This chapter differs from the other chapters in Part III. It describes how a youth health audit tool was developed and applied in primary health care (PHC). The chapter offers guidance for those developing an audit tool in any area of PHC with less developed clinical guidelines and a less well-established evidence base.

Youth health

Youth is a critical period of development and transition in a person’s life. Young people who are in good health between the ages of 12 and 24 are more likely to achieve better educational outcomes, transition successfully into work, develop healthy adult lifestyles, and experience fewer challenges when establishing families and parenting than young people who experience poor health and wellbeing.1

How the transition from childhood to adulthood is defined differs between cultures and over time, nevertheless adolescence is a time of intense physical, neurological, social and emotional change. We build our sense of self, grow more concerned about peers’ opinions, learn to manage emotions and relationships, and seek independence from parents and other adults in our lives as we develop more ability to reason and to think logically, critically and morally.2 This occurs within a complex system of family, peer, school, community, media and broader cultural influences.3

Youth is a time when behaviours and habits can be formed, experimentation and taking risks may occur and mental health problems are likely to emerge.4 Accidental injuries and violence, poor mental health, substance misuse, and problems related to nutrition, infectious diseases and sexual reproductive health are among the health issues commonly experienced by young people in many countries.5 These occur regardless of wealth, with mental health problems being the most common health issues facing young people worldwide.6 Furthermore, in many low-income countries, more than 50 per cent of the population is younger than 20 years.7 Seventy-five per cent of global mental illness starts by age 24;8 globally, almost one in seven young people meets diagnostic criteria for a mental health disorder9 but fewer than two-thirds of young people with mental health problems and their families are likely to access professional help.10 Focusing on the prevention of mental health problems early in life is important for improving population health and lives.

As the first point of contact with the health system for many young people and their families, it is critical that PHC professionals have the expertise and resources to engage with young people and to provide high-quality PHC for this group, including mental health care and trauma-informed care. From the perspective of PHC services, this life phase presents an opportunity for supporting healthy lifestyles, identifying and reducing risk factors for future ill health and promoting social and emotional wellbeing.11 It also presents an opportunity to make up for any developmental deficits and health threats caused by a child’s living environment (for example, food shortages, lack of access to school, conflict and displacement, violence and abuse).12 Yet many barriers prevent access to health services for this group, including availability, acceptability and equity.13 Some PHC professionals say they lack skills and confidence relating to young people.14

The need to make health services more adolescent- and youth-friendly has been identified as a priority,15 and international standards of health care for youth have been developed.16 Improving PHC for young people is an important investment in creating healthy futures for individuals and for public health and prevention more generally.

What we know about improving youth health through PHC

The international literature offers general strategies for improving youth health.

Targeted strategies and information

Adolescents and young adults, like other specific population groups, need targeted primary healthcare strategies and information. PHC services should aim to achieve these outcomes:

• provide youth-specific health facilities, or facilities that are appealing, that acknowledge the diversity of young people and are appropriately equipped and easily accessible
• use strategies that make PHC services more acceptable and accessible for young people, such as opening hours that allow young people to come outside school hours, staff who relate well to them, and assurance that confidentiality will be respected
• provide accurate health information and age-appropriate programs and resources
• use the internet when appropriate or possible to deliver information and evidence-based programs, including via mobile phone apps and social media
• regularly update and share information about age-appropriate health, education, social, cultural and recreational resources available to young people in the local community
• use marketing strategies that encourage young people to access preventive services.17

Mental health care

A strong focus on youth mental health care is essential – now more than ever. Youth mental health care needs were well documented prior to 2020. The Covid-19 pandemic further inequitably affected the mental health of young people, putting them at higher risk of mental illness. Extended time away from education, friendships and relationships, sport, social life, cultural and community events had a particular effect on young people, for whom peer relationships are especially significant. Many have felt lonely. Many young people worldwide have suffered loss and grief from losing important people in their lives to the virus. The Covid-19 experience highlights these needs:

• focusing on developing young people’s resilience and preventing mental health problems early
• providing mental health training for PHC practitioners tailored to youth needs, including locally available referral options and skills to identify and support young people in distress18
• strengthening links between PHC services, schools and community resources for young people, such as social services, mental health and counselling services, alcohol and other drugs programs, suicide prevention programs and crisis response services
• overcoming known barriers to young people seeking and accessing mental health care
• barriers for young people include stigma, embarrassment, concerns about confidentiality and trust in a person they don’t know, cost, difficulties with recognising problems and a desire to deal with difficulties themselves19
• barriers for families include cost, wait times, trust and confidence in health professionals, and knowing where to get help20
• barriers for communities are having little or no access to affordable or appropriate mental health services.

