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Objective: To quantify barriers to healthcare for young people (12-24 years) and identify socio-demographic correlates and predictors. Methods: This cross-sectional survey targeted young people living in New South Wales, Australia, with oversampling of marginalised groups. Principles Component Analysis (PCA) identified clusters of barriers. Ordinal regression identified predictors of each barrier cluster. Results: A total of 1,416 young people completed surveys. Participants with chronic conditions and increasing psychological distress reported a greater number of barriers. Of 11 potential barriers to visiting a health service, cost was most common (45.8%). The PCA identified three clusters: structural barriers (61.3%), attitudinal barriers (44.1%) and barriers relating to emerging autonomy (33.8%). Conclusions: Barriers to healthcare reported by young people are multi-dimensional and have changed over time. Structural barriers, especially cost, are the most prominent among young people. Approaches to overcome structural barriers need to be addressed to better support marginalised young people's healthcare access. Implications for public health: Understanding predictors of different barrier types can inform more targeted approaches to improving access. Equitable access to healthcare is a priority for early diagnosis and treatment in young people, especially reducing out of pocket costs.
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2019 Online Australian and New Zealand Journal of Public Health 1
© 2019 The Authors
Access to healthcare is an important
social determinant of health. Barriers
to healthcare for young people in
Australia and internationally are well known,
with condentiality concerns consistently
cited as the most important.1-3 Technology
has the potential to improve access to
healthcare; for example, through enhancing
access to information about health and health
services as well as young people’s ability
to communicate with services.3 However,
relatively few studies have examined its role
in these activities.4
To achieve equitable health outcomes
across populations, including those who are
marginalised, access must also be equitable.5
Marginalised young people experience
access barriers common to all young people,
such as lack of suitable services, cost and
lack of health literacy.3 However, these are
exacerbated for certain marginalised young
people. For example, structural barriers have
been highlighted for homeless young people6
and condentiality concerns have been
identied as a signicant concern by rural
young people.7 Further, some marginalised
groups of young people also experience
barriers around language and culture,
discrimination and stigmatisation.3
This study aimed to quantify young people’s
barriers to healthcare access and their
predictors to examine how these vary by
socio-demographic and socio-cultural factors,
including marginalisation, and the role of
technology in help-seeking.
Methods
Design
A cross-sectional survey was conducted as
one component of a larger study, known as
Access 3. The detailed Access 3 study protocol
paper has been published.8 Youth consultants
provided advice on the survey instrument,
recruitment methods, interpretation of
ndings, policy translation and dissemination.
Sample
Participants were a non-probability sample
of young people aged 12 to 24 years living
in New South Wales (NSW), Australia, with
oversampling of ve marginalised groups:
Predictors of young peoples healthcare access in
the digital age
Fiona Robards,1 Melissa Kang,1,2 Georgina Luscombe,3 Lena Sanci,4 Katharine Steinbeck,5 Stephen Jan,6
Catherine Hawke,3 Marlene Kong,7 Tim Usherwood1,6
1. Department of General Practice, The University of Sydney, Westmead Clinical School, New South Wales
2. Australian Centre for Public and Population Health Research, University of Technology Sydney, New South Wales
3. School of Rural Health, The University of Sydney, New South Wales
4. Department of General Practice, University of Melbourne, Victoria
5. Discipline of Child and Adolescent Health, The University of Sydney, New South Wales
6. The George Institute for Global Health, University of New South Wales
7. The Kirby Institute, University of New South Wales
Correspondence to Ms Fiona Robards, Department of General Practice, The University of Sydney, PO Box 154, Westmead, New South Wales 2145;
e-mail: ona.robards@sydney.edu.au
Submitted: December 2018; Revision requested: August 2019; Accepted: August 2019
The authors have stated they have no conict of interest.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modications or adaptations are made.
Aust NZ J Public Health. 2019; Online; doi: 10.1111/1753-6405.12936
Abstract
Objective: To quantify barriers to healthcare for young people (12–24 years) and identify socio-
demographic correlates and predictors.
Methods: This cross-sectional survey targeted young people living in New South Wales,
Australia, with oversampling of marginalised groups. Principles Component Analysis (PCA)
identied clusters of barriers. Ordinal regression identied predictors of each barrier cluster.
Results: A total of 1,416 young people completed surveys. Participants with chronic conditions
and increasing psychological distress reported a greater number of barriers. Of 11 potential
barriers to visiting a health service, cost was most common (45.8%). The PCA identied
three clusters: structural barriers (61.3%), attitudinal barriers (44.1%) and barriers relating to
emerging autonomy (33.8%).
Conclusions: Barriers to healthcare reported by young people are multi-dimensional and have
changed over time. Structural barriers, especially cost, are the most prominent among young
people. Approaches to overcome structural barriers need to be addressed to better support
marginalised young people’s healthcare access.
Implications for public health: Understanding predictors of dierent barrier types can inform
more targeted approaches to improving access. Equitable access to healthcare is a priority for
early diagnosis and treatment in young people, especially reducing out of pocket costs.
Key words: young people, adolescents, access to healthcare, marginalised youth, technologies
2 Australian and New Zealand Journal of Public Health 2019 Online
© 2019 The Authors
Robards et al.
Aboriginal and/or Torres Strait Islander; living
in rural/remote areas; homeless; refugee or
vulnerable migrants; and sexuality and/or
gender diverse.
Recruitment
Recruitment comprised online and
oine strategies. Online recruitment
included targeted emails to youth-relevant
networks, social media (Facebook,
Twitter and Instagram) and opportunistic
online promotion of the survey. Oine
recruitment occurred face-to-face in youth
accommodation services and youth forums.
To purposively sample marginalised young
people, we worked with networks and
advocates from a range of community-
based organisations using convenience and
snowball sampling methods to achieve our
sample size. Participants went into a draw
to win one of 20 vouchers worth A$50 upon
survey completion.
Data collection
The anonymous questionnaire was
administered online using LimeSurvey, a
survey web application,9 or via hardcopy.
The study period was from February 2016
to February 2017. Consent was implied by
survey completion.
Measures/instrument
Questionnaire development was guided by
published evidence10,11 about barriers to
access and health service ‘youth-friendliness
indicators. Questions about the impact
of technology on whether, when and
how to access healthcare were included.
Demographic data were collected and the
ABS socioeconomic index for areas (SEIFA)
Index for Relative Socioeconomic Advantage
and Disadvantage (IRSAD) and having
a Health Care Card were used as proxy
measures for respondent’s socioeconomic
status.
The identication of marginalised groups
was based on self-reported survey responses.
Rurality was calculated using postcode data
and the Australian Bureau of Statistics (ABS)
Australian Standard Geographic Classication
(ASGC) Remoteness Structure and dened
to include rural (inner and outer regional)
and remote (remote and very remote).
Homelessness was identied based on
living situation (e.g. living with relatives,
friends, in foster care, in a refuge/supported
accommodation, boarding house, on the
street/outside), using the Australian cultural
denition of homelessness.12
Health status was measured by self-
assessed health status,13 the Kessler 10 (K10)
questionnaire that measures psychological
distress14 and presence of chronic physical
and/or mental health conditions or disability
selected from a predened list.
