| Project Objectives / Summary:
The aim of the pilot project was to:
- Strengthen the relationship between General Practitioners and adolescents (aged between 13 and 16 years) within three Divisions of General Practice in South Australia. This was to be achieved by supporting General Practitioner involvement in broader community development strategies for young people in rural areas.
- Enhance collaboration and sustainable partnerships between General Practitioners, school staff and local and regional health workers by supporting and promoting a coordinated approach to the identification and assessment of "at risk" youth in both the GP practice and school setting.
A Coordinated Approach to Improving Adolescent Health in Rural South Australia was a pilot project implemented by three Divisions of General Practice across rural SA (Mid North Rural SA DGP, Yorke Peninsula DGP and Barossa DGP.) As all three Divisions of General Practice are within the one health region, (Wakefield Regional Health Service), the interdivisional approach aimed to assist in breaking down Divisional boundaries, and to provide a strong lobby for youth at a regional level to ensure that available human and financial resources are used effectively.
The project's approach to improving rural adolescent health was innovative in that a school in each Division was linked with a specific General Practice. This aimed to strengthen the relationships between General Practitioners and students (aged between 13-17 years) in these schools, and to break down some of the barriers between them. This approach also aimed to enhance collaboration between GPs, school staff and local health workers. Up skilling opportunities were provided in a number of ways, and training was offered in youth issues & health, as well as in the identification and care of "at risk" youth both in the GP and school settings. Parents were involved in education seminars at the local schools. Resources were developed for information, to help coordinate and "publicise" current services and to facilitate the transferability of the project.
Project Collaboration:
The project directly involved three Divisions of General Practice, three GP clinics, six GPs, three schools, three school counsellors, and Year 10 and Year 11 students. Indirectly the project involved GP clinic staff, school teachers and chaplains, and other adolescent health professionals and organisations.
Project Outcomes:
Over the life of the project, the need for ownership and flexibility within each Division was highlighted, allowing local differences to be accommodated. Expert evaluation of the project's processes has proved invaluable, and has contributed much to the development of this manual, enabling easy implementation of the project in other areas.
Through implementation of the project and the establishment of networks between GPs, schools and health workers, Youth Health issues are highlighted and GPs are able to contribute much to the youth community.
The Adolescent Health Project (AHP) has met its overall aim by achieving several key outcomes including:
- The development of inter-Divisional collaborative relationships and practices;
- The development of a centralised management/support and local delivery model;
- The development of key strategies including Educational seminars, GP school Visits, Student Visits to GP Clinics; Parent Seminars; and structures such as the local Steering Committees;
- The development of resources for Divisions (Divisions Manual), GPs (Youth Health Management Resource/ Referral Options, GP Consultation Protocol), GP Clinics (Youth Friendly Practice Manual) and students (Survival Kit);and
- The development of partnerships between GPs, Schools and students.
Overall the AHP has:
- Improved GP relationships and comfort with dealing with young people;
- Improved GP relationships with school counsellors; and
- Improved Divisional relationships with local schools; and increased student knowledge about GPs, confidence and comfort with accessing GPs.
It is important to recognise that these findings need to be interpreted with caution for two reasons:
- The evaluation findings have emerged predominantly from self-report data (feedback forms and semi-structured interviews) from a sample of AHP participants, and that no objective measures have been made of actual practices.
- Given that no key performance indicators (KPIs) existed at the start of the AHP but only expected outcomes, the evaluation has had to extrapolate and interpret the self-report data with regard to the extent to which progress has been made to achieving expected outcomes
Based on a capacity building framework (NSW Health, 2000), overall the AHP model and strategies has contributed to building the capacity of Divisions, GPs, and school counsellors to improve adolescent health care provision in rural South Australia, by contributing specifically to workforce development, organisational development and resource allocation.
With regard to resource development overall the AHP has contributed to the body of evidence regarding best practice in adolescent health care provision within primary health care. However, due to the timeframe for resource development and evaluation, it was not possible to evaluate the appropriateness, relevance and usefulness of AHP resources at the GP and Division level.
Anecdotal feedback to the Divisional Project Officers from GPs has revealed that the Youth Health Management Referral Options have been positively received. The evaluation of the HEADSS (ie. GP Consultation Protocol) revealed that GPs who had received the HEADSS were clear on how to use, just over half reported using it occasionally, and approximately two-thirds intended to use the HEADSS in future consultations. Despite these results being from only 26 (39%) GPs, they are promising as the HEADSS was mailed out to GPs from the Division as one -off strategy.
As far as the AHP impacting on parents, the evaluation revealed that despite
parent seminars being organised by the Divisions, which were poorly attended, the parent related AHP activities were not consistent across the three Divisions and Divisional Project Officers reported that there was a lack of resources (staff and time) allocated to parent-related activities.
The evaluation revealed several unexpected outcomes at the:
- GP level (e.g., GPs reported that the AHP had highlighted the "real" need for a Divisional Project Officer to provide centralised support, coordination and organised activities for them; Divisional level (eg., establishment of Aboriginal Health Check- ups in the York Peninsula Division);
- School counsellors level (eg. School counsellors reported that the AHP had increased student awareness of their role); and service provision model level (eg. the evaluation also highlighted the breadth and depth in terms of leadership, expertise, support and commitment that SARRSMSA had at the AHP conceptualisation, planning, implementation and evaluation phases.
The evaluation has also revealed that the AHP model, structures and strategies had worked at a Regional level (ie. three Divisions located in the Wakefield Regional in Rural South Australia) and in particular has contributed to the capacity of Divisions, GPs and School Counsellors to improve adolescent health care. Given this, it is important that consideration be made as to whether the model, structures and strategies would work at a State or National level. Within General Practice there are several initiatives that have used a comparable models such as in the Quality Use of Medicines area (eg. DiNCQUM GP) and Immunisation area (eg" GPII- General Practice Immunisation Scheme). It was beyond the scope of this evaluation to fully assess the appropriateness and feasibility of the AHP to be run at a state or National level, however, the analysis of the AHP using the Capacity Building Framework has provided some insights into its potential success.
Recommendations:
It was recommended that DoHA continue to provide funds to further disseminate and implement the AHP using a centralised management/support and local delivery model via Divisions of General Practice; participating Divisions, GP Clinics, Schools and evaluators work as one team from the start; overall AHP outcomes, strategies and key performance indicators be clarified using a Program Logic approach; a Capacity Building framework be used for directing further project development and evaluation, and that future AHPs be evaluated using a developmental and formative evaluation approach given that now a model and structures have been developed.
As an innovative project, the AHP provided support for the view that the Commonwealth Department needs to embrace and support Adolescent Health as a National Health Priority issue, particularly within the rural setting and allocate resources to further develop policy, program and research that informs the development of best practice models, structures and strategies in adolescent health care provision within General Practice.
AHP Implementation I
It was recommended that:
- Future AHPs have a clearly defined planning phase, pre- implementation phase and an implementation phase. The evaluation revealed that in the first six months there was not adequate planning, task identification nor resource development.
- GP Clinics and Schools be selected on the basis of commitment and capacity (workforce, organisational and resources) and that contractual type arrangements are made. The AHP had no formal GP Clinic and School selection and recruitment criteria, and no agreed upon roles nor responsibilities.
- In any future AHPs, a structured GP education program about adolescents be a high priority, be provided prior to any contact with students and be resourced. GPs skills as educators is highly variable and GPs were not provided with any formal education and training prior to conducting the GP School Visits.
- Future AHPs continue to use a complementary set of multi- level (GP, GP Clinic) strategies, particularly GP school Visits and Student Clinic Visit. The GP School Visits and Student Clinic Visit were perceived by all AHP participants as complementary and key to success of the project.
- In future AHPs the purpose, composition, and size of Steering Committees be reviewed. AHP participants reported that the usefulness of the committees was limited by their lack of clear purpose, composition and size.
- GP Clinic staff and School Counsellors need to be more involved, be provided financial incentives, and educational opportunities. Overall GP Clinic staff were not greatly involved in the AHP, and staff were seen as key to enhancing the youth friendliness of clinics. School counsellors were seen as key, however they needed to be supported so that AHP was not an 'extra-curricular activity' but part of their job description.
Disseminating Project Information:
Resources:
- Youth Friendly General Practice Manual
- Rights and Responsibilities for Young People Poster
- Implementation Manual
The comprehensive project manual includes strategies developed, difficulties experienced and lessons learnt. Resources have been well researched, and include lesson plans, youth-friendly practice checklists and where to access information on youth issues and health. The manual aims to be an easily accessible reference on how to best implement part, or all, of the project, but at the same time encourages flexibility and responsiveness to local needs.
Lessons / Assessment:
Several key lessons have emerged from the project including:
- A centralised management/support and local delivery model which ensures quality and coordination was successful in engaging and building the capacity of Divisions, GP Clinics, GPs, School counsellors to improve adolescent health care in a rural setting;
- A Tri-Division approach was appropriate at both the organisational and individual level;
- Having an Inter-Divisional Coordinator was critical for collaborative Divisional projects to support Divisional Project Officer and coordinate the planning, development and implementation of strategies;
- Having a GP Manager was key to ensuring that the project is relevant, appropriate and feasible in the General Practice setting;
- Adequate resources and time is required in the first six months for identifying, planning, and undertaking key tasks that underpin strategies (e.g., student needs assessment, GP education/training; and resource development);
- Local steering committees work best when they are small in size, comprised of a Project Officer, GP, School counsellor, student representative, co- opts members as needed, and meets when needed; and
- The AHP encouraged the Youth Friendliness of participating GP Clinics, as indicated by changes in GP consultation/communication practices with young people and school counsellors.
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