alexa Health Care Experiences and Needs of Adolescents in Urban Greece: Implications for Planning Appropriate Health Care

ISSN: 2375-4273

Health Care : Current Reviews

  • Research Article   
  • Health Care Current Reviews 2017, Vol 5(4): 4
  • DOI: 10.4172/2375-4273.1000208

Health Care Experiences and Needs of Adolescents in Urban Greece: Implications for Planning Appropriate Health Care

Adamandia Xekalaki1*, Dimitris Papamichail2, Polixeni Nikolaidou3, Anastasios Papadimitriou3 and Takis Panagiotopoulos2
1Department of Developmental and Social Pediatrics, Institute of Child Health, “Agia Sophia” Childrens’ Hospital, Papadiamadopoulou and Thivon, Athens, Greece
2Department of Child Health, National School of Public Health, Athens, Greece
3School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
*Corresponding Author: Adamandia Xekalaki, Department of Developmental and Social Pediatrics, Institute of Child Health, “Agia Sophia” Childrens’ Hospital, Papadiamadopoulou And Thivon, Athens, Greece, Tel: 2104201165, Email: [email protected]

Received Date: Sep 21, 2017 / Accepted Date: Sep 26, 2017 / Published Date: Oct 03, 2017

Abstract

Purpose: This study aims to explore experiences and views of 15 year old adolescents on primary health care services in large cities in Greece, and make policy and practice recommendations. Methods: A representative sample of 15 year old students, living in large cities of Greece, was selected using stratified cluster sampling. Information was collected using a structured questionnaire. Results: The questionnaire was completed by 2019 of the 2342 students in the school classes selected (response rate 86%). Girls were 54%; 92% were born in Greece. Half of the students (50%) reported having communication problems with the physician(s) they usually visit. Reasons of communication problems included: a/organizational problems, e.g. inadequate consultation time (17%); b/privacy and confidentiality issues, e.g. not having the opportunity to be alone with the doctor (36%), lack of confidence that their discussion with the doctor will not be disclosed to their parents (46%); c/lack of understanding their perspective, e.g. the doctor “is not interested in my problems” (15%), he/ she “does not treat me with respect” (13%). The gender of the physician is important for about one third of the students of the study sample (girls 48%, boys 23%) and girls tend to prefer a female doctor (54%).
Conclusion: Adolescents in this study pointed out that they need doctors who are aware of their way of thinking and problems and can communicate effectively with them; they require more consultation time, continuity of care, confidentiality and privacy. Service provision should be accordingly modified.

Keywords: Adolescent; Communication problems; Confidentiality; Health care; Greece

Introduction

Appropriate adolescent health care delivery is an important component of policies to improve adolescent health [1-3]. A substantial amount of research has shown that important health issues emerge during adolescence that can affect present health status and have a serious impact on adult life [1-6]. Depression, anxiety and other mental health problems, injuries, infectious diseases and risk factors such as iron deficiency, unsafe sex, alcohol and substance misuse contribute to the emerging disease profile of young people [1,3,4,7-9]. Chronic diseases, such as diabetes and early signs of cardiovascular disease, appearing in teenagers and young adults, may lead to a substantial drop in life expectancy [7]. A systematic analysis of mortality trends in children and young people in the past 50 years has shown that all cause mortality in adolescents and young adults was reduced less than in children [10].

Reported poor health, specific health problems and lack of life satisfaction among adolescents, especially girls, have been consistently found to be associated with unfavourable socioeconomic conditions [1,11-14]. In the mid-2000s, mortality of adolescents and young people (10-24 years old) living in low and middle income countries was found 3.6 times higher than that of those living in high income countries [15].

Improving primary health care services and implementing measures to make them appropriate for young people can allow them engage with their health and result in both short and long term population health gains [1-3,16,17]. Kang et al. [18] recommended seven principles to improve access and quality of primary health for youth. These principles include access facilitation, evidence-based practice, youth participation, collaboration, professional development, sustainability and evaluation [18]. Globally many countries fail to put emphasis on the health needs of adolescents [7,19]. This is also the case in Greece, where adolescents share the same health facilities with adults or with children, with no special care for their particular needs. In addition, the unfolding effects of the financial crisis have an impact not only on people’s income but also on the capacity of the health system to promote population health and manage health services [20,21].

