Health information and teenagers in residential care A qualitative study to identify young people's views
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Health information and teenagers in
residential care A qualitative study to identify
young people’s views
Study setting and sample
Annabelle Bundle presents the results of a quali-
The study was carried out between
tative study, undertaken in a mixed residential August and November 1998 in a mixed
children’s home, which aimed to identify what looked residential children’s home for young
after young people see as important in terms of people aged 12–16+ years, with a school
health information. The young people wanted inform- on site. Situated in the north of England,
ation particularly on mental health issues, keeping fit, the home has 32 beds, eight being in a
secure setting. It is a national facility,
substance use and sexual health. Many were reluct- suitable for those with previous place-
ant to request appointments for personal matters ment breakdown and school failure.
and did not feel they were encouraged to ask about Forty-six young people were resident at
personal health concerns during medical examinations. some time during the study period. Ten
were admitted on emergency placements
and were excluded from the study. Of the
remaining 36, the age range was 13–16
Annabelle Bundle is Introduction years, with more males at the younger
Associate Specialist A school-based survey in 1997 found that and more females at the older end of the
Community most young people preferred to share age range. All were white. Eight had
Paediatrician,
Central Cheshire
health worries with their mother (Balding, experienced multiple episodes in care.
Primary Care Trust, 1998). Because breakdown of family The mean number of placements per child
Winsford, Cheshire relationships is a contributory factor to was six. The mean length of time being
residential placement for many teenagers, looked after was 30.9 months. Thirty-
Key words:
those in residential care may not be able three residents attended the on-site school
teenagers, looked after
children, residential to share health concerns with a parent. and three attended other schools. Seven-
care, public care, Education and behaviour problems are teen had a statement of special educa-
health information common in looked after children and tional needs (60 per cent for emotional/
there is a high rate of psychiatric illness behavioural disorders and 20 per cent for
in adolescents in care (Halfon et al, 1995; moderate learning difficulties).
McCann et al, 1996; Mather et al, 1997;
Broad, 1999). Many looked after children Methods
have poor school attendance and school A list of questions to be covered in the
refusal (Berridge and Brodie, 1998; interviews was compiled by the author and
Sinclair and Gibbs, 1998). Consequently, discussed with her supervisor. As a pilot,
they may miss out on health education. semi-structured interviews were carried
Concerns about headaches, acne, diet, out with a 15-year-old boy and a 14-year-
sexual health, drugs and mental health old girl attending mainstream secondary
have been identified in studies of looked schools and not in public care. Transcripts
after young people, with written informa- of the interviews were reviewed by the
tion wanted by those in residential care author and her supervisor to identify bias
(Coutts and Polnay, 1997; Mason, 1997). and any additional questions to be asked in
However, published reports often lack the study interviews.
details of methodology or involve very Following the two pilot interviews and
small numbers of young people (Mapp, an additional discussion with two other
1996; McGuire and Corlyon, 1997; young people (not in public care) about
Landon, 1998). This research sought to the variety of issues that could be in-
clarify what a specific group of teenagers cluded under the heading ‘health’, it was
in residential care see as important in the felt that a ‘Health Information Topics’ list
area of health information. would be helpful when introducing the
research to the residents at the children’s
ADOPTION & FOSTERING VOLUME 26 NUMBER 4 2002 19home. The list contained 25 suggestions past and for most there was more than
and each resident was asked to choose up one: nine had received information from
to ten topics they wanted information school, seven from parents, six from care
about. They were not asked to put these in staff and five from a doctor. Five also
order of priority, nor were they asked to looked for information in magazines.
indicate if they had previously received Information from doctors was not always
information on these topics. They could well understood and the comprehensi-
add further topics if they wished. The bility of written information depended on
Health Information Topics list was com- how it was phrased. When asked where
pleted prior to semi-structured interviews. they would go to find out about a particu-
Some chose to complete it on their own, lar health issue, ten said a doctor, five a
others preferred to do it after discussion clinic, five a member of the care staff,
with the author. three a teacher and three a library. Only
Consent to interview was obtained three said they would ask a parent, but
from the young person and, where appro- one of these said her mother was the
priate, a person with parental responsi- person she would talk to if it was a per-
bility. Interviews were conducted privately, sonal problem. Accessibility of informa-
recorded on audio-tape with the young tion was a concern. Telephoning a parent
person’s consent and transcribed as soon was a possibility, but the majority needed
as possible afterwards. Assurance was permission to go off site. For personal
given that data would be anonymised. issues, having to ask permission to make
Frequency data were produced from an appointment and leave the site was a
the Health Information Topics list. In- problem.
formation from interviews was analysed Three felt that some health informa-
by identifying themes and categories, tion already received had not been re-
collating responses to each question and quired. For one, repetition of information
coding the information (Burnard, 1998). at different schools was unwelcome;
Audio-tapes were also reviewed by the another felt he already knew most of the
author. Quotes from the young people sex education he had received. Seven felt
have been included to illustrate themes. that some information should have been
given at a different age, or updated as
The study participants they became older. For girls this applied
Eight males and three females aged 13– to sex education, contraception, sexually
14 years, and four males and seven transmitted infections and pregnancy.
females aged 15–16 years completed the This was also mentioned by one boy. A
Health Information Topics list. This 15-year-old girl felt strongly about sex-
reflected the age and sex distribution of ually transmitted infections, that:
the residents.
