Social Determinants of health certainly shapes who faces more or less barriers in accessing care as well as can have real impacts on health and wellbeing. This can look like the inter-generational impacts of colonization, who has access to support networks, to financial resources, criminalization or weathering the impacts of facing discrimination – racism, sexism, homophobia, transphobia and more.
Teen Talk, Klinic Community Health is a youth health education program that is part of Klinic Community Health Centre in Winnipeg. We are a provincial program serving youth in urban, rural and Northern Manitoba. We see youth age 14-19 in schools and after-school programs, as well as youth in treatment, incarcerated youth, and youth in care. We provide services for youth from a harm reduction, prevention education perspective. We focus on sexuality, reproductive health, body image, substance use awareness, mental health, diversity and anti-violence issues. We adhere to the belief that by providing youth with accurate, non-judgmental information they can make healthier decisions and choices for themselves.
About the author: Teen Talk, Klinic Community Health
Teen Talk, Klinic Community Health works to connect youth with health services by promoting local Manitoba Teen Clinics. We know that youth continue to face barriers when it comes to accessing health care services (access, stigma, judgmental attitudes). At Teen Talk we work towards breaking barriers by educating youth on where they can go (the teen clinic nearest to them), what will happen when they go there (intake or testing, for example), and by normalizing things like testing, treatment, pregnancy options, and mental health.
Here are some of the direct services we provide to youth:
Workshops for Youth
Our skilled Youth Health Educators develop and deliver interactive workshops to youth aged 14-19 in schools, custody, care or treatment facilities as well as alternative schools. The Workshops for Youth program also acts as a community link by disseminating resources to youth on several important health matters such as reproductive and sexual health, mental health, dating violence, body image, communication skills, substance use awareness, and diversity.
Peer Support
The Peer Support Program at Teen Talk provides a 35 hour training for youth to help educate their peers about issues like sexual health and mental health. Peer Supporters initiate activities in their schools and communities such as skit presentations, information tables and educational events. In addition to the full training, we provide supplemental training workshops on a variety of topics to in-school or community groups including Peer Helper groups and GSA’s. Training takes place throughout the year and across the province of Manitoba.
Teen Talk North
The Teen Talk North program provides trainings and post-training support to Manitoba’s Northern service providers who are working with youth. The training and materials provide the opportunity to discuss strengths and challenges (resulting from the ongoing effects of colonization) particular to Northern and Indigenous youth.
Barriers to Health
Although “youth” are not a homogenous group, many share similar challenges and have similar experiences, needs and desires when it comes to their health and getting the information and services they need to make important decisions about it. Youth are capable and interested in taking care of their health and wellness, including their sexual and reproductive health. Youth oriented health care services go a long way in making that possible by reducing the need to navigate complex systems and reducing some barriers so that youth can get what they need.
Shame and stigma can certainly have major consequences on the health and wellbeing of youth in our communities as well as impact their ability to access services, have honest conversations about sexuality as well as sexual and reproductive health. Many health issues are stigmatized. Young people may fear judgment and/or face a barrage of stigmatic assumptions and stereotypes from peers, from educators, community leaders, media and service providers. This makes it harder to talk about important health matters and even find accurate and non-judgmental information to work with.
Many health issues are stigmatized, which can lead youth to secrecy. This can isolate them from support systems and may complicate how they access care even in possibly urgent situations. These could include having an abortion; being diagnosed with HIV; having an STI, being pregnant at a young age, and more. This can be complicated by what are real or perceived obstacles to building trust with local service providers, like non-heterosexual sexual orientations; being trans or gender divers; having a mental illness, being abused, their substance use, etc.
Lack of culturally relevant or culturally safe health care services and health information resources. This can be especially damning for Indigenous youth, youth of color or any youth who are navigating marginalized identities. It can also manifest as language barriers as youth who do not use English (or French in Francophone communities) as a first language may have challenges in navigating their care.
The need to use Identification and documentation to access services can reduce access. For example, many youth are not able to access their health identification, as it may be kept by a parent or guardian. Youth may not have a relationship with their parent(s) or guardian that allows them to be open about accessing health services.
