Marginalised young people’s healthcare journeys: Professionals’ perspectives

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

Introduction

Equity of access to health care is a social justice issue. Some groups of young people experience multiple disadvantage on the basis of their sociocultural and demographic backgrounds (Patton et al., 2016). These processes of marginalisation can affect their healthcare access, contributing to poorer health outcomes.

To date, most research on marginalised young people’s healthcare access has considered single groups of young people (Robards et al., 2018). This has limited understanding of the experiences of young people belonging to multiple marginalised groups and the impact of intersectionality. Intersectionality refers to the compounding of disadvantage resulting from intersecting social inequalities (Guittar and Guittar, 2015). One Canadian study with health professionals focussing on sexuality and gender diverse young people identified intersectionality as an emerging theme (Travers et al., 2010), indicating that further research would be valuable.

Professionals within the health system play an important role in advocating for, designing and delivering services to address inequities of health care in marginalised populations. More senior professionals, such as health service managers and experienced clinicians, are uniquely positioned to shed insight into systemic and structural inefficiencies of the health system.

Studies among health professionals have found that young people in general are perceived as challenging. Clinicians often can lack skills and confidence to engage young people (Gearing et al., 2012) or require more time to manage some health and psychosocial issues (Dadich et al., 2014; Jarrett et al., 2011). Some clinicians do not always see it as their role to provide comprehensive and coordinated care for young people (Dadich et al., 2015). At the service level, there is a need to improve continuity of care, develop seamless systems and service partnerships, broaden roles and strengthen linkages between services and sectors (Allison et al., 2008; Fortenberry et al., 2012).

Research focussing on marginalised young people has identified additional issues for health professionals and systems. For example, clinicians who work with sexuality and/or gender diverse young people have expressed the need for training on how to discuss sexual orientation and gender issues, as well as more inclusive service policies and structures (Kitts, 2010; Knight et al., 2014; Pallotta-Chiarolli and Martin, 2009; Travers et al., 2010; Vance et al., 2015). A study of emergency department staff found that homeless young people were perceived as difficult to manage, while a lack of support staff and policies impeded streamlined service provision (Nicholas et al., 2016). Service providers’ perceptions of barriers for refugee young people’s access to mental health services include staff characteristics (cultural competence, style and approach, and appropriate use of interpreters) and service issues (lack of flexibility, lack of integrated care models and follow-up care) (Colucci et al., 2015).

Research to date tends to have focused on specific parts of the health system, rather than the system as a whole, and navigation between and around its different components. With the advent of the digital age, consideration of online health service delivery, as part of the health system and the role of technology in health system navigation, is necessary and particularly relevant for young people.

Technologies have the potential to enhance face-to-face mental health care for rural young people (Orlowski et al., 2016), provide a way for gender and sexuality diverse young people to assess the appropriateness of face-to-face services and make contact (Byron et al., 2016; Robinson et al., 2014), as well as provide online service options (Pallotta-Chiarolli and Martin, 2009). However, to date, studies have not explored professionals’ perspectives on the use of technology to help facilitate marginalised young people’s healthcare engagement, access and navigation (Robards et al., 2018).

This article reports on one component of a four-part study known as Access 3 in New South Wales (NSW), Australia’s most populous state. The Access 3 project has a deliberate focus on marginalised young people and policy translation, with an explicit intent to influence state government policy to address equity of access to health care. This particular study component explores professionals’ views of healthcare access, engagement and navigation for marginalised young people (12–24 years), including perspectives on the potential role of technology. The populations of interest were young people living in rural and remote NSW, homeless or at risk of homelessness, refugee or vulnerable migrant background, Indigenous and/or gender and/or sexuality diverse. These groups were selected because they represent substantial sub-populations of young people in NSW who are, or may be, marginalised by their sociodemographic or sociocultural characteristics. Understanding professionals’ perspectives of marginalised young people’s healthcare journeys provides an opportunity to advocate for better equity of access for all young people, including those who experience multiple disadvantage.

Methods

Access 3 explores the experiences of marginalised young people accessing and navigating the health system, including the barriers and facilitators they face, and aims to promote translation of its findings into policy. Details of the study design and methods are published elsewhere (Kang et al., 2017).