This study aims to explore experiences and views of 15 year old adolescents on primary health care services in large cities in Greece, and make policy and practice recommendations.

Methods

We selected a random sample of 15 year old students (fourth grade of secondary school) living in large cities of Greece using stratified cluster sampling. Cities with a population of more than 60,000 were included, stratified by size. We used three strata: a/Athens, b/Thessaloniki, and c/other cities. In each stratum a number of schools were selected proportionate to stratum size according to the population of 15-19 year old. In each stratum, schools (clusters) were selected by systematic sampling, with a probability of selection proportionate to the school size (depending on the number of fourth grade school classes), using as sampling frame lists of schools provided by the Ministry of Education. From each school in the sample, two fourth grade classes were selected randomly. All children in the selected school classes were included in the study. On the whole, 51 schools were selected (102 classes), 62 in Athens, 18 in Thessaloniki and 22 in the other cities. We collected information on the adolescents’ experiences and views about primary health care services using a structured questionnaire. We included questions on the usual context of their visits to primary care services, their perceived health status and usual problems, their opinion on several aspects of the organization of the services and the quality of their communication with health professionals. The questionnaire was administered to the students in the classroom during school hours. The maximum time needed to complete the questionnaire was 20 min. Written consent from parents had been previously obtained. Approval of the research protocol has been obtained by the Bioethics Committee of the Institute of Child Health. We carried out data entry using Epidata (Epidata association, Denmark, version 3.1). Consistency and range checks were performed for data validation. The analysis was carried out using STATA (Stata Corporation, TX, USA, version 11). In the descriptive part of the analysis we calculated proportions and 95% confidence intervals adjusting for the sampling design implemented (stratification and cluster sampling). For testing the statistical significance of differences between proportions we used the chi square (χ2) test.

We carried out multiple logistic regression to identify predictive factors independently associated with outcome variables. As outcome variables we used a) satisfaction from primary care visits and b) reporting communication problems with physician. Initial regression models were constructed including all variables for which the p-value in the bivariate analysis was less than 0.1. We removed variables one at a time from the initial models on the basis of significance testing (p<0.1) with the likelihood ratio test. The adjusted risk ratios derived from binomial regression using all the variables of the final logistic regression models are presented.

Results

The questionnaire was completed by 2019 of the 2342 students selected (response rate 86.2%). The mean age of students participating in the study was 15.1 years (standard deviation 0.5 years) and girls were 54%; 92% were born in Greece. More than half of the children were living in Athens (59%), about one fifth in Thessaloniki and one fifth in other cities (Table 1). Most students were living with both parents (85%), divorce being the main reason of living with one parent.

  Total
n (%)a
(N=2019)
Boys
n (%)a
(N=927)
Girls
n (%)a
(N=1092)
P value
City
Athens
Thessaloniki
Other cities
Total
1191 (59.0)
389 (19.3)
439 (21.7)
2019
548 (59.1)
183 (19.7)
196 (21.1)
927
643 (58.9)
206 (18.9)
243 (22.3)
1092
0.835
Country of birth
Greece
Albania
Other
Total
1811 (91.9)
80 (4.1)
80 (4.1)
1971
832 (93.0)
33 (3.7)
30 (3.4)
895
972 (91.0)
47 (4.4)
50 (4.6)
1076
0.172
Father’s age
<45
45-54
= 55
Total
466 (25.4)
1119 (60.9)
253 (13.8)
1838
195 (23.7)
510 (61.9)
119 (14.4)
824
271 (26.7)
609 (60.1)
134 (13.2)
1014
0.417
Mother’s age
<45
45-54
= 55
Total
1118 (59.8)
731 (38.1)
38 (2.0)
1869
496 (59.7)
315 (37.9)
20 (2.4)
831
622 (59.9)
398 (38.3)
18 (1.7)
1038
0.616
Father’s educational level
Lower secondary education
Upper secondary education
Tertiary education
Total
357 (19.3)
579 (31.4)
910 (49.3)
1846
170 (20.2)
268 (31.9)
403 (47.9)
841
187 (18.6)
311 (30.9)
507 (50.4)
1005
0.496
Mother’s educational level
Lower secondary education
Upper secondary education
Tertiary education
Total
283 (15.0)
717 (38.0)
886 (47.0)
1886
126 (14.6)
321 (37.2)
416 (48.2)
863
157 (15.3)
396 (38.7)
470 (45.9)
1023
0.643

a: Percentages adjusted for stratification and cluster design.

