Primary Care for Adolescents

Adolescence is a time when a young person develops his or her identity, acquires greater autonomy and independence, experiments and takes risks and grows mentally and physically. To successfully navigate these changes, an accessible and health system when needed is essential. We assessed the structure and content of national primary care services against these standards in the ﬁ eld of adolescent health services. The main criteria identi ﬁ ed by adolescents as important for primary care are as fol-lows: accessibility, staff attitude, communication in all its forms, staff competency and skills, con ﬁ dential and continuous care, age appropriate environment, involvement in health care, equity and respect and a strong link with the community. We found that although half of the Models of Child Health Appraised countries have adopted adolescent-speci ﬁ c policies or guidelines, many countries do not meet the current standards of quality health care for adolescents. For example, the ability to provide emergency mental health care or respond to life-threatening behaviour is limited. Many countries provide good access to contraception, but specialised care for a pregnant adolescent may be hard to ﬁ nd. Access needs to be improved for vulnerable adolescents; greater advocacy should be given to adolescent health and the promotion of good health habits. Adolescent health services should be well publicised, and adolescents need to feel empowered to access them.


Introduction
Adolescents (defined in this survey as individuals aged 10À19 years) have specific needs compared with younger children. They are in the process of developing their identity and acquiring autonomy, their bodies and minds are growing, and it is a time of experimenting and risk-taking, and increasing independence (Jansen et al., 2018;Michaud, Blum, & Ferron, 1998;WHO, 2014b). Adolescents need to feel confident in their ability to access primary care services, in the form of advice, prevention and treatment services À independently of their parents or guardians if appropriate (Michaud et al., 2010). Models of Child Health Appraised (MOCHA) has identified young people as an important group in terms of their health and also in terms of children's rights (United Nations General Assembly, 1990). Adolescents should be respected and involved as much as possible in all decisions regarding their life and their health. To provide optimal services, the primary healthcare system and the health professionals providing services need to recognise the needs of adolescents and adapt policies accordingly .
The health of an adolescent depends on many factors that lie beyond the healthcare system, such as the economic situation of the country, the climate and the culture, the organisation of the educational system, the presence or absence of preventive activities and so on (see Chapter 17; Patton et al., 2012;Patton et al., 2016;World Health Organization, 2014b;World Health Organization, 2017;WHO, 2014a). MOCHA investigated the extent to which the current health systems of European countries met the healthcare needs of adolescents aged 10 − 18, as being the upper age of childhood as defined by the Convention on the Rights of the Child (CRC) (United Nations, 1989).
There are models of quality health care available for adolescents Michaud, Weber, Namazova-Baranova, & Ambresin, 2018;World Health Organization, 2014;World Health Organization, 2015a;World Health Organization, 2015b;World Health Organization, 2015c), most of which refer to the concept of adolescent/youth-friendly health services and care jointly developed by the World Health Organization (WHO), United Nations Children's Fund (UNICEF) and United Nations Population Fund (UNFPA). These models have also been validated by young people themselves (Ambresin, Bennett, Patton, Sanci, & Sawyer, 2013), as a result of surveys about the main ingredients of fair and high-quality health services and care. The main criteria mentioned by young people in this survey are as follows: • accessibility (flexible schedule, possibility to drop in), location (public transportation), affordability (financial coverage) and equity; • staff attitude: respectful, supportive, empathetic, trustworthy and honest; • communication: developmentally appropriate, understandable, active listening and provision of information; • staff competency and skills, both technical and medical (health care), and comprehensive and holistic approach (multi professional: e.g. providing curative and preventive services in the broad area of adolescent health, including mental health, substance use, sexual & reproductive health) (see Chapter 13); • guideline-driven care: confidentiality, autonomy, privacy and continuity of care; • age appropriate environment: clean and teen-oriented physical space, health information, access to internet, pamphlets and leaflets; • involvement in health care, participation, shared decision-making approach and continuity of care; • equity and respect of adolescents' rights (CRC); and • link with the community, networking approach and community support; These comments align closely with MOCHA findings from young people about their experiences of primary care (see Chapter 3), and MOCHA sought to address whether the experience of primary healthcare services met these standards.
This report complements the survey on school health services, as described in Chapter 11, and assesses the extent to which the structure and content of primary care services comply with available standards in the field of adolescent health care.

