Y- Wait   Rosemary Kirkman  & Maggie Flint.

Rosemary Kirkman - I’m really here just to introduce Maggie.  I’m the doctor person and Maggie is the do-er person.  I came in time to hear Mr Tonkin’s opening address and he set the scene with questions ‘who speaks for youth?’ and ‘how do we engage youth’, and I think the previous speaker, Anne, has shown that girls are the same the world over.  We have the same problems in North Manchester and I think Maggie has shown the way forward with the answer.  So, over to you Maggie 

This is the first time I have spoken at a conference like this so if you hear something knocking, it’s my knees.   My name is Maggie Flint and I am the project worker for a project based in North Manchester called Y Wait.  It is a girls and young women’s health project and it’s based on peer education.

Y-Wait actually stands for Young Women’s Advice and Information and Time to talk.  We are not encouraging people not to trying things without thought.  We have actually been reported in the local press as being called WHY WAIT.  We are also not an eating disorders project although we do cover eating disorders in our work, as in WHY WEIGHT.

Y Wait for the last six years has been offering an alternative health service to the young women under 25 in North Manchester.  The service that they offer includes a weekly drop in with a doctor and a family planning nurse who work along side the trained volunteers, and a drop-in local youth centre, and we always have a crèche.   It is a comprehensive service, including emergency contraception.  We do pregnancy testing and we also do referrals for termination of pregnancy.  The majority of work that we do is actually around sexual health.  Now that wasn’t planned in the beginning.  It is a general health project, what we have found is that the majority of things that the girls and young women come in for are actually related to sexual health issues.  The other service that the project offers, is the trained volunteers go out and do talks and workshops in local schools and youth centres, usually on request.

The project actually started from HIV and AIDS money.  It started in 1989 with two short term six month grants, and it then went on to be awarded a three year ‘pump priming’ grant to pilot the project and then in 1994 we were ‘purchased’ - which was the jargon we were given.  The project was actually independent for three years, run by young women for young women, it now has funding from the local health authority.

I’ll just tell you a little bit about the structure of the project.  The project employs a part-time worker for 18.5 hours (which is actually me!), and I am the only worker and I am there to facilitate what the volunteers want actually happens.  I have to make sure that the drop-in happens, make sure that the drop-in staff and arrange all the meetings and what the girls want to do happens.  We also employ a trained doctor and a family planning trained nurse on a session basis for the drop-in and we always have a crèche worker for all the things we organise because some of the girls have their own children, or they have responsibility for younger children.  At the moment we have got 10 trained volunteers who run the drop-in and they are aged between 15 and 23 and their involvement is in staffing the drop in and running workshops.  They get involved in the training of the new volunteers as well. 

We meet once a month so that the volunteers can decide what direction they want the project to go in, so they are actually tell me what they want me to do.  Some of the things they have done in the passed - they have produced their own leaflet on young women and pregnancy, because they thought that the existing material was aimed at older women and wasn’t aimed at them, they had been pregnant young and the material they had been given they didn’t find was accessible to them. We also made a video two years ago with a young women’s sexual health project for young women with learning difficulties which Channel 4 actually used.

So, now I will take you back to the beginning.

We actually started as the North Manchester girls and young women’s health project.  North Manchester health promotion actually commissioned a piece of work for six months to action research the health needs of girls and young women’s needs in the area.  It was part of the AIDS and HIV strategy.  At the time there was the growing concern about the spread of AIDS, HIV, and the girls and young women were not presenting anywhere.  North Manchester actually has an excellent family planning service and an excellent well women’s service, but the girls and young women weren’t showing up.  So this piece of research was commissioned to found out why.  A series of meetings were held across the district to reach as many girls and young women as possible.  They were actually asked what they thought of existing services and what they would like to have in the future, and the findings of this consultation formed the basis of what was to become Y Wait. 

Now some of this actually over-laps  with what we have already heard.  What we found was that the girls perceptions of the existing services were not actually from experience.  What they were doing was perceiving what would happen if they  used the service so some of it was not fair comment on the actually staff of the well women’s clinic, but this was how they thought they would be treated if they turned up.  There was a deep mistrust of health professionals, particularly your GP - they were not to be trusted.  As soon as you left the room your GP would be on the phone to your parents and told them what you had been there for.  Family planning clinics were not being used as the girls were not planning families, it was as simple as that - ‘I wasn’t planning a family’.  They didn’t know about the other services which were offered at these clinics, they didn’t know they could get on the spot pregnancy tests.  And the well women clinics they saw definitely as a provision for older women and also they were a service their mother’s used, so they wouldn’t go there in case they bumped into their mum, their aunt, or their older sister.

So they were actually asked if they could change the service what they would like to have and the first thing they said was that they didn’t want a receptionist.  They don’t like walking into a place and having to give out personal details in a public place to someone they don’t know, giving details such as name, age, address and what they were there for.  So, when Y Wait was set up we cut out the receptionist bit and the volunteers actually do that.  When the girls arrive at the drop-in, they are greeted by a volunteer who just walks up and introduces themselves, by their first name, and asks the girl for a name to call her by - because if you are going to talk to somebody that’s all you need a first name, initially you don’t need to know their full name, how old they are and so on.  This is to put them at their ease.

As to the setting, the girls didn’t want a clinic.  They felt that as soon as you walked into a clinic everybody knew what you were there for.  Originally,  the project was set up in a community education centre, quite anonymous, as when you arrived there you could have been there to throw a pot or learn sign language, even though we did have sole use of the building, there were no other classes going on at the time, it was known as this was a community education centre, and this was the sort of thing that happened there so that possibly you could be going there for something else.

The other thing that they wanted was a doctor and a nurse who were friendly.  They felt that their GP and doctors very often talked down to them, they used language that they didn’t understand, and they felt that decisions were being made for them and they weren’t being given enough information to make their own informed choices.  They also felt like they had to go with a problem that needed solving, and they needed to know what it was that was wrong before they went so that someone could tell them.  So they wanted a nurse and a doctor who were friendly and who didn’t wear the white coats and have the stethoscope round their neck, they wanted a doctor who would sit with them and take a turn at brewing up - which is what they did get. 

The doctor and the family planning nurse which we have got were actually interviewed by the volunteers before they were taken on by the project.  I was as well - it was gruelling!

They decided that it would be girls and young women only.  This was actually their decision, they felt that the boys were less mature and they didn’t actually take some of the subjects, especially sex, as seriously as they did themselves.  They didn’t trust the boys to use the same facility as them and to go out round the corner and say ‘hey I just saw so-and-so going on their and she’s on the pill’.  So they wanted it for themselves. 

They didn’t want just a contraceptive service.  They wanted a service where they go for anything.  It might be that they had had a row at home, or they couldn’t do their homework, or they just wanted to get out, they wanted their own space.  So it was taken on as a general health project.  You can actually walk through the door with anything.  You don’t even need to have a problem, we actually encourage it as a social situation we encourage the girls to come before they have a problem, because once they have a problem it is even harder to walk through the door.  Whether you are a young person or not, one of the hardest things to do is to walk through a door and not know what was on the other side - I have done it this morning coming in here - so, if you are a young person with a problem it magnifies it.  So we encourage them to come and visit us first, have a brew, have a biscuit, and find out what we are here for, so that if you need us in the future you know where we are.  Or, if you have a friend who needs us you can bring her. 

The thing about Y Wait is that it is based on peer education, and it is run by women for young women which means that the volunteers need training.

The training courses which we run are all different because they are based on the perception of the young women, what they define as their health needs.  So both the content of the volunteer health training programme and the length differ.  Now the original health training course took 8 months, but this included the planning of the drop-in, finding a location and actually setting it up.  That took 8 months and included meeting weekly in the evenings, it also involved four full days training and two weekends of residential training, so it was quite intensive.  The training was negotiated with the trainees and the original development worker for the project did it along with a women’s health worker and two youth workers, so they did have some intensive support through this 8 month period.   But it was the girls themselves who decided what their health concerns were and what might be the concerns of the users of the drop-in.  There were 25 girls who actually started that training and 19 completed it.  The original training group ages ranged from 14 to 22, which is quite a large age gap when you are actually training volunteers. 

The group also meet socially.  This was seen as really important for the team and confidence building, because what was going to happen at the end of the training was that they were going to be handed over control of the project.  So they met socially, they went ten-pin bowling, they had meals out, they went to the cinema, all that was funded by the project.  

Three of the original volunteers are still with the project, but obviously as the years go on volunteers leave and the volunteer training remains on-going.  The project actually aims to recruit annually, and this is done through local schools and youth centres.  It is done by posters, leaflets and visits to explain what we are doing.

The content of the training does vary, but we find that much of it comes up all the time.  There is always the sexual health stuff.  They always want to know about contraceptives, pregnancy testing and whatever.  At the moment in Manchester we have a zero tolerance campaign going on for male violence and the girls have picked up on that, the current training course have picked up on it and they have said that they want to know more about domestic violence.  Others might want to know about eating disorders.  Whatever is an issue to them.

Following the training it is up to the volunteers how much time they want to offer.  If the volunteers do the training and then drop out, we don’t see it as a failure, because what they have done is, they will still carry on with the peer education because they have got the knowledge and the confidence to talk about it they will pass it on.  Even if they are not doing it through the project.  So we don’t say the girls when they start that they must make a commitment to this project.  It is entirely up to them.

They usually staff the drop in.  That is done on a rota basis and that is decided at the monthly meetings.  But more often than not they all actually turn up every week.  Some of the volunteers have had further training to do group work and their contraceptive workshop is very popular.  They go around the local youth centres and do that.  Two of the volunteers actually had babies before they were 16, and they frequently go out and talk about their experiences.  I could actually go along and talk to young women about pregnancy and child birth, but when Tracy stands up and says ‘I was pregnant at 13 and I had my first baby at 14’ she has got a captive audience.  I couldn’t do that.  I couldn’t achieve that.  And the questions they ask, like, ‘what did your mum say, did she go mad?’, these are the things that they actually want to know to give them an understanding of the situation, and I couldn’t do this.  I mean, my mum was over the moon when I had my first baby!

The project has actually continued in this format until the beginning of this year.  But at the beginning of this year we were actually forced to move premises.  This was because of the change in the funding.  When Y Wait was grant funded, we were actually classed as voluntary organisation although we had the support of the community services unit who provided the doctor and the nurse and all the family planning supplies.  But the community education centre where we were based, because we were a voluntary organisation there was a small affiliation fee, they gave us the use of the building with no rent.  So, when we were actually purchased by the Manchurian Community Trust and the ‘powers that be’ found out, we were classed as a statutory funded and they wanted more money and they wanted £1,000s and when the project was originally costed it wasn’t costed with rent.  So it was a case of ‘we want the rent or you are moving out.  Education is not providing what the Health should be paying for’.  And then, in stepped the Youth service who said ‘pick a youth centre, any youth centre you like, and move in it and tell us what you want’.  The Youth service in Manchester were really keen to get involved once they given the opportunity.  So in January this year we moved into a youth centre, we moved into Moston Youth Centre.  And then in April of this year Manchester Youth Service actually went into partnership with us and I became full time and they also gave us two youth workers to work with the project, two sessions a week.  We have just recruited - the idea is to set up two more drop-ins in two more locations - thirty-three more young women with the aim to open up these two new drops-ins and have just started the training now.  So watch this space!

