Student Essay Prize

YPHSIG Student Essay Prize 2021

The winner of the YPHSIG Student Essay prize 2021 is Rebecca Howitt, a third-year medical student at the University of Oxford.

Her essay “What improvements should be made to adolescent healthcare in the UK over the next decade and what steps could be taken to reduce socio-economic heath inequalities?” impressed our panel of judges with its ideas for increasing service accessibility and improving transition to adult services.

You can read her full essay below.

Congratulations also to runners up: Ishika Bansal (University College London) and Monica Mangoro (University of Nottingham) who both showed great insight in their reflections on young people's healthcare.


Winning essay 2021 (clik to expand/collapse)

What improvements should be made to adolescent healthcare in the UK over the next decade and what steps could be taken to reduce socio-economic health inequalities?

Introduction

Adolescents form a unique group within healthcare as they transition from children to adults. It is a time where behaviour shifts towards risk-taking, many individuals become sexually active and habits which have long-term health implications such as drinking and smoking begin . Moreover, it is a time period associated with a steep increase in depression and anxiety diagnoses. Therefore, ensuring adolescents can easily access healthcare, particularly sexual health clinics and mental health support, is vital for the wellbeing of this age-group. Additionally, ameliorating the transition from adolescent to adult services and the shift to self-management of conditions, is crucial to preserving the future health of young people. Such improvements over the next decade can be achieved through a variety of ways but given the growing awareness of socioeconomic health inequality in this age-group, ensuring such changes target these disparities, rather than heightening them, is crucial to improve health outcomes for all adolescents.

Community-Based Healthcare

A key change to improve adolescent healthcare over the next decade would be to make it easier for adolescents to access primary care services. One way to achieve this would be to run clinics within schools or colleges so adolescents can receive care in a safe setting, but in the absence of their parents from whom they may not wish to disclose their health concerns. These could be generic GP or nurse clinics, or those with specific foci such as reproductive health. Given that under-18 conception rates in the poorest areas of England and Wales are over double those of the richest areas , making it easier for young people to access contraception at school could help tackle this health inequality, and pilot schemes have shown such drop-in services attract ‘hard-to-reach’ young people .

In addition, improving health education in schools, and other initiatives such as targeted social media campaigns, could also tackle behaviours which promote poor health. Two-thirds of smokers begin by the age of 18 and smoking rates in under 18s follow a socioeconomic gradient . Also, the UK has the highest obesity rate for 15-19 year-olds (8.1%) compared to 14 other European countries, and bar Finland, the highest inequality in obesity rates between those from affluent and deprived backgrounds . Whilst promoting individual behaviour change through targeted education campaigns is useful, it is important to recognise how deeply intertwined the issues of obesity and deprivation are, and so tackling upstream factors such as food poverty will also be key in promoting change over the next decade.

However, school-based clinics are not the only example of how adolescents can be better reached. Young people often reside at more than one address, in particular first-year university students, but also adolescents with separated parents. Therefore, allowing them to register at more than one GP practice would make it easier for them to access care when they need it, rather than waiting until they return near their registered GP or repeatedly switching practices, resulting in a lack of joined-up care.

Another solution would be to increase telemedicine for the adolescent population. Not only has the notion of increased reliance on technology for communicating with healthcare providers proved popular with adolescents , but it has been necessitated in many cases by the COVID-19 pandemic. An adolescent and young adult medicine clinic in San Francisco reported a shift from 0% to 97% of consultations being carried out via telemedicine, and these were well-received by patients . Whilst some difficulties were encountered such as it being hard to find a private space, these were often resolved, e.g. using the Zoom chat function to reply to questions if they felt uncomfortable when near other household members. However, whilst potentially a revolutionary tool for some aspects of adolescent healthcare, it is important to note that factors such as crowded housing and poor internet connectivity are higher in lower socioeconomic status households and may make telemedicine unsuitable for these patients. Therefore, implementing telemedicine alongside easy to access face-to-face clinics would prevent the health inequality gap being widened, instead of narrowed.

Hospital-Based Care for Adolescents

As well as improving primary care, steps should be taken to improve the experiences of adolescents receiving hospital treatment. From small steps such as ensuring there are adequate numbers of adult-sized chairs at outpatient clinics, to larger ones such as the creation of teenage wards/bays within paediatric inpatient units, ensuring adolescents feel acknowledged, and not treated like small children, is vital. Indeed, patients report higher satisfaction when being treated on adolescent specific cancer wards , such as those run by the Teenage Cancer Trust, and so extending this across both general and specialist units may improve patient experience.

Mental Health Support

Adolescents present their own health needs and requirements. Of particular note is the need for mental health support, with 75% of mental health problems emerging in adolescence . Moreover, the risk of mental health problems is four times higher for children growing up in adverse socioeconomic circumstances and socioeconomic disadvantage increases the risk of suicide . Together these highlight that although improving mental health care for all adolescents is important over the next decade, there needs to be a particular focus on outreach to those most at risk.

As highlighted previously, school-based approaches can be useful, and a survey of school leaders by the mental health charity Place2Be highlighted that 66% of schools already provide external professional support for mental health . However, extending this universally would be a good improvement to make over the next decade. Additionally, linking school support systems with Child and Adolescent Mental Health Services (CAMHS) may help children receive more specialist support before issues escalate further. This is currently not the case, with only 4% of those school leaders surveyed feeling that CAHMS responded quickly to requests for support15.

In addition, self-referral schemes would make it easier for young people to request support from CAHMS. Whilst these mechanisms are in place in some regions, e.g. Buckinghamshire, they are not in others, e.g. Oxfordshire, creating regional disparities in access to mental health support for adolescents. Regional disparities are also seen in waiting times and referral rejections (17% of CAHMS referrals were rejected in London in 2019, compared to 22% in the North) and specific mental health services for looked after children are not available in all areas on the country . Addressing these differences is important in ensuring that all adolescents across the UK can receive adequate mental health support, particularly those who are the most vulnerable and who may not be in school to receive support there.

Finally, online resources and apps for mental wellbeing could be beneficial to adolescents, who as a patient group are more likely to engage with technology . These not only would provide ongoing support between appointments, but adolescents may discuss usage among peers and recommend them to one another, furthering their effectiveness. However, a recent review highlighted that despite their promise, no mental health apps have been specifically designed for adolescents , so this could be an avenue for improvement in the future.

Improving Transition from Adolescent to Adult Services

Finally, ensuring that adolescents receive adequate support when moving from child to adult services is a key change to be made over the next decade. Whilst NICE guidance recommends that transition planning should begin in Year 9 , only 4% of adolescents report experiencing a smooth transition from CAHMS to adult services . Therefore, having handover consultations where healthcare professionals from both services meet to discuss the continuation of care could potentially see a reduction in the rate of adolescents disengaging with adult mental health services upon transition, which currently stands at 50% . This is particularly important for vulnerable patients and care-leavers.

Improved care transition is also important for adolescents with chronic health conditions. Not only is there a shift in service provision, but also a shift from parental management of conditions, to self-management. In the UK, the asthma mortality rate for young people is 0.3 per 100,0008 which compares poorly with other high-income countries. Whilst the reasons underpinning this are not entirely clear, a survey by Asthma UK suggests that adolescents have relatively poor understanding of their symptoms and struggle with managing their health independently . Especially given patients living in more deprived postcodes have higher rates of hospital admissions with acute asthma , engaging young people in taking an active role in managing their conditions is crucial in improving healthcare outcomes for adolescents both whilst they are under child and adult services.

Conclusion

In conclusion, adolescents present their own healthcare needs, particularly surrounding sexual, reproductive, and mental health. Ensuring easier access to services over the next decade, such as through schools or via an increased reliance on technology, would improve care for this unique subgroup of patients. Moreover, ensuring the transition from adolescent to adult care is as smooth as possible is also of paramount importance. Yet achieving this in a way which reduces, and not further increases, socioeconomic health inequality is vital to improve both the current and future health of young people.

WORD COUNT: 1499

References

1. Hagell A, Shah R and Coleman J (2017) Key Data on Young People 2017. Association for Young People’s Health. www.youngpeopleshealth.org.uk/key-data-on-young-people. Accessed 29 January 2021

2. Hankin B et. al. (1998) Development of depression from preadolescence to young adulthood: emerging gender differences in a 10-year longitudinal study. J Abnormal Psychology, 107(1), 128-140

3. Gregory AM et. al. (2007). Juvenile mental health histories of adults with anxiety disorders. American Journal of Psychiatry, 164, 301-308

4. Office for National Statistics (2018) Conceptions in England and Wales: 2018. Office for National Statistics. www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/conceptionandfertilityrates Accessed 31 January 2021.

5. Ingram J, Salmon D (2010) Young people's use and views of a school-based sexual health drop-in service in areas of high deprivation. Health Educ J. 69, 227–235

6. Health and Social Care Information Centre (2015) Statistics on Smoking, England – 2015. Health and Social Care Information Centre. https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-smoking/statistics-on-smoking-england-2015 Accessed 30 January 2021.

7. NHS Digital (2014) Health and Wellbeing of 15-year-olds in England: Main findings from the What About YOUth? Survey 2014. NHS Digital. https://digital.nhs.uk/catalogue/PUB19244. Accessed 29 January 2021.

8. Shah R, Hagell A and Cheung R (2019) International comparisons of health and wellbeing in adolescence and early adulthood. Research report, Nuffield Trust and Association for Young People’s Health.

9. Radovic A, McCarty CA, Katzman K, Richardson LP (2018) Adolescents' Perspectives on Using Technology for Health: Qualitative Study. JMIR Pediatr Parent. 1(1), e2.

10. Barney A, Buckelew S, Mesheriakova V and Raymond-Flesch M (2020) The COVID-19 Pandemic and Rapid Implementation of Adolescent and Young Adult Telemedicine: Challenges and Opportunities for Innovation. Journal of Adolescent Health 67(2): 164–171.

11. Reynolds BC, Windebank KP, Leonard RC, et al. (2005) A comparison of self-reported satisfaction between adolescents treated in a “teenage” unit with those treated in adult or paediatric units. Pediatr Blood Cancer 44, 259–63

12. Kessler RC, Berglund P, Demla O, Merikangas KR and Walters EE (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication, Archives of General Psychiatry 62(6), 593

13. Straatmann, V. S. et. al. (2019) How do early-life factors explain social inequalities in adolescent mental health? Findings from the UK Millennium Cohort Study. Journal of Epidemiology and Community Health 73, 1049–1060

14. Samaritans (2017) Dying from Inequality: Socioeconomic disadvantage and suicidal behaviour. Samaritans. www.samaritans.org/dying-from-inequality/report. Accessed 31 January 2021

15. Place2Be and NAHT (2020) Huge rise in school-based counsellors over past three years. Place2Be. https://www.place2be.org.uk/about-us/news-and-blogs/2020/february/significant-rise-in-number-of-school-based-counsellors/ Accessed 30 January 2021

16. Crenna-Jennings W and Hutchinson J (2020) Access to child and adolescent mental health services in 2019. Research report, Education Policy Institute.

17. Bakker D, Kazantzis N, Rickwood D, Rickard N (2016) Mental health smartphone apps: review and evidence-based recommendations for future developments. JMIR Ment Health 3(1):e7

18. Grist R, Porter J, and Stallard, P (2017) Mental Health Mobile Apps for Preadolescents and Adolescents: A Systematic Review. Journal of Medical Internet Research 19(5): e176.

19. National Institute for Health and Care Excellence (2016), Transition from children’s to adults’ for young people using health or social care services, National Institute for Health and Care Excellence https://www.nice.org.uk/guidance/ng43/chapter/Recommendations#transition-planning. Accessed 31 January 2021

20. Appleton R, Connell C, Fairclough E, Tuomainen H, and Singh SP (2019) Outcomes of young people who reach the transition boundary of child and adolescent mental health services: a systematic review. European Child & Adolescent Psychiatry 28(11), 1431-1446

21. Care Quality Commission (2018) Brief guide: Transitions out of children and young people’s mental health services CQUIN. Care Quality Commission. https://www.cqc.org.uk/sites/default/files/20180228_9001400%20_briefguidetransition_CQUIN.pdf Accessed January 31 2021

22. Asthma UK (2019) The reality of asthma care in the UK: Annual asthma survey 2018.

23. Grecian S et. al. (2013) The relationship between social deprivation and hospital admissions with asthma. European Respiratory Journal 42(Suppl 57), 957


Previous Winners

YPHSIG Student Essay Prize 2020

The winner of the YPHSIG Student Essay prize 2020 was Jessica O'Logbon, 2nd year medical student at Kings College London,.

Her essay "‘How should adolescent health services change by 2040 to better accommodate young people?" impressed our panel of judges with its ideas for patient participation in healthcare. You can read the full essay below.

Congratulations also to runners up: Daisy Lu (University College London) and Triya Chakravo (University of Oxford) who both showed great insight in their reflections on young people's healthcare.

Winning Essay 2020 (Click to expand/collapse)

How should adolescent health services change by 2040 to better accommodate young people?

INTRODUCTION

Adolescence is a period of increasing freedom, personal autonomy and risk-taking behaviours that lead to preventable morbidity and mortality [1]. This makes it a critical time for engaging this population in their health. Until recently, adolescents were seen as being relatively healthy and were not considered to be a priority in terms of health service delivery [2]. A number of factors have now changed this perception. The rate of mortality in adolescents is declining much slower than other age groups with increasing morbidity [3]. It is also of great concern that there has been no reduction in rates of deaths from intentional injury among 10-18-year olds in three decades with suicide rates rising [4, 5]. This highlights important contributors to morbidity such as mental health and substance abuse [6]. Literature review, focus groups and workshops have sought the views of children and adolescents in regard to what they felt was important for their health and well-being. Key areas emerged such as being more informed and involved in decisions about health services; for schools to play a greater role in their health and better access to age-appropriate services when needed [7]. This essay explores innovative ways that adolescent health services can improve in these areas to better accommodate young people in the next 20 years.

INVOLVING ADOLESCENTS IN HEALTH

“Adolescents and youth should be supported and empowered to contribute to designing, implementing and assessing policies, programs and systems that contribute to their health and wellbeing” was considered the single most important theme by youth advocates across the world [8]. Working with young people, youth workers and other professionals can achieve more accessible, appropriate services. This can be improved further by fostering close relationships with voluntary and community sectors. NHS trusts should open a dialogue with youth organisations like the UK Youth Parliament to take account of young people’s concerns and ideas regarding health matters, with a particular focus on barriers to access.

There is a much higher rate of success where use of resources or services has been planned jointly with young people [9] and The GP Champions Project is an example of this. The project aimed to find unique ways of improving the health of young people aged 10 to 24 years. Some of these included weekly pop-up GP services for students attending Lewisham Southwark College and supporting young people to produce their own leaflets for every GP in Sheffield and Cornwall. Additionally, young people have created training materials such as videos on young people’s needs around mental health and wellbeing for GPs, pharmacists and reception staff [10]. These initiatives empower adolescents to take control of their care and allow professionals to form a deeper understanding of young people’s thoughts and feelings when accessing services. Similar videos have been used in the e-learning Adolescent Health Programme which is available for free to all health professionals working within the NHS, but more awareness needs to be raised amongst staff about undertaking this programme and its importance in practice.

Establishing systems for the training, mentoring and participation of youth health advocates has the potential to transform traditional models of healthcare delivery to create adolescent-responsive health systems [8]. This is particularly important for marginalised adolescents such as those who are homeless, looked after by the state, young offenders or LGBTQ+ and who often experience inequalities in health. As these groups are less able to access health services in any event, there is an even greater urgency in ensuring their unique needs are identified and met [2]. This can only be known through dialogue and more effort must be made in order to listen to and consult with young people about the effectiveness and suitability of adolescent health services [11].

BRINGING HEALTH SERVICES CLOSER TO ADOLESCENTS

Adolescents spend most of their time in education, employment or at home. They are often surrounded by their peers and family members and the majority of teenagers have access to the Internet and are using it daily. This presents a range of opportunities to increase accessibility.

Many young people would like health services to be provided within their school [12]. Health drop-ins in schools are easy to access and enable young people to attend without the knowledge of their parents. This is particularly important for young people from rural areas [13. It can also appear less stigmatising than a ‘problem specific’ service. School health drop-ins can reduce unnecessary delays and deliver basic care, especially for sexual, reproductive and mental health concerns with a clearer understanding of young people’s needs in ways that work better for them [14]. Most services are held during the lunch break to avoid young people missing teaching time, but this results in short consultations when many students attend. Therefore, clinic opening hours before or after school should be made available and this should also be applied to primary care opening times to make them more adolescent-friendly.

In addition to this, adolescents’ wide use of technology can pave the way for the integration of technology into their health care. Teens are comfortable on the Internet and use it for a variety of reasons such as social and emotional support, relationship creation and maintenance, entertainment and information seeking [15]. They can investigate topics they consider embarrassing or that might arouse their parents' suspicions without adult interference or supervision. Adolescents are attracted to customisation, interactivity and multimedia formats such as games, quizzes, and personalised health check tools so health care providers can utilise these methods to ensure health information is reaching them.

Digital health interventions are a promising way to intervene early and promote health and wellness among adolescents. They are most effective when they focus on an adolescent’s strengths and their online peer interactions [16]. Evidence suggests that adolescents would like to use technology-based communication tools with their health care providers [17]. To streamline this process, collaborating with adolescents to provide the patient perspective is vital, such as establishing a young people’s panel to advise on ways in which digital technologies might be used to provide health information, improve access to services and encourage engagement and participation. With health experts to inform content, technological experts to develop software and research teams to measure effectiveness with data collection tools built into media platforms, teens and young adults can begin using evidence-based, secure and seamlessly integrated social media sites to prepare for their upcoming doctor's visit – and then tell their friends to use it too [18].

ENHANCING HEALTH LITERACY IN ADOLESCENTS AND THOSE AROUND THEM

Limited health literacy can reduce opportunities for young people to develop the capabilities needed to be actively involved in decisions about their health and care.

Peer and parent influences are especially relevant for youth. Families provide the primary structure within which children are born, grow, and develop, and from which adolescents transition to adult lives. Considering the complexity and variety of UK health services available, it can be difficult for adults to navigate through the health care system let alone adolescents. Consequently, many parents themselves have only basic health literacy skills and find it difficult to guide their children about health matters. Public Health England reports that 42% of working-age adults (aged 16-65 years) in England are unable to understand and make use of everyday health information, rising to 61% when numeracy skills are also required for comprehension [19]. Therefore, it is crucial that parents as well as children are informed about health services.

Alternative ways to disseminate information such as open engagement events held at hospitals or local GPs, similar to parent-teacher association meetings held at schools, can foster active engagement from parents and break down barriers to navigating through the healthcare system. School, community and family-based interventions to promote health literacy have shown promising results. For example, the Adult Education Trust’s ‘Talk about Alcohol’ intervention, delivered in UK secondary schools, has reported a statistically significant delay in the age young people start drinking alcohol, as well as increased knowledge about the effects of alcohol [20].

Peer education is also an effective tool for promoting healthy behaviours and teaching skills among adolescents [21]. Adolescents who have been through the healthcare system themselves and students who understand how it works and the services available (e.g. healthcare students) means that there is already a reserve of accumulated experience and knowledge which can be shared with others. Embracing this new concept can help the way adolescents view healthcare and address their worries about accessing it.

CONCLUSION

The most powerful actions to improve adolescent health arise from directly learning from adolescents as individuals. More time spent understanding what they need and want from healthcare services can be scaled-up with funding and support given to youth health initiatives to create more adolescent-responsive healthcare services. Ensuring that there are high-quality health services provided in UK schools and better educational strategies to raise health literacy can reduce barriers to accessibility. Technology provides an exceptional opportunity for coordinating actions between health services as well as bringing them closer to adolescents.


REFERENCES 1. El Achhab, Y., El Ammari, A., El Kazdouh, H. et al. Health risk behaviours amongst school adolescents: protocol for a mixed methods study. BMC Public Health 16, 1209 (2016). https://doi.org/10.1186/s12889-016-3873-42. Coleman J. Meeting the health needs of young people. Journal of Epidemiology & Community Health 2001;55:532-533.3. Wolfe I, Macfarlane A, Donkin A, Marmot M, Viner R. Why children die: death in infants, children and young people in the UK. Part A. May 2014 (On Behalf Of: Royal College of Paediatrics and Child Health, National Children’s Bureau and British Association for child and adolescent public health)4. Royal College of Paediatrics and Child Health & University College London. Child Health Research UK – Clinical outcomes review programme. Overview of child deaths in four UK countries. 2013. London. RCPCH5. Bould H., Mars B., Moran P., Biddle L., Gunnell D. Rising suicide rates among adolescents in England and Wales, The Lancet, Volume 394, Issue 10193, 2019, Pages 116-117, https://doi.org/10.1016/S0140-6736(19)31102-X6. Lawrence RS, Appleton Gootman J, Sim LJ. Adolescent Health Services: Missing Opportunities. Washington (DC): National Academies Press (US); 2009. 7. Annual report of the Chief Medical Officer 2012, our children deserve better: prevention pays. Department of Health, London20138. Patton GC, Sawyer SM, Santelli JS, et al. Our future: A Lancet commission on adolescent health and wellbeing. Lancet. 2016;387(10036):2423–2478. doi:10.1016/S0140-6736(16)00579-19. Street C., Warner-Gale F., Sedgewick J., Roberson J., Anderson Y. Taking on the Challenge: Shaping Health Services Through Young People’s Participation10. Association for Young People’s Health (AYPH), Royal College of General Practitioners, Youth Access to Information & Advice and Counselling (YIACS) GP Champions for Youth Health: Toolkit for General Practice 2015. 11. Milne AC., Chesson R., Health services can be cool: partnership with adolescents in primary care, Family Practice, Volume 17, Issue 4, August 2000, Pages 305–308, https://doi.org/10.1093/fampra/17.4.30512. Department of Health (2012) Getting it right for children, young people and families. London: Department of Health.13. Miller B., Baptist J., Johannes E. Health needs and challenges of rural adolescents.14. Mason-Jones, A.J., Crisp, C., Momberg, M. et al. A systematic review of the role of school-based healthcare in adolescent sexual, reproductive, and mental health. Syst Rev 1, 49 (2012) doi:10.1186/2046-4053-1-4915. Elaine N. Skopelja, Elizabeth C. Whipple & Peggy Richwine (2008) Reaching and Teaching Teens: Adolescent Health Literacy and the Internet, Journal of Consumer Health on the Internet, 12:2, 105-118.16. Aschbrenner KA, Naslund JA, Tomlinson EF, Kinney A, Pratt SI, Brunette MF. Adolescents' Use of Digital Technologies and Preferences for Mobile Health Coaching in Public Mental Health Settings. Front Public Health. 2019;7:178. Published 2019 Jul 2. doi:10.3389/fpubh.2019.0017817. Radovic A, McCarty CA, Katzman K, Richardson LP. Adolescents' Perspectives on Using Technology for Health: Qualitative Study. JMIR Pediatr Parent. 2018;1(1):e2. doi:10.2196/pediatrics.867718. Wong CA, Merchant RM, Moreno MA. Using social media to engage adolescents and young adults with their health. Healthc (Amst). 2014;2(4):220–224. doi:10.1016/j.hjdsi.2014.10.00519. Aarendonk D., Akinwale B., Berry J., Cabe J., Connolly A., Gann B. Local action on health inequalities Improving health literacy to reduce health inequalities20. Martin, K., Nelson, J. and Lynch, S. (2013). Effectiveness of School-Based Life-Skills and Alcohol Education Programmes: A Review of the Literature. Slough: NFER21. Abdi F, Simbar M. The Peer Education Approach in Adolescents- Narrative Review Article. Iran J Public Health. 2013;42(11):1200–1206.

(Abridged version of winning essay) Updated 09/07/2020

Message from the YPHSIG student link representatives

It has been a pleasure to organise the first YPHSIG Student Essay Prize. We received such a high standard of entries from medical students across the UK last year. It was a joy to read their insightful and innovative views on different aspects of adolescent health. Our entries varied from incredibly thoughtful reflections on a specific case that impacted the author to broad ranging and inspiring ideas on what adolescent healthcare might look like in 2040.

The YPHSIG student essay prize has allowed us to explore what thoughts and perceptions medical students have about adolescent health. The engagement of medical students nationally has demonstrated that they are engaging with adolescent health at an early stage in their careers. We hope that this annual essay prize and other future YPHSIG student events can continue to encourage medical students to get involved in adolescent healthcare and develop their interest.

Robbie Bain and Francesca Neale

YPHSIG student link representatives

Francesca NealeYPHSIG Student Link Representative
Robbie BainYPHSIG Student Link Representative