Community Approaches to Young People’s Health

1. Community Approaches to Young People’s Health Dr Lisa Fitzgerald School of Population Health l.fitzgerald@sph.uq.edu.au

2. Overview • To provide an overview of the main health issues affecting young Australians • To describe current thinking in youth health- a ‘positive youth development approach’ – which is a move from the focus on individuals and risks to community-wide positive approaches to addressing young people’s health issues • To consider factors influencing young people’s use of health services

3. Learning Objectives • List key Population Subgroups(e.g.,age groups – young people) and provide examples of the different health issues affecting them. • List key Social Issues (e.g.,poverty, homelessness, substance misuse, smoking, violence, sexual behaviour, obesity, suicide, unplanned pregnancy) and provide examples of research that demonstrates their relationshipto health. • Give examples to demonstrate the nature and prevalence of societal problems in different communities (i.e. amongst young people). • Describe and appraise strategies for managing youth health at the individual and community levels (e.g., positive youth development, community development, harm minimisation, early intervention programs, legislation).

4. Factors impacting across the life course: Young people (from Robyn’s Life course lecture) • Culture • Mental health • Traditions (family and community religion, ethnicity) • Sexualities • Identities • Lifestyles • Physical activities, leisure • Alcohol and drugs • Risks of accidental injury and death Key Determinants: • Supportive and safe environments • Family and or/ household insecurity • Exposures to stressors- mental health • Cultural and structural contexts of risk

5. Who are Australian young people? • Young people aged 12–24 represent one fifth of the Australian population (2.7 million) • Two in three 12–19-year-olds live at home with two parents (66%), and a further 20% live with one parent, • 1/100 is homeless • Indigenous people account for 3.6% of all 15–19-year-olds and 2.8% of all young people aged 20–24 years (86000) • One in five Australian young people were born overseas – mostly in Asia (6.6%) or Europe (2.6%) 1/5 speak a second language at home • Most live in cities (68%) only 2% live in very remote • STATE OF AUSTRALIA’S YOUNG PEOPLE: A Report on the social, economic, health and family lives of young people, Office for Youth, DEEWR 2009.

6. Youth : A time of change and transition • Characterised by educational, employment and personal change and achievements • increasing income, increasing independence, new experiences, transitions and broad optimism • Balancing of competing demands of education, work, domesticity, friends and community participation • Can be a time of positive changes but also risk taking • CHANGE, TRANSITIONS • ‘extended youth transitions’

7. Adolescent development Stages Chown, P., Kang, M., Sanci, L., Newnham, V., Bennett, D.L.(2008).

8. Young Australians and the Social Determinants (AIHW 2007)

9. Areas of concern: Australian young people • 1 in 100 young people who are homeless; • 1 in 3 young people who have engaged in unwanted sex at some time and the 1 in 3 sexually active young people who do not use condoms; • The number of young lone parent households experiencing poverty; • The increase in the number of young people involved in cyber bullying; • The almost 1 in 3 young people who are an unhealthy weight; • The almost 1 in 3 15–17-year-old males, 1 in 5 15–17-year old females, 1 in 2 18–24-year-old males, and more than 1 in 3 18–24-year-old females who drink alcohol at levels above 2009 NHMRC recommendations; • The 1 in 4 young people who have a mental disorder in a given year and 1 in 3 young people who experience moderate to high levels of psychological distress. • STATE OF AUSTRALIA’S YOUNG PEOPLE: A Report on the social, economic, health and family lives of young people, Office for Youth, DEEWR 2009.