Context of health visits

The vast majority of students (80%) reported frequent visits to a physician, i.e., at least every six months. For 1340/1837 of the children (73%) the visits were usually paid to a “generalist physician” (pediatrician or internist in ambulatory settings, according to the practice in Greece). Half of them reported that they always visited the same doctor. Nine in ten students usually visited a primary care ambulatory setting, while 4% usually visited a hospital outpatient clinic. Girls were more likely to visit a female physician than boys (Table 2). For half of the adolescents, the last visit to a doctor was a well-child care visit or a preparticipation athletic evaluation. Only one in four reported illness as the cause of the last visit. The usual waiting time was ≤ 15 min for six in 10 students and for a similar proportion of students the usual time of consultation was ≤ 15 min. Half of the children reported that visiting the doctor was usually a common decision of the parents and themselves, but three in 10 reported they had no say in the decision. When asked if they had ever visited the doctor alone, 47% replied affirmatively; boys were more likely to have visited a doctor on their own. About one in four adolescents reported having a health problem (girls 29%, boys 18%), although 90% stated that their health status was very good or good (Table 2).

Questions Total
n (%; 95% CIa)b
(N=2019)
Boys
n (%; 95% CIa)b
(N=927)
Girls
n (%; 95% CIa)b
(N=1092)
P value
How often do you visit a doctor?
At least once in every six months
= once per year Total
1609 (80.0; 77.4-82.3)
403 (20.0; 17.7-22.6)
2012
736 (79.8; 76.9-82.5)
186 (20.2; 17.5-23.1)
922
873 (80.1; 76.6-83.2) 217 (19.9; 16.8-23.4) 1090 0.887
What was the cause for your last visit to a doctor?
Well child visit +/- vaccination
Sickness
Health assessment for sports
Other issue
Total
437 (22.2; 20.2-24.4) 475 (24.1; 21.6-26.8) 653 (33.2; 30.3-36.3) 402 (20.4; 18.5-22.5)
1967
170 (19.0; 16.6-21.7)
204 (22.8; 19.5-26.4)
331 (37.0; 33.0-41.1)
190 (21.2; 18.7-24.0)
895
267 (24.9; 22.0-28.0)
271 (25.3; 21.9-29.0)
322 (30.0; 26.4-33.9)
212 (19.8; 16.8-23.1)
1072
0.006
The doctor that you usually visit:
Is always the same person
Most of the times is the same person
Most of the times is a different person
Total
923 (47.2; 45.2-49.3) 815 (41.7; 39.5-43.9) 216 (11.1; 9.3-13.1) 1954 427 (47.9; 44.9-50.8)
372 (41.7; 38.9-44.5) 93 (10.4; 8.2-13.2) 892
496 (46.7; 44.0-49.4)
443 (41.7; 39.0-44.5) 123 (11.6; 9.5-14.1) 1062
0.612
What is the sex of the doctor that you usually visit?
Always a man
Always a woman
Most of the times a man
Most of the times a woman
Total
648 (32.4; 30.2-34.7) 340 (17.0; 15.2-19.1) 660 (33.0; 31.0-35.1) 350 (17.5; 15.5-19.7) 1998 341 (37.2; 34.2-40.3)
144 (15.7; 13.1-18.7)
296 (32.3; 29.5-35.2)
136 (14.8; 12.4-17.6)
917
307 (28.4; 25.6-31.4)
196 (18.1; 15.6-20.9)
364 (33.7; 31.0-36.4)
214 (19.8; 17.2-22.7)
1081
<0.001
Who does normally decide that you need to visit the doctor?
Parents
Myself
Parents and myself
Another person
Total
581 (28.9; 26.6-31.4)
265 (13.2; 11.8-14.7)
1135 (56.5; 54.1-58.9)
28 (1.4; 0.9-2.2)
2009
270 (29.3; 25.9-32.9)
148 (16.1; 14.1-18.2)
485 (52.7; 49.2-56.1)
18 (2.0; 1.2-3.3)
921
311 (28.6; 25.9-31.5)
117 (10.8; 9.0-12.8)
650 (59.7; 56.6-62.8)
10 (0.9; 0.4-1.9)
1088
<0.001
Have you ever visited the doctor alone?
Yes
No
Total
907 (46.6; 43.4-49.9)
1038 (53.4; 50.1-56.6)
1945
497 (56.7; 52.6-60.8)
379 (43.3; 39.2-47.4)
876
410 (38.4; 34.4-42.5)
659 (61.6; 57.5-65.6)
1069
<0.001
What is the usual waiting time?
= 15 min
>15 min
Total
1271 (63.3; 61.0-65.5)
738 (36.7; 34.5-39.0)
2009
597 (64.8; 60.9-68.4)
325 (35.2; 31.6-39.1)
922
674 (62.0; 58.7-65.2)
413 (38.0; 34.8-41.3)
1087