This article describes one part of Access 3 involving semi-structured interviews with 22 health professionals. We purposefully selected professionals with extensive private or public sector clinical experience of working with young people (including marginalised young people) or who occupied senior management roles within the public health system who might be expected to have knowledge about the health system and how it supports young people’s access to health care. We included participants from a range of service sectors (government and non-government) and levels of the health system (primary, secondary and tertiary).

The study was conducted between May 2016 and May 2017. Participants were contacted via email and provided written consent. Two of the authors (F.R. and M.K.) conducted all the interviews, in person or via telephone. Interviews took between 40 minutes and 1 hour.

The interviews focussed on access and navigation, barriers and system inefficiencies; perspectives on marginalised young people’s access compared to other young people; the nature and relevance of health information provided by the system to young people; suggestions for improvements within the health system; perspectives on the role of technology; and examples of programmes and initiatives that could improve access and navigation.

Interviews were recorded, transcribed verbatim, checked by interviewers and imported into NVivo Pro, version 11. Two authors (F.R. and M.K.) participated in the coding and analysis of transcripts. Coding and analysis of data followed the constant comparative methods of Grounded Theory (Corbin and Strauss, 2015). Codes were continuously revised, expanding to include new perspectives and collapsing together overlapping categories. Comparisons were made with data emerging from young people in other parts of the Access 3 project, leading to an understanding of potential incongruities between young people’s and professionals’ perspectives. Descriptive codes were then combined to develop analytical themes. This process of integration was achieved via researcher discussion and memo writing.

Ethical consent was obtained from The University of Sydney Human Research Ethics Committee and the NSW Aboriginal Health and Medical Research Council Ethics Committee.

Results

The 22 participants included 13 managers and nine clinicians – three hospital specialists working in emergency departments, four senior nurses and two general practitioners (GPs). Nine participants (41%) were women. Seven were from rural areas, seven from urban areas and a further eight were located in an urban area but worked for a state-wide service. Participants were deliberately selected from a range of healthcare settings to ensure coverage across the health system as described in Table 1. Six professionals declined the invitation to participate citing a lack of time, a perceived lack of expertise or change in professional role.

Table 1.

Healthcare settings represented in sample.

	n
Youth health service/youth health coordinator¹	5
State-wide service (sexual health, mental health, transition care,² justice health and refugee health)	5
Community-based service (Aboriginal Medical Service, community health and mental health)	3
Hospital	3
Emergency department (children’s and adult hospital)	2
Primary Health Network (PHN)³	2
General practice	1
Peak body⁴	1
Total	22

Themes

Clinicians were more likely to describe specific barriers to access and obstacles to smooth system navigation, while managers were more likely to describe the need for conceptual shifts on the part of clinicians, services and governments to improve access and navigation for young people. These slightly different perspectives nevertheless gave rise to common themes that included (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.

Intersectionalities: understanding the complexity of multiple disadvantage

Participants recognised that marginalised young people’s needs are complex but expressed difficulty in fully understanding their lived experience and the impact of multiple disadvantage. They recognised staff attitudes and health systems can be discriminatory and suggested that listening to diverse groups of young people is one of the ways to better understand their needs.

Understanding the complexity of compounding disadvantage leads to a better understanding of marginalised young people

Participants, particularly managers, expressed a degree of compassion towards the circumstances of marginalised young people while struggling to understand their specific healthcare needs. However, it was widely understood that marginalised young people face more access barriers. For example, they suggested that transport and cost barriers would be amplified for those without family support and resources. They perceived that marginalised young people often present to services only in crisis, and a common view was that services are not well equipped to meet these needs and that staff failed to understand and/or lacked the skills to work with complex, compounding disadvantage:

The more pressing or urgent or complex your health issues are, the less services there are with the skills to respond to it. (Youth health coordinator, rural area)

Participants noted that health systems often discriminate against marginalised young people and that this could discourage them from accessing services. In rural areas, participants spoke about stigma and community attitudes leading to a lack of understanding of the needs of sexuality and gender diverse young people:

Being homosexual, gay or lesbian … there’s that stigma there and … for young people who are transgender or intersex, I think that’s probably something that people are only just hearing about in a lot of communities. (Senior clinician, rural hospital)

Participants were more aware of compounding disadvantage for Indigenous young people and their families:

You get kind of a double whammy when you’re a young Aboriginal person in a remote town. (Manager, peak body)

Services need to listen to diverse groups of young people

Youth participation in service design and review was seen as a way to make services relevant to the needs of marginalised young people. While many professionals described youth participation as a solution, few spoke of examples in practice:

We generally don’t listen enough to young people. (Manager, peak body)

Participants said that they wanted the resources, tools and support to enable youth participation. There was interest in engaging young people in auditing health services using checklists to provide feedback to services.

Health system fragmentation leads to inefficiencies, inertia and advocacy

There was a shared view among participants that health systems do not currently meet the needs of marginalised young people. Participants expressed frustration about system inefficiencies associated with fragmentation and powerlessness to create change. This led some to feel compelled to advocate for system reform, while others believed that perceived powerlessness led to inertia.

Fragmentation disrupts healthcare journeys

Health system fragmentation was seen by participants as a significant cause of service gaps, disruption and inability to engage which affects participants as well as young people. Participants felt that fragmentation resulted from, but also reinforced, silo-ing, duplication and system inefficiencies. Many believed that ‘other’ health professionals protected their own service in isolation from the whole system:

[The health system is] not agile enough … someone … might present to one service for depression or one service for sexual health … [it would be good for services] to recognise there may be another issue and … allow access for that … there is a gap there. Either a gap that someone falls through, or they’re unable to get to the next place. (Manager, state-wide service)

Some participants suggested that fragmentation results from a disconnect between public and private systems. For example, although GPs are an entry point to the health system, the majority work within private general practices, tend to refer to private specialists and are often unaware of free public services available. Although Australia has a national health insurance scheme, private practitioners (GPs, medical specialists and allied health professionals working outside of public hospitals) can charge their own fees, which often leads to a gap payment and, therefore, presents a cost barrier:

General practice is the first port-of-call for many young people … services just aren’t integrated very well … It’s unusual for a private GP to refer you to a public clinic. They nearly always refer privately. Then you’ve just got the inevitability of the extra cost involved. (GP, urban youth health service)

Participants were also concerned about inconsistent availability of services and long waiting times in rural areas for some groups of young people and health conditions (e.g. mental health):

Certainly, for our more rural remote sorts of areas where we’ve got higher populations of Aboriginal people … services aren’t there. (Manager, community-based service, rural area)

Gatekeeping and bureaucracy add to health system complexity

There was recognition that system rules and processes can be difficult for young people to understand and tolerate, but participants believed that system process and redesign are needed:

The very, very bureaucratic way [services] do things … you have to go here first, … then go there for specialist tertiary care but you have to see your GP first to get that referral to go across there, and then you’re faced with another appointment … the system is very user-unfriendly … kids, particularly of refugee and migrant background, are often totally overwhelmed and quite defeated … by that system. (Senior clinician, state-wide service)

Costs of health care are only partially understood

Participants were unclear about the extent of direct and indirect costs. For example, several participants said they were not clear about the cost of accessing a GP although a GP referral was required to access their service:

I don’t know who bulk bills and who doesn’t but I think there’s an opportunity for getting access through bulk billing⁵ in most situations. (Medical specialist, rural hospital)

Participants said some free services, such as public dental care (a service for disadvantaged people and an alternative to private services), were being underutilised. However, there was the recognition that for disadvantaged young people, the ability to connect with a service requires confidence and empowerment, but could be made easier by services communicating more clearly and addressing access barriers such as cost. In one example, the issue of bulk-billing was raised:

It takes an assertive young person to actually negotiate with the general practitioner about bulk-billing, but also it takes a broad thinking general practitioner to actually to consider bulk-bill to the young person. (Youth health coordinator, urban area)

Inefficiencies lead to missed opportunities

Participants blamed system inefficiency for creating missed opportunities for both engagement and holistic and preventive health care:

You’re losing the opportunity you would have to otherwise engage people if you had a more engaging service. (GP, urban community-based service)

