Volume 183 Issue 8

Perceptions of young people’s health and wellbeing vary greatly, reflecting differences between disciplines, ideologies and generations. Young people are resilient, adaptable and doing well but, at the same time, are experiencing increased rates of important mental and physical health problems. While some of the contradictions in the evidence can be explained — for example, between measures of life satisfaction and happiness and indicators of psychosocial health — tensions between perspectives remain. We describe briefly a project involving cross-disciplinary synthesis that sought to gain a better understanding of the points of convergence and divergence in the commentaries and evidence on young people’s wellbeing in Australia. The project suggests that, if young people’s situation is to be optimised, there needs to be greater focus in both research and policy on: the “big picture” of the social changes reshaping life today; total health and wellbeing, not just ill health; the “mainstream” of youth, not only those young people who are marginalised and at-risk; and social and cultural resources that are as important to wellbeing as material and economic resources.

Richard M Eckersley BSc(Hons), MScSoc · Ani Wierenga BA(Hons), PhD · Johanna Wyn BA, MA, PhD

The concept of self-management is based on the notion that it will improve wellbeing and strengthen self-determination and participation in health care, while reducing health care utilisation and health costs. Increasing self-management is a desirable goal for the 15%–20% of children and adolescents who have a significant ongoing health care need related to a chronic health condition. Promoting self-management in young people with chronic illness can be difficult for parents and health care practitioners. Doctors can help parents recognise the potentially competing aspects of the parenting role — protecting young people’s health while supporting their growing independence and autonomy. Optimal care may or may not be achievable, depending on a young person’s level of development. As children mature through adolescence, they increasingly want their own voice to be heard, as well as the right to privacy and confidentiality in health care consultations. As well as listening to parents and supporting their roles, doctors should see young people alone for part of the consultation, taking a psychosocial history and carefully maintaining confidentiality.

Susan M Sawyer MB BS, FRACP, MD · Rosalie A Aroni PhD

Community debate about confidential health care for adolescents was triggered recently by the federal government’s proposal to allow parents of teenagers aged 16 years and under access to their children’s Health Insurance Commission data without their consent. Extensive research evidence highlights the importance of confidentiality in promoting young people’s access to health care, particularly for sensitive issues such as mental and sexual health, and substance use. Involving parents is important, but evidence for any benefit from mandatory parental involvement is lacking. The law recognises the rights of mature minors to make decisions about their medical treatment and to receive confidential health care; however, the doctor must weigh up certain factors to assess maturity and ensure that confidentiality around such treatment will be in the young person’s best interests. Evaluation of maturity must take into account characteristics of the young person, gravity of the proposed treatment, family factors, and statutory restrictions.

Lena A Sanci MB BS, PhD, FRACGP · Susan M Sawyer MB BS, MD, FRACP · Dagmar M Haller MD, FMHGen Med(Switz) · George C Patton MB BS, MD, FRANZCP · Melissa S-L Kang MB BS, MCH