10. Young Australians - Common causes of mortality • In 2005 – 1,309 deaths (46 per 100,000). 73% were males. • Injury, including poisoning, is the leading cause of death in 2005 – 70% of all deaths. • Death rates have halved in the last 20 years – the reduction is largely attributable to declines in injury related deaths. • Two-thirds of all deaths due to some form of injury, including traffic crashes (39%) and suicide (32%) • In 2004/5, 24% of young people had experienced an injury requiring self or professional help in the last 4 weeks (e.g. cuts, being hit or hitting something, falling from low height) (AIHW 2008)

11. Mortality 13-19 years - 2006 (AIHW 2008)

12. Young Australians - Common causes of morbidity • Most Australian young people 15-24 regard their general health as good to excellent (93%) • 10% experience long-term health condition • Obesity and eating disorders are on the increase • Mental health problems and behavioural disorders account for the major burden of disease – approx 50% • Just over 20% of those aged 12-16 yrs and 27% aged 18-24 yrs had mental health problem • Primarily anxiety disorders, affective disorders, substance abuse disorders STATE OF AUSTRALIA’S YOUNG PEOPLE: A Report on the social, economic, health and family lives of young people, Office for Youth, DEEWR 2009.

13. Mental health • Leading cause of disability among young people (16-24 years) 1 in 4 young people • Young people most likely group in the population to experience mental illness • 75 % of adult mental health and substance use disorders begin in childhood and adolescence • Associate with other physical social and emotional issues e.g. physical health problems, exclusion from education, employment, social isolation • Suicide – a leading cause of death for young people (8.3 in every 100,000) decreased over last decade • STATE OF AUSTRALIA’S YOUNG PEOPLE: A Report on the social, economic, health and family lives of young people, Office for Youth, DEEWR 2009.

14. Long term chronic conditions • 66% reported a long term condition – including hay fever (19%), short sightedness (18%) and asthma (12%), diabetes (0.4%). • The rate of asthma has declined from 16% - 12% between 2001 and 2004/5 • Cancer - 32 per 100,000 9% of deaths (27% melanomas; 12% testis; 12% Hodgkin disease). • 2% of young people have a severe disability (AIHW 2008)

15. Some groups of young people are comparatively worse off than others • Indigenous young people • Death rates 2.8 times higher for males and 2.0 times higher for females • Young people from lowest socio-economic groups • Males 1.7 times more likely to die and 1.4 times more likely to be hospitalized (for females 1.4 and 1.2 respectively • Unemployed young people • 22% rated their health as ‘fair’ or ‘poor’ (cf. 8%- 9% of employed or students) • Rural and remote location • poorer health (higher death and hospitalization rates) compared with those in capital cities and metropolitan areas

16. Lifestyle-related social factors • A time of change- characterized by rapid physical and psychological transition, experimentation and risk taking • ‘transition to adulthood’ – experimenting with new roles, activities, social networks and more likely to be influenced by their peer and popular culture • Most people can successfully navigate these changes but// some key social issues young people face: • Alcohol • Smoking • Illicit drug use • Dangerous driving • Sexual activity • Safety, crime and child protection system

17. Social-Behavioural issues • 40% of those aged 20-24 yrs smoke • 25% of those aged 14-19 yrs smoke • 1 in 5 males and 1 in 10 females aged 18-24 yrs had substance abuse disorder; rates of illicit drug use increased between 1995-98 • 38% of young people aged 14-24 years reported marijuana use in the past year • 22% of those aged 15-24 yrs have a BMI in the overweight or obese range • STATE OF AUSTRALIA’S YOUNG PEOPLE: A Report on the social, economic, health and family lives of young people, Office for Youth, DEEWR 2009

18. Specific health problems and developmental needs differ from children and adults • Causes of ill health mainly psychosocial rather than biological • Young people often engage in health risk behaviours that reflect adolescent development process of experimentation • Often lack of awareness of harm associated with risk behaviours and skills to protect themselves • Lack of knowledge about how and where to seek help for their concerns

19. What are important health issues to young people themselves? Mission Australia (2009) In Their Own Words

20. Mission Australia (2009) In Their own Words

21. Some conclusions … • The health issues identified have a strong behavioural and social components, reflecting young people’s interactions with the social environment: peers, family members, other adults, school, community, culture, media etc. • They are health issues less likely addressed by traditional health services • They demonstrate the importance of preventive efforts that emphasise health promotion and community based services