Sexual and reproductive health

Often sexual and reproductive health, an important aspect of youth health, is the entry point to health services for adolescents. Primary healthcare services should prepare in these ways to help young people:

• train practitioners to share information with young people about sexual and reproductive health, in ways that promote understanding21
• ensure that sexual and reproductive health services can be accessed confidentiality and without judgement
• include sexual and reproductive health services discreetly as part a wider range of services (rather than a specialised clinic).

Community- and systems-based approaches

Comprehensive PHC for young people integrates clinical care with other wellbeing programs and services. These services may offer points of contact between youth and health service staff. In this area of practice, primary healthcare services should have these aims:

• working with schools and other agencies to provide holistic care, such as homelessness, counselling, disability and employment services
• connecting with young people in the places where they spend time – through school programs, sports and social clubs, entertainment venues and social media22
• where possible, engaging young people through peer educators and influencers.

Community- and systems-based approaches to PHC are described in Part IV. Chapter 15 includes an example of a school-based program to strengthen the resilience of teenagers in boarding schools.

Young Aboriginal and Torres Strait Islander peoples

In Australia, Aboriginal and Torres Strait Islander peoples aged 10–24 represent 5 per cent of the total Australian youth population. Many are connected to their culture, and participation in sporting, social or community events is high. Of those living in remote areas, more than 80 per cent surveyed recognised their traditional homelands, and participated in cultural activities. More than 75 per cent of those aged 15 to 24 years reported being happy all or most of the time.23 Another positive wellbeing indicator for young Aboriginal and Torres Strait Islander people is the proportion completing secondary education (Year 12 or equivalent), which has increased from 47 per cent in 2006 to 68 per cent in 2021.24 Around 74 per cent of young Aboriginal and Torres Strait Islander people aged 15–19 consider family relationships extremely or very important, and most aged 15–24 reported they had family or friends to confide in. The proportion of this age group who smoke decreased from 45 per cent in 2002 to 31 per cent in 2014–15.25

Building on these strengths is crucial, because young Aboriginal and Torres Strait Islander people have poorer health, as a population group, than other Australian young people. This is largely due to higher rates of mental illness, substance use and injuries26 – a legacy of colonisation that resulted in dispossession of land, disruption of family structures and social and cultural practices, and exclusion from societal opportunities. In 2014–15, for example, racial discrimination was experienced by young Aboriginal and Torres Strait Islander people aged 15–24 in most types of settings (for example, educational, health, work, public places);27 in 2022, two in five (40 per cent) young Aboriginal and Torres Strait Islander people reported that they had been treated unfairly or discriminated against in the past year.28 Young people exposed to racism are much more likely than others to have anxiety, depression, be at suicide risk, and have poor overall mental health.29 Compared with their non-Indigenous peers, young Aboriginal and Torres Strait Islander people also experience higher rates of chronic conditions, including diabetes, hearing loss, rheumatic heart disease and other health challenges.30 Aboriginal and Torres Strait Islander adolescents living in remote areas have the poorest adolescent health outcomes in Australia.31 Reducing these inequities for a healthier future requires systemic and social change and high-quality health care.

Aboriginal and Torres Strait Islander youth underuse health services and engage with health care at more advanced stages of illness and for shorter periods in comparison to non-Indigenous youth.32 For example, in 2014–15, only 23 per cent of the young Aboriginal and Torres Strait Islander people reporting high or very high levels of distress in the previous 12 months had been seen by a health professional.33 The quality, capacity and cultural appropriateness of health services are key factors in whether or not young people engage with services and in their health outcomes.34 Understanding the effect of intergenerational trauma, racism and socio-economic inequality is important for understanding the experiences of young Aboriginal and Torres Strait Islander people, the challenges they face in the transition to adulthood and their interactions with healthcare providers.35 The experiences of particular groups (for example, young people in out-of-home care, boarding school students), the context and language in which interactions take place (for example, clinic or community venue, first language), and the relationship between a young person and a health professional (for example, kinship links, cultural understandings or differences) are also likely to influence their engagement with health care.

The National guide to a preventative health assessment for Aboriginal and Torres Strait Islander people36 includes guidelines for youth health checks, and recommendations for reducing risks of unplanned pregnancy, sexually transmissible infections and illicit drug use. Useful tools, as recommended by National Aboriginal Community Controlled Health Organisation and the Royal Australian College of General Practitioners, include the HEEADSSS assessment tool and the Aboriginal and Torres Strait Islander youth social and emotional wellbeing assessment and question guide. The HEEADSSS assessment tool includes items relating to home and environment, education and employment, eating and exercise, activities and peer relationships, drug use/tobacco/alcohols, sexuality, suicide and depression, and safety.

