To the extent of our knowledge this is the first study to assess Swedish YCs’ degree of youth-friendliness from the perspective of young people using these services. The participants perceived the YCs as very youth friendly across the measured domains. YCs were perceived in a similar way regardless of the respondents’ gender, but other sociodemographic factors influenced some of the domains.
The YCs were overall assessed very positively by the young people answering the questionnaire. This is an important finding that allows us to label northern Swedish YCs as a good example of youth-friendly services. There are, to the best of our knowledge, no similar studies in other countries to compare with so far. However, during the validation of the YFHS+ questionnaire with primary health care centres in Bosnia-Herzegovina, the scores were considerably lower in Bosnia- Herzegovina (4). Results from our study confirm previous unpublished evaluations from FSUM and findings from qualitative studies that stress that the “special” youth-centred approach of YCs and the motivation of the staff working on these services make them accessible, acceptable, and appropriate for young people (11, 12). Since there are few examples of existing and sustained youth-friendly services in Europe (18, 19), the lessons learnt from the Swedish YC model can inspire efforts to implement such services in other countries.
According to the new proposed model by WHO, it is not only a matter that specific, differentiated services should be friendly towards young people, but that the entire health system should embrace such an approach, and all health care services to which young people could come should be youth-friendly (20). It would be interesting to apply the YFHS-Swe questionnaire to other health care services that also assist young people in Sweden (primary health care services, youth psychiatry, school health) in order to assess whether they are equally youth friendly.
In terms of differences based on the sociodemographic characteristics of youths, it is interesting to highlight that there were no significant differences based on gender. Studies, and routine data from YCs’ consultations (and even the composition of our sample) highlight that girls and young women outnumber boys and young men in consultations in YCs (21). This is a pattern not only for Swedish YCs, but for youth-friendly health care services in general. This study, however, also points out an interesting finding: when it comes to those youths actually attending YCs, boys and young men (and also those who do not categorize themselves in gender binary ways) perceive all domains of YCs as high as do girls and young women.
Still it is important to note that the girls/ young women in this study scored youth-friendliness high. It is known that teenage girls and young women take high responsibility for sexual health and contraceptives in partner relationships (22). In addition, young women are overrepresented in sick-leave and self-reported health problems (e.g. mental health problems), as well as in exposure to gender-based and sexualised harassment and violence (23, 24), which is why youth-friendly strategies for continuous, early health promotion are important to develop for these groups.
Sexual orientation was one aspect that influenced how young people perceived YCs. The literature shows that LGBTQ youth face barriers to accessing health care services (25-28). However, most studies take together as a group all non-heterosexual youths, and the mentioned studies were not performed at YCs. In our study, there were no significant differences between heterosexual, homosexual and bisexual youths, while queer, asexual and non-sexual youth as well as youth with trans experiences rated YCs’ differently—and generally lower. This could reflect the fact that while training, LGBTQ certifications, and other efforts might have had an impact in how health care services for youth address sexual diversity, youth with less normative sexualities still face increased barriers for accessing services.
The young people’s, and especially their parents’, country of birth were the variables that were most strongly associated with YCs’ lower rating in the different domains. The literature shows that migrants might face more barriers to accessing health care services, based on characteristics of the migrants themselves—e.g. socioeconimc status, language and information barriers—and, especially based on factors at the health-system level—e.g, policies that restrict access, and health care professionals’ attitudes, such as discrimination and racism (29-32). Despite equity being in the core of the YCs’ mandate, previous studies have highlighted that YCs’ staff perceive that young people with a migrant backgrounds access YCs to a lesser extent (11). This study goes further, pointing out that for those young people with a migrant background who actually reach YCs, their perceptions of the services are also a bit poorer.
Equity is a domain of youth-friendliness that other studies show as being among the most difficult to fulfil (2, 6, 11). While previous population-based studies have already pointed out that there are socioeconomic inequities in accessing YCs in Sweden (33), and YC staff’s perceptions support the hypothesis that certain sub-groups of young people access YCs (11, 12, 33) much less, this study reveals that sexual orientation and especially ethnic background are markers of inequities when it comes to YCs’ youth-friendliness.
Finally, and related with the equity domain as well, it is important to highlight that the sample does not represent the overall young population in Sweden (women, heterosexual, born in Sweden youth are overrepresented). We hypothesize that this, more than being a bias in the selection of the participants, is a reflection of who access youth clinics, and who does not. Special attention should therefore be given to implement strategies to improve access to certain subgroups of young people who might be in more need but accessing clinics less. There are a number of strategies in place when it comes to improving access to certain subgroups of youth, i.e. LGBTQ certification of clinics, visits of students when they are in 9th grade (15-16 years), tailored information and specific drop-in hours addressing those identifying themselves as boys/young men, and certain clinics collaborate with organizations working with unaccompanied youth. However, we claim that more measures need to be taken, including better promotion of the existence and services provided in youth clinics for all young people, especially for rural youth and those who have moved to Sweden recently and might not be familiar with the services. Crucial is also removal of any barriers related to payment (i.e. for young people who have not been granted legal residence). To date, there are some promising initiatives to overcome barriers and improve access such as the possibility to receive support via digital technologies (i.e. psychologist), including a web-based youth health clinic which is partly translated to additional languages (www.youmo.se).
Methodological considerations
The distribution of the questionnaires within the YCs might have differed and youth who were perceived to be less satisfied or who were not fluent in Swedish might have been excluded. Internal missing was evident in most questions. This study was only able to capture the visiting youths’ perceptions, and not other youths’ perceptions. Moreover, we were not able to gather information on how many young people declined to answer the survey and their sociodemographic characteristics.