Safer Sexual Health Choices for Homeless Young People, County Durham and London

Themes this local practice example relates to:

  • Youth
  • General resources

Priorities this local practice example relates to:

  • Increasing the engagement of young people in positive activities so as to achieve the ECM outcomes
  • Delivering better outcomes for young people by increasing the impact of targeted youth support and development

Basic details

Organisation submitting example

FPA (Family Planning Association)

Local authority/local area:

County Durham and North-East/London


The context and rationale

Sexual health charity FPA provides straightforward information, advice and support to everybody across the UK on all aspects of sexual health, sex and relationships. Our mission is to support people to make responsible choices so they can enjoy sex and look after their own well-being and that of their partners.

We want to see:

• fewer unwanted pregnancies
• lower rates of sexually transmitted infections
• fewer dysfunctional relationships.

We also want to avoid another generation of young people growing up not knowing how their bodies work. We believe that the best way to achieve this is to provide accurate, non-judgemental information so people can make informed choices and take responsibility for their own actions.

We provide information, advice and support in many ways: 

• We develop and produce resources, in the form of booklets, leaflets, books and DVDs and in electronic formats, that are aimed at teachers, professionals and the general public. Many of these resources help children get through puberty by giving them straightforward honest information about their body changes and their feelings. 
• We run projects in the community, particularly with teenagers and parents, that provide practical solutions to everyday problems. For example, we support parents to be able to talk to their children about sex, relationships and growing up in the ‘Speakeasy project’ and we help teenagers build up their levels of confidence and self- esteem so they are more respectful within the relationships they develop.
• We run a confidential sexual health helpline answering 50,000 calls and web enquiries every year. 
• We deliver non-clinical training courses that enhance skills and knowledge to support people’s sexual health and rights.
• We run national awareness campaigns to change people's perceptions and behaviour and improve sexual health services. We also lobby on sexual health, working with the UK's parliaments and assemblies.

Our work covers puberty and fertility, pregnancy and contraception choices, sexuality and sexual rights. Talking about sex and relationships is often about understanding behaviour, building trust, building friendships and knowing when and how to say no, so our work covers issues such as levels of individual confidence, negotiation skills and self-esteem. Consequently, the impact of our work goes beyond sexual health and into other areas of life such as drugs, alcohol, gun and knife crime and gang culture.

Sex and relationships are central to individual and societal well-being yet many people find it hard to talk about them. FPA gives people crucial skills and knowledge to make it easier.

The idea was to create a unique sexual health project which was informative, engaging and accessible, specifically targeted to young homeless people. Working in partnership with the charity Centrepoint (in Durham/North-East and London), other homelessness organisations and statutory health service providers, we wanted to increase and improve homeless young people’s knowledge of sexual health. The project Sleepin’ Safe Sexin’ Safe was created and named in consultation with homeless young people.

Homeless young people are some of the most disadvantaged and socially excluded in our society. Many of the young people are likely to have a number of complex problems, including physical and mental health problems, alcohol and substance misuse and anger management issues and to have suffered sexual abuse, domestic violence and trauma. 

There was a gap in providing sexual health information to homeless young people so FPA partnered with Centrepoint to create a strategy to tackle the problem. FPA has expertise in sexual health and Centrepoint works with homeless young people and, therefore, each complemented the other’s skills and knowledge.

To build this programme, we have drawn upon national knowledge and the Every Child Matters outcomes, specifically regarding the Teenage Pregnancy Strategy and targets to lower teenage conception rates. Within the strategy, there is a focus on targeted interventions with young people at greatest risk of teenage pregnancy, in particular looked-after children and the most vulnerable, including those experiencing homelessness. The two areas (London and Durham/ Northeast) have extremely high rates of teenage pregnancy nationally and this is the reason for targeted intervention in these areas.

We wanted to provide a group work programme that provided young people with the skills, knowledge and confidence to negotiate their own sexual health and relationships. Additionally, the project wanted to enable the young people to gain accreditation and provide them with opportunities to be involved in co-facilitating the group work programme as well as developing the existing programme.
Homeless young people were more at risk of contracting Sexually Transmitted Infections (STIs) and unwanted pregnancies than any other group as sex is often exchanged for food, shelter, drugs and money. 40 years of research from the homeless charity Centrepoint, shows that it may take ‘as little as 6 hours for a young person to find themselves on the streets before they are exchanging sex for goods to ensure their survival’ (Centrepoint 2005). Homeless young people have not had the same choices as many of their peers. Often they lack basic information about sexual health and contraception and are, therefore, not aware of the risks or the services available to them. We want to empower young people by giving them choices so they are able to take control of their well-being and make informed decisions about their sexual health. 
Homeless young people are not accessing statutory sexual health services, even when those services are located close to the hostels in which they live. FPA’s consultation with homeless young people revealed that there are three main reasons for not accessing the services available to them: they are unaware that the services exist, they do not understand the problems they have or the treatment needed, and/or they lack the confidence or are embarrassed to access the services.

