Adolescent friendly services need to accessible, equitable, acceptable, appropriate, comprehensive, effective, and efficient (1). Provider behavior is an important determinant of adolescent satisfaction with their health care. In a survey of 124 adolescents attending a university-based general adolescent medicine clinic, pre-visit attitudes about provider style predicted satisfaction with the consultation, and visit satisfaction was associated with intention to keep follow-up appointments (2). When 188 young people in the United Kingdom were asked what they wanted from their general practice, 80% rated confidentiality as important; 50% having a doctor interested in teenagers; 40% same day appointments; 33% choice of doctor gender; 39% drop-in clinics; 30% friendly receptionists (3). However, young people perceive barriers to accessing health care (4). In 253 14- and 15-year-olds interviewed with semi-structured questionnaires, knowledge of available health services was found to be poor (5). In spite of this, they expressed clear views of what was required from health services were expressed, and, again, confidentiality was identified as very important (5). Furthermore, Beresford and Sloper reported that the experiences of chronically ill adolescents in communicating with doctors raised attitudinal, behavioral, and practical factors regarding the delivery of care that the young people felt negatively affected their interactions with the doctor. Adolescents were reluctant to raise personal or sensitive issues or to ask questions that revealed poor adherence (6).
Contrary to the perception that adolescence is not associated with health problems, visits to health care professionals appear to be frequent and often problematic. Balding found that 50% of 12-15 year olds reported visiting a general practitioner (GP) within the past 3 months, 85% in the past year with 27% of females reporting feeling quite or very uneasy about the consultation (7). Donovan et al. also found that among 4000 young people aged 15 to 16 years, 53% reported problems with GP consultations (8). There has been interest in the reasons for consultations with a GP and Churchill's group found that the commonest reasons were respiratory, dermatological and musculoskeletal complaints (9). Perhaps of concern, the proportion attending for mental health problems was very small—4%, which is not in keeping with the known prevalence rates of mental health disorders in adolescents, 9% to 13% of 11- to 15- year-olds (10), suggesting a reluctance of young people to consult about these issues.
Health professionals have also reported concerns regarding their own knowledge and skills in providing adolescent health services. Out of 57 GPs interviewed individually and participating in focus groups, 91% had no or little formal training and 75% had concerns about their own competence and knowledge in delivering adolescent health care. A range of barriers was identified including confidentiality, communication and cost (11). Similarly, in a survey of a pediatric advanced trainees to elicit satisfaction with developmental-behavioral training, more than half considered themselves to be ill informed about adolescent problems (12).
There have been similar findings within the nursing profession. A national U.K. survey of 212 hospital nurses found that that average nurse spends up to 20% of his/her time with teenage patients, but only 1 in 5 had specific training to manage the emotional needs and problems that may occur in this age group (13). Gregg et al. found that GP practice nurses were uncomfortable discussing psychological issues with teenagers such as depression as well as bullying, safe sex, and drug use (14). Examining a wider range of health professionals including doctors, nurses, social workers, psychologists, and nutritionists perceived competencies for key areas of adolescent health have also been found to be low (15). In a Swiss national survey of six medical disciplines involved in adolescent care, strong interest in adolescent medicine was expressed particularly for functional symptoms, acne, obesity, and communication. However, confidentiality/legal issues, injury prevention, and the impact of chronic conditions were rated as low priority areas, reflecting further educational and training needs in epide-miological and legal/ethical issues (16).
Approximately 10% to 20% of adolescents have a chronic condition, and many will need to be able to access adult health care services for their condition when they are older. Making the change from pediatric to adult health services can be difficult. Shaw et al. conducted focus groups of young people and their carers regarding this issue and found that this time was often fraught with difficulties, anxieties, and concerns (17). The young people reported feeling "dumped" or "tossed" by their pediatric teams without any preparation for coping with adult care. Their carers or parents also had great concerns about the quality of care for their children as they became older (17). Therefore this aspect of health care delivery—transitional care is crucial and appropriate training of health care professionals in key areas for affected adolescents is essential. In a survey of 263 health professionals involved in transitional care, McDonagh et al. found that there were many unmet needs in key areas of transition, and informational resources and transitional issues were the most frequently reported areas of need. Lack of training, lack of informational resources aimed at adolescents, and limited clinic time were also identified in a second smaller survey of 22 clinical personnel (18). (For further discussion of transition, see Chapter 16.)
In a more detailed study of a children's hospital staff (n=159) and trainee pediatricians (n=54), no specific training in adolescent health was reported by 60% of the former and 58% of the latter. The most common topic to have been covered in prior teaching was the definition of adolescence and of biopsychosocial development during adolescence, but practical issues around common adolescent problems such as acne, menstrual, and mental health and musculoskeletal problems, chronic pain, chronic fatigue, epidemiology, chronic illness, resilience, and risk behaviors were rarely addressed. These topics were rated as having either high or very high importance by the majority of respondents for 85% of topics (19). Reflecting this, perceived knowledge, confidence, and skill in these areas were reported as low. High knowledge was reported in one area, which was confidentiality. There was a significant relationship between prior teaching and perceived knowledge, confidence, and skill (19). There were no major differences between the unmet training needs of doctors compared to other health professionals  supporting the potential of multiprofessional training.
Most published information comes from survey work, which does have its limitations, including low completion rates, nonrespondent biases, respondents' anxieties about admitting ignorance and unawareness of educational/training needs. Only perceived knowledge/confidence and skills can be assessed, which may not reflect the results of assessment of actual competency.
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