They expressed frustration about parts of the health system, such as emergency departments, where psychosocial assessments should be, but are not, routine practice:

We don’t do enough psychosocial assessment for early intervention … I think we waste some opportunities … those much more complex issues that we’d want to address if we could … (Manager, peak body)

System inertia prevents change

Participants were aware of current barriers and could visualise more innovative approaches, but they felt they could not do much to change the system, citing issues of personalities, space and needing to fit in with existing structures. They wanted to make the healthcare journeys for marginalised young people easier but felt powerless to create change. One example was the use of outreach that several participants identified as underutilised:

Services, even when they are aware, often feel their hands are tied in terms of ways they might respond – classic being outreach … very few … are actually either trying to … make that happen. (Manager, peak body)

Participants also wanted to use technology to engage young people but often feel blocked and powerless due to organisational barriers and technical restrictions:

We know that young people and information on the online space is where it’s at, is the future, and provides many opportunities that we don’t use yet … all that deliberate misinformation of people that have a health agenda outside of evidence will seize that space … We’ve got to get faster and get really smart. (Manager, peak body)

Powerlessness and frustration lead to advocacy

For some participants, the bureaucratic inertia of the health system led to passivity. For others, stagnation and frustration led them to feel they must advocate for system change, especially in achieving more equitable outcomes for marginalised young people:

It’s a situation which in some respects is grounded in a philosophy of whether health care is privilege or a right. I think that’s a real problem. (CEO, urban Primary Health Network [PHN])

Services need to be turned on their head: rethinking service delivery and models of care

Participants acknowledged that ‘traditional ways of doing business’ create difficulties for marginalised young people when it comes to accessing and navigating the health system. There was a view that services need to be ‘turned on their head’.

Health professionals, services and governments need to look more broadly

Participants openly discussed the need for governments at all levels to shift conceptually and invest differently. Furthermore, individual health professionals and services can step outside of the boundaries of their training and service definitions to look more broadly at prevention and at addressing social determinants of health such as stigma.

Some participants felt services and organisations (including government) need courage to take risks to change the way they conceptualise health care and service delivery. Without this, they believed that inertia will maintain a fragmented health system. Participants acknowledged that the traditional ways of doing business are no longer engaging young people:

So, there’s a pattern that we’ve maintained as a service provider, and I don’t necessarily blame our young people for not accessing it. How do we make ourselves accessible to them? (CEO Aboriginal Medical Service, rural area)

Services need to reach out to young people

Participants recognised that services and staff expect young people to come to them and to negotiate a complex set of process to engage with the health system. Connecting with young people by reaching out to them was a strong theme. Participants said assumptions need to be challenged and work practices disrupted to fit young people’s preferences:

Providing 9 to 5 Monday to Friday is just rubbish. They need to be mobile services that can go to skate parks or rave parties or wherever and they need to be open at times when kids start to think about health things … we don’t exactly encourage young people to come to us, do we? (CEO, rural PHN)

Services need to embrace technology

Participants expressed a need to embrace technology to provide better access to information. They believed that technology provides an opportunity to improve health literacy and make health system navigation easier for marginalised young people. Most participants spoke about the need for change and more appropriate information provision for young people:

I just don’t think that we make it easy for young people. I don’t think Health takes responsibility for the overall healthcare and what young people need to know … making information more accessible so that young people can actually help look after themselves and know where to go, it seems like nobody really thinks about it. (GP, urban youth health service)

Participants displayed an understanding that services need to promote themselves online, ideally via a brand that is trusted and recognisable. They suggested a central website or app to link health and service information to make it easier to navigate the health system. There was interest in the potential for technology to promote health literacy:

[Technology is] never going to take away the face-to-face, but it allows the young person some autonomy, it educates them about themselves, and it educates them where to get help. (Manager, state-wide service)

Participants (from both urban and rural areas) said that the health system should make efforts to reach out to young people in rural areas. The need to address the inequitable distribution of services across the state was highlighted by many. Telehealth (the use of video technology for remote clinical consultations) was an example of how young people from rural areas can be connected to professionals with specialist expertise. However, its use is contingent on professionals facilitating this process. Professionals are, therefore, essential to navigating these care pathways.

