An exploratory survey on the state of training in adolescent medicine and health in 36 European countries

Worldwide, the specific health needs of adolescents are increasingly being addressed [13, 16, 18]. As mentioned in a recent publication of the World Health Organization (WHO) [23], “Investments in adolescent health bring a triple dividend of benefits for adolescents now, for their future adult lives, and for the next generation. Their health and well-being are engines of change in the drive to create healthier, more sustainable societies.” Policymakers and health professionals need to develop the technical capacity for policy, programming, research, and clinical care in all regions of the world. Several documents have recently outlined how high-quality health care can be achieved for adolescents [3, 15, 17, 22], in which the training and competencies of health care providers play a pivotal role [9, 12, 14]. When asked about their training needs in the area of adolescent medicine and health, paediatricians express a wish to acquire a variety of knowledge and skills. For instance, in a survey conducted among French paediatric residents, 81% considered that paediatricians should acquire skills in adolescent medicine and health; they reported major difficulties in providing care for teenagers reluctant to seek health care, or in managing suicidal adolescents [8]. In another survey carried out 15 years ago among Swiss primary care providers in private practice [10], two-thirds wanted to acquire more skills in managing functional disorders and half expressed a desire to receive training in areas such as communication skills, mental health (including eating disorders), substance use, or coping with dysfunctional families.

Training in the area of adolescent medicine and health needs encompasses more than just the delivery of knowledge; it also involves acquiring specific competencies and skills that allow the trainee to develop a mutually respectful relationship with an adolescent. Furthermore, it involves helping to develop appropriate screening and counselling approaches in reviewing the adolescent’s lifestyle, as well as learning how to deal with family conflicts and address situations posing ethical dilemmas. Finally, it means acquiring the capacity to deal with health issues such as exploratory and risk behaviours, mental health, and sexual and reproductive health as applied to adolescents10. This is why, in the opinion of the authors, it is insufficient to include some information on adolescent medicine within sessions dealing with broader areas; rather, it is important to devote dedicated stand-alone sessions to this field [12, 14]. Medical students and residents should be trained to deal concretely with clinical situations via interactive participative training sessions, bedside teaching and observation, and discussion of videos, and by testing out their skills with simulated patients [7, 12, 14]. In the USA, Canada, and Australia, and to a lesser extent in some South American nations, adolescent health and medicine is considered a medical discipline or sub-discipline, and most medical school and university hospitals provide both lectures and training sessions specifically addressing this population of patients [11, 16]. Compared with these countries, Europe is lagging behind [6, 11]. This study aims to evaluate the structure and content of adolescent training curricula in the European region for medical students, paediatricians, and other physicians who, regularly or occasionally, work as primary care providers, such as family physicians (GPs), gynaecologists, and psychiatrists. Specifically, it assesses the extent to which training in the field is provided as a stand-alone topic or embedded in the programmes of other disciplines, and whether it is mandatory or optional. A second objective is to explore the content of such training programmes in terms of issues that are most relevant to this period of life, such as communication skills, and issues pertaining to mental or sexual and reproductive health.

This survey is part of the 4-year-long EU-funded MOCHA research programme (“Models of Child Health Appraised”), initiated by leading experts from Imperial College in London. This research programme aims to assess various aspects of primary care delivered to children and adolescents in EU countries, including topics such as quality assessment, economic factors, structure of health care delivery, training, and ethical aspects [4]. The overall project was undertaken by several specialist groups of researchers working in collaboration.

The responses to the questionnaire were provided by a MOCHA network of 30 experts, who, in each of their respective countries, were in charge of collecting data on various topics as a mandate of the MOCHA European project. To obtain as much information as possible, we used not only the MOCHA network but also other channels (Table 1). Thus, responses were gathered through two more sources: (1) paediatrician national delegates of the European Academy of Paediatrics (EAP) and (2) trainee representatives from “Young EAP” (e.g. paediatric residents and chief residents belonging to the Academy). The respondents from the MOCHA network were local experts in child health services, acting as informants for obtaining data requested by the scientists in charge of a given round; they used local indigenous sources to respond. These experts, one for each country, were selected for their expertise in child health services (paediatricians, psychologists, public health professionals) and were trained by the MOCHA project’s lead researchers. The respondents from the EAP were paediatricians, representatives of their country, while those answering from the Young EAP network were experienced paediatric residents or chief residents. All of these three groups’ respondents were instructed to do their best to gather valid data, e.g. asking colleagues and reviewing available documents. They all received the same questionnaire for collecting the data.

