Working alongside young people as they navigate sometimes turbulent waters

• Rates of depression, anxiety, psychosis and suicidal ideation increase rapidly from puberty, illustrating the impact of challenges faced during young adulthood.
• Among young people, Māori, Pacific and those from lower-income neighbourhoods are most likely to be unable to access healthcare when they need it.
• To improve healthcare access and mental health statistics for young people, it is important to raise awareness of your service and make it “youth friendly”, think about cost, promote local youth-specific resources and supports, treat young people as individuals, build trust and work in partnership with them.

Let me put this disclaimer up front – I am definitely not a specialist in young people’s health. I haven’t done any extra qualifications, and I’m not as up-to-date with all the research in this space as I would like to be, but I do truly love working alongside this unique age group in my role as a GP at Mauri Ora, the student health and counselling service for Victoria University of Wellington. I have learnt a huge amount from the patients I have seen there over the years. Plus, I am a mother to three teenagers, which I suspect has taught me as much as any postgraduate paper might have done!

A time of transition

A time of transition Adolescence or young adulthood is a time of great change and transition. For young people, it is a time to develop their own sense of identity and to firm up their views about the world around them. They may experience rapidly changing and fluctuating levels of physical, emotional and psychological maturation. They will be subjected to a shift in social roles, with a tendency to pull away from the influence of parents and family, towards that of friends and peers.

They are likely to be exposed to new and potentially risky behaviours, including the obvious ones around driving, sex, alcohol and drugs. Add to all this the pressure to succeed at education, to find employment and choose a future path, and to contribute to the “bigger picture”, and it’s easy to see why, for some, it can be a time of great challenge.

Figures around mental health are stark reminders of the potential impact these challenges can have on young people – rates of depression, anxiety, psychosis and suicidal ideation increase rapidly from puberty. Tragically, New Zealand has one of the worst youth suicide rates in the developed world: 175 young people aged between 10 and 24 took their life in the 12-month period from 2018 to 2019.

As primary care clinicians, we really are in a unique and privileged position to support young people through this time of transition and to have a positive impact on these appalling statistics. To do this effectively takes effort and a willingness to look through a slightly different “lens” than we might with our other patients. What

What is a young person?

The terms “adolescent”, “youth” and “young person” seem to be used pretty interchangeably, and there isn’t a consensus out there as to which is preferred. Personally, I find the term youth a bit derogatory, and I avoid using the word adolescent as it has a narrower definition in terms of the age range, so I tend to refer to young people. If you are someone who likes definitions, WHO’s terminology is the most commonly utilised:¹

• adolescent – someone aged 10–19
• youth – someone aged 15–24
• young person – someone aged 10–24.

Other than for funding purposes, when we might be compelled to be bound by these definitions, I encourage you to think of this period as a developmental stage, as opposed to an exact age range.

We can all think of somewhat “precocious” eight or nine-year-olds who are facing many of the developmental challenges of a young person. Likewise, we may well know of those in their mid-twenties who haven’t yet come through this stage.

From a clinician’s perspective, tailoring our care and support to match the developmental stage of the patient is more important and likely to be more effective than just being guided by their age.

Lost opportunities for quality healthcare²

The latest information from the truly wonderful and invaluable Youth2000 surveys – the Youth19 Rangatahi Smart Survey (youth19.ac.nz) – makes for interesting and, at times, sobering reading.

This survey of secondary school students in Aotearoa highlights that most young people do access healthcare, with nearly 80 per cent having seen at least one provider in the preceding year. The most commonly used service is the GP clinic, or “family doctor”, particularly among females and those from higher-income neighbourhoods. Other services accessed include school-based clinics and youth “one-stop-shops”.

On the flip side, this survey sadly also points out that 20 per cent of students interviewed were unable to access healthcare when they needed it. This was particularly true for those from low-decile schools, low-income neighbourhoods and small towns, and for Māori rangatahi and Pacific young people.

Even when young people are able to access a health provider, it isn’t always effective. Youth19 found less than 50 per cent of their participants were assured of their confidentiality during the consultation or were offered the opportunity to talk to the clinician in private.