22. So what works for improving the health of young people? • Much existing research focuses on measuring risk factors, often hospital based clinical research • Move to understanding the role of risk and protective factors • From deficit model to Positive Youth Development

23. Positive Youth Development • Grounded on premise that youth are “ resources to be developed, rather than problems to be solved’ • Providing youth with support, relationships, experiences, resources, and opportunities needed to become successful and competent adults • Enhancing positive factors in the lives of youth such as connectedness to family, school and community can reduce the likelihood youth will engage in health-jeopardising behaviours. • Bernat D, Resnick, M (2006) ‘Healthy youth development: science and strategies’, J Public Health Management Practice, S10-16.

24. Resiliency • Came out of cohort studies in US in 1960s and 1970s • The process in which individuals show positive outcomes, despite adversity • Risk and protective factors: • risk factors = experiences that can increase likelihood of negative outcomes e.g. exposures to stressors • protective= experiences that reduce the likelihood of negative outcomes e.g. cohesive environment

25. What do youth need to develop into successful adults? • US Add health study- 90,000 young people The National Longitudinal Study of Adolescent Health (Add Health) Protective factors: • Connectedness to family • Connectedness to other adults • Connectedness to school • Connectedness to community

26. Healthy Youth Development • Works to develop skills, competencies and positive experiences with caring adults who have high expectations and a positive attitude towards young people • See young people as inherently capable • This approach has been utilised in the Australian National Youth Strategy (2010) • http://www.youth.gov.au/nationalstrategy.html

27. Components of effective youth development programmes • Programs informed by theories and best practices • Promote protective and reduce risk factors • Multiple behaviours and multiple systems focus • Focus on prevention and health promotion • Appropriate duration and intensity • Rigorous evaluation

29. http://www.youtube.com/watch?v=pacEHRR4Hns&feature=related • youth in Baltimore describing positive youth development using photovoice

32. Where do young people go for advice and support (Mission Australia 2007)

33. People Approached for Help About Distressing Life Events Donald et al (2000) Queensland Young People’s Mental Health Survey

34. GPs as primary care provider for young people • GPs most accessible primary health care provider for young people and usually their first point of contact with he health system • Young people perceive doctors as one of the most credible sources of health information • BUT often reluctant to visit GPs: • Fearful, embarrassed about discussing sensitive issues eh drug, sexuality, mental health • Concerned about lack of privacy and confidentiality • Many think GPs treat only physical ailments, and are unaware that GPs could help them with emotional and psychosocial concerns • GPs attitudes and communication style • Access and clinic environment • Cost • Development characteristics of young people

35. Barriers to seeking general practice or specialist care • Too embarrassed/shy - 18% • Concern doctor might feel negatively about you - 10% • Negative feeling/self perceptions - 7% • Denial/pride – 5% • None – 23% Additional concerns associated with seeing Specialists • Trust/privacy/confidentiality 6% • Cost – 5% • Concern that what the specialist might say is wrong – 5% Jorn et al 2007

36. Barriers to seeking general practice or specialist care “It costs too much” “I don’t understand what the doctor says” “The magazines are old and boring” “I can’t get to the surgery” “The doctor will tell my parent(s)” Source: Australian Medical Association, Young Patients - A Fact Sheet for GPs

37. Barriers to GPs • Inadequate training in consultation skills and managing psychosocial problems in adolescents • Lack of knowledge and skills in communicating with adolescents • Time constraints and inadequate remuneration for providing longer consultations to young people • Concerns about medico legal issues

38. When a young person presents… “Every time an adolescent encounters a health professional, an opportunity could be lost or gained to try to find out what realistically could be done to help this young person negotiate growing up safely.” (Tresidder, 1996, ANZJPH)

