Health Education Research Advance Access originally published online on July 25, 2007
Health Education Research 2007 22(6):879-894; doi:10.1093/her/cym032
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‘You think you know? ... You have no idea’: youth participation in health policy development
The SOLAR Action Research Centre, University of the West of England, Bristol, BS16 1QY, UK
* Correspondence to: B. Percy-Smith. E-mail: barry.percy-smith{at}uwe.ac.uk
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Abstract
IntroductionThis paper draws on research in the United Kingdom which set out to explore young people's understandings and experiences of health as experienced in their everyday lives and according to their own terms of reference, rather than in response to policy priorities. The project involved a peer research process followed by a large community learning event in which practitioners, community leaders and decision makers were brought together in dialogue with young people to develop understanding and explore responses to young people's health needs as a collaborative process. The paper documents an ‘alternative’ ‘participative action research’ approach to involving young people in research and developing responses to issues and problems that affect them. The paper highlights the value of a dialogical and enquiry-based approach supported by the use of visuals for engaging professionals in collaboration with young people in a process of learning for change. It draws attention to the ‘policy gap’ between professional understandings of young people's health needs and young people's lived realities and how this is reflected in differences in what young people and professionals consider appropriate responses to stress.
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Introduction |
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Across the public sector in the United Kingdom, there is a rapidly developing culture of involving young people in decision-making process [1–4]. The rationale is to improve the effectiveness of services by giving service users a voice, while simultaneously extending rights of citizenship. However, critics have begun to question the impact participation is having on the lives of young people and public services [2, 5–7]. The target-driven policy agenda of public sector agencies are often seen as being at odds with the priorities and concerns of young people [5, 8, 9]. Barriers in organizations have been identified as undermining the participation of young people through, for example, inflexible bureaucratic structures which are not conducive to facilitating participation [1, 3], leading to calls for organizations to build cultures of participation to support the involvement of young people in service improvement [3]. This requires the development of new forms of research which engages service users more fully in collaboration with professionals in processes of systemic learning for change.
More recently, writers have argued that effective participation of young people requires partnerships with adults [5, 10, 11]. The UK Department of Health declare that ‘participation should go beyond consultation and ensure that children and young people initiate action and make decisions in partnership with adults ... making decisions about their carer and treatment or day to day decisions about their lives’ [12].
In relation to these current critical issues in young people's participation, this paper demonstrates how the ‘gap’ between policy and young people's lived realities can be bridged through an ‘alternative’ collaborative action research approach to policy learning and user-involvement which brings young people and professionals together in a process of dialogue, learning and reflection. The paper draws on research which sets out to explore young people's understandings and experiences of health as experienced in their everyday lives and according to their own terms of reference, rather than in response to policy priorities, and through dialogue to explore possibilities for effective responses to the health issues which emerged.
The health issues which emerged through this work focussed predominantly on stress and mental health issues. Although these issues are not the explicit focus of this paper, it is important nonetheless to briefly discuss the increasing incidence of stress and mental health issues for young people in the United Kingdom. A recent government paper [13] states that at least 10% of young people have a diagnosable mental disorder. The British Medical Association drawing on Office of National Statistics data suggest that up to one in five young people can experience psychological problems at any one time [14]. Policy responses have targeted resources on acute cases of mental illness [15, 16], yet there is increasing recognition of problems concerning young people's general emotional and psychological well-being [17, 18]. These are manifest in a range of symptoms such as depression, anxiety, self-harm and stress [19–22] and corresponding risk behaviours to cope with these conditions [23–25].
In spite of this trend, a UK government report [13] acknowledges that mainstream health services are falling short of addressing the mental health needs of young people (see also [26]). Colquhoun [20] argues that the failure of statutory responses is due to stress being understood as an individualized problem based on medical models of health, rather than understanding the complex socially contextualized nature of mental health problems [27]. Jensen [28] sees this as a problem of moralistic, rather than democratic, approaches to health education, in which health decisions are imposed rather than made by young people themselves, in spite of a growing ethos of user-involvement in health services [29–31].
Within this context, the aim of this paper is to put forward a participatory alternative to user involvement in research and policy development which emphasizes dialogue, reflection, social learning and action enquiry in response to young people's health issues. Young people gave this project the title: ‘Mind the Gap’ because they felt adults and professionals did not listen to, or understand, young people and had different ideas about what was important and where services should be directed creating a dissonance between young people's health concerns and current policy [32].