In total, 18 young people were inter- children should be told as soon as they
viewed. Eight males and one female were are old enough to understand about it, at
aged 13–14 years, and three males and six their level of maturity. They should be
females were aged 15–16. Four who told straight away.
completed the Health Information Topic
list declined interview. Drugs were mentioned by a 16-year-old
girl as an issue which should be covered at
Results a younger age than 11 or 12, and two boys
wanted information about smoking at age
Health information 10–12. Twelve said previous information
Preferred topics for health information in had influenced some aspect of their
the two age bands, identified by the behaviour. Of these, seven had tried to stop
Health Information Topics list, are given smoking or decided not to start; five had
in Table 1. become aware of the importance of safe
The semi-structured interviews showed sex; one had learned not to be lazy.
that the young people had obtained in- However, despite previous information,
formation from a variety of sources in the two said they would continue to smoke and
20 ADOPTION & FOSTERING VOLUME 26 NUMBER 4 2002Table 1
Health Information Topics list: choice of health information topics in order of frequency*
Topic % who selected No. in age group 13–14 No. in age group 15–16
each topic who selected each topic who selected each topic
Stress 64 6 8
Keeping fit 64 7 7
Drugs 59 8 5
Alcohol 59 8 5
Smoking 59 8 5
Sex education 54 9 3
Family planning 45 4 6
Healthy eating 45 6 4
Sexually transmitted diseases 41 4 5
Acne 41 4 5
Staying healthy 41 5 4
Depression 35 5 3
Asthma 32 2 5
Eating disorders 27 1 5
Child development 27 4 2
Sports injuries 27 4 2
Bullying 23 2 3
Personal safety 23 2 3
Personal hygiene 23 2 3
Eczema 23 1 4
Puberty 18 3 1
Sun protection 14 0 3
Epilepsy 9 1 1
Diabetes 5 0 1
Immunisations 5 0 1
one said he would continue to use drugs. Two stressed the importance of health
Two (14-year-old males) said they would information being available to all
only learn by their own experiences. residents. Five only wanted to receive
Written information about health health information verbally. Some felt
issues was wanted by 13, with the option information on computer might be useful,
of discussing it before or afterwards. The and a 14-year-old male said computer
opportunity to take it away to read them- games on bullying and hygiene would be
selves was important: more interesting to teenagers. However,
there was uncertainty about access to a
I like to have something given me to read, computer in the home.
‘cause I can sit in my room and read it. The young people were asked whether
*Additional topics, each identified by a different person, were: first aid, respect for old people,
living accommodation after leaving care, cystitis, anaemia and where teenagers can get help with
health issues.
ADOPTION & FOSTERING VOLUME 26 NUMBER 4 2002 21health information would be more accept- bullying as well, but kids could not know
able to them if teenagers helped write it. what’s happening.
Their views varied. Eight felt this would
be a good idea, although seven of these She felt this was an issue the young people
felt such information should be checked in the home knew about, but that should be
for accuracy by a professional. One said: available to children in all schools.
I would like it to be in my own words. You Their own health
get things at the doctors all in medical Twelve of those interviewed had some
jargon and you just don’t understand it. concern about their present health.
Several talked about missed immunisa-
In contrast, eight felt it was better for tions, particularly BCG. Other concerns
information to be written by older people. included sexually transmitted infections,
One 15-year-old girl said: asthma, anorexia nervosa, acne, puberty
and general fitness. Although many were
I’d probably tend to read it more if I knew not interested in their past health, one
it was somebody a bit older who’d done it, talked about his ‘lifeline’. This contained
because I still go by the, you know, the information he had asked for about such
older the wiser sort of motto. things as which day of the week he was
born and when he had been in hospital.