When I was asked to take on writing for Dolly magazine’s “Dolly Doctor” column in 1993 I was more excited than if I’d won a Dolly total hair, body and personality makeover at age 13. This was a unique opportunity, which would not come along very often, to enter part of an adolescent’s world on her terms. The first question asked of me by anyone (including teenagers) about Dolly Doctor is, “Are the questions made up?” The answer is a resounding “No!”. In 1993, the magazine received 1000 letters a year to its health and sex columns. Today, it receives 1000 emails every 3 weeks, and the occasional mailed letter. And it keeps growing. A few years ago, the magazine expanded its health section, calling the whole segment Dolly Doctor, rather than just the one-page medical column. There is now a psychologist who answers questions about mental health issues, relationships and feelings. There are feature articles as well as personal stories, and earlier this year I began answering boys’ questions as well. Being a Dolly Doctor hasn’t always been easy. Sometimes I just don’t know the answer. For example, what is the green ointment that’s supposed to remove moles but instead caused a scar after 2 weeks and “didn’t work much”? Or, could the 3 cm piece of long dangly skin hanging from the vulva actually be a Bartholin’s gland, and if not, then what is it? Perhaps all this terminology is just too confusing. It’s clear that too much information can also mix health messages, such as the letter from the girl who “can’t stop masturbating” and is terrified because she doesn’t want to have a Pap smear yet. And what do I say to a 13-year-old whose best friend and she share the same crush, but one has taken the trouble to write and ask for advice about torn loyalties while the other has doubtless just “gone in for the kill”? Maternal responsibilities and Dolly Doctor have also caused consternation. I wouldn’t allow my children to read the magazine when they were prepubertal, but they were permitted to tear out wall posters to decorate their bedrooms (does anyone else remember “Hanson”?). One day my then 8-year-old son, playing at a friend’s house, told the mother that he’d like a “condom on his sandwich please”. In Year 4, he started a “sex club” at school, a fact I discovered when the mother of another boy approached me in the playground to express her concern about the pernicious effect my work was having on my family. (I should add that being in the sex club involved walking around saying “we’re in the sex club” and nothing more.) This same son (now 16) and my 15-year-old daughter seem to know the answers to all the questions I receive, and more besides. My daughter recently laughed at my ignorance of a (supposedly) common word used to describe a particular phallic shape. Only after she explained this to me was I able to answer the question correctly. All makes for interesting dinnertime conversation too. The number of Dolly magazines lining my bookshelves outnumbers my peer reviewed journals by about 10 to 1. So, as much as Dolly Doctor was my guide to life, as it has been for many teenagers since the magazine started in 1970, it now helps to guide my life as an adolescent-health professional. For every “desperate” teenager writing to Dolly Doctor each month, for every straightforward or heart-wrenching, amusing, bizarre or even downright ridiculous question that comes my way, there is some poignant reminder of what is so wonderful about adolescents.

Melissa S-L Kang MB BS

We need to incorporate adolescent health needs into mainstream policy-making, to evaluate services and to collaborate across sectors Over the past two decades, the barriers to health care access for adolescents have been extensively researched. This research was sparked by worrying trends of adolescents’ worsening mortality and morbidity, such that their health status was worse than that of their parents, and the observation that their health services, compared with those for other age groups, had not improved.1,2 Based on this research, the US Society for Adolescent Medicine has been issuing position statements on effective health care access for adolescents since the early 1990s. In Australia, several national and state initiatives propelled an adolescent health movement, not least in primary care.3 Divisions of General Practice had the scope and financial resources to address local needs, and some chose to run youth-friendly health access projects. Training in adolescent health for clinicians and other professionals emphasised the biopsychosocial model of care and had evidence of effectiveness.4 In this issue of the Journal, the study by Kefford and colleagues (page 418) shows that, despite these major gains, uptake of the youth health access agenda has not been systematic, and barriers to effective health care for Australian adolescents still exist.5 Adolescents recently reported fears about lack of confidentiality, judgement from health professionals, cost and inconvenience of services, and inexperience recognising health needs and where to seek help.6 Kefford’s study gives voice to adolescents’ concerns and suggestions for maximising their access to health services and preventive health messages. Youth in this study suggest that health services be based on “being well” rather than on “diagnosis of illness”. Preventive health messages need to be delivered through a variety of settings, such as gymnasiums or pharmacies, or delivered by approachable youthful peers and reinforced by physicians during visits to health services. The World Health Organization recently commissioned a global review of published and unpublished literature on means of improving adolescents’ access to health care,7 and a consortium of eight leading British health professional organisations published a report to guide service and professional development in adolescent health.8 Along with the latest US Society for Adolescent Medicine recommendations,9 these documents emphasise that accessible, “adolescent-friendly” health services should not be restricted to a particular setting or model of service delivery, but should address critical issues, such as confidentiality, cost, youth participation, competent staff, evidence-based treatments, efficient systems and collaboration across sectors. With these themes echoing through the last decade, we now need to go beyond the idea of “breaking away from the medical model”.5 We need strong leadership to ensure that the principles of effective access are implemented and engrained into mainstream policy-making, clinical work, professional training and youth education, and have ongoing evaluation to ensure effectiveness. Several deficits in these areas provide directions for the future. First, government policies on youth health access are currently non-existent or low profile, and many health services and general practice divisions still fail to target youth in their service planning. Implementation of the frameworks outlined by WHO could guide policy development and health service improvement, including involving adolescents as often as possible in the policy and planning initiatives that affect them. Secondly, there is confusion about how to facilitate access in the Australian context, either within existing primary-care infrastructure or through alternative models. There is little peer-reviewed published evidence on improved access from different models of adolescent health care — most relates to school-based health centres. A review of retrospective cohort and cross-sectional studies of school-based health centres found that they facilitate access, particularly for those who are hard to reach, such as adolescent boys with mental health problems, and socioeconom-ically disadvantaged and rural adolescents.10 In contrast to the few well evaluated Australian projects addressing youth health care access,11 many initiatives lack evidence of effectiveness. A recent survey of 77 NSW youth health programs found that, despite many exciting and innovative programs, none were fully evaluated, mainly because of lack of resources and competing priorities.12 We need to define appropriate, measurable outcome indicators for adolescent services, to evaluate services against these, using sound methodology, including progression to large-scale trials when results of smaller projects are inconclusive or contradictory, and to publish results in both peer-reviewed journals and policy documents. Effective services need to be sustain-able and systematically accepted into practice. Notably, there is already sufficient evidence for policy on factors improving access, such as confidentiality,6-9 longer appointments, and multidisciplinary teams.11 Thirdly, Australia’s primary health care system is fragmented. Most primary health care occurs in general practice, but youth-specific health centres (which are much valued by adolescents) are more prominent in some states than others, and there is little communication between these important groups of providers.13 These services are needed in each region to cater for the more complex needs of adolescents and provide support and training for GPs and other primary health care providers.14 Professional colleges need to ensure training of undergraduates and postgraduates in adolescent health, and interdisciplinary training might help improve communication across sectors.15 Finally, as exemplified by the participants in Kefford et al’s study, an adolescent’s world crosses boundaries, and opportunities for promoting health care access and other health messages exist outside the health care sector. Yet health, education, recreational and community sectors do not often collaborate. Consistency of health messages to youth, reinforcement of help-seeking behaviours, and referral, if appropriate, is the minimum required. Two large Australian school-based mental health promotion programs involving pathways to accessing health care from school to general practice are currently being tested.16,17 Other promising programs involve school-based workshops on the knowledge and skills for seeking care and information from a variety of sources. Given the barriers reported by adolescents, school curricula could routinely incorporate such health access content. Successfully meeting the primary health needs of adolescents involves recognising their unique developmental stage, delivering services in ways that overcome barriers to access, and supporting positive health and help-seeking behaviours. Australia needs a systematic, coordinated, policy-driven and evidence-based approach to improving access, which is one prerequisite to improving adolescents’ health. The rising problems of sexually transmitted infection, unwanted pregnancy, substance abuse, obesity, road accidents, depression and self-harm among adolescents demand that societies make adolescents’ access to health care a mainstream priority.

