Challenges and strategies for sustaining youth-friendly health services — a qualitative study from the perspective of professionals at youth clinics in northern Sweden

Health-care services can contribute to improving youth health, as long as they are accessible, acceptable, equitable, appropriate and effective for different youth subpopulations — what the World Health Organization calls ‘youth-friendly health-care services’. However, few countries can claim that they have a health-care system that is friendly for youths. This study was conducted in Sweden, which is amongst the few countries where youth-friendly services (called here ‘youth clinics’) have been part of the health system for more than 40 years.

In order to explore the challenges and strategies in providing sustainable youth-friendly health-care services, we interviewed 11 health-care professionals working in four different settings in northern Sweden. We analysed these data guided by the five key aspects of youth friendliness, namely accessibility, acceptability, equity, appropriateness and effectiveness.

The informants in this study perceived that professionals working in youth clinics were motivated, interested and knowledgeable about youth, that the clinics ensured confidentiality and prioritized responding to youth health needs, and that they were considered an indisputable part of the Swedish public health-care system. However, they also pointed out some challenges: some youths faced more difficulties in reaching the clinic, the clinic work was not well monitored, the organizational structure and leadership were perceived as unclear and weak, and there were huge inequities in the resources available and the services provided between larger and smaller youth clinics.

Organized and systematic health services oriented to respond to youths’ needs have a positive impact in their health, through enhancing youths’ trust and access to health care services and, to a certain extent, through promoting health behaviours, e.g. safer sex practices [1‐5]. However, research points out that health-care services are, in general, less accessible for young people and few countries have implemented and sustained strategies to make health-care services more responsive to youth health needs [5‐8]. The Swedish national network of youth clinics is a good example of health-care services for youths that are integrated within the public health system [9, 10].

Health-care services can provide information on health-related issues, treat youths who are ill, and reach those who are in vulnerable situations [2, 4‐6, 11]. However, for health-care services to be beneficial for youths, it is important that they are youth-friendly, or, as defined by the World Health Organization (WHO): accessible, acceptable, equitable, appropriate and effective for different youth subpopulations [5, 12]. A systematic review shows that from young people’s perspective, eight domains are central to a positive experience of care: accessibility of health care, staff attitude, communication, medical competence, guideline-driven care, age-appropriate environments, youth involvement in health care and health outcomes [6]. Youth-friendly health-care services (YFHSs) should be based on supportive policies, respond to youth needs while ensuring confidentiality, promote dialogue with the community, coordinate with other services and implement outreach preventive/promotive activities [4, 12]. Studies exploring health care professionals’ perspectives point out the importance of considering young people as a distinctive group, taking a holistic approach, prioritizing health education and promotion and working in an interdisciplinary way; while barriers such as lack of managerial and financial support, and scarce training and support are mentioned as limiting the implementation and sustainability of YFHSs [13‐16].

One important aspect is that of the sustainability of youth-friendly health-care services. In order to be sustained, YFHSs have to be considered part of public health policies, programmes and systems and not organized as isolated initiatives dependent on external support [2, 4, 5, 17]. In fact, the WHO has recently highlighted the need to move forward from YFHSs into youth-responsive health systems [18]. However, progress has been slow, despite the fact that the literature shows that implementing YFHSs is a cost-effective intervention that could contribute to better health among young people [2, 17, 19, 20]. Even in countries where public health systems perform well, health care for young people is usually a neglected area that lacks clear guidelines and political will. Some reasons for that might be: 1) the strong influence of sociocultural norms and policies (e.g. norms and policies regarding age-related competency for informed consent, privacy and confidentiality might hinder the implementation of such services), 2) the biomedical focus of many national health systems does not facilitate responding to youth health needs that are complex and might not be centred in curative services, 3) the limited training on adolescent/youth health issues of health care professionals, 4) funding priorities are given to other age groups and morbidities, 5) effective YFHS need to be linked with other sectors and programme such as sex education in schools [5, 9, 21‐23]. Sweden is among the few countries where YFHSs have been integrated within the public health system and sustained for more than 40 years [9, 10, 24, 25], lessons extracted from this experience could be useful for improving health systems’ responsiveness towards young people.