0.303
What is the usual consultation time?
= 15 min
>15 min
Total
1270 (63.2; 61.0-65.4)
738 (36.8; 34.6-39.0)
2008
593 (64.4; 61.2-67.4)
328 (35.6; 32.6-38.8)
921
677 (62.3; 59.2-65.3)
410 (37.7; 34.7-40.8)
1087
0.338
Do you have a health problem?
Yes
No
Total
476 (23.7; 21.7-25.9)
1532 (76.3; 74.1-78.3)
2008
166 (18.0; 15.3-21.0)
756 (82.0; 79.0-84.7)
922
310 (28.5; 25.4-31.9)
776 (71.5; 68.1-74.6)
1086
<0.001
How would you describe your health?
Very good
Good
Moderate
Bad
Total
936 (46.9; 44.3-49.4)
863 (43.2; 40.4-46.1)
174 (8.7; 7.5-10.1)
24 (1.2; 0.7-1.9)
1997
500 (54.3; 50.8-57.9)
350 (38.0; 34.9-41.3)
61 (6.6; 5.1-8.5)
9 (1.0; 0.5-2.0)
920
436 (40.5; 36.9-44.2)
513 (47.6; 43.7-51.5)
113 (10.5; 8.8-12.4)
15 (1.4; 0.8-2.3)
1077
<0.001

a: 95% Confidence Interval
b: Percentages adjusted for stratification and cluster design

Communication problems

Half of the students participating in the study reported having communication problems with the physician(s) they usually visit in the framework of primary care (1017/2016, 50%). Reasons of communication problems reported by these adolescents included: a/ organizational problems, e.g. not having their own doctor (25%), inadequate consultation time (17%); b/ privacy and confidentiality issues, e.g. not having the opportunity to be alone with the doctor (36%), lack of confidence that their discussion with the doctor will not be disclosed to their parents (46%); c/ lack of understanding their perspective, e.g. the doctor “is not interested in my problems” (15%), he/she “does not treat me with respect” (13%), he/she “criticizes the way I dress or behave (13%), “we do not speak the same language” (20%). Of note, about one third of the adolescents who reported communication problems stated as a reason that doctors are “authoritarian and absolute” (Table 3).

Question Total
n (%; 95% CIa)b
(N=1017)
Boys
n (%; 95% CIa)b
(N=451)
Girls
n (%; 95% CIa)b
(N=566)
P value
Time with the doctor is insufficient
Yes
No
Total
176 (17.3; 14.7-20.4)
840 (82.7; 79.6-85.3)
1016
99 (22.0; 17.7-26.9)
352 (78.0; 73.1-82.3)
451
77 (13.6; 11.1-16.7)
488 (86.4; 83.3-88.9)
565
<0.001
No confidentiality (disclosure to parents)
Yes
No
Total
466 (45.9; 42.5-49.3)
550 (54.1; 50.7-57.5)
1016
204 (45.2; 40.5-50.1)
247 (54.8; 49.9-59.5)
451
262 (46.4; 42.3-50.5)
303 (53.6; 49.5-57.7)
565
0.692
I am never alone with the doctor
Yes
No
Total
370 (36.4; 33.1-39.8)
646 (63.6; 60.2-66.9)
1016
157 (34.8; 30.2-39.7)
294 (65.2; 60.3-69.8)
451
213 (37.7; 33.2-42.4)
352 (62.3; 57.6-66.8)
565
0.381
The doctor is not interested in my problems
Yes
No
Total
152 (15.0; 12.5-17.9) 864 (85.0; 82.1-87.5) 1016 92 (20.4; 16.8-24.6) 359 (79.6; 75.4-83.2) 451 60 (10.6; 8.2-13.7)
505 (89.4; 86.3-91.8)
565