Participants were asked about attitudes
towards accessing healthcare and health
service utilisation within the previous six
months. They selected one or more responses
from a list of eleven potential barriers that
would prevent or stop them from accessing
healthcare (see the Supplementary File for
the survey questions).
Telephone numbers for youth support
services were provided at the end of the
survey for any young people wanting to
access support. A contact number was also
provided within the participant information
sheet if young people wanted to get in touch
about the study.
Analysis
Data from paper surveys were entered into
the same LimeSurvey database. Relationships
among categorical demographic variables
were explored using chi-square analyses (e.g.
dichotomised age [12–17 years, 18–24 years]
and number of marginalised groups: none,
one, two or more). Where continuous data
were skewed, they were reported as median
and interquartile range (IQR). To examine the
relationship with reported barriers, responses
were explored using Principal Components
Analysis (PCA) to reduce the number of items
and determine if there were identiable
clusters of barriers. PCA with varimax rotation
was rst performed in a randomly selected
‘training set’ of 30% of the sample then
repeated for independent validation in the
remainder. For each, the Kaiser-Meyer-Olkin
determined sample adequacy and items
were retained if their eigenvalue was >1 and
loading size >0.5.
To identify associations with barrier clusters
or ‘types’, ordinal regression models were
run, with the number of barriers identied
within a cluster as the dependent variable.
Model comparisons were based on likelihood
ratio tests. Potential predictor variables in the
model included age (years), gender (male,
female, other), socioeconomic status (SEIFA
IRSAD decile), had a Health Care Card, had
private health insurance, marginalisation
(belong to none, one or two or more of the
ve marginalised groups), number of chronic
health conditions, level of psychological
distress (K10), number of health professional
types other than general practitioners (GPs)
seen in the previous six months (since most
participants had visited a GP) and frequency
of use of the internet to decide which health
service to attend (not at all, sometimes,
frequently). Analyses were conducted using
IBM SPSS version 24,15 and alpha was set at
0.05 for all analyses.
Ethics
Ethics approval was obtained from the
University of Sydney Human Research Ethics
Committee and the Aboriginal Health and
Medical Research Council of New South Wales
Ethics Committee.
Results
Sample
Of the 1,416 young people (12–24 years) who
completed the survey (68.4% female, 28.7%
males, and 3.0% other), 1,012 completed
the survey online and 404 on hard copy.
One hundred and twenty-nine (9.4%) had a
parent, carer or someone from school to help
them complete the survey. Eight hundred
and ninety-seven participants (63.3%)
belonged to at least one of the pre-dened
marginalised groups (Table 1). Adolescents
(12–17 years) were more likely than young
adults (18–24 years) to belong to multiple
marginalised groups (27.9%, 196/703 vs.
17.8%, 127/713; p<0.001). Table 1 summarises
the socio-demographic characteristics of the
sample.
Health status
Health status is described in Table 1. While the
majority of respondents rated their health as
good to excellent (80.8%, 1,139/1,410), almost
half had high or very high psychological
distress according to the K10 (52.1%,
729/1,400). Male respondents were most
likely to report very good to excellent health
(54.7%, 221/404; female 40.0%, 386/964;
other gender 26.2%, 11/42), and other gender
respondents most likely to report poor to fair
health (33.3%, 14/42; female 21.1%, 203/964,
male 13.4%, 54/404; p<0.001). There was
a signicant association between gender
and psychological distress (high/very high
K10 scores): other gender (80.9%, n=34/42)
respondents were more likely to experience
signicant psychological distress than female
2019 Online Australian and New Zealand Journal of Public Health 3
© 2019 The Authors
Young people’s healthcare access in the digital age
(55.0%, n=529/961) or male respondents
(41.8%, n=166/397; p<0.001).
Just over half the sample reported at least
one chronic health condition or disability
(51.9%, 736/1,416). Female and other gender
participants were more likely to report having
a chronic health condition or disability
(female 54.8%; 530/968; other gender 83.3%,
35/42) compared with males (42.1%, 171/406,
p<0.001).
Psychological distress (high/very high K10)
was signicantly higher among those who
belonged to at least one marginalised group
(57.1%, 504/882) compared with those who
did not belong to any (43.4%, 225/518,
p<0.001). Similarly, those who belonged to
at least one marginalised group were more
likely to report having at least one chronic
health condition (55.4%, 497/897) compared
to those who did not belong to any (46.1%,
239/519, p=0.001).
Health service utilisation
Most of the 1,416 participants had visited at
least one health professional in the previous
six months; this was most likely to have been
a GP (81.4%, 1,149/1,411). Other types of
health professionals visited by more than
one-third of the sample included a dentist
(45.0%, 635/1,411), pharmacist (42.1%,
594/1,411) and mental health professional
(counsellor or psychologist 29.3%, 413/1,411;
psychiatrist 9.9%, 140/1,411). Visits to
medical/surgical specialists, nurses, allied
health professionals and traditional healers in
the previous six months were also reported.
Access to technology and online
activity
The great majority (96.1%, 1,326/1,410) had
ongoing access to the internet while the
remainder had intermittent access via school,
the library or youth services (3.9%, 55/1,410),
or none at all (1.1%, 16/1,410). Young adults
were signicantly more likely to have internet
access compared to adolescents (97.9%,
696/711 vs. 94.3%, 660/700, p<0.001).
Participants who belonged to one or more
marginalised groups were signicantly less
likely to have internet access (94.4%, 843/893)
compared to other young people (99.0%,
513/518, p<0.001).
Most participants owned a mobile phone
with internet access (87.0%, 1,227/1,411), or
without internet access (8.4%, 119/1,411),
while 4.6% did not own a mobile phone
(65/1,411). The majority (94.0%, 1,326/1,410)
Table 1: Sociodemographic and health characteristics of sample (n = 1,416).
Median age 18 years (IQR 16 to 20)
Gender n (%)
Female 968 (68.4)
Male 406 (28.7)
Other 42 (3.0)
Cultural diversity
Born overseas 233 (16.6)
Born overseas and speak a language other than English 126 (9.0)
Education
Current study
High school 645 (45.8)
Intensive English Centre (IEC) in high school 21 (1.5)
Full-time tertiary studies 441 (31.3)
Part-time tertiary studies 80 (5.7)
Not studying 195 (13.9)
Other 25 (1.8)
Current employment
In full time paid work 106 (7.6)
In part-time or casual work 506 (36.3)
A carer or doing home duties 22 (1.6)
Unemployed: looking for work 358 (25.7)
Unemployed, not looking for work, studying 283 (20.3)
Unemployed, not looking for work, not studying 15 (1.1)
Unable to work due to sickness or disability 37 (2.7)
Other 66 (4.7)
SEIFA IRSAD decile (lower indicates greater disadvantage)
Median (IQR) 6 (4 – 9)
Range 1 – 10
Healthcare card, private health insurance, youth allowance and Medicare card
Healthcare carda391 (27.7)
Private health insuranceb634 (44.9)
Youth allowancec312 (22.5)
Own Medicare cardd634 (45.1)
Marginalised groups
Aboriginal and/or Torres Strait Islander 169 (12.0)
Rural 478 (33.9)
Homeless 118 (8.4)
Refugee 75 (5.3)
Sexuality and/or gender diverse 426 (30.1)
None of the above groups 519 (36.7)
Self-reported health rating
Poor 62 (4.4)
Fair 209 (14.8)
Good 521 (37.0)
Very good 461 (32.7)
Excellent 157 (11.1)
Level of psychological distress (K10 score)
Low (1015) 354 (25.3)
Moderate (1621) 317 (22.6)
High (2229) 322 (23.0)
Very high (3050) 407 (29.1)
Chronic health conditions (self-reported)
None 749 (52.9)
Mental health condition only 409 (28.9)
Physical health condition only 136 (9.6)
Both 122 (8.6)
Notes:
IQR, interquartile range; note, marginalised groups are not mutually exclusive.
a: A government-issued concession card to enable access to subsidised medicines
b: A voluntary scheme that allows individuals to be treated as a private patient in a public or private hospital and nancial reimbursements for services not
covered by Medicare.
c: Government nancial assistance for young people aged 24 or younger who are studying, doing an apprenticeship, looking for work or who have a health
condition.
d: A government-issued card that enables access to a range of medical services and prescriptions at a lower cost and free care as a public patient in a public
hospital. Children are included on their family’s card; young people are eligible to get their own card from 15 years.
4 Australian and New Zealand Journal of Public Health 2019 Online
© 2019 The Authors
spent time online every day, and 51.6%
(728/1,410) were online for 2–6 hours/day.
Only 1.7% (24/1,410) did not spend time
online. The times of day participants were
most commonly online were evening (6–
11pm, 60.9%, 856/1,405) and mid-afternoon
(3–6pm, 21.3%, 299/1,405).
Barriers to accessing health services
More than four-fths (80.9%, 1,146/1,416) of
the sample identied at least one barrier to
accessing health services, with a median of
two barriers (IQR 1–4). Frequencies of barriers
are listed in Table 2. The most commonly
cited barrier was ‘cost’ (45.8%, 649/1,416) and
the least common was ‘language or cultural
reasons’ (Table 2). When all 11 barriers were
included in the PCA, a stable factor structure
was not found. However, with the exclusion
of ‘language or cultural reasons’ (barrier
recognised by 5.9%, 83/1,416), three stable
clusters of barriers emerged. Those who cited
‘language or cultural reasons’ were more likely
to be older respondents (young adults 7.3%,
52/713 vs. adolescents 4.4%, 31/703, p<0.05),
and those identifying as refugees (16.0%,
12/75 vs. 5.3%, 70/1,333, p=0.001).
The three clusters of barriers included:
structural (61.3%), attitudinal (44.1%), and
barriers relating to emerging autonomy
(33.8%), see Table 2. Structural barriers
included cost, opening hours and diculty
getting to the service. Attitudinal barriers
included feeling embarrassed, feeling judged,
the gender of the doctor/health professional
and worry about condentiality. Barriers
relating to emerging autonomy included
needing to ask parents/carers to take them,
not having own Medicare card and not
knowing which service/s to go to.
Predictors of barriers to access
healthcare
Predictors of barriers to access healthcare
are described in Table 3. There were no
substantial issues with multicollinearity
between potential demographic and other
predictors of barriers including psychological
distress.
Predictors of structural barriers included
older age (74.1%, 528/713 of young adults
vs. 48.4%, 340/703 of adolescents, p<0.001),
female gender (67.3%, 651/96 vs. 46.6%,
189/40 of males, p<0.001) and residing
in a more socioeconomically advantaged
area (higher SEIFA IRSAD, p<0.05). Those
with higher psychological distress (66.0%,
481/729 vs. 56.9% 382/671], p<0.05) and an
increasing number of chronic conditions or
disability (p<0.01) were more likely to report
structural barriers, as were participants who
had seen more health professionals during
the previous six months (p=0.001) and those
who used the internet to decide which health
service to go to (71.2%, 510/716 vs. 51.1%,
356/696, p<0.01). The model accounted for
19.2% of variance in the number of structural
barriers recognised by participants (log
likelihood Χ2=268.06, df=15, p<0.001).
Attitudinal barriers were more likely to
be reported by female and other gender
respondents (49.6%, 480/968 and 59.5%,
25/42 respectively), compared with males
(29.3%, 119/406, p<0.001 and p<0.01), by
those with private health insurance (50.3%,
319/634 vs. 39.2%, 305/779, p<0.05), those
with more chronic conditions or disability
(p<0.01) and with higher psychological
distress (55.6%, 405/729 vs. 32.2%, 216/671,
p<0.001). Young adults (43.9%, 313/713 vs.
adolescents 44.2%, 311/703, p<0.05) and
those with a Health Care Card were less likely
to report attitudinal barriers (40.2%, 157/391,
vs. 45.7%, 467/1,022, p<0.01). Those who used
the internet to decide which health service
to go to were more likely to report attitudinal
barriers (48.2%, 345/716), compared to
those who did not use the internet for this
purpose (40.1%, 279/696, p<0.05). The model
accounted for 13.4% of variance in the
number of attitudinal barriers recognised by
participants (log likelihood Χ2=179.11, df=15,
p<0.001).
Barriers relating to emerging autonomy
were less likely to be reported with older age
(young adults 22.3%, 159/713 vs. adolescents
45.5%, 320/703, p<0.001), by those with a
Health Care Card (23.3%, 91/391 vs. 38.0%,
388/1,022 of those without, p<0.001) and
those belonging to two or more marginalised
groups (30.3%, 296/897 vs. 35.3%, 183/519
those belonging to none, p<0.05). Those
with higher psychological distress were more
likely to report barriers relating to emerging
autonomy (42.4%, 309/729 vs. 24.9%,
167/671, p<0.001). The model accounted
for 16.0% of variance in the number of
barriers relating to emerging autonomy (log
likelihood Χ2=196.72, df=15, p<0.001).
Discussion
This is the rst Australian study to quantify
barriers to healthcare among a large
sample of young people, and to identify
their association with a range of socio-
demographic and socio-cultural factors,
health status and technology use. To our
knowledge, this is also the rst study
internationally to include substantial
numbers of young people belonging to
one or more marginalised groups, which
allowed for measuring the eect of increasing
marginalisation on access.
We found lower self-reported good health
and higher psychological distress in our
sample. Just 80.8% of study participants rated
their health as good to excellent compared
to 91.1% in a national representative
sample of Australian young people (15–24
years) in 2014–2015.13 Our sample also had
signicantly higher levels of psychological
distress compared to this population:
52.1% had high or very high K10 scores,
compared to 11.7% of young Australians.13
The comparatively poor health status of our
sample might be due to oversampling of
marginalised groups, given the proportion
with high or very high mental distress and
the presence of a chronic health condition
Table 2: Final Principal Components Analysis on healthcare access barriers.
