Young peoples’ perspectives about care in a youth-friendly general practice

KEYwords: Adolescent; adolescent health services; general practice; health services accessibility; primary health care; qualitative research; quality improvement; young people; youth-friendly.

Little is known about support for young people to transition from accessing general practice as children (with caregivers) to independently accessing general practice as adults. Creating youth-friendly health-care environments may help.¹ Youth-friendly environments are accessible – affordable, convenient, and visible; acceptable – responsive to cultural, ethnic, gender and social diversity, culturally appropriate and confidential; equitable – available to all young people, not just selected groups; appropriate – provide the right health services; and effective – care provided in the right way to make a positive contribution to youth health.^2,3

Supporting young people to access health care is important because poor youth health outcomes have life-long impacts on individuals, whānau (family) and society.⁴ Young people (aged 15–24 years) are 13% of the New Zealand (NZ) population and they face complex health, social and developmental needs that are different from children and adults.⁵ Prevalence of mental health disorders is higher among youth, and in NZ, the average youth suicide rate for people aged 15–19 years from 2013 to 2015 was the second-highest across the Organisation for Economic Co-operation and Development (OECD) and European Union countries.^6–8 Particular groups of NZ young people with poorer health and challenges in accessing health care include Māori, Pacific, gender-diverse, refugee and recent migrants, rural youth and youth of lower socio-economic status.^7,8 Young people’s health service utilisation is the lowest of any age group,^9–12 and although only a small proportion of young people have long-term conditions,¹³ they have a high unmet burden of health and social needs.¹⁴

In NZ, most care for young people is provided by general practices, which are locally available and, for most, a known service through childhood attendances.^10,14 General practices should provide appropriate health care to young people as part of their commitment to and skill-set for providing care across the life-span.¹⁵ General practices have a key role to play in the delivery and improvement of youth health care and youth health outcomes.^8,15,16 Internationally, young people report numerous barriers to seeking care from general practices,^1,17,18 but little research has explored young people’s views of general practice care in NZ. A few NZ general practices have made substantial attempts to offer specific youth health services and provide youth-friendly environments to meet the needs of their enrolled population and be attractive to potential new young-person clients. One such practice is located in a Wellington suburb with a large youth population and high deprivation levels. The practice, community context and youth initiatives are summarised in Table 1.

Table 1.  Practice context and youth-friendly model of care

We aimed to explore the experiences of young people seeking health care from this youth-friendly general practice and to identify aspects of care that were most important to young people.

This qualitative study employed a general inductive design, appropriate for investigating topics when little is known about them.¹⁹ Because it was exploratory, a small number of participants were sought. The practice youth-care nurse approached eight young people about the research and they completed a form to allow researchers to independently contact them and explain the study. Young people who had experienced a variety of services were chosen. All agreed to take part. Participants could choose to be interviewed by a youth health specialist interviewer or a university researcher at a location of their choice, either face-to-face or over the phone. Of the eight young people who agreed to be interviewed, one was unable to attend on the day due to a family health emergency and one failed to attend the interview and did not respond to follow up.

A total of six young people were individually interviewed: five females and one male. Ethnicities included: Cook Island Māori (1), Māori (1), Tokelauan (1), Pakeha (1) and Samoan (2). Ages ranged from 17 to 23 years. Four were in paid employment and two were caring for young children.

After consenting, interviews were conducted by phone (3) and face-to-face (3). Interviews followed a semi-structured interview guide and enquiry-based open-ended questions. These explored young peoples’ views and experiences of care at the practice, including barriers and enablers to seeking care, although the interviews were discursive according to the young person’s lead.^20,21 Interviews lasted 21–51 min.

Interviews were audio-recorded, transcribed and managed in NVivo 12 (QSR International). Two researchers used an iterative, inductive process to undertake a thematic analysis.²² Coding discrepancies between researchers were discussed until agreement was reached.

Comments from young people during interviews largely related to their experiences with youth-care nursing and social care staff members, with fewer comments about general practitioners (GPs). Five participants reported they had been enrolled with the study practice for several years, often since childhood. Five reported attending the practice reasonably frequently, particularly to see the youth-care-funded staff, for a variety of complaints. One reported attending intermittently.

Four themes were identified from their narratives: going ‘to the doctor’ is not easy for a young person; the attributes of staff make all the difference; specific youth-friendly consultation practices help young people; and youth-friendly physical environments can help young people access services and feel safe.

Young people reported that they faced difficulties in independently seeking health care, even in a practice that specifically welcomes youth. They consistently expressed that ‘going to the doctor’ (code for going to the general practice) was hard.

An important part of young peoples’ reluctance to attend the practice was about not wanting to be seen (and judged or curiosity aroused) by members of the community in the practice waiting room.

‘…it’s just like everyone’s eyes are on you … and let’s say you’ve just disclosed with your doctor something really heartfelt and emotional and you’re just like in a tragic state and you walk out there and everyone’s just staring at you.’ [F04]

Young people said they were self-consciousness and even when they gained courage to come to the practice, they found disclosing their concerns a challenge. They described struggling to overcome their awkwardness in starting conversations and then finding the right words to express themselves. They appreciated staff who helped tease out their issues.

