Objectives: To identify perceptions of health, health concerns, and health service needs among young people in a suburb of Sydney, New South Wales.
Design: Qualitative study using focus groups.
Setting: Berowra, a geographically isolated suburb on the outskirts of Sydney, between December 2002 and April 2003.
Participants: 40 Berowra residents aged 14–24 years, recruited from two local government high schools (two groups), a local youth drop-in centre (one group), and the community, through advertising at the youth centre, local schools and church groups (one group).
Results: Focus group findings were classified into four broad themes. 1: Personal safety is a primary health concern. Berowra needs more recreational facilities to prevent drug and alcohol use related to boredom. 2: Health is more about quality of life than disease and illness. 3: Most health information comes from sources other than health providers. Health education must enable young people to make wise choices for the future. 4: Access to health services is of concern. More education is required on how Medicare works. Young people need to trust their service provider and will only see a doctor if they perceive themselves to be severely ill. Young people value meeting general practitioners in the school and community setting and not just in the doctor’s consulting room.
Conclusions: Young people desire a whole lifestyle approach to health rather than the traditional model based on diagnosis and disease. Health information needs to be accessible anonymously, and healthy lifestyles need to be promoted throughout the whole community, using youth workers and sporting leaders as role models.
Although two out of three Australian youth rate their health as “excellent” or “very good”,1 the transition from childhood to adulthood is often characterised by risk-taking and other behaviour associated with substantial morbidity and mortality.1,2 Yet, young people find it difficult to access primary health care services.3-8 Barriers include cost, lack of knowledge about Medicare, concerns about confidentiality, embarrassment, fear and shame.2,6,9,10 In addition, general practice encounters may not identify important health problems in adolescents,2,11 and, even when young people have a trusting relationship with a general practitioner, it is not necessarily accompanied by improved health behaviour.12
A holistic approach has been suggested as necessary to improve the physical, mental and social wellbeing of young Australians.11 A suggested strategy is to involve young people in plannning their own services. For example, the Clockwork Young People’s Health Service in Geelong, Victoria, is a youth-specific health clinic that successfully designed services in consultation with young people in the area.13 In the United Kingdom, schemes that involved adolescents in determining their health services have resulted in youth drop-in clinics supported by GPs for family planning.14
Any strategies to improve the health of young people need to be informed by an understanding of their health beliefs.11,15 Two significant reports on the health and wellbeing of Australia’s young people highlighted the gap in our understanding of knowledge, attitudes and perceptions of young people regarding health and wellbeing.1,10
In Berowra, a relatively isolated suburb of Sydney, New South Wales, concern about the levels of alcohol and marijuana use and perceived higher teenage pregnancy rates among young people led the local community health centre to suggest establishing a youth-specific health clinic. We undertook a study of perceptions about health, issues of concern, and perceived health care needs among young people in the suburb to explore the need for and feasibility of establishing this clinic.
This was a qualitative study using semi-structured interviews conducted with focus groups. The project was approved by the University of Sydney Human Research Ethics Committee and the NSW Department of Education and Training.
Berowra is a geographically isolated suburb on the northern outskirts of Sydney. The nearest shopping and business centre and hospital are in Hornsby, 15 km to the south. The population of Berowra comprises mainly young families. The 2001 census found a total population of 8294, with 1477 (17%) aged between 12 and 24 years. Figures for the local government district, Hornsby Shire, show that among young people in this age group, 76% were born in Australia, and 83% speak English at home. Youth unemployment rates are lower in Hornsby Shire than in the rest of NSW.16
There are limited facilities for young people in the suburb. A youth drop-in centre, the Berowra Gatehouse, is run by a trained youth worker financed by local churches, and opens some Thursday, Friday and Saturday nights. Other social groups for youth include local church groups, Scouts and Rovers, and soccer and netball clubs.
We conducted four focus groups between December 2002 and April 2003, each comprising 10 Berowra residents aged between 14 and 24 years. The groups were designed to include both school attendees and non-attendees.
Two groups were run from government high schools in neighbouring suburbs. Participants responded to a letter about the project sent to all students in school Years 8 to 11 whose residential address was in Berowra. Consent forms were signed by each volunteer and by their parent or guardian before the groups met.
A third group was recruited from the local Gatehouse drop-in centre by one of the authors (C K), who visited the centre, explained the project to the young people present and asked for volunteers. The fourth group was recruited from the community, with volunteers responding to advertising at the drop-in centre, local schools and church groups, and word of mouth from siblings.