One preferred a mixture of writers, dep- When asked about previous medical
ending on the seriousness of the issue, consultations, either with the general
and two felt they could put information practitioner (GP) or when attending for
together themselves, with the help of their statutory annual medical examina-
someone who knew about the subject. tion, only six felt they had been useful,
Most of the young people therefore wanted and only three of these felt they had been
information they could understand and given encouragement or opportunity to
which came from a respected source. ask about their own health concerns. For
When asked if it would be useful to most, arranging an appointment to see the
have telephone helpline numbers, eight GP would be done by a member of the
felt they either would not use helplines or care staff. One 16-year-old said she could
their previous experience was unfavour- make her own appointment, but would
able. They represented both sexes and all need permission to be off site. Six did not
ages. One preferred to talk to someone feel comfortable seeing the GP and
face to face. However, ten said helpline several said that when they had to see a
numbers would be useful. The importance doctor they would prefer seeing the same
of Freephone numbers was stressed by one each time. For one, the staff member
three, and another said numbers should who accompanied her to the appointment
be available to all residents, not just kept was important, as was having a choice of
in a central place. Specific rather than whether this person would remain outside
general helplines were mentioned by the consulting room:
several:
It would depend on if the staff were sitting
It needs to be someone who knows exactly in, because if it was someone I didn’t know
what you’re talking about, for the answers well and I was told, right you can come
you need. and talk to the doctor about your eating,
but . . . was coming in, I wouldn’t talk in
All those interviewed were given the front of her. But if I was told a member of
opportunity to raise any additional health staff was sitting outside the door or if I
information needs. One girl talked about was told I’d have a member of staff I felt
information on abuse: comfortable with, it wouldn’t be a problem.
I think we should have leaflets on abuse Confidentiality was not asked as a
and things like that, or people going into specific question, but was raised by four
schools and talking. It comes under people as being important, and implied by
22 ADOPTION & FOSTERING VOLUME 26 NUMBER 4 2002a further four who said they would not in residential children’s homes. Acne and
tell staff the reason for wanting an puberty were identified in both the Health
appointment if the matter was personal. Information Topics list and the interviews
as being of concern to several male resi-
Discussion dents. Looked after children often have
The Department of Health consultation poor school attendance, so they are likely
document, Promoting Health for Looked to miss personal, social and health
After Children (1999), includes health education lessons when these issues
promotion as one of the key areas of would have been discussed.
healthcare planning for looked after Sex education was wanted by more of
children. A National Children’s Bureau the younger age group, while family
report on health promotion and looked planning and sexually transmitted infec-
after children (McGuire and Corlyon, tions were of interest to more of the older
1997) stresses the importance of viewing group. It is likely that this reflects their
health promotion as more than simply own experiences. Giving such informa-
giving information to individuals, rather tion at an early age was stressed by one
it should focus on ‘the creation or young woman, though she recognised that
improvement of structures that can pro- this would need to be tailored to the
vide help and support to young people maturity of the individuals.
and those who care for them’ (p 3). Although Broad (1999) found specific
This study could be criticised for health information about smoking and
concentrating on health information, but drinking was wanted by care leavers, in
the latter is an essential step in planning this study information about substance
health promotion intervention (Warwick use of all kinds was of more interest to
et al, 1998). Discussion of the Health the younger age group. Interventions
Information Topics list with some of the aimed at reducing the likelihood of
young people, prior to them completing younger residents starting to misuse sub-
it, could have introduced bias into their stances should be considered, while
responses, but they were encouraged to taking account of circumstances that
give their own views. Knowledge of their affect drug use (Health Education
views assists in planning appropriate Authority, 1997).
provision, and the experiences of service There was a variety of views about the
users should inform the process of pro- format of future information. Written
viding services to children in need information was preferred by 72 per cent
(Mather et al, 1997; Warwick et al, 1998; of those interviewed, although some also
Department of Health, 2000). wanted an opportunity to discuss it. When
Mental health issues are of concern to discussing the Health Information Topics
young people in residential care (Mason, list, two young people stressed the
1997; Mather et al, 1997). This study importance of information being available
found that 64 per cent wanted information to every resident, not simply displayed in
about stress and 36 per cent information a central place. Any written information
about depression. Eating disorders were needs to be accessible, accurate and
also of concern. The study was not appropriate in content, style and reading
designed to diagnose mental health pro- age. Involving young people in compiling
blems, but the extent of concerns raised information could be considered, as this
by the young people themselves high- may improve both their understanding
lights their need for access to emotional and motivation to use it. The use of
support and, where necessary, specialist information technology was mentioned by
mental health services, as recommended some and should be explored, though
in the draft National Healthy Care access to a computer and privacy when
Standard (National Children’s Bureau, using it may be difficult in a residential
2002). home, as they might with telephone
Information about keeping fit was helplines.
wanted by 64 per cent and opportunities Although many of the young people
for physical activity should be available expressed little interest in their previous
ADOPTION & FOSTERING VOLUME 26 NUMBER 4 2002 23health, this information may become 1999). In the area in which the study
more important to them as they get older. home is situated, mainstream secondary
A health record which is retained by the schools have regular school nurse ‘drop-
young person has been advocated (Butler in’ clinics, in addition to health inter-
and Payne, 1997; Irving et al, 1997). views offered to all Year 7 pupils. The use
Such a record could contain the of a school nurse to provide a similar
information that one resident had asked service in residential children’s homes
for in his ‘lifeline’. would give these young people easier
Social workers and carers may discour- access to a knowledgeable health profess-
age teenagers from attending the statutory ional, with an opportunity to talk confi-
annual medical examination (Irving et al, dentially about their own health concerns
1997). Physical examination may not be and to discuss any written health informa-
the best way to assess the health of teen- tion they receive. The nurse could facili-
agers. Mental and emotional well-being, tate referrals where required and also
health promotion and gaps in the uptake address such issues as incomplete
of child health promotion should also be immunisations.
addressed (Polnay et al, 1996; Butler and The young people in this study may
Payne, 1997; Irving et al, 1997; Mather et have needs that are different from those in
al, 1997). However, where physical exam- foster care or smaller residential units.
ination is indicated, providing a choice of Those in foster placements may have less
doctor and continuity when further restriction on their movements, facilita-
appointments are required, is important. ting confidential access to telephones and
This would help address the concern healthcare services. The lack of a trusted
raised by some young people of wishing adult has been identified by young people
to see the same doctor each time. Those in public care (Mather et al, 1997). There
interviewed had found a lack of encour- may be greater opportunities to build a
agement to raise their own health con- trusting relationship with a long-term
cerns at medical examinations. This must foster carer, with whom they can share
be taken seriously as 67 per cent had health concerns. However, foster carers
concerns about their current health. may be unsure of their responsibilities in
Therefore, any consultation with a health respect of health promotion and young
professional should be combined with an people in their care (McGuire and
opportunity for teenagers to talk about Corlyon, 1997). Smaller residential units
their own concerns. may also facilitate the development of
McGuire and Corlyon (1997) identi- such a relationship of trust, but a high
fied the need for: ‘an adult from outside turnover of residents may make this
the young person’s immediate environ- difficult (Polnay et al, 1996; Sinclair and
ment from whom they can obtain inform- Gibbs, 1998). Minimising the number of
ation on such subjects as sex and drugs placement changes is crucial for all
and with whom they can share personal children in public care.
details if they so wish’ (p 74).
In this study, more than a quarter of Implications for practice
those interviewed saw clinics as a source Teenagers in residential care are a part-
of information. Promoting Health for icularly disadvantaged group, frequently
Looked After Children (Department of having unmet health needs and poor
Health, 1999) emphasises the importance educational attainments. It is important
of looked after young people having ‘the that they are not disadvantaged further by
opportunity to enjoy a standard of care as lack of provision of services available to
good as all children of the same age teenagers in mainstream secondary
living in the same area’ (p 3). School schools. Although provision of health
nurses have a key role in meeting the information is only part of the wider
health needs of school-age children and scope of health promotion, providing
some issues may be addressed more information in a format acceptable to
appropriately by nurses (British Paediatric them, covering issues which they have
Association, 1995; Department of Health, identified as areas of concern, is import-
24 ADOPTION & FOSTERING VOLUME 26 NUMBER 4 2002ant. If this is combined with opportunities planning, assessment and monitoring,
to talk to a health professional, such as Consultation document, London: DH, 1999
occurs at school nurse drop-in clinics, it Department of Health, Department for
could help reinforce the message and Education and Employment, Home Office,
increase its effectiveness. Whether this Framework for the Assessment of Children in
would lead to improvement in the health Need and their Families, London: The
of the residents will need to be moni- Stationery Office, 2000
tored. All health professionals who have Halfon N, Mendonca A and Berkowitz P,
contact with young people should give ‘Health status of children in foster care’, Arch
them encouragement and opportunity to Pediatr Adolesc Med 149, pp 386–92, 1995
talk about their own health concerns, and Health Education Authority, ‘Health promotion
maximise the health promotion oppor- in young people for the prevention of substance
tunities such contacts provide. misuse’, Health Promotion Effectiveness
Reviews, Summary Bulletin 5, 1997
Acknowledgements
Irving M, Evans S and Watson L, ‘British
This research was undertaken for the Agencies for Adoption and Fostering in
MMedSc in Child Health at the Univer- Scotland: Scottish medical advisers’ survey’,
sity of Leeds. I am grateful to Dr S Wyatt Public Health 111, pp 225–29, 1997
and Dr M Rudolf for their advice and
Landon J, ‘Children in care: responding to their
support; also to the Community Liaison
health education needs’, Healthlines, March,
Officer, young people and staff at the pp 12–14, 1998
home.
McCann J, James A, Wilson S and Dunn G,
‘Prevalence of psychiatric disorders in young
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