Young parents’ views andexperiences of interactionswith health professionals

Claire Norman,1,2 Suzanne Moffatt,3 Judith Rankin4

1Foundation Doctor, Institute ofHealth & Society, NewcastleUniversity, Newcastle upon Tyne,UK2Foundation Doctor, RoyalAlexandra Hospital, Paisley, UK3Senior Lecturer in Sociology ofHealth, Institute of Health &Society, Newcastle University,Newcastle upon Tyne, UK4Professor of Maternal &Perinatal Epidemiology, Instituteof Health & Society, NewcastleUniversity, Newcastle uponTyne, UK

Correspondence toDr Claire Norman, Institute ofHealth & Society, NewcastleUniversity, Baddiley-ClarkBuilding, Richardson Road,Newcastle upon Tyne NE2 4AX,UK; Clairenorman90@gmail.com

Received 8 February 2016Revised 25 April 2016Accepted 16 May 2016

▸ http://dx.doi.org/10.1136/jfprhc-2016-101536

To cite: Norman C,Moffatt S, Rankin J. J FamPlann Reprod Health Care2016;42:179–185.

ABSTRACTBackground Although teenage pregnancy levelsare declining, the North East of England still hasthe highest rate of young parenthood (age <18years) in the UK. Young parents and theirchildren often face many health and socialproblems, requiring interactions with a widerange of health professionals, such as midwives,doctors and health visitors.Aim This qualitative interview study aimed toexplore young parents’ views and experiences ofinteractions with health professionals.Methods Young mothers and fathers (n=10)were recruited from youth groups and Sure Startparenting classes in Newcastle upon Tyne duringthe period April–June 2013. They took part inone-to-one or small group semi-structuredinterviews regarding their experiences ofinteracting with health professionals about theirown health and that of their child. Theinterviews were transcribed and analysed usingthematic content analysis.Results Emergent themes included: beliefsabout children’s health; proving oneself as aparent; and positives of parenting. All theparticipants distinguished between being a ‘first-time parent, not just a young parent’ and all, tovarying degrees, challenged the authority andjudgement of medical and nursing practitionerswith regard to their children’s health.Conclusions The findings of this study highlightthe need for health professionals to beparticularly aware of the sensitivities arising fromthe power imbalances perceived by youngparents of ill children. This can be achieved byfollowing communication skills frameworks(e.g. the Calgary-Cambridge framework) thatemphasise the importance of techniques such asactive listening and building rapport.

INTRODUCTIONUnder-18 conception rates are one of theindicators for ‘Health improvement’ in

the Public Health Outcomes Frameworkfor England 2013–2016,1 indicating theimportance placed on teenage pregnancyand its consequences for health and well-being. Although under-18 conceptionrates are currently at the lowest levels inEngland and Wales since records began in1969, the North East of England con-tinues to have the highest rates in thecountry: 30.6 conceptions per 1000 15–17-year-olds compared to the Englandand Wales average of 24.3 per 1000.2

Young mothers (typically classified instudies as those aged <19 years at thetime of birth, although other age categor-ies can be used) are at an increased riskof postnatal depression,3 obesity4 anddeath due to violence or assault.5 Theirchildren are at increased risk of beingborn pre-term and dying within the first28 days of life.6 Importantly, socio-economic factors are also likely to impacton these outcomes as deprivation is con-sidered both a consequence and a causeof teenage pregnancy.7

Existing literature on young parents ofchildren with disabilities’ interactionswith healthcare professionals has foundthat parents often feel judged by the pro-fessionals and that their opinions are

Key message points

This study highlights a need for:▸ Better health education for young

people and parents with thorough expla-nations at the point of service use.

▸ Increased availability of services andmore services for parents aged 18–24years.

▸ Non-judgemental attitudes from allhealth professionals.

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perceived as invalid.8 Tensions can exist between pro-fessionals and parents of all ages regarding whoknows best for the child and there may be a dichot-omy between wanting to seek help promptly but alsonot wanting to ‘bother’ the doctor, making it difficultfor parents to take the action perceived as correct.9

Like most health service users, young people valueconfidentiality, empathy and thorough explanationsfrom their healthcare professionals10 and they do notwant to be patronised or judged.11 As the quality ofpatient–practitioner interaction is known to impact onlevels of adherence to treatment12 and healthoutcome,13 it is important that these interactions areof a high standard. Communication frameworks suchas the Calgary-Cambridge framework are often usedas a gold standard for consultations.14

The aim of this study was to explore young parents’views and experiences of interactions with healthcareprofessionals. Despite the fact that young parents arealready known to be a vulnerable group with whomgood communication is key to positive interaction,this study highlights aspects of care that could still beimproved.