<0.001
I don’t believe that I can tell my problems to the doctor
Yes
No
Total
513 (50.5; 47.0-53.9) 503 (49.5; 46.1-53.0) 1016 221 (49.0; 44.4-53.6) 230 (51.0; 46.4-55.6) 451 292(51.7; 47.2-56.1) 273 (48.3; 43.9-52.8) 565 0.369
The doctor doesn’t treat me with respect
Yes
No
Total
136 (13.4; 11.2-15.9) 880 (86.6; 84.1-88.8) 1016 76 (16.9; 13.2-21.2) 375 (83.1; 78.8-86.8) 451 60 (10.6; 8.2-13.7)
505 (89.4; 86.3-91.8)
565
0.012
The doctors are criticizing the way I dress and behave
Yes
No
Total
127 (12.5; 10.4-14.9) 889 (87.5; 85.1-89.6)
1016
72 (16.0; 12.4-20.2) 379 (84.0; 79.8-87.6)
451
55 (9.7; 7.5-12.5)
510 (90.3; 87.5-92.5)
565
0.006
Doctors don’t speak the same language with me.
Yes
No
Total
202 (19.9; 17.3-22.7)
814 (80.1; 77.3-82.7)
1016
103 (22.8; 19.3-26.8)
348 (77.2; 73.2-80.7)
451
99 (17.5; 14.6-20.9)
466 (82.5; 79.1-85.4)
565
0.022
Doctors are authoritarian and absolute.
Yes
No
Total
281(27.7; 24.4-31.1)
735 (72.3; 68.9-75.6)
1016
128(28.4; 24.1-33.1)
323(71.6; 66.9-75.9)
451
153(27.4; 23.3-31.3)
412(72.9; 68.7-76.7)
565
0.618
Doctors think that I am still a little child and I don’t understand things
Yes
No
Total
368 (36.2; 33.2-39.3) 648 (63.8; 60.7-66.8)
1016
170 (37.7; 32.9-42.7) 281 (62.3; 57.3-67.1)
451
198 (35.0; 31.5-38.8) 367 (65.0; 61.2-68.5)
565
0.375
I don’t have my own doctor
Yes, I don’t have my own doctor
No, I have a doctor of my own.
Total
266 (26.2; 23.2-29.4)
750 (73.8; 70.6-76.8)
1016
118 (26.2; 22.1-30.7)
333 (73.8; 69.3-77.9)
451
148 (26.2; 20.2-30.6)
417 (73.8; 69.4-77.8)
565
0.992

a: 95% Confidence Interval
b: Percentages adjusted for stratification and cluster design.

Table 3: Communication problems reported.

Interestingly, among participants reporting communication problems with physicians, students from Thessaloniki were more likely to affirm that physicians do not treat them with respect (23% vs. 13% for students from Athens and 11% for those from other cities, p=0.017), don’t “speak the same language” (30% vs. 18% and 22% respectively, p=0.025) or don’t give them enough time (30% vs. 16% and 17% respectively, p=0.009), while students from “other cities” were more likely to raise confidentiality issues (54% vs. 43% for participants from Athens and 45% for those from Thessaloniki, p=0.017).

Views and suggestions of adolescents

The large majority of adolescents in the study sample stated that they would like to have the opportunity to visit the doctor on their own (boys 72%, girls 61%) and to have a private and confidential discussion with him/her (boys 86%, girls 87%); most of the children (87%) believed that their parents would not object to confidential consultations. The gender of the physician is important for about one third of the students (girls 48%, boys 23%) and girls tend to prefer a female doctor (54%). More consultation time available for discussing important matters was suggested by one third of study participants and one in five stated that doctors do not provide adequate explanations. The majority of children (78%) affirmed that, on the whole, they were satisfied (very much or sufficiently) with the health care they get (Table 4).

