Guest Editorial
in children were highly correlated with the levels in their mothers. The feasibility of an EU-harmonized approach has been demonstrated and using the lessons learned, policy-makers can now start to envisage a European survey programme. The third speaker demonstrated the multi-agency efforts required to assess the health risks from discrete radioactive objects found in several outdoor environments. The example focussed on the public health implications of radioactive objects found during beach monitoring in the vicinity of the Sellafield site in Cumbria. Finally, the potential risks of human exposure resulting from the radioactive release from the Tokyo Electric Power Company’s Fukushima Daiichi nuclear power plant after the earthquake and tsunami in Japan on 11th March 2011 were presented. PHE contributed to the
WHO’s risk assessment applied to the general population groups in Fukushima prefecture, neighbouring prefectures, the rest of Japan, neighbouring countries and the rest of the world. The results showed that the lifetime risks for some cancers may be somewhat elevated above baseline rates in certain age and sex groups in the areas most affected. For the less affected areas of Fukushima Prefecture, the rest of Japan and the rest of world, the excess cancer incidence risks for all the cancer sites under consideration are estimated to be much lower than the expected natural variation in background cancer rates. Professor Anthony Kessel Miss Emmeline Buckley Dr Ann Hoskins Dr Sam Bracebridge Dr Isabel Oliver
Dr Naima Bradley Public Health England Professor Fiona Brooks University of Hertfordshire
References 1. Hagell A, Coleman J, Brooks F. Key Data on Adolescence 2013: 8th Edition. 2013. London: Association for Young People’s Health (AYPH). 2. Viner R, Barker M. Young people’s health: the need for action. BMJ 2005: 330, 901-903. 3. MacDonald D. Affordable Warmth Interventions in North Lancashire. Perspectives in Public Health 2014: 134(5) 4. Teasdale G. Achieving Success in Reducing Teenage Pregnancy in Hull. Perspectives in Public Health 2014: 134(5) 5. McCulloch J, Bracebridge S, Thompson M, van de Venter E, Oliver I. Developing capacity in field epidemiology in England. Perspectives in Public Health 2014: 134(5) 6. Exley K, Aerts D, Biot P, Casteleyn L, KolossaGehring M, Schwedler G et al. Human biomonitoring to assess environmental chemical exposures: work towards a UK framework. Perspectives in Public Health 2014: 134(5)
Achieving success in reducing teenage pregnancy in Hull There are disproportionately poor outcomes for those who become teenage parents. Gail Teasdale, Integrated Services Manager for Children and Young People’s Health, Hull City Council, looks at the success of the local teenage pregnancy strategy in Hull, and how this success can be furthered in the future.
Teenage pregnancy is a complex issue with a range of contributing risk factors including poverty, low educational attainment, truancy, not being in education, employment or training (NEET), low self-esteem, early sexual activity and poor contraception use. There are disproportionately poor outcomes for those who do become teenage parents. At age 30, teenage mothers are 22% more likely to be living in poverty, 20% more likely to have no qualifications than mothers giving birth aged 24 or over and are much less likely
to be employed or living with a partner. Research and evidence-based practice has shown this issue cannot be addressed through a single intervention or service as the majority of teenage pregnancies are unplanned. Instead a consistent and co-ordinated partnership approach at a strategic and operational level across schools, health, youth services, social care and voluntary sector organisations is required to deliver improved outcomes. An early intervention and prevention approach which aims to reduce risks and build
292 Perspectives in Public Health l September 2014 Vol 134 No 5 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 17, 2015
resilience, along with effective use of local data and performance management is vital to maximizse impact and ensure those areas/groups of young people most at risk are reached and supported. This paper aims to summarize the successful implementation of the National Teenage Pregnancy Strategy1 at a local level. It aims to inform future commissioning and policy and build on the evidence base to sustain the current downward trend, maximize impact and continue to deliver positive outcomes in a cost effective way for young people on this and other health issues.