METHODSThis research used qualitative research methodsemploying semi-structured interviews. Ethical approvalwas obtained from Newcastle University’s Faculty ofMedical Sciences Research Ethics Committee (Ref:00627/2013).

Sample and data collectionMothers and fathers who were aged 18–24 years atthe time of interview, but who had had their firstchild under the age of 20 years, were eligible forinclusion in the study. Participants were recruitedfrom Sure Start groups [NB. Sure Start children’scentres are a government-led initiative that aim toprovide high-quality education and childcare support

for preschool-aged children.],15 a voluntary teenagepregnancy service and local independent youth groupsin Newcastle upon Tyne during the period April–June2013. Given that this population is challenging torecruit, some flexibility on participant characteristicswas required. One participant was 24 years old at thetime of his child’s birth but as he was attending a‘Young Dad’s’ group, his experiences were still felt tobe relevant; likewise a mother who was 20 years oldwhen she gave birth but identified herself as being ayoung parent was also included. Participants wereinterviewed alone or in pairs of friends at a locationthat the young parents were comfortable with andwhere their children could be looked after during theinterview. A request was made to audio record theinterview, most participants (n=8/10) gave consent.The two participants who refused to be recordedagreed to contemporaneous notes being taken.Interviews lasted 20–45 minutes; a topic guide wasused which covered experiences of good and bad con-sultations, experiences regarding seeking help forthemselves and for their children, and any issues theyfelt were particularly relevant to young parents.

Data analysisInterviews were transcribed in full, checked for accur-acy and extensively re-read by CN, with input fromSM and JR. Thematic content analysis16 was usedwhereby themes were derived from the interview datain its transcript form, using line-by-line analysis.A coding frame was drawn up by all authors,grounded in the data from the first three transcripts.The initial 146 explanatory and analytical codesdeduced were grouped into a framework of sub-themes and overarching themes (Figure 1) and appliedto the rest of the transcripts. NVivo software was usedto code and manage the data, and constant compari-son of the transcripts allowed concepts to emerge andbe mapped to the framework. Deviant case analysis,

Figure 1 Themes, subthemes and over-arching themes.

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where we sought out and examined narratives whichmodified or contradicted the analysis, was used toenhance validity.17 18

RESULTSParticipant characteristicsSeven women and three men aged 18–24 years (nonein a partnership) were interviewed (Table 1). Sevenparticipants lived in socio-economically deprived areasof Newcastle (as derived from their residential post-code at the time of interview), one was a universitystudent, one lived in a relatively affluent area andpostcode data was not obtained from the final partici-pant. Pseudonyms are used throughout and illustrativequotes are presented.

Research findingsA total of 146 initial codes were mapped to 12 sub-themes and six overarching descriptive themes(Figure 1). Two overarching themes of ‘judgement’and ‘challenging authority’ were also identified asbeing present throughout all interviews. The themesdeemed most relevant to improving practice areexplored below. Young father-specific issues are notincluded as we felt their views have been extensivelyresearched by Ross et al.19

Features of interactions with healthcare professionalsDifficulties in accessing healthcare was a commontheme throughout the interviews. Young parents werefrustrated by difficulties in obtaining appointments tosee their general practitioner (GP) or health visitor.One mother attended a GP surgery with a drop-inclinic for babies and felt this service should be morewidely available. Conversely, a number of the otherparents lived in an area with a drop-in centre thatwould not see children under the age of 2 years,resulting in parents inappropriately using emergencyappointment slots at their GP surgery or attending ahospital accident and emergency department.Regarding the consultation itself, positive attributes

and traits included professionals who made it obvious

that they were listening and non-judgemental, as wellas those who were perceived as competent and inter-acted well with children. Negative features were theconverse of these: professionals who were rushed,condescending or were perceived to make incorrectdiagnoses and management plans. Some participantsmentioned that they felt like most health professionalswere in a different class to them, and although thisgenerally led to a poorer relationship it could be bene-ficial if the professional acted as an advocate.

“At the [social services] meeting [midwife] was sayingsome of the things that I was trying to get across …

and with her being a professional, obviously peoplelisten to professionals, unlike me being a nobody.”[Rob, 24 years old]

Child health beliefs and proving oneself as a young parentDisagreements between parents and health profes-sionals regarding the health of a child was a commoncause of negative feeling. Participants felt that they (ortheir own parents) knew more about bringing up chil-dren than ‘pushy’ health visitors. They gave examplesof times when they had intuitively known somethingwas wrong with their child but were told it was “just aviral [virus]”. Dismissal of concerns with the explan-ation that symptoms were due to a viral illness was acommon complaint; participants avoided seeking helpbecause they were never satisfied with the outcome ofthe consultation. One mother was keen to point outan occasion when her GP had dismissed her concernsand the child had subsequently needed hospitalinvestigations.