Sweden has a well-established network of differentiated YFHSs, called ‘youth clinics’ (Ungdomsmottagningar). According to the national guidelines Swedish youth clinics (YCs) cater for youths aged 12 – 25, although age limits varied between regions, clinics and services [24, 25]. Beginning in the early 70s, a network of youth clinics was developed nationwide in order to improve young people’s access to health information and services. Nowadays it has expanded to over 250 youth clinics across the country [9]. Information is also provided by a web-based national youth clinic (www.​umo.​se). The clinics are organized into a national association (the Swedish Society for Youth Centres or FSUM) founded in 1988, with the mission of stimulating the development of existing youth clinics [25].

The development and implementation of the youth clinics (YCs) has to be understood in the broader context of the Swedish political, social and cultural norms. In general, the Swedish society has liberal attitudes towards teenage sexual relations, and sexual and reproductive health issues are given priority. Young people have received sex education at schools since the 1950s, abortion has been free on demand since 1975 - all women in Sweden despite their age have the right to have an abortion, although for young women under the age of 18, it is up to the health care provider to judge the maturity of the young person-, and contraceptive counselling and access are easy. In some counties contraceptives are free of charge for young people. Emergency contraceptives are sold over the counter and provided free of charge at youth clinics; cost-free testing for chlamydia and other sexually transmitted infections is easy to access.

However, some backlashes have also been noticed: sex education has been taught less since the nineties and social inequities in youth health have increased [26‐28]. Young people from more disadvantaged backgrounds suffer more from health problems, face greater risks to health and have poorer access to health services [29]. Gender and ethnicity also play a role both in health and access to healthcare, i.e. subjective health complains are two times more likely among young women [30], many more of whom report anxiety [31]; Sámi youth — the indigenous populations living in northern Scandinavia and Russia- face specific health challenges such as higher levels of stress connected with experiences of discrimination [32]. Youth from non-Swedish ethnic backgrounds might be at higher risk of being bullied, and refugees have more difficulties accessing healthcare services. In Sweden, as elsewhere, access to health care for youth is modulated by other axis of inequity based on gender, gender identity (trans experiences vs cis experiences), sexual orientation, socioeconomic status, disability, education or ethnicity, i.e. young men, those with trans experiences, those from a non-Swedish ethnic background and those from lower socioeconomic status might face more barriers in accessing healthcare services [33].

Youth clinics can be considered as part of the broader health system, but different from ordinary primary health care and specialized clinics. The Swedish Society for Youth Centres (FSUM) guidelines state that YCs work primarily with health promotion in all areas of youth health with a special focus on sexual and reproductive health. All staff should have a youth-oriented perspective with knowledge of the biological, psychological and social aspects of youths’ development, gender, gender identity and sexuality. It is important that the staff includes professionals educated in andrology, gynecology, psychotherapy and sexology and the goal is to be able to help all young people with their questions, whatever they may be. Youth clinics do not deal with severe or complex somatic or psychiatric problems or diseases. However, since young people might access YCs more easily than other health care services, YCs might become an entry point for youths into the health system, connecting them to primary health care or specialist care for assessment and treatment [34, 35]. The clinics are mainly run by county councils, e.g. within the ‘first line’ primary care services, although municipalities and private organizations run some of them or may collaborate in certain clinics. How each clinic is staffed and which services are provided vary. According to the (FSUM) guidelines, the minimum staff of a YC includes a midwife and a social counsellor or psychologist, with a physician working part-time. In order to improve accessibility, most youth clinics are located off the premises of general health services, and consultations are free of charge. In addition, promotion work, mainly through school visits of 15-year-old pupils to the clinics, increases young people’s awareness of the services offered by youth clinics [10].

There is concordance between the Swedish Youth Clinics’ handbook, published in 2015, and the WHO criteria for youth friendliness (Table 1). The FSUM’s handbook serves as a national guide (even if not legally binding) for youth clinics [34].