Financial and logistical barriers can seriously get in the way of getting of accessing health care and that is especially true for youth who may not have access to the necessary resources to flatten them. Some services may not be available or easily available in a given community, which leads to sometimes having to cover transportation and accommodation expenses. When someone is asked or made to access care outside of their regular points of services, it demands the ability to navigate complex health systems, including having to figure out what their requirements are when it comes to treat youth and maintain confidentiality.
Many youth struggle with knowing where to go or where to begin to address health issues they are facing. That said, even when they do know, some of the places where we can or have to go to when we need health care (government offices, large health centres, hospitals, walk-in clinics, etc.) can be tricky to navigate for many youth. Opening hours, locations, forms, documents needed, gate keepers, uninformed service providers assuming the need to notify parents or guardians, and widely held assumptions about youth can spring up along the way and can act as barriers to the health services themselves, or getting in the way of quality care.
For example, if a physician requires parental consent for abortion services for minors, a youth seeking that service without their parents knowing may have to find alternate options. Youth may be further impacted when they live in smaller, more remote, isolated, and/or under serviced communities.
It is important to now underestimate the fear of getting into trouble when it comes to either accessing care or helping a friend access care. This can be especially true for youth who use substances, or who have addictions, who are sexually active in communities where that is frowned upon, when facing an unintended pregnancy, had past problems with police, live in an abusive environment or are involved in child protection systems.
This can also manifest as the fear of “ratting someone out” when facing an urgent situation where a friend needs urgent care but it involves issues like suicide attempts, abortion complications, substance use, overdoses, pregnancy, etc.
Youth, just like many people in society, struggle with self-esteem issues on a daily basis and are navigating a time in their lives where they are actively building their sense of self. This can manifest at times in youth not feeling entitled to care. Youth who struggle with self-esteem, are depressed, or who are dealing with suicidal thoughts, may not think they deserve care. Youth who are living in poverty or caring for younger siblings may also not feel they are “important” enough to get care.
The lack of comprehensive, mandatory sexual health education is a major impediment to youth having what they need to take care of their health and there is often little done to palliate for the lack of accessible information. Education that is sex-positive, informative, and allows youth to evaluate their own values on sexual activity, STI/HIV status, contraception, and pregnancy options is crucial. The lack of health care providers who provide youth-friendly services and information means that little fills that educational gap, which can mean important information is left out during office visits, questions are not asked, misinformation is not addressed, etc.
This also makes it more difficult for young people to have the tools needed to assess the information they find online. This may mean relying on inaccurate web based information, information that is values based (i.e. anti-choice sites), dated and un-updated or not applicable in Canada (i.e. American sites).
Restrictive school policies can limit access to health care services, for example, schools not being able to give out condoms, welcoming peer-educators or sexual and reproductive health care workers or host workshops; mandating parental permission for youth to access trainings or classes; restricting information exchange and supports on issues like abortion, non-heterosexual sexual orientations and masturbation, among others, etc. This can be a major barrier to students’ abilities to make informed decisions about their sexual and reproductive health and to be informed patients when accessing health care services.
For example, it can be very frustrating for youth who have a lot of information, skills and resources, who want to help their peers make healthier decisions about their sexual and reproductive health when their school will not support them in educating their peers. For example, when condoms aren’t allowed to be distributed in school or can only be accessed by talking to a teacher or guidance counsellor, youth may not access safer sex supplies they need.
Little resources to support health care service providers who may already stretched so they can better support youth. Many health practitioners have multiple roles in a centre and/or the community and the pressure to serve diverse clientele can mean streamlining processes, resources, etc.
The moral or religious values of a community’s service providers and leaders, for example, being anti-abortion, or against comprehensive sexuality education, can seriously impede youth’s ability to access services as they may not have the ability to travel farther to seek care elsewhere.
The lack of community support for sexual health education and the distribution of resources, including information products, in youth friendly spaces can drive risk taking behaviours underground, preventing youth from getting what they need to be safer.
Harmful Assumptions
Many youth struggle to be taken seriously and respected as individuals who can make decisions about their own health care. Positive encounters where youth feel heard, understood and respected by service providers can go a long way in creating better health practices and outcomes.
