the four characteristics that differentiated subgroups from each other were: gender, age, socio-economic status and geo graphic location. For young people, gender may affect participants’ willingness to speak openly, par ticularly on sexual health issues, and consequently focus g roups composed of females were conducted separately from those with males. Separate groups were also conducted for different ages and for young people from different socio-economic status backgrounds, on the basis that power differences may inhibit Table 1: Number and location of focus groups conducted with service providers and young people. Urban Service providers (18 groups) (12-15 participants per group) GPs CHC staff YHWs School students (76 groups) (6-10 participants per group) Boys 12-13 years 14-15 years 16-17 years Girls 12-13 years 14-15 years 16-17 years Out-of-school young people (five groups) (10 participants per group) 14-18 years (boys and girls) Rural VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 28 NO. 5 Mothers, Children and Adolescents Primary health care for adolescents and 11 in-school groups (see Table 1) in age with mixed gender due to the difficulties in recruiting these young people. Data from ser vice providers – general practitioners (GPs), community health-centre staff (CHCs) and youth health workers (YHWs) – was collected simultaneously in the same geographic areas. This was to ensure that any differences in the perceptions of the service providers and young people were not a function of having collected data at different times or in different places. included differences within subgroups (between boys in Year 7/ 8) and differences across subgroups (all boys in all years). Ethics The study was approved by The Children’ Hospital at s Westmead’s Human Research Ethics Committee, the NSW Depar tment of Education and Training, and the Human Ethics Committees of the Area Health Services in which health staff were inter viewed. All participating in-school young people provided infor med consent and parental consent and out-of-school young people provided their own informed consent. Data collection and analysis Topics for discussion used in the focus group topic guide29 were identified through the published literature, from the experience of the investigators and members of the project’s advisory group (representing youth health, general practitioners, community health and public education), and through the f indings from the pilot focus groups conducted with young people. The topic guide was used as an ‘aide memoire’ by the facilitator, to ensure that specific topics were raised in all groups (such as the meaning of health, with whom young people discussed any health issues, their barriers to presentation and their ideal health model). In addition, there was considerable oppor tunity for participant-initiated discussion on related topics in the main study. All focus group sessions were tape recorded with the permission of the par ticipants and transcribed. All out-of-school young people’ g roups (five) and service s provider groups (18) were analysed using NUD*IST 4. Because a large number of focus groups were conducted with in-school young people (76), analysis using NUD*IST 4 was conducted until saturation was reached (after the analysis of 51 g roups).30,31 Additional transcripts were searched manually and nothing new was identif ied. The average number of g roup participants for inschool young people was 6-10, for out-of-school y oung people it was 10, and for ser vice providers it was 12-15. Emergent themes were then identif ied and the text of the transcripts categorised under these themes. Consistency of experience in each group (i.e. the majority view) was indicated in the analysis using carefully selected quotes. Exceptions or atypical views were also described and illustrated using quotes. These Results Our findings on health concerns from the perspectives of young people and ser vice pro viders have been published and consequently are only briefly summarised here.18,19 We repor t more extensively on providers’ and young people’s views on bar riers to seeking help and ideal service models to indicate differences and similarities and why these are significant . Health concerns Although young people in our study def ined health primarily in ter ms of physical health, “f itness”, “food”, “your physical state”, “h ygiene”,“keeping your body in good condition” (compilation of comments) they were able to identify a broad range of situations, conditions or behaviours that they believed might have an impact on their health. These were consistent across groups of young people (in- and out-of-school), although there was some variation in emphasis by age, gender and location for specif ic issues.19-21 For example, se xual health issues were discussed more by females in the older (Y 10/11) age g roups19 ear and limited employment and educational opportunities were more of an issue in rural areas.20 While this was the area of greatest congruence between young people and providers, it is interesting to note (see Table 2) that one of the issues of g reatest impor tance for young people (relationships) was of least importance for providers. Service providers did not always see such issues as part of their realm of treatment, as indicated by the following quote: “I wouldn’t really see relationships as something we have the time to deal with, nor is it necessarily appropriate”(GP). Table 2: Comparison of the importance of young people’s health concerns as reported by young people and service providers. Health concerns Mental health Sexual health Drug and alcohol Stress Diet and body image Bullying Relationships Opportunities for employment and education Young people high high high moderate high low high high (rural) Service providers high high high low high not discussed low high (rural) Barriers to accessing health services Young people identified a range of bar riers to accessing services. By far the most important group of bar riers were personal concerns. Of these, confidentiality and tr ust were of greatest prominence. “Not man y people trust … (service provider) because they think not everything is confidential. (Y 10 girl). For young ” ear people, there were several aspects to the notion of confidentiality. These included difficulty in disclosing health concerns that were personal, fears around what ser vice providers might tell parents and teachers, as well as concerns about being seen when accessing a service. Young people often felt self conscious, embarrassed, 2004 VOL. 28 NO . 