Services need to be better at engaging marginalised young people

Participants identified that health services need to be more welcoming for all young people, particularly marginalised young people. They articulated that to facilitate engagement issues such as staff attitudes, service environments and promotion of health services need to be addressed. Some participants recognised that services could be perceived as, or be, discriminatory:

You know, with Aboriginal people anyway there’s an element of shame around presenting, so if someone’s already short and rude with you and doesn’t … welcome you straight away, the likelihood of you wanting to hang around there is pretty slim. (Manager, state-wide service)

Taking time to connect with young people is an important part of engagement. Services that are welcoming, respectful and safe recognise diversity and address discriminatory systems (e.g. health records that include space for ‘other’ gender and preferred name).

We need to make navigation easier for young people moving through the health system

There was the suggestion that navigation for marginalised young people requires system and service advocacy, practical assistance and better access to information. Participants identified the need to better equip young people and improve systems and make care pathways clearer, providing flexible and relevant services.

Entry points into the health system, including hospital emergency departments, were identified as opportunities to engage young people in their healthcare journey even if these were not the most appropriate service to respond to their health issue:

They have an understanding that they can access the emergency department, and they’re not always aware of how to access other services, so the emergency department becomes their first port of call. (Emergency department medical specialist, children’s hospital)

Participants said improving young people’s access and navigation of the health system required building their confidence and health literacy skills. Participants identified that there needs to be more education of young people and information available to increase service and system awareness, including community-based alternatives to the hospital emergency department:

They need to know, ‘This is your local public hospital. This is where you go for those sort of things. There are GPs … If they’re closed, the emergency department’. (Emergency department manager, adult hospital)

Several participants identified that marginalised young people need support to deal with system demands and complexity. Navigation support could involve youth workers, a regular GP or other services helping young people navigate the system on their health journey. This included practical assistance such as help to negotiate cost or to source brokerage funds to pay for services:

It’s difficult for them to know … if they don’t have their own GP, how do they navigate other parts of the health service without having that person to lead them? (Senior clinician, youth health service)

Other participants suggested more assertive follow-up is part of supporting young people’s healthcare journey and letting the young person know they are important:

I think we have more of an assertive method of follow-up with phone calls, because I think it’s about relationship. Young people want to know that somebody cares for them and is interested in them … (Medical specialist, children’s hospital)

While most participants acknowledged that marginalised young people need support to navigate the health system, most professionals could not give an example of a programme that currently supports young people’s navigation. Only a few mentioned Trapeze, the state-wide service in NSW, Australia, which aims to support young people with a chronic illness to transition from paediatric to adult services. However, some Indigenous services have also focussed on providing broad navigation support for families.

Discussion

This study explored health service managers’ and experienced clinicians’ views on marginalised young people’s access to, engagement with and navigation of the health system. We found that (1) professionals need a better understanding of the complexity of compounding disadvantage; (2) health system fragmentation leads to inefficiencies, inertia and advocacy; and (3) services need to be turned on their head by rethinking service delivery and models of care.

Our findings broadly reflect calls for national health reform in Australia, particularly the need to address inequity and provide connected and comprehensive care (Bennett, 2013). Study findings also support the recommendations from research with service providers that marginalised young people would benefit from simpler pathways to care and for services to prioritise early intervention and work collaboratively (Platell et al., 2017).

This study builds on previous research by identifying the value of understanding the impact of multiple, intersecting disadvantage. Unlike previous research which has focussed on individual groups of young people, we looked at multiple and intersecting marginalised groups. We found an intuitive appreciation of, but lack of depth in understanding, intersectionality in the context of health inequities (López and Gadsden, 2016). A better understanding of the impact of multiple disadvantage on the way marginalised young people interact with services may promote healthcare access and reshape services towards providing respectful and welcoming services.

