For this last lecture on health services, I want to move our thinking beyond traditional clinical services, to think about the wider array of platforms that can be used to deliver health services. And there's quite some variety to consider. Much acute healthcare continues to be delivered to young people through hospitals. However, the majority of healthcare is delivered to young people in the community, historically through family or community based clinics. In addition to these, many countries run school based services that can offer a variety of clinical services, ranging from counseling for mental health concerns. To preventive healthcare for sexual and reproductive health. To the actual provision of sexual and reproductive health resources such as condoms and contraceptives through to acute healthcare. Other forms of community based health services can be more focused such as, days or weeks in a community where a particular health issue or context such as immunization days or special clinics that might focus on provision of long acting contraception or circumcision clinics, deworming medication or mosquito protecting bidnets are the focus of care. And then in addition to clinically based services, other community based health services use various outreach models. Lady Health Workers in Pakistan are one form of this, but in other countries and context, health professional provide outreach services to particularly vulnerable young people such as homeless young people, those who engage in transactional sex, or injecting drug users. Many health services in these contexts are linked to wider resources, whether that might be clean needles for injecting drug users or access to housing for homeless youth. These types of outreach services are often provided free of charge with a goal of reducing financial barriers to accessing important preventive and treatment services for more highly vulnerable young people. And then other models engage young people themselves to deliver healthcare. While most peer based models use peer education, others are based around the provision of peer support. In addition to the opportunities provided by trained peers to promote access to traditional health services through education, or by reducing stigma around seeking help. Other models of peer support can themselves be seen as therapeutic. In my own service for example at the World Children's Hospital in Melbourne, we run a peer support program for young people with chronic health conditions that's known as CHIPS. Many of the complex young people that I'm referred to by other doctors benefit as much, perhaps if not more, from the peer support that can be provided by other young people with chronic conditions through the CHIPS group, then what I might be able to provide as a doctor. This is particularly the case for young people with mental health co-morbidities of complex physical disorders who often are reluctant to obtain specialist mental healthcare. And of course there is growing interest around the opportunity provided by newer information and communication technologies to deliver clinical services. Not simply to provide information as education, as we have talked about previously. Some countries have a reasonably long history of running school bus clinics such as in the United States. However, even in these countries, school health services appear to be on the rise, as shown here. There is growing relevance for school health services in low and middle income countries, given the growing participation in secondary schools by adolescents, especially adolescent girls. The benefits of school health services are especially around geographical and financial access. Why do benefits relate to opportunities to integrate clinical care and counseling with public health interventions and environmental change strategies within schools. Such as broader approaches to preventing and responding to bullying or obesity, for example. A recent review of school-based health services across the world identified that a large variety of health services is provided by different types of health professionals in school health services. Including nurses, doctors, dentists, and counselors. In many parts of the world, these services continue to focus on individual factors that might influence educational participation or learning outcomes such as vision and hearing testing. In many low and middle income countries, poverty and pregnancy are probably two of the major reasons that girls might not continue to participate in secondary education. Yet the extent to which sexual and reproductive health services are provided to girls in these countries, through school health services, is unknown. Arguably, school health services have failed to address the burden of disease in adolescents or the particular advantages that such health services might provide through being more geographically accessible, more financially accessible, and potentially less stigmatized. in this regard, access to mental health counseling could be a priority, but doesn't yet to be, appear to by a priority in most parts of the world, and certainly not in low or middle income countries. Adolescents with chronic physical disorders, such as HIV AIDS, type 1 diabetes, and asthma, also appear to have been largely neglected by school health services. Yet for each of these conditions there are distinct opportunities for school services to support self-management practices in non-stigmatizing ways. Certainly there are great opportunities for school health services to better engage with the wider content of the educational curriculum. I agree with a number of recommendations of this review, in particular that there could be far better alignment between the burden of disease in adolescence and the content of school health services. And that there needs to be better use of evidence based interventions where these are available. Such as availability of cognitive behavior-based counseling interventions, but also that there needs to be improved collection, analysis and use of data, and greater emphasis on the development and implementation of service standards. More broadly, however, many school health services are characterized by piecemeal actions that are not well integrated with the school's educational focus, and where there is insufficient integration between health and education programs and staff. If we turn to ICT as a platform for healthcare delivery, we can appreciate that young people are typically early adopters of technology, which provides many opportunities for them. Engagement with various IT platforms can promote development of social connections that are critical to well-being. In addition to old media, newer forms of media such as simple websites can provide highly accessible and non-stigmatized ways of obtaining health information. Such websites can normalize common negative experiences such as bullying. More interactive forms of media such as the website we've talked about previously, sex etc., the US based website that enables young people to ask questions about sexual and reproductive health. Provide a platform where young people can gain highly individualized information without fear or judgment, ridicule, shame, or stigma. And then there are specific interventions that intentionally set out to improve health and well being. There are now a multitude of apps that target young people. You may well have some favorite ones for health, but one I particularly like is Smiling Minds, that promotes mindfulness as an approach to reducing anxiety. Games can also be used as a therapeutic intervention, such as ReachOut Central. A game that's been designed to engage young men in particular around their emotional well-being. In a manner that is intentionally therapeutic rather than simply educational. E-health and m-health interventions hold much promise, and if we think of a country like India which has yet to develop any significant mental health workforce let a lone scale up mental health services. There is clearly great enthusiasm and promise in these such interventions. A further challenge is that once there is evidence of effect, how is it that particular interventions can best be matched to young people with a particular health need? No shortage of research here. The interview with professor Bicurum Battelle would be appropriate to view now because he talks more about this topic. A Canadian study used focus groups with young people to explore the most frequently sought information from IT sites. I think we can readily appreciate the opportunity of IT platforms to access private or stigmatized information, such as sexual health topics. But it is interesting to note in this study, that in addition to social and school concerns, that young people used IT to explore specific medical conditions, body image and nutritional concerns. As well as issues related to violence and personal safety more than for sexual and reproductive health concerns. I can imagine that the ranking of such lists could be very different in other countries according to the different availability of information for young people in the community, as well as in response to the different burden of health issues experienced by young people in different countries. Vulnerable young people are at greater risk of not accessing and engaging with traditional health services for a range of reasons. Why might this be? You may wish to think about this briefly and pause here. We've previously discussed a range of barriers to healthcare. Many of which are amplified in certain groups of vulnerable young people, such as financial barriers or reduced health literacy, but there are other barriers as well. Many vulnerable young people have fewer family supports, such as immigrant young people whose families may be far less knowledgeable about the local healthcare system. As well as being less confident in knowing how to access health services. Other vulnerable young people have higher health needs, particularly around, say, substance use and abuse, bullying, interpersonal violence, mental health, and sexual health. Yet for different reasons they be maybe less empowered to engage honestly and openly with health services about these health risks and needs. Especially if these relate to illegal activities, such as injecting drug use, or transactional sex. Many vulnerable young people are also less respected by health providers, which also reduces the likelihood of them being honest about their behaviors, as well as making them less likely to return for follow up care. But there are many other reasons that you might also wish to consider. A particular challenge is that not withstanding the increasing diversity of health services that are now available for the young. Many vulnerable young people will also have less access to these, such as school bus services or even web based resources. In this regard, as with many other issues around young people, there is no single or simple solution.
