Ethan, aged 16 years, recently moved into a medium term youth refuge in western Sydney. He had lived with his mother and stepfather until the age of 14 years, when he 'got kicked out'. He then spent some time with his biological father (who drinks heavily), with other relatives and on the streets. His stepfather has a history of violence toward his mother. He has an older sister whom he misses and two younger half brothers whom he is worried about as they are still living with his mother and stepfather. Ethan recently spent 6 weeks in a juvenile detention centre. He was released 2 months ago. He presented to the youth health service initially requesting assistance with accommodation, as he was staying in a crisis refuge immediately after discharge from juvenile justice. Through this contact he was offered a health assessment with a youth health nurse, which he accepted. He was also offered an appointment with a counsellor but declined. The youth health nurse identified three significant medical concerns and so an appointment was made for Ethan to see the doctor, who conducts a medical clinic once a fortnight. Medical assessment revealed a sexually transmissible infection (STI), a scrotal lump and chronic knee pain. Ethan received free treatment for the STI, with appropriate contact tracing and sexual health advice. He was referred for a scrotal ultrasound, with bulkbilling requested. An epididymal cyst was diagnosed. To manage his chronic knee pain, the youth health doctor liaised with a local general practice that bulkbilled. Ethan's pain was investigated by a general practitioner, who referred him to a physiotherapist under the Enhanced Primary Care (EPC) program. With Ethan's permission, the youth health doctor forwarded other health information to the GP. Ethan now attends the general practice for ongoing medical care. The youth health doctor also identified a potential mood and/ or adjustment disorder and spoke to Ethan again about seeing a counsellor. Ethan remains in contact with the youth health nurse and says he will 'think about' seeing a counsellor.
The health status of young people (12–25 years of age) has not improved significantly over the past few generations. Overweight and obesity, mental health problems, sexually transmissible infections and health risk behaviours are prevalent in this age group and can lead to acute and chronic health conditions, morbidity and mortality.1
Marginalised young people experience the same health problems as the broader youth population, but with added complexity. Reasons young people become marginalised may include homelessness or risk of homelessness, involvement in the juvenile justice system, disability, same-sex attraction, or being from an Indigenous, non-English speaking or refugee background. While lack of access to healthcare is often a significant aspect of their marginalisation, basic needs including shelter, food and money may be their highest priority. This can make it difficult for this group of patients to manage health conditions and participate in preventive healthcare, including keeping appointments and following health advice. Marginalised young people are often hard to reach and generally only access services when in crisis. Despite their need for support and treatment, they often feel isolated and can be unfamiliar with and/ or distrust mainstream services, which they perceive as judgemental and unsympathetic to their life situation.2,3 In addition, the healthcare system can be incredibly complex and difficult for young people to navigate (Table 1).
Table 1. Access issues for marginalised young people
- Knowledge of services
- Concerns about confidentiality
- Availability of services; particularly in regional, rural and remote areas
- Poor previous experiences
- Location of services
- Complicated systems and referral processes
Research worldwide has shown that young people experience barriers to accessing healthcare and that these barriers exist across both genders and in all socioeconomic groups. However, certain subgroups of young people, such as young men and Indigenous youth may be exposed to a higher risk of poor health outcomes because they are not accessing healthcare.4 Prominent barriers to access described by young people include fears about confidentiality and embarrassment about discussing health concerns.5 Health professionals, including GPs, have reported finding working with young people challenging because of communication difficulties, time, uncertainty about medicolegal status for those under 18 years and/ or living with parents and managing consultations with parents present.6
Accessibility means more than just being able to get there. A 'youth friendly' health service must be accessible geographically, physically, culturally and in all its procedures including financial and administrative arrangements.7 On a practical level, the single most important consideration for marginalised young people (regardless of their Centrelink status) is access to free or minimal cost healthcare (including consultation, diagnostic testing and where possible, pharmaceuticals and treatment).
The youth health service model8 has gained support in recent years through the national 'headspace' initiative (see Resources).9 Some patients may prefer youth specific services where available, however, general practice remains the cornerstone of primary healthcare for young people.10 General practitioners can improve accessibility and quality of care for marginalised young people and enhance the satisfaction of both patient and doctor with the help of principles of youth friendly practice such as those described in the Youth Health Better Practice Framework (see Resources) (Table 2).11 The application of these principles are discussed in further detail below as they apply to youth health services in western Sydney (New South Wales). The role of the GP in the care of marginalised young people is outlined in Table 3.