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A community based action research project with young people |
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The research on which this paper is based was commissioned by the Community Health Council (CHC) from Hounslow Metropolitan Borough in London, UK. The research brief was to undertake a consultation exercise with young people to learn more about their health needs to improve local health service provision. Two considerations guided the planning of this work. First, that young people should have the opportunity to explore and articulate their own interpretations of health concerns in the context of their everyday lives using their own terms of reference. Second, that they should be able to communicate and discuss their findings with practitioners and decision makers as part of a policy learning process. The aim of this work was not, however, simply to undertake a phenomenological study of young people's experiential realities [33, 34], rather to engage young people alongside adults in making sense of their views, experiences and priorities and consider different actions and choices within the context of current local service provision. To this extent, the task was less about identifying issues and more about social action. Social action refers to processes through which individuals and groups enhance their ability to take control of their own lives [35].
Kemmis [36], following Habermas's theoretical discourse of system and lifeworld [37], develops a theory of social action or critical action research in terms of what he refers to as ‘communicative action’ [36]. For Kemmis, communicative action enables the critical social scientist to ‘explore and address the interconnections and tensions between system and lifeworld aspects of a setting as they are lived out in practice’ (36: p. 98). Communicative action spaces are created so that participants, through dialogue and interaction, can engage in a process of learning, reflection and action in terms of personal, social and systemic development.
This project similarly used a collaborative action enquiry approach based on principles of social learning, participatory action research [38–45] and theories of post-positivist knowledge production [45–47]. Action enquiry can be understood as the collaboration of multiple stakeholders in processes of learning to support change [38, 39, 43]. Within a participatory research paradigm, emphasis is placed on generating socially robust research outcomes and processes which have validity for those taking part and for whom the research is meant to serve [45]. For Reason and Bradbury [40], the primary purpose of critically reflexive action research [38] of this kind is to produce practical knowledge that is useful to people in the everyday contexts of their lives. In this research, the focus was on supporting dialogue, learning and action in response to young people's health needs.
The research began with a peer research process with 11 youth peer leaders, aged 14–19 years, undertaking seven pieces of research. Two of the peer leaders were male, and all were from minority ethnic groups (mainly young Asians). In addition, two white, male, peer leaders started the peer research but did not produce peer research data (ironically due to exam pressure at the time), although were active in the event. The CHC already had a youth peer leader scheme operating from which volunteers for this research were recruited. The youth peer leader scheme was established by the CHC to support individual young people in taking a more active role in their community, working with the CHC to promote healthier lifestyles. There was no limit placed on the number of young people who wished to take part in the research.
The 11 youth peer leaders were given training in research methods and were supported in thinking about different interpretations of health. The task for the youth peer researchers was simply to explore with peers what they felt the main health issues affecting their lives were in order to uncover any unmet health needs. The young researchers decided on research methods they would use and the peer group they would research. The different pieces of peer research were conducted in schools, colleges, CHC offices and on the streets in their neighbourhood.
Young people were supported in undertaking the peer research and analysing and preparing their findings for presentation. One of the pieces of peer research used video and the remainder used posters to present findings from the peer research. A majority of the peer research posters involved a mix of visual symbols, images, pictures and words (see e.g. Fig. 8).
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The posters from young people's peer research were presented and discussed at a large-scale event involving 62 young people aged 13–21 years from diverse contexts and 36 professionals (including practitioners, directors of services and elected members) from education, health, youth services, voluntary sector and community organizations. Approximately two-thirds of the young people who attended the community event were female and
75% were from minority ethnic (largely Asian) groups. No limit was placed on the number of young people who came to the event, although young people who had been involved in the peer research were encouraged to attend for continuity. The young people had to seek authorized permission from parents and their head teacher to attend the event. Schools and colleges were given written permission from the Director of Education in the local authority to absent young people from school for this event, which ran from 12 p.m. until 6 p.m. The purpose of the event was to bring young people together with professionals to communicate, reflect on and understand better the real health issues for young people. The event provided an opportunity for young people to communicate their health concerns and for professionals to reflect on the effectiveness of current strategic policy priorities and practice with respect to health and young people. A key objective was to go beyond simply identifying and presenting issues, instead to engage in a process of ‘social learning’ [48] where, through dialogue, professionals and young people could jointly make sense of and respond to the health issues identified. According to Wildemeersch et al. [48], social learning can be understood as:
The learning [of] groups, [...] organizations and communities, [...] emphasis is on the optimal use of the problem-solving potential of which a group, institution or community disposes. Social learning is action and experience oriented, it is critically reflective, meaning that actors question the validity of particular opinions, judgments, strategies, actions, emotions, feelings etc. It is cooperative and communicative, which means that the dialogue between actors is crucial, continually involved in [...] processes of negotiation.An informal atmosphere was created using a ‘Knowledge Café’ approach [49] to maximize small group interaction and to provide a less intimidating context (Fig. 1).