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Bernard et al. Article vulnerable or ashamed that they needed help. They often believed that they would be judged negatively by providers: “I think if you are a drug user they don’t want to help you, they see you as the lowest . . . (out-of-school young person). Nevertheless, some ” young people did state that if they knew a provider and had a trusting relationship with them they would be far more willing to access services: “I’ve known my GP for a while and he’s reall y good. He helps me to think through the issues. (Y 11 boy). ” ear Another frequently mentioned barrier was young people’ lack s of knowledge of the existence of services or what they provided. Only a small number of young people mentioned structural issues concerning the operation of services, such as opening hours, inadequate transport, cost and waiting lists (see Table 3). The congruence on barriers to presentation was low. Indeed, this was the area of most divergence between the views of providers and young people. Service providers’ perspectives were that structural barriers represented the greatest impediment to young people accessing health care. These included opening hours, access to public transport and appointment systems as well as the attitude of receptionists, daunting/unappealing service venues, location and the age of ser vice providers.Youth health workers mentioned these factors slightly less frequently compared with other service providers. While some service providers recognised young people’s personal barriers to presenting, the y saw them as secondary to structural barriers: “The biggest barrier s for young people are probably, having to make appointments and the cost involved. (GP). ” In an oblique way, some ser vice providers did recognise the difficulties young people experienced in attempting to present their concerns when they expressed some fr ustration in trying to unearth exactly why a young person had come to see them: “Sometimes it’s difficult to know why they are really here, how you can help them. (GP). Young people’s perceptions that many ” service providers “don’t understand” also had some foundation given service providers’ own repor ted barriers to providing health care to this group. 18,32 One difference here was youth health services, who seemed to have less difficulty relating to young Table 3: Comparison of the importance of young people’s barriers to access/help seeking as reported by young people and service providers. Barriers Confidentiality Embarrassment/shame Lack of knowledge of service or provider skills Lack of knowledge of how to access Inflexible systems (including appointments) Opening hours Cost Transport Lack of female provider people and who were generally perceived as youth friendly: “It touches our hearts when you come into a place like this (youth health service), being a little bit scared and you have these nice, beautiful people come up saying…it makes us feel a little bit confident” (out-of-school y oung person). Ideal service model There was moderate cong ruence between the vie ws of providers and young people on an ideal service model. While there was general agreement on what should be done (such as needing to become more flexible with more accessible outreach components as well as creating improved awareness of services), there was less agreement on how services should be provided. First, while both providers and young people recognised the need for more widespread education, they disagreed on the form of deliver y. Providers often offer standard method deliveries (e.g. lectures), to which young people (according to many in our study) do not listen. Young people recommended alternatives to these, including groups, peer educators or sessions with people who have experienced particular health issues (e.g. depression). Service providers completely underestimated how emphatically young people recommend input into schools as being of prime importance: “It’s so much easier to make contact if services are linked to schools. (in-school young person). Service providers ” focused more on providing optimal clinical settings: “After hours, weekends, drop in, bulk billing, younger GPs.” (GP). Young people and providers both recognised the importance of the confirmation of confidentiality. Service providers stated the need for better collaboration between providers. This fits with the views of y oung people who w anted varied contacts and information depending on their circumstances and who were confused by the cur rent multitude of different services. Fur ther Table 4: Comparison of importance placed on aspects of ideal service model, by young people and ser vice providers. Aspects of service model Contact of providers with schools Peer education/role models Group discussions Well publicised Education on accessing services Understanding staff, including female doctors Medicare only/free Explanation of confidentiality and its limitations Structural and policy changes Dedicated YWs/youth ser vices Funding for GP work in schools Non-episode funding Representation of young people on committees/service providers on school forums Young people high high moderate high high high high high not discussed moderate not discussed not discussed moderate Service providers moderate not discussed low high moderate high high high moderate high (CHC/YWs) high (GPs) high (CHC) moderate Young people high high high high low low low not discussed moderate Service providers low low low not discussed high high high high low AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH VOL. 28 NO. 5 Mothers, Children and Adolescents Primary health care for adolescents discussion from the service provider perspective is available.22 Table 4 summarises the areas of congruence and difference. Discussion, conclusions and implications Despite the high degree of cong ruence between the health concerns of young people and those perceived by service providers as relevant for them, some of the major health