39. Key roles for GPs • Adolescent health is complex and requires multidisciplinary approach to deal with co-morbidities and psychosocial issues. • Providing comprehensive health care appropriate to young person’s developmental needs and socio cultural background • Managing interaction with young person, time and using appropriate communication skills to engage them, • Developmentally appropriate treatment and prevention • Culturally sensitive • Detection, early intervention and education for health risk behaviours • Working with family, school and other key people in young person’s life

40. Promoting young people’s access to health services • Making GP practices ‘youth friendly’ • Act as gateway to health system • Ensure practice is culturally sensitive • Help reduce barriers to young people in accessing services, especially those at high risk • Advocate for young people’s health needs within the health system, their families schools and wider communities Adopting a collaborative approach to patient management -

41. When a young person presents... • Find out some basic information by • Listening (Why is he or she presenting?) • Asking appropriate questions (e.g., Who do they live with? Do they live in your local area? Do they go to school?) • Let him/her know that you are able to • Provide confidential advice and information about other health matters • Give details of other adolescent-friendly health professionals and services • Don’t overlook mental health issues • Eg (HEEADSSS assessment tool)

43. What else can doctors do? (1) • Ensure that your health service is ‘young-people friendly’ • Keep up-to-date with young people’s issues • Take time out of clinical practice to network with other people about what local services are available to young people • Contribute to (and learn from) locally-based programs (e.g., those developed in school settings)

44. What else can doctors do? (2) • Provide leadership e.g., policy development; lobbying government and other bodies/agencies; increasing awareness; shaping community opinion • Recognise the multiple influences that can affect young people’s health and the role of settings outside health - schools, families, peer groups, media • What changes could be made to the social environment to support the development and maintenance of health promoting behaviour? • http://www.youtube.com/watch?v=qJUsZM3c4-U

45. Many of today's and tomorrows leading causes of death, disease and disability can be significantly reduced by preventing 6 interrelated categories of behaviour that are initiated in youth and fostered by social and political policies and conditions: • Tobacco use • Behaviour that results in injury and violence • Alcohol and substance use • Dietary and hygienic practices that cause disease • Sedentary lifestyle • Sexual behaviour that causes unintentional pregnancy and disease

46. Further Resources STATE OF AUSTRALIA’S YOUNG PEOPLE: A Report on the social, economic, health and family lives of young people, Office for Youth, DEEWR 2009 AIHW (2008) Australia’s Health 2008, AIHW: Canberra http://www.youth.gov.au/Documents/YoungPeopleReport.pdf Mission Australia (2009) In their own words: Insights into the concerns of young Australians Snapshot http://www.apo.org.au/sites/default/files/In%20their%20own%20words.pdf Bernat D, Resnick, M (2006) ‘Healthy youth development: science and strategies’, J Public Health Management Practice, S10-16. http://journals.lww.com/jphmp/fulltext/2006/11001/healthy_youth_development__science_and_strategies.4.aspx Chown, P., Kang, M., Sanci, L., Newnham, V., Bennett, D.L.(2008). Adolescent Health: Enhancing the skills of General Practitioners in caring for young people from culturally diverse backgrounds, GP Resource Kit 2nd Edition. NSW Centre for the Advancement o Adolescent Health and Transcultural Mental Health Centre, Sydney. http://www.caah.chw.edu.au/resources/gpkit/Complete_GP_Resource_Kit.pdf Robards, F. (2009). Increasing the resilience of young people at risk: A literature review, NSW Centre for the Advancement of Adolescent Health, The Children’s Hospital at Westmead, Westmead and Centre for Clinical Governance Research, University of New South Wales, Randwick http://www.caah.chw.edu.au/policy/CAAH_policy_literature_report.pdf

47. Further resources • http://www.cpc.unc.edu/projects/addhealth • NSW Centre for Advancement of Adolescent Health (NSWCAAH) www.caah.chw.edu.au • The Centre for Adolescent Health University of Melbourne www.rch.org.au/cah • http://www.youth.gov.au/nationalstrategy.html