National context The Labour Government’s Teenage Pregnancy Strategy for England1 had a national target to reduce under-18
Current Topic & Opinion Figure 1
conceptions nationally by 50% by 2010. All local authority areas agreed on a local reduction target ranging between 40% and 60%. If all areas had met their targets then the national 50% target would have been achieved. However impact varied with some areas seeing significant reductions while others saw smaller reductions or even, in some cases, increases. Differing outcomes related to a range of local factors highlighted in this article including level of investment and prioritization of the issue at a senior and political level. The national strategy1 was informed by an international evidence review which identified thirty key action points categorized under four main themes: •• joined up action, nationally, regionally and locally; •• improved sex and relationship education; •• access to youth friendly contraception and sexual health services; and •• improved support for young parents to improve the disproportionately poor outcomes for them and their children. There was also a national campaign to reach young people and parents. Over the course of the strategy, further national guidance and updated strategies were published nationally and implemented locally. 2-7. These were informed by emerging evidence which
underpinned the importance of key aspects of the strategy including high quality sex and relationships education (SRE)8 and the importance of improving access to and increasing the uptake of contraception.9 Furthermore the guidance was informed by “deep dive” reviews which compared similar areas (statistical neighbours) with contrasting progress which showed reductions associated with all elements of the strategy being in place.
Progress made in Hull Reducing under-18 conception rates was identified as a key issue for Hull following the launch of the National Teenage Pregnancy Strategy in 1998. As the strategy developed locally it was further informed by local consultation and research to address gaps in provision and enable service redesign to meet need, including understanding local barriers to accessing services,10 the sexual health needs of boys and young men,11 barriers to preventing unplanned conception,12 an evaluation of support for teenage parents13 and the local biannual Young People’s Health and Lifestyle survey. In Hull the local strategy was launched in 2001, applying national guidance to local context. This became a key performance indicator for both the local authority and the NHS. This shared target enabled joint commissioning of services which improved costeffectiveness. A local multi-agency
Reducing Teenage Pregnancy Strategic Partnership was established with themed operational working groups. This strategic group reported to the Children’s Trust board, ensuring progress was monitored at a senior level. Over the course of the strategy (1998-2012) Hull has seen a reduction of 53.5% in under-18 conceptions (from a rate of 84.6 per 1,000 to 39.3 per 1000). This reduction occurred across both births and terminations with births reducing from 57.3 per 1000 to 28.6 per 1000 and terminations from 27.3 per 1000 to 10.7 per 1000. This is a larger reduction than achieved nationally (a 40.6% reduction over the same period). Hull has also achieved a larger decrease than most of its statistical neighbours. In addition, Hull has seen significant reductions in repeat conceptions from 17.66% in 2008 to 13.79% in 2011. With regards to the current age profile of under-18 conceptions in Hull, approximately 80% now occur in 16 and 17 year olds with none under 13, illustrating that not only has the overall rate reduced but that young people who do become pregnant do so later. This suggests that the delay strategy promoted through SRE and media campaigns has had an impact. There is no strong evidence that an abstinence only approach is effective and all services locally were commissioned with a pro-choice, empowerment ethos. This is evidenced by Kirby8 who concluded
September 2014 Vol 134 No 5 l Perspectives in Public Health 293 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 17, 2015
Current Topic & Opinion Table 1 2001
2012
Sex education varied from school to school. Mainly focused on biology and some schools only delivered though annual health days. No SRE post-16.
Comprehensive and regular SRE to build knowledge and skills to support young people to develop healthy, safe relationships as part of a whole school approach across primary and secondary schools. (APAUSE programme in secondary schools (2005-2009). Christopher Winter Programme across primary and secondary schools (2010 to present)). This is delivered by trained educators (as part of the national CPD programme). Development of post-16 SRE sessions in 6th form colleges.
Development of a peer education programme in secondary schools and colleges which complemented core SRE delivery.
Shift of focus from biology only to a risk and resilience approach including improved communication and negotiation skills, healthy relationships, access to services and resisting peer pressure.