concerns of young people, such as mental health, drugs and alcohol, and relationships, presented the greatest challenges to ser vice providers, a f inding consistent with other studies on service providers.13-17 There was a low degree of cong ruence between young people’s perceptions of barriers to presentation and those of health service providers, with young people placing a greater importance on personal barriers and service providers placing greater emphasis on the structural characteristics of services. Our f indings on young people’s barriers to accessing services are also consistent with other studies conducted in Australia and overseas.10,17,33-35 There was moderate cong ruence between the views of providers and young people on the ideal model of ser vice provision. Their agreement on the need for more flexible outreach components to service delivery is also supported by the literature.36 Our study identif ied some major discrepancies between the perceptions of service providers and the needs of young people. This is important as it is not possible to provide quality services to young people without an accurate understanding of their needs. Service providers’ knowledge of young people was based on the knowledge of those young people w ho attended their services and their own preconceptions. This study included the views of many young people that providers did not see in their practices and with whose views they were therefore unfamiliar. The views of these non-attendees indicate that they are even less likely to present for consultation with the issues that are of most concern for them. This is an impor tant finding, emphasising the need to raise health service providers’ awareness that some of the neediest young people in terms of health ser vices are highly unlik ely to attend conventional health services. In addition, many other young people, while not so ‘at risk’, are also electing not to attend. Efforts to engage these young people are crucial. This problem can be addressed by the active encouragement of ‘help-seeking behaviour’, as well as conveying to ser vice providers the critical importance of gaining young people’s trust by attending respectfully to their concerns about confidentiality and helping them feel more comfortable about disclosing personal information. The positive regard with which youth health ser vice providers are viewed by out-of-school young people indicates that the y have an approach that could fruitfully be adopted by other health service providers. Opportunities for service providers to develop these skills in professional development should be made available, 37,38 service environments could be made more youth friendly and young people’s input into service deliver y should be sought.32,37,39 Efforts to improve access should also tackle young people’s lack of knowledge. Ser vices can provide young people with information on what services are available, how they operate and 2004 VOL. 28 NO . 5 what they might reasonably expect when they approach a ser vice. School visits by service providers can help demystify and clarify providers’ roles, as well as raise young people’ awareness of s services and represent a f irst step in gaining their acceptance and trust. Providers also need to consider how to promote their service more appropriately to young people. Outmoded education strategies should be replaced with more appropriate methods, such as interactive g roup-work and peer training. Although the structural characteristics of services were not emphasised by young people as an important barrier to the same extent as repor ted by service providers, this may have been because few young people had accessed services to date. If we are encouraging increased access, these str uctural issues also need to be addressed. While some providers understood what young people would prefer, they encountered difficulties delivering such services. Fur ther structural changes required to overcome these difficulties include improved outreach, altered funding protocols, the provision of some drop-in, longer opening hours, receptionist training and the establishment of more services close to transport. The importance of long consultations to adequately deal with young people’ concerns was another major finding. It is essential s that remuneration policies recognise the need for providers to have long consultations with some young people without being financially disadvantaged. Similarly, community health services should not be measured only b y occasions of service. Many providers also described refer ring to, or working with, other services as problematic. It would be helpful to explore systemic problems and communication issues between ser vices, as well as recognising the lack of mental health staff to meet demand. The cur rent lack of these elements impedes the service provider’ s capacity to be innovative, develop a trusting relationship, and work as effectively as they would like with young people and has not encouraged young people to present to health services in great numbers.36,39 In summary, our findings suggest less than optimal cong ruence between the views of young people and health service providers. In par ticular, there are still major misunderstandings around bar riers to presenting for help. These misunderstandings need to be addressed in order to encourage ‘help-seeking behaviour’ among young people. Our f indings also suggest that there could be a range of service deliver y models acceptable to both young people and service providers for which service providers need adequate suppor t, training and infrastructure, and young people require appropriate infor mation.34,36,38 Finally, should changes be made the y would need to be e valuated to deter mine their effectiveness in improving young people’ access to ser vices and s the quality of the services provided. Acknowledgements This research was under taken by the NSW Centre for the Advancement of Adolescent Health with funding from NSW Health. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Bernard et al. Article http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Access to primary health care for Australian adolescents: How congruent are the perspectives of health service providers and young people, and does it matter?