As the study’s authors state, “These findings highlight lost opportunities for quality health interactions for youth. Access to private and confidential healthcare for young people is important for good health and wellbeing and helps them to establish good lifelong relationships with future providers. Youth are unlikely to disclose personal concerns (eg, mental health) when providers do not assure them of confidentiality or when a caregiver is present.”

Looking back at previous Youth2000 surveys, it appears that, sadly, we haven’t made much progress when it comes to enabling access. Māori and Pacific young people, as well as those from lower-income neighbourhoods, continue to be the ones affected most.

In an ideal world, all young people would have transparent access to free, quality healthcare, provided in a way and in a setting that works for them, taking into account their unique cultural and developmental needs. However, until that dream becomes a reality, there are things that we can all do to improve the status quo.

Practical tips for improving engagement³

Improve awareness of your service – this might be as simple as offering to give a talk about pertinent health issues to your local secondary school or providing resources or staff for a school-based clinic. Ask the young people registered with your practice for feedback, to help identify areas for improvement.

We did an exercise like this to try to engage more of our Pacific and Māori young people, and the results were enlightening – before they arrived at the clinic, they wanted transparent, “upfront” information about things such as charges (including prescription fees), confidentiality, who they were going to see, whether or not they could bring a friend, and what sorts of “health stuff” they could talk to us about. They also suggested some wording and design for a poster that we put in the waiting room and on our website.

This approach was remarkably easy and effective, and it highlighted areas such as sexual health and contraception that we were able to provide at lower cost.

Promote local youth-specific resources, supports and health providers – do this as visibly as you can. This might be on your practice website or portal, in your waiting room or via social media. It creates another avenue for a young person who may not want to use the same provider as the rest of their whānau.

Make your practice “youth friendly” – this can be as simple as making sure the posters, decor or music in your waiting room, or the design and wording of your website, have a youth focus. It could extend to offering types of appointments that might appeal more to young people (eg, after school hours, or “drop-in” as opposed to bookable appointments).

If you’d like to look at how youth friendly and accessible your practice is, consider using the following self- assessment tool, courtesy of Counties Manukau Health: https://bit.ly/2ZiRG3E

Think about the cost barrier – cost is a massive barrier for young people, particularly if they are financially dependent on their parents or have to travel to see you. Wherever possible, keep charges to a minimum and utilise other funding avenues, such as sexual health, improved access, healthcare home or contraceptive claims. If you know of low or no-cost services in your area, make sure their contact details are visible to your younger patients so they know there is an alternative if they can’t afford to come to you.

Build trust and talk about confidentiality – of those surveyed in Youth19, less than half had been assured of their confidentiality. This is one of the most crucial things we can improve on. Young people won’t discuss the issues worrying them most unless they know their information is going to be protected.

Openly stating at the start of a consultation that what you talk about is just between you and them, and that you will only discuss it with someone else if you have real concerns for either their or someone else’s safety (and even then, you will work alongside them if you feel you need to), goes a long way towards establishing trust, and it creates a safe space for discussing what are often sensitive issues.

Treat them as an individual – less than half of the Youth19 cohort reported that they were offered the opportunity to see the clinician on their own. Unless we create this space, many young people won’t feel safe disclosing what is worrying them.

It can feel like a delicate conversation when you have a parent or caregiver you have known for years in the room, but presenting it as “business as usual” typically works. Offer time at the beginning for everyone to be present, but state that after a few minutes, you’d like to talk to the young person on their own, as you do for every patient of that age.

When you have them on their own, spend time building rapport with them as an individual and listening to what is really on their mind, not just what others are concerned about.

Make it clear that they can come to you independently of their whānau. If that is going to be too hard for them, suggest a local school-based clinic or youth adverse Make it clear that they can come to you independently of their whānau. If that is going to be too hard for them, suggest a local school-based clinic or youth one-stop-shop they can go to.

Work in partnership with them – like the rest of us, young people want to be genuinely heard and to be offered the tools and support they need to manage their health and wellbeing. Working alongside them, creating joint management plans and involving them in “solutions” is not only empowering but effective.

Being a small part of their journey as they navigate the sometimes turbulent waters of this stage of life is a real privilege, and getting to witness their growth and resilience as they do it successfully is a huge reward.

Cathy Stephenson is a GP at Mauri Ora, Student Health and Counselling Services, Victoria University of Wellington

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