Despite the fact that Swedish youth clinics constitute one of the most comprehensive and consolidated examples of a nationwide network of health-care services for young people, to the authors’ knowledge, there are no studies exploring how they work to operationalize the criteria of youth friendliness and how and why the YCs have become sustainably integrated with the health system. Some possible factors might be related with Swedish progressive policies in relation to youths’ sexual and reproductive health and rights and autonomy, public investment on health, education and social services, and the harmonizing and coordinating role of the Swedish Association of Youth Clinics (FSUM) which provides continuing professional development and training, produces highly respected guidelines, policies and best practices, and ensures exchange of information among YCs’ members. The exploration of the Swedish case could shed some light on: 1) what the main challenges in providing and sustaining youth-friendly health-care services as part of the health system are, and 2) what strategies can be used to overcome them.

This study consequently aims to explore the challenges and strategies involved in providing sustainable youth-friendly health-care services, from the perspective of professionals working in youth clinics in northern Sweden.

Four themes emerged from the analysis of the data. The theme ‘Meeting youths on their own terms— the key to ensuring a holistic and youth-centred care’ was related to the acceptability and appropriateness of the services. The theme ‘Organizational challenges and strategies in keeping professionals’ expertise on youth updated’ referred to the domain of effectiveness. The theme ‘Youth clinics are accessible for those who know and can reach them’ was related to the domains of accessibility and equity. The theme ‘The challenge of combining strong directions and flexibility in diverse local realities’ touched upon different aspects of the WHO domains but at another level; it focused on the struggle to sustain the youth clinics organization and their goals within the broader health system. A summary of themes, subthemes, strategies and challenges can be found in Additional file 1.

Professionals in this study felt that Swedish youth clinics adhere to the WHO domains of youth friendliness, both at the level of what was proclaimed in policies and guidelines and their implementation. However, challenges were also pointed out, especially in terms of ensuring equity, quality and organizational support.

In line with other studies, this paper emphasizes the importance of professionals’ attitudes in ensuring the acceptability and appropriateness of services [6, 8, 11, 15, 38, 39]. A strategy used to ensure professionals’ motivation was to make efforts in the recruitment process to select professionals not only with the proper skills and education but also who were highly committed to working with youth. However, in smaller rural clinics the recruitment of health-care professionals is more difficult and candidates to choose from are not usually available [40, 41]. While high personal commitment might be key, it needs to be supported by an organizational structure that provides continuous training and that enables the time and freedom to put it into practice [15, 39, 42]. As stated in the results, ‘Working with the left hand’ does not ensure that the services provided are effective and might contribute to frustration and demotivation. There have been efforts to refresh training of professionals working in YCs in northern Sweden, especially in regards to LGBTIQ certification. However, as this study points out, inequities between clinics in access to such programs exist and affect the quality of the services provided. Beyond continuous training of already employed professionals, incorporating training on youth health during undergraduate and postgraduate studies adds to the sustainability of these services, and constructs youth health as (also) the responsibility of the diverse health care professions. However, this is a strategy that has been scarcely implemented worldwide.

Ensuring confidentiality has been highlighted in other studies as something that youth take into great consideration when deciding to seek care [6, 8, 9, 15, 38]. An important point raised in this study was the balance between ensuring that the YCs ensure confidentiality and privacy for their users, while at the same time remaining visible and presenting an image of openness. As other studies have also pointed out, confidentiality is more difficult to ensure in smaller places [40, 43, 44]. Informants in this study were aware of this problem, although they did not come up with potential strategies to handle it.

