The aim of this study was to investigate the relation between youth primary healthcare service use and psychological distress in times of increasing mental health problems. Based on Andersen’s healthcare utilization model, we expected an increase in psychological distress, such as the increase seen among the youth of Norway, would lead to an increased need for primary healthcare services and an increase in help-seeking behavior among the distressed. We found that between 2014 and 2018 psychological distress among young people continued to increase alongside increasing rates of primary healthcare service use. A large proportion of young people used available primary healthcare services, ranging from 10% using a psychologist to 60% using their family doctor over a 12-month period. Overall, psychological distress has a conditional association with youth primary healthcare service use and can explain between 16-66% of the change in the use of services between 2014 and 2018, depending on the service type. Young people with high levels of psychological distress tended to seek help from primary healthcare services twice as often as their peers with low levels of distress. Contrary to our hypothesis, the absolute increase in primary healthcare service use observed between 2014 and 2018 appeared to be driven mainly by young people with low levels of psychological distress and not by the increasing proportion of young people with high levels of psychological distress. While young people with low psychological distress use services more over time, young people with high levels of psychological distress use services less and less. This is suggestive of a converging trend. This decrease in service utilization among distressed young people was seen in all the youth primary healthcare services, except in the school health service.
Why do young people with high levels of psychological distress use primary healthcare services less over time despite the increasing prevalence of psychological distress?
In our data, based on self-reports, the proportion of young people with high levels of psychological distress increased from 13% in 2014 to 18% in 2018. An increase in psychological distress in Norway has previously been observed by other researchers in the period between 1992 and 2018 [4-8]. This increasing trend of mental health problems among young people is regarded as a public health concern . Psychological distress is usually considered to be strongly associated with primary healthcare service utilization among young people [12, 13] and according to Andersen’s health service utilization model , increasing rates of psychological distress should theoretically lead to an increased need for primary healthcare services. For young people this should constitute increased primary healthcare service utilization within the school health service and youth health centers or other primary healthcare services. Superficially, this appeared to be the case as we found that young people with psychological distress tend to use primary healthcare services twice as much as their peers with low levels of distress. However, between 2014 and 2018, youth service utilization of primary healthcare services declined yearly by 150 consultations per 1000 young people among those with high levels of psychological distress.
The cause of the decline in the utilization of primary healthcare services among distressed young people is unknown and was unexpected based on our proposed theoretical framework. The healthcare utilization model suggests that deteriorating health outcomes would create a greater need for care leading to greater primary healthcare service utilization. However, since our study does not support this idea, the implication is that there may be serious barriers between perceived need for care by young people and primary healthcare service access. This is in line with previous research that has shown that young people access services less than adults . The possible barriers between care needs and help-seeking behavior is particularly worrying in times of the increasing prevalence of psychological distress in the youth population.
At the present, it is not clear whether young people with high levels of psychological distress seek help elsewhere within the healthcare system (for example within the specialized healthcare service or from other care services), from informal sources (such as family and friends) or whether their healthcare needs remain unmet. There are indications that the proportion diagnosed with a mental health related disorders in the specialist health service (BUP) increased between 2011 and 2016, from 5% to 7% per year (mainly depression, anxiety-, adjustment- and eating disorder) among adolescent girls. The trend remained stable among younger children and boys. It is feasible that young people with high levels of psychological distress (especially adolescent girls) are more frequently referred from primary healthcare to the specialist healthcare in 2018 compared to 2014. However, as primary healthcare services are responsible for referrals to the specialized healthcare service, one would still expect an increase in youth primary healthcare utilization among the young people with high levels of psychological distress, contrary to the findings in the current study. According to the Norwegian Institute of Public Health the cause of increased referrals to the specialist healthcare service among adolescent girls remains unknown, although it is unlikely that direct changes in referral or diagnostic practices has contributed to the increase .