Evidence and knowledge

Research has shown that homeless young people are at increased risk of acquiring STIs compared with the general population (Noell et al, 2001; Ochnio et al, 2001; Hwang et al, 2000). 

Research has also shown homeless young people are notoriously poor users of primary care facilities (Crane and Warnes, 2001). 

Local Initiatives

London

The London Health Inequalities Action Plan (April 2010) specifically highlighted homeless people as a group for whom a special effort needed to be made to overcome their health problems. 

County Durham

The Sustainable Community Strategy for County Durham 2010-30 highlighted the importance of reducing health inequalities and high rates of teenage conceptions. 


Project Aims (by the end of 3 year project):

- to increase the knowledge and understanding of sexual health of homeless young people 
- to increase access to statutory sexual health services of homeless young people
- to improve sexual health support and information provision by homeless organisations and staff
- to increase confidence of homeless young people in accessing services, increase education and employment opportunities and provide evidence of young people’s achievements.

Project Targets 

• to reach 580 young homeless people (120 by end of March 2009, a further 240 by end of March 2010, and another 220 by end of March 2011)
• to help homeless young people be better informed about sexual health, increase their uptake of sexual health services and generally feel more confident in their achievements. 
• for 80% of the course attendees to achieve accreditation.

To achieve this, additional targets are to run 100 sexual health sessions by end of March 2009, a further 200 by end of March 2010, and another 185 by end of March 2011.

The practice

FPA, a Sexual Health Charity, works in partnership with Centrepoint and other homeless charities that support homeless young people aged up to 25 years old. FPA has implemented, ‘Sleepin’ Safe, Sexin’ Safe’, a community-based programme which adopts a holistic approach to sexual health intervention, based on the needs of the client group in London and the Northeast of England. The programme delivers 12 ‘Sexwise’ units that educate and empower young people, so that they are better able to make informed choices about their sexual health and engage in healthy relationships. 

The programme promotes social inclusion and participation, develops independent living skills and educates the young people in their rights and responsibilities. The active participation and learning helps to break down barriers and removes the fear and embarrassment associated with sexual health services and gives the young people the confidence to seek professional intervention. For each ‘Sexwise’ unit that is completed, the young person is awarded an Assessment and Qualification Alliance (AQA) accreditation. The achievements of AQA certificates are significant in improving confidence and the progression towards education, employment and training. 

In both London and the Northeast, a course of 12 modules (typically 1-1.5 hours each) were run by a Project Officer and co-facilitated and/or observed by a Homeless/Health Worker (a Centrepoint professional in London). These covered a range of sexual health topics, including contraception, STIs, relationships, sexual behaviour, and self-esteem. The course can lead to accreditation by the AQA. As noted earlier, the target for the end of the project was for 80% of young people who took part to achieve this accreditation.

The ‘Sleepin’ Safe Sexin’ Safe’ project has been successful in engaging with a total of 616 homeless young people, who together have achieved a total of 1860 AQA accreditations over 490 sessions to date (end Jan 11).

FPA understands that ensuring sustainability training of professionals working with homeless young people is imperative to their learning and understanding of sexual health issues. This increases capacity and meets the needs of vulnerable young people. Staff from homelessness services are now equipped with up-to-date knowledge, so that they are confident to discuss sexual health with their clients. Joint working with a range of professionals strengthens development, enabling them to refer young people to appropriate services.

Evidence and evaluation - making a difference to children, young people and families

The project was implemented in June 2009 and has been successful in addressing the sexual health needs of homeless young people, whilst also helping Centrepoint/homeless provider’s staff to be better equipped to provide sexual health support to the young people using their services.

The young people are better able to make informed choices regarding their sexual health and relationships. Many of them have fed back to the Project Officers that since the intervention, they now regularly access sexual health services and feel more confident negotiating sexual issues with partners, friends and professionals.

As a direct result of the ‘Sleepin’ Safe Sexin Safe’ project, homelessness services where the programme was implemented are now registered condom distribution sites. All staff member have to be trained to distribute the condoms and issue C-Cards. The services are now offering on-site chlamydia and gonorrhoea postal packs and pregnancy tests. Having these on-site and available to the young people, removes barriers that may prevent them from accessing services. On-site pregnancy tests mean that staff member are able to identify those who may be engaging in sexual risk-taking behaviour and offer support. 