Social and emotional wellbeing assessments for young people (as for other age groups) can be done opportunistically or as part of an annual youth health check to obtain a holistic assessment of health and to determine risk factors affecting wellbeing. Assessment should take a strengths-based approach that focuses on the capabilities of the young person and the community, advocates for a positive sense of cultural identity, and acknowledges potential for change, growth and success. When referrals are needed, the services and programs need to be culturally appropriate.

These health and care needs reinforce the need for PHC services to build the Aboriginal and Torres Strait Islander workforce and to connect positively with young people to provide culturally safe, affirming and holistic care. Strategies may include the following:

• increasing the number of Aboriginal and Torres Strait Islander staff, including Elders and young workers
• supporting community-led and youth-guided PHC solutions based on Aboriginal and Torres Strait Islander ways of knowing, being and doing
• connecting with young people and their families in the places they come together (for example, sports and cultural events)
• engaging young people to develop and spread health messages using preferred media and communication tools (for example, social media, digital technologies)
• using or co-designing age-appropriate resources37 and health promotion activities
• integrating care with the work of other youth and family services (for example, schools, training providers, child and youth protection, housing and youth justice) (see also Chapter 15).

The ongoing development and use of CQI approaches are important for monitoring progress and improving young people’s access to high-quality PHC. Good documentation of care processes in health records is essential for effective CQI. Community stories about what works well and not so well to improve services and outcomes for young people should also be documented and should reflect the voices of young people and their families. This aspect of CQI remains under-documented, and such stories are an important source of data for improving health promotion activities as part of comprehensive PHC.

Developing a clinical audit tool to measure the quality of care for youth – an implementation case study

Recognising that systems for monitoring and improving the performance of youth health services were limited, our research group developed and piloted a clinical audit tool for assessing the quality of PHC for young Aboriginal and Torres Strait Islander people aged 12–24, including mental health services provided within primary care. Few published pilot and validation studies of audit tools contain explicit information about the methodology used to develop indicators or the assessment criteria used to evaluate them.38 Here we explain the systematic approach taken to develop the audit tool, and how challenges that emerged during the development process were overcome.

Approach and methods

Traditionally, the development of quality indicators follows Donabedian’s theoretical approach to measuring quality of health care based on structures, processes and outcomes of care (see Chapter 4), and involves a combination of evidence-based guidelines and expert consensus. Where standards of care have not been defined, evidence-based guideline recommendations are identified and audit items developed using a systematic expert consensus approach and explicit selection criteria.39 This was the approach the group took in the absence of agreed standards of care for Aboriginal and Torres Strait Islander youth health.

As part of the project design, opportunities were provided for developing the capacity of Aboriginal and Torres Strait Islander researchers and stakeholders at all levels of the project, including two chief investigators. The development process, as detailed in a paper by Puszka and colleagues,40 is summarised here:

• Establishment of expert reference group (to determine content validity of the tool). Members from primary healthcare services and research organisations had collective expertise in Aboriginal and Torres Strait Islander youth health. They represented diverse PHC settings and services, and had knowledge of factors relevant to the health system and youth population (for example, appropriateness of services, priority health conditions and risk factors) and to PHC services (for example, client information systems, feasibility to complete audit). The group met monthly for 18 months.
• Development of audit items. Relevant guidelines for Aboriginal and Torres Strait Islander youth health were identified (16 in total) and used as a basis for development of initial audit items. Six criteria for including or excluding an audit item were developed (see Box 14.1). Group facilitation techniques were used to achieve consensus amongst members about audit items. Where members disagreed on the inclusion of a specific item in the audit, disagreements were generally resolved with reference to the inclusion criteria.
• Pilot tested. Four health centres ranging in size and governance arrangements piloted the tool in urban, regional and remote communities. Pilot testing aimed to assess the recording in client records of specific items of care and the ease of use of the audit tool. Testing was done using both paper-based and electronic patient information systems. At each pilot site, 30 client records were audited by trained auditors and health service staff.
• User feedback. Notes and feedback from auditors were used to assess performance and, at one site, a focus group discussion explored user experiences of the tool. Analysed data were fed back to the expert reference group for consideration.
• Refinement. The audit tool and protocol underwent four further phases of development as the expert reference group considered an initial draft and results from pilot testing and user feedback at the pilot sites. Each phase enabled revision and further refinement, taking account of user feedback, the gaps and conflicts in relevant guidelines for Aboriginal and Torres Strait Islander youth health, a lack of agreed standards of care, and the state of development of client information systems.41

Youth audit tool content

The audit tool43 includes items under five main headings:

• client information recorded in attendance records
• health checks
• scheduled immunisations
• protective factors, risk factors and brief interventions and referrals
• scheduled services including preventive health care.