Methods
We created a questionnaire on adolescent primary care services to be sent to the MOCHA country agents (see Chapter 1). The questionnaire was divided into three sections and contained 43 questions on structural and content issues that are specific to adolescent care. Each section began with a typical clinical vignette to assist the Country Agent in understanding what information was expected. These included the existence of guidelines or policies regarding adolescentfriendly health services and care, the respect of adolescent rights, access of adolescents to appropriate health care as well as the continuity of care. The two last sections of the questionnaire focussed on two major healthcare areas during adolescence: mental health and self-harm, and sexual and reproductive health. Complete data from all thirty countries were available for analysis.

Adolescent Primary Care Services
We assessed the country agent answers against the existing adolescent-friendly health services and care (AFHSC) guidelines. Thirteen out of the 30 countries surveyed indicated that they were aware of and follow the AFHSC guidelines, and a document to this end is available nationally. However, it was impossible to ascertain whether the documents are applied and to what extent. One of the questions tackled the existence of specialised services for adolescents. More than half the countries (16/30) have set up such specialised centres to deliver adolescent health care, although these are likely to be in selected cities and not in all regions of a country. Some units address specific issues (such as sexual and reproductive life or mental health), and some are more broadly oriented. Many, if not most, are run by multidisciplinary team (N = 16), and in eleven countries, the country agents claim that professionals in charge have received formal training in adolescent health (see Chapter 13). Figure 12.1 shows the countries that have an extensive policy on adolescent health services as recommended currently (Kokotailo et al., 2018). For more information, see Jansen et al. (2018).

Adolescents' Rights and Ethical Issues
The respect of confidentiality and privacy is, according to young people, of utmost importance, and this applies to all countries of the world (see Chapter 3; Baltag & Mathison, 2010;Bell, Breland, & Ott, 2013; Committee on Adolescence, 2016; National Research Council and Institute of Medicine, 2009;World Health Organization, 2016;Michaud et al., 2010). Indeed, when it comes to discussing sensitive issues such as sexual conduct or contraception, risktaking, problematic eating patterns or substance use, young people need to be confident that the healthcare professional will not disclose information unless the situation is life threatening or unless the adolescent feels comfortable to disclose. However, the right to confidentiality is linked with the young person's decision-making capacity (competence), and healthcare providers are not necessarily well equipped to assess such a capacity (Michaud, Blum, Benaroyo, Zermatten, . In 13 out of the thirty countries surveyed, the existence of a formal legislation or policy tackling the issue of confidentiality was confirmed by country agents. Five countries also have policies but restricted by an age range. In only nine countries, guidelines are available about how to assess a young person's competence. Another important aspect of confidentiality is the right of a young person to access health care without the knowledge of parents. In 20 countries, adolescents have the right to consult a doctor without parents (or any substitute) knowing, and in around the same proportion of countries, adolescents have the right to choose their doctor themselves (N = 17). Finally, shared decision-making, for example the right to refuse a treatment or choosing another alternative than the one chosen by the parents, is a right that should be given to competent young patients. In around half of the countries (N = 9), a policy exists to guarantee such a right.

Access to Health Care
Access to health care is an important issue for adolescents. Blair, Rigby, and Alexander (2017) stated that most European countries provide some kind of sustainable insurance system that covers the healthcare expenditures of children and young people. The potentially limiting factors to access of adolescents to health care is thus more likely linked to a lack of knowledge of what exists and where to be able to consult freely and expect high-quality health care. In addition to this, it is sometimes difficult to access services because of a lack of availability, due to under-resourcing or a shortage of health professionals skilled in adolescent health care. This is particularly pertinent to so-called vulnerable adolescents, such as migrants and adolescents from deprived socio-economic background or 'drop-out' adolescents who are homeless or in temporary accommodation. Globally, around 50% of countries have developed policies or strategies that aim to improve access to care for adolescents facing situations of vulnerability. In around half of the countries (N = 16), it is possible for adolescents in such situations to consult primary care spontaneously. Half of the countries are able to offer translators if needed, at least in some regions, and/or to provide professionals who have an expertise in cross-cultural issues. Moreover, just about two thirds of the countries (N = 20) have policies which encourage an inter-professional approach to disruptive behaviour adolescents having left or being about to leave the mainstream educational system (see Chapter 11).