Services focus on clinical provision only – medical model
Complimentary, non-clinical services developed to support young people to reduce risks and build resilience, e.g. boys and young men’s project, peer education, streetbased outreach. Services broadened to include relationships and sexuality. Joint delivery between clinical and non-clinical young people’s provision.
Contraception accessed through traditional adult Easy access to free youth-friendly sexual health services including: family planning services in clinical settings or GP.
• City centre young people’s sexual health services
• Outreach nurses providing a contraception in schools, colleges, youth centres etc.
• Teenage mothers offered contraception visit at home within four weeks of birth.
• Improved access to condoms through youth services, school nurse drop-in etc.
• Services designed and commissioned in line with ‘You’re Welcome’ quality standards.
Lack of workforce training in place for all services working, with young people e.g. youth workers, social workers, etc.
Comprehensive training program open to all services across the partnership. This included training on condom distribution and also pregnancy options for non-clinical staff (Education for Choice training).
Focus of strategy aimed at girls only.
Gender-specific services to target work with boys and young men and training for generic staff to improve work with boys and young men.
Distorted perception of peer norms.
Research and campaigns which challenge perceived peer norms and give clear consistent messages on delay and access to services.
No work with parents on issue.
Implementation of the national Family Planning Association Speakeasy program to support parents to discuss sex and relationships with their children in an age appropriate way.
Teenage pregnancy seen as a social services issue.
Initially part of the National Sure Start Plus programme, Hull developed the Teenage Pregnancy Support Service, a holistic support service for young parents. This improved early access to maternity services as well as improved outcomes for pregnant teenagers, fathers to be and teenage parents on education, employment, health, parenting and prevention of repeat conceptions.
City wide data only available. Lack of data to Effective dataset in place to evidence impact and improve targeting of services. inform targeting of provision to maximize impact. Lack of a joined up multi agency (strategic or operational) approach.
Strategic board established with operational themed working groups. Annual action plan.
294 Perspectives in Public Health l September 2014 Vol 134 No 5 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 17, 2015
Current Topic & Opinion Figure 2 The Hull Model14
Effecve use of peer norms to change culture and behaviour
Improved SRE/Health Literacy in Schools and Colleges
Early Intervenon through exisng services
Consistent messages to young people parents and praconers
Holisc support to teenage parents
Effecve Strategic Leadership and Governance
Targeted work with boys and young men
Workforce Development and Training across the partnerships
Targeted services and support for young people at risk
Ongoing engagement, evaluaon and research
Effecve use of data for local performance management
that a dual message of delaying early sexual activity while providing information about contraception and safer sex is most effective in supporting young people. In addition to the strategic impacts the following operational impacts have also been delivered: •• Improved knowledge and ability of young people to make informed health choices (Hull biannual Health and Lifestyle survey); •• improved access to contraception including long acting reversible contraception (LARC) (local service data shows an increase of approximately one third);
Support for parents to discuss sex and relaonships
Young people friendly, accessible clinical services
•• improved engagement and access to services by vulnerable and hard-toengage groups through delivery in non-clinical settings through youth services; •• improved access by boys and young men (in 2001 less than ten young men under-18 accessed local sexual health services annually compared to 1800 girls. Now access has increased to approximately 8,000 with 50% being boys and young men. In addition 1005 one-to-one support sessions were delivered to boys and young men on issues relating to sex and relationships; and •• reduced need for social care interventions in teenage parents (the
teenage pregnancy support service prevented the need for social care intervention in 165 cases in one year due to early intervention and support). Over the last ten years, local and national research, consultation and evaluation as well as evidence-based best practice from other areas has been used to adapt and revise the local strategy to maximize impact.
Distance Travelled – Before and After In 1998, Hull had one of the highest under-18 conception rates in England with a rate of 84.6 conceptions per 1000 girls aged 15-17. Approximately two
September 2014 Vol 134 No 5 l Perspectives in Public Health 295 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 17, 2015
Current Topic & Opinion thirds continued with the pregnancy and one third accessed a termination. 20% of all under-18 conceptions were repeat conceