Youth Health: A Guide to Action

(full text version)

Published in September 2002

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1. Why a health action plan for young people?

Most young people are healthy most of the time. Generally, this age group is at the peak of physical health.

But the years between 12 and 24 are also the years when the chances of being caught up in risk-taking behaviour are high, and where the negative consequences can be lifelong. While most young people appear to deal successfully with the developmental changes that occur during this period, there is evidence that many do not.

Compared with other age groups, young people have:

• high rates of mental illness
• high rates of alcohol and drug use and abuse, particularly among young men
• a higher rate of suicide and suicide attempts
• high rates of sexually transmitted infections.

Morbidity and mortality data show that young New Zealanders have higher rates of suicide, teenage pregnancy, abortion and suffer more injuries – especially from traffic accidents – than their counterparts in other OECD countries
(Ministry of Health 2002).

Both the age group and the international comparisons suggest that, as a community, we are paying insufficient attention to the health of young people and the importance of creating a healthy environment for youth development. That young Māori continue to suffer more ill health than their non-Māori counterparts is a matter of particular concern.

On the basis that healthy young people become healthy adults, it is in the community’s interest to focus on keeping young people well, and to find more effective ways of doing this.

Between 12 and 24 are the years when the chances of being caught up in risk-taking behaviour are high, and where the negative consequences can be lifelong.

2. Who are 'young people'?

Terms such as ‘youth’, ‘rangatahi’, ‘teenagers’, ‘adolescents’ and ‘young people’ are often used interchangeably to describe both the whole group and various sub-groups in the age range from around 10 years to the mid-twenties.

Young people who are the primary focus of this plan are those between the ages of 12 – 24 years. This is consistent with the age group defined as ‘youth’ in the Government’s Youth Development Strategy Aotearoa and fits with the World Health Organization definition of ‘young people’.

It is important to recognise, though, that there are different needs and risks associated with various developmental stages within this age range, and what works for young people aged 12 and 13 years may well be inappropriate for those aged 16, let alone for those aged over 20 years.

Proportion of the total population
Young people aged 12 to 24 years account for around 20 percent of New Zealand’s population (Statistics New Zealand NZ Census 2001).

Health status of young people
Young people’s current health status is described in detail in the Youth Health Status Report (Ministry of Health 2002), which was commissioned to support this action plan. In the sections below we highlight some of the data from the Report.

Mortality Rates
In 1998, a total of 495 young people aged between 12 and 24 years died. This represents an age-specific death rate of 71 deaths per 100,000 young people aged 12 to 24.

More males than females aged between 12 and 24 years die each year in New Zealand. Males accounted for 72 percent of the young people who died in 1998.

Māori young people are more at risk of dying than are non-Māori youth. The death rate of young Māori (99.3 per 100,000) was 57 per cent higher in 1998 than the death rate of young non-Māori (63.3 per 100,000).

Within the age group 12 to 24 years, young people aged 16 to 24 years are at the greatest risk of dying prematurely.

The most common cause of death among young people aged 12 to 19 years is from injury in motor vehicle accidents. The second most common cause of death is suicide. For those aged 20 to 24 years, suicide is the most common cause of death, followed by motor vehicle accidents.

Between the mid-1980s and the mid-1990s significant changes occurred in the death rates associated with specific causes: deaths from motor vehicle crashes dropped by 40 percent for males and 30 percent for females, but deaths
from suicide increased by over 100 percent for males, and over 160 percent for females.

Hospitalisation
The most common cause of hospitalisation in young males is some type of injury. In females, it is fertility-related issues.

Young females in the 12- to15-year-old group are hospitalised at approximately the same rate as males. (However, the rate changes with age as female fertility increases.)


Specific health risks for young people

		Key Points
	Specific health risks for young people
		1. Alcohol and drugs Approximately 79 percent of 14- to 17-year- olds drink alcohol Young men aged 18 to 24 years are disproportionately heavy drinkers, and are most likely to consume six or more drinks in a single session. Females’ volume of drinking increased between 1995 and 2000 across all age groups. Around 23 percent of deaths in the 15 to 24 year age group were attributable to alcohol (1996 data). Around 10 percent of young people are estimated to be dependent on cannabis by the age of 21.
		2. Mental illness Mental illness becomes more common as young people move through adolescence. Young men tend to have higher rates of conduct disorder and alcohol and substance abuse. Young women tend to have higher rates of anxiety and depression. Alcohol and drug abuse is frequently associated with mental illness in young people.
		3. Injury Falls, road traffic and other transport accidents, assault and abuse, sports injuries and self- inflicted injury were the leading causes of injury-related hospitalisation in 1999 and resulted in over 14,000 hospitalisations among young people aged 12 to 24 years. Males have higher rates of death caused by injury than females. Māori have higher rates of death from injury than non-Māori .
		4. Tobacco While a new survey shows the rate of smoking among fourth formers (year 10) is the lowest since 1992 (ASH 2002), smoking rates among young people are still high. Smoking prevalence increases rapidly during the late teens. Females are more likely to smoke than males. Young Māori women are the most likely to smoke with nearly half of those surveyed smoking daily, weekly or monthly.
		5. Sexually transmitted infections and unwanted pregnancies The number of cases of bacterial infections – chlamydia and gonorrhoea –among young people 15 to 24 years has increased since 1996. Six out of 10 pregnancies among women under the age of 25 years are reportedly ‘unwanted’ (Dickson et al 2002). Between 1988 and 2000, the abortion rate increased by 62 percent among females aged 15 to19 years and by 66 percent among those aged 20 to 24 years.