Question Total
n (%; 95% CIa)b
 (N=2019)
Boys
n (%; 95% CIa)b
 (N=927)
Girls
n (%; 95% CIa)b
 (N=1092)
P value
I would like to visit the doctor alone sometimes
I agree/probably agree
I disagree/probably disagree
Total
1329 (73.5; 71.4-75.6) 478 (26.5; 24.4-28.6)
1807
665 (79.9; 76.9-82.7)
167 (20.1; 17.3-23.1)
832
664 (68.1; 64.7-71.3)
311 (31.9; 28.7-35.3)
975


<0.001
I would like some issues to remain private and confidential
I agree/probably agree
I disagree/probably disagree
Total
1530 (80.5; 78.9-81.9)
371 (19.5; 18.1-21.1)
1901
683 (79.6; 77.2-81.8)
175 (20.4; 18.2-22.8)
858
847 (81.2; 78.9-83.3)
196 (18.8; 16.7-21.1)
1043
0.332
Is the sex of the doctor important to you?
Yes
No
Total
738 (36.7; 34.5-38.9) 1273 (63.3; 61.1-65.5)
2011
214 (23.2; 20.2-26.5)
709 (76.8; 73.5-79.8)
923
524 (48.2; 44.8-51.5) 564 (51.8; 48.5-55.2) 1088

<0.001
What sex do you prefer the doctor would be?
Man
Woman
I don’t care
Total
243 (12.1; 10.9-13.5) 743 (37.0; 34.8-39.3) 1020 (50.8; 48.7-53.0)
2006
183 (19.9; 17.7-22.3)
155 (16.9; 14.2-19.9)
581 (63.2; 59.8-66.5)
919
60 (5.5; 4.1-7.4)
588 (54.1; 50.9-57.2) 439 (40.4; 37.1-43.7) 1087
<0.001
My parents would not allow me to speak alone with the doctor
I agree/probably agree
I disagree/probably disagree
Total
255 (13.3; 11.8-14.8)
1668 (86.7; 85.2-88.2)
1923
125 (14.1; 11.8-16.7)
761 (85.9; 83.3-88.2)
886
130 (12.5; 10.6-14.7)
907 (87.5; 85.3-89.4)
1037
0.345
The waiting room makes me feel uncomfortable
I agree/probably agree
I disagree/probably disagree
Total
584 (29.8; 27.2-32.5)
1379 (70.2; 67.5-72.8)
1963
256 (28.4; 24.4-32.7)
645 (71.6; 67.3-75.6)
901
328 (30.9; 27.7-34.2)
734 (69.1; 65.8-72.3)
1062
0.343
The waiting time is usually too much
I agree/probably agree
I disagree/probably disagree
Total
935 (48.0; 44.8-51.2)
1012 (52.0; 48.8-55.2)
1947
400 (44.5; 40.2-48.9)
499 (55.5; 51.1-59.8)
899
535 (51.0; 47.1-54.9)
513 (49.0; 45.1-52.9)
1048
0.016
I would like more time to discuss with the doctor
I agree/probably agree
I disagree/probably disagree
Total
603 (32.2; 29.3-35.3)
1267 (67.8; 64.7-70.7)
1870
270 (31.5; 27.9-35.4)
586 (68.5; 64.6-72.1)
856
333 (32.8; 29.1-36.8)
681 (67.2; 63.2-70.9)
1014
0.203
I feel uncomfortable during the examination
I agree/probably agree
I disagree/probably disagree
Total
650 (33.4; 30.7-36.2)
1297 (66.6; 63.8-69.3)
1947
176 (19.6; 16.1-23.8)
720 (80.4; 76.2-83.9)
896
474 (45.1; 41.8-48.4)
577 (54.9; 51.6-58.2)
1051