Several reports and studies from other contexts such as Australia and Vanuatu have stressed the importance of overcoming structural or operational barriers, such as; inconvenient hours of operation, high cost of service, to increase accessibility [45, 46]. Our study suggested that the structural barriers were tackled by three important strategies implemented to enhance accessibility mentioned in this study 1) ensuring that services were free of charge and 2) ensuring that opening hours were generous and 3) ensuring that youths had diverse ways of getting to the clinic. An Australian study found that youths considered important to be able to reach the clinic without the requisite of a booked appointment [46], a strategy that was also valid for the Swedish youth clinics system of ‘drop in’. The concept of ‘drop-in’ consultations was considered especially valuable and the main form of access in smaller places with fewer working hours. However, this study also stresses that ensuring that opening hours are youth-centred is not always easy to implement, and leadership support and resources are needed to implement such changes. Other studies pointed out that opening hours and appointment arrangements are key to ensure accessibility [5, 6, 11].

In this study, youth centredness relied on staff’s respectful attitudes and confidentiality, and also on ensuring that YCs had a holistic approach to health. Swedish YCs have managed to deliver the message that they are different from other health-care services and that youth are welcome to go to their YC with any issue or problem. This approach makes YCs more appropriate for responding to the complex needs of young people, which often are not limited to one specific health problem, or when the reason for consultation might be merely the starting point for revealing other issues. Previous studies have also highlighted the importance of ensuring that youth and their needs are in focus in order to ensure that health-care services are appropriate [4, 47]. In that sense, youth-centred care is not different from person-centred care, and YCs might be in the vanguard of how other health-care services might approach health and users in a more holistic way and with better user satisfaction [48, 49].

Purposively locating the YCs outside health-care facilities helps to make them more accessible for young people. This strategy did not seem feasible in smaller places and funding issues were claimed to be the reason for that. The WHO guidelines point out that efforts should focus on making existing health-care services youth-friendly instead of developing new service delivery points to youths; however, the guidelines also stress that differentiated services might be more accessible, especially for marginalized and stigmatized groups of youths [4]. Evaluations comparing the cost-effectiveness of the two approaches are lacking.

One possible disadvantage of this image of YCs being ‘not so much about medical problems’ might be that youth clinics might be losing an opportunity to be the entry point into the health system for severely ill young people who might refrain from accessing any health care service (e.g. psychiatric care). Although the role of YCs is not to treat those youths who are severely ill, they can play an important role in detecting youth at an early stage and directing them toward adequate support. The debate on which should be the role and level of competence of YCs in terms of health issues beyond sexual and reproductive health, and the connection between YCs and other health care services is ongoing and very relevant in order to facilitate youths “navigation” within the different health care services in Sweden. The literature has already pointed out that youths get less time for consultation in ordinary health services, and risk becoming an ‘invisible’ group [50, 51], and some Swedish youth risk ‘falling between’ services like YC and specialist care, or between somatic and psychiatric care, or child and adult services [52].

The YCs in Sweden may be looked upon as a flagship within health care, as they provide young people with access to information, counselling and support related to sexual health issues such as birth control, pregnancy and STI testing, and can equip young people with the attitudes, knowledge and skills they need to make informed choices now and in the future, enhance their independence and self-esteem, and help them to experience their sexuality and relationships as positive and pleasurable [53].

Two issues that this study identified as big challenges were related to the difficulties in institutionalizing community work to enhance accessibility and the scarcity of specific strategies to ensure equitable access to YCs for all youths. Community orientation is commonly recognized as one of the most challenging attributes to achieve when implementing a primary health-care approach within health systems [54]. In terms of YCs, despite their holistic and youth-centred approach, outreach and community work was hard to make compatible with office consultations, was less prioritized and harder to sustain among the smallest YCs. A noteworthy exception is the coordinated work with schools that all YCs do. YCs have used the strategy of school visits for many years and it seems that it works for promoting the existence and services of YCs among their potential users. This strategy seems easy to transfer to other countries and is not demanding in terms of the resources involved.

