Developing an adolescent-competent workforce
At the heart of every health system, the workforce is central to improving health.119 A wide range of professionals are involved in health care for adolescents at the primary and referral levels. In the WHO consultation with primary care providers, a wide range of professionals indicated their involvement in adolescent health care: primary care physicians (general practitioners, family doctors, paediatricians, adolescent medicine specialists); nurses (public health nurses, school nurses, nurse practitioners); allied health professionals (psychologists/counsellors, social workers, community health workers, health educators, pharmacists, physiotherapists, nursing assistants); specialist physicians (obstetrician/gynaecologists, endocrinologists, child and adolescent psychiatrists, medical officers); and midwifes.
New competencies needed for adolescent health. Efforts are underway to re-orient training programmes for health-care professionals from an acute care model to a chronic and preventive care model. This shift highlights the need for new competencies for service providers working in various settings, including primary care, school health services and outreach programmes.120-124
In adolescent care the developmental phase and context of the individual require additional skills in consultation, interpersonal communication and interdisciplinary care.125-127 One-third of primary care providers participating in the online consultation indicated that they feel somewhat confident or not confident to communicate effectively about such issues as family or intimate partner relationships, nutrition or substance use, and about half were not fully confident communicating about domestic and school violence. Furthermore, providers serving adolescents need competencies in integrated health risk assessment, motivational and cognitive approaches to counselling, awareness of the implications of the evolving capacity of the adolescent, confidentiality and transition care. Examples of specific needs are adolescents with chronic illnesses, including perinatally HIV-infected adolescents,128 129 and adolescents living with physical and mental disabilities.
Training and supervision required. Much needs to be done to achieve the reasonable expectation that every primary care provider graduates from medical or nursing school with basic knowledge about the special needs of adolescents. In reality, there is often little training, if any, provided in either pre-service or post-graduate education about the distinctive health and development needs of adolescents and how they shape clinical practice.130-134
Respondents in the consultation with primary care providers for this report very seldom reported that adolescent health was part of their pre-service training. Most of them indicated that adolescent health should be part of the undergraduate curriculum and that, without more active engagement of primary care providers in adolescent care, noncommunicable diseases and their risk factors cannot be successfully addressed. They indicated, also, a lack of the supportive supervision that is important to improve performance, job satisfaction and motivation.135 Better training opportunities and better opportunities for multidisciplinary work experience were among the three most important factors for primary care providers to engage more in adolescent health care.
The “adolescent-friendly” projects and programmes that have had a training component have, overwhelmingly, focused on in-service training rather than pre-service training. Furthermore, most funding for these interventions comes from donor agencies, which raises concerns about sustainability.
Improving providersUsing the WHO Orientation Programme and the Adolescent Job Aids, as well as other programme support materials, many countries have made progress in postgraduate in-service training of health-care providers.136-140 E-health and m-health technologies may increase health-care providers’ access to distance learning programmes as well as facilitate disease monitoring, data collection and processing for adolescent diagnosis and referral, test result notification and appointment reminders.142
assessing an adolescentChanging attitudes. Health-care providers’ performance depends on more than knowledge and skills. Community acceptance of a particular type of service and health workers’ own sociocultural backgrounds and motivation are also important.143 Health workers’ own attitudes and beliefs may deny certain services to adolescents (for example, refusing contraception to unmarried sexually active girls).144 Hand-in-hand with developing competencies in adolescent health care, training programmes, therefore, need to pay attention to exploring and changing providers’ attitudes toward adolescents and their right to quality health care.
Community health workers also should play an important role, providing adolescents with information145 and prevention services146 and referring them to appropriate services. Studies of community health workers delivering adolescent health services are limited, however.147 Monitoring and evaluation will be important to identify and disseminate effective practices.
Health workers
In order to have to see specialists, I would need my parents' approval. However, asking them to see a nutritionist or counselor would make them worry.
female, 15-17, United States of America
I use free healthcare services offered by the government. So nothing gets in the way of me using those services even if they’re not necessarily the best, I am just happy it’s an option because I don’t have the means to pay at a clinic.
female, 18-19, Mauritius
Adolescents on what stops them from using health services: Negative and judgmental attitudes of health care providers, long waiting periods, lack of trust in diagnosis (especially for elective counselling i.e.: pill pushers due to pharmaceutical company endorsement), expensive.
female, 18-19, Romania
I am scared of the gynecologist, I know I have to go one day, but the idea terrifies me.
female, 18-19, France
Adolescents on what stops them from using health services: Lack of financial resources and lack of access to good treatment.
male, 18-19, Morocco
Adolescents on what can be done to improve health services: That there be more places that offer free services as it is very necessary.
female, 18-19, Mexico
Adolescents on what can be done to improve health services: Make access to psychiatric services easier because in my opinion, it is vital to see a psychiatrist when you are an adolescent.
female, 18-19, France
Health risks are so high that services don’t have enough resources. Also the doctors are difficult to access. There are few doctors for many illnesses.
male, 18-19, Burundi
The demand for services at community health centers is far too high, which quickly becomes exasperating, and the services are terrible. The government spends more money on guns for the army than on the well-being of its population.
male, 15-17, Guatemala
Adolescents are not able to pay for themselves and have to be dependent on parents for consultations.
female, adolescent physician, India
Linking organizational and delivery of care to payment might raise the profile and lead to better care being offered. QOF drives care in the UK to a large extent and if youth health is absent from the QOF be default it is off the radar.
female, general practitioner, United Kingdom
The cost. Also the hours and availability. Calling only to find out you can have an appointment in six months, it’s discouraging.
female, 18-19, Switzerland
Adopt a system of universal healthcare, because if society possess both systems, the private system will have the tendency to look at patients as though they were clients.
male, 15-17, Canada
Adolescents on what can be done to improve health services: Educate more doctors and reinforce their competences, construct more sanitary infrastructures and equip them with modern healthcare materials.
male, 18-19, Burundi
The only problem I really want to see anyone about is, ironically, my anxiety. I intend to seek therapy after leaving home as it's meant to be extremely good. That being said, I am surprised that the NHS doesn't offer general health check-ups - nobody has ever checked to see if I am suffering from symptoms unless I bring it up myself.
male, 15-17, United Kingdom
I may not be able to improve my sexual life (as I want to be a girl) because I live in a small town with a population of approximately 25,000, and there are no experts on this subject.
trans, 12-14, Argentina
Adolescents on what stops them from using health services: In my country, the high levels of disorganization, the lack of resources. The lack of time, as there are big lines for getting medical attention that start forming extremely early in the morning.
male, 18-19, Peru
Adolescents on what can be done to improve health services: Greater flexibility and efficiency during emergencies and routine appointments, of any kind in public hospitals. Better equipment, medications in schools, more efficiency when distributing medications in hospitals, and also warmth and patience with patients.
female, 18-19, Mexico
My mum would have to know, and I am not comfortable with that.
female, 12-14, United Kingdom
I am an adolescent clinical nurse specialist and work exclusively with adolescents. However I do not have the time or resources to see them all. System problems stop me from seeing all patients.
female, nurse, United Kingdom
There is a lack of information about how to reach health services. For example, I just recently found out that my school has a nurse - two years after getting there!
female, 18-19, Peru
Improve public education and the way in which health is taught. Improve public hospitals. To have a kind of place of care or assistance where youth can go without involving parents.
female, 15-17, Mexico
Community people are conservative minded; services in the health centre are not sufficient.
male, community health worker, Bangladesh
They usually scold me when I go to clinics, saying that I am too young to have sex or ask for condoms.
male, 15-17, Mexico
Long distance from the health center, lack of information on available health services and lack of money to pay for health services like STI's treatment.
female,18-19, Uganda
Adolescents on what stops them from using health services: Fear, distance, not being aware that they are available in your region, language barriers.
female, 15-17, Switzerland
Adolescents on what stops them from using health services: Time, because there are too many people in health clinics and few doctors, meaning the waiting times are long, and I honestly don’t have the time to wait.
female, 18-19, Mexico
If I want to go to the gynecologist for any given reason, I can't go because it would show up in insurance. I can't get birth control pills, for example, because it would show up on insurance, and there's no free clinics nearby.
female, 18-19, United States of America
Education of adolescents is important - they don't know the services available to them.
female, general practitioner, Australia
Adolescents on what can be done to improve health services: To be allowed access to health services without being judged.
female, 18-19, Mexico
Delays in public services, like at the hospital; often they attend to your needs but it’s already too late, and they can be very rude, which is psychologically damaging.
female, 18-19, Mexico