We also identified a need to reshape professional roles and service structures to make the health system easier for young people to access and navigate. This includes professionals having a better understanding of the direct and hidden costs of health care. The increase in out-of-pocket costs of health care in Australia over the past decade has been well documented and disproportionately affects those who are poor (Laba et al., 2015). Yet in this study of the range of barriers that marginalised young people face, cost was more likely to be overlooked. Health professionals can support marginalised young people’s access by promoting awareness of, and negotiating access to, free and low-cost services and low-income support systems (e.g. via charity brokerage funds). To achieve equity, there needs to be more consideration of the impact of cost on healthcare access.

To support system navigation, we found professionals were open to identifying pathways to care, for example, via service entry points such as emergency departments. In Australia, emergency department access is increasing, with young people aged 15–24 years being among the highest users in 2015–2016 (Australian Institute of Health and Welfare [AIHW], 2016), but it has been unclear whether professionals view this as appropriate. We found senior emergency department staff felt such usage was acceptable and could lead to support to find the right pathway through the health system. This finding differs from that in a Canadian study which found homeless young people were not always welcomed by emergency departments (Nicholas et al., 2016). However, professionals from other parts of the health system suggested that more regular use of holistic psychosocial assessments in the emergency department is needed.

We also identified the potential of technologies to support marginalised young people’s healthcare journeys. Study participants were largely calling for the adoption and take-up of technology in service provision, particularly to promote health literacy. This has shifted since an earlier Australian study found professionals’ views were more concerned about online environments being risky for young people (Blanchard et al., 2008). Many professionals in this study were frustrated by the slow take-up of technology which they recognised as a key way services can provide information to support young people’s health literacy and system navigation. Participants also recognised the potential of technology to support health literacy. Technology may also have the potential to disrupt health care and be a catalyst for service and system redesign and better integration of services. However, implementation barriers include the complexity of information, confidentiality, legal concerns, concerns about risk and management priorities (Blanchard et al., 2008; Moreno et al., 2009). Successful integration of technologies into health service communication will require policy support, staff training, technology resources and a change of professional roles (Harris and Robards, 2015).

Our findings have a range of policy implications and potential implementation possibilities. Resources and structures to embed youth participation as part of core business are needed. We found an interest in youth-led service audits to provide a basis for understanding marginalised young people’s experiences and service change. By understanding the lived realities of experiencing multiple disadvantage, health professionals can make informed structural-level changes. The varying views of experienced clinicians and managers can also be bought together via sharing their unique insights about creating system change, particularly to increase understandings of intersectionality and health care. This could be the role of youth health coordinators who are already employed in local health districts in NSW to facilitate access to health care. Enhancement of their role could include supporting regular forums for professionals working with marginalised groups. To assist professionals and services to better understand the needs of marginalised young people and intersectionality, demographic data collection could be expanded to be more inclusive. For example, the addition of an ‘other’ field with respect to gender so that gender diverse groups may be identified would be helpful (Bowleg, 2012). Being able to identify young people at risk of homelessness is also important but would require more information than the recording of a current address. Similarly, there is currently no simple way to record whether a young person is from a refugee background. Processes for capturing this information require sensitivity and consultation with the target populations.

This study is, however, limited by its small sample size. Although participants were key stakeholders across the health system, which allowed for breadth of perspectives, this limited the depth of findings from each setting listed in Table 1.

Conclusion

The Australian health system faces many challenges: its complexity, fragmentation and duplication lead to inefficiencies. Professionals can use their positions of power within the system and harness their frustration for system inertia to advocate for reform. Professional organisations can support system advocacy to overcome the impact of multiple disadvantage, particularly as systems themselves contribute to marginalised young people’s discrimination.

Services need to be turned on their head to increase their reach to marginalised young people, both face-to-face physically and online. Marginalised young people require system and service advocates to help navigate the health system while also making services more welcoming, respectful and flexible to their needs. Youth participation can enable service and system redesign to improve healthcare journeys.

Equity of healthcare access for all young people, including those who are marginalised and experience multiple disadvantage, is a matter of social justice. In the long term, there will be significant costs to the healthcare system – and to society overall – if this need is ignored.

Footnotes

Acknowledgements

We acknowledge the role of the following groups in supporting the study: our chief and associate investigators, the project youth consultants, and members of the study’s urban and rural reference groups.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Access 3 study was funded by NSW Health.

ORCID iD

Fiona Robards

Notes

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