VOL: 99, ISSUE: 30, PAGE NO: 32
Anne Sherman-Jones, MA, is assistant director, commissioning and service development, Mid Sussex Primary Care Trust
The plethora of government health targets can lead to assumptions that young people’s health needs relate almost exclusively to giving advice on issues such as sexual health, drugs and smoking. In fact, the targets relating to reducing teenage pregnancy, drug abuse and smoking may detract attention from the wider health needs of young people and make it difficult for them to approach health professionals for more general advice on health issues.
There is a view among some professionals that young people have access to plenty of health information, as the following quote from a practice manager exemplifies:
‘These young people - they have so much information, but still they get involved in taking drugs, and the girls get pregnant…’
This article reports on a study investigating young people’s perceptions of the advice available to them and how access to advice might be improved. It also compared their views with those of professionals working with young people, and sought to identify barriers to young people accessing services.
Review of literature
One aspect of health services for young people, which has attracted a great deal of attention in recent years, is teenage pregnancy. The average age of first sexual intercourse in the UK is not markedly different from that in other European countries, but the UK has higher than average rates of teenage pregnancy. These rates are obviously linked to the use of contraception: research suggests that only 50 per cent of young people in the UK use contraception at first sexual intercourse compared with 85 per cent in the Netherlands (Social Exclusion Unit, 1999). In this, and other areas of health care, young people in the UK need advice to be provided in a way that is easy for them to access. It is also important that services are designed to be appropriate for their needs.
Although teenage conception has been identified in the health care literature as a problem for both society and teenagers, little research has been done to ascertain teenagers’ perspective on the issue. Jewell et al (2000) found that although teenage pregnancy may be considered a problem by society in general, it is seen as less of a problem by the teenagers themselves. If this is the case, interventions by health service providers designed to reduce teenage conceptions may not be successful. The authors conclude that if there is to be an improvement in the successful use of contraception by teenagers, young people should be involved in the planning of both sex education and contraceptive services.
Studies that have asked young people what is important to them in health services have invariably identified confidentiality as one of the key factors. However, there has been a lack of clarity among health professionals about the extent to which they can guarantee confidentiality to young people. In an attempt to clarify the position the British Medical Association (1994) issued guidance, which stated that the duty of confidentiality owed by professionals to young people is as great as the duty owed to any other person.
In other studies, including research carried out by West Sussex Health Authority and West Sussex County Council in developing the West Sussex Teenage Pregnancy Strategy (2001), many teenagers told researchers they thought their parents would be notified if they tried to obtain contraception. In one survey in 1993, 66 per cent of pregnant teenagers said they thought it was illegal to go to either a GP or a family planning clinic (Social Exclusion Unit, 1999; Dines, 1996).
The aim of this study was to move away from any preconceptions about what might be thought to be the most important aspects of health services for young people, and to allow young people themselves to establish the key factors. To ensure the validity of the study it was important that a wide range of young people were interviewed.
To identify suitable participants, contact was made with local schools, the West Sussex youth cabinet coordinator, a youth centre and local groups for young mothers. Young people were also identified through the professionals who were interviewed. The professionals participating in the research included school nurses, a practice nurse, youth workers, a GP, a practice manager and a health promotion worker.
The overall aim of the research was to inform the commissioning of services for young people and to enable improvements to be made in this area. The research questions were designed to achieve the following objectives:
- To examine the perceptions of young people aged 16 to 17 years old concerning the sources of health advice available to them;
- To identify the preferences of young people in Mid Sussex for accessing health advice;
- To identify ways in which it would be possible to improve access to health advice for 16 to 17-year-olds in Mid Sussex;
- To compare the views of young people and the professionals working with them;
- To identify the barriers for young people accessing health advice.
The interview structure was carefully designed to use open questions wherever possible. Participants were also encouraged to use the questions as a starting point only. This method facilitated an open discussion with all the young people interviewed, whether this was on a one-to-one or a focus-group basis. It was also designed to find out the most important aspects of services for young people as well as what the professionals thought these aspects would be.
It was apparent that it would not be an easy task to find young people who would be willing to be interviewed. Therefore, the study was designed to be as flexible as possible in terms of seeing young people in their preferred setting.
Non-directive, open-ended interview questions were designed to elicit the views of young people and professionals on the research questions. One-to-one semi-structured interviews were carried out with nine professionals working with young people in health care and youth work fields. Interviews were also carried out with two young people, and a third young person chose to write her responses to the interview questions instead of being interviewed.
Focus groups with young people
Six focus groups were held with young people in East Grinstead, Burgess Hill and Haywards Heath: two groups were from a school, two from a youth centre and two groups were young mothers. The participants came from a wide range of backgrounds, including some in full-time education (Year 11 and 12) and some who looked after young children, either their own or other people’s.
Age of participants
The youth centre members and school students were aged from 15 to 17 years old. The young mothers were slightly older, aged 19 to 24 years old, but as they had had children while in their teens, their perspective of services for young people was extremely relevant to the study. The young mothers were also involved in training to be peer educators for other local young people. The young people interviewed on a one-to-one basis were both 16 years old.
The transcripts of interviews with young people and professionals were analysed by identifying the following categories of questions:
- Professionals’ perceptions;
- Young people’s perspectives;
- Finding out what young people want;
- Identifying ways to improve services;
Professionals working with young people were asked for their views on what aspects of health services are most important to young people. The professionals were clear that it is important for young people that services are easy to access, avoid barriers and are non-judgemental. The professionals also recognised the importance of being perceived by young people as having a young outlook while being competent at the same time. Confidentiality was identified by the professionals as another important factor. A school nurse said:
‘It is important for young people to know that they are talking to competent, qualified professionals… I think young people want a service that will respect their confidentiality. They want to be treated by young people, they don’t like to be treated by old people, and for teenagers that means over 35. It is difficult for young people to take advice about sensitive subjects from people they see as older… It’s not always physical age, more about how you come across, young outlook, and it’s important for them to be seen in areas acceptable to them.’
The professionals were asked whether they felt that health services were equally well targeted at both young men and young women. There was a consensus that young men are not as well targeted as young women. They said one reason for this was that most health professionals other than GPs are female. Young people find it easier to talk to someone that they can identify with, that is someone of the same sex and within the same age group. Another reason cited was the attitude of young men to health issues.
Young people’s perspective
Young people were asked what were the most important aspects of health services from their perspective. They identified the most important aspects as having professionals who are prepared to listen in a non-judgemental, confidential and accessible setting. They wanted advice and health education to be provided by young people. They also wanted a range of health advice about general health topics including dieting as well as sex and drugs. They were frustrated with the perceived stereotyping of their concerns by adults. A 16-year-old girl explained:
‘Someone you can go to with the kind of problems we have, to treat you properly, listen to you, not just sit back in the chair… confidentiality is important, and the way you’re treated.’
The young people were also asked whether they believed that health advice was accessible. While some felt they would know how to access health information, most identified barriers and difficulties, particularly in accessing information discreetly. A 16-year-old girl said:
‘It’s mainly just getting hold of information, that’s the hardest thing - you’re not sure where to go, especially if it’s something you’re embarrassed about - that’s what people are afraid of, that you might be laughed at, so people don’t try.’
Finding out what young people want
Professionals were asked if they thought that enough had been done to ascertain what young people wanted. The unanimous response to this question was that not enough had been done, although some professionals were aware of work that had been done in some areas.
The study also revealed that some professionals were frustrated at not being given the opportunity to say what was needed. One surgery had been very proactive in talking with young people, but their work had not been widely disseminated in the other practices in the primary care trust.
Identifying ways to improve services
The young people were asked what they wanted from their GP. The following quote from a youth cabinet member is typical of the responses received:
‘Confidentiality… Not to be judgemental… A degree of understanding/empathy… Not intimidating.’
Both young people and professionals were asked what could be done to improve health services for young people. The professionals’ responses included the following suggestions from a school nurse:
‘Take them out of the school setting, make it more accessible. My colleagues will hate evenings, and me for this, but try on Saturdays and look at where young people meet… Peer education is big.’
Young people’s suggestions included the following examples, given by a member of the youth cabinet:
‘Re: family planning clinic… difficult to understand when open and when not. Generally better advertisement [in schools, youth clubs] would be beneficial.’
Young people were asked how they would design a health advice service for young people. A typical response from someone attending a young mum’s group is as follows:
‘It would be like a drop-in centre, where they can talk to you, and have tests, with a counsellor there as well.’
The young people who were interviewed varied widely in their understanding of and belief in the confidentiality of services. Most expressed the belief that they could talk confidentially to health professionals. However, they also felt worried about being seen using the services, for example by their neighbours. One member of a young mum’s group said:
‘I am happy that what is said in the consulting room is confidential, but being overheard or seen in the waiting room is a problem.’
An area of concern for young people was when they were asked why they wanted to see the doctor when they phoned for an appointment. An attendee of a Year 11 focus group explained:
‘I always find, when you phone up, they say I’ll just transfer you to the nurse, then you get through to the nurse and they say ‘well what’s it about’ and you go ‘well it’s private’, and they go ‘well we need to know’, so I have to tell them and that, and eventually they give you an appointment.’
Professionals were asked for their views on how to ensure that young people felt they could access services confidentially. A school nurse said:
‘I don’t think they have the confidence that you will respect confidentiality… School nurses are seen talking to teachers in the corridors… Often the young people assume that you are talking about them, telling what they have just told you, when in fact you are talking about a lesson you are planning… Difficult to convince young people that you will keep everything they say confidential, within certain criteria obviously.’
School nurses also felt they were in a difficult position:
‘We can say we will hold everything in confidence, unless you tell us something like x, y, z, in which case we would have to hand it on. We could address it much better, clearer, so they understand totally what we mean… for example a 14-year-old having sex with a 16-year-old, we wouldn’t have to pass that on, whereas the schools would.’
Is there a gap between professionals’ and young people’s views?
Richardson et al (2001) carried out a similar study with young people and professionals in Wales. One of the key themes of this study is reflected in its title, Bridging the Gap, which refers to the gap between the views of professionals and young people. In Mid Sussex, the comparison between responses from professionals and young people showed that, in most cases, the professionals interviewed were aware of the young people’s perspective. They appreciated how important it was to treat young people with respect and to provide them with accessible services. They also appreciated that there was a shortfall in the provision of advice on drugs.
The most significant gap in Mid Sussex was the appreciation of how difficult it was for young people to know what services were available. Most of the young people interviewed were not aware of the information ‘shops’ in the area where 13 to 25-year-olds can access information and advice, or the availability of health information at the youth centre and the teenage family planning clinic, which is a drop-in clinic held at one of the local surgeries.
The second gap was the assumption that young people’s main concerns were related to sex and drugs. In fact young people wanted access to a much wider range of health advice in an easy-to-use setting. A 16-year-old girl said:
‘They seem to assume that the only problems you’d have would be pregnancy and it’s not. They only seem to have family planning clinics, if someone says teenage clinic, then that means family planning, that’s not what we need… What we need is someone you could just talk to, they’d give you the advice you needed, on general problems, girl problems, dieting, pregnancy is one of them.’
The gap in understanding about confidentiality was also important. However, it was not a gap between young people and professionals, but a gap between the ideal of comprehensible information about confidentiality and the reality, which was a confusing situation for both young people and professionals.
Conclusions and recommendations
This research, carried out with young people and professionals in Mid Sussex, has resulted in an improved understanding about the needs of teenagers for confidential, accessible and non-judgemental health advice. Gaps have been identified in the provision of advice about drugs and a lack of clarity about confidentiality.
Recommendations resulting from the research include involving young people in the design of services aimed at them and improving communication about what is available. In addition, the results also show that professionals need to be trained to work more effectively with young people.
Training for staff in dealing with young people
Most staff are conscious of the needs of young people, but they may be unaware of how difficult it is for young people to ask for advice about sensitive issues. Therefore, a series of training sessions should be developed for nurses, receptionists, GPs and all health professionals who have contact with young people. These would reinforce the importance of respecting young people’s views, making the process of booking appointments as smooth as possible and giving young people sufficient time to talk. Training is also required in providing advice on drugs and support for professionals so that they do not risk criticism for being seen to encourage drug use.
As recommended by the Independent Advisory Group on Teenage Pregnancy (2001), all professionals working with young men and women should receive guidance on confidentiality, supported by appropriate training and the production of clear confidentiality statements and leaflets for young people explaining confidentiality.
Overwhelmingly, the young people taking part in this research asked for a drop-in centre to provide them with general health advice. The location of this centre needs to be discreet, possibly in a school setting, and the centre should be able to provide emergency contraception as well as general health advice.
Drugs advice needs to be made more accessible and objective. Young people should be involved in providing some of the advice as they can identify with the problems faced by their peers. Training and support should be provided to enable professionals to deal with this subject confidently.
Links with schools
Better communication should be fostered between health professionals and schools about issues such as confidentiality, the need to provide health advice in schools and shared targets for ensuring that no young person is afraid to ask for advice or support.
Professionals should be aware that many young people do not know what services are available to them, and information on the opening times of clinics needs to be improved. A young people’s health magazine or website could be developed containing details of what services are available, the times and locations of relevant clinics and what young people are entitled to expect regarding confidentiality. The primary care trust should work closely with service providers and the media to develop information in a format that is attractive and free of the ‘embarrassment factor’.
Midwife for young parents
Discussions with the young parents support group have indicated a need for midwifery staff to work with young mothers. Although the numbers are small, the problems can be significant if young mothers are not offered services in a way they find accessible.
Involving young people in planning services
The literature review suggested that young people should be invited to participate in planning services. This was supported by the views of the West Sussex Youth Cabinet, particularly in relation to designing drugs education packages. Young people also wanted to have more young people involved in providing health advice, for example peer support workers.
Further research should be carried out to elicit the views of users of specific services, such as sexually transmitted infection clinics, maternity services, and child and adolescent mental health services. This research should also involve professionals working with young people in these areas.