Overview

The National action plan for the health of children and young people 2020–2030 recognises there are several key life stages and transition points that provide opportunities to engage young people in preventive healthcare to enhance protective factors and provide effective interventions to support positive health and wellbeing outcomes.⁶ Health professionals can support Aboriginal and Torres Strait Islander young people’s health and growth through strengths-based approaches and an empathic understanding of their needs.

Consistent with Aboriginal and Torres Strait Islander holistic perspectives on health, strengths-based approaches are now accepted as the expected and necessary norm in health service delivery to the Aboriginal and Torres Strait Islander population.⁷ Such approaches focus on the strengths and capabilities of an individual and the community, advocate for a positive sense of cultural identity, and acknowledge there is potential for change, growth and success.⁸ Promoting the strengths of young people can be the beginning of an independent journey of health engagement to benefit the young person’s later life. This is a departure from a deficit approach, which focuses on disease risk factors.
Aboriginal and Torres Strait Islander and non-Indigenous young Australians are concerned about confidentiality, privacy and the cost of care and medications, and may be embarrassed to discuss sexual and other highly sensitive matters or access contraception. Health professionals may be unsure how to engage with young people and may be uncomfortable discussing health risks. This can result in young people being reluctant to seek information or help from health professionals. Acquiring skills in youth engagement and providing youth-friendly environments will help with better engagement of young people.⁹
 

Cultural safety

It is imperative that the rights of Aboriginal and Torres Strait Islander young people are respected so they are supported in feeling proud of their identity and culture. Connection to culture is a protective factor,^10,11 and clinicians must be committed to building trust through respecting cultural protocols and understanding historical factors that may impact people and their health and wellbeing.¹² It is also essential to recognise the social and other determinants that affect individuals and communities.¹³

A youth-friendly environment

Youth-friendly practice environments play a significant role in creating safe spaces for young people to engage with health services and need to be designed with input from young people. Youth-specific recommendations include:^9,26

• ease of access and location of the practice
• longer clinic hours and the ability to attend for ‘walk-in’ appointments
• bulk-billed or no out-of-pocket costs for appointments
• a welcoming space and waiting room setting that is comfortable for young people
• waiting room materials that are youth focused and give information on health, healthy living, bulk billing, Medicare cards and transport
• the provision of youth-specific flyers and printed or displayed information
• the availability of health information in different media formats (eg digital, printed, image/photo based, video)
• making sure the space and the way services are provided ensure appropriate confidentiality.

Cultural safety

Keeping our kids safe: Cultural safety and the national principles for child safe organisations provides guidance about organisational structures that improve cultural safety for Aboriginal young people.¹² Ensuring physical environments are reflective of Aboriginal and Torres Strait Islander cultures indicates cultural respect and safety and can signal to Aboriginal and Torres Strait Islander young people that they will be heard and respected. There are emerging examples demonstrating the effectiveness and efficiency of codesigned services for youth.²⁷ The following measures are therefore helpful:

• displaying acknowledgement of Country and Traditional Owners, flag representation, and artwork – it is important to seek local Aboriginal and Torres Strait Islander community input into how they would like their culture represented
• offering central and flexible focal points of service, coordinating referral pathways and incorporating cultural and community elements into care
• creating partnerships with young people to influence service design
• having spaces that are welcoming, especially of families and broader kinship networks
• hosting community groups and events.

Continuous quality improvement

• Review the structure and environment of the organisation and the attitudes, skills and behaviour of all staff to ensure the service is youth friendly and culturally safe for Aboriginal and Torres Strait Islander young people.
• Where possible, consider the codesign of services in partnership with Aboriginal and Torres Strait Islander young people and their communities.¹⁷

• Young people are in a development continuum of early (age less than 13 years), middle (age 14–17 years) and late (age greater than 17 years) adolescence.¹⁴
• Developmentally, they are figuring out who they are (sense of identity) and where they belong (sense of connection). This involves learning to be independent and forming relationships with their peers.
• The rapid physical, cognitive and psychosocial growth that occurs in adolescence affects the way they think, act, feel and make decisions.²
• Adolescence is also a period of risk taking and experimentation, which is normal and necessary to develop resilience. However, the risk taking combined with inexperienced risk-assessment and decision-making skills also makes young people vulnerable to adverse health outcomes, including physical and mental injury and death.¹⁴
• The transition through adolescence into young adulthood is when habits and lifestyle behaviours are becoming established, including eating, physical activity, sleeping, substance use and sexual activity.² Hence, ‘promoting healthy behaviours during adolescence, and taking steps to better protect young people from health risks are critical for the prevention of health problems in adulthood’.¹⁵
• Young people are sensitive to and affected by their environments, which can be beneficial or harmful to their health depending on context. Nurturing family support, positive peer networks and supportive educational or employment opportunities are associated with the development of good self-esteem and resilience.¹⁴
• Although social and economic factors can influence health in all age groups, the adverse health outcomes for young people are strongly influenced by family breakdown, physical abuse, sexual abuse, neglect and homelessness.¹⁴
• Most health problems in young people are considered to be due to psychosocial factors (ie engaging in high-risk behaviour, mental health issues and the external factors mentioned above).^14,16

Therefore, the health needs of young people are distinct from those of children and adults, and their sexual and reproductive health needs are different from those of adults. These differences are important considerations in engaging with and supporting young people’s health. A type of counselling technique that has been specifically identified as important in youth health is anticipatory guidance.^17–19 Anticipatory or health guidance is defined as proactive counselling that focuses on a young person’s stage of development. It can be provided to young people and to their parents/carers to promote optimal health outcomes.

