Introduction
Adolescence and young adulthood is a pivotal time of development in a young person’s life [
1,
2]. During this period, young people go through major biological and cognitive changes as well as forming their identities both within themselves and in their social surroundings [
3], and studies show that young people are particularly susceptible to social stimuli as well as prone to risk taking [
4]. Although young people are generally healthy, the past decades have seen an increase in mental health problems in this age group [
1,
5,
6]. It has also been shown that mental health issues often start during adolescence and young adulthood and then persist through the lifespan [
7,
8]. Studies have shown increased incidence of clinical diagnoses such as depression and anxiety [
9‐
11], as well as sub-clinical symptoms e.g. stress [
12]. This trend in increasing mental health problems is particularly worrying, since studies have also found that poor mental health during childhood and adolescence is a predictor of negative outcomes in adulthood, such as poor educational attainment, unemployment, and future mental health problems [
13,
14]. In contrast to this, young people also tend to underutilize available traditional healthcare services, since they are perceived as not meeting young people’s specific needs, such as a feeling of trust and mutual respect with care staff, high levels of confidentiality and help managing the perceived stigma of poor mental health [
15‐
17]. This entails a risk of them not receiving adequate treatment for their mental health problems.
To be able to cater to the needs of adolescents and young adults, the World Health Organization (WHO) established guidelines for youth-friendly health services (YFHS) in 2012 [
18], sometimes also referred to as adolescent-friendly health services. These guidelines may be formulated as eight standards [
19] that in turn may be summarised in five domains: YFHSs are accessible, acceptable, equitable, appropriate, and effective [
18,
20]. YFHSs may provide all types of care but are often tasked predominantly with providing care and advice for sexual health as well as mental health, but the focus of different clinics and service providers differ. The guidelines for YHFSs have been applied to health services to varying degrees in different nations [
21,
22], but often on a limited project basis. Few countries have well-established structures for YFHS in place permanently.
In Sweden, there has been a system of youth health clinics (YHC) in place since the 1970’s. These clinics mostly seem to meet WHOs criteria for YFHSs [
20,
23], although some domains, e.g. accessibility, vary between clinics. The clinics provide free sexual and mental health care for patients aged 12–25 years and are present in all regions of Sweden [
24]. Young people may seek out the YHCs specifically for help with mental health issues, but it is also common that young people initially contact the YHCs primarily seeking other services, foremost for sexual health issues. While at the clinic other health issues e.g. poor mental health might be identified [
24]. The YHCs have a stated aim of low-threshold, preventative care [
24]). Studies have also found that young people using the YHCs perceive them as youth-friendly and welcoming [
25], although other studies have found that young people from a non-Swedish cultural background find these clinics less accessible and less suited to their needs [
26].
YHCs can play a crucial role in early detection and treatment of poor mental health, by providing accessible and available care as well as ensuring confidentiality, privacy, being non-judgmental and having an inclusive approach [
18]. To ensure that adolescent voices are at the centre of decision-making processes for their mental health it is important to understand what mental health, both good and poor, means to them [
27]. Some studies have explored how young people perceive health in general [
27‐
30], with findings including the important role played by responsible adults surrounding young people [
27]. Findings also show the central importance of mental health in relation to young people’s perceptions of their overall health, with physical health described in a study of 15-years old boys as “subordinate” [
29]. Studies have also explored young people’s perceptions of mental health specifically [
31], but no such studies have, to our knowledge, focused on patients at YFHCs specifically, and it cannot be ruled out that young people using the YHCs have unique health perceptions or healthcare needs. The aim of the present study was to investigate how young people visiting YHCs perceive the concept of mental health and factors they view as central to maintaining mental health.
Discussion
This interview study gives many insights into how young people visiting YHCs perceive the concept of mental health and how they try to achieve it. From the inductive analysis of the interviews, two themes emerged; (1) Mental health is helped and hindered by the surroundings and (2) Mental health is difficult to understand and difficult to achieve. Both themes indicated uncertainty in having mental health from a young person’s point of view. Theme 1 shows that mental health is perceived as heavily influenced by social surroundings, which are often outside one’s control, while Theme 2 shows that mental health entails hard, continuous work, even though one might not know what the end goal is. Taken together, this entails that young people may find conversations about mental health intimidating, while at the same time expressing a need to be asked how they’re doing in order to be able to talk about how they are feeling. At the same time, young people interviewed underline that they need adults in general, and health care professionals in particular, to ask about their mental health, as they will not give this information without prompting. These insights should be kept in mind when approaching young people concerning mental health.
The centrality of the social surroundings for young people’s mental health is in the present study brought to the forefront. The potential positive and negative impact of friends, family, and schooling is at the core of how young people describe health. This is echoed in some previous findings concerning how young people perceive health generally and mental health particularly [
27‐
30], but is further emphasised in the present material. These findings also mirror findings concerning the importance of peers and family to mental health in young people [
37,
38], and are also in tune with the centrality of social stimuli to the adolescent developmental phase [
3,
4]. The findings in the present study also show that the young people interviewed are aware of the connection between social circumstances and mental health. This, in turn, holds important implications for both assessments of how young people are feeling, which may achieve increased accuracy by including a social perspective, and treatment of poor mental health. It also implies that mental health should be an important focus for school health services, a suggestion that is brought up in the interviews. However, it is, as stated above, important to keep in mind that young people may feel uncomfortable discussing how social circumstances affect their health, and the circumstances of the individual need to be taken into account.
The need for an individualised, person-centred approach for young people in the healthcare system is also brought up as a prerequisite for young people being able to, or rather being motivated to, access healthcare. Person-centred healthcare in adult patient populations has been found to increase self-efficacy and satisfaction with care [
39], amongst other findings, and is also a government priority in Sweden [
40]. That the young people interviewed in the present study clearly state a need for a person-centred approach underlines the need for further effort from the YHCs specifically, but the healthcare establishment in general, to expand research and healthcare efforts towards person-centred care for this particular group.
Several of the criteria in the guidelines set up by the WHO for YFHSs [
18,
20], particularly the criteria of accessibility (free healthcare and flexible hours/modalities for contact), acceptability (individualised care, trust and safety, right to secrecy) and appropriateness (seeing the whole individual), are also highlighted as particularly important for healthcare services to attract patients. On one hand this seems reasonable, since the young people interviewed were all patients at YHCs, clinics that seem to approximate the YFHS guidelines. Previous studies have also shown that YHCs are perceived as youth-friendly by young people [
23,
25]. However, in [
25], for example, the semi-structured interview guides were based on the central domains of YFHS, while the present study had a more general aim and structure of the interview guide. The fact that naïve subjects, who are unaware of the WHO guidelines, still bring up these criteria for being able to access healthcare spontaneously may be interpreted as an indicator of the content validity of the WHO guidelines themselves.
Young people interviewed on the one hand seemed to contrast the YHCs with conventional health care, but on the other hand had uniform expectations on “health care services”. In the interviews, two questions enquired about how “health services” should approach young people. The way the term “health service” was used in the interviews can apply to all health care, including both “regular” health services, such as primary care or psychiatric care, and the YHCs. In the interviews, young people tended to separate “regular” health services and YHCs and view them as different entities in response to questions concerning “health services”. The “regular” health care services, particularly the psychiatric services, were sometimes brought up as an example of negative experiences with seeking help, despite not being the focus of the interviews, whiles the YHCs overall received positive reviews. This is not surprising since the present study used only participants who for different reasons choose to seek out the YHCs, but it is a clear indicator that “regular” health services at least by some are not viewed as “youth-friendly”. It also serves as a reminder of the importance of the guidelines to facilitate health care access for the group.
Finally, it is important to note that mental health and mental health problems to the young people interviewed seem to be the most important aspect of their health. The young people echoed findings in current research [
1,
5] and referred to mental health as the biggest health issue facing young people today. In some of the interviews “poor health” even seems to be used synonymously with “poor mental health”. Although not surprising, since young people are generally physically healthy [
1,
2], it is also worth noting that mental health, and particularly poor mental health, seems to be an important part of young people’s self-image, even to the extent that poor mental health may feel safe compared to striving to attain good mental health. Self-image has in numerous studies been found to have causal relationships with poor mental health [
41], and studies have also found that young people who engage in behaviours such as non-suicidal self-injury sometimes do so to strengthen a sense of belonging to a peer group [
42]. This finding may hold implications for treatment of mental health as motivation for improvement may be lacking if good mental health in itself is perceived as a frightening prospect. Further research may focus on how poor mental health forms part of how young people view themselves and if this in turn affects the recovery process.
The present study has certain limitations. The additional interviews performed in 2023 did not include any participants identifying as non-female, meaning that any possible difference in perceptions and needs between 2018 and 2023 in male and youth with other gender identities at the YHCs may not be captured in the study. While the gender distribution as well as other background factors in the present sample reflects the population who attend YHCs, findings may not be transferable to adolescents and young adults who do not seek treatment at YHCs. Also, in order to respect the YFHS guideline of a right to secrecy, no participants who would have required parental consent were recruited for the present study. This entails that the findings may not reflect the views of the very youngest people attending the YHCs.
Interviews were carried out by two separate interviewers (MA and PVL) and codes from both interviewers went into forming all categories and themes. No differences in themes or categories were found between interviewers, indicating that the results of the interviews carried out by both interviewers are substantially the same. The second interviewer read the interviews carried out by the first interviewer before performing the additional interviews which may strengthen dependability. Conversely, it may also pose a threat to dependability, since the second interviewer may have been influenced by the first set of interviews. The interview guide used for the semi-structured interviews was not pilot tested prior to the interviews, implicating a risk that the questions asked were insufficient to fulfil the stated aim of the study. However, the interview guide consistently asked participants questions in an open manner, as well as continuously asking if there was anything further they’d like to ask, which may lessen this risk. Also, while the participants in the study as stated above reflect the population at YHCs, no data was kept on who was approached by staff and asked to participate, which means there is no way for the present study to account for who refused to participate in the study or why. Finally, the participants were not shown the transcripts of the interviews. While the transcripts are verbatim from the recordings, participants have thus not had the opportunity to correct any misunderstandings arising in the interviews. Nor were participants asked to give feedback on findings from the analysis, which also entails a risk of lack of depth in the analysis.
In order to enhance trustworthiness and improve the credibility of the data analysis, both coding and analysis were validated by different members of the research group. The first author, MA, has many years of experience working as a psychologist at a YHC, which gives unique insight into the topic studied. However, this experience with working in a YHC may also entail bias concerning the patient group or how they perceive mental health. No other authors involved in the analysis process had specific experiences from YHCs, ameliorating any bias.
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