Lena A Sanci PhD, FRACGP · Melissa S-L Kang MB BS, MCH · B Jane Ferguson BA, MSW, MSc(Econ)

Objectives: To identify perceptions of health, health concerns, and health service needs among young people in a suburb of Sydney, New South Wales.Design: Qualitative study using focus groups.Setting: Berowra, a geographically isolated suburb on the outskirts of Sydney, between December 2002 and April 2003.Participants: 40 Berowra residents aged 14–24 years, recruited from two local government high schools (two groups), a local youth drop-in centre (one group), and the community, through advertising at the youth centre, local schools and church groups (one group).Results: Focus group findings were classified into four broad themes. 1: Personal safety is a primary health concern. Berowra needs more recreational facilities to prevent drug and alcohol use related to boredom. 2: Health is more about quality of life than disease and illness. 3: Most health information comes from sources other than health providers. Health education must enable young people to make wise choices for the future. 4: Access to health services is of concern. More education is required on how Medicare works. Young people need to trust their service provider and will only see a doctor if they perceive themselves to be severely ill. Young people value meeting general practitioners in the school and community setting and not just in the doctor’s consulting room.Conclusions: Young people desire a whole lifestyle approach to health rather than the traditional model based on diagnosis and disease. Health information needs to be accessible anonymously, and healthy lifestyles need to be promoted throughout the whole community, using youth workers and sporting leaders as role models.