Aboriginal and Torres Strait Islander young people

There are several important considerations for Aboriginal and Torres Strait Islander youth in addition to those outlined above. From a demographic perspective, in the 2021 Census, 204,644 people aged 12–24 years identified as Aboriginal, Torres Strait Islander or both.²⁰ This comprises 5.1% of the total Australian population of young people in that age range, and 25% of the total Aboriginal and Torres Strait Islander population. In contrast, young people comprise 15.7% of the total Australian population.²⁰

Most Aboriginal and Torres Strait Islander young people live in major cities (39%), inner-regional areas (24%) and outer-regional areas (20%).²⁰ However, in very remote areas of Australia, the majority of young people are Aboriginal and Torres Strait Islander.²⁰

In 2014–15, a majority of Aboriginal and Torres Strait Islander people aged 10–24 years recognised their traditional Country or traditional homelands, and most (69%) were involved in cultural activities.²¹ The majority of Aboriginal and Torres Strait Islander people aged 15–24 years were happy all or most of the time.²¹ Almost all rated their health at least as ‘good’, with only 10% rating their health as ‘fair or poor’.²¹

Racism is now acknowledged as a health risk factor. (see Chapter 1: Health impacts of racism ). A 2011 study by Priest et al found that 32% of Aboriginal and Torres Strait Islander youth had reported experiencing racism and were two- to three-fold more likely to have anxiety, depression, overall poor mental health and be at risk of suicide.²²

Aboriginal and Torres Strait Islander youth are less likely to drink alcohol than non-Indigenous Australian youth.²¹ However, other health risk factors, such as obesity, physical inactivity, smoking, lower educational attainment and imprisonment, are more prevalent among Aboriginal and Torres Strait Islander youth than non-Indigenous Australian youth.²¹

A synthesis of population data in 2017 found the burden of illness in Aboriginal and Torres Strait Islander young people is attributable to mental disorders such as anxiety and depression, substance use and injuries.⁴ The same study found that the death rate for Aboriginal and Torres Strait Islander young people was more than twice that for non-Indigenous young Australians, with intentional self-harm and road traffic injuries the leading causes of death, accounting for approximately 60% of mortality.⁴ It is more concerning that almost 80% of mortality is deemed potentially avoidable, with almost all being potentially preventable.⁴

Despite the relatively higher prevalence of preventable illness, 11% of Aboriginal and Torres Strait Islander youth did not seek healthcare, even when they needed to.²³ This was higher among youth living in non-remote areas, and reasons included deciding not to seek care, other priorities, lack of appointments, fear or embarrassment, not liking the service or health professionals, transport or distance and cost.²¹

Other barriers that Aboriginal and Torres Strait Islander young people face include lower health literacy, culturally unresponsive systems and a consequent sense of ‘shame’. The concept of ‘shame’ extends beyond embarrassment and includes feeling disrespected and that accepted personal and/or cultural norms have been breached, leading to a sense of self-doubt, inadequacy and disempowerment.²⁴

Some topics, such as sex, are particularly sensitive among some Aboriginal and Torres Strait Islander groups. In addition, for many Aboriginal and Torres Strait Islander people there are gender-based cultural protocols that determine who can discuss what, often described as ‘Men’s Business’ and ‘Women’s Business’. Primary care services that either are unaware of or do not accommodate these possibilities create additional barriers to accessing healthcare.²⁵ Therefore, providing youth-friendly primary care services that are sensitive to the administrative, financial, cultural and psychological hurdles experienced by Aboriginal and Torres Strait Islander youth is an integral step in delivering effective preventive interventions.^7,9,14,24,25

A youth-friendly environment

Youth-friendly practice environments play a significant role in creating safe spaces for young people to engage with health services and need to be designed with input from young people. Youth-specific recommendations include:^9,26

• ease of access and location of the practice
• longer clinic hours and the ability to attend for ‘walk-in’ appointments
• bulk billed or no out-of-pocket costs for appointments
• a welcoming space and waiting room setting comfortable for young people
• waiting room materials that are youth focused and give information on health, healthy living, bulk billing, Medicare cards and transport
• the provision of youth-specific flyers and printed or displayed information
• the availability of health information in different media formats (eg digital, printed, image/photo based, video)
• making sure the space and the way services are provided ensure appropriate confidentiality.

Cultural safety

Keeping our kids safe: Cultural safety and the national principles for child safe organisations provides guidance about organisational structures that improve cultural safety for Aboriginal young people.¹² Ensuring physical environments are reflective of Aboriginal and Torres Strait Islander cultures indicates cultural respect and safety and can signal to Aboriginal and Torres Strait Islander young people that they will be heard and respected. There are emerging examples demonstrating the effectiveness and efficiency of codesigned services for youth.²⁷

The following measures are therefore helpful:

• Displaying acknowledgement of Country and Traditional Owners, flag representation, and artwork – it is important to seek local Aboriginal and Torres Strait Islander community input into how they would like their culture represented
• Offering central and flexible focal points of service, coordinating referral pathways and incorporating cultural and community elements into care
• Creating partnerships with young people to influence service design
• Having spaces that are welcoming, especially of families and broader kinship networks
• Hosting community groups and events

Continuous quality improvement

• Review the structure and environment of the organisation and the attitudes, skills and behaviour of all staff to ensure the service is youth friendly and culturally safe for Aboriginal and Torres Strait Islander young people.
• Where possible, consider the co-design of services in partnership with Aboriginal and Torres Strait Islander young people and their communities.¹⁷