Profile of young people's advice clinic in reproductive health, 1988-93BMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6957.786 (Published 24 September 1994) Cite this as: BMJ 1994;309:786
- E C Williams,
- R J E Kirkman,
- M Elstein
- Mancunian Community Health NHS Trust, Manchester M20 9LJ20Department of Obstetrics and Gynaecology, University of Manchester, Manchester M20 8LR.
- Accepted 6 June 1994
For an unprepared sexually active teenager the 1990s present a minefield of potential problems in addition to the most obvious problems of unplanned pregnancy and sexually transmitted disease. Promoting the importance of a healthy sexual and reproductive life to young people requires openness, better sex education, realistic discussion of related issues, and provision of contraception, as well as support if things go wrong. The Woodhouse Park Clinic in south Manchester opened in October 1988 with the aim of providing weekly advice sessions to young people up to the age of 18. Advice is given on topics such as substance misuse and smoking as well as on family planning. Attendance has steadily increased over the years; from April to June 1993 the average number of attenders per session was 39, one third of whom were young men.
The Health of the Nation highlighted unplanned teenage pregnancy as one of its key areas for priority action.1 Careful Planning is essential to use resources efficiently. The first priority is to attract young people to clinics that give contraceptive advice and the second is to ensure that these clinics' services and advice are appropriate for them. We describe here the background and development of a community health clinic for young people that has been open since 1988 and has been outstandingly successful.
Setting and background
Woodhouse Park Clinic serves Wythenshawe, a large, sprawling, council housing estate in south Manchester comprising the adjacent administrative wards of Benchill, Baguley, Sharston, and Woodhouse Park. The district has a total population of 48072 residents, with about 1 in 10 households that comprise a single person aged over 16 living with one or more dependent children aged under 16.2 The conception rate in girls aged 11-15 in this district is high, with an average during 1989 to 1991 of 17.1 per 1000 compared with 12.2 in the north west of England, and 9.9 in England and Wales.3
In 1986 family planning managers, school nurses, and the local midwife and parentcraft tutor planned a weekly clinic specifically intended to lower the rates of teenage pregnancy in the area. Two days of preliminary staff training, organised by the district health authority's promotion department, included drafting objectives of the planned service; discussion and role play of possible legal, ethical, and practical problems; and team building exercises. All doctors and nurses who were to cover clinic sessions were invited to the training days.
The clinic opened in October 1988, staffed at each session by two school nurses, the midwife and parentcraft tutor, and one family planning doctor; all the staff were female. One session a week was held throughout the year, including school holidays, from 3 30 pm to 5 30 pm on a Thursday afternoon to coincide with young people coming home from school. The clinic was held in a multipurpose community health centre at Woodhouse Park, which is on a quiet but accessible corner near other amenities.
The sessions were advertised initially by school nurses in their schools and by the midwife in her club for young parents, and posters and leaflets were distributed to doctors' surgeries, libraries, and other public places. Since the launch, however, word of mouth has had by far the greatest impact on attendance.
The clinic includes a reception area with a prominent poster that states the name of the clinic and its purpose. Here a clerk takes minimal details from attenders and explains to them that this helps in keeping confidential records. She gives new attenders a small membership card (fig 1). In an adjacent waiting area music plays from a cassette recorder or a video is shown on sexual topics related to health. The clinic has several consultation rooms and a larger room (accommodating up to 20 young people) for education sessions or discussions.
Flow through the clinic is important as rowdiness can easily develop if waiting times are too long. Attenders are seen singly or, more commonly, in groups, depending on their preference and the number of young people attending the session. The roles of the doctor and the nurses are interchangeable in some aspects, such as initial interviewing and health education.
The aim of the clinic is to help young people with a range of problems, such as substance misuse, bullying, and smoking, although the staff's skill lies in family planning. If simple counselling is insufficient or a problem is serious the staff refer teenagers in confidence to another professional agency. The staff have a list of all the appropriate local services and use Manchester's child protection procedures if they suspect child abuse.
No lower age limit exists for young people wishing to attend; from April 1992 to March 1993 the ages ranged from 11 to 17 (table). The youngest are usually only curious; they are welcomed, shown around the clinic, and encouraged to ask questions. Most young people who attend come for contraceptive advice (box). Questions are encouraged and are answered in a factual, non-judgmental way. The clinic caters specifically for young people not yet at ease with their developing sexuality so attendance is restricted to those under 18. At 18 they attend adult sessions of the same clinic, held at different times.
Follow up consultations
The young people may of course not be truthful in front of peers, but we aim to build up trust. Further consultations may reveal more information as their confidence and feeling of personal responsibility grow.
Follow up after a contraceptive method has been explained is essential. Compliance in pill taking is often poor, and further discussion is needed to ensure that the pill is being taken correctly and consistently. Young women can come back to the clinic if they have queries or can telephone the main centre, open daily, for urgent advice.
Young women are assured that routine clinical examinations are not required. Pelvic examination may be needed, however, to estimate gestation and for suspected infection and may include high vaginal and endocervical swabs for culture for chlamydia. Routine cervical smear tests begin at age 20 (in the adult sessions) or at the discretion of the family planning doctor if a girl has been sexually active for at least one year.
A common reason for first attendance is for a pregnancy test, and testing on site is therefore essential. Two test kits are used, one for routine use and the other for the rare occasions when a more urgent result is needed. Testing may be useful to exclude pregnancy before a new method of contraception is used or before a depot method is continued in young women with amenorrhoea who are overdue for an injection.
