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Young People: Understanding the Links Between Satisfaction With Services and Their Health Outcomes in Primary Care
Journal of Adolescent Health 60 (2017) 358e359
www.jahonline.org Editorial
Young People: Understanding the Links Between Satisfaction With Services and Their Health Outcomes in Primary Care In many health care systems, primary care doctors such as general practitioners (GPs) and family physicians provide the first point of contact for patients of all ages, including young people. However, because young people are relatively infrequent users of services compared with other age groups [1], they may not only be given less priority in terms of consultation duration [2,3] but may also have less attention paid to their opinions and experience. For example, in a review of surveys of patient experience in the National Health Service in England over a 10year period, Hargreaves and Viner [4] found that only one of 38 included the views of young people under the age of 16 years. Consequently, any surveys that do seek the opinions of adolescents are particularly valuable in providing insights into their attitudes, experience, and use of health services. In this issue of the Journal of Adolescent Health, Yassaee et al. [5] report the findings from a large school-based crosssectional survey of young people aged between 11 and 15 years in England in 2014. This was part of the larger international World Health Organization Health Behaviours of School-Aged Children study but included additional questions relevant to individual national health care services. The results reported in this article are based on four questions about patient experience in relation to the respondent’s last GP visit (feeling respected, feeling at ease, satisfied with explanations, and feeling able to talk about personal things) and five questions about health concerns (headaches, sleep disturbance, low mood, self-harm, and overall health status). The study population was based on a random sample of school attenders in accordance with the overall study protocol and is therefore likely to be relatively representative of the general population. The authors found that approximately 80% of young people had consulted their GP within the previous 12 months and, of those who did, the majority reported a positive experience. However, despite this, nearly half felt unable to discuss personal matters with their GP and, overall, there was an inverse relationship between self-reported health status measures and satisfaction with the consultation. Young people from lower income families were likely to not only express more health
concerns but also to consult less frequently and express less satisfaction. The results of cross-sectional surveys such as this must be interpreted with caution, especially in relation to possible cause and effect. In addition, apart from headache, the health status measures in the survey were either nonspecific or directly related to psychological health and so may not reflect the fact that most primary care consultations are for physical symptoms such as respiratory, dermatological, and musculoskeletal problems, with consultations for nonspecific symptoms and mental health problems being relatively infrequent [6,7]. The results make more sense when they are interpreted in the context of what we know about primary care consultations for mental health problems, where there may not be a direct linear relationship between health concern, help seeking, consultation, and health outcome. First, during the early teenage years, symptoms of psychological distress may not be recognized or acknowledged as such by young people themselves. Even if they are, then help-seeking behavior is strongly influenced by family and peers, with the latter becoming more important with age. This is particularly so for psychological health problems where GPs are perceived as only being trained and approachable for physical health problems [8]. Young people and their parents also perceive barriers to accessing care for psychological problems and, importantly, such perceptions are greatest among those with least resources to overcome them [9]. Providing young people with information about what they might expect from a GP, including specifying their role in psychological health, may be a simple but effective way of influencing attitudes and promoting appropriate help seeking [10]. Second, within the consultation itself satisfaction is strongly influenced by whether an individual’s needs have been met. The prevalence of mental health problems in young people consulting a GP is much higher than in the community (up to one in four), but only a small proportion are detected and appropriately managed [11]. Open discussion of psychological issues in GP consultations has been found to be the most important factor in determining whether psychological difficulties are detected by
See Related Article on p. 388 Conflicts of Interest: The author has no conflicts of interest to disclose. 1054-139X/Ó 2017 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2017.01.012
Editorial / Journal of Adolescent Health 60 (2017) 358e359
GPs [12,13], but such discussion may be inhibited by embarrassment or fear that concerns will not be taken seriously [6,14]. Structured approaches to inquire about psychosocial issues in general [15] or depression specifically [16] may facilitate disclosure and detection. Failure to detect a problem may not only result in ongoing psychological distress but also in a spiral of diminished satisfaction leading to reduced likelihood of consultation or disclosure of personal problems in the future. Like most other surveys of young people’s experience, Yassaee et al. [5] acknowledge that they failed to inquire about parental involvement in the GP consultation. Early to middle adolescence represents the stage at which many young people start to develop autonomy in terms of help seeking and consultation for health problems, but this may be constrained both by health service structures and parental influence. Parents may influence decisions about whether to consult in the first place [17], while the presence of parents in the consultation itself may act to either facilitate or inhibit disclosure of information [18]. This, in turn, will affect the experience and satisfaction of the young person. Finally, while Yassaee et al. [5] propose future populationbased surveys that include more variables to allow further understanding of the trends and associations identified, there is also an urgent need for in-depth exploration of the young person-clinician encounter. This will facilitate an understanding of causality and will provide the evidence needed to refine interventions and training for practitioners to optimize both health outcomes and satisfaction for young people consulting in primary care. Richard D. Churchill, D.M. Division of Primary Care University of Nottingham Medical School Nottingham, England
References [1] Rowlands S, Moser K. Consultation rates from the General Practice Research Database. Br J Gen Pract 2002;52:658e60.
359
[2] Jacobson LD, Owen PA. Study of teenage care in one general practice. Br J Gen Pract 1993;43:349. [3] Freed GL, Spike NA, Sewell JR, et al. Changes in longer consultations for children in general practice. J Paediatr Child Health 2013;49:325e9. [4] Hargreaves DS, Viner RM. Children’s and young people’s experience of the National Health Service in England: A review of national surveys 2001e2011. Arch Dis Child 2012;97:661e6. [5] Yassaee AA, Hargreaves DS, Chester K, et al. Experience of primary care services among early adolescents in England and association with health outcomes. J Adolesc Health 2017;60:388e94. [6] Churchill RD, Allen J, Denman S, et al. Do the attitudes and beliefs of young teenagers towards general practice influence actual consultation behaviour? Br J Gen Pract 2000;50:953e7. [7] Yates P, Kramer T, Garralda E. Depressive symptoms amongst adolescent primary care attenders. Levels and associations. Soc Psychiatry Psychiatr Epidemiol 2004;39:588e94. [8] Leavey G, Rothi D, Paul R. Trust, autonomy and relationships: The helpseeking preferences of young people in secondary level schools in London (UK). J Adolesc 2011;34:685e93. [9] Nanninga M, Sijmen A, Reijneveld SA, et al. Expectations of barriers to psychosocial care: Views of parents and adolescents in the community. Eur Child Adolesc Psychiatry 2016;25:107e17. [10] Aarseth S, Ingvild Dalen I, Rikard Haavet O. Encouraging adolescents to contact their GP: A community-based trial. Br J Gen Pract 2014;64: e262e7. [11] Kramer T, Garralda ME. Child and adolescent mental health problems in primary care. Adv Psychiatr Treat 2000;6:287e94. [12] Martinez R, Reynolds S, Howe A. Factors that influence the detection of psychological problems in adolescents attending general practices. Br J Gen Pract 2006;56:594e9. [13] Freer M, Shiers D, Churchill D. Meeting the mental health needs of young people: A GP’s perspective. In: Goldie I, ed. Public Mental Health: A Handbook. Brighton: Pavilion; 2010. [14] Seamark C, Blake S. Concerning women: Questionnaire survey of consultations, embarrassment, and views on confidentiality in general practice among women in their teens, thirties and fifties. J Fam Plann Reprod Health Care 2005;31:31e3. [15] Bradford S, Rickwood D. Psychosocial assessments for young people: A systematic review examining acceptability, disclosure and engagement, and predictive utility. Adolesc Health Med Ther 2012;3: 111e25. [16] Iliffe S, Gallant C, Kramer T, et al. Therapeutic identification of depression in young people: Lessons from the introduction of a new technique in general practice. Br J Gen Pract 2012;62:e174e82. [17] Shraim M, Blagojevic-Bucknall M, Mallen CD, Dunn KM. The association between GP consultations for non-specific physical symptoms in children and parents: A case-control study. PLoS ONE 2014;9:e108039. [18] Binder P, Caron C, Jouhet V, et al. Adolescents consulting a GP accompanied by a third party: Comparative analysis of representations and how they evolve through consultation. Fam Pract 2010;27:556e62.