A key component of the tool is its assessment of protective factors, risk factors, brief interventions and referrals. Audit items in this section are based on the internationally accepted youth psychosocial assessment known as HEEADSSS (see above in “Young Aboriginal and Torres Strait Islander people”).

Results of testing

The testing process44 showed that a few audit items had lower reliability. These items were refined and reviewed. While the tool was found to be user friendly, the time taken to complete the audit and feedback on the length of the tool provided impetus to prioritise audit items. The availability of information in client records led to further refinement.

The variable quality of documentation in client records presented challenges. Some audit items were not well documented and were difficult to audit. For example, there were inconsistencies in the recording of non-clinical items such as referrals and reports received from referral services, and in the terminology used in client records (for example, relating to psychosocial wellbeing). In response, clear definitions of terms were included in the audit protocol.

The documentation of screening for the psychosocial wellbeing of young people was found to vary greatly between psychosocial domains and between testing sites. There were also differences in the provision of treatment or referral in response to different psychosocial concerns. For example, there were gaps in service delivery for tobacco use. A decision was made to group some psychosocial items into a “lifestyle discussion”.

Brief interventions were the most common form of treatment provided, with the exceptions of mental health, where referral was more common, and sexual behaviour risks where “other treatment” was commonly provided (usually recorded as testing for sexually transmitted infections). An unexpected finding during the pilot study was that no prescription or discussion of contraception was documented in response to concerns about sexual behaviour risks across all sites.

The testing process demonstrated how the audit could help educate staff about best practice for youth health and encourage reflective practice. It reinforced the role of a clear, user-friendly audit protocol for collecting consistent data for measuring the quality of care for youth and tracking improvements over successive audit cycles. The practitioners who tested the tool questioned whether there should be scope to note why care standards were not met (for example, clients refusing treatment and their reasons), and whether the audit should include communication with referral services.45 While out of scope of the audit tool, this feedback highlighted the need to combine clinical audit results with other assessments of how well PHC systems are functioning to engage young people and respond to their healthcare needs. The One21seventy Youth Health Clinical Audit Tool was published in 2014.46 

Wider implications of the tool for improving the quality of care for young people

The potential health benefits and savings of health systems with a focus on prevention and early intervention are well documented.47 A greater emphasis on prevention and early intervention, particularly for psychosocial issues, caring staff who relate well to young people and the sustained use of measurement and monitoring frameworks for youth health may help reduce the gap in health outcomes between young Aboriginal and Torres Strait Islander people and young non-Indigenous Australians. In this PHC context, frameworks need to incorporate Aboriginal and Torres Strait Islander perspectives on health and wellbeing.

Audits can only capture care processes and indicators that are documented in clients’ health records. When care processes are well documented, there is more likelihood that audit findings will be accurate and that improvement strategies based on the data will be effective. Well-functioning client information systems are also crucial for the follow-up and management of young people’s health needs. Use of the Youth Health Clinical Audit Tool provides new evidence for improving PHC for young people. The participation of Aboriginal and Torres Strait Islander PHC team members (particularly young team members) in interpreting CQI data and guiding improvement strategies helps to ensure the evidence is put into practice in ways that build on youth and community strengths to improve care quality.

Conclusion

Developing the youth health audit tool required the developers to determine key measures of evidence-based care. This involved a systematic approach, drawing on existing evidence and expert consensus in combination with a more pragmatic process of determining the key items of care that could reasonably be expected to be provided and documented in the PHC context.

Audits and audit tools need to reflect the state of development of healthcare systems, client record systems and clinical guidelines or standards of care. They also need to reflect reasonable expectations about what care is feasible, even in relatively well-resourced health systems like those in Australia. Particularly in low-resource settings, but also more generally, policymakers and clinicians developing audit processes would need to ensure that audits are not used to assess practitioners and health services against unreasonable expectations. When audits are used in combination with systems assessments and with sensitivity to context, the findings are particularly useful for informing achievable goals and strategies for improving systems of care. The aim of introducing and using any CQI tools is to support teams and services to continuously learn and improve healthcare quality.

References