Despite the long-term work of YCs in this part of the country, informants were well aware of the existence of inequities in access for youths, i.e. based on gender, gender identity or ethnic background. While large clinics were coordinating activities with other organizations to reach youths that might be in vulnerable situations, e.g. newly arrived refugees, this was not possible in smaller clinics. The fact that YCs are mainly used by young women was mentioned, and it also aligns with the statistics from the YCs in this county where between 75 and 90% of the people consulting are women. Interestingly in the largest YC that offered mental health services, the percentage of young men accessing such services rose to 29% (while they accounted only for 17% of the total consultations). This can also be related with the fact that the majority of the staff in the clinics are also women. The fact that YCs are mainly used by young women have also been reported both in Sweden and in YFHSs in other settings [9, 55]. The other axes of inequity mentioned in this study — gender identity, sexual orientation, ethnic background and disability — deserve further exploration. Other studies have pointed out that the domain of equity is the one that is usually less developed when YFHSs are implemented [2, 42, 56].

The most recent WHO recommendations push for moving beyond youth-friendly health-care services towards youth-responsive health systems. This study supports this approach and unveils some of the challenges and strategies involved in ensuring that YFHSs are fully integrated and sustained within the health system. It also underscores that in order to be responsive to youth people’s needs, health systems should be people-centred, namely: 1) place people’s voices and needs first, 2) be guided by principles of quality, safety, longitudinality, closeness to community and responsiveness to changing requirement, 3) acknowledge the centrality of human interactions in service delivery, and 4) be grounded on values of rights, respect and equality [57].

According to the informants, in the Swedish context the existence of youth clinics is not questioned. More than 40 years of work and the existence of a national organization make it possible for YCs to be sustained and consolidated as a legitimate part of the public health system. This is not the case in many other countries where resource constraints and the controversies surrounding YFHSs might hinder the likelihood that policies and services for youth get prioritized. This finding underlines the importance of political and socio-cultural aspects in ensuring that health systems are responsive to youth [15, 42, 58].

The way the YCs started (small scale) and the way they have continued to work — in a flexible, bottom-up fashion, where a national organization integrated by the YCs themselves serves as a guiding structure — has been successful in ensuring that a certain ‘style’ of services has become the rule. Swedish YCs have been able to build a style of working that differentiates them from ‘ordinary health-care services’ and that makes them realize most of the domains of youth friendliness. This flexibility has allowed them to adapt their services to local realities and to have freedom in the way they work. This way of implementing YFHSs in pilot sites has been proven to be useful in other settings [15, 38], but this is the first time that a study has pointed out this flexibility and freedom as a feature for sustaining YFHSs within a national health system structure. One key aspect that brings sustainability to this bottom-up approach might be the role of the FSUM in building a structure that brings coherence and unity beyond the specific characteristics of each region and clinic. Without such a guiding role, local flexibility and freedom could have led to complete anarchy and losing the mission and vision of the YCs.

However, while the FSUM has a legitimate position in guiding the YCs, and makes big efforts to influence policymakers, it has no decision-making power within the health system structure. Thus, since YCs depend upon different managerial structures (some upon municipalities, most upon county councils, a few upon private institutions), it is unclear who should be responsible for ensuring that YCs do what they are supposed to do. That lack of clarity and leadership was mentioned as a key challenge to sustainability in this study. Informants reflected on existing inequities between large and small YCs, and the way resources were allocated was not transparent for professionals working in the YCs. Despite YCs being well legitimated within the Swedish health system, they seem to face the same problems in terms of resource constraints and increased workload as the other primary care services [59]. The funding for youth health recently allocated by the government might improve this situation.

To the best of the authors’ knowledge, this is the first study to explore the challenges and strategies involved in implementing YFHSs within the Swedish youth clinics. The long history of the youth clinics and their well-established national network make them a good case for further study on this issue.

Swedish youth clinics’ policies adhere to the WHO domains of youth friendliness. The health-care professionals interviewed in this study stated that YCs’ staff are motivated, interested and knowledgeable about youth and that the clinics ensure confidentiality and a youth-centred and holistic approach. However, challenges were also pointed out, especially in terms of ensuring equitable access to different youth subpopulations, improving monitoring routines, and ensuring training and competence for all professionals, independently of the location and characteristics of the clinic. Youth clinics were perceived as an indisputable part of the Swedish health system, but organizational challenges remained, and these were pointed out in terms of weak clear directives and leadership, heavy workload, local/regional diversity and unequitable distribution of resources.