Other researchers highlight the paradoxical nature of increased provision of healthcare services, expenditure and utilization combined with a lack of improvements in mental health outcomes - one would expect that when healthcare services are effective, psychological distress and mental health outcomes would be improved . Thus, it is the responsibility of the healthcare system to provide equitable primary healthcare proportionate to healthcare needs in order to reduce psychological distress among young people. Great measures are taken in Norway to ensure high quality, easily available youth primary healthcare, but the extent to which the services provided are standardized and evidence-based is still under debate. Several Norwegian systematic reviews suggest that there is still room for improvement in the provision of youth primary healthcare services [41, 42]. The authors argue that the lack of improved mental health may be related to the quality of the care service provided and that currently these services do not meet the minimum standards of clinical practice guidelines. In addition, the services may fail to adequately provide preventive efforts in the pursuit of health promotion among young people and adults. This may suggest that the quality of the services provided for young people in Norway does not currently meet the needs of young people with psychological distress and that many distressed young people seek help elsewhere or possibly not at all.
Our finding that young people with high levels of psychological distress used primary healthcare services less between 2014 and 2018 despite deteriorating mental health supports the recommended quality improvements in healthcare systems suggested by Jorm et al. , in order to make primary healthcare services more effective in preventing further deterioration of mental health in the youth population and in order to ensure equitable primary healthcare service utilization proportionate to healthcare need.
Concerningly, at the present time there is no known explanation as to why young people with high levels of psychological distress utilize primary healthcare services less over time despite the growing proportion of psychological distressed youth in the Norwegian population. Policy makers and care providers should be advised that primary healthcare services should be made more attractive and youth-friendly in order to ensure equitable access for young people with high levels of psychological distress.
Why do young people with low levels of psychological distress use services more often over time?
Young people with low levels of psychological distress use primary healthcare services relatively less than those with high levels of psychological distress. However, between 2014 and 2018, service use among young people with low levels of psychological distress increased substantially. Compared to 2014, young people with low levels of psychological distress had 350 more primary healthcare consultations per 1000 young people in 2018. This leads to many questions regarding psychological distress and its effects on primary healthcare utilization. Since young people with low levels of psychological distress use primary healthcare services more often over time, this may suggest a change in the propensity to seek care, such as a lower threshold for seeking healthcare [43, 44].
A previous study found that the mean level of psychological distress among young people using psychiatric services between 2002 and 2010 decreased suggesting a lower threshold for help-seeking behavior among young people in Sweden. However, this development was not found among adults. The authors therefore argued that a lower threshold of help-seeking behavior among young people may explain the recent increase in psychiatric service use in Sweden and perhaps in other developed countries . Another study involving patient data from 34 countries investigated the propensity to seek healthcare and found that it was weakly associated with greater use of a family doctor . In addition, the authors found that the characteristics of the healthcare system might influence patients’ decision to seek help, potentially leading to either overuse or underuse of health services . According to the Norwegian Institute of Public Health , underuse of primary healthcare services appears to be more likely in the general population. On the other hand, the Norwegian Institute of Public Health points out that if help-seeking behavior were to increase among those with low levels of psychological symptoms as opposed to those with high levels of symptoms, as seen in our study and in a study by Kosidou et al. , this might instead indicate overuse of health services.
