Experiences among personnel in the education, child welfare and health care sectors with collaboration for young people with long-term fatigue

Abstract Background Long-term fatigue among young people is increasingly referred to as a challenge and can have major consequences for the young people's lifeworld. Fatigue often impacts schooling, social participation and psychosocial development. Research shows that young people with long-term fatigue have a particular need for comprehensive and coordinated follow-up from the specialist and primary health service, schools and social services. Previous studies indicate that fragmented services, lack of continuity and challenges in coordination between services often impair follow-up. Methods Three focus group interviews with nine participants from the education and municipal child welfare sector and health care in Mid-Norway were conducted in March 2025. Qualitative analyses with a phenomenological approach were applied to explore these professionals’ experiences with cross-sectoral collaboration for young people aged 15–18 years who had been assessed in hospital for long-term fatigue. Systematical text condensation (STC) was used for analysis. Results Three main themes were identified: (1) We must think holistically, highlighting the complexity of cases, the importance of young people`s own goals and social participation, and the need to address the impact on the whole family; (2) Challenges with collaboration, highlighting that collaboration was often person-dependent, inconsistent, and vulnerable; and (3) Opportunities with collaboration, highlighting that early, coordinated efforts increased the likelihood of individually tailored follow-up of young people. Conclusions Collaboration in the follow-up of young people with long term fatigue is complex and depends on several interrelated factors. Our findings highlight the need for comprehensive, coordinated services that work across schools, primary care, specialist healthcare, and welfare services, often extending beyond established organizational frameworks. Successful collaboration relies not only on organizational structures, but also on strong relationships, mutual understanding, and effective processes. A holistic approach, trusting relationships, and active involvement of the young person in decisions and goal settings are key prerequisites for effective follow-up. Strengthening interdisciplinary and cross-sectoral collaboration, together with sufficient resources to implement statutory initiatives, may contribute to improving continuity and quality of the follow-up for young people with long term fatigue.