**4. Discussion**

The stories and experiences of youth seeking health information and care are integral to appraising their critical HL skills and health-seeking behaviors. This type of research is imperative to discussions on reducing health disparities, particularly in rural towns where health outcomes are often worse than urban or suburban areas due to the lower socioeconomic status of residents, poor service availability, and more hazardous living conditions [40]. Although research has suggested that Mexicans from low socioeconomic backgrounds have benefited in some ways from the universal healthcare system (i.e., Seguro Popular [12]), the present study offers a qualitative exploration of youth perspectives in the context of a rural Mexican town and details the lived experiences of struggle with the local health clinic provided under the Seguro Popular healthcare model. Theoretically, these results offer support for using Massey et al.'s [29] framework for analysis of adolescent critical HL in Mexico. On the one hand, the youth indicated they were able to navigate the system and understood the basic rights of the patient to be understand and applied these rights by asking clarifying questions of their doctors. However, they also spoke to a lack of basic preventative care practices, information seeking outside of the family, barriers to a productive relationship with healthcare professionals, and preferred family and other nonformal sources when they sought health information. An understanding of the strengths and limitations of the youth's critical HL can guide interventions to increase competence in each of the framework's five domains.

Participants in this study mentioned several barriers to developing a positive relationship with doctors including embarrassment, fear, mistrust, and doctor's use of medical language. These are barriers to critical health literacy as outlined by Massey et al.'s [29] model and common concerns for adolescents across cultures. Two recent qualitative studies in the US found that the use of non-age appropriate medical language was one of the biggest barriers in effective communication between adolescent cancer patients and their doctor [41,42]. Embarrassment is also a common barrier to healthcare utilization by adolescents [43], and one of the main reasons youth turn to the internet to research health problems rather than making an appointment with their doctor [44]. As the youth in the present study suggest, sexual health specifically seems to lead to feelings of embarrassment and hesitation to speak to a healthcare professional [45]. Feedback from member checking with the Mexican psychologists reiterated sexual topics as particularly difficult for adolescents to broach with healthcare providers and their families, despite the developmental importance of these to youth. While fear and mistrust do tend to impact the patient-doctor relationship and healthcare utilization among youth across cultures [45–47], these two themes are particularly prevalent within samples of Hispanic adolescents [47,48]. For example, in a sample of immigrant Latino adolescents in the U.S., qualitative results suggested that mistrust of doctors stemmed from fear of deportation, cultural misunderstandings, and negative experiences with other authority figures, such as teachers [49].

Although youth in the sample overall understood how to utilize the health clinic in their community, there was less understanding of how to navigate the barriers inherent in the system, which is a key element of an adolescent competent in the service navigation domain of Massey et al.'s [29] model. Even though their understanding of how to navigate the barriers inherent in the healthcare system may be somewhat limited, their ability to identify system limitations is a strength that should not be overlooked. This skill is certainly more aligned with critical HL than functional HL, although it is not directly accounted for in Massey et al.'s model [29]. The ability to identify limitations coupled with the apparent inability to navigate barriers suggests that adolescence

may be the ideal time to promote critical HL skills. While it may be tempting to think that functional HL skills should be developed at a young age followed by the development of critical HL skills in early adulthood, it may be that critical HL skills would be most beneficial if taught simultaneously alongside functional HL at a young age.

The systematic barriers of the healthcare clinic—specifically the poor customer service, unprofessionalism of clinical staff, and the token system—mirror many of the same issues that were targeted by the Mexican Ministry of Health prior to implementation of Seguro Popular [50]. In a 2001 report based on samples of Mexican healthcare consumers, the Mexican Ministry of Health touted low emergency room wait times, high satisfaction with care, high levels of staff kindness, and positive experiences scheduling appointments. However, only 25% of the hospitals and clinics surveyed were public entities, suggesting that the findings were, in essence, a report on the private healthcare sector. The public health system, which has dramatically grown since the 2001 report due to the implementation of Seguro Popular, is an altogether different entity, and the experiences of youth in this study seem to sugges<sup>t</sup> that healthcare utilization issues may be of concern in rural Mexico.

Preventative care practices that involved seeing a doctor were very rare among youth in our sample. In fact, only one person mentioned going to the doctor when they were not sick. Low use of preventive care practices in Mexico is not unique to youth in this study. An Organisation for Economic Cooperation and Development [13] report cites the lack of preventative care as a major issue facing the current Mexican healthcare system, especially in rural parts of Mexico. One study, analyzing data from a public Mexican health survey, found that over 30% of patients requiring inpatient medical services did not have access to their needed health service [15]. As rural sates in Mexico have some of the lowest patient–provider, patient–nurse, and patient–paraprofessional ratios in the country [14], there is limited access to primary care providers in these rural towns, which makes preventative care visits difficult [13]. Decreasing barriers to access and increasing knowledge of the importance of preventative care practices is key to increasing adolescent HL [29].

Aside from issues around access, expectancy theory can also shed light on how the barriers to positive patient–provider relationships as the systemic issues present at the clinic may relate to a lack of preventative care practices by adolescents. Vroom's [51] expectancy theory postulates that the motivations driving behaviors are linked to expected values and outcomes. Academic healthcare literature commonly uses expectancy theory to interpret patient expectations, perceived service quality, and satisfaction in both adult and adolescent populations [52–56]. Comments throughout our focus groups suggested that the local healthcare clinic has a bad reputation, and youth have had various negative interactions with the doctors and nurses. Expectancy theory suggests that this may lead to a diminished motivation to utilize the local healthcare clinic, with youth perhaps more likely to turn to less reliable sources for information with their healthcare questions and concerns (i.e., family members and the internet).

There are clear systemic changes that could improve the experiences of patients at the health clinic and increase service navigation and utilization. Changes to the token system (e.g., implementing an appointment-based system) could decrease long wait times. Changes to the operating hours of the clinic would better meet the schedules of adolescent patients in school (i.e., extending pharmacy hours beyond 12:00 pm). Frenk, Gomez-Dantes, and Knaul [57] identified long wait times at both outpatient clinics and hospitals, and lack of care hours during evenings and weekends as some of the major challenges facing the Mexican healthcare system after the implementation of Seguro Popular. The qualitative results of this study support the need for these areas, within the service navigation domain of Massey et al.'s [29] model, to continue to be explored by healthcare professionals and lawmakers in Mexico, particularly among rural healthcare providers.

On a community level, there are a variety of changes that could reduce the negative expectations of adolescents towards the local healthcare clinic, increase critical HL, and improve the utilization of health services. According to the short demographic survey completed by study participants, 64% of the students had attended a health class. To target the population who had not ye<sup>t</sup> attended

a health class, policy changes could require health education classes for all students in primary school, similar to what many states have already done in the U.S. [58]. Within the health class curriculum, a specific section or focus on patients' rights could also increase competence in the rights and responsibility domain of adolescent HL [29]. Furthermore, to decrease negative views of doctors, local physicians from the health center could be featured as gues<sup>t</sup> speakers during the required health classes. This would give them an opportunity to provide an overview of the medical services offered through the local clinic and answer student questions. Various studies sugges<sup>t</sup> that increased familiarity with doctors can enhance the patient–provider relationship and provide more positive healthcare experiences for youth [59–61]. Within the context of Massey et al.'s [29] model, interventions to increase positive patient–providers relationships are key in increasing adolescent HL.

Finally, a large number of the youth stated that they turn to a parent or family member for health information. Although this certainly speaks to the importance of immediate and extended family in the Mexican culture [62], it is imperative to consider the quality of the advice they are receiving, especially as appropriate information seeking and the ability to critically examine health information is an essential skill of adolescent HL [29]. Due to the increased availability of the internet, it is critical that youth and parents know about legitimate online resources and websites that can provide accurate information [63]. Furthermore, much like other school subjects such as math [64], if health information from presentations at school are not reinforced at home, it is unlikely to be retained by youth. Incorporating parents into the health education of adolescents is considered a promising model [65], so parents should be offered resources from school or provided the opportunity to attend health classes similar to what their children are receiving. This would reinforce student learning, help parents become more health literate, and increase both students' and parents' ability to critically analyze the health information they are receiving [29]. Further, incorporating family and the community was deemed important in feedback from our Mexican research psychologists who communicated that school is not valued by many students who often did not attend class or who dropped out altogether.

Returning to the Massey's [29] model for adolescent HL, our results sugges<sup>t</sup> that this could act as a cross-cultural framework to explore the critical HL/health behaviors of adolescents, as the original thematic analysis fit within Massey's framework. There were, however, clear cultural differences of themes within each dominion between our focus groups in Mexico and the American context of Massey et al.'s model [29]. For example, while the youth in this study spoke about issues with the token system, adolescents in Massey's interviews spoke to the difficulty in getting an appointment time, which show the differences between the Mexican and American healthcare system. Perhaps the biggest cultural difference was the inclusion of parents, and especially extended family, in healthcare. While the American youth in Massey's interviews viewed parents as gatekeepers to their healthcare and did not bring up the role of extended family [29], the Mexican youth spoke specifically to the role of the extended family in their healthcare. Therefore, the model could serve by including a domain on the role of social networks (including peers, family, extended family, and extended kin), especially in international research on adolescent HL, to gain a fuller understanding of the role family has in adolescent healthcare. Overall, though the domains fit well with the themes that emerged, they also provided a framework to organize the aspects of critical HL of adolescents in rural Mexico, which can guide future policies and interventions.