The survey questionnaire was developed by the MOCHA group researching school and adolescent services, and was reviewed by colleagues from EAP and Young EAP. The content was based on a recent World Health Organization document: “Core competencies in adolescent health and development for primary care providers” [20]. Eleven questions concerned the structure and content of adolescent training curricula and pertained to different target learners, that is, students and residents of different disciplines. Given the fact that health care systems vary across countries (e.g. some systems train primary care paediatricians and others only secondary/tertiary care paediatricians), we decided to merge the information provided for these two groups. The questions evaluated whether the training sessions were mandatory or optional, and whether they were proposed as stand-alone sessions or were embedded within the curriculum of various disciplines. These questions did not address the existence of national curricula in adolescent medicine but pertained rather to whether training in this area did actually take place. A set of questions dealt with the content of these curricula or sessions, targeting five issues critical for adolescent health that were considered to be of particular importance by the working group [14, 19‐21]: communication skills and counselling techniques as applied to adolescents, ethical and legal issues as applied to adolescents, screening of adolescent lifestyles and identification of risky behaviour, adolescent mental health, and adolescent sexual development and reproductive health. All the answers from the three groups were entered on a single comprehensive excel file and analysed manually. The annex provides the content of the questionnaire, as well as the instructions given to the experts. All questionnaires were administered in English, and the responses were provided in English as well. The survey took place during 2017 and 2018 and was sent out by email, and responses were collected via email too. One reminder was sent to those not responding to the first request. Most answers to the questions were proposed as yes/no or utilized a closed list of specific items (type of professional, location, etc.). Part of the answers are summarized in Tables 2 and 3. No statistical analysis was used. This survey was not submitted to an IRB, as it did not involve human subjects but dealt rather with procedures and policies.

For the majority of participating countries, data were received from more than one source (Table 1), i.e. for seven countries from three sources, for another 20 countries from two sources, and from nine countries from one source only. In some instances (not more than four to eight occasions, depending on the nature of the question), data available from different sources were only partially consistent. In cases where answers were inconsistent, the answer included in the final analysis was the one confirming that a training activity did indeed take place. This approach was based on the assumption that people who answered “yes” to the question knew of the existence/content of a training programme, while those who answered “no” may simply have not been aware of it. A complete set of answers (i.e. answers via either one or all of the three different sources) was received in 2017 or 2018 from all 36 European countries. Most questionnaires were adequately completed, with very few questions left unanswered (< 5%).

Paediatricians and primary care providers (such as GPs) should acquire specific basic competencies in order to respond to the health care needs of adolescents [9, 12, 16]. In the USA, there are currently 26 accredited centres that offer CME programmes, residency to younger paediatricians or family doctors, as well as 2- or 3-year fellowships. Some of these centres have been in operation for more than 30 years. In addition, several academic institutions provide training programmes dealing with adolescent health for dieticians, psychologists, nursing students, or social workers. Australia also offers 4-year fellowship programmes in the field of “AYA” medicine (Adolescent and Young Adults). Both countries have created an official certified sub-specialisation in adolescent medicine. Some South America nations (Argentina, Chile, and Brazil) have their own academic centres. These academic centres have included areas in their educational programmes such as the acquisition of sound communication skills, expertise in dealing with sexual and reproductive health or substance misuse, and how to care for adolescents with chronic conditions; all these initiatives have an impact on the delivery of health care. While it is difficult to assess the impact of such training on the care of adolescents, a recent survey conducted in the USA shows that 43–81% of adolescents received provision of preventive services over the course of a year [1]. In contrast, such an achievement cannot be expected in the European region, given the lack of specific education in adolescent medicine and health within many training institutions [15, 21, 24]. Indeed, only seven out of the 36 surveyed European countries include mandatory stand-alone sessions in the undergraduate training of medical students, while in another seven countries, such sessions exist but are only optional. In several countries, residents in paediatrics receive training sessions covering important topics such as communication skills and ethics, screening of lifestyles, mental health, or sexual and reproductive health. However, in many instances, such training sessions are neither mandatory nor provided as stand-alone sessions. Moreover, it is likely that this type of education is not available in all regions of the countries in which they exist. The results regarding the training of general practitioners are of even greater concern: only three countries (< 10%) offer mandatory courses in the field.

A similar survey run on behalf of the EPA (European Paediatric Association—UNEPSA) [6] showed that in 2008, undergraduate education in adolescent medicine was offered in half of the countries surveyed (N = 14), and training in the field was provided in 18 out of 29 countries in the context of paediatric residency programmes. This earlier survey did not distinguish between mandatory and optional education and did not either investigate stand-alone teaching and learning. Given this situation, which seems not to have improved in the last 10 years, it comes as no surprise that, according to a recent UK survey, many adolescents feel dissatisfied with the provision of the health care they receive [25].