Dr Elizabeth Heycock - ‘A young person’s confidential health record’

Today I would like to present to you a booklet that has been devised in North Staffordshire to provide young people with their own health record along with advise and information pertinent to health issues which are prevalent in today’s adolescent population.

The background to this booklet is related to international, national and local concerns about adolescent health in the widest range.  Local worries about the rates or alcohol and drug misuse among young people, along with high teenage pregnancy rates mirror national findings..

The district of North Staffordshire has a total population of just under half a million with a mix of rural, semi-rural and urban population groups.  Currently the services that are available t young people, in addition to general practitioners surgeries, family planning clinics, and school health clinics, include drop-in clinics held by our school nurses held in a majority of secondary schools, and three young people’s advice clinics held specifically for the under 21 age group in different parts of the district.  Some health care practices also undertake a sixteen plus health review.

A study undertaken in North Staffordshire in 1994, through semi-structured interviews of over 250 14-16 year old youngsters indicated a lack of knowledge of services and service providers, along with worries over confidentiality, concerns about access and a tendency to consult the peer group at times of need.  We undertook to develop this hand book as one way of tackling some of  the problems fed back to us by the young people themselves. 

We recognise that the problems that young people face today are complex and multi-factorial, and that health issues must be considered within the social context.  So, a multi disciplinary group has met together to develop this booklet which is currently being piloted in two schools within out district.

Initial discussions between health education and health promotion include a very lively debate about the size of the booklet, the type of binding it should had, the reading age of the text, the topics we should cover, the inclusion or not of pictures, and the method of use once the young people had obtained the booklet.  There were very real concerns about whether the young people would use the booklet and whether they would understand it. 

The jacket of the booklet has been devised in a way to engage young people’s interest.   The majority of our working group felt that the booklet itself should be presented as a document of importance which could be referred to into adult life, thus enabling young people to sense that they were trusted to use the booklet in a sensible and adult manner.  There was concern that the booklet needed to be hard wearing, however this had to be balanced against the possible advantages of using a loose leaf booklet which could facilitate additional pages for groups of youngsters with special needs such as children with epilepsy.

Confidentiality was considered a very important factor to the young people and therefore use of the hand book by other professionals such as general practitioners and school nurses has initially has been left open.  Although our working group effectively debated many issues, and worked together the content of the booklet, we are keen to engage young people at this formative stage of the booklet in order to gain their ideas for further development and use. 

The booklet itself has been presented to young people in the pilot as a confidential document which can been kept entirely private by themselves or can be shown to other people if they choose to do so.  The booklet in draft stage has been introduced to pupils for their evaluation, and is currently is in a bound form and is A5 in size.

In order to obtain a representative view from the young people themselves during the pilot study we approached two mainstream schools, one situated in a semi-rural area with a population of mixed social/economic grouping, the other in a more deprived urban area where pupils are of relatively of a lower ability with the average reading age of pupils on entry to the school being two year below chronological age.

Once we had obtained consent from school governors and parents, we introduced the booklet to years 9 and 10 at these schools.  All teachers involved have been very positive about the use of this booklet and very supportive of this pilot programme, as have the young people themselves.  When the booklet were introduced, the young people recruited to the study were given a brief discussion about the background of the booklet and they were asked to fill in a questionnaire, in the classroom setting, under supervision, before receiving this booklet.  The questionnaire had been devised using topics covered in the booklet to measure young people’s knowledge on health related subjects before obtaining the booklet.   The young people were then given a copy of the booklet and to consider it as their own confidential property which they might refer to when needed.  We emphasised the value we placed on their opinion on the booklet, indicating that the future production and use of the booklet was largely dependant on their views.  We explained that at some later stage we would want to learn their views about the booklet as well as repeat the knowledge of health questionnaire. 