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Wiley
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Copyright © 2004 Wiley Subscription Services, Inc., A Wiley Company
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1326-0200
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1753-6405
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10.1111/j.1467-842X.2004.tb00033.x
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Abstract

Diana Bernard NSW Centre for the Advancement of Adolescent Health, The Children’s Hospital at Westmead, New South Wales Abstract Objective: To explore the extent of congruence between the views of service providers and young people (on adolescents’ health concerns, barriers to accessing health services and ideal service model) in order to improve and increase the appropriateness, quality and usage of primary health care ser vices. Methods: A qualitative data collection technique was used. During 2001/02, focus groups were conducted in urban and rural locations with adolescents (in and out of mainstream education), general practitioners, community health staff and youth health workers. Results: Service providers and young people identified a similar range of health concerns for young people, with young people adding additional issues of great importance to them that service providers felt were not in their ‘domain of treatment’. There was reasonable congruence in regard to ‘ideal service model’ with some differences relating to methods of information delivery. However, for ‘barriers to accessing services’ there were major discrepancies. Conclusions: While there is some common understanding between young people and service providers on certain aspects of health services, there are clearly areas where perceptions differ. This discrepancy matters because it may adversely affect the quality of provideradolescent interaction and the willingness of adolescents to access services. Implications: To deliver optimal health services to young people, the differences in understanding regarding services need to be addressed. Strategies could include promotion to, and encouragement of, young people to seek help, continuing professional education of providers and changes in remuneration policies. ( Aust N Z J Public Health 2004; 28: 487-92) Susan Quine School of Public Health, Univ ersity of Sydney, New South Wales Melissa Kang Department of General Practice, University of Sydney at Westmead Hospital, New South Wales Garth Alperstein Area Community Health Ser vices, Central Sydney Area Health, New South Wales Tim Usherwood Department of General Practice, University of Sydney at Westmead Hospital, New South Wales David Bennett Department of Adolescent Medicine, The Children’s Hospital at Westmead, New South Wales Michael Booth Centre for Research into Adolescents’ Health, University of Sydney, New South Wales mproved access to health care services by adolescents, both actual and perceived, can contrib ute significantly to their health and well-being. A number of studies have documented the health concerns most commonly e xperienced by young people and the reasons for their failure to access health care services.1-5 Other studies have discussed the variety of bar riers that young people f ace in accessing services or seeking help. These include: inadequate knowledge of available services and the processes required to access them; various concer ns regarding conf identiality and anonymity,6 embar rassment, and difficulty communicating intimate concer ns;7,8 and the percei ved attitudes of health ser vice providers, their personal characteristics, and style of consultation with young people.9-11 Studies of the provision of health care ser vices to y oung people from the perspectives of health care providers have consistently found that ser vice provider conf idence and competencies in adolescent Correspondence to: Ms Diana Bernard, School of Public Health A27, Univ ersity of Sydney, New South Wales 2006. Fax: (02) 9907 8207; e-mail: dianab@health.usyd.edu.au or dianabernard@ozemail.com.au Submitted: May 2003 Revision requested: November 2003 Accepted: May 2004 2004 VOL. 28 NO . 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Bernard et al. Article health are least strong in areas that present the greatest threats to adolescent health and well-being, such as mental health and drug and alcohol issues.12-15 Other studies have sought to describe health care provider perspectives on why young people f ail to access their ser vices. Barriers identified include lack of after hours care, long waiting times16 and cost.1,16 Most studies have examined barriers to health care from either the perspective of y oung people or the perspective of ser vice providers. Few studies have described both perspectives and none have discussed the congruence between them. The only study in the UK to examine both ser vice providers and young people’ vie ws on primary health care suggested that s ser vice providers were still inclined to stereotype adolescent clients as “indulging in risk behaviours” and that young people saw providers as authority f igures who communicated with them briskly. 17 The findings reported here for m part of the multi-phased ‘Access Study’ 18 designed to improve the quality of, and positively influence access to, primary health care for Australian adolescents. Our study suggests that young people do not attend as frequently as their health concerns warrant. We wanted to explore the views of the two groups (providers and young people) and identify the extent to which their views were congruent. It is important that the range of views of young people regarding their needs is understood by service providers in order that service provision be appropriate and of high quality. Otherwise, young people will choose not to attend or young people and service providers will continue to enter the consultation process negotiating from different perspectives, as well as different positions of power with young people feeling that their needs are not being met. The issue of congruence is not addressed in our other papers, which examined other aspects of our data: age, gender and socioeconomic differences in young people’s perceptions,19 rural/urban comparisons,20,21 and ser vice providers’ perspectives.22 interaction. It was important to have sufficient focus groups within these subgroups so that we could identify the range of differences. Sampling For the selection of study participants we used a combination, or mixed purposeful, sampling strate gy This involves using a . combination of strategies to achieve the most desirable sample relevant to the topic of interest.26 In conjunction with NSW Health, we selected 10 of the 17 Area Health Services (community health) to cover the range of locations (urban/rural/regional). In urban areas, we also stratif ied by socio-economic status. Within these same metropolitan and rural/regional communities, local GP Divisions and youth health workers were invited to participate. We sampled for diversity, 27 inviting two groups of adolescents to participate in the study: those who regularly attended school and out-of-school adolescents (those who did not attend school, attended sporadically or who had left mainstream education and attended alternative education programs). For young people in schools, we stratif ied by the characteristics (gender, age, socioeconomic status and geographic location) and recruited suf ficient students to fill the cell sizes (quota) for focus groups for each characteristic. This is a form of non-probability stratified purposive sampling25,28 used in qualitative research. Out-of-school young people were stratif ied by urban/rural place of residence (see Table 1). Recruitment Within each of the selected areas, quota sampling by required characteristics (location and socio-economic status) was used to select the high schools from which students were subsequently recruited. Out-of-school young people were recr uited through youth health ser vices in urban and rural areas and were paid for their participation. Their groups were equivalent to the Year 9/10 Method This exploratory study used a cross-sectional design to e xplore the views and experiences of young people and service providers regarding health concerns and health services. 23 A qualitative technique, focus g roups, was used to collect the data. Homogeneity in the composition of focus groups, putting participants with similar characteristics together, is recommended to encourage participants to interact freely.24 For young people, the characteristic common to all subgroups was that the y were adolescents living in New South Wales (NSW).25 For school students, the four characteristics that differentiated subgroups from each other were: gender, age, socio-economic status and geo graphic location. For young people, gender may affect participants’ willingness to speak openly, par ticularly on sexual health issues, and consequently focus g roups composed of females were conducted separately from those with males. Separate groups were also conducted for different ages and for young people from different socio-economic status backgrounds, on the basis that power differences may inhibit Table 1: Number and location of focus groups conducted with service providers and young people. Urban Service providers (18 groups) (12-15 participants per group) GPs CHC staff YHWs School students (76 groups) (6-10 participants per group) Boys 12-13 years 14-15 years 16-17 years Girls 12-13 years 14-15 years 16-17 years Out-of-school young people (five groups) (10 participants per group) 14-18 years (boys and girls) Rural VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 28 NO. 5 Mothers, Children and Adolescents Primary health care for adolescents and 11 in-school groups (see Table 1) in age with mixed gender due to the difficulties in recruiting these young people. Data from ser vice providers – general practitioners (GPs), community health-centre staff (CHCs) and youth health workers (YHWs) – was collected simultaneously in the same geographic areas. This was to ensure that any differences in the perceptions of the service providers and young people were not a function of having collected data at different times or in different places. included differences within subgroups (between boys in Year 7/ 8) and differences across subgroups (all boys in all years). Ethics The study was approved by The Children’ Hospital at s Westmead’s Human Research Ethics Committee, the NSW Depar tment of Education and Training, and the Human Ethics Committees of the Area Health Services in which health staff were inter viewed. All participating in-school young people provided infor med consent and parental consent and out-of-school young people provided their own informed consent. Data collection and analysis Topics for discussion used in the focus group topic guide29 were identified through the published literature, from the experience of the investigators