“He telt [told] me that my baby was fine when she wasin hospital with suspected meningitis so why should Ilisten to him … he’s useless.” [Kay, 20 years old]

The participants were determined to prove them-selves as good parents. Mothers felt that their age ledto being ‘looked down on’ by health professionals andmembers of the public.

“The doctors look at you like you’re just young andstupid and they know everything and you don’t knowanything.” [Lisa, 21 years old]

Interestingly this was not a feeling shared by theyoung fathers, who denied feeling judged.Although insistent that they should not be treated

differently because of their age, some participants feltthat they would benefit from extra support. They typ-ically had positive experiences of parenting classessuch as those run by Sure Start, although stressed thatattendance at these should be voluntary not manda-tory – another indication that autonomy and self-determination is very important to young parents.The participants seemed keen to show that they

were different from the stereotypical perception ofyoung parents. They themselves looked down uponothers they knew who had been significantly younger

Table 1 Participant characteristics

Characteristic n (%)

Female 7 (70)

Male 3 (30)

White British 10 (100)

Age (in years) at birth of first child

16–17 6 (60)

18–19 2 (20)

20+ 2 (20)

Employed or in education 5 (50)

One child 8 (80)

Lives in lowest index of multiple deprivation (IMD) quintile 7 (70)

Living with child’s other parent 3 (30)

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when becoming pregnant or whom they felt had onlystarted a family for financial gain. This lack of solidar-ity or ‘othering’ could be viewed as an attempt to dis-tance themselves from the negative stereotypesdirected at teenage parents and is commonly foundamong already stigmatised groups.20

“Obviously you do get teenagers doing things like justto get a house … cos obviously there is a lot of peoplethat do that, so they just judge all teenage mums.”[Lisa, 21 years old]

Judgement and challenging authorityJudgement and ‘challenging authority’ were two over-arching themes present throughout all interviews.Poor relationships between participant and practi-tioner were often fuelled by disagreement over whoknew best regarding the child’s healthcare. The youngparents saw themselves as experts regarding theirchild; a position that most of them were seldom inand as such reluctant to let go of, particularly to ahealth professional whom they perceived to be disin-terested and from a different social background. Theywanted to challenge the paternalistic patient–practi-tioner relationship.Not all professionals were criticised, however.

Midwives were generally viewed favourably by theyoung parents, compared to health visitors or GPs.This may have been due to the timing of their involve-ment; midwives being present before and immediatelyafter the birth of the child, giving advice and encour-agement. A perinatal psychiatric nurse was particularlypraised.

“I just got like a really good bond with her, really good… it didn’t feel like she was judging us or anything likethat.” [Lisa, 21 years old]

This compared unfavourably with doctors whowere sought when something was going wrong andhealth visitors who were perceived as ‘checking up’on the child and parent.

“[Health visitor] thinks that as a young mum that Icouldn’t do anything. Like I was stupid.” [Kayleigh, 20years old]

In difficult or stressful scenarios there may havebeen more chance for perceived criticism of parentingabilities.Young parents felt they were being judged and criti-

cised for being a parent – “everyone just slates you forbeing a mum at 16”, said Alyssa, aged 20 years. Thisjudgement was felt to be linked to age and perceptionsof intelligence.

“I guess if you’re younger, you’re less educated andthey just assume you don’t know as much.” [Rachel,24 years old]

Feeling looked down upon was commonly experi-enced, and consequently young parents were reluctant

to engage with health professionals. Even midwiveslost favour if they were ‘bossy’ or ‘pushy,’ highlightingagain the young parents’ need to feel in control oftheir situation and have their views taken seriously.

DISCUSSIONThis study confirms what is already known aboutwhat young parents want from a health practitioner;professionals who listen, are non-judgemental andeasy to contact.8 10 11 These are aspects of holistic,patient-centred care that all professionals should beproviding.21 However, this study also found thatyoung parents’ feel the need to prove their worth ascaregivers, often manifesting in a tendency to chal-lenge the authority of health professionals. Thisreflects Brady et al.’s22 work highlighting the import-ance of young parents feeling in control when acces-sing healthcare. We suggest that this urgency to provetheir parental knowledge and abilities is a response tothe prevailing societal judgement and stigma directedtowards young parents.23 24 Participants’ accountsdemonstrated that they were angered and dismayedwhen their concerns were dismissed. They were facedwith a quandary similar to the participants in Neilet al.’s 2013 study; either be put off seeking help andbe regarded as a bad parent or attend and be subse-quently criticised for wasting time with a viral illness.In contrast to studies from the 1970s,25 26 our studyparticipants showed no indication of being ‘in awe’ ofthe health professionals. They saw instant access tohealthcare as their right, and some participants madescathing judgements regarding health professionals’competence.Particularly negative experiences could prevent the

