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Introduction
Overview
Health justice partnerships (HJPs) are integrated service models established to mitigate the impacts on health from issues that have a legal origin and that, if left unattended, can be detrimental to the health of individuals1. Typically, HJPs represent collaborations between health services and legal services whereby a lawyer works within the healthcare agency or setting. Evidence from HJPs demonstrates the positive contribution of legal services on the mental health of program recipients including improvements in depression, stress, anxiety and wellbeing upon delivery of legal assistance2. HJPs provide a tangible intervention for addressing the social determinants of health2, a concept whereby societal factors, economic factors and inequalities diminish the health of individuals and communities3-5.
A regional HJP for youth (referred to as the health justice partnership for youth, HJPY) was established in 2015, providing services to a region comprising six local government areas that include areas of disadvantage (including disability and non-school completions) and raised criminal incidents6,7. This article reports on research conducted alongside this program.
Health justice partnerships in Australia
Evidence from Australian HJPs provides broad support for these nuanced, integrated health and legal services. This includes programs that support adolescents and young people who may be experiencing homelessness, family violence or have chronic health conditions8-10.
Place can lead to disadvantage and vulnerability, with regional and rural populations experiencing higher levels of poverty, elevated health risks, decreased mental health, reduced incomes and education attainment11-13. Diminished access to support services further compounds the negative health outcomes for young people in these areas14. A small number of HJPs have been established to support youth experiencing barriers in regional and rural Australia. Evidence highlights that these programs empower young people to seek support for their legal matters6,9.
About this study
The present research extends the limited available research about HJPs for youth in regional Australia by examining (1) the perceptions of regional young people, and youth and allied health workers, about the impact of legal matters on the health and wellbeing of young people and (2) the role of this HJPY in addressing these matters in the health of young people.
About the health justice partnership for youth
Commencing in 2015, the HJPY involved a partnership between three local organisations: a tertiary institution, community health service and community legal service (the partner agencies). The program supported youth experiencing legal barriers and was established in a regional location associated with disadvantage7. Consistent with most HJPs, an integrated service was delivered between the community health service and the community legal service. The program lawyer was co-located at the community health service. The tertiary institution was the lead organisation, which procured and administered funding, and conducted research to evaluate the program7. In 2018, a statewide legal service replaced the local community legal service. Reduced funding for the HJPY led to a reduction in the operational hours from 2 days per week to 1 day per week in the latter stages of the program.
Data collection by legal services
Data were collected for two periods when the HJYP was operational. There was a pause in the HJPY service delivery when the service was temporarily unfunded.
- Data collection 1 (community legal service), July 2015 to December 2016: A total of 133 young people (female: n=57; male: n=78) aged 15–25 years were referred to the program and for whom a file was opened. The majority (n=101) of the young people were aged 18–25 years.
- Data collection 2 (statewide legal service), October 2018 to December 2020: A total of 286 young people were referred to the program. Of these, a file was opened for 74 young people (female; n=47; male; n=24) aged 15–25 years. The majority (n=36) of young people were aged 18–25 years. Age was not recorded for 31 young people.
For both periods of data collection, a file was opened if a young person was referred to the HJPY and a lawyer provided them with legal advice. If a young person was referred to another service, and no legal assistance was provided through the HJPY, a file was not opened.
Data collected by the community and statewide legal services differed. Specifically, for data collection 2, data were incomplete for young people across some variables (e.g. age was not recorded for 31 young people). The data from the statewide legal service were anonymous and prevented cross-referencing with existing/previous clients, so there may be some overlap between clients for the two data collections.
Referrals to the HJPY originated from workers at partner agencies, from young people (self-referrals), family and friends, and from workers at external agencies (including community, disability and health services, and schools).
Methods
For young people
Young people received a letter of invitation about the research immediately after their first HJPY consultation. Young people agreeing to participate in the study were invited to complete two surveys: an intake survey (available online) and an exit survey (the latter offered to young people 3 months after their case closure). The exit survey was administered by phone by one of the researchers only after the young person verbally consented to participate in the study. The intake survey comprised 14 questions relating to demographics, current/previous legal problems, and the perceived effects of their legal issue on health and wellbeing. This was examined through factors such as stress, sleeping, relationships with friends and family, concentration, perceptions about how well they looked after themselves, their confidence, and if they felt supported. Responses to the questions required tick boxes and a Likert scale, with options available for supplying additional comments and further information. The exit survey comprised six questions. The first comprised eight statements about their experience of the legal service, to which participants could respond by choosing ‘yes’, ‘no’ or ‘not sure’. Participants were also asked to comment on the perceived impacts on their health and wellbeing following their involvement in the HJYP. There were a series of nine statements, to which participants could respond ‘better’, ‘no change’ or ‘worse’. The final questions in the exit survey asked young people to comment on whether seeking assistance with their legal problem made a difference and in what way, and whether they had any other comments about their experience of seeing a lawyer. The intake and exit surveys were written in ‘Easy English’ and informed by past research instruments15-17.