and members of the project’s advisory group (representing youth health, general practitioners, community health and public education), and through the f indings from the pilot focus groups conducted with young people. The topic guide was used as an ‘aide memoire’ by the facilitator, to ensure that specific topics were raised in all groups (such as the meaning of health, with whom young people discussed any health issues, their barriers to presentation and their ideal health model). In addition, there was considerable oppor tunity for participant-initiated discussion on related topics in the main study. All focus group sessions were tape recorded with the permission of the par ticipants and transcribed. All out-of-school young people’ g roups (five) and service s provider groups (18) were analysed using NUD*IST 4. Because a large number of focus groups were conducted with in-school young people (76), analysis using NUD*IST 4 was conducted until saturation was reached (after the analysis of 51 g roups).30,31 Additional transcripts were searched manually and nothing new was identif ied. The average number of g roup participants for inschool young people was 6-10, for out-of-school y oung people it was 10, and for ser vice providers it was 12-15. Emergent themes were then identif ied and the text of the transcripts categorised under these themes. Consistency of experience in each group (i.e. the majority view) was indicated in the analysis using carefully selected quotes. Exceptions or atypical views were also described and illustrated using quotes. These Results Our findings on health concerns from the perspectives of young people and ser vice pro viders have been published and consequently are only briefly summarised here.18,19 We repor t more extensively on providers’ and young people’s views on bar riers to seeking help and ideal service models to indicate differences and similarities and why these are significant . Health concerns Although young people in our study def ined health primarily in ter ms of physical health, “f itness”, “food”, “your physical state”, “h ygiene”,“keeping your body in good condition” (compilation of comments) they were able to identify a broad range of situations, conditions or behaviours that they believed might have an impact on their health. These were consistent across groups of young people (in- and out-of-school), although there was some variation in emphasis by age, gender and location for specif ic issues.19-21 For example, se xual health issues were discussed more by females in the older (Y 10/11) age g roups19 ear and limited employment and educational opportunities were more of an issue in rural areas.20 While this was the area of greatest congruence between young people and providers, it is interesting to note (see Table 2) that one of the issues of g reatest impor tance for young people (relationships) was of least importance for providers. Service providers did not always see such issues as part of their realm of treatment, as indicated by the following quote: “I wouldn’t really see relationships as something we have the time to deal with, nor is it necessarily appropriate”(GP). Table 2: Comparison of the importance of young people’s health concerns as reported by young people and service providers. Health concerns Mental health Sexual health Drug and alcohol Stress Diet and body image Bullying Relationships Opportunities for employment and education Young people high high high moderate high low high high (rural) Service providers high high high low high not discussed low high (rural) Barriers to accessing health services Young people identified a range of bar riers to accessing services. By far the most important group of bar riers were personal concerns. Of these, confidentiality and tr ust were of greatest prominence. “Not man y people trust … (service provider) because they think not everything is confidential. (Y 10 girl). For young ” ear people, there were several aspects to the notion of confidentiality. These included difficulty in disclosing health concerns that were personal, fears around what ser vice providers might tell parents and teachers, as well as concerns about being seen when accessing a service. Young people often felt self conscious, embarrassed, 2004 VOL. 28 NO . 5 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Bernard et al. Article vulnerable or ashamed that they needed help. They often believed that they would be judged negatively by providers: “I think if you are a drug user they don’t want to help you, they see you as the lowest . . . (out-of-school young person). Nevertheless, some ” young people did state that if they knew a provider and had a trusting relationship with them they would be far more willing to access services: “I’ve known my GP for a while and he’s reall y good. He helps me to think through the issues. (Y 11 boy). ” ear Another frequently mentioned barrier was young people’ lack s of knowledge of the existence of services or what they provided. Only a small number of young people mentioned structural issues concerning the operation of services, such as opening hours, inadequate transport, cost and waiting lists (see Table 3). The congruence on barriers to presentation was low. Indeed, this was the area of most divergence between the views of providers and young people. Service providers’ perspectives were that structural barriers represented the greatest impediment to young people accessing health care. These included opening hours, access to public transport and appointment systems as well as the attitude of receptionists, daunting/unappealing service venues, location and the age of ser vice providers.Youth health workers mentioned these factors slightly less frequently compared with other service providers. While some service providers recognised young people’s personal barriers to presenting, the y saw them as secondary to structural barriers: “The biggest barrier s for young people are probably, having to make appointments and the cost involved. (GP). ” In an oblique way, some ser vice providers did recognise the difficulties young people experienced in attempting to present their concerns when they expressed some fr ustration in trying to unearth exactly why a young person had come to see them: “Sometimes it’s difficult to know why they are really here, how you can help them. (GP). Young people’s perceptions that many ” service providers “don’t understand” also had some foundation given service providers’ own repor ted barriers to providing health care to this group. 18,32 One difference here was youth health services, who seemed to have less difficulty relating to young Table 3: Comparison of the importance of young people’s barriers to access/help seeking as reported by young people and service providers. Barriers Confidentiality Embarrassment/shame Lack of knowledge of service or provider skills Lack of knowledge of how to access Inflexible systems (including appointments) Opening hours Cost Transport Lack of female provider people and who were generally perceived as youth friendly: “It touches our hearts when you come into a place like this (youth health service), being a little bit scared and you have these nice, beautiful people come up saying…it makes us feel a little bit confident” (out-of-school y oung person). Ideal service model There was moderate cong ruence between the vie ws of providers and young people on an ideal service model. While there was general agreement on what should be done (such as needing to become more flexible with more accessible outreach components as well as creating improved awareness of services), there was less agreement on how services should be provided. First, while both providers and young people recognised the need for more widespread education, they disagreed on the form of deliver y. Providers often offer standard method deliveries (e.g. lectures), to which young people (according to many in our study) do not listen. Young people recommended alternatives to these, including groups, peer educators or sessions with people who have experienced particular health issues (e.g. depression). Service providers completely underestimated how emphatically young people recommend input into schools as being of prime importance: “It’s so much easier to make contact if services are linked to schools. (in-school young person). Service providers ” focused more on providing optimal clinical settings: “After hours, weekends, drop in, bulk billing, younger GPs.” (GP). Young people and providers both recognised the importance of the confirmation of confidentiality. Service providers stated the need for better collaboration between providers. This fits with the views of y oung people who w anted varied contacts and information depending on their circumstances and who were confused by the cur rent multitude of different services. Fur ther Table 4: Comparison of importance placed on aspects of ideal service model, by young people and ser vice providers. Aspects of service model Contact of providers with schools Peer education/role models Group discussions Well publicised Education on accessing services Understanding staff, including female doctors Medicare only/free Explanation of confidentiality and its limitations Structural and policy changes Dedicated YWs/youth ser vices Funding for GP work in schools Non-episode funding Representation of young people on committees/service providers on school forums Young people high high moderate high high high high high not discussed moderate not discussed not discussed moderate Service providers moderate not discussed low high moderate high high high moderate high (CHC/YWs) high (GPs) high (CHC) moderate Young people high high high high low low low not discussed moderate Service providers low low low not discussed high high high high low AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH VOL. 28 NO. 5 Mothers, Children and Adolescents Primary health care for adolescents discussion from the service provider perspective is available.22 Table 4 summarises the areas of congruence and difference. Discussion, conclusions and implications Despite the high degree of cong ruence between the health concerns of young people and those perceived by service providers as relevant for them, some of the major health concerns of young people, such as mental health, drugs and alcohol, and relationships, presented the greatest challenges to ser vice providers, a f inding consistent with other studies on service providers.13-17 There was a low degree of cong ruence between young people’s perceptions of barriers to presentation and those of health service providers, with young people placing a greater importance on personal barriers and service providers placing greater emphasis on the structural characteristics of services. Our f indings on young people’s barriers to accessing services are also consistent with other studies conducted in Australia and overseas.10,17,33-35 There was moderate cong ruence between the views of providers and young people on the ideal model of ser vice provision. Their agreement on the need for more flexible outreach components to service delivery is also supported by the literature.36 Our study identif ied some major discrepancies between the perceptions of service providers and the needs of young people. This is important as it is not possible to provide quality services to young people without an accurate understanding of their needs. Service providers’ knowledge of young people was based on the knowledge of those young people w ho attended their services and their own preconceptions. This study included the views of many young people that providers did not see in their practices and with whose views they were therefore unfamiliar. The views of these non-attendees indicate that they are even less likely to present for consultation with the issues that are of most concern for them. This is an impor tant finding, emphasising the need to raise health service providers’ awareness that some of the neediest young people in terms of health ser vices are highly unlik ely to attend conventional health services. In addition, many other young people, while not so ‘at risk’, are also electing not to attend. Efforts to engage these young people are crucial. This problem can be addressed by the active encouragement of ‘help-seeking behaviour’, as well as conveying to ser vice providers the critical importance of gaining young people’s trust by attending respectfully to their concerns about confidentiality and helping them feel more comfortable about disclosing personal information. The positive regard with which youth health ser vice providers are viewed by out-of-school young people indicates that the y have an approach that could fruitfully be adopted by other health service providers. Opportunities for service providers to develop these skills in professional development should be made available, 37,38 service environments could be made more youth friendly and young people’s input into service deliver y should be sought.32,37,39 Efforts to improve access should also tackle young people’s lack of knowledge. Ser vices can provide young people with information on what services are available, how they operate and 2004 VOL. 28 NO . 5 what they might reasonably expect when they approach a ser vice. School visits by service providers can help demystify and clarify providers’ roles, as well as raise young people’ awareness of s services and represent a f irst step in gaining their acceptance and trust. Providers also need to consider how to promote their service more appropriately to young people. Outmoded education strategies should be replaced with more appropriate methods, such as interactive g roup-work and peer training. Although the structural characteristics of services were not emphasised by young people as an important barrier to the same extent as repor ted by service providers, this may have been because few young people had accessed services to date. If we are encouraging increased access, these str uctural issues also need to be addressed. While some providers understood what young people would prefer, they encountered difficulties delivering such services. Fur ther structural changes required to overcome these difficulties include improved outreach, altered funding protocols, the provision of some drop-in, longer opening hours, receptionist training and the establishment of more services close to transport. The importance of long consultations to adequately deal with young people’ concerns was another major finding. It is essential s that remuneration policies recognise the need for providers to have long consultations with some young people without being financially disadvantaged. Similarly, community health services should not be measured only b y occasions of service. Many providers also described refer ring to, or working with, other services as problematic. It would be helpful to explore systemic problems and communication issues between ser vices, as well as recognising the lack of mental health staff to meet demand. The cur rent lack of these elements impedes the service provider’ s capacity to be innovative, develop a trusting relationship, and work as effectively as they would like with young people and has not encouraged young people to present to health services in great numbers.36,39 In summary, our findings suggest less than optimal cong ruence between the views of young people and health service providers. In par ticular, there are still major misunderstandings around bar riers to presenting for help. These misunderstandings need to be addressed in order to encourage ‘help-seeking behaviour’ among young people. Our f indings also suggest that there could be a range of service deliver y models acceptable to both young people and service providers for which service providers need adequate suppor t, training and infrastructure, and young people require appropriate infor mation.34,36,38 Finally, should changes be made the y would need to be e valuated to deter mine their effectiveness in improving young people’ access to ser vices and s the quality of the services provided. Acknowledgements This research was under taken by the NSW Centre for the Advancement of Adolescent Health with funding from NSW Health. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Bernard et al. Article

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Oct 1, 2004

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