The first section of the booklet, which occupies one fifth of the booklet, is a health record.  This has spaces for the young person to fill in his or her own details such as name, address, general practitioner, school nurse, and soon.  It also has a page devoted for them to write in their own personal medical history.  We hope that this will increase their interest in their own health and help facilitate them taking more responsibility for their health.  We have included three pages for the young person to write in before, during or after any consultation, there are also growth charts for the child to fill in when they are measured.

The second and larger section of the booklet is an information and advise section, which is divided into four parts, which are colour coded, for ease of recognition by the young people.  The broad issues covered are:  General Advice on health - including areas on immunisation, healthy eating, exercise and areas which cause young people very much concern such as depression and eating disorders.  There is a section of advice on pubity, and a section on how to protect yourself, which contains information on stress, anxiety, bullying, and on child abuse as well as action protection as well as a section on first aid.  This slide shows one of the texts, this one in relation to accidents, particularly with relation to road traffic accidents.  For each topic the advice is given in this text form, which is by necessity compact, focusing on key points and there are a list of local and national telephone numbers at the end of each topic section for the young person to refer to and use, and we have also put all the telephone numbers contained in the book in a rear index section of the booklet. 

This is another slide of text, in this case giving advice about alcohol.  Again it emphasises key points, and again providing information which is immediately relevant to the young person as well as information of later consequences.

There was much discussion in the early stages of forming this booklet as to whether the text should be accompanied by pictorial representations either in cartoon form or diagrams.  We felt that for the pilot study we would have a blank page following each topic, allowing youngsters to develop any thoughts they might have about diagrams, cartoons or other pictures which might push home any definite messages to them.

We are now in a position to revisit the pupils with the repeat knowledge of health questionnaire and also a questionnaire that we are using to evaluate the booklet.  There has been an enormous amount of interest in the booklet on the young peoples behalf, and they have come up to me with individual comments and this is just one example of something a group of six youngsters initiated themselves, they gave me a series of papers about what they thought of each stage of the booklet.

At present I can only give very preliminary results on the evaluation of the booklet.  But these results do indicate that our early concerns about whether the children would use the booklet, and whether they would understand them, were probably wrong.

In this pilot study of 155 young people aged 13 to 16, the results to a question as to whether they felt the booklets were helpful or not, indicated that 82% of the young people did feel that they were helpful.  And 72% of the young people indicated that they understood the advice within the booklet.  The category of ‘don’t know’ to the second question is interesting.  It became very evident when we went into the classes of the schools, that because we were serving pupils of very mixed ability, some of the young people had difficulty in understanding some very simple questions that were set, so that the answer ‘don’t know’ really contains a heterogeneous group of opinions, and I think we need to look into this in more detail.

136 of the young people that we asked felt that the booklet should contain pictures.  Interestingly 63% of them favoured photographs rather than cartoons, again perhaps suggesting that they want a more adult representation of the facts, rather than a less adult one.  

Currently in this pilot stage, the booklet has been introduced into schools with no re-enforcement.  We believe that this positive response rate would be increased if the booklet was referred to in personal health and education sessions and in other health related contact points.  Including sessions that the police hold in relation to drug abuse and accident prevention. 

In terms of exploring the value of the booklet further, to young people themselves and to their health related behaviour, we do recognise that knowledge is only one fact in the equation and we are currently exploring other avenues in which we can use we can measure the impact of the booklet on young peoples use of services.  This will require co-operation of all the agencies involved with young people. 

In conclusion, as this booklet develops, we are keen to take on board the views of the young people themselves and to develop their ideas further, both through focus groups and through their participation in our working group.  Preliminary discussions with teachers and health education leaders have indicated that they would be very keen to use much of the information in the booklet in their sessions at school.  This would help to reaffirm key messages contained in the booklet and to remind the youngsters to use them when they need to.  We are also keen to explore other ways in which the booklet might be used, for instance in peer group teaching and in regular debate in schools and youth groups.  We hope that by adopting this collaborative approach, we will provide some improvement in health indices in our young adult population.