parents interviewed consulting with a GP or healthvisitor. Instead, parents would go straight to the acci-dent and emergency department at the hospital,which is far from ideal when UK secondary care ser-vices are already stretched.27 As patient satisfactionand health outcome is linked to the quality ofpatient–practitioner relationship,13 the poor healthstatus of young parents and their children may belinked to their perceived poor relationship withvarious healthcare professionals.The young people in this study spoke highly of their

local Sure Start groups, which provide practical helpand advice as well as an opportunity to make friendswho were sharing similar experiences. Although it wasfelt that attendance at these classes should be volun-tary not mandatory, they were obviously a valuedasset. Unfortunately, services such as these are subjectto funding cuts due to austerity -driven public sectorbudget reductions, which are disproportionatelyhitting the poorest areas with the worst health out-comes hardest.28 Worryingly, further cuts to publicspending and welfare will result from the latest UKgovernment budget.29 Suggestions for improvementincluded better advertising of existing services by GPs

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and midwives and more services aimed at parentsaged around 18–24 years, who felt that their needswere neglected in favour of very young mothers (<16years) or older, professional women.The strengths of this study lie in the acquisition of

primary data from a group of young people who arechallenging to recruit into studies. Early engagementwith stakeholders ensured that the subject topics wererelevant and acceptable, which was helped by the factthat the primary researcher was of a similar age to theparticipants. Thematic content analysis provided athorough and rigorous exploration of the data.Limitations of this study included that participants

were normally attendees of Sure Start or similargroups, and as they had already shown a willingnessto engage with such services, their views may have dif-fered from those of less engaged young people. Someparticipants (n=4) were aware that the interviewer(CN) was a medical student, which may have influ-enced their answers. The older participants may havehad different experiences and their views may not beas applicable to younger parents.Ultimately, this research demonstrated the need for

better communication skills and mutual respectbetween young parents and the health professionalswho care for them and their children. Many of thegrievances aired by participants related to the dismis-sal of health complaints as trivial. If health profes-sionals had more time to establish what parents’ ideas,concerns and expectations were and, if necessary,

explain to the parents why they were not recommend-ing further treatment for the child, better understand-ing and relationships might ensue. Healthprofessionals need to convey the fact that they aretaking concerns seriously and that they are actively eli-citing and listening to the parents’ concerns. Ideally,the formation of a collaborative relationship betweenparent and practitioner could result in the youngparent leaving the consultation feeling reassured abouttheir child’s health and also educated about similarcomplaints in the future, rather than sensing real orenacted criticism. However, the constraints of time inthe consultation make this a challenge to achieve.Adequate ‘safety-netting’ is required to ensure that a

parent knows to bring their child back to the attentionof the health services should the health of the childdeteriorate. Active listening and safety-netting are nowcore communication skills that are taught to healthprofessionals using tools such as the Calgary-Cambridge framework, but it may be necessary topromote their more widespread use in practice.30

Applying experiences of good and bad practice ontothe Calgary-Cambridge framework, as shown inFigure 2, demonstrates how the findings of this studycould form the basis of further training for healthprofessionals working with this client group. Thisframework was chosen as an example due to its wide-spread use in undergraduate and postgraduate medicaleducation.31 Positive examples are highlighted with agreen box and negative examples are bordered red.

Figure 2 Positive and negative experiences mapped to the Calgary-Cambridge framework.

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CONCLUSIONSThis study demonstrated the ease with which commu-nication between health professionals and youngpeople can break down. Young parents, most ofwhom were from socioeconomically deprived back-grounds, felt the need to challenge authority andhealth professionals’ clinical judgement in order toprove themselves as parents, and almost all of themfelt judged because of their age. These factors reducedthe young parents’ willingness to constructivelyengage with health professionals regarding theirhealth or that of their child. Health professionalsneed to be aware of the sensitive nature of this groupand need to work at ensuring the provision of access-ible, friendly and non-judgemental healthcare toeveryone, regardless of their age or level of education.These findings are particularly relevant to sexual andreproductive health practitioners given the sensitivenature of their interactions.Future research could explore the views of a larger

group of young parents, from different parts of theUK and beyond. Specifically, younger parents andthose from other ethnic groups should be included toexplore whether they have had different experienceswhen seeking healthcare. To complete the picture, theviews of healthcare professionals themselves shouldalso be gathered.

Acknowledgements The authors would like to thank all theparents for agreeing to take part in this study, as well as localSure Start groups and the Barnardos Teenage Pregnancy Team.

Competing interests None declared.

Ethics approval Newcastle University Ethics Committee (Ref:00627/2013).

Provenance and peer review Not commissioned; externallypeer reviewed.

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