Our finding of increased primary healthcare service utilization among the less distressed are rather unexpected, based on the healthcare utilization theory, and it is a topic that has seldomly been explored in research. Subsequently, it is unknown to what extent this may represent a general phenomenon, reflecting greater societal awareness- or reduced stigma of mental health problems [13, 44]. Other researchers, however, suggest a more specific cause of increased primary healthcare utilization, specific to Norwegian youth. Bakken et al  suggest that a school-absence policy to reduce truancy, introduced in Norway in 2016, is likely to have caused inflated healthcare utilization rates of family doctors by young people, not related to morbidity. From the start of the 2016/17 school year, new rules for absence were introduced in upper secondary schools . The main feature of the new regulations is that students with more than 10% undocumented absence in a school subject lose their right to a graded semester assessment without which they are unable to graduate. In case of illness, only a medical certificate or documentation issued by a qualified healthcare professional will be considered as valid absence documentation following more than 10% absence from upper secondary school. According to Bakken et al. , the number of consultations in the general practice services increased by 30% in the age group 16 to 18 years in the year the reform was introduced compared to the previous year. This led the authors to believe that it is very likely that the school absence policy is inadvertently causing young people to overuse primary healthcare services. Bakken et al.  only included data on the use of family doctors among young people, but since health personnel (e.g., physiotherapists, dentists, psychologists) other than the family doctor may also document absence for the students , a similar increase could conceivably be observed in other primary healthcare services as well. Interestingly, our study partially confirms this. Young people in general (and to a greater extent young people in upper secondary school) with low levels of psychological distress had a general increase in primary healthcare service use after the policy change in 2016 above that of young people with high levels of psychological distress. This might suggest that part of the increase in youth primary healthcare service use is not a sign of increased morbidity, but rather in part due to young people needing a medical certificate to avoid failing subjects, further supporting the notion of overuse among young people with low levels of psychological distress.
Alternatively, the increased use of primary healthcare services among young people with low levels of psychological distress might partly be explained by a change in how young people utilize primary healthcare services for matters not directly relating to psychological distress and not captured in our study. Young people use primary healthcare services for a wide range of reasons, including sexual health (such as pregnancy, contraception and sexually transmitted infections) which is also one of the most common reasons for contact with youth primary healthcare alongside mental health issues .
It is challenging to elucidate on the cause of increasing primary healthcare utilization among young people with low levels of psychological distress. On the one hand, young people are known to utilize healthcare services less than adults, therefore a lowered threshold to seek-help may be seen as positive. On the other hand, since the trend of utilization of primary healthcare is disproportionate to expected healthcare needs this might also represent inequities in youth primary healthcare service utilization among young people. In addition, indications of inflated utilization rates not related to morbidity among the less distress youth are a worrying development that warrant further investigation. The propensity for young people to seek care remains understudied and more research is needed in order to determine if increased utilization of primary healthcare services among young people with low levels of psychological distress are due to overuse mechanisms.
Predisposing and enabling factors of service use
The predisposing and enabling factors covered in this study, gender, age, socioeconomic status, service availability and psychological distress, are all important indicators of primary healthcare service utilization among young people. In regard to gender and youth primary healthcare service use, it is well known that females use primary healthcare services more than males, a finding that is also observed in the current study. Given that males have the same need for primary healthcare services when they have psychological distress, it is not thoroughly understood why males report less help-seeking behavior. Empirical evidence indicates that low treatment rates among males cannot be explained by better health but must be attributed to a discrepancy between perception of need and help-seeking behavior [48, 49]. Furthermore, we found that older young people generally used primary healthcare services more often.
In terms of service availability, we found that youth primary healthcare utilization generally increased when services were more widely available.
We also found that overall, socioeconomically disadvantaged young people used primary healthcare services more than the more advantaged. This might suggest services utilization proportionate to those with the greatest need .
Strengths and limitations
A major strength of this study is that it is based on a very large sample of young people and has a yearly data collection scheme allowing the investigation of trends in the general youth population in Norway. In addition, data are weighted and adjusted in order to ensure national representativeness of young people growing up in Norway . However, one limitation is that the repeated cross-sectional design used in the current study does not enable strict causal inference. In addition, this study relies on self-reported data, which provide the overall picture from the young people’s own perspective and might be distinct from objective data. Moreover, due to ethical guidelines, additional subgroup analysis of primary healthcare services disparities in vulnerable groups were not possible. Finally, the use of youth primary healthcare services is a general outcome in the survey and therefore the specific reason for the consultations are not known and could be related to health outcomes other than those studied in our paper.