The focus group questions were derived from the literature about health perceptions, beliefs and attitudes.12 A pilot focus group was conducted in a neighbouring suburb, and the questions were discussed with youth health providers and community centre workers in the area. Final topics raised in the focus group are shown in Box 1. The focus groups were terminated when no new information was emerging. The group sessions were audiotaped, transcribed and analysed by two of the authors (C K and L T). Thematic analysis was conducted on transcripts, and consensus achieved between the two researchers.
The composition of the four focus groups is described in Box 2. Participants comprised approximately equal numbers of males and females, with about two-thirds attending high school.
The findings of the focus groups about living in Berowra, health perceptions and beliefs were classifiable into four themes.
Participants in the focus groups observed that Berowra is a small, quiet, and friendly community, but that it is geographically isolated and lacks recreational and social facilities for young people.
They described feeling let down by local government promises for sporting facilities, which have never eventuated. They associated boredom with increased use of drugs and alcohol, and were concerned that substance use and abuse was often associated with violence.
If we have nothing there to provide us with places to socialise, people will go to drugs and alcohol. [16-year-old female school student]
A lot of the fights are induced by alcohol, people can’t control themselves and you try and calm your friends down, and they don’t, then they turn on you. [young adult male]
Personal safety was of great concern, particularly related to driving and violence. Young people felt there was a need for increased law enforcement.
There are no cops. Unless there is a disturbance and they’ll come . . . they’re all under-age drinking, when they come on the street, the cops take down their names but they don’t do anything. [16-year-old female school student]
Berowra is getting gangs now. Stuff going on . . . They have batons and things, that is scary for Berowra, they are all local people. [17-year-old male]
I’m a driver, and I’ve seen about five or six mates have big car accidents from drink driving. [18-year-old male]
Good health was perceived by participants to be a necessity for the lifestyle they desired and for pursuing the life goals that they set. These young people linked health to quality of life, fitness, motivation and activity, rather than absence of disease or illness. They also included emotional and mental wellbeing, happiness, confidence, positive self-esteem, and a positive attitude in their definition of health. Risk-taking behaviour was seen as a normal part of rebellion against authority, but also as an issue that could affect health.
Some people just rebel and do it, despite their parents, or they want to get at their parents, or have grown up living like that. [16-year-old female school student]
Participants reported that health information was often obtained from schools, parents, television, brochures, magazines and other people, particularly those met at the gym or other sporting activities. Parents were seen as an important source of information, but participants were less likely to ask parents for advice on relationships in case they received a “lecture”. Some young people suggested that parents should be educated about drugs, privacy and confidentiality.
Television was reportedly a popular source of health information, but participants were wary of advertising, particularly for new alcoholic drinks that “taste like cordial”, and depictions of tobacco or marijuana use on TV.
Health education at school was generally seen as useful, but participants would have liked to receive it from a knowledgeable young adult, particularly someone with whom they could identify. Teachers and doctors imparting health knowledge were thought to be authoritarian, and their advice would be sought only for problems that were very serious. Participants wanted anonymous access to reliable written information enabling informed choice. They had limited knowledge about sources of information, helplines, websites, access to services and rights for consent and confidentiality.
Health teaches you about yourself really, not like maths, that will help you get a job, but they don’t tell you how to get along with people, and I guess that is what is different about it. That is important, life skills, teaching you about a group, and being responsible and taking responsibility for what you do. Like not getting pregnant and wearing a condom. Rather than stuff you learn that isn’t so important. [16-year-old female school student]
Should send that information out to all the schools with pamphlets. I didn’t know at what age I could get a Medicare card. Most people don’t know that. [17-year-old male school student]
Be physically and mentally aware of things that might prepare you, to best be healthy as you can, have knowledge to make choices, be aware of things that are bad, that might harm you, lead to implications down the track, things that you might not be aware of and will regret later in life. [18-year-old male school student]
The young people in this study preferred to use the drop-in centre youth workers for health information and to consult a medical practitioner only if they were very unwell. They felt there was nowhere to go for mental health issues, although a few young people said they would go to a GP if they were severely depressed. Their perceived barriers to going to the doctor were cost, travel, confidentiality, waiting times, and having to sit among sick people. Some thought that doctors were judgemental, and felt embarrassed.
Participants preferred an informal, holistic health care environment connected to sport or leisure activities, where they are likely to congregate. They wanted a focus on preserving and restoring health and wholeness, not on treating sickness. They spoke of obtaining health information in the community, at the gym or pharmacy, and of being able to access an informed but young, approachable, relaxed person for discussing issues and asking questions in an environment away from the “medical model”.
If needing to see a medical practitioner, participants valued a choice of doctor, continuity of care, and a trusting relationship. “Bulk billing” was important and, if a sexual issue needed to be discussed, a health professional of the same sex was preferred. Familiarity with doctors through school and community programs was thought to be a helpful strategy to overcome some of these barriers.