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Groups were moved around throughout the event to deepen and share understanding. Simple participatory and visual techniques were used including posters, photo montage and post-its to focus discussion, support communication and provide an efficient way of recording data (the visual material presented in Figs 2–7
in this paper were produced by participants during the research event. Fig. 8 was produced as part of the peer research). Visuals have been used extensively with children and young people in therapeutic interventions, for example, in Art and Play Therapy [50–52] and increasingly in participatory research with children [2, 53, 54]. Despite the different intentions of participatory social research and therapy, both involve forms of ‘learning’ which can be supported effectively through the use of visuals as ‘metaphors’ to explore and communicate complex ideas in ways that may be difficult linguistically [55].
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The event involved four phases. Phase 1 concerned presentation of the youth peer research—with opportunity for participants to respond with their own comments and questions to focus subsequent inquiry. Phase 2 involved bringing young people and professionals together to discuss ‘what a healthy life means to young people’ and to consider ‘what most affects young people's health’, based on the peer research. This allowed for a more holistic and socially contextualized understanding to be developed, grounded in young people's everyday realities. Specially designed flip sheets were used to capture key issues and conversations. Professionals were invited to reflect on what they were learning from young people about their health needs and experiences, in light of their own assumptions and practices. Phase 3 involved professionals and young people working separately using visual media to envision how to create more healthy futures for young people in response to understanding of emerging health issues. Participants were invited to work in small groups to produce a newspaper front page with a headline, visual material and written detail of the changes they felt were necessary. Young people and professionals were then invited to regroup to reflect on the local policy implications of the messages in the posters. The final phase involved a plenary discussion with a panel of young people and professionals to reflect on the learning and actions from the event.
Analysis of data was undertaken in three parts. In the first instance, the youth peer research involved a level of sense making by young people and peer leaders. Secondly, in keeping with principles of participatory research, all participants were actively involved in analysing, sense making and responding to the data during the event as part of the wider process of collaborative social learning [43, 48]. Given the ‘post-positivist’ research approach adopted, we did not engage in a linear process of finding answers to pre-determined questions instead sought to generate local socially contextualized knowledge characterized by depth of meaning rooted in the experiential lifeworlds of young people and the systems in which they are a part. As such, new insights, questions and ‘ways of seeing’ were valued as learning outcomes to support further enquiry and action as much as answers to starting questions.
The third level of analysis was undertaken by the research team after the event for the purpose of writing the research report. Given the nature of the research commission, the final phase of analysis was not guided by theoretical frameworks and questions, instead by what had been learnt from participants. A ‘grounded theory’ approach [56] was used to thematically collate data.
The paper is structured as follows. First, the data produced using this approach are presented and discussed providing examples of what young people prioritize and make sense of in connection with their health concerns. The paper uses two issues—stress and body image—to illustrate how this approach can provide a quality of insights to support dialogue and change in response to health issues. Second, the paper discusses the importance of learning and dialogue between young people and professionals by highlighting the policy gaps, disjunctions and paradoxes between service provision and young people's health needs. Third, the paper discusses some issues and challenges in identifying effective responses to key health concerns using this approach. The paper finishes with some critical reflections on the overall process and outcomes of this approach.
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Young people using visuals to communicate their health concerns |
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A primary driver for this work was to support young people in articulating and making sense of their health on their own terms rather than in response to policy drivers. In contrast to surveys and consultations, the peer research process provided an opportunity for young people to have more control on the research process and how they conveyed their perspectives and experience. The key substantive issues which emerged out of the research—stress, body image and wider mental health issues—are in themselves not new. However, the purpose of the research was not just about identifying issues rather about how a different enquiry-based approach process might more effectively support learning for change in response to the issues at hand. In what follows, two examples are used to illustrate the value of a visual, enquiry-based approach to working with youth health issues. The first concerns stress from educational achievement and exams and the second concerns stress related to body image.