The project has a progression route available for those who successfully engaged in the ‘Sexwise’ programme and wish to take their sexual health learning further. The young people participate in a professional training course, through which they are able to achieve 15 Universities and Colleges Admissions Service (UCAS) credits. They are also given the opportunity to participate in a mentoring and leadership programme which trains them to become peer educators who can promote sexual health to other homeless young people. The progression route enables them to enter further and higher education and makes them better equipped to access employment opportunities.

Milestones have been achieved by successful networking and liaising with several youth homelessness organisations and statutory services. The outcomes are measured and collected as data to show the number of accreditations awarded, number of sessions and number and details of young people.

The project is externally evaluated to evidence the outcomes. By the end of year 2, 468 young people (aged 14 to 25) completed questionnaires about their experiences: 

80% of young people have fed back that they feel better placed to access statutory sexual health services.
80% of young people have fed back that they have increased confidence to access statutory sexual health services.
90% of young people who have taken part in the programme have achieved accreditation.

All intended project aims/outcomes (please see section 4) have been achieved and exceeded.

Many of the hostels and homelessness providers have signed up to the C Card (Condom Card) scheme enabling them to have condoms on their premises to give to the young people for free. Many have also signed up as chlamydia self-testing pack distribution sites, which encourages responsible testing amongst young people. Relevant and up-to-date sexual health information is now available in the services, as well as information about other services they may want to access. 
In Durham and the North-East, many staff have had opportunities for raising further awareness of sexual health issues through free training from Durham and Darlington Primary Care Trust (PCT). Staff in services where the sessions are delivered are receiving additional sexual health knowledge including: chlamydia screening awareness, C Card and Pregnancy Decision Making training, and Sex and the Law. 

Service providers were highly complementary of the Project Officers. The following qualities were continually mentioned:

• ¬capable and knowledgeable
• open and approachable
• good speaker and listener
• struck the right balance between learning and fun.

“[M]’s good at sensing if young people are losing their interest a little bit, and if that happens she usually will say, well I think we’ll come back to that. Or she might ask what they want to talk about, and move on to that and fit the other bit without them realising.” (North-East)

“I’ve noticed with some of the quiet people, when we’re doing the quiz, [M] doesn’t push them to speak out loud. She will just go through the answer with them as a group.” (North-East) 

“She just really connected with them and really got them to pay attention. She was really upbeat and knew when they were lagging and was like, ‘ok, let’s move on to this’ ” (London)

To ensure longevity of the sexual health intervention delivered by FPA, groups of young people who have completed the ‘Sexwise’ programme are participating in the progression route. They are developing their knowledge and skills to deliver elements of the programme with an FPA project worker, as well as having the opportunity to be peer educators to other homeless young people. 

The Project Officers work with multi-agency partners, linking in with sexual health services that provide individual on-site sexual health intervention in the form of condoms, chlamydia testing kits and pregnancy tests. These partnerships will continue. Health professionals who have been involved with the project are now better informed and better equipped to provide support to the homeless people they work with. 

The practice from this project is transferable to other geographical areas with high deprivation and can also be expanded to incorporate those dealing with vulnerable groups of young people, not necessarily homeless, including youth settings and training providers.

The project is sustainable with a further 3 years funding to be confirmed soon. An additional Domestic Violence project specific to the North-East region and FPA/Centrepoint partnership is also being set up replicating the practice, methodology and achievements from the current sexual health project.

Sustaining and replicating your practice

We have evaluated the programme by collecting and collating qualitative and quantitative data. The evaluation relates to the outcomes including the number of participants, number of sessions and number of young people achieving accreditations.

Project Targets

Year 1 (target of 120 young people, 100 sessions)

Actual targets achieved: 180 young people 
111 accredited sessions

Year 2 (target of 240 young people, 200 sessions)

Actual targets achieved: 280 young people
242 accredited sessions

Year 3 (target of 220 young people, 185 sessions)

Targets so far this year…160 young people
138 accredited sessions

We have exceeded all targets set for year 1, 2 and aim to do the same for year 3.

We have also used questionnaires for young people taking part in the sessions and questionnaires for staff observing the sessions. The project has also been externally evaluated, including all of the information about participants, such as date of birth, gender, any disabilities, sexuality and religion. The external evaluation also included independent interviews with staff and young people who had taken part in the group work sessions from both regions to get qualitative data and to highlight impact of the sessions.
Some feedback from questionnaires from the young people:

When asked: what is the most interesting/important thing you have learnt today?