For partner and external agency workers
Youth and allied health workers from the partner and external agencies received an email with information inviting their participation in the research, with a link to an online survey. The survey comprised 13 questions, six of which sought demographic information about the participant’s role, the frequency of referrals to the HJPY, and about their experience of the HJPY. Two questions focused on any noticeable outcomes, and whether they had observed changes in the health and wellbeing of young people referred to the program. The focus of the remaining questions was on the website and the legal health check. With the exception of the demographic questions, all questions comprised two parts: the first was a yes/no response and the second part asked participants to provide examples.
Ethics approval
This research received approval from the Human Research Ethics Committee at Federation University Australia (A15-061).
Results
Secondary data
Data provided by the legal services show that young people experienced 207 legal matters during the two data collection periods. Some young people (27%) presented with multiple legal matters requiring different legal responses. In this article, legal matters are problems where there is a legal remedy. They were categorised into three groups across the three jurisdictions:
- civil (n=82), relating to intervention orders, Victims of Crime Tribunal
- criminal (n=87), relating to drugs, driving offences and breaches of intervention orders
- family law (n=38), relating to custody arrangements and paternity testing.
During 2018–2020, legal information and advice constituted the majority of legal assistance delivered to young people. Additional services included referrals and other forms of representation (eg letters and court/tribunal services).
Responses of young people
A total of 64 young people completed an intake survey. Young people (72%, n=46) indicated that their current legal issue was ‘very important’ to them, requiring them to seek assistance with a range of legal matters including attendance at court, family violence, victim of crime, access to children or custody issues, unpaid fines, driving offences, credit/debt and sexual assault. Most young people (61%; n=39) indicated that their current legal issue(s) were affecting their life. This ranged on a continuum from minor to significant on the following health and wellbeing factors:
- sleep (n=46)
- stress level (n=46)
- how they were feeling, generally (n=42)
- how supported they felt (n=41)
- concentration (n=40)
- level of confidence (n=39).
Young people (n=14) commented that their legal problem was affecting them in other ways, including the loss of a driver licence and inability to retain work. For other young people, the legal problem had affected how they were feeling generally, with two young people commenting that the legal problem was affecting them ‘in every way’ and that it was ‘always on their mind’.
Ten young people completed the exit survey. Most young people (n=9) indicated improvements in their health and wellbeing in relation to their stress levels, sleep, concentration and how supported they felt. Family relationships and how young people were feeling had generally improved but there was limited change in interactions with friends, as shown in Table 1.
Table 1: Young people’s reporting of changes in health and wellbeing indicators following attendance at the health justice partnership youth (n=10)
| Indicator | Better | No change | Worse | No response |
|---|---|---|---|---|
| How they concentrated | 9 | 1 | ||
| How they were sleeping | 7 | 3 | ||
| Stress levels | 8† | 1 | 1 | |
| How supported they felt | 8 | 2 | ||
| How confident they felt | 4 | 4 | 2 | |
| How they were feeling generally | 5 | 2 | 3 | |
| Family relationships | 6 | 3 | 2 | |
| How they looked after themselves | 4 | 5 | 1 | |
| Hanging out with friends | 3 | 7 |
† One person noted that their stress was at a level that was ‘the best they had been in for 4 years’.
Responses of partner and external agencies
The surveys were completed by youth and allied health workers from 20 partner agencies and 28 external agencies. Most youth and allied health workers (56%; n=30) observed changes in their clients following attendance at the HJPY, with some (n=14) observing no changes. Observed changes were associated with improvements to the wellbeing of young people, including their mental health, through reduced anxiety and improved mood. Some workers observed improvements to positivity, self-worth and confidence in young people attending the HJPY. These ideas are reflected in the following feedback:
Reduction in anxiety and increase in empowerment and assertiveness. (partner agency worker feedback, survey time 1)
Clients’ mental health and general wellbeing has improved knowing their issues are being addressed. (partner agency worker feedback, survey time 1)
… rates of anxiety, mood concerns, self-esteem have all improved. (external agency worker feedback, survey time 2)
Workers commented that the resolution of legal problems enabled their clients to move their attention from legal matters to other important aspects of their life, including health, personal and social matters. These ideas are captured in the following comments:
The legal issues they were faced with have been eased or alleviated. (external agency worker feedback, survey time 2)
Better engagement with programs. Lowered clinical symptom profiles. Improved confidence and ability to focus on other health and social needs. (external agency worker feedback, survey time 2)
There have been clear positive outcomes of healthier relationships, stable accommodation, decreased offending etc. (partner agency worker feedback, survey time 1)
Workers also commented that the HJPY had enabled some young people to feel ‘empowered and supported’. One worker commented that the program had alleviated the stress that the legal issue caused young people. The HJPY had also reduced the sense of isolation experienced by some clients as a result of legal matters. These ideas are captured in the following quotes:
They [the young people] feel more empowered and supported. (partner agency worker feedback, survey time 1)
Young man has become more optimistic and feels empowered to negotiate accommodation options. He has secured better accommodation now and is getting on with his life. (partner agency worker feedback, survey time 1)
Number one [priority] is just feeling supported by someone as clients often feel [and are] very alone in their legal issues. (external agency worker feedback, survey time 2)
… alleviation of avoidable stressors that may not have been identified prior to the program’s inception. (external agency worker feedback, survey time 2)
Discussion
The findings from research conducted alongside this HJPY demonstrate the positive influence of the program on the health and wellbeing of young people. It also highlights the pervasive and detrimental impact that legal matters can have on the health and wellbeing of young people, if left unaddressed.