Young people at breaking point
Stress and issues concerning young people's emotional and psychological well-being emerged from this research as being the most important health issues for young people. Of the seven pieces of peer research, five made direct reference to stress or pressure as key health concerns. Related health issues included anxiety, depression, self-harm, low self-esteem, self-image and suicide. Health problems more customarily associated with youth such as smoking, alcohol and drugs are seen by young people as symptoms of stress rather than problems just in their own right. These are not new findings. However, the value of using visual material to convey views and experiences allowed young people to engage in dialogue about stress with professionals in ways which were meaningful for young people, which were rooted in their own experiential lifeworlds and which provided high impact qualitative data to support reflection among adult service providers and managers. Figure 2 provides an example of how young people experience and make sense of stress.
This poster produced by young people conveys powerful images about their experience of stress as a key health issue. The poster relates how they feel ‘trapped’, talks about reaching ‘breaking points’ and being ‘on lockdown’. The use of the statements ‘Don't say a word’ and ‘I'll never tell’ symbolizes young people's sense of alienation with their feelings without knowing where to go with them, and because of this, the statement ‘Don't judge me before you know me. Just listen’. This captured how some young people felt misunderstood and frustrated by adults who assume they know what young people are going through. The image of the guitar with the caption ‘some things never get fixed’ highlights pessimism about the possibility of change. The image of a grim-faced man holding a gun, with the statement ‘everyone has a breaking point’ suggests that the response to reaching breaking point can be desperate, and that young people may have already reached this point. Indeed, the statement from another young person ‘You think you know? You have no idea...’ superimposed on a picture of a rope hanging from a tree branch reflects the desperation that young people feel when they reach breaking point.
While stress in young people is not a new issue, the use of visuals in this way provides a medium for young people to talk about what is a key health issue for them in a more youth friendly way. At the same time, these images provide an effective means of supporting others in developing a better understanding of how stress is manifest in young people's lives. It is difficult to respond to stress on face value without knowing how it is manifest. To illustrate this point, Fig. 3 refers to a poster produced by young people about exam pressure as a cause of stress. Again, we already know that exam pressures can create stress (see e.g. [19, 20, 23, 24, 57]); however, the use of visual material in a research workshop setting provides an opportunity for a different quality of dialogue and engagement with young people.
The poster in Fig. 3 starts to identify possible areas where changes can be made in terms of placing more emphasis on coursework rather than on exams. What is interesting is why this continues when many professionals acknowledge that exams are limited in their effectiveness for assessment as the Director of Education at the workshop stated:
We know exams are not best in terms of what we try to test, [...] to try to understand if someone has understood something [...]. We need to [...] go down different roads that don't have exams and all these tests, because frankly they are a source of unnecessary stress and don't necessarily give us the answers we need. This society [...] is obsessed with exams and league tables. That is missing the point.The statement above is, however, useful in identifying where attention might be focussed to reduce these detrimental health effects, for example, through a more holistic approach to education emphasizing personal and social development, as the Director of Education went on to suggest. A key issue here is why change does not follow research findings. So often, traditional research is written up in reports or papers, but nothing changes in practice. Despite the value of viewing education and health as interrelated contexts of experience for young people, health is so often seen as a separate policy issue detached from education. Yet, the health issues highlighted above are rooted in the nature of the education system itself, posing new challenges for health and education systems alike. This project aimed to see whether, through the adoption of a different participatory action enquiry approach, change is more likely to result from research, as will be discussed later.
Wound up in looks. But how much is too much?
A second key issue emerging from this research linked to stress concerned body image and the pressure from the media to look right (Fig. 4). Again, we know that this is not a new finding; however, what was interesting through the use of dialogue and images was the insights provided into how young people are already trying to deal with these pressures. For example, the image in Fig. 4 illustrates how young people are grappling with the question of whether size matters or not. On the one hand, they reveal how they feel slaves to fashion. ‘We all need to look good and be part of the fashion chain’. But simultaneously they reveal how difficult it is to develop their own sense of identity, confidence and self-esteem in spite of their body image. While the emphasis here is on girls and body image, there are parallel concerns for boys around masculine identity and mental well-being [18, 19], feeling they have to appear strong even if they have a problem and only seeking help when crisis point is reached.
We know that identity development and image are major pre-occupations for young people [58–61]. We also know that the pressure of media and advertising on young people to look a certain way and to possess particular symbolic commodities are related to peer pressure and affect young people's sense of identity and self-esteem [20, 60–63]. But what was striking about this research was the extent to which anxiety about looking right affected young people's well-being [64] and the extent to which ‘cosmetic surgery’ was part of the vocabulary of looking good (Fig. 5).
If we now make a link back to the stress-creating issues associated with education discussed previously, we can begin to see how the disproportionate emphasis placed on academic qualifications rather than on personal well-being as the foundation for social participation in schools may be misplaced with huge contingent effects on young people's health and well-being. On a positive note, the comments ‘Have we forgotten that real beauty is on the inside’ and ‘Young people should be accepted and respected for who they are’ suggest that young people are already trying to develop strategies for resisting pressures to look a particular way. People are aware of the solutions, but the pressure to follow the crowd is powerful. An issue for professionals is that supporting young people to resist peer and media pressure, develop resilience and make more informed choices may be more important to their health than trying to stop smoking or changing diets. Figure 4 offers further insights into possible responses through more positive female role models, counselling services for young girls and encouraging young people to be proud of who they are regardless of size and shape. It is difficult to control media images; however, it is possible to help young people respond differently to the images they see.
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The importance of dialogue and learning |
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By providing an opportunity for young people to start talking about health from the context of their own lived experiences, issues and concerns surfaced which were not necessarily contiguous with the focus of current policy and service provision. The lack of policy awareness of the extent to which young people experienced stress and emotional and psychological problems was evident, for example, in the following reflective comments from professionals about what they were hearing from young people:
Pressure and stress seem to be more important than physical issues like diet/exercise.The importance of professionals becoming more informed about young people's health needs is not just about increased awareness but about achieving a greater understanding of how health issues are experienced which can better inform health policy responses. By researching health issues from the context of young people's lifeworlds, participants were able to derive a quality of learning about the complexity of multiple interacting factors which effect young people's health, which is not possible in the same way through survey results and which is not reflected in current policy responses. The use of visual material and the act of physically bringing together young people and professionals in dialogue provides an opportunity for professionals to learn more effectively first hand from young people about their health concerns than is likely from reading the printed pages of a report. Moreover, the responses and feedback from professional participants at the end of the research workshop suggest that there is a greater likelihood for action to follow if they have been present, especially since reported research, unless directly commissioned, can often go unnoticed.Emotional rather than physical things are important.
Importance of mental health—family, exam stress and unsympathetic doctors.
The main issue—stress.
I was surprised about exercise and diet not being there, but about the centrality of stress and young people's ability to cope.
In spite of existing academic knowledge about the health issues young people talked about in this research, it was striking how little practitioners and heads of service understood about how these health issues were experienced by young people with the result that policy responses are so often misguided. For example, the findings from this research indicate that young people's key health concerns go beyond issues related to physical well-being such as smoking, exercise, physical fitness and diet, but instead emphasize ‘mental health issues’. They reflect social, rather than individualized, medical interpretations of young people's health needs rooted in everyday social interactions, contexts, relationships and experiences (see also [20, 26, 65–67]). Yet, policy responses to youth health issues continue to be characterized predominantly by medical models and responses. As a result, there was considerable scope for policy learning in this research, as one of the professionals reflected:
Being healthy is a little bit about health services and lots more about the whole of your lives, education, where you live, how you live, relationships ... we're beginning to understand that employment, housing, relationships are just as important as GPs.Many of the key health issues for young people are to a large extent the result of social factors beyond the control of young people—such as the media, the school curriculum, the political economy, inter-generational social relations, the quality of local neighbourhoods, the norms and values of society and the lifestyles it promotes, creating a ‘social ecology’ [68] of young people's health. These findings suggest that health issues cannot be addressed solely by conventional health care provision, instead require holistic, socially contextualized solutions. If the key health issues from this research are already common knowledge to academics, it is clear that this knowledge is not exchanged very effectively with the world of policy and practice, underlying the value of the action research approach reported here.
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Mind the Gap! between youth and professional responses to stress: identifying possibilities for meaningful action |
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So often, adults assume they know how best to respond to young people's concerns. By developing participation as collaborative action enquiry, this research revealed the different assumptions held by young people and professionals about effective solutions to stress, providing substantial policy learning for professional participants. In response to problems of stress, professionals tended to see solutions from a service provider's perspective, arguing young people need a ‘place to chill out’ (see Fig. 6).
Young people argued that they should have such places anyway, but these alone would not address the underlying causes of stress, such as pressure from education and parents. In contrast, young people looked for solutions which addressed the social causes of stress by arguing for more supportive and less pressurized environments in schools, more respectful relationships and help to develop their ability to thrive in the world and feel good about themselves.
This research provides further insights into the solutions young people identified themselves which could provide the focus for professional support. In response to pressures concerning body image, one of the posters articulated how young people are thinking about solutions in terms of feeling (rather than looking) good and taking control. The research demonstrated how young people do not necessarily need professionals to go off and sort their problems out for them, instead need support in addressing problems themselves.
Information, discussions and honesty and people's ability to make up their own minds in light of honest assessment of the consequences are crucial. (Professional)This requires a different relationship between young people and professionals based on constructions of youth as active rather than passive in their own health development [69, 70]. Young people are quite clear about the way feelings affect their well-being and ability to engage with the world. At the same time in seeking to overcome stress, young people recognize the importance of having someone to talk with about difficulties they may be facing (Fig. 7).
Providing support for young people involves adults and professionals listening to and engaging in dialogue with young people. However, a striking finding from this research was the extent to which young people felt a lack of support in dealing with stress from ‘dependable’ adults (see also [19, 23, 27, 71]) with the result that problems affecting their mental well-being often go unaddressed. Young people talked about how they felt pressured by teachers, in conflict with parents, distrusting of GPs and lacking faith in health services (see Fig. 8).
It is ironic that those customarily seen as dependable figures in young people's lives are not only failing to provide support but are also identified as sources of stress. This poses a fundamental dilemma of who to turn to when needing support. Evidence suggests that young people are more likely to resort to each other to provide education, advice and support, in the absence of quality relationships with adults.
Mental health resources tend to be directed more towards acute cases, such as young people with psychiatric or psychotic disorders. This research, however, reveals a significant policy gap in providing early preventative support for all young people, such as community-based counselling and advice services which are accessible and appealing to young people and which provide young people with the tools to deal with stress [14, 26, 72, 73]. The emphasis young people place on solutions rooted in everyday contexts, relationships and environments challenges the assumption that social problems are best solved by professionals and agencies through changes to service provision. Instead, there is a need to focus on social responses to health needs through community-based interventions targeted at improving the quality of community ‘spaces’ [74] in which young people's everyday interactions and experiences are played out. Given the complex and multifaceted nature of stress as a health problem for young people, there is a need for further research to explore the range of possibilities that may be needed as apart of a comprehensive local policy response. For example, providing services in terms of counselling, support and a youth venue to chill out need to be matched by efforts to rebuild trust in communities, in families and in professional practices such as with GPs and teachers. Equally, young people need support in developing the means to cope with pressures by building up their own resilience.
The research findings presented here are a powerful statement from young people about the state of their health and well-being. They should not be seen as revelatory findings, instead by echoing a growing literature concerning stress and mental well-being, they reveal the extent to which these needs are insufficiently acknowledged in youth health policy discourses. At the same time, this paper reveals how, by adopting a different approach to research and development, new choices and actions become possible, arising out of learning through dialogue and inquiry in response to images constructed from young people's lived realities.
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Reflections on the research approach |
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This research sets out to support young people in articulating their health needs and concerns, to engage in dialogue about these with key adults and, where possible, identify solutions. The health issues revealed by this research are not new and have been echoed elsewhere (see e.g. [24]). However, as a social action project, the primary value of this research was not solely in identifying issues, rather in engaging young people alongside adults in a process of learning to support change. The young participants found the process worthwhile, valuing the opportunity to engage with adult professionals:
I enjoyed the interactions between the young people and professionals ... it was an interesting experience, as we got to see both sides ... The older generation were able to adjust to our views and how we felt about certain issues ... Most were very communicative and engaged, but some were less engaged and concerned with their own self interests. (Young participant)Many professionals also found the process worthwhile:
One of the major challenges at the beginning of the 21st century is to engage young people in public policy. That's why I found this process so exhilarating. Here ... young people showed their understanding of health issues, suggested a variety of ways to improve matters, and ended up fearlessly holding the representatives of public bodies to account. Now it's up to us to deliver. (Professional)These quotes reflect the success of the event in achieving its objectives of engaging young people and adults in a process of dialogue and learning to find solutions to health issues and to do so in a way that models an alternative approach to engaging young people beyond just having a say. Young people valued the opportunity to undertake the peer research, but felt constrained by time.