www.jahonline.org Editorial
Young People: Understanding the Links Between Satisfaction With Services and Their Health Outcomes in Primary Care In many health care systems, primary care doctors such as general practitioners (GPs) and family physicians provide the first point of contact for patients of all ages, including young people. However, because young people are relatively infrequent users of services compared with other age groups [1], they may not only be given less priority in terms of consultation duration [2,3] but may also have less attention paid to their opinions and experience. For example, in a review of surveys of patient experience in the National Health Service in England over a 10year period, Hargreaves and Viner [4] found that only one of 38 included the views of young people under the age of 16 years. Consequently, any surveys that do seek the opinions of adolescents are particularly valuable in providing insights into their attitudes, experience, and use of health services. In this issue of the Journal of Adolescent Health, Yassaee et al. [5] report the findings from a large school-based crosssectional survey of young people aged between 11 and 15 years in England in 2014. This was part of the larger international World Health Organization Health Behaviours of School-Aged Children study but included additional questions relevant to individual national health care services. The results reported in this article are based on four questions about patient experience in relation to the respondent’s last GP visit (feeling respected, feeling at ease, satisfied with explanations, and feeling able to talk about personal things) and five questions about health concerns (headaches, sleep disturbance, low mood, self-harm, and overall health status). The study population was based on a random sample of school attenders in accordance with the overall study protocol and is therefore likely to be relatively representative of the general population. The authors found that approximately 80% of young people had consulted their GP within the previous 12 months and, of those who did, the majority reported a positive experience. However, despite this, nearly half felt unable to discuss personal matters with their GP and, overall, there was an inverse relationship between self-reported health status measures and satisfaction with the consultation. Young people from lower income families were likely to not only express more health
concerns but also to consult less frequently and express less satisfaction. The results of cross-sectional surveys such as this must be interpreted with caution, especially in relation to possible cause and effect. In addition, apart from headache, the health status measures in the survey were either nonspecific or directly related to psychological health and so may not reflect the fact that most primary care consultations are for physical symptoms such as respiratory, dermatological, and musculoskeletal problems, with consultations for nonspecific symptoms and mental health problems being relatively infrequent [6,7]. The results make more sense when they are interpreted in the context of what we know about primary care consultations for mental health problems, where there may not be a direct linear relationship between health concern, help seeking, consultation, and health outcome. First, during the early teenage years, symptoms of psychological distress may not be recognized or acknowledged as such by young people themselves. Even if they are, then help-seeking behavior is strongly influenced by family and peers, with the latter becoming more important with age. This is particularly so for psychological health problems where GPs are perceived as only being trained and approachable for physical health problems [8]. Young people and their parents also perceive barriers to accessing care for psychological problems and, importantly, such perceptions are greatest among those with least resources to overcome them [9]. Providing young people with information about what they might expect from a GP, including specifying their role in psychological health, may be a simple but effective way of influencing attitudes and promoting appropriate help seeking [10]. Second, within the consultation itself satisfaction is strongly influenced by whether an individual’s needs have been met. The prevalence of mental health problems in young people consulting a GP is much higher than in the community (up to one in four), but only a small proportion are detected and appropriately managed [11]. Open discussion of psychological issues in GP consultations has been found to be the most important factor in determining whether psychological difficulties are detected by
See Related Article on p. 388 Conflicts of Interest: The author has no conflicts of interest to disclose. 1054-139X/Ó 2017 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2017.01.012
Editorial / Journal of Adolescent Health 60 (2017) 358e359
GPs [12,13], but such discussion may be inhibited by embarrassment or fear that concerns will not be taken seriously [6,14]. Structured approaches to inquire about psychosocial issues in general [15] or depression specifically [16] may facilitate disclosure and detection. Failure to detect a problem may not only result in ongoing psychological distress but also in a spiral of diminished satisfaction leading to reduced likelihood of consultation or disclosure of personal problems in the future. Like most other surveys of young people’s experience, Yassaee et al. [5] acknowledge that they failed to inquire about parental involvement in the GP consultation. Early to middle adolescence represents the stage at which many young people start to develop autonomy in terms of help seeking and consultation for health problems, but this may be constrained both by health service structures and parental influence. Parents may influence decisions about whether to consult in the first place [17], while the presence of parents in the consultation itself may act to either facilitate or inhibit disclosure of information [18]. This, in turn, will affect the experience and satisfaction of the young person. Finally, while Yassaee et al. [5] propose future populationbased surveys that include more variables to allow further understanding of the trends and associations identified, there is also an urgent need for in-depth exploration of the young person-clinician encounter. This will facilitate an understanding of causality and will provide the evidence needed to refine interventions and training for practitioners to optimize both health outcomes and satisfaction for young people consulting in primary care. Richard D. Churchill, D.M. Division of Primary Care University of Nottingham Medical School Nottingham, England
References [1] Rowlands S, Moser K. Consultation rates from the General Practice Research Database. Br J Gen Pract 2002;52:658e60.
359
[2] Jacobson LD, Owen PA. Study of teenage care in one general practice. Br J Gen Pract 1993;43:349. [3] Freed GL, Spike NA, Sewell JR, et al. Changes in longer consultations for children in general practice. J Paediatr Child Health 2013;49:325e9. [4] Hargreaves DS, Viner RM. Children’s and young people’s experience of the National Health Service in England: A review of national surveys 2001e2011. Arch Dis Child 2012;97:661e6. [5] Yassaee AA, Hargreaves DS, Chester K, et al. Experience of primary care services among early adolescents in England and association with health outcomes. J Adolesc Health 2017;60:388e94. [6] Churchill RD, Allen J, Denman S, et al. Do the attitudes and beliefs of young teenagers towards general practice influence actual consultation behaviour? Br J Gen Pract 2000;50:953e7. [7] Yates P, Kramer T, Garralda E. Depressive symptoms amongst adolescent primary care attenders. Levels and associations. Soc Psychiatry Psychiatr Epidemiol 2004;39:588e94. [8] Leavey G, Rothi D, Paul R. Trust, autonomy and relationships: The helpseeking preferences of young people in secondary level schools in London (UK). J Adolesc 2011;34:685e93. [9] Nanninga M, Sijmen A, Reijneveld SA, et al. Expectations of barriers to psychosocial care: Views of parents and adolescents in the community. Eur Child Adolesc Psychiatry 2016;25:107e17. [10] Aarseth S, Ingvild Dalen I, Rikard Haavet O. Encouraging adolescents to contact their GP: A community-based trial. Br J Gen Pract 2014;64: e262e7. [11] Kramer T, Garralda ME. Child and adolescent mental health problems in primary care. Adv Psychiatr Treat 2000;6:287e94. [12] Martinez R, Reynolds S, Howe A. Factors that influence the detection of psychological problems in adolescents attending general practices. Br J Gen Pract 2006;56:594e9. [13] Freer M, Shiers D, Churchill D. Meeting the mental health needs of young people: A GP’s perspective. In: Goldie I, ed. Public Mental Health: A Handbook. Brighton: Pavilion; 2010. [14] Seamark C, Blake S. Concerning women: Questionnaire survey of consultations, embarrassment, and views on confidentiality in general practice among women in their teens, thirties and fifties. J Fam Plann Reprod Health Care 2005;31:31e3. [15] Bradford S, Rickwood D. Psychosocial assessments for young people: A systematic review examining acceptability, disclosure and engagement, and predictive utility. Adolesc Health Med Ther 2012;3: 111e25. [16] Iliffe S, Gallant C, Kramer T, et al. Therapeutic identification of depression in young people: Lessons from the introduction of a new technique in general practice. Br J Gen Pract 2012;62:e174e82. [17] Shraim M, Blagojevic-Bucknall M, Mallen CD, Dunn KM. The association between GP consultations for non-specific physical symptoms in children and parents: A case-control study. PLoS ONE 2014;9:e108039. [18] Binder P, Caron C, Jouhet V, et al. Adolescents consulting a GP accompanied by a third party: Comparative analysis of representations and how they evolve through consultation. Fam Pract 2010;27:556e62.