Young people are keenly aware of the impact that unresolved legal matters have on their physical and psychological wellbeing and are uniquely placed to identify a remedy for their legal matters. Evidence for this is apparent in the number of self-referrals (21%) to the HJPY7. This exemplifies the willingness of some young people to seek help for their legal matters, signifying a positive outcome, particularly given that young people are notoriously poor at connecting with services to resolve their legal matters15. HJPs and the collaborative partnerships between health and legal services deliver greater opportunity for awareness-raising with young people about where they can go for free and accessible legal assistance.
The resolution of legal matters impacted on the health and wellbeing of young people through perceived reductions in stress; and improved concentration, sleep, family relationships and how they generally felt. Partner and external agency workers also observed improvements in the mental health of young people attending the HJPY, including reduced anxiety, and increased optimism and empowerment.
These findings are consistent with evidence documenting the detrimental impacts of legal matters on health and behaviours18,19. The present findings extend the emerging body of research from Australia9,20 and internationally2 about the contribution, support and integrity of HJP. Although legal matters in and of themselves are not considered a social determinant of health, ‘legal services have an important role to play in mitigating many of the socio-economic determinants that disproportionately impact the health of low income and vulnerable groups’ (p. 159)1.
Practice implications
Working in rural and regional communities can facilitate increased opportunities for interprofessional collaboration21. Youth and allied health workers support young people in the regions and are pivotal to identifying if their clients have legal matters and facilitating timely referrals to legal support services. Professionals working with young people often do so over an extended time and can explore a range of issues where young people need assistance. Their role as trusted practitioners provides the foundation needed to support young people to make informed decisions22.
Awareness and education around the identification and burden of legal matters on health enables workers to respond quickly to the needs of clients and to identify pathways for early intervention. Provision and access to information and resources enables workers to learn, explore and understand the potential impacts of legal matters for their clients. A legal health check, for example, provides a practical support to assist youth workers to identify legal matters with clients7.
Limitations
Gaps in data were a limitation of this study, particularly with different reporting mechanisms used by the legal services for collecting data. The researchers sought to reduce this impact through the collection of primary data, which enabled continuous data verification across the evaluation time intervals. Another limitation was the small sample size and the low number of young people completing exit surveys. Young people were difficult to re-engage after their legal issue was resolved. While workers provided feedback about the perceived impact of the program on young people, the lack of insights from young people after completing the services dilutes the findings.
There are several options for potentially increasing the input of young people, including through co-design, a method gaining popularity23. Financial incentivisation is another consideration for increasing research participation24. A further option includes a final ‘check-in’ appointment with the young to ensure that no further legal support is required.
While there is strong research evidence that the HJPY contributed to improved health and wellbeing outcomes for young people, caution is still necessary when interpreting these findings. Young people might self-report feeling better for reasons that are unconnected to accessing the HJPY. This research did not explicitly control for this possibility, particularly as the program was established so that all young people could access support through the HJPY program.
Conclusion
In this study the self-reported and observed impacts of legal matters on young people have a pervasive and negative impact on their health and wellbeing. There is a need for health and legal organisations, together with other agencies working with young people, to deliver services that reduce the negative impacts of legal matters on young people. Although limitations in accessing funding are likely to restrict available services in regional areas, there is nonetheless an important opportunity for youth and allied health workers to harness and build interprofessional relationships and to incorporate practices around early identification of legal matters in young clients and to facilitate referral pathways. This is essential in regional locations, where there is limited legal support and HJPYs may be unavailable.
Acknowledgements
The authors acknowledge the young people and workers for their participation in the original research and acknowledge the Victorian Legal Services Board (initial project funder) and partner agencies for supporting the research.
Funding
Funding from the Victorian Legal Services Board established the HJPY reported in this research.
Conflicts of interest
The authors report no conflicts of interest.