3. What is a ‘healthy young person’?

Health has more than just a physical dimension. This action plan shares the Māori view that
health is holistic. For Māori, health has four equally important elements:

• te taha hinengaro (emotional and mental health)
• te taha whānau (connection to family)
• te taha wairua (spiritual health)
• te taha tinana (physical health).

For young people, care and support on all of these levels is important for healthy development.

In this section we list some of the characteristics that are generally agreed to be indicators of good health and wellbeing.

Emotional and mental health
Young people who are emotionally and mentally healthy have a strong sense of identity.1 They understand and feel at ease in their particular cultural settings. They have a sense of self worth and a sense of purpose. They see a pathway ahead leading to a positive future.

They are optimistic. They feel safe – emotionally, physically and sexually. They are not abused physically, sexually or emotionally. If they need help and support, they know where to find it. They are able to form friendships and maintain
healthy relationships. They are sensitive to and accepting of diversity. They are able to manage conflict and express both positive and negative emotions

They have the opportunity to explore their potential in a wide range of areas – academically, in sports and in a diverse range of occupations.

Physical health
Young people who are physically healthy eat sensibly and are physically active. They understand and are able to manage the physiological changes that are happening to them. They don’t smoke and don’t drink excessively.

Physically healthy young people are comfortable in seeking health advice and know where to find it. They have a healthy appreciation of their sexuality and know how to protect themselves from harm. They explore their physical potential in a range of sporting and physical recreational activities.

Cultural and spiritual health
Young people who are culturally and spiritually healthy are likely to be secure in their particular cultural identity, and have the ability to express this identity without fear. They have an appreciation of values other than the material, and accept the diversity of values and cultures of the people around them.

They have the opportunity to explore fully their own cultural and spirtual heritage. They are able to express themselves fully in a variety of artistic media such as performance, visual and written creative arts.

Secure, safe and valued in their family, their whānau and their community
Young people who are secure, safe and valued have sufficient food, warmth and shelter. They are supported by warm and loving caregivers. They are safe from physical and emotional abuse. They have older people they can trust and confide in.

They are given the opportunity to develop within reasonable boundaries. They feel able to express themselves without fear of ridicule.

Safe, secure and valued young people are likely to have good friends who support them. They are able to maintain healthy relationships.

Their ideas, energy and skills are appreciated by their communities, and they have the opportunity to participate in community affairs. They are not discriminated against in the workplace or other settings.

4. Young people’s views on health services

In this section we look at the type of health service provision young people have said they would like to see, what they experience as barriers to health care, and the implications of these views for the design and delivery of health care.

Where young people go for health care
A recent survey of students from Lower Hutt secondary schools asked 'Where do you usually go for health care?' Students could tick more than one option.

The responses were:

• Family doctor (93 pecent)
• Accident and emergency/after hours clinic (23 percent)
• Hospital clinic (22 percent)
• School clinic (12 percent)
• Youth health centre (6 percent)
• Traditional healer (5 percent)
• Alternative therapist (4 percent)

(Lower Hutt Youth Project 2002)

The same survey showed that over a quarter of the students didn’t get health care when they needed it because of cost, or because they ‘didn’t want to make a fuss’.

Traditional health service providers are under-utilised by people aged 10 to 24 years

Young people’s preferred style of health care
Other studies have indicated that existing health services are under utilised by people aged 10 to 24 years (Midland Health 1996. Wellington Youth Health Project, 2001).

In these studies, young people indicated a preference for youth-specific health services, particularly those linked with other youth activities like recreation and sport.

There is anecdotal evidence that young people are high users of internet health information sites. In support of this claim, a US survey (FPANZ 2002) found that half of the young people surveyed used the internet to find out information on topics including sexually transmitted infections, diet, fitness and exercise, sexual behaviours, contraception, physical abuse and dating violence.

What kind of services young people want
A survey of young people in Wellington (Wellington School of Medicine 2001) indicated that the services they wanted most were:

• sexual and reproductive health services
• counselling
• alcohol and drug services
• general practitioner services.

The combined data from the research (Gray 1994; Midland Health 1996; Wellington School of Medicine 2001)
indicate that young people believe that the ideal health service would be:

• free or affordable
• locally delivered
• confidential
• non-judgemental
• culturally appropriate
• staffed in a gender-appropriate way
• offering a comprehensive range of health care services
• staffed by people who can relate to young people
• easy to access (services available where and when young people require them).

Perceived barriers to good health care
The studies also found that although young people report being reasonably happy with the health care they receive, many report barriers to access to care. Among these are:

• the cost of doctor’s visits and prescriptions
• embarrassment, and a concern to avoid making a fuss
• lack of, or perceived lack of confidentiality
• lack of appropriate and accessible services for mental health and drug and alcohol problems
• lack of knowledge about sexual and reproductive health care services, as well as embarrassment and concerns about affordability
• an absence of Māori, Pacific or Asian staff and/or a lack of cultural sensitivity
• a lack of accessible information regarding services
• the perception that communication between adults and young people is sometimes authoritarian, judgemental and patronising
• lengthy waiting times or inability to get an appointment
• the physical location and accessibility of services, including transport problems.

Implications for health service design and delivery
Young people’s health needs, their service preferences and patterns of service use are gradually being reflected in changing patterns of primary health care delivery.

Over the past few years, more youth-focused services have begun to emerge – with a number of schools expanding their health service provision, and other community-based one-stop shops being established in a number of cities.

Are these youth-specific services providing more effective health care for young people? In the next section the evidence is examined.

5. What works for young people

As a part of the groundwork for the Youth Health Action Plan, the Ministry of Health commissioned an evidence-based review of the effectiveness of youth-specific health services (Matthias 2002). We asked the reviewers to look at the impact of youth-specific primary care on:

• access
• use of health services
• use of emergency services
• health outcomes, and specifically their impact on mental health.

The review produced the following findings:

• Youth-targeted primary care (eg, schoolbased health centres, ‘one-stop shops’) increases access and utilisation of health care significantly for young people. In one study, young people used youth-specific health services up to 10 times more than traditional health services such as family doctors.

• Young people who use these services most, tend to be those who are most vulnerable – those from lower socioeconomic settings, those who have chronic health problems, those with the highest health risk behaviours (eg, unprotected sex, drink driving).

• The youth-targeted primary care services that demonstrate the greatest increase in access and use are those that offer mental health, substance abuse counselling, sexual health, and preventive services such as cervical screening, STI screening or general checkups.

• A number of studies demonstrated reduced use of emergency departments and after hours services among youth who have access to youth-focused primary care services. It is likely this drop is due to appropriate management of health problems in primary care with continuity of care and provider.

• When youth are asked what they prefer in health services there is resounding support for services that are targeted at youth, whether they are in a separate physical setting (eg, a school-based health centre, a youth centre, or within a traditional provider setting, such as an adolescent clinic run by a family doctor).

• There is some evidence of better health outcomes (such as greater use of contraceptives, lower depression scores) for young people who use youth-targeted primary care services. However, given that health outcomes have multiple contributing factors, it is difficult to attribute a change in health to a single intervention such as youthfocused primary care.

• There is evidence that shows that increased access to and utilisation of health services results in better health status.

‘There is resounding support for services that are targeted at youth, whether they are in a separate physical setting (eg, a school-based health centre, a youth centre, or within a traditional provider setting, such as an adolescent clinic’

What works for Māori ?
Health services that work for Māori are likely to be based on the five principles identified by Mason Durie (1995) as being associated with successful outcomes:

• choice – ensuring that mainstream and kaupapa Māori options are available for Māori consumers
• relevance – providing services that address actual needs and are culturally meaningful
• integration – ensuring that health services are connected and that there are links with other sectors, in line with an holistic approach to health
• quality – providing high quality of care and evidence-based treatment linked with good outcomes
• cost-effectiveness – considering economies of scale and value for money.

Public Health Programmes

Public health programmes play an important role in keeping young people well. Some public health programmes are long-term investments in young people’s health – like fluoridation of the water supply, and legislation setting age limits for the legal sale of harmful products such as tobacco, alcohol and gambling. Some respond to new health risks – like the development of the vaccine against meningicoccal disease. Others aim to change attitudes and behaviour like the anti-smoking ‘Why Start?’ campaign, and the ‘Like Minds, Like Mine’ programme that aims to change attitudes toward people with mental illness. Successful public health programmes can reduce the risk and impact of injury and disease, improve the quality of life, prolong life and may well reduce the need for health care services over time.

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