When health care providers make blanket assumptions about the young people they see, youth are less likely to get their needs met and to build trust with those in a position to care for their health. Not only can these assumptions alienate youth, they can make it harder for service providers to get accurate information about their clients.
Common assumptions to be mindful of
While there are many challenges, solutions do exist. Here are some possible scenarios and suggestions to help build positive relationships for healthy bodies, healthy communities and healthy partnerships.
Youth are less able to make good choices about their health care.
Youth are sexually active/ Youth are not sexually active (neither assumption is helpful, and either may result in excluding the experience of some youth)
If sexual activity is happening, it is always consensual (there are many reasons youth may not disclose a sexual assault), or, alternatively, can’t be “fully consensual” as they are too young to know better, to navigate complex needs, situations, concepts and/or circumstances.
Youth are heterosexual and/or, alternatively, they are too young, to “really know” (i.e. “It’s a phase”, “it’s not serious”, “it’s trendy”, “it’s for attention”, etc.)
Youth are cisgender (identify with the gender that matches their birth sex) and/or, alternatively, they are too young to “really know” (i.e. “It’s a phase”, “it’s not serious”, “it’s trendy”, “it’s for attention”, etc.).
Youth feel comfortable accessing health care services in the same ways adults do.
Young relationships aren’t serious (“puppy love” and casual experimentation).
It’s also important to consider the needs of specific populations. For example, it’s a common assumption that incarcerated youth are not sexually active, which can result in those youth having a lack of access to sexual health services and information.
What to do? Quick tips to be part of the solution!
In communities and areas that have community based health care with designated teen hours of operation (i.e. teen clinic), youth often have continuity of care and develop ongoing relationships with their health care practitioners.
Youth benefit from access to school-based, or community based, youth friendly health services where they can trust their needs will be met (specifically, the need for confidential, non-judgemental, timely, and affordable health care services that are offered during hours that ease access for those who are students, can’t travel too far, etc.). The availability and promotion of services like teen clinics which work towards addressing these needs increases the health and wellbeing of youth.
Reference: https://www.gov.mb.ca/healthychild/mcad/had_teenclinicservices.pdf
Make your space youth friendly
The waiting room should include youth friendly posters and magazines showing diverse youth accessing care. Consider having movies playing for busy clinics with long wait times.
Have hours that are readily accessible to the busy and varied schedules many youth have (school, extra-curricular activities, part-time work, etc.).
Do a safety audit within the immediate vicinity of the clinic to ensure people are safe walking to and from your office space.
Have free or low-cost health safer-sex supplies, birth control and, when possible, harm reduction supplies available.
Put out treats like suckers and individually wrapped candies, etc. Mixing these into bowls of condoms can help youth feel more comfortable taking condoms.
Make it welcoming to boys and young men, letting them know they can access services.
Have youth friendly staff
See that staff is trained to work with youth.
Ensure that everyone involved in patient care and clinic work has respect for young people’s lives and experiences.
Engage youth in the design of guidelines, material, programming and facilitate ongoing feedback.
Check your perceptions and assumptions about youth.
Become part of networks of youth-serving organizations in your area (i.e. the Teen Services Network in Manitoba).
Find opportunities for staff training from youth or youth serving agencies
Make confidentiality protocols known to youth
Concerns around confidentiality are repeatedly highlighted by youth. Letting youth know what their rights are and rules around confidentiality can help them to feel more comfortable accessing services. Requiring care-giver consent can be a barrier for many youth, whenever possible allow youth to consent to their own care.
Respect personal privacy
Use first names, or first names and a last initial when calling client’s name (in the waiting room). Confirm identity in the examination room.
If possible, offer a private windowless waiting room separate from more public areas.
Each visit should include some time alone with the client, even if they came with a support person (partner, friend, etc.).
Give options for being contacted for follow-up, i.e, e-mail, text, or sending a message through a friend.
Block call display on all outgoing calls from the health centre, but inform clients this is the case (may need to call from alternate number depending on phone plans.)
When addressing parents/guardians:
- Do not acknowledge or confirm that their child has attended the clinic. Remind them of clinic policy around confidentiality and a third party.
- When talking to parents, it may be helpful to describe the health centre as a “walk-in” for teens.
- If a parent or guardian continues to ask questions regarding the youth suggest that they follow-up with the health centre director.
Location and Hours
Aim for school-based or community based clinics.
Have location be easily accessible by bus.
Building design should reduce barriers for all youth, including youth with disabilities. This can include elevators, automatic door openers, signs in large print and Braille.
Building should have at least one gender neutral washroom to reduce barriers for transgender and gender variant youth.
Forms and documentation
Avoid complicated forms wherever possible.
Use large print, plain language and have Braille version available.
Offer to help fill out forms
Have a private place set aside where someone could have a conversational intake
Find ways to offer services to youth who do not have documentation with them (such as a provincial health card/number). If you can, offer what the youth needs and ask them to bring their card later, or even call or text in the information if they are not able to return.
Be mindful of questions that may be barriers for LGBTTQ* youth. For example, if you need gender information, leave it open ended rather than providing Male/Female only options.
Make a space for youth to give you the name they would like you to use
Information sharing and decision making
Start where they are at and build from there.
Have time for building comfort before beginning health histories. Respect people’s pace in sharing information and disclosing what can be complex circumstances as trust building can be a long term investment in the health and well-being of your patients.
Don’t assume they don’t know much about their body or what they came to see you for.
Youth learn in different ways, it’s important to incorporate visuals like diagrams and demonstrations, as well as allow youth to handle things like birth control methods, have them practice putting condoms on woodies, etc.
Share only accurate information with no judgment or bias, and allow the youth to make a decision that works best for their life.
Example: If someone wants birth control, you could begin by asking “what are some things you have heard about birth control” or “what methods have you heard of.” Better yet, ask what interests them about birth control, and make a birth control plan that suits what they want to get out of it. Ask questions about the person’s life – will they be able to remember a daily pill? If not, maybe a patch is better. Will they have to hide their BC use from family? Explore birth control options that could best fit the individual’s specific needs.
Continuum of care and appointments
Consider partnering with other organizations to offer a range of services at one time (this can limit appointments).
Focus on the full range of health care needs, mental health, nutrition, sexual and reproductive health, stress, injuries, and general primary care.
Adopt a team approach where different providers can integrate services from different sites.
Limit the number of times a youth has to come see you, where possible. (This is especially important for youth who have unhealthy or abusive relationships, or who do not have positive parental support to access health services like those of a teen clinic.)
Give youth time to tell you what they need, and for you to answer all of their questions. A ten minute drop in appointment will not be enough time for youth to give you a picture of what’s happening in their life which may be leading to negative health outcomes.
Welcome drop-in clients or arrange appointments quickly.
Don’t penalize youth for missing appointments
Offer follow up appointments, this can go a long way in creating a positive provider-client relationship.
*Adapted with permission from the Government of Manitoba
Clinics and office spaces: during appointments and in your community
Give simple, concrete information and avoid technical jargon or unnecessarily big words. For example, define acronyms like “STI”, explain procedures simply and clearly, use words like “birth control” instead of “contraceptives”, “condom” instead of “prophylactic”, “vagina, cervix, uterus, etc.” instead of “female genital tract”
Explain more complicated words or concepts using language you know your clients can relate to.
Respect the use of slang and allow youth to speak about their body parts in a way they are comfortable. For example, if a client says “dick’, you can simply respond neutrally using the word “penis”. If you are unfamiliar with slang, rather than make an assumption- ask for clarification.
If you are introducing a term that might be new or unfamiliar, make sure you define it, even using diagrams/ models if appropriate (especially with anatomy). For example, youth may understand the term “sexually active” as having recently had penis in vagina intercourse. To alleviate confusion, clarify by asking if they have had any kind of sex, and then ask other questions if needed.
Avoid words that may infer judgments or values. This is especially important when discussing pregnancy options. For example, use “fetus” instead of “baby”, “placing for adoption” instead of “giving up the baby”, “ending a pregnancy” instead of “destroying the fetus”, “continuing a pregnancy” instead of “keeping the baby”, etc.
Ask for and respect the name and gender pronouns youth want you to address them with.
Avoid using gendered language when discussing health with transgender or gender variant youth. For example, instead of “women” or “females” you can say “person with a vagina/uterus/ovaries”. Mirror the language Trans and gender variant youth use for their body parts
Always use neutral language when referring to romantic or sexual relationships, unless client indicates their partner’s gender. Use “partner” instead of boyfriend or girlfriend. If “partner” is not understood, use both. (i.e. “do you have a boyfriend or girlfriend?”)
We all make mistakes! If you make an error, simply apologize, correct yourself, and move on.
Other possible positive interventions
Health centres ensuring a presence in the school and community
Encouraging health seeking behaviors by making sure you and your colleagues make a point of being available and youth friendly: The more open and available practitioners and support staff are, the more likely youth are to trust them and seek them out in urgent situations.
Train emergency staff on the importance of validating the importance of calling 911, and the importance of letting youth know that it was the right thing to do.
Including the support person in transitions in cases where there is an emergency situation and an ambulance is called or emergency care is necessary.
See to reduce costs when possible or offer sliding scale payments when that makes sense.
See to offer Web/mobile based resources and information, chat and text options
Make your support for peer education model visible.
Provide Health promotion signs/posters to establishments where youth can be found, like school building and bathrooms, community centers, etc.
In youth friendly spaces, offer Q&A services, for example, youth volunteer able to answer questions with adult supervision, or service provider visiting youth spaces.
Community mapping
Community asset mapping is a positive approach to building strong communities. Generally speaking, here are some people in your community it might be helpful to connect with:
Public health nurses
Treatment centre facilitators
Traditional Healers and Medicine People
Recreation and drop-in program coordinators
Community Therapists
Elders
Mental health or Addiction workers
Guidance counselors
HIV/AIDS organization coordinators
Cultural and Spiritual advisors
Suicide Prevention Workers
Youth serving agencies and networks
Youth activist groups (i.e. Winnipeg’s “Meet Me at the Bell Tower”)
Resources to know about in your community
Youth Mental Health Resources: Hospital programs, eating disorder programs, community based counselling services, etc.
Sexual and Reproductive Health Services: Local drop in/ teen clinics, Planned Parenthood affiliated clinics, Public Health Nurses etc.
Pro-Choice Pregnancy and Parenting supports: Programs offered by community agencies, NGOs, or government that can assist overcoming some of the barriers faced by pregnant and parenting youth. This could include financial assistance resources; local child and family service agencies; places to access free/low cost clothing, furniture, food, formula; safe houses for pregnant/parenting youth ; Breast feeding supports, parenting supports; schools with built-in childcare, etc.
Community specific education and advocacy groups such as LGBTTQ* serving organizations, Anti-Racist organizations, Women’s organizations, Newcomer serving organizations, Prisoner advocacy groups, Indigenous Rights organizations and more.
Places/services that can help youth build connections to their community can increase their resiliency. While it may not be common practice for a health practitioner to refer youth to, say, a basketball program at their school or an LGBTQ* summer camp, helping youth connect with these kinds of activities/places can increase protective factors against negative health outcomes. Some examples are Youth Drop-in’s, shelters, after school programs/ community groups, volunteer opportunities, other free opportunities (informal education, sports, leisure, etc.)
Local Indigenous Elders, Healers and Medicine People, as well as community gatherings, celebrations and ceremonies.
A list of trustworthy Internet resources: It is important to provide youth with up to date, accurate, pro-choice, youth friendly internet sources for information.
Tips for creating and maintaining your own resource lists
It is important to contact individuals and services before including them on any reference lists, especially if you are distributing the information to clients. It might help to ask the following questions.
What kinds of services are available, and is there a drop in time for youth?
What is your confidentiality policy for working with youth?
Are all services and materials free or are there costs?
Can you include a specific person’s name and contact info?
Is non-judgmental counseling on all 3 pregnancy options available? Do you do abortion referrals?
Can you recommend any other services to include?
*Services change over time, be sure to call back at least annually to ensure your resources are up to date. To see the resources we refer people to, please visit www.teentalk.ca/resources
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