<0.001
I feel uncomfortable in asking questions.
I agree/probably agree
I disagree/probably disagree
Total
568 (29.1; 26.9-31.5)
1381 (70.9; 68.5-73.1)
1949
211 (23.8; 20.1-27.8)
677 (76.2; 72.2-79.9)
888
357 (33.6; 30.7-36.7)
704 (66.4; 63.3-69.3)
1061
0.005
Doctors don’t explain what is wrong with me and what I should do.
I agree/probably agree
I disagree/probably disagree
Total
351 (17.9; 16.0-20.0)
1609 (82.1; 80.0-84.0)
1960
152 (17.1; 14.6-19.8)
739 (82.9; 80.2-85.4)
891
199 (18.6; 16.2-21.4)
870 (81.4; 78.6-83.8)
1069
0.341
Are you satisfied with the health care that you have experienced?
Very much
Sufficiently
Moderately
Not at all
Total
481 (24.2; 22.0-26.4) 1071 (53.8; 51.5-56.1) 391 (19.6; 17.7-21.8)
48 (2.4; 1.9-3.1)
1991
263 (28.9; 25.8-32.1)
475 (52.1; 48.6-55.6)
144 (18.8; 13.0-19.0)
29 (3.2; 2.2-4.5)
911
218 (20.2; 17.4-23.2)
596 (55.2; 52.4-58.0)
247 (22.9; 20.3-25.7)
19 (1.8; 1.2-2.5)
1080
<0.001

a: 95% Confidence Interval
b: Percentages adjusted for stratification and cluster design.

Table 4: Adolescents’ views on health care provision.

Multivariable analysis

According to the multivariable analysis staying in Thessaloniki or in other cities and the higher educational level of the father is positively correlated with better communication with the doctor. In contrast adolescent smoking is increasing the chance of communication problems. Furthermore, higher educational level of the mother and living with both parents is associated with more satisfaction from health care; adolescents who smoke are less likely to be satisfied with health care they receive (Table 5).

  Satisfaction from
health care experience
  Communication problems
with physician
 
Predictive factor Adjusted RRa (95% CIb)
(N=1846)
P value Adjusted RRa (95% CIb)
 (N=1831)
P value
Sex
Boy
Girl
Ref.
0.93 (0.89-0.98)
0.010 NA‡  
City of residence
Athens
Thessaloniki
Other cities
Ref.
1.00 (0.93-1.07)
1.09 (1.03-1.16)
0.948
0.005
Ref.
0.47 (0.35-0.63)
0.92 (0.78-1.09)
<0.001
0.344
Father’s educational level
Medium educational levelc
High educational leveld
NAe   Ref.
0.89 (0.82-0.97)
0.009
Mother’s educational level
Medium educational level
High educational level
Ref.
1.06 (1.01-1.10)
0.008 NAe  
Living with both parents
No
Yes
Ref.
1.09 (1.00-1.19)
0.033 NAe  
Adolescent smoking
No
Yes
Ref.
0.91 (0.84-0.97)
0.005 Ref.
1.18 (1.07-1.31)
0.001

a: Adjusted risk ratio
b: 95% Confidence Interval
c: Medium educational level: up to higher secondary school level graduates
d: High educational level: tertiary education graduates
e: Non-applicable (not in the final model of multivarable analysis)

Table 5: Predictive factors for adolescents being satisfied from health care and for reporting communication problems: final model of logistic regression analysis.

