Youth-specific primary healthcare - access, utilisation and health outcomes: a critical appraisal of the literature
Record ID 32002000553
This study was commissioned by the New Zealand Ministry of Health to provide an evidence-based review of the effectiveness of youth-specific primary health care. The primary objective was to assess the impacts of youth-specific primary care on access, utilisation, mental health, health outcomes and emergency department use.
Secondary objectives were to describe factors that increase access and utilisation and improve health status in delivery of primary care services to youth and to encourage outcome evaluations of youth health interventions
Authors' results and conclusions:
Access and utilisation Seventeen studies considered the impact youth-targeted primary care has on access and utilisation. Two were retrospective cohort studies and the remainder cross-sectional studies. All 17 studies reported high levels of utilisation of youth-specific primary care services.
Seven studies reported on relative health service utilisation by youth users of school-based health clinics (SBHC) versus comparator groups without access to a SBHC. All seven studies described significantly greater utilisation (mean annual visits) of health services by students with access to youth-targeted care. Some of these studies show that young people who particularly benefit from enhanced access, are those who are socio-economically disadvantaged, female and at-risk. Whilst some studies demonstrate increased access for ethnic minorities, the evidence is not consistent. Evidence suggests increased access for rural youth compared to urban youth in using SBHCs.
Overall research evidence clearly supports enhanced access to primary health care through youth-specific services.
Mental health Eight studies considered access and utilisation of mental health services within primary care, and two studies evaluated the effect on self-reported mental health status.
Four studies evaluating accessing of mental health services at a SBHC, described greater utilisation of youth-targeted service Of two robust retrospective cohort studies, showed mental health visits were 10 times higher in students with SBHC access, and one study demonstrated that males with SBHC access were 45 times more likely to access mental health service than those only with traditional primary care. Mental health consultations made up one-fifth to onequarter of all consultations at a SBHC.
Two studies found no statistical difference in use of the SBHC related to self-reported mental health variables (Kisker and Brown 1996; Pastore et al. 1998). Evidence supports enhanced utilisation of mental health services within a youth-specific primary care service, but shows no evidence of improved self-reported mental health status among clinic users.
Emergency department use Five studies evaluated the impact of youth-specific primary care on emergency department use. Three of the methodologically more robust studies described significant reductions in emergency department use by students with access to youth-specific primary care. Juszczak (1999) found youth who had never had SBHC access were six times more likely to use the emergency department than youth with SBHC access. Kaplan et al. (1998) found students with SBHC access used the emergency department a half to a third as often than those without SBHC access. This is confirmed by Santelli for students who had SBHC access for greater than one year (Santelli et al. 1996a). The two studies which showed no difference in emergency department use between students with, and without, SBHC access are less robust. On balance, the research evidence suggests youth-targeted primary care reduced emergency department usage. Further methodologically sound research is required to confirm this.
Health outcomes Only four studies assessed health outcomes among young people using youth-specific primary care. All four studies assessed outcomes related to reproductive health (sexual activity, contraceptive use, pregnancy rates), and all were methodologically poor to moderate in quality. One study described a small, but statistically significant increase in reported condom and contraceptive pill use after SBHCs started in two of six schools. Overall, there is currently insufficient evidence to support improved health outcomes among young people using youth-targeted primary care.
Evidence strongly supports enhanced access and utilisation of primary care and mental health services within primary care, by young people through youth-specific services. It suggests youth-specific primary care can reduce emergency department use. Currently, there is insufficient evidence to demonstrate changes in physical or mental health status through youth-specific primary health care.
There is, therefore, an urgent need for further New Zealand based and international research to determine the effectiveness of youth-specific primary health services. It should address limitations in study design and types of evaluation discussed in this review. These should include appropriate matched comparator groups.
Importantly, studies are needed that evaluate health outcomes of attendance at youth-specific primary health services. If funds are invested into programmes, it is essential to know what effect these have on health status
English language abstract:
An English language summary is available
- Consumer Behavior
- Adolescent Health Services
- Primary Health Care
New Zealand Health Technology Assessment
Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, University of Otago, P.O. Box 4345, Christchurch, New Zealand. Tel: +64 3 364 1145; Fax: +64 3 364 1152;
New Zealand Health Technology Assessment (NZHTA)