Barrier N=1,416
[n %]
Eigenvalue % of
variance
Component
1
Component
2
Component
3
Attitudinal 624 (44.1) 2.45 24.54
I would feel embarrassed 393 (27.8) 0.77 -0.05 0.19
I would feel judged 287 (20.3) 0.78 -0.04 0.10
The gender of the doctor/health professional 267 (18.9) 0.59 0.21 -0.001
I worry about condentiality 217 (15.3) 0.58 0.06 0.17
Structural 868 (61.3) 1.47 14.72
Cost 649 (45.8) 0.01 0.64 0.21
Opening hours mean I need time o study or work 449 (31.7) 0.04 0.77 -0.16
Diculty getting there 336 (23.7) 0.08 0.67 0.13
Barriers relating to emerging autonomy 479 (33.8) 1.05 10.52
I would have to ask my parents/carers to take me 313 (22.1) 0.29 -0.04 0.52
I don’t have my own Medicare card 173 (12.2) -0.03 0.05 0.82
I don’t know which service/s to go to 165 (11.7) 0.20 0.20 0.55
Robards et al.
2019 Online Australian and New Zealand Journal of Public Health 5
© 2019 The Authors
was signicantly higher among those who
belonged to at least one marginalised group
compared with those who did not belong to
any. Participants with more chronic health
conditions and/or disability or with greater
psychological distress were more likely to
report all types of barriers, potentially due to
increased awareness of shortcomings of the
health services with increased health service
use. A New Zealand study also found forgone
care was greater for adolescents with higher
healthcare needs.16
Use of technology to decide which health
service to attend was associated with
reporting attitudinal and structural access
barriers. This could indicate that a reliance
on online information for health system
navigation may not be eective and
additional resources for online tools may be
needed to support technology-facilitated
healthcare decision making and navigation.
Alternatively, technology use may be both a
way to overcome barriers and an indicator of
higher health need and more help-seeking.
Two Australian studies have found sexuality
and gender diverse young people use
technology to identify healthcare providers
and services who are welcoming.17,18
Participants who belonged to one or more
marginalised groups were less likely to have
internet access, yet access rates were still high
indicating technology solutions are worth
considering for this group. However, there
is a need for health literacy to enable young
people to identify quality health advice,19
particularly as health literacy has been viewed
as the greatest barrier to seeking help for
mental health issues by parents and young
people.20
Cost was the most frequently reported
barrier, which is a concern given Australias
universal health insurance scheme. Although
approximately 80% of Australian general
practice consultations are bulk billed21 (where
a doctor accepts the Government payment
as full payment, so patients do not have to
pay the gap), this appears to be insucient to
meet need. Out-of-pocket costs of healthcare
in Australia have increased signicantly over
the past decade and disproportionately
aect those who have a very low income.21
These include gap payments for specialist
and allied health consultations, diagnostic
tests and medications, while indirect costs
include forgoing work and costs of travel.
Cost was more commonly cited by young
adults, suggesting increasing autonomy
brings more nancial stress. The cost barrier
was also more prevalent among those living
in a higher socioeconomic area. While this
seems paradoxical, it could signify healthcare
in wealthier areas is more expensive and
participants may have lower access to
concessions and bulk-billing services. Further,
young people from higher socioeconomic
areas may be more likely to be in full-time
education, restricting their ability to work.
In our related Access 3 study of health
professionals, we found they commonly
overlooked cost as a barrier.22 Cost has been
identied as the primary barrier by in-school
New Zealand adolescents16 and was a
signicant access barrier for marginalised
young people, including sexuality diverse
young people in Canada23 and young people
with substance use issues in the US.24
Condentiality, previously considered
the most important barrier,2 was only
cited by 15.3% of the sample. Possible
explanations for this apparent decrease
include increased adherence over time by
health professionals to clinical guidelines to
explain condentiality,25 and young people
understanding and expecting condentiality.
It may also reect that social media has
changed the way today’s young people
understand condentiality.
Principal component analysis armed
quantitatively three clusters of barriers that
have previously been described qualitatively.
Structural barriers were the most common
barrier, followed by attitudinal and then
barriers relating to emerging autonomy.
Most studies have identied structural (e.g.
service availability, opening hours, cost)
and attitudinal (e.g. fear, embarrassment,
shame, self-consciousness) barriers for
young people26 and several have found
that their prevalence varies for dierent
marginalised groups. Structural barriers
Table 3: Predictors of barriers to accessing healthcare.
Attitudinal
OR (95% CI)
Structural
OR (95% CI)
Emerging autonomy
OR (95% CI)
Age (years) 0.96 (0.92-0.99)* 1.16 (1.12-1.20)* 0.82 (0.79-0.86)*
Gender
Male Ref Ref Ref
Female 1.86 (1.43-2.41)* 1.58 (1.24-2.01)* 1.20 (0.91-1.59)
Other 2.36 (1.26-4.39)* 1.43 (0.77-2.64) 1.60 (0.80-3.20)
SEIFA IRSAD decile 1.02 (0.98-1.06) 1.05 (1.01-1.09)* 1.01 (0.96-1.06)
Health Care Card
No, not sure Ref Ref Ref
Yes, has a health care card 0.69 (0.53-0.89)* 0.81 (0.64-1.03) 0.51 (0.38-0.69)*
Private Insurance
No, not sure Ref Ref Ref
Yes, has private health insurance 1.31 (1.04-1.64)* 1.10 (0.88-1.36) 1.14 (0.88-1.46)
Marginalisation
None Ref Ref Ref
One marginalised group 1.22 (0.96-1.56) 0.93 (0.74-1.18) 0.89 (0.68-1.17)
Multiple marginalised groups (2+) 0.90 (0.65-1.25) 0.77 (0.57-1.05) 0.70 (0.49-0.995)*
Number of chronic conditions 1.21 (1.06-1.38)* 1.24 (1.09-1.40)* 1.16 (0.998-1.34)
Psychological distress (K10)
Low Ref Ref Ref
Moderate 1.13 (0.82-1.57) 1.24 (0.92-1.66) 1.57 (1.09-2.27)*
High 1.99 (1.44-2.74)* 1.41 (1.04-1.90)* 2.58 (1.81-3.70)*
Very high 2.55 (1.84-3.55)* 1.48 (1.09-2.02)* 2.72 (1.88-3.94)*
Health professional types (other than GP)
seen in previous six months
1.03 (0.96-1.10) 1.10 (1.03-1.18)* 0.98 (0.91-1.06)
Use the internet to decide which health
service to go to
Not at all Ref Ref Ref
Sometimes 1.30 (1.02-1.64)* 1.47 (1.17-1.84)* 1.16 (0.89-1.50)
Frequently 1.62 (1.18-2.21)* 2.31 (1.71-3.11)* 0.98 (0.68-1.41)
179.11, df=15,
p<0.001
13.4%
268.06, df=15,
p<0.001
19.2%
196.72, df=15,
p<0.001
16.0%
Note:
* Statistically signicant. An Odd Ratio (OR) over 1 indicates a positive association (i.e. increased odds of reporting an increasing number of barriers),
while an OR under 1 indicates a negative association.
Young people’s healthcare access in the digital age
6 Australian and New Zealand Journal of Public Health 2019 Online
© 2019 The Authors
have been reported more frequently than
personal barriers for homeless young people6;
whereas, attitudinal barriers were more
important for rural young people.7,27 All three
groups of barriers – structural, attitudinal and
barriers relating to emerging autonomy –
were described in earlier Australian research
among young people.11 Thus, while all
clusters of barriers are important among
young people, it is useful to recognise
these might be inuenced by psychosocial
transitions that occur during adolescence.
Young people across the age spectrum
experienced dierent types of barriers.