We had a lot of freedom, which means we were given the work we had to do, but could do it our own way.We underestimated the amount of learning and support needed for the peer research. For logistical reasons, after initial training of peer researchers, much of the support was provided by CHC staff, who themselves had limited research experience.Limits of time ... having to rush to complete the research when more time would have made the experience more enjoyable.
The effectiveness of traditional academic research is normally assessed in terms of new findings. In action research, outcomes are seen in terms of the quality of involvement of stakeholders in producing practical knowledge useful in terms of action in the everyday contexts of their lives. Action can be interpreted as learning of individuals and groups, for example, in terms of shifts in thinking, as well as direct outcomes from the research. In this research, adults and young people articulated shifts in thinking about appropriate responses to the issues explored. The visioning work undertaken by participants were instructive in focussing where attention needs to be placed and as such constitute worthwhile and effective outcomes to this process. We saw this initial identification of solutions as a first stage in formulating comprehensive local policy responses. Ideally, this process would be followed up after the event with a series of ‘action enquiry’ groups to explore effective strategies for taking action and subsequently evaluating these actions. Unfortunately, this was not possible within the scope of this commission, with our involvement finishing after the event. However, this did not preclude the participants who were involved from taking further action. Indeed, there was a strong feeling during the event that actions should come out of this research process.
The issues that we talked about should be taken into account and taken further in research and work.Despite promises to act on this work, one year later there was no sign of commitment to follow up action. This is more a reflection on local professionals response to the research rather than the research approach itself. Instead, paradoxically professionals were preoccupied with implementing current government policy for children's services. This situation is common in that so often young people are consulted but nothing changes. A key issue is the extent to which professionals and systems respond to what young people are saying. However, responding to research findings is not just about listening to young people and filling gaps in provision. It is also about reflecting on systems and practices as a result of research evidence. There is a need to create a dynamic learning system in which user-involvement is matched with accountability, but within organizational cultures of democratic participation involving mutually respectful collaboration [75]. The approach discussed in this paper provides one way forward.Councilors and officers should go back to their council and say we want a dialogue with the youth council and call for a meeting where we get people together and we say, look what are you going to do after the things that have been said here today. (Young people)
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Conclusion |
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The fact that stress is a widespread problem for young people seems beyond question. What seems more important is what can be done about it. The evidence in this research provides an indication of the ‘policy learning gap’ between professional assumptions about young people's health needs and the reality of young people's own health concerns. This research has posed significant challenges for practitioners and policy makers, in terms of the extent to which young people's health concerns are reflected in policy formulation, but also in how policy is formulated and delivered. This research challenged health professionals to reflect on their own assumptions and practices in response to the complex health concerns of young people and the need to connect more effectively with the real lives of young people in research and policy development. The collaborative action enquiry approach used models an ‘alternative’ and arguably more effective approach to policy learning involving young people, providing further evidence of the value of action research in health sector research [76, 77]. The comments from professional participants and young people bear testimony to the potential contribution this approach can make to policy innovation and young people's agency as partners in that process. Whether this happens depends on the commitment of adult professionals.
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Funding |
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Hounslow Community Health Council.
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Conflict of interest statement |
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None declared.
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Acknowledgements |
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The author would like to thank Ann Blanche and colleagues (especially Rob Hill and Hardeep Rai) at what was Hounslow CHC for being so accommodating and supportive throughout. This was as much a learning experience for them as it was for us. Special thanks to Hardeep and all the young people who enthusiastically contributed to this research and to Sue and volunteers at St Pauls Church Centre in Brentford. Thanks to Clare Carney who provided invaluable input as a community artist and to colleagues at SOLAR who helped facilitate the event, with analysing data and writing the report. The author would also like to acknowledge the valuable comments of anonymous reviewers of this paper.
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Received on November 1, 2006; revision received on March 29, 2007; accepted on April 25, 2007
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