You should probably try to tie a skate park and entertainment type area with the Gatehouse [youth drop-in centre] and connect this even further to Lifeline [a telephone counselling service] and a resource centre and maybe not doctors as such, but having information available, possibly a counsellor or chemist who could give information. Linking things together. [16-year-old male school student]
Talking at schools and things . . . about what they [doctors] do, and saying you should feel comfortable coming to talk to us, and encouraging them if they have problems to see their doctor, so they aren’t afraid. [adolescent male in community group].
This study provides some new perspectives on adolescent perceptions and attitudes to health and health care. It highlights the prominence of personal safety and violence as concerns of young people in this community. Wellbeing, fitness and a positive approach to health appear to be a preferred framework for working with youth, rather than traditional medical models. In addition, there is an encouraging view among participants that health information is of value, yet there is a need to provide access more anonymously to this information and to promote it through non-traditional means, such as sporting venues and young-adult role models.
Our findings support the view that health promotion to young people requires a broad-based strategy, based on the whole context of young peoples’ lives, and collaborative relationships with all individuals and institutions working with youth.17 However, some of our findings, particularly the need for a broad wellbeing focus, are not consistent with the results of the NSW Health Access study, which reported that most young people initially defined health in purely physical terms.10 Only on further probing, and more so for the older women in the group, did the participants include mental and social issues in their perceptions of health. However, the Access study concurred with our finding that young people associate boredom and lack of recreational facilities with increased use of drugs and alcohol.
The results of our study concur with the results and recommendations of an evaluation of the National Youth Suicide Prevention Strategy.8 This also showed that continuing commitment is needed from the whole community to social justice and to reforms to prevention strategies and services for young people.8 These studies can help inform health service planning and will need to engage the non-health sector (eg, local, state and federal governments) more effectively in providing recreational, transport and social facilities for youth.
An important strategy for improving youth health may be to enlist youth workers, community pharmacists and influential sporting leaders in health promotion. Recreational groups, such as church youth groups, Venturers scouting groups, gymnasiums and sporting clubs, may be more appropriate avenues for health promotion than traditional medical models. The websites and newsletters of these organisations deserve more consideration and evaluation as vehicles for health promotion. The youth-developed website, Headroom,18 provides a potential model for future youth health initiatives. This website, written by young people, is an information source for mental health issues and has different sections for health professionals, parents and friends, 6–12-year-olds and 12–18-year-olds. The usefulness of websites as sources of health information for young people requires more rigorous evaluation before becoming standard practice. Involving youth in developing their own services has been shown to be an effective strategy for achieving youth health outcomes.15
The health information provided to youth needs to have a practical emphasis, particularly in the areas of sexual health, nutrition, drug action, communication skills, decision-making, conflict resolution, anxiety, depression and relationships.
Our findings also provide support for “GPs in schools” programs run by Divisions of General Practice. This is a way for young people to meet and know their local GPs, to find out what GPs do and ways they can help with youth health, and to identify those who bulk bill. Our results are consistent with those of other studies showing that a concerted effort is needed through schools and other services to educate young people about Medicare and how the Australian health system works.9,19,20
Involving the community in taking responsibility for educating young people about health may contribute to their sense of “belonging” to the community. A sense of belonging is postulated to contribute positively to developmental outcomes, including avoidance of drug use.21 Young people who lacked ties with social groups such as family, schools and churches and who had “contracultural” values were more likely to engage in frequent drug use. Programs that assist young people to bond with society can help to engage young people in seeking positive health outcomes.21
In conclusion, young people in Berowra value health and identify it with quality of life. Education on healthy lifestyles can be gained most effectively in the course of their life activities and experiences, rather than traditional medical consultations and youth-specific health clinics. Consequently, simple changes in the community, such as providing health brochures and access to reputable youth health websites in pharmacies, gyms, schools, church offices and sporting venues, as well as in doctors waiting rooms, can provide many of the education needs and services required. Young peoples’ health care and wellbeing need to be addressed throughout the whole community and not just in doctors’ consulting rooms.
1 Topics discussed in the focus groups
Living in Berowra How long have they lived in Berowra? What is it like? What is it like for young people?
Health attitudes What does healthy mean? What is it like to be healthy? Can young people improve their health? Is it worth it?
Health education Where do young people learn about health? From whom? Does it have an impact? Do they need more information? What? Where do young people in Berowra go for health information?
Health services Where do young people in Berowra go when they are sick? What is it like? What puts you off going to the doctor? What would make it easier?
Common health concerns Which of a list of common health concerns are concerns for young people in Berowra?
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