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Family physicians with full practices and busy schedules struggle to help youth who present with pressing health issues and complicated lives. Our own offspring report difficulty finding primary care as they become independent. Our experience helping youth and young adults negotiate complex resource-constrained systems of care has posed challenges and contradicts the belief that youth do not need or want much health care.
All youth are potentially at risk of adverse health and mental health outcomes, owing to environmental factors, family situations, personal choices, or social pressures. Youth are less likely than adults to seek or receive primary care and they experience more gaps in health and mental health care than adults do.1 The health attitudes and behaviour youth develop in adolescence and early adulthood have a lasting effect on their health, well-being, and life course as adults. Youth need primary care that is sensitive to their unique stage of biologic, cognitive, and psychosocial transition to adulthood.2
To understand how primary care can support the health of youth, we conducted a systematic literature review on youth access and engagement with health and mental health services (page 778).3 Key principles and activities that support youth-friendly practice emerged. We met with local high-school youth to ask how they would like youth health care to be offered in our community. Then we attempted to incorporate these findings into a more youth-friendly practice. Some changes have been easy to implement, and some require more resources and time.
A report found in the literature review provided a framework for the evidence that emerged. The framework, developed by Kang et al4 from practice and research with youth in Australia, is based on 7 key principles: accessibility, evidence-informed practice, youth participation, collaboration, professional development, sustainability, and evaluation. This framework guides our commentary, which is intended to foster conversation on supporting youth-friendly practice.
Transportation is an issue for many youth. If your office is not centrally located, consider offering youth health care in partnership with a local community centre or school, or wherever youth congregate. Be aware that out-of-school youth might be excluded from school-based settings.
Offer some same-day advanced access appointments. If youth call or drop in and they can be seen the same day, they are more likely to receive care.
Youth in school or at work all day have limited opportunities to seek care during regular office hours. Early evening drop-in visits are more accessible for youth in and out of school. Consider offering a regularly scheduled 1- to 3-hour drop-in youth clinic that requires no appointments, in which any youth health needs (physical, emotional, or sexual) can be addressed. If this is open to any youth in your community, even those without regular family physicians might engage the offered services.
Advertise youth health services to youth, parents of youth, schools, and youth service providers. Spread the word with posters in the office and community, notices in the local paper, electronic bulletin boards, inserts in school newsletters or report cards, and word of mouth.
It takes time. It took 3 or 4 months for our weekly local youth clinic to become widely known, trusted, and busy.
The following evidence is distilled from the literature, conversations with local youth, and our own practice.
Youth might not feel comfortable sharing their concerns with a receptionist or in a crowded waiting room. Allow them to write the reason for their visits on patient agendas, or wait until they are in the privacy of the examination room to ask. Our optional agenda has 3 questions:
Youth say their willingness to seek care is affected by the way front-office staff and physicians treat them. If staff are friendly, respectful, and nonjudgmental, this helps put youth at ease.
Youth want clear and explicit information about confidentiality. Post your office confidentiality policy in plain language in the waiting and examination rooms, or offer copies to patients. Clearly explain the circumstances under which legal constraints affect confidentiality.
Youth want reassurance that you understand their issues and have expertise in youth health care. Choose youth-specific skill development as part of your continuing professional development, and share your expertise with other local service providers. If you have extra skills in reproductive care or youth mental health or addictions, and are willing to see youth with these concerns, let youth and other youth service providers know.
Youth want clear, developmentally appropriate, understandable explanations of all the options available when addressing a problem, and nonjudgmental support for making their own choices and decisions. When upset, it takes longer for them to process information and they might need things explained more than once. Asking “Do you understand?” might be less effective than asking “Could you tell me what you understand about this?”
When asking about sensitive subjects such as sexual health, personal habits, or relationship issues, how questions are phrased influences the response. Providing context for sensitive subjects with phrases such as “I usually ask all my patients about their smoking and alcohol use. Is it OK for me to ask you about this as well?” helps ensure that youth do not feel as if they are being singled out for interrogation.
Regularly ask local youth for feedback on the care they have received, any barriers they and their friends have encountered, and how they would like to access care. Sharing what you have learned and what changes you have made as a result of their intelligence can keep youth engaged in offering their expertise. Short, anonymous questionnaires or a suggestion box in the waiting room can help gather this feedback.
Youth suggested that our office should partner with local schools to showcase youth art and photography on waiting room and examination room walls. Youth enjoy seeing their own work posted, and older patients also express enjoyment at seeing local youth art.
Reach out to youth service providers in your community (school counselors; youth outreach workers; youth employment services; boys and girls clubs; youth leaders in sports, arts, and businesses; and youth employers). Communicate your interest in providing youth-friendly care. Request support for your practice and ideas on service improvements. When we had difficulty finding samples of oral contraceptives and condoms for our youth clinic, we asked local pharmacies; each one offered a unique solution.
Initially it seemed there were no youth resources in our community. We inquired and discovered that some resources did exist. They were stretched to capacity and working in isolation, but they welcomed engagement with family physicians.
The following activities support youth-friendly practice:
Once we made our interest known and started looking for opportunities to learn more, we discovered a wealth of expertise and support for youth-friendly practice among colleagues, in traditional continuing medical education, and in interprofessional and non-academic settings.
Establishing a youth-friendly practice can start with small initiatives or changes and gradually build on success and networking with other providers.
We started offering advanced access appointments for all patients, especially youth, every office day. Then we offered a drop-in, youth-only (ages 13 to 25) clinic in our office every Tuesday from 5:00 to 8:00 PM. Local youth suggested this would coincide with other youth activities in the same area, including a youth drop-in gym and youth employment service. The cost of the youth clinic to our practice is 3 hours of receptionist time and 3 hours of physician time weekly; easily recouped through the number of patients seen.
Remaining responsive to changing needs over time requires systematic feedback and review. Asking youth and other youth service providers for feedback through a suggestion box or questionnaire is a first step. Keep practice-level data on numbers of youth patients, presenting complaints, use of services, and gaps in available services for youth, and regularly review youth feedback or comments on what works and what does not.
In the first 9 months of our youth clinic we have met a variety of health needs for youth who did not otherwise have access to care. We regularly solicit suggestions for improvement, which have been helpful and constructive.
This opportunity to learn from the energy and intelligence of local youth has provided rewarding practice and professional development, and a better understanding of the challenges youth face. There are simple things most family doctors can do to increase youth access to primary care, and there are other areas where we need to lobby in partnership with youth to ensure that the resources they need will be available.
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.