Structural barriers were more commonly
identied by young adults, while attitudinal
barriers and those relating to emerging
autonomy were associated with being
younger. We are not aware of any studies
that have quantied the eect of age on
access barriers, perhaps because previous
studies considered narrower age ranges.2,16,28
Barriers relating to emerging autonomy and
attitudinal barriers were negatively associated
with increasing age, presumably because as
young people mature they are less aected
by attitudinal and knowledge-based barriers.
In contrast, structural barriers were positively
associated with age. This may be due to
adolescents gaining more independence
from their parents but being challenged by
taking increasing responsibility for healthcare
access.
Young women had higher odds of citing an
attitudinal or structural barrier, consistent
with a New Zealand study where barriers
were reported at higher levels by females
aged 13–17.16 Since young women in our
sample also reported more chronic illness
and psychological distress, their presumed
increased need to access healthcare could
lead to identication of barriers. Females
have also been found to be more likely to
seek help and perceive help seeking as
benecial compared to males,29 but in doing
so they may have similarly identied a range
of attitudinal or structural barriers. Stigma,
particularly in relation to sexuality and
pregnancy, aects young women accessing
healthcare.30 Other gender participants
were more likely to cite attitudinal barriers
and, consistent with other studies among
transgender young people,18 they also had
higher levels of psychological distress. We
found participants who had seen a greater
number of health professional types (other
than GPs), during the previous six months
were more likely to report structural barriers.
Similarly, it may be that these young people
had more chronic illness and mental health
concerns, resulting in a need to access more
healthcare, leading to identication of more
barriers.
Surprisingly, marginalisation was
not a predictor of any barrier cluster.
The paradoxical eect of increasing
marginalisation being inversely associated
with barriers relating to emerging autonomy
was unexpected. This may be due to bias
in our sample given younger participants
were more likely to belong to multiple
marginalised groups. Our ndings might
also suggest existing structural supports
for marginalised people (including
additional nancial subsidies, specialised
multidisciplinary and/or integrated services)
are having some impact. We found that
having a Health Care Card reduced the
odds for reporting attitudinal barriers and
barriers relating to emerging autonomy. US
studies have also found access to healthcare
insurance is benecial for healthcare access
for homeless young people31 and those living
in low socioeconomic areas.32
There are recognised limitations to a study
that it is both cross-sectional and based
on self-report. The associations we found
between a range of variables and barriers
do not necessarily imply causation. The
pilot testing of the questionnaire and use of
validated items for health status, combined
with the assistance of parents, carers, teachers
or youth workers for some participants
completing the survey, may have increased
validity.
Our study has policy and practice implications
relevant to all young people, but particularly
those who are marginalised and experiencing
poor health, higher psychological distress
and/or chronic physical and mental health
conditions.
Support is needed across the full 12 to 24
years age spectrum and responses may
need to be tailored for developmental stage.
Addressing health literacy through formal
school curricula to increase knowledge of
health services and the role of universal
insurance remains critical for adolescents
who may nevertheless rely on parents for
the logistics of access (e.g. transport). Cost as
a barrier to healthcare access needs greater
attention by governments. A wider range
of services could be covered by Medicare
and bulk billing for young people could
be increased. Locating health services in
schools could be one way of addressing this
barrier. Although attitudinal or structural
barriers were signicantly greater for young
women, the needs of young men’s access to
healthcare should not be overlooked.33
This study will be of interest to service
providers, especially as previous research
has demonstrated their perceptions dier
from young people’s descriptions of their
barriers.1,7 Varying groups of young people
experience barriers dierently and these have
been explored further in our longitudinal
qualitative study in the Access 3 project. While
‘language or cultural reasons’ was removed to
make the barrier clustering more robust, this
is likely to be an important barrier for refugee
young people.34
Implications for public health
There were three ndings in this study that
were counter to expectations. Structural
barriers aected those living in lower
socioeconomic areas less than those living in
higher socioeconomic areas, marginalisation
was not strongly associated with any barrier
cluster and use of technology to decide which
health service to go to was associated with
more barriers. The rst two of these ndings
suggest a good news story – that targeted
access and concession programs are working
for disadvantaged and marginalised young
people. The third nding implies a need to
improve not only e-health literacy but also
to better integrate technology with service
delivery.
Addressing barriers is important to ensure
equity of access and optimal health outcomes
for young people. Accessible primary
healthcare is essential for early diagnosis and
treatment together with prevention advice
in order to reduce longer-term healthcare
costs resulting from delayed access to care.
This means barriers need to be addressed
and young people involved in the solutions at
both policy and practice levels.
Acknowledgements
We acknowledge and thank NSW Health for
funding the study, Youth Consultants, Urban
and Rural Reference Groups, Jessica Harper
and Eun-Ae Cho for research support, The
University of Sydney, Department of General
Practice Westmead, partners who assisted
with paper survey recruitment Isha Deep,
Orange Aboriginal Medical Service and Jessie
Hunt, Yfoundations.
Robards et al.
2019 Online Australian and New Zealand Journal of Public Health 7
© 2019 The Authors
Funding
The Access 3 study was funded by the NSW
Ministry of Health.
References
1. Bernard D, Quine S, Kang M, Alperstein G, Usherwood
T, Bennett D, et al. Access to primary health care
for Australian adolescents: How congruent are the
perspectives of health service providers and young
people, and does it matter? Aust N Z J Public Health.
2004;28(5):487-92.
2. Samargia LA, Saewyc EM, Elliott BA. Foregone mental
health care and self-reported access barriers among
adolescents. J Sch Nurs. 2006;22(1):17-24.
3. Robards F, Kang M, Sanci L, Usherwood T. How
marginalised young people access, engage with
and navigate health care systems in the digital age:
Systematic review. J Adolesc Health. 2018;62:365–81.
4. Kauer SD, Mangan C, Sanci L. Do online mental health
services improve help-seeking for young people? A
systematic review. J Med Internet Res. 2014;16(3):e66.
5. Patton GC, Sawyer SM, Santelli JS, Ross DA, A R, Allen
NB, et al. Our future: A Lancet commission on adolescent
health and wellbeing. Lancet. 2016;387(10036):2423-
78.
6. Chelvakumar G, Ford N, Kapa HM, Lange HLH, McRee
A-L, Bonny AE. Healthcare barriers and utilization
among adolescents and young adults accessing
services for homeless and runaway youth. J Community
Health. 2016;42(03):437–43.
7. Johnston K, Harvey C, Matich P, Page P, Jukka C, Hollins
J, et al. Increasing access to sexual health care for rural
and regional young people: Similarities and dierences
in the views of young people and service providers. Aust
J Rural Health. 2015;23(5):257-64.
8. Kang M, Robards F, Sanci L, Steinbeck K, Jan S, Hawke
C, et al. Access 3 project protocol: Young people
and health system navigation in the digital age:
A multifaceted, mixed methods study. BMJ Open.
2017;7(8): e017047.
9. Survey Monkey. Limesurvey: The Online Survey Tool. Palo
Alto (CA): Survey Monkey Inc; .2019.
10. Ambresin A-E, Bennett K, Patton GC, Sanci LA, Sawyer
SM. Assessment of youth-friendly health care: A
systematic review of indicators drawn from young
people’s perspectives. J Adolesc Health. 2013;52(6):670.