‘facts on sex and age’
‘different types of contraception and diseases’
‘about discrimination’
‘low self esteem is bad!’
‘about loving relationships and sexual intercourse and how old you had to be when you are in a sexual relationship’
‘different views on abortion’
‘what STI can do to your body’
‘all different and new contraception’
‘the differences between porn and normal world’
‘the different kinds of relationships’

I think this session was most helpful to me because:

‘it taught people a thing or two that they didn’t know’
‘it let me know how I want my relationships’
‘more in depth knowledge and insight of STDs and methods of contraception and why you should use protection’
‘gave me more options of my sex life, different types of contraception’
iIt gave me ways that I can build up my self esteem’
‘it's made me feel more confident about what to find in a relationship’
‘I learnt about STIs, symptoms that I didn't really know about’
‘it was good because you can talk about stuff you would normally avoid’

The questionnaires also show that the knowledge they had got from the sessions has been effectively translated into sexual behaviour:

“It’s made me be more safer, when it comes to intercourse and things like that. Taking precautions. I was a bit careless [before].” (Female, 25, London)

“I used to be a bit of a man-eater. That’s really changed – made me think about what I’ve been doing.” (Female, 24, North-East)

“It makes people more careful about the people they choose to sleep with.” (Female, 22, London) 

“She bought us leaflets to look at. It was about, if a boy or a girl loved you, they could show they loved you without trying to make you have sex. I was quite interested in that actually.” (Female, 18, North-East)

“I use protection now.” (Female, 19, North-East)

“It’s woken us up to being more careful. If I’m going out or whatever, make sure I’ve got something [a condom].”(Female, 17, North-East)

There are several barriers to working with very vulnerable groups, including how to ensure attendance at the voluntary sessions. Homeless young people have competing demands on their time, for example, through meeting Key Workers, the Youth Offending team, Drug and Alcohol workers or benefits agencies. The young people’s lifestyles are also often very chaotic.

To overcome these barriers, already existing programmes of work needed to be understood and fitted in with, which has helped to ensure attendance. Services offering lunch and vouchers as incentives for attending three or more sessions have also helped. Flexibility has been key for the Project Workers who deliver the program at various times over the week. Delivering the work over a longer period, while having a captive audience (either a half day or full day) has also helped maintain attendance where it was difficult for some young people to attend weekly over a longer period.

Service providers were clear that participation is always voluntary, but did say they encouraged their young people to take part so they could benefit from the advice and information given. Some young people were automatically included in ‘Sexwise’ through being involved with other courses, such as Lifewise, and the Peer Mentoring scheme. For others, service providers used a variety of techniques to garner interest and enthusiasm.

The main methods were:

• providing refreshments
• offering vouchers
• giving out freebies

“The vouchers go down a treat as they all budget, and buy their own food here.” (North-East)

“We usually bribe them with food!” (North-East)

Interestingly, the most effective method for encouraging young people to participate was through highlighting that the course was accredited, and could therefore benefit them in the future in terms of other training and employment. This was felt to be particularly important, given that many of the young people did not have any other qualifications. For example:

“They love the certificate at the end. For some of them, they come along and it might be the first certificate they’ve ever had. It makes them feel proud, like they’ve actually achieved something.” (North-East)

“The accreditation is quite a big motivation, because a lot of the young people don’t have any formal qualifications. They use these certificates to pursue education and employment.” (North-East) 

Year 3 delivery

As the targets are on track, a clear message is to continue delivery in a similar manner to Year 2. The data suggests that continued delivery will achieve the Year 3 targets in terms of reach.

The young people’s data suggests that delivery received is satisfactory and having some noticeable impact on knowledge, attitudes and, in some instances, behaviour. 

The young people also clearly felt that the mixed sex groups were preferable to the single sex groups, and also that the sessions were not too long. There were some instances of where the course could have been ‘more fun’.

A further isolated area to improve was classroom disruption. Although this is in some ways inevitable, the Project Officers need to be mindful of innovative ways to reduce this obstacle to increased learning and participation.

An overarching concern, but particularly pertinent to this sample of young people, is maintaining consistency in their course attendance. On average, of the 12 sessions run, a person typically attended 4.5 different sessions in the North-East, 2.5 sessions in London and a 3.1 sessions across both regions.

Future recommendations

Recommendations from the young people and service providers are summarised as follows:

1) Promote links with local sexual health centres. 

2) Use more multimedia, particularly DVDs to give more diversity to the sessions.

3) Incorporate more practical activities, particularly when engaging younger people. 

4) Increase frequency of sessions to avoid some people missing out.

5) Give C-Cards directly to young people. 

6) Widen the course out to younger people.

7) Keep sessions to 3 hours and under.

8) Make sure to have regular contact with the young people to encourage familiarity.

9) Promote inclusion of all young people by having option of single sex groups and smaller groups. 

10) Provide an online service, where people could follow up and finish the course.

 

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