While I tried to note the questions, please forgive me if I do not answer those that were asked. I will do my best.
The first question, on peer education, was directed to Mr. McAleenan. We work with TravAct, an organisation working with Travellers in Coolock. One of our dietitians works with Traveller women in the area and staffs a project to develop a resource pack which focuses strongly on the women's stated preferences in terms of nutrition, specific health issues they faced and ways in which they wanted to manage them. The project's use of a partnership approach worked and it emerged very well from an evaluation. Unfortunately, however, it is being introduced on a staggered basis because we are waiting for the final go-ahead to extend in response to many requests to do so. This project is an example of a peer education programme in which Traveller women approach other Traveller women and speak in their language, reflect their experience and share information. Having received training, they will have accurate information which they will then deliver to others. It is a concrete measure and an example of women being empowered at community level.
In terms of pre-natal options and openings in the health service for identifying and addressing literacy issues, none of us likes someone to point out what might be a weakness. A number of different issues arise in this regard. We are more likely to address an issue if someone raises it in a sensitive manner, it is raised almost organically or the relationship with the person is not power imbalanced. If a woman attending the Rotunda before the birth of her baby deals with a different member of staff on each visit, the chances are no relationship will form and the proper context for having the issue addressed will not arise. For this reason, I am not sure pre-natal care is the best setting in which to have literacy issues addressed.
A person may also lack local links and as a result few opportunities will arise to ask him or her whether he or she has considered joining a local read and write scheme or to offer support in making this decision. Other players in the health system with whom a person may have had contact, for example, a local general practitioner or public health nurse, may be more suitable contact persons if they are appropriately trained. This option has definite potential if the health professionals in question act in a sensitive manner and raise the issue appropriately.
Based on a European model, the community mothers' programme has been operating here for 12 or 13 years and has been shown to be significantly beneficial to children and families. It has had a positive impact and has had excellent long-term outcomes in that children who have been through the programme with their parents have stayed at school and their educational attainment, including in literacy, has improved. The programme has also offered an opportunity to engage mothers in the area of literacy. It focuses on the skill level of the parents involved and is run in a positive rather than patronising way. It is a peer programme which is offered in a limited number of areas such as Ballymun, Coolock and Finglas in Dublin. If it was more widely available to families, we could repeat its long-term successful outcomes elsewhere.
Parents could be linked in to family learning programmes. Instead of asking a parent to do a parenting course, one informs the parent that a programme on child care is available which may give him or her some support in working with the child. These are positive programmes which take an inter-generational approach and encompass literacy, child rearing and health. Participants find that others attending the programme are in the same boat. Like most new parents, regardless of literacy levels, they are all trying to learn how to do things properly.
The health boards have also been involved in the teenage health initiative aimed at encouraging young people to make good health choices. It also examines a broader range of issues around what young people as potential parents do, how they make decisions and so on. The programme focuses on very young parents and links vulnerable young people to services. It is a case of making a connnection with them and getting them on board in terms of having access to people they can trust if they become pregnant. By having that relationship in place, they can engage, say they are terrified of whatever it might be and get the support they need to be able to work through the problem.
These are a number of the initiatives that can help. They are not the only answers but they are potential solutions. The key thing is relationship. If something is said to people who are not ready to receive it, this may be damaging and could prevent them from coming to the service for another ten years. The same would be true if there was any element of coercion and we must be mindful of this.
In terms of identification of problems vis-à-vis literacy and making a recommendation for action in that regard, we have trained our staff and other staff on the floor to promote literacy awareness training in the workplace. It is not the be all and end all and it does not guarantee subsequent sensitivity but at least it is shifting the mindset and raising awareness. Other measures, such as plain English becoming the rule rather than the exception, must be put in place in the long term. A huge stigma is still attached to illiteracy and the more we get the message out there that it is okay to seek help, the better. Similarly, the more it is perceived that workplace literacy programmes are okay and that they are not uncool, the less is the stigma attached to them. This allows people to build up confidence. It is important to be able to engage and that is not only dependent on the written word. Literacy is connected to self-esteem.
A number of clinical dieticians are involved in our service. They found that people were not turning up for appointments for which they had received written notification. The letters were written in a way that a person with a basic level of literacy could understand. The dieticians were so concerned at the no-show rate that they decided to do something about it. One of our staff began to contact people in advance to say that their GP had suggested they come to see the dietician for a chat about nutrition and diet and gave them the details. The attendance rate improved dramatically.
Staff are providing a service and building relationships with people. They can get the message across and work with them. More recently, people began to demand a visual element. I do not know if people watched Gillian McKeith's television programme. I do not endorse her by any means but one of the things she does is to make a pile of all the food that people eat. As a result, some of our dieticians have brought props such as plastic portion dishes of various sizes so people can make comparisons. People have a strong visual sense and this helps to improve communication by showing people what they eat. Props are very important because using everything at one's disposal builds confidence in communications.
They key groups of people with whom we deal whose first language is not English are asylum seekers and refugees. We work with some of the specialist agencies such as SPIRASI, which is run by the Holy Ghost Fathers, BARN, the Blanchardstown Asylum Seekers and Refugee Network, and Access Ireland.
One of the programmes on which we have been working with SPIRASI is entitled "Being Well", which was developed by the Department of Health and Children back in the early 1990s. It is a holistic health programme that looks at a number of different issues. We have worked with the SPIRASI team which has representatives from different countries. We are carrying out a health impact assessment and examining what the programme has to offer and how useful or relevant it might be. It is about encouraging communication and encouraging people to reflect on their own experience and using and adapting that. That is one of the programmes on which we work.
Language development and confidence building relate to people's motivation and the resources they have at their disposal. The different points of contact where people engage with services are well documented. There are different life crossing points. If one has children, one might be more inclined to tap into the services as an opportunity for education. When children start going to school and begin to ask parents questions they cannot answer, they need some support. We tap into those needs. The programmes are applicable to the Irish community as well as people from other countries.
Many of the programmes offer empowerment to parents, children and families. This can come through a different medium such as the community mothers' programme or peer education programmes. We have a healthy food made easy programme which is peer-led and which involves adults working with their own communities.
We use peer-led groups for some of the health and literacy work we do. We train people to work with their peers and they are given special support for the programmes in which they are involved. We also have a number of different partnerships for health. We work with the City of Dublin VEC, homeless projects and foundations projects. We have also worked with SPIRASIand the Traveller community. We also do health promotion in schools and support the social, personal and health, SPH, programme in schools. They are about laying the foundations for good decision-making and building self-esteem and confidence in young children.
Regarding workplace initiatives, it is important to look at all the ways of getting literacy on the agenda in as many places as possible. While literacy is the focus, we also get involved in health fairs. Following a health fair in one workplace, the issue of literacy among staff was identified and in response we provided literacy classes there. Staff were released to do that and the programme has been well received.