11. Booth ML, Bernard D, Quine S, Kang MS, Usherwood
T, Alperstein G, et al. Access to health care among
Australian adolescents young people’s perspectives
and their sociodemographic distribution. J Adolesc
Health. 2004;34(1):97-103.
12. MacKenzie D, Chamberlain C. Youth homelessness
2006. Youth Stud Aust. 2008;27(1):17-25.
13. Australian Bureau of Statistics. National Health Survey:
First Results, 2014–15 — Australia. Canberra (AUST): ABS;
2015.
14. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK,
Normand SLT, et al. Short screening scales to monitor
population prevalences and trends in non-specic
psychological distress. Psychol Med. 2002;32(6):959-76.
15. SPSS: Statistical Package for the Social Sciences. Version
24.0. Armonk (NY): IBM Corp; 2016.
16. Denny S, Farrant B, Cosgri J, Harte M, Cameron T,
Johnson R, et al. Forgone health care among secondary
school students in New Zealand. J Prim Health Care.
2013;5(1):11.
17. Byron P, Rasmussen S, Wright Toussaint D, Lobo R,
Robinson K, Paradise B. ‘You Learn from Each Other’:
LGBTIQ Young People’s Mental Health Help-seeking and
the RAD Australia Online Directory. Sydney (AUST):
Western Sydney University Young and Well Cooperative
Research Centre; 2016.
18. Robinson KH, Bansel P, Denson N, Ovenden G, Davies
C. Growing Up Queer: Issues Facing Young Australians
Who are Gender Variant and Sexually Diverse. Melbourne
(AUST): Young and Well Cooperative Research Centre;
2014.
19. Freeman JL, Caldwell PHY, Bennett PA, Scott KM.
How adolescents search for and Appraise online
health information: A systematic review. J Pediatrics.
2018;195:244-55.e1.
20. Lawrence D, Johnson S, Hafekost J, Boterhoven De Haan
K, Sawyer M, Ainley J, et al. The Mental Health of Children
and Adolescents. Report on the Second Australian Child
and Adolescent Survey of Mental Health and Wellbeing.
Canberra (AUST): Australian Department of Health;
2015.
21. Laba T-L, Usherwood T, Leeder S, Yusuf F, Gillespie J,
Perkovic V, et al. Co-payments for health care: What is
their real cost? Aust Health Rev. 2015;39(1):33.
22. Robards F, Kang M, Tolley K, Hawke C, Sanci L,
Usherwood T. Marginalised young people’s healthcare
journeys: Professionals’ perspectives. Health Educ J.
2018;77(6):692-704.
23. Hadland SE, Kerr T, Li K, Montaner JS, Wood E, Hadland
SE, et al. Access to drug and alcohol treatment among a
cohort of street-involved youth. Drug Alcohol Depend.
2009;101(1/2):1-7.
24. Williams KA, Chapman MV. Comparing health and
mental health needs, service use, and barriers to
services among sexual minority youths and their peers.
Health Soc Work. 2011;36(3):197-206.
25. beyondblue. Clinical Practice Guidelines: Depression
in Adolescents and Young Adults. Melbourne (AUST):
beyondblue; 2010.
26. Hudson AL, Nyamathi A, Greengold B, Slagle A, Koniak-
Grin D, Khalilifard F, et al. Health-seeking challenges
among homeless youth. Nurs Res. 2010;59(3):212-18.
27. Hernan A, Philpot B, Edmonds A, Reddy P. Healthy minds
for country youth: Help-seeking for depression among
rural adolescents. Aust J Rural Health. 2010;18(3):118-24.
28. Perry L, Steinbeck KS, Dunbabin JS, Lowe JM. Lost in
transition? Access to and uptake of adult health services
and outcomes for young people with type 1 diabetes in
regional New South Wales. Med J Aust; 2010;193(8):444.
29. Rughani J, Deane FP, Wilson CJ. Rural adolescents’
help-seeking intentions for emotional problems: The
inuence of perceived benets and stoicism. Aust J
Rural Health. 2011;19(2):64-9.
30. Whitley R, Kirmayer LJ. Perceived stigmatisation of
young mothers: An exploratory study of psychological
and social experience. Soc Sci Med. 2008;66(2):339-48.
31. Winetrobe H, Rice E, Rhoades H, Milburn N. Health
insurance coverage and healthcare utilization among
homeless young adults in Venice, CA. J Public Health
(Oxf). 2016;38(1):147-55.
32. Klein JD, Shone LP, Szilagyi PG, Bajorska A, Wilson K,
Dick AW. Impact of the State Children’s Health Insurance
Program on adolescents in New York. Pediatrics.
2007;119(4):e885-92.
33. Pirkis J, Currier D, Carlin J, Degenhardt L, Dharmage
SC, Giles-Corti B, et al. Cohort prole: Ten to Men ( the
Australian Longitudinal Study on Male Health). Int J
Epidemiol. 2017;46(3):793.
34. de Anstiss H, Ziaian T. Mental health help-seeking and
refugee adolescents: Qualitative ndings from a mixed-
methods investigation. Aust Psychol. 2010;45(1):29-37.
Supporting Information
Additional supporting information may be
found in the online version of this article:
Supplementary File 1: NSW Youth Health
Access Survey.
Young people’s healthcare access in the digital age
... State health policy is developed by the NSW Department of Health, while state government health services are administered by smaller units, the local health districts (LHDs) and speciality health networks (SHNs) [19]. Approximately one third of young Australians (12 to 25 years) make up 16.5% of the overall NSW population [16]. Prominent health issues for young people in NSW include mental health, suicide, chronic conditions, disability, obesity, accident and injury, sexual and reproductive health, and risk behaviours including substance misuse [16]. ...
... Approximately one third of young Australians (12 to 25 years) make up 16.5% of the overall NSW population [16]. Prominent health issues for young people in NSW include mental health, suicide, chronic conditions, disability, obesity, accident and injury, sexual and reproductive health, and risk behaviours including substance misuse [16]. Socioecological factors intersect to play a complex role in determining health outcomes for young people in NSW [16,17]. ...
... Prominent health issues for young people in NSW include mental health, suicide, chronic conditions, disability, obesity, accident and injury, sexual and reproductive health, and risk behaviours including substance misuse [16]. Socioecological factors intersect to play a complex role in determining health outcomes for young people in NSW [16,17]. Both structural and cost factors impact access to care, particularly for marginalized youth [16]. ...