Access to Mental Health Care and Sexual and Reproductive Health Care
Issues such as conduct disorders, violence, depression and self-harm/suicide are increasingly recognised as important threats to adolescents' mental health (Nair et al., 2015;Patton et al., 2012;Potrebny, Wiium, & Lundegard, 2017;Steinberg et al., 2017). The majority of countries (N = 25) have some kind of suicide prevention programme, and a similar number are able to provide same-day referral appointments for suicide or mental health breakdown, but only half (N = 14) of the surveyed countries provide guidelines to primary care physicians as how to screen for mental health problems and disorders in adolescents, and only fourteen provide recommendations as how to screen for adolescent mental health problems (Table 12.

1).
In all the countries who replied to the questionnaire (n = 30), it is possible for a young person to obtain emergency contraception. In about half of the countries (n = 24), there are multiple options where a young person can obtain emergency contraception, such as in a pharmacy, a health clinic, the emergency department of a hospital or via a primary care practitioner. 25 countries have multiple options to obtain pregnancy tests, and in most countries (n = 24), condoms are easily available. Only eleven countries, however, provide oral contraception free of charge, although, on the whole, adolescents can obtain such contraception easily in most countries, but in only 16 countries, it is possible for the adolescents to visit a doctor without their parents knowing. More than half of the surveyed countries (N = 16) have centres which provide counselling and care in sexual and reproductive health (although some centres address all ages, not specifically adolescents). In terms of primary care, however, only eight countries have specific guidelines or policies about how to address adolescent pregnancy.

Summary
Although around half of the MOCHA countries have adopted policies or guidelines that aim to secure equal access to primary care for most adolescents, including the most vulnerable, many countries of the EU and EEA lag far behind the current standards of quality health care for adolescents. The situation seems not to have improved since ten years (Ercan et al., 2009) Only a minority of countries are equipped to identify and respond to mental health emergencies and life-threatening behaviour. Access to contraception is good in most countries, but very few have developed guidelines for practitioners to help care for a pregnant adolescent. In addition, while many countries support the concept of confidential health care, only a small number provide guidelines to professionals as how to address adolescents' competence. This situation is all the more problematic as evidence suggests that the quality of primary care services has a positive effect on the health of young people (Carai, Bivol, & Chandra-Mouli, 2015;Kalamar, Bayer, & Hindin, 2016;Sanci et al., 2015). Addressing the need for specific training of health professionals is of prime importance to improve the delivery of adolescent-focused health care (see Chapter 12), and successfully addressing the complex, changing needs of adolescents (World Health Organization, 2015c).
In summary, there is a need for all European countries to endorse policies and strategies regarding adolescent-friendly primary care in order to improve access and quality of care for young people. The creation of specific youth clinics and addressing other important primary care services, such as public or private consultation offices and hospitals, will help to achieve these aims. No country comprehensively responds to the many facets of quality adolescent care: some have strong policies but do not secure easy access while others are in the opposite situation. Thus, all European countries, and especially those that have a weak corpus of policies, recommendations or specific healthcare strategies (Cyprus, Hungary, Iceland, Latvia, Lithuania, Malta, Poland, Romania and Slovakia) can begin improvement in different ways.
• Physicians, especially those involved in scientific organisations or in public health activities should advocate for adolescent health, sensitising colleagues and policy-makers to the importance of this cohort. Adoption of good lifestyles during this period of life will profoundly affect their health for the rest of their life (see Chapter 2). • Addressing health-compromising behaviour, supporting healthy habits is the responsibility of adolescents' primary care providers (Patton et al., , 2016World Health Organization, 2017). European countries must develop policies and strategies which improve access to adolescents facing situations of vulnerability; particularly in the area of mental health and sexual and reproductive health. Schools, ambulatory settings and hospitals should offer easily identified, low-threshold comprehensive health care and a culturally appropriate approach, given the number of migrant adolescents being hosted in most European countries (see Chapter 11). • Also, services to adolescents, even if they follow the evidence-based standards, will not be effective if young people themselves are inadequately informed or able to access them. It is the task of both the education and the healthcare systems to assist young people to understand their rights and responsibility for their health, and how and where to access to adequate care. • One of the best ways to improve the quality of care delivered to adolescents is to improve the training of healthcare providers (Michaud et al., 2017). This is addressed in Chapter 13.