Introduction

Mental health conditions are worldwide public health issues, and they are on the rise among young people, including those younger than 18 years of age, especially those from lower-income families and communities. In 2019, a new California State Bill (SB12) stated that one half of the youth population will meet the standard for one or more mental health conditions during their lifetime (Beall et al. 2019). A 2019 study from the Born this Way Foundation (BTWF) found that 90% of young Californians (age 13 to 24) are concerned about their mental health; however, 1 out of 3 reported that they lack adequate access to mental health services (BTWF and MHSOAC 2019).

To improve mental health in the U.S., youth-friendly clinics have opened in areas of high need. They are all equipped to offer mental health services on site to minors, including free, nonrestrictive and fully funded sexual and health services (WHO 2012; LADPH 2018). These clinics also offer support for addiction disorders, domestic and intimate partner abuse, and a wide range of mental health services (WHO 2012).

However, poverty at the family and community level, along with a lack of knowledge among clinic staff regarding mental health practices as mandated by recent legislation, can prevent minors from accessing mental health-related services (Patel et al. 2007; Gulliver et al. 2010). Staff’s presumed lack of training and motivation to properly engage with young people add to the challenges and missed opportunities that youth face as they seek mental health care (Patel et al. 2007).

Moreover, poverty is associated with increased rates of sexually transmitted diseases and susceptibility to mental illness (Hogben and Leichliter 2008; Santiago et al. 2013). According to data from the Los Angeles County Department of Public Health (LADPH), in 2017, 68.3% of the population living in Service Planning Areas (SPA) 6, 7, and 8 (854,231 people) were in households with an income less than 100% of the official federal poverty level; and 73,694 of them were children younger than 18 years of age (LADPH 2017).

In this pilot study, we interviewed front staff members of youth-friendly clinics located in Los Angeles, County SA 6, 7 and 8, to gauge their awareness of mental health services provided by their clinics.

Methods

Study Design

Six interns were trained via webinar as clinic site evaluators. They administered a five-question survey tool (Appendix 1) face-to-face to front office administrative staff at 36 high-priority, youth-friendly clinics located in SPA 6, 7, and 8 between September and October 2018. In Los Angeles County, there are a total of eight SPAs, which are specific geographic areas of LA County. Interns surveyed clinics in SPA 6, 7, and 8 that agreed to participate in the LADPH Youth Prevention Program, a Division of the HIV and STD Program. The survey was designed to assess the awareness of responding clinics’ front office personnel regarding new standards that allow minors to receive reproductive, sexual, and mental health care without parental consent (Appendix 1). Of note, all surveyed clinics in the three SPAs offer mental and sexual health services on site, and all 36 clinics are able to refer patients for mental health and sexual health services if more specialized care is necessary.

Statistical Analysis

A paper-based survey tool was used to collect raw data on participant responses. These were then compiled into a single report using Microsoft Excel. Statistical analyses were conducted using the SAS Studio version 9.4 programming language. The chi-square test and Fisher’s exact test were conducted to identify factors influencing clinic staff awareness.

This study was approved by the Western Institutional Review Board (WIRB No: 1-1057191-1).

Results

Descriptive Statistics

All 36 clinics contacted completed the survey. The collected data are summarized in Table 1.

Table 1 Clinic front desk personnel response by SPA
Full size table

Out of the 36 clinics surveyed, front desk personnel in 6 (16.7%) clinics knew that there was no minimum age for minors to receive birth control without parental permission (Fig. 1). front desk Personnel in 14 (38.9%) clinics knew that minors 12 years and older can receive STD/HIV testing, treatment, and prevention services (including HPV vaccination) without parental permission (Fig. 1). Front desk personnel in 25 (69.4%) clinics were aware of the availability of Family-PACT insurance for minors (Fig. 1). Front desk personnel in 21 (58.3%) clinics reported providing resources to minors experiencing domestic abuse or intimate partner violence. And front desk personnel from 20 (55.5%) clinics reported providing resources to minors struggling with either mental health issues (such as anxiety or depression) or alcohol or drug abuse (Fig. 1), meaning that in slightly more than half of the participating clinics minors had access to mental health services.

Fig. 1
figure 1

Youth-friendly clinic front desk personnel’s correct responses to health services questionnaire

Full size image

Front desk personnel in clinics in SPA 6 were more likely to be aware of the new legislation allowing minors to receive sexual and mental health services without parental consent; however, in more SPA 7 clinics the personnel was aware of the availability of mental health services and resources for domestic abuse or intimate partner violence compared with SPA 6 (Table 1). Only four clinics were surveyed in SPA 8; therefore, data from that SPA are too limited to allow for comparisons with SPAs 6 and 7. Chi-square analysis and Fisher’s Exact test did not indicate any significant relationship between clinic front desk staff being aware of the minor healthcare legislation or Family-PACT insurance and whether these clinics offered pregnancy, STD/HIV, mental health or HPV vaccine services to the minors; however, the sample size is too small to draw definitive conclusions.

Discussion

In this pilot study of youth-friendly clinics in SPA 6, 7, and 8 in Los Angeles County, front desk staff in 30 (61.1%) of the clinics did not know about the legislation that allows minors to receive care for pregnancy, STDs, and HIV, as well as the HPV vaccine, without parental consent. Front desk staff at 76% of the clinics surveyed knew about the availability of Family-PACT insurance for youth. Front desk staff of only about half of the surveyed youth-friendly clinics from SPA 6 and SPA 7 knew about the legislation that allows minors to receive, mental health care and support for alcohol or drug use disorders and domestic/intimate partner abuse, even though they were fully authorized and equipped to do so.

Essential to the training of health workers are the general guidelines that dictate and reinforce adequate youth health services (Tylee et al. 2007). The World Health Organization (WHO) has developed such policies for clinics to follow in the provision of sufficient and reliable healthcare services to youth (Tylee et al. 2007; WHO 2012). A 2007 study in England found that in both developing and developed countries, the use of WHO guidelines and the proper training of health providers increased young people’s access to health services, as well as the quality of the services they received (Tylee et al. 2007). In 2019, California SB 12 noted the lack of awareness and understanding of youth mental health services, as well as their accessibility. The bill recommends that staff who participate in youth mental health programs be able to engage with youth and afford access to a full range of mental health, substance abuse, and physical health resources (Beall et al. 2019).

The lack of staff awareness described above is especially prevalent in low socioeconomic communities, where the need for services is typically high (Hogben and Leichliter 2008). Recommendations for clinics offering youth programs include increasing awareness, communication, and logistical support between staff and youth. A 2015 study by the Netherlands Institute for Health Services Research suggested that general practitioners be trained to recognize the presence of mental health issues among minors and refer them to appropriate services (Verhaak et al. 2015). A 2007 study focusing on communication proposed to improve health professionals’ outreach to youth by expanding delivery of mental health services (Rickwood et al. 2007). Lastly, regarding logistical support, a 2013 study recommends enhancing teamwork between clinical staff and other health professionals with a view toward offering affordable and accessible health services to meet the mental health needs of youth.

This pilot study shows that the front desk personnel in only about half of clinics in participating SPAs are aware of the availability of mental health services to the minor youth in the clinic. This gap in knowledge may lead to missed opportunities in Los Angeles County regarding the provision of mental health support to at-risk youth. More research is needed to better understand the factors influencing the awareness of youth-friendly clinic front desk personnel in California on the legislation and best approaches to train them.