Objectives: To identify the sexual health needs of young people in order to establish a service suited to these needs.
Methods: A peer designed questionnaire piloted to a small group of young people was followed by a more widely distributed, amended questionnaire. The questionnaire survey was delivered to 744 pupils aged 11–18 years in six secondary schools and a pupil exclusion unit in central London. Factors encouraging or discouraging the use of young people’s sexual health services were measured.
Results: Several findings challenged existing models of care for young people’s sexual health services. Notably, pupils wanted clinics to run more frequently than the usual once a week; the staff attributes that were most important were attitudinal rather than to do with sex, age, or physical appearance; and they did not mind if the waiting room contained older people. Many findings, however, agreed with existing data—young people wanted the clinic to be open after school; girls preferred to attend with a friend; a confidential, walk-in service was preferred.
Conclusions: Large financial outlays are not necessary for the establishment of effective sexual health services for young people. Existing facilities and staff may be utilised with training of these staff to be sensitive to, and aware of, the needs of young people. Clinic opening times should coincide with school closing times. Although pupils stated a preference for female staff, this was not a high priority. More important was feeling that staff would listen to them and take their problems seriously, and that confidentiality would be maintained.
- young people
- sexual health
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Teenage pregnancy is associated with poor physical, psychosocial, and educational outcomes for both mother and child. The United Kingdom has one of the highest teenage pregnancy rates in Europe.1 In 1997, there were approximately 90 000 pregnancies in girls under the age of 20 in England alone. Of these, some 7700 were in girls under the age of 16 and 2200 in girls aged 14 or under.1 The UK teenage birth rate is twice that of Germany, three times that of France, and six times as high as that in the Netherlands. Thirty five per cent of teenage pregnancies result in a termination.2 Teenagers who do not use contraception have a 90% chance of conceiving in 1 year, and from a single act of unprotected sex with an infected partner, a teenage girl has a 50% chance of acquiring gonorrhoea and a 30% chance of contracting genital herpes infection.1
The incidence of sexually transmitted infections (STIs) is rising rapidly in the general population, and fastest among teenagers. Between 1995 and 2000, cases of gonorrhoea rose by 150% in the 16–19 year age group in England and Wales, while genital chlamydia diagnoses increased by 159% in the same period.2
Improving the sexual health of young people is now, more than ever, a national priority. The government’s teenage pregnancy strategy, published in 1999, details the magnitude of the problem in the United Kingdom and aims to halve the rate of teenage pregnancies in 10 years.1 It proposes to do this by improving education (both generally and on relationships and sex), so that teenagers do not feel compelled to have sex or become pregnant; by creating job opportunities and by increasing awareness among teenagers of the real responsibilities of being a parent. It also advocates increased support of teenagers if they do have a child in terms of encouragement to complete their education, better job prospects, and encouraging teenage mothers to stay with parents or in supervised accommodation so that they are not isolated.
It is well known that young people have particular difficulties with accessing healthcare. These include issues of confidentiality, of competence, and restrictions associated with school commitments. A search of the medical literature reveals that most studies involve people already using services; these will obviously fail to sample those with greatest difficulty in accessing services,3–6 including those who do not attend for reasons of ignorance, fear, or a perception that they do not need such services. Little exists with respect to the establishment “from scratch” of a service for young people with input from teenagers before it is set up.
The National Strategy for Sexual Health and HIV7 aims to “shape services around patients, their families and their carers,” and specifically highlights the need for targeted sexual health information and HIV/STI prevention towards young people. It emphasises the importance of ensuring that the location and opening hours of services match the needs of the local population and states that users and potential users of services should be involved in the development of access policies.
The aim of this study was to identify factors that encouraged young people’s use of sexual health services in order to create a service suited to their needs.
To assess the needs of young people in the area, staff from the Victoria Clinic for Sexual Health established a focus group involving six Year 12 students from a local school (Pimlico School). Students were recruited to the focus group by answering poster advertisements put up around the school. The group also included a health adviser, charge nurse, senior doctor, and receptionist from the clinic. The young people were facilitated to lead the project, to identify issues that were felt to be important in encouraging or discouraging the use of services by teenagers, and to devise a questionnaire to be used by their peers. Of particular importance were finding some way of encouraging boys (notoriously poor users of health services) to attend, and finding differences between males and females that might be of importance in promoting the service to users of a particular sex. The questionnaire was piloted to 224 pupils in Years 10–13 at the same school as the focus group. Following analysis, questions not yielding useful information were deleted. The questionnaire was then distributed to a further 522 pupils in five other local schools and a pupil exclusion unit. The pupil exclusion unit was sampled to provide data from young people who were not attending school in an effort to ensure that the sample was as representative of young people as possible. Schools were chosen to provide a wide variety of backgrounds. The schools involved were: Marylebone School (Church of England, all girls but mixed sex 6th form); Westminster Community School (mixed sex); London Nautical (all boys); Greycoats Hospital School (Church of England, all girls); Westminster City School (Church of England, all boys); Westminster Pupil Referral Unit (mixed sex). In total, 746 questionnaires were distributed.
A member of the clinic/school staff or a peer group member guided respondents with reading or language difficulties through the questionnaire.
Ethnicity data were not collected as the focus group had felt strongly that in conjunction with the age and school data, it might allow identification of respondents.
The data from the questionnaires were entered onto Microsoft Access, extracted as an ASCII text file, then transferred to SAS statistical package. Qualitative data were analysed using χ2 statistics and, where appropriate, Yates’s correction was used.
Univariate and multivariate logistic regression analyses were used to test for an association between girls’ responses to questions relative to boys’ responses. The data were analysed separately for young girls (11–14) and older girls (15–18), as there was a significant interaction between sex and age groups. Variables were entered into the multivariate model if level of significance was <0.2.
A total of 746 questionnaires were completed. Two students whose age was >18 years were excluded, leaving a total sample number of 744. A total of 294 males and 450 females were sampled with a 100% response rate. For statistical purposes, pupils were stratified according to whether they fell into 11–14 and 15–18 year age groups. Differences in response were analysed comparing age and sex.
Many findings were consistent with data from studies of existing services. Pupils wanted to attend after school (71%) or on a Saturday (49%); a walk-in (62%) rather than appointment service (35%) was preferred; the preservation of confidentiality was paramount.
Four further points stood out:
A significant majority of students (84%) felt that clinics should be held more than once a week. This preference was more strongly expressed by girls than boys (88% v 78%).
Most students (53.9%) did not mind who was in the waiting area or were happy with a mixture of ages. A minority (37.1%) expressed a wish to have only young people in the waiting area.
Twenty three per cent of young people would not wait longer than 15 minutes to be seen.
Only 19% of teenagers said that they would access care from their general practitioner.
Pupils were asked which statements they agreed with (table 1).
Pupils did not appear to mind whether the clinic was attached to, or away from, a main hospital, although younger ones appeared to be more likely to prefer it to be within a hospital (p=0.013). Younger pupils were more likely than older ones not to mind it being attached to the family doctor (p=0.04). Older pupils, particularly girls, felt that the entrance to the clinic should be on a side street (p=0.0009) and close to public transport (p=0.058).
Appointments and registration
Pupils were asked how they would like to “get to see someone” at the clinic, how they would like to register, and how they would like to let the clinic staff know that they were here (table 2).
Overwhelmingly, there was a desire to be able to walk in without an appointment. Most young people (59%) declared a preference for being taken aside to register in private and at that time giving a reason for their attendance, rather than registering at the desk on arrival, or in advance at school. There was no significant difference between boys and girls in either age group.
In addition, 58% wished to be called by a number rather than their name.
The clinic environment
The answers to questions regarding who they would like in the waiting room and what were important qualities in the clinic staff are given in table 3.
Older pupils did not seem to mind who was in the waiting room, however pupils in the 11–14 year age group appeared to prefer that only younger people be present. This difference was statistically significant (p=0.001). There was no difference between male and female students.
Sixty one per cent of girls preferred to attend with their friends compared with 20.7% of boys.
Students also expressed a preference for informality in the way they addressed members of staff, wishing to use first names rather than job titles, and for informality of staff dress. Boys were more likely to prefer formality than girls. Both males (51%) and females (76%) expressed a preference to see a female member of staff.
What services would you require? (table 4)
Younger students were more likely than older ones to require advice before having sex for the first time (p=0.001). Older girls were far more likely than their male counterparts to want this advice (p=0.0001).
Information about HIV/AIDS was equally important to pupils of both age and sex cohorts.
Older boys were much less likely to request advice about using condoms than girls or younger boys, although they were more likely to request condoms than any other group. Older girls were in fact more likely than boys of the same age to require condom advice. This is possibly because older girls are more aware of the consequences of unprotected sex than their younger counterparts. This knowledge may be partly responsible for the fact that older girls were also more worried about infections and were more likely to want contraceptive advice.
Girls were more likely to want relationship advice than boys. Younger pupils were more likely to want this advice than older teenagers (p=0.001).
When asked if they might require help with other worries concerning sex and sexuality, older boys (35.8%) were much less likely than younger boys (54.8%) or girls (59.6% in both age groups) to want this.
Only 50% of younger boys and 57% of younger girls felt that they would require more general contraceptive advice. In contrast, 45.2% of older boys and 71% of older girls said that they would require this advice (p=0.0001).
By far the easiest time to visit the clinic was after school. Older pupils were more likely to find this time easier than younger pupils (p=0.001). A strong preference was also expressed for being able to attend on Saturdays with no significant difference between age or sex groups. Older students also appeared to find it easier to attend at lunchtime than younger ones (p=0.038).
The findings of this study confirm the results of other surveys of young people, showing that girls prefer to attend with their friends, and are more concerned about contraceptive issues than boys. Also demonstrated is the high priority placed on confidentiality. However the study also challenges existing models of care on several fronts including the assumption that young people prefer younger staff to whom it is felt they might be able to relate more easily. This appears not to be so, as most of the pupils in this survey said that the age of staff was not an issue. Although most students said they would prefer to see a female doctor, this was very low on their list of priorities.
Fifteen to 18 year olds did not mind sharing a waiting room with older people, although those in the younger group did. This may need to be taken into consideration when deciding who the users of a service should be. In general, however, the provision of an effective service for young people does not necessarily mean that additional staff or separate premises are needed. What is mainly required is that existing staff be trained to be sensitive to, and aware of, young people’s needs.
It remains a difficult proposition to attract young males into sexual health services; many boys stated that free condoms were something that they would want from such a service. This may be a useful means to encourage them to attend. The importance of sexual health education of young people is paramount, not only in terms increasing knowledge about STIs and pregnancy, but also as a means of improving negotiating skills within relationships. Without this, any strategies to improve services are likely to be futile.
We wish to acknowledge the invaluable assistance of Julie Ross and Tony Kerly in entering the data, Irene O’Donnell (focus group receptionist), and most especially the pupil focus group and pupils and staff of all the schools involved.
CONTRIBUTORS NN and AM wrote the manuscript; LC, GH, and AM were part of the focus group; SM was responsible for statistical analysis.
Young people�s views on provision of sexual health services
N Nwokolo, A McOwan, G Hennebry, L Chislett and S Mandalia
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