Article
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Background Effective integration of evidence and youth perspectives into policy is crucial for supporting the future health and well-being of young people. The aim of this project was to translate evidence from the Access 3 project to support development of a new state policy on youth health and well-being within New South Wales (NSW), Australia. Ensuring the active contribution of young people within policy development was a key objective of the knowledge translation (KT) process. Methods The KT activity consisted of a 1-day facilitated forum with 64 purposively sampled stakeholders. Participants included eight young people, 14 policy-makers, 15 academics, 22 clinicians or managers from NSW health services, four general practitioners and one mental health service worker. Research to be translated came from the synthesized findings of the NSW Access 3 project. The design of the forum included stakeholder presentations and group workshops, guided by the 2003 Lavis et al. KT framework that was improved by the Grimshaw et al. KT framework in 2012. Members of the Access 3 research team took on the role of knowledge brokers throughout the KT process. Participant satisfaction with the workshop was evaluated using a brief self-report survey. Policy uptake was determined through examination of the subsequent NSW Youth Health Framework 2017–2024. Results A total of 25 policy recommendations were established through the workshop, and these were grouped into six themes that broadly aligned with the synthesized findings from the Access 3 project. The six policy themes were (1) technology solutions, (2) integrated care and investment to build capacity, (3) adolescent health checks, (4) workforce, (5) youth participation and (6) youth health indicators. Forum members were asked to vote on the importance of individual recommendations. These policy recommendations were subsequently presented to the NSW Ministry of Health, with some evidence of policy uptake identified. The majority of participants rated the forum positively. Conclusions The utilization of KT theories and active youth engagement led to the successful translation of research evidence and youth perspectives into NSW youth health policy. Future research should examine the implementation of policy arising from these KT efforts.
... To directly inform new policy in the state of New South Wales (NSW), Australia, this cross-sectional study, the NSW Youth Health Access survey [11], was part of a larger project ("Access 3") which was designed to explore barriers to access to healthcare, health system navigation, and the role of technology. The methods have been fully described in the study protocol [12], and a summary is provided below. ...
... The sociodemographic characteristics of sample have previously been published [11]. ...
... In a linked Access 3 study we found that increasing marginalisation was inversely associated with reporting of the number of healthcare access barriers [11]. This could be a good news story that highly marginalised young people are reaching the healthcare required. ...
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Background: The aim of this study was to measure young people's health status and explore associations between health status and belonging to one or more socio-culturally marginalised group. Methods: part of the Access 3 project, this cross-sectional survey of young people aged 12-24 years living in New South Wales, Australia, oversampled young people from one or more of the following groups: Aboriginal and or Torres Strait Islander; living in rural and remote areas; homeless; refugee; and/or, sexuality and/or gender diverse. This paper reports on findings pertaining to health status, presence of chronic health conditions, psychological distress, and wellbeing measures. Results: 1416 participants completed the survey; 897 (63.3%) belonged to at least one marginalised group; 574 (40.5%) to one, 281 (19.8%) to two and 42 (3.0%) to three or four groups. Belonging to more marginalised groups was significantly associated with having more chronic health conditions (p = 0.001), a greater likelihood of high psychological distress (p = 0.001) and of illness or injury related absence from school or work (p < 0.05). Conclusions: increasing marginalisation is associated with decreasing health status. Using an intersectional lens can to be a useful way to understand disadvantage for young people belonging to multiple marginalised groups.
... The Access 3 Project was comprised of four activities [23][24][25][26][27]. The rst three activities were 1) a crosssectional survey of young people residing in New South Wales [25], 2) a longitudinal qualitative study of a subsample of marginalised young people and their journeys through the health system over six to twelve months [26], and 3) interviews with health professionals [27]. ...
... The Access 3 Project was comprised of four activities [23][24][25][26][27]. The rst three activities were 1) a crosssectional survey of young people residing in New South Wales [25], 2) a longitudinal qualitative study of a subsample of marginalised young people and their journeys through the health system over six to twelve months [26], and 3) interviews with health professionals [27]. ...
Preprint
Full-text available
Background Effective integration of research evidence and youth perspectives into policy is crucial for supporting the future health and wellbeing of young people. The aim of this project was to translate findings from the Access 3 research studies to support development of a new state policy on youth health and wellbeing within New South Wales, Australia. Ensuring the active contribution of young people within policy development was a key objective of the knowledge translation process. Methods The knowledge translation activity consisted of a one-day facilitated workshop with 64 purposively sampled stakeholders. Participants included eight young people, fourteen policymakers, fifteen academics, twenty-two clinicians or managers from New South Wales (NSW) health services, four general practitioners and one mental health service worker. The design of the workshop was guided by the knowledge translation frameworks of Lavis et al [1] and Grimshaw et al [2]. Research findings to be translated came from the NSW Access 3 studies. Participant satisfaction with the workshop was evaluated using a brief self-report survey. Policy uptake was examined through exploratory document analysis of the subsequent NSW Youth Health Framework 2017-2024. Results A total of twenty-five policy recommendations were established through the workshop and these were grouped into six themes. The six policy themes were: 1) Technology solutions, 2) Integrated care and investment to build capacity, 3) Adolescent health checks, 4) Workforce, 5) Youth participation, and 6) Youth health indicators. Forum members were asked to vote on the importance of individual recommendations. These policy recommendations were subsequently presented to the NSW Ministry of Health with some evidence of policy uptake identified. The majority of participants rated the forum positively. Conclusions The utilisation of knowledge translation theories and active youth engagement led to the successful transfer of research evidence and youth perspectives into NSW youth health policy. Future research should examine the implementation of policy arising from these knowledge translation efforts.
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Background The integration of digital technology into everyday lives of young people has become widespread. It is not known whether and how technology influences barriers and facilitators to healthcare, and whether and how young people navigate between face-to-face and virtual healthcare. To provide new knowledge essential to policy and practice, we designed a study that would explore health system access and navigation in the digital age. The study objectives are to: (1) describe experiences of young people accessing and navigating the health system in New South Wales (NSW), Australia; (2) identify barriers and facilitators to healthcare for young people and how these vary between groups; (3) describe health system inefficiencies, particularly for young people who are marginalised; (4) provide policy-relevant knowledge translation of the research data. Methods and analysis This mixed methods study has four parts, including: (1) a cross-sectional survey of young people (12–24 years) residing in NSW, Australia; (2) a longitudinal, qualitative study of a subsample of marginalised young people (defined as young people who: identify as Aboriginal and/or Torres Strait Islander; are experiencing homelessness; identify as sexuality and/or gender diverse; are of refugee or vulnerable migrant background; and/or live in rural or remote NSW); (3) interviews with professionals; (4) a knowledge translation forum. Ethics and dissemination Ethics approvals were sought and granted. Data collection commenced in March 2016 and will continue until June 2017. This study will gather practice and policy-relevant intelligence about contemporary experiences of young people and health services, with a unique focus on five different groups of marginalised young people, documenting their experiences over time. Access 3 will explore navigation around all levels of the health system, determine whether digital technology is integrated into this, and if so how, and will translate findings into policy-relevant recommendations.
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Homeless and runaway youth are at disproportionate risk for adverse health outcomes. Many barriers to accessing healthcare have been documented; however, the relative impact of discrete barriers on homeless youth healthcare utilization behavior is not firmly established. We administered a survey examining reported barriers and healthcare utilization among adolescents and young adults accessing services at three community centers for homeless and runaway youth. Of 180 respondents, 57 % were male, 80 % non-White, and 21 % identified as a sexual minority. Stepwise logistic regression models, controlling for age and study site, explored associations between barriers and 3 healthcare utilization outcomes (doctor visit in past 12 months; regular care provider; frequent emergency department (ED) visits). The most commonly reported barriers were "don't have a ride" (27.2 %), "no insurance" (23.3 %), and "costs too much" (22.8 %). All fear-based barriers (e.g., "I don't trust the doctors") were reported by <5 % of surveyed youth. Significant predictors of having seen a doctor in the past 12 months included sexual minority status (OR 2.8, p = 0.04) and possession of health insurance (OR 4.9, p < 0.001). Female sex (OR 5.2, p < 0.001) and reported external barriers other than health insurance (OR 0.2, p < 0.001) were associated with having a regular care provider. Fear-based concerns were associated (OR 3.8, p = 0.02) with frequent ED visits, as was being insured (OR 2.2, p = 0.03). These results underscore the need to clearly define healthcare outcomes when investigating barriers to care among homeless and runaway youth as the impact of discrete barriers varies depending on outcome of focus.
