Chapter 12

Primary Care for Adolescents

Pierre-André Michaud, Johanna P.M. Vervoort and Danielle
Jansen

Abstract
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 field of adolescent health services. The main
criteria identified by adolescents as important for primary care are as fol-
lows: accessibility, staff attitude, communication in all its forms, staff com-
petency and skills, confidential 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-specific policies or guidelines, many
countries do not meet the current standards of quality health care for ado-
lescents. 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 find.
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 adoles-
cents need to feel empowered to access them.

Keywords: Adolescents; health care; preventive care; primary care services;

mental health; sexual and reproductive health

r European Commission. Published by Emerald Publishing Limited. This chapter is

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238 Pierre-André Michaud et al.

Introduction
Adolescents (defined in this survey as individuals aged 10 19 years) have spe-
cific needs compared with younger children. They are in the process of develop-
ing 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 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 pro-
viding services need to recognise the needs of adolescents and adapt policies
accordingly (Sawyer et al., 2014).
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 &
Baltag, 2015; 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 trans-

portation), 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
 Primary Care for Adolescents 239

curative and preventive services in the broad area of adolescent health, includ-
ing 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 adolescent-
friendly health services and care, the respect of adolescent rights, access of ado-
lescents 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 ado-
lescence: mental health and self-harm, and sexual and reproductive health.
Complete data from all thirty countries were available for analysis.

Results
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 adoles-
cent 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
240 Pierre-André Michaud et al.

Figure 12.1. Countries with extensive policy on AHS.

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 recom-
mended 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, risk-
taking, 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 dis-
close. However, the right to confidentiality is linked with the young person’s
decision-making capacity (competence), and healthcare providers are not neces-
sarily well equipped to assess such a capacity (Michaud, Blum, Benaroyo,
 Primary Care for Adolescents 241

Zermatten, & Baltag, 2015). In 13 out of the thirty countries surveyed, the exist-
ence 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 sus-
tainable 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 add-
ition to this, it is sometimes difficult to access services because of a lack of avail-
ability, due to under-resourcing or a shortage of health professionals skilled in
adolescent health care. This is particularly pertinent to so-called vulnerable ado-
lescents, such as migrants and adolescents from deprived socio-economic
background or ‘drop-out’ adolescents who are homeless or in temporary accom-
modation. Globally, around 50% of countries have developed policies or strat-
egies 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 adoles-
cents in such situations to consult primary care spontaneously. Half of the coun-
tries 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 pre-
vention 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
242 Pierre-André Michaud et al.

Table 12.1. Indicators of quality management for mental health services and
sexual and reproductive health care for adolescents.
 Primary Care for Adolescents 243

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 coun-
tries (n = 24), there are multiple options where a young person can obtain emer-
gency 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), con-
doms are easily available. Only eleven countries, however, provide oral contra-
ception 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 coun-
tries have specific guidelines or policies about how to address adolescent
pregnancy.

Summary
Although around half of the MOCHA countries have adopted policies or guide-
lines 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 coun-
tries, 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 prob-
lematic as evidence suggests that the quality of primary care services has a posi-
tive 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
244 Pierre-André Michaud et al.

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 life-
styles 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., 2014,
2016; World 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 sys-
tems 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.

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