Discussion

We carried out a cross-sectional study in a random sample of 15 year old adolescents living in large cities in Greece to investigate their experiences and views on health care services and make policy recommendations. About half of the adolescents participating in the study reported having communication problems with the physician they usually visit. This is a significant problem with far reaching implications, which has been attributed by study participants to several specific conditions. These include organization of care in a way that does not provide them “their doctor” (i.e., continuation of care), inadequate consultation time, lack of sensitivity from the part of physicians to “understand them”, as well as aspects of care and physician behavior that do not ensure privacy and make them feel uncertain about confidentiality. Communicating effectively with adolescents requires knowledge of this unique stage of development and an ability to understand the social context of health behaviors in adolescence, which are different from those of children or adults [22]. Research has shown that pediatricians can view adolescents as difficult or demanding patients with a special agenda of issues they cannot always understand or handle [23,24]. Lack of training can be an important barrier in delivering effective adolescent health care and formal training is suggested for physicians and other health care professionals [23-27]. In a review, Melville (1989) argued that teenagers frequently have a hidden agenda behind the presenting physical symptoms, which, unless trained, a health professional may find it difficult to unlock [28]. Teaching of consultation and communication skills has been shown to be an effective means of improving doctors’ skills in consulting, and specific training in consultation skills for pediatric encounters has been advocated [29,30]. It has been shown that health professionals have credibility among adolescents and the advice they give may have a positive impact on health behavior [31]. Furthermore, studies have reported that a familiar trusted person can improve communication and adolescents are more willing to discuss topics that have been previously discussed [31]. Time available for consultation is an important parameter of increased quality in health care of adolescents, as has been consistently shown [23,24,27,32,33]. Confidentiality and privacy have been also shown to be critical for high quality health care for adolescents and research has shown that adolescents who forgo health care due to confidentiality concerns are particularly vulnerable and in need of health services [34,35]. Many adolescents want to speak alone with their doctors about sensitive health topics but often refrain due to lack of opportunity for private discussion [34]. The issue of adolescent confidentiality in health care presents challenges for health care providers related to family, medical, ethical, legal, social and administrative processes [36]. Parents are usually willing to allow their daughters and sons consult doctors alone, as long as confidentiality policy and limitations are explained to them [33]. The importance of parents’ agreeing to a private discussion is related to the legal aspects of consent, competence and confidentiality regarding adolescents under the age of 18 in the context of the legal framework of any given country [18,35,37]. Even though parental consent may be granted, uncertainty over ethical and legal rights and responsibilities may lead professionals to refuse to see adolescents on their own for fear of incurring parental wrath or even legal action [37,38]. Due to the importance of these issues, various health care organizations have issued relevant guidelines [33]. Of note, none of the specialties involved in primary care of adolescents in Greece have any systematic training in adolescent medicine, while this is not a recognized subspecialty in Greece. Moreover, adolescent medicine is not part of the core curriculum at pre-graduate level. In the present study, we found that 90% of adolescents’ visits to a doctor are paid to a “generalist physician” (pediatrician or internist in ambulatory settings), which is in line with previous reports [29]. In most cases (75%), these visits were carried out in the context of “well child visits”. Furthermore, 80% of adolescents reported that they visit a doctor at least once in every six months (Table 2). This is consistent with research findings in other developed countries, which indicate that 70-90% of adolescents contact primary health services at least once a year [2,31]. Therefore, present practice provides opportunities for consultations with adolescents, which, if appropriately oriented, can address critical problems of this stage of development. It is noteworthy that despite adolescents’ critical views about the primary care services they get, as discussed above, the majority of them (78%) reported that they were very much or sufficiently satisfied with the health care they had experienced (Table 4). This possibly reflects low expectations from physicians and health care encounters, particularly regarding advice on sensitive issues.

Strengths and Limitations

A notable strength of the present study is that it provides detailed and quantified information on adolescents’ views regarding their health care and their encounters with primary care physicians in the context of large cities in Greece; these can serve as a basis for a comprehensive plan to reorganize health care services for adolescents in Greece, particularly at a time when restructuring of primary care services is under way [39]. Furthermore, our study provides information on groups of adolescents whose needs should be particularly the focus of attention by services and physicians, as they report more communication problems with doctors and/or reduced satisfaction from health services (e.g. children with parents of low or medium educational level, children of one-parent families, adolescents who smoke (Table 5).

An important limitation of our study is the fact that the study population was adolescents from large cities (60,000 inhabitants or more). Therefore, our conclusions refer to this type of populations in Greece and cannot be directly extrapolated to adolescents from smaller areas. Moreover, our findings are based on views of adolescents through a detailed questionnaire; although these give an important insight, views of parents and physicians as well as morbidity based measures of health care needs are also important, but have not been included in the present study. In conclusion, adolescents in this study pointed out that they need doctors who are aware of their way of thinking and problems, and can communicate effectively with them, they require more consultation time, continuity of care, respect of confidentiality and opportunities for consultations in privacy. In Greece, the reform of primary health care which is in progress and modifications planned for curricula of health professional education and specialization should take seriously into account the specifics of adolescent health care needs.

References

Citation: Xekalaki A, Papamichail D, Nikolaidou P, Papadimitriou A, Panagiotopoulos T (2017) Health Care Experiences and Needs of Adolescents in Urban Greece: Implications for Planning Appropriate Health Care. Health Care Current Reviews 5: 208. Doi: 10.4172/2375-4273.1000208

Copyright: ©2017 Xekalaki A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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