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The second Australian Child and Adolescent Survey of Mental Health and Wellbeing (Young Minds Matter) was designed to provide current information about the mental health and wellbeing of children and adolescents in Australia and the extent to which they use health and education services to obtain help with problems. Using area-based random sampling the survey collected interview data from 6,310 parents and carers or 55% of eligible households responded and 2,967 or 89% young people aged 11-17 years in those households for whom their parents or carers had given permission also completed a questionnaire. Analyses showed the sample to be representative of Australian children and adolescents aged 4-17 years on the basis of the age and sex of the child, family structure, parental education, income and employment, housing tenure and country of birth of both children and adolescents and their parents and carers. The main aims of the survey were to determine: 1. How many children and adolescents have which mental health problems and disorders. 2. The nature of these mental health problems and disorders. 3. The impact of these problems and disorders. 4. How many children and adolescents have used services for mental health problems and disorders. 5. The role of the education sector in providing services for children and adolescents with mental health problems and disorders. Extensive estimates of prevalence, severity, service use and burden are reported along with detailed associations with demographic and other risk and protective factors.
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Purpose: This systematic review examines how marginalized young people access and engage with health services and navigate health-care systems in high-income countries. Methods: Medline, CINAHL, PsychInfo, The University of Sydney Library database, and Google Scholar were searched to identify qualitative and quantitative original research, published from 2006 to 2017, that focused on selected definitions of marginalized young people (12 to 24 years), their parents/carers, and/or health professionals working with these populations. A thematic synthesis was undertaken identifying themes across and between groups on barriers and/or facilitators to access, engagement, and/or navigation of health-care systems. Results: Of 1,796 articles identified, 68 studies in the final selection focused on marginalized young people who were homeless (n = 20), living in rural areas (n = 14), of refugee background (n = 11), gender and/or sexuality diverse (n = 11), indigenous (n = 4), low income (n = 4), young offenders (n = 2), or living with a disability (n = 2). Studies were from the United States, Australia, Canada, United Kingdom, New Zealand, and Portugal, including 44 qualitative, 16 quantitative, and 8 mixed-method study types. Sample sizes ranged from 3 to 1,388. Eight themes were identified relating to ability to recognize and understand health issues; service knowledge and attitudes toward help seeking; structural barriers; professionals' knowledge, skills, attitudes; service environments and structures; ability to navigate the health system; youth participation; and technology opportunities. Conclusions: Marginalized young people experience barriers in addition to those common to all young people. Future studies should consider the role of technology in access, engagement, and health system navigation, and the impact of intersectionality between marginalized groups.
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Objective: To conduct a systematic review of the evidence concerning whether and how adolescents search for online health information and the extent to which they appraise the credibility of information they retrieve. Study design: A systematic search of online databases (MEDLINE, EMBASE, PsycINFO, ERIC) was performed. Reference lists of included papers were searched manually for additional articles. Included were studies on whether and how adolescents searched for and appraised online health information, where adolescent participants were aged 13-18 years. Thematic analysis was used to synthesize the findings. Results: Thirty-four studies met the inclusion criteria. In line with the research questions, 2 key concepts were identified within the papers: whether and how adolescents search for online health information, and the extent to which adolescents appraise online health information. Four themes were identified regarding whether and how adolescents search for online health information: use of search engines, difficulties in selecting appropriate search strings, barriers to searching, and absence of searching. Four themes emerged concerning the extent to which adolescents appraise the credibility of online health information: evaluation based on Web site name and reputation, evaluation based on first impression of Web site, evaluation of Web site content, and absence of a sophisticated appraisal strategy. Conclusions: Adolescents are aware of the varying quality of online health information. Strategies used by individuals for searching and appraising online health information differ in their sophistication. It is important to develop resources to enhance search and appraisal skills and to collaborate with adolescents to ensure that such resources are appropriate for them.
Article
Abstract Introduction: The pursuit of social justice includes a commitment to health equity for marginalised young people. Health professionals are central to marginalised young people’s engagement and access to health care and their navigation of health systems. They are also uniquely positioned to shed insight into structures and inefficiencies within the health system, including the role of technology, and to advocate for system change. Methods: This qualitative cross-sectional study employed in-depth semi-structured interviews with 22 health service managers and experienced clinicians to better understand service providers’ perspectives. The sampling frame comprised professionals from different sectors and levels of the health system. Analysis used Grounded Theory methods. Results: Three major themes were identified in the data: (1) intersectionalities – understanding the complexity of multiple disadvantage; (2) health system fragmentation – leading to inefficiencies, inertia and advocacy; and (3) services needing to be ‘turned on their head’ – rethinking service delivery and models of care. Conclusion: A better understanding of marginalised young people’s healthcare experiences, including the complexities of multiple disadvantage, and how this contributes to health inequalities could lead to more welcoming and respectful services. Services can reconceptualise their roles by reaching out to young people, both physically and online, to make the navigation of the health system easier. Marginalised young people’s healthcare journeys can be supported by advocates that help them navigate the health system. Keywords: Accessibility, adolescents, health services, healthcare providers, marginalised groups
Article
Unprecedented global forces are shaping the health and wellbeing of the largest generation of 10 to 24 year olds in human history. Population mobility, global communications, economic development, and the sustainability of ecosystems are setting the future course for this generation and, in turn, humankind. At the same time, we have come to new understandings of adolescence as a critical phase in life for achieving human potential. Adolescence is characterised by dynamic brain development in which the interaction with the social environment shapes the capabilities an individual takes forward into adult life.3 During adolescence, an individual acquires the physical, cognitive, emotional, social, and economic resources that are the foundation for later life health and wellbeing. These same resources define trajectories into the next generation. Investments in adolescent health and wellbeing bring benefits today, for decades to come, and for the next generation. Better childhood health and nutrition, extensions to education, delays in family formation, and new technologies offer the possibility of this being the healthiest generation of adolescents ever. But these are also the ages when new and different health problems related to the onset of sexual activity, emotional control, and behaviour typically emerge. Global trends include those promoting unhealthy lifestyles and commodities, the crisis of youth unemployment, less family stability, environmental degradation, armed conflict, and mass migration, all of which pose major threats to adolescent health and wellbeing. Adolescents and young adults have until recently been overlooked in global health and social policy, one reason why they have had fewer health gains with economic development than other age groups. The UN Secretary-General's Global Strategy for Women's, Children's and Adolescents' Health initiated, in September, 2015, presents an outstanding opportunity for investment in adolescent health and wellbeing. However, because of limits to resources and technical capacities at both the national and the global level, effective response has many challenges. The question of where to make the most effective investments is now pressing for the international development community. This Commission outlines the opportunities and challenges for investment at both country and global levels (panel 1).