‘Like I think it’s just knowing what I want to say but yeah, it’s just knowing how to say it.’ [F02]

Young people feared being judged by staff for their actions, behaviour or their lack of health knowledge.

‘I … worry about what’s the nurse going to say about say for example like a stupid decision that you’ve made or …. like a word that you’ve said wrong.’ [F02]

Young people were not aware if they could seek help from their general practice for health or other issues that were not physical complaints.

‘I mean you go to the doctor … for your physical health. Sometimes they [young people] don’t understand that they’re also there for their mental health as well.’ [F03]

Visiting the practice and opening up to staff depended on establishing trusting relationships. Some felt they needed time, whereas others seemed to immediately relate.

‘… it took a while for me to actually want to talk to the nurses about my situation or situation that I’ve been in.’ [F03]

Young people talked of growing confidence to take responsibility for their health and seek care when things went well at the practice.

‘It’s kind of weighing up your odds … we have to kind of take that leap of faith … it’s either your health or your ego - which one are you going to pick.’ [F02]

The most important factor influencing young people’s engagement with general practice was the staff and their ability to create a safe, welcoming environment.

Young people reported being acutely sensitive to visual facial cues and non-verbal responses, which they read as being welcoming, or not (smiles, using names, open arms), with staff use of humour being affirmed.

‘… from just calling out your name … they’re happy to see you and happy that you come in …’ [F03]

Reception staff and some GPs were viewed as less friendly and nurses and social care staff seemed more friendly. When they entered the practice, young people immediately judged how welcome they were by whether receptionists frowned or smiled or how hurried or dismissive they were; the latter threatening the chance they would return.

‘…smiling goes a long way and …when young people walk in, they see someone angry … they’re not going to feel comfortable.’ [F04]

Irrespective of age, the cultural background and match of the staff was an important boost for the mainly Pacific and Māori young people. Most nurses and social care staff were Pasifika and lived locally (including the youth-care staff); this was perceived to result in a culturally safe environment.

‘if you try and joke around with a different culture nurse or doctor they’re not going to see [it] as funny as another culture will. … it’s better to have someone who’s of the same culture or close, as a doctor or a nurse.’ [F06]

Young people reported a particular affinity with the younger staff members. Their experiences of similar challenges were perceived to make them more understanding and less judgemental than older staff.

‘… usually teenagers don't want to talk to older people about what they’re going through you know sometimes they go what do you know about…’ [F03]

‘…you know she’s (staff member) actually been through what you’ve been through and all of that, she makes it feel better and I prefer her over any of the other doctors.’ [F06]

Staff–patient gender match and gender diversity were also mentioned as important factors.

‘…making [it] comfortable for males, young males to come in and talk to her, have a male receptionist …. Like both sexes can and non-binaries … [F06]

Young people reported they were more likely to engage with staff they thought understood their needs as young people. This was reflected in the following consultation practices:

Young people appreciated staff routinely assuring and reassuring them of the confidentiality regarding what was discussed in the consultation.

‘… it was like - is she like a snitch? but I was like it’s okay … the doctor sticks to her job. You know doesn’t like tell my mum ... gives assurance that it’s confidential …’ [M01]

Young people felt that the youth-care worker and some other clinical staff respected them as independent decision-makers with a valuable contribution to make and a voice to be heard.

‘…she’s [staff member] really driven to making us feel like we are important and what we want to say then and there is important as well and it should be treated just as equally as everyone else.’ [F03]

Young people appreciated staff in the practice who were flexible and could work in non-traditional ways with young people, allowing them to ‘be themselves’ and bringing friends for support.

‘You know they’re open to hearing what you want to say. So every time I come in here it’s like you know just be yourself so I’ve come in here with like five friends at once.’ [F06]

The introduction of no-charge consultations for people aged <25 years removed the need to inform whānau of a visit to the practice to obtain money for the consultation.

‘… definitely important that ‘the doctors’ are free. You know a lot of young people don’t really have money.’ [M01]

However, they pointed out the cost of prescriptions was still a barrier.

‘… how am I going to pay for my pills after I see the doctor?’ [F02]

Young people wanted to message or text rather than phoning to book appointments. They appreciated being able to use the practice app ‘Manage My Health’ to book appointments online, view results or order prescriptions.

‘… every young person’s got a phone …. It’s easier just to be a click away from the doctors.’ [F06]

Young people valued simple, clear explanations in language they could understand. They appreciated being offered choices and not being told what to do.

‘She [youth nurse] knew how to explain stuff better [than the doctor] and like knew how to communicate whereas my doctor was just telling me.’ [F05]

A youth-friendly physical environment was important to young people. It was described as accessible for travel and booking appointments, and where the waiting areas in the practice helped them feel comfortable and safe.

Young people described the central location of the practice in the community and the proximity to public transport as facilitating access. Having convenient regular opening hours (and an evening clinic 1 day per week) and a co-located pharmacy were mentioned positively.