Carolyn H Kefford MB BS, FACPsychMed · Lyndal J Trevena MB BS(Hons), MPhilPH · Simon M Willcock MB BS(Hons)

An adolescent with autism and intellectual disability presented with severe depression related to menstruation. Because of the complex medical, psychiatric and ethical issues involved, her care was coordinated by a hospital-based adolescent medicine unit. After trials of other therapies over an extended period and interdisciplinary and intersectoral case conferencing, it was decided that hysterectomy was the most appropriate management. This case highlights the complexity of adolescent health care in a tertiary hospital, the importance of intersectoral cooperation between hospital and community, and the integral role of interdisciplinary care of adolescent patients with chronic conditions.

S Rachel Skinner PhD, FRACP · Cindy Ng MB BS(Hons), DCH · Ann McDonald MPaed, FRANZCP · Tamara Walters FRANZCOG

Paediatricians could raise parents’ awareness of potential problems with media exposure by asking a few simple questions during consultations “This instrument can teach, it can illuminate; yes, and it can even inspire. But it can do so only to the extent that humans are determined to use it to those ends. Otherwise, it is merely wires and lights in a box.”1 The media cut across virtually every major area of concern that parents and paediatricians have about adolescents — aggressive behaviour and violence, suicide, sex, drugs, obesity and eating disorders, and learning problems.2 Yet, both parents and paediatricians seem to show little understanding of the media’s impact on young people, and to take little time to try to consider the current situation — in which teenagers are inundated with messages in the media that are potentially harmful to their health. Why? My own theory is that parents and paediatricians are just too busy raising and caring for children and adolescents to have much time to watch, listen to, or read much media themselves. Furthermore, on the list of “important things” for parents to fight with teenagers about, their media use ranks near the bottom for most. Parents may also buy into the Hollywood myth that television and movies are merely fantasy entertainment. For paediatricians, it is difficult to have time to talk about the media in a busy office visit when there are so many other, “more important” topics to cover — vaccinations, seat belts, bicycle helmets, proper nutrition. However, the media should rank at the top of all concerns because they can have an impact on so many crucial areas of a teenager’s life, and paediatricians and parents need to realise that the media’s influence begins at a very young age. According to the first wave of the long-term Growing Up in Australia study, infants are already spending nearly 1.5 hours a day watching television, and 4–5-year-olds are spending about a third of their total play time (2.1 hours) watching television.3 In 2002, a study of more than 1000 Australians aged 10–13 years found that median screen time for this age group was up to nearly 4 hours per day (Tim Olds, Associate Professor, School of Health Sciences, University of South Australia, personal communication), and more than half of all Australian children aged 8–18 years have a television set in their own bedroom.4 The latest Kaiser Foundation study found that older children and teenagers spend more than 6 hours a day multi-tasking with a dizzying array of media, ranging from television and video games to the Internet, mobile phones and instant messaging, and iPods.5 What we knowMedia violence: There are more than 1000 studies linking exposure to media violence to real-life aggressive behaviour.6-8 Media violence also leads to desensitisation and to the belief that violence is an acceptable solution to everyday problems. A recent study found an association between viewing media violence at a young age and bullying.9 In fact, the connection between media violence and real-life aggression is nearly as strong as the link between smoking and lung cancer, and stronger than the connections between lead and IQ, homework and achievement, calcium and bone mass, and exposure to asbestos and cancer.2,6 Although much of the research has been done in the United States, an Australian Psychological Association position paper in 200010 and the Royal Australasian College of Physicians in 20044 acknow-ledged the significance of media violence. Teen suicide: Numerous studies in the US and Europe have shown a link between media coverage of suicide and subsequent increases in suicides among teens.11 Sex: Only a handful of studies have examined sexual content in the media and its impact on teenagers, but they all show that there is an impact.12 In the absence of effective sex education, the media have become one of the leading sex educators of children and teens today.12 In the most recent study of nearly 1800 teenagers, teens’ viewing of sexual content led to a doubled risk of earlier sexual initiation.13 In addition, most teenagers have been exposed to pornography online, whether intentionally or inadvertently.14,15 Drugs: Young people view as many as 2000 advertisements annually for beer on television alone in the US, and such ads do have an impact.16,17 Children and teens who view R-rated movies (designated suitable for ages 17 years and older in the US) are three times more likely to begin smoking.18 Obesity and eating disorders: Overweight and obesity are increasing at alarming rates in Australia, with a 2.5-fold rise over the past 20 years.19 Australia now has one of the highest rates of type 2 diabetes in the developed world.20 Numerous studies show that there is probably a causal connection between TV viewing and obesity,2 although the exact reasons remain unclear — might the constant barrage of junk food advertisements21 be contributing? A recent study from the Australian Divisions of General Practice found that there is an average of one junk food advertisement per commercial break in children’s television programming, and that 99% of all food advertisements during children’s TV was for junk food.22 Watching TV also correlates with unhealthy body self-image among young girls and teen girls.12,23 A recent study found a cause-and-effect relationship between the introduction of American TV programs into Fiji and the development of new eating disorders and abnormal body self-image among adolescents there.24 Learning problems: In the first study of its kind to examine this concern, researchers found that hours of television viewed per day at both ages 1 and 2 is associated with attentional problems at age 7.25 What we don’t knowWe don’t know why parents and paediatricians don’t pay more attention to the media’s influence on children and adolescents. During an office visit, how long would it take to ask two simple questions of parents? How much TV (and other media) does your child view each day? Is there a TV set in your child’s bedroom? For children and teens who are aggressive, obese, or who are doing poorly in school, perhaps a more detailed media history could be obtained. The recent report from the Royal Australasian College of Physicians outlines a variety of ways that paediatricians can be more attuned to this issue.4 For example, they can be far more assertive in providing counselling to parents about the impact of media on children, and encourage household rules about media use. They should avoid placing TV sets in their waiting rooms. Paediatricians should also be at the forefront of discussions with filmmakers about depicting cigarette smoking in mainstream movies. Finally, both parents and paediatricians need to lobby governments for more funding for research into the crucial areas of how the media affect children and teens, what can be done to maximise pro-social media and protect against harmful media’s influence, better programming for young people, and more funding for media education campaigns and media education programs in schools. TV, movies, and video games may seem like “harmless entertainment” to adults and to Hollywood, but they exert a potent influence on young people. The question is not whether children and teenagers are learning from the media; it is how much and what are they learning.

Victor C Strasburger MD

Objective: To determine the extent to which comprehensive health screening of adolescents was undertaken in a tertiary inpatient setting.Design and setting: Retrospective review of 100 consecutive medical records of 13–18-year-old adolescents admitted to The Royal Children’s Hospital, Melbourne (first 20 consecutive admissions in 2001 to each of five units — general medicine, adolescent medicine, specialty medicine, general surgery, and specialty surgery).Main outcome measures: Documentation of screening for biomedical (height, weight, pubertal staging, and hepatitis B vaccination) and psychosocial concerns (HEADSS framework categorised into four screening levels — none, incomplete, adequate, thorough). Risks identified and actions taken.Results: Weight was recorded for 98 patients, height for 17, pubertal staging for 12, and hepatitis B vaccination status for nine. Documentation of psychosocial screening was absent from 62 charts, inadequate in 29, thorough in three, and complete in seven charts. Adolescent medicine inpatients were more likely than patients in other units to have any screening of psychosocial risk recorded and more likely to be thoroughly screened (P < 0.005). Screening was more often documented for less sensitive issues (eg, home, tobacco) than higher risk behaviours (eg, illicit drug use) (P = 0.013). When screening identified risks, appropriate action was undertaken in most cases.Conclusions: This study highlights deficiencies in comprehensive health screening in adolescents admitted to a tertiary children’s hospital. These results support the development of more consistent approaches to screening adolescent inpatients.

Michele S M Yeo MB BS, FRACP · Lyndal M Bond MA(AppPsych), PhD · Susan M Sawyer MB BS, FRACP, MD

Experimentation with alcohol is a normal part of teenage psychosocial development. Society’s approach to adolescent alcohol consumption is ambiguous and sends young people mixed messages. Epidemiological data demonstrate disturbing trends in patterns of alcohol use by young people, including widespread early-onset, regular binge drinking. The acute harms of excess adolescent alcohol consumption are well documented, and data on long-term harms are now also emerging. As alcohol is an integral part of our culture, we urgently need to manage teenage drinking appropriately and comprehensively, and to guide young people to a “healthy norm” for adolescent alcohol consumption.

Yvonne A Bonomo FRACP, PhD, FAChAM

This state-wide Aboriginal community child health survey, the first of its kind in Australia, describes physical and mental health and their antecedents in Western Australian Aboriginal children and young people. Aboriginal young people had significantly more physical and mental health problems and were more likely to engage in lifestyle risk factors than non-Aboriginal young people. Aboriginal young people tend to be caught up in a cycle of disadvantage that includes family and community factors as well as recent history, facilitating their making less optimal life choices, thereby perpetuating the cycle. A coordinated approach will be required to break this cycle, in which appropriately and sympathetically provided medical attention is necessary but not sufficient.

Eve M Blair PhD · Stephen R Zubrick PhD · Adele H Cox DipAppSci

In Australia, where about 16% of young people are born overseas and 24% are from a non-English-speaking background, adolescent health care is a multicultural challenge. “Cultural competency” involves challenging one’s own cultural assumptions and beliefs, developing empathy for people from other cultures, and applying specific communication and interaction skills in clinical encounters. For health professionals, sensitivity to the cultural, ethnic, linguistic and social diversity among young people helps to avert problems and misunderstandings, improves satisfaction for all concerned and leads to better outcomes. Engaging the family and gaining the trust of parents is critical in treating young people from cultural backgrounds in which participation in health care is a family concern rather than an individual responsibility.

David L Bennett MB BS, FRACP, FSAM · Peter Chown BSc(Psych), MAPS(Hons) · Melissa S-L Kang MB BS, MCH

This is a very old Ford and it is a big 5.8L and I like cars. Paul, 22 years Most publicly available information about mental health appears to focus on mental illness, and research shows that most young people interpret “mental health” as meaning mental illness. It is also known that many “at-risk” young people lack the necessary social support networks and skills to cope with adverse life events and that the creative arts are a useful tool for promoting self-expression, health and wellbeing. In Focus was a pilot project that aimed to engage and support at-risk young people (aged 12-25 years) from diverse cultural and linguistic backgrounds by promoting positive mental health and wellbeing though the creative medium of photography. This collaborative project was funded by the NSW Transcultural Mental Health Centre and was proudly sponsored by Platinum Imaging (a Chakra Alliance Member) and Fuji Film. The Transcultural Mental Health Centre’s Youth Mental Health Project worked in partnership with several youth health, mental health and multicultural services across eastern, central, south-western and western Sydney in 2003. Young people were recruited to participate in interactive workshops and outings, culminating in a roving photography exhibition (October 2003 to April 2004). They were given disposable cameras and encouraged to explore and capture images that they felt best reflected positive mental health and wellbeing and the experience of living in a culturally diverse society. In Focus enabled service providers to connect with young people who were particularly at risk because of language barriers, poor literacy skills, homelessness or risk of homelessness, education break down, or under-utilisation of youth health services because of stigma or lack of awareness. The project allowed youth health workers and young people to engage in a creative, positive and constructive process to explore issues and portray images relating to mental health and multicultural Australia — themes particularly relevant in today’s political and social climate. Most importantly, In Focus promoted the mental health and wellbeing of the young people involved by providing them with access to early intervention services such as counselling; encouragement to re-engage with their schooling to pursue the creative arts; and the chance to express their thoughts and make new friends. As a medium for self-expression for these young people, photography proved to be an accessible yet powerful communication and educational tool. Well, the reason I chose to take this type of image is that I think that the type of possessions we own are valuable as they reflect on what type of person we are. The types of possessions shown in my image are very valuable to me as they show that I’m a very colourful and outgoing teenage girl. They reflect on the type of personality I have, on the type of person I am, which is important. Asia, 16 years

Vanessa D'Souza

Dagmar M Haller,* Lena A Sanci,† George C Patton,‡ Susan M Sawyer§ * General Practitioner and PhD Candidate, ‡VicHealth Professor and Director of Adolescent Health Research, §Professor of Adolescent Health, and Director, Centre for Adolescent Health, Murdoch Children's Research Institute and The University of Melbourne, 2 Gatehouse Street, Parkville, VIC 3052. †Senior Lecturer, Department of General Practice, The University of Melbourne, Melbourne, VIC. dagmar.hallerATmcri.edu.au To the Editor: We recently advocated the inclusion of a mature-minor clause in the National Health and Medical Research Council ethics guidelines on teenagers’ participation in research.1 This would allow minors (teenagers younger than 18 years) who show sufficient maturity and understanding to consent to participation in minimal risk research (eg, observational studies and quality assurance studies) without requiring parental consent. This is important in primary care research, as teenagers presenting to general practitioners without an accompanying parent or carer frequently wish their visit to remain confidential. To exclude this group from research would deny them the benefit of potential improvements to their health care as a result of research. As no such data were available in Australia, we sought to document, as part of a larger primary care study of young people’s perspectives on their health problems and their expectations from a GP consultation, the proportion of teenagers aged 16 to 18 years who potentially would not be able to participate because they presented without a parent. We also documented whether, when present, parents would express concern about not being asked to provide consent for their teenaged child to participate. We recruited up to 20 consecutive patients aged 16 to 24 years in each of 26 randomly selected practices throughout Victoria and invited them to participate in an interview on their perspectives on the health problem for which they had come to see the doctor and their expectations from the consultation. Our institutional ethics committee approved inclusion of minors aged 16 to 18 years without parental consent. One of the authors, a GP (D H), obtained consent from participants and conducted the interviews. Results are reported with 95% confidence intervals adjusted for clustering within practices. Of the 501 young people approached, 101 were minors. Five minors (5%; 95% CI, 0.6%–9%) were excluded (too unwell, intellectually disabled or non-English speaking), and another five (5%; 95% CI, 1%–8%) declined participation. Of the 91 minors who consented to participation, 40 (44%; 95% CI, 35%–53%) had come without a parent. Although 37 of the parents of the 51 minors who were accompanied (73%; 95% CI, 59%–86%) went into the GP consulting room with their children, only one was concerned about her child consenting and participating in an interview on his own. Had parental consent been mandatory, nearly half the patients aged 16 to 18 years could not have been included in this primary care study. When present, the overwhelming majority of parents did not disapprove of their children consenting and participating on their own. These findings support the idea that, for low-risk studies in primary care, mature minors should be given the opportunity to consent to participation on their own.

Dagmar M Haller · Lena A Sanci · George C Patton · Susan M Sawyer

A United Nations photographic exhibition Website: <http://www.chasingdream.org/> The exhibition profiles the lives of eight young people in Brazil, Cambodia, India, Jamaica, Morocco, Uganda, the Kyangwali Refugee Settlement in Hoima, Uganda and the Ukraine. Using touching and sometimes confronting photographs by photojournalist Diego Goldberg, and brief articles which draw heavily on the young people’s own stories by international columnist Roberto Guareschi, it succeeds in being both poignant and hopeful as it explores the young people’s difficult circumstances, their efforts to improve their lives, and their dreams for the future. Urideia, a 19-year-old Brazilian girl who lives in a São Paolo favela (slum), has just completed a three-month cooking course at Citizen Cook, an NGO located in the middle of the favela. She poses with her classmates behind the food they have prepared to celebrate the end of their coursework. Urideia dreams of having her own restaurant where she could provide jobs for other people in the favela. Photos courtesy: © 2005 Diego Goldberg/PixelPress/UNFPA. Twelve-year-old Kaima lives in Rajasthan in the Thar Desert. Unlike the women in previous generations of her family she can read and write. She dreams of becoming a military pilot. Below: Kaima, the eldest in her family still living with her parents, plays with her cousin (red scarf) and sister (in blue) outside her house. As required by tradition, Kaima is already married; she plans to finish her studies before she moves in with her husband. Below: Kaima speaks at a meeting of more than fifty women who have rallied together to demand more water for their village, located in the middle of the Thar desert. Photos courtesy: © 2005 Diego Goldberg/PixelPress/UNFPA. Silvia (right), a 15-year-old Ugandan girl whose parents have died, sits with a group of friends inside the home she shares with her partner Charles and another couple. Determined to overcome her poor living conditions, Silvia puts all her energy into her education and, unlike many of her peers, has avoided contracting AIDS or getting pregnant. Photos courtesy: © 2005 Diego Goldberg/PixelPress/UNFPA. Using homemade instruments, Mohammed, aged 18, and his friends play music inside his home in the small Moroccan village of El Borj. Mohammed dreams of running water for his village, getting a driver’s license to carry goods to other villages and, one day, making enough money to marry. Photos courtesy: © 2005 Diego Goldberg/PixelPress/UNFPA.