Table 2. Principles of youth friendly practice according to the Youth Health Better Practice Framework11
- Evidence based practice
- Youth participation
- Professional development
Table 3. The GP's role in the care of a marginalised young person
- To instigate and maintain engagement in a trusting professional relationship
- To assess and manage health problems
- To function as a case manager where appropriate
- To understand the specific psychosocial and cultural barriers to and facilitators of good health and wellbeing for individual patients
- To be an advocate for marginalised young people – within the health system and sometimes beyond
Youth health services in western Sydney
Youth health services within the Western Sydney Local Health District (WSLHD) form part of the district's primary care and community health network and comprise two discrete services: High Street Youth Health Service at Harris Park, and Western Area Adolescent Team at Mt Druitt. These services target young people aged 12–25 years who reside, study or work in the WSLHD catchment area and who are marginalised, disadvantaged or at risk, with a particular focus on young people who are homeless or at risk of homelessness. These services provide specialist, integrated, multidisciplinary care including the provision of information, support and counselling, assertive case management, therapeutic group work, dental and medical services, and health promotion activities. To best meet the needs of young people, services are offered on-site, including a drop-in service, and via outreach, and work in partnership with other government and nongovernment services including general practice. Youth health services in WSLHD are funded through the Innovative Health Services for Homeless Youth (IHSHY) program. This program was introduced in 1991 in response to the Human Rights and Equal Opportunity Commissions Our Homeless Children (Burdekin) report.12 This report found that homeless young people exhibit chronic health problems but are reluctant to seek treatment through mainstream services as they view them as judgemental and unsympathetic to their needs and life situations.
Youth health services in WSLHD recognise the unique health needs of young people in a holistic and innovative way that takes into account the complexities of working with this client group. They advocate a strength based, harm minimisation approach that is respectful and supportive of clients taking responsibility for their own healthcare and making decisions accordingly. Prevention, early identification and intervention are key underpinning principles. Strong partnerships and a strong focus on capacity building initiatives are essential in order to make these approaches sustainable. Importantly, young people have a right to exercise choice attending healthcare providers and many may choose to attend generalist community health services or other mainstream health services. To support this, youth health services in WSLHD work closely with mainstream services and provide a professional consultation and training service to support other professionals to respond to the needs of marginalised and at risk young people.
Improving access in general Practice
The Youth Health Better Practice Framework11 (Table 2) provides guidance on how GPs can better meet the needs of this population (and hence, improve access) in their own practices. The framework recommends that GPs have a practice confidentiality policy that is visible to all patients and that they explain confidentiality at the start of consultations with new adolescent patients. Educating marginalised young people about what you and your practice can provide is also helpful. For example, if you provide counselling services, let them know. As money may be an issue, practices should consider bulk-billing young people, especially those who are marginalised, and requesting bulk-billing for all pathology and diagnostic tests. If a young person presents without a Medicare card, reception staff can assist by obtaining their Medicare number for them and assisting them to obtain their own card. Having Medicare application forms handy is also useful.
A long appointment may be needed when seeing a marginalised young person for the first time and where possible, practices should make allowances for marginalised young people to be seen without an appointment. After building rapport and trust, GPs and practice staff can help educate them to attend appointments and/or attend punctually. Framework recommendations11 around access are implicitly evidence based. In addition, evidence based medical care is assumed, including the importance of psychosocial screening to identify risk and protective factors.
The framework recommends youth participation where possible. In the general practice context, young people can be asked to give feedback or suggestions (eg. for posters or magazines they would like to see in the waiting room).
It is important to develop and maintain strong collaborative relationships with local services relevant to marginalised young people and to think outside-the-square when considering their needs. Accommodation, education and welfare services, and government and nongovernment organisations are all potentially important collaborators. It is also useful to identify public mental health services and bulk-billing specialists, and become familiar with specialist outpatient services in your area. In order to collaborate effectively, work with the young person to obtain their permission to communicate with other service providers, so as not to breach confidentiality and to help them feel involved in their own healthcare. Collaboration may involve occasional communication or case conferencing to discuss clinical issues, but may extend beyond this to involve partnerships and service agreements (eg. via divisions/Medicare Locals).
Youth friendliness is a whole-of-practice proposition. To this end, it is helpful to have GPs, practice nurses and reception staff undertake basic training in youth friendly healthcare. This can help improve sustainability along with other activities such as the adoption of youth friendly policies and advocacy at practice or regional level. Finally, it is important to evaluate your efforts toward youth friendliness. Evaluation methods may include obtaining consumer feedback or conducting practice audits. These can be incorporated into accredited quality improvement activities.
- The Adolescent Health GP Resource Kit, 2nd edition, is a general practice specific resource aimed at improving youth friendly healthcare developed by the NSW Centre for the Advancement of Adolescent Health and Transcultural Mental Health Service: www.caah.chw.edu.au/resources#03
- The Centre for the Advancement of Adolescent Health in collaboration with the RACGP has developed two active learning modules in adolescent health care: Youth Friendly General Practice Training Toolkit, NSW Centre for the Advancement of Adolescent Health, The Children's Hospital at Westmead, Sydney, 2012
- Headspace: www.headspace.org.au
- The Youth Health Better Practice Framework: www.caah.chw.edu.au/resources /access_fact_sheets.pdf.
Conflict of interest: none declared.