‘Yes, well definitely [accessible], well the bus stop [is] right close to it… so it takes me about five minutes to get here.’ [F04]

Young people made numerous comments about the ‘clinical’ appearance of practice waiting areas, which they felt could have been improved.

‘Just like maybe the colours like less of a hospital feel, more like you’re just in a room getting checked out.’ [F06]

Suggestions were made for creating a more youth-friendly, less clinical environment; for example, art, posters with ‘less words’, more seating, activities or toys for children of young parents, activities for young people (books, magazines, crosswords, adult colouring books, etc). One young person suggested a completely separate youth area in another building, with free pregnancy tests and sexual health information.

‘Maybe like set up like a chalk board or something for the kids to draw on…especially with kids running around. It would be real helpful.’ [F05]

This study confirms findings found in international^1,17,18 and NZ research^12,23–26 showing young people face considerable barriers to accessing general practice care in NZ. Even if young people have attended a practice as children and the practice has implemented youth-friendly initiatives, they still find it intimidating and scary seeking health care as a young person. As the first point of contact for most young people seeking care,^10,14 all general practices should consider ways to make their services more youth friendly.

Consistent with international research,^16,27–29 welcoming personal qualities of practice staff were the single most important factor facilitating young peoples’ engagement with the practice. In reassuring and building trusting relationships with young people, friendliness, younger age, matched ethnicity and cultural understanding, and ability to relate were important. Fifteen-minute GP consultations are a barrier to engagement, as often this will not be long enough for the ‘real’ health need to be revealed. Many consultations with young people are appropriately undertaken by nurses²⁶ and, if needed, a ‘warm transfer’ of care to a GP.³⁰ Young people found practice receptionists often unfriendly and unwelcoming, consistent with other research in the UK³¹ and in NZ,³² which confirms the critical facilitator role of receptionists as the front face of general practices. Encouraging general practice staff to be obviously warm, cheerful and appropriately humorous plus appearing to have ‘all the time in the world’, helps young people to relax.

The diverse range of skills available at the service were appreciated by young people, including specific youth care roles. These roles providing integrated primary health and social care (youth health specialist nurse or GP, youth social worker, youth community support) are not routinely included in NZ general practices, yet are critical to providing comprehensive, holistic and supportive care.³³ Establishing these roles in practices located in communities with high numbers of young people is important, if they are permanent, ongoing roles and fully embedded in the staffing arrangements of the practice. Services using ‘service to increase access’ (SIA) funding³⁴ often end up to be temporary. This is detrimental to building staff capacity and raises unrealistic expectations for young people themselves.³⁵

Young people’s privacy concerns related to being seen, recognised or judged when in the waiting room. A separate waiting room (as in this practice) may not be feasible for all practices (a discrete corner may be possible), but making waiting areas welcoming, not ‘clinical’ and with visible ‘nods’ to youth culture (visuals, music, furnishings) enhances youth friendliness. Young people like to manage the timing and confidentiality of their interactions via texting, phone apps, patient portals and e-messaging, particularly for booking appointments and receiving results. Promoting and using this technology will support access to care.

Young people are very self-conscious, and fear being judged by clinicians for their limited health knowledge and difficulty in expressing themselves. This was further complicated by not knowing what practices could help with (including mental health issues), as has also been found in other studies.^31,36 Advanced communication training is needed to build staff skills to elicit health-care needs and help young people to articulate these needs, particularly the need to effectively and routinely convey the principle of confidentiality.^37–40

Cost is an ongoing issue restricting health-care access for young people,^24,26 and despite the consultations being free in the practice in this study, prescriptions were not. Greater gains in health care for young people could be made if consultations were free for everyone aged <25 years and prescription charges were waived.

Recruitment of young people for interview-based research is challenging, with general age-related reluctance a factor and particular ethical safeguards required. In this study, even with an intermediary in the recruitment process, the possibility of unintended coercion cannot be ruled out. Despite there only being six participants, some diversity was achieved in age, gender and ethnicity; however, data saturation may not have been achieved and further issues may have been elicited if more interviews were undertaken, including exploring cultural and social economic influences and seeking out young people who had not received health care. Future studies could include more participants, particularly more males, with some from younger age groups. Offering the option of phone or zoom interviews may be helpful for youth participants, particularly in light of COVID-19 changes.⁴¹ In this study undertaken in 2019 (pre COVID-19), phone interviews appear to yield comparable data and may be a good option for some young people.⁴²

This study shows that even in an intentionally youth-friendly practice, barriers exist in offering an accessible, acceptable, equitable, appropriate, effective safe consulting environment. To assist general practices in undertaking this important work, information from these findings is being used to inform the development of a youth-friendly quality improvement tool for general practices to identify aspects of care, staff approaches and the physical environment that could be improved.

The authors declare no competing interests. The study was approved by the University of Otago, Human Ethics Committee (H19/014) in 2019.

This research was funded by grants from Lotteries Health Research and the University of Otago Wellington.