In 1993, 95 pregnancy tests were performed, of which 27 yielded positive results. Of the young women who were pregnant, nine were aged under 16, 14 were aged 16 or 17, and four were aged 18-20.
If pregnancy is confirmed then appropriate support and counselling are given. Young women wishing to continue with their pregnancy are introduced to the midwife and parentcraft tutor, who arranges a “booking in” appointment at the local district hospital and encourages her to attend parentcraft classes and community antenatal care. Young women requesting termination are referred directly by telephone to the same hospital. In all cases full details are given in a letter to the hospital consultant, with a copy to the young woman's general practitioner unless in the case of termination she wishes otherwise.
Management of clinic
Clinic procedures are continually discussed and revised. Extra staff have been taken on since the clinic opened. The clinic now has a volunteer health visitor and an additional school nurse, and it receives frequent visits from health care professionals wishing to see how the clinic is run. Staff usually meet up to an hour before a session starts to set up and discuss general administration. Policy meetings are held about once every three months. A written protocol, which begins with a policy statement (box) is being developed. It will include clinical procedures; aspects of the law and child protection guidelines; confidentiality; and management of practical problems such as aggression and unruliness, misuse of supplies, and parental complaints.
Policy statement of Woodhouse Park Clinic's protocol
“We aim to see and advise young people in a sympathetic, non-judgmental manner maintaining confidentiality within the confines of the established code of practice for doctors and nurses and following the city of Manchester Child Protection Procedures.”
Attendances have grown dramatically since 1988; data have been collected from 1 April 1991 onwards (fig 2). Attendances averaged 39 per session in the second quarter of 1993 (fig 3). Of the 39 attendances, on average 24 were returns and 15 were new (10 young women, five young men).5 Of particular interest is the use of the service by boys aged under 16, usually a difficult group to attract; between 1 April 1991 and 31 March 1992, 63 such boys registered in 52 sessions held by a doctor.
Teenagers are a difficult group to attract to advice clinics for complex reasons, including issues of confidentiality, lack of confidence, and perceived disapproval by society of adolescent sexual activity. This clinic meets the first criterion for success in that many teenagers attend bringing their friends, which implies that some needs are being met and obstacles to access are being overcome. The attendance rate in boys aged under 16 is higher than that at other advice clinics, with the rate of first attendances per doctor session being 60-fold that of the Brook Advisory Centre for the same 12 months.6 We believe that certain features of our service have contributed to this achievement (box).
Aspects considered important for success of teenagers' clinic
No lower age limit but upper limit of 18 years
Drop in system, after school; weekly clinic, including school holidays
Clinic should be accessible and quiet, with no other clinic sessions running
Regular, committed, and well trained; seen to be welcoming and cheerful; male staff not essential if staff are confident with young men
Establishment and demonstration of confidentiality; time allowed for numbers to build up; choice for clients to be seen individually or in groups; no smoking, swearing, or rowdiness allowed
Involvement of teenagers in teaching - for example, demonstrating condom use to friends on a glass model
Full range of services on site, including facilities for pregnancy testing, high vaginal swabs, and endocervical swabs and provision of barrier methods, oral and postcoital contraception, depot injection, intrauterine devices, and slow release implant
Comparative data from northern Europe and the United States showed that the Netherlands and Sweden - where teenagers were encouraged to recognise their developing sexuality, access to contraception was easy, and sex education was provided - had much lower rates of teenage pregnancy and abortion than the United States and Britain, although rates of sexual activity were similar in all countries surveyed.7 To prevent sexually transmitted infection young people should learn, from an early age, to be assertive in asking difficult questions. They should be helped to gain high self esteem especially in matters of loving relationships and sex. The Dutch way of encouraging young people to discuss openly with their peers and adults the implications of developing sexuality from pubescence onwards is effective in that the Netherlands has the lowest rate of abortion of any developed country.8 Giving young people the opportunity to discuss openly sexual behaviour and contraception and providing easy access to information, advice, and supplies leads to responsible behaviour and promotes individual wellbeing.
To measure any changes that have arisen as a result of our service we looked at specific outcome indicators.
Teenage conception rate - The release of the numbers of conceptions per year in girls aged under 16 for a small geographical area raises issues of confidentiality; official data are not available and local schools refused to provide information.
Rate of sexually transmitted disease - The rates of attendances by teenagers at the local genitourinary clinic were reviewed. Statistics from this source, however, show that less than 1% of all attenders were aged under 16, and therefore the numbers were too small to identify a change in a pattern. We have found, however, a doubling in the number of examinations for symptoms of infection over the previous year, with 25 swabs having been taken in 1993, of which seven were positive by culture for chlamydia. Many factors may be responsible for this increase in testing for infection, including a higher index of suspicion by doctors and an increased willingness by girls to admit to symptoms. The high rate of positive results on chlamydia testing (28% of samples for the under 18s' clinic, compared with only 7.3 (75/1026 tests) from pooled data of all other south Manchester family planning clinics) indicates the importance of the test, easy referral to a treatment clinic, and increased awareness in young people.
We intend to compile our own data on outcome indicators, in particular on numbers of pregnancies and rates of sexually transmitted infection in young people aged under 18. The information and experience gained will facilitate further training of medical and nursing staff who provide services for teenagers.
We thank all those who have helped in the training for and the planning and service provision of the under 18s' clinic, particularly Dr Ellis Friedman; Elizabeth Law; Jim Stanton; Amy Hill; school nurses Gill Atty, Christine Rooke, and Colleen Boyle; and parentcraft coordinator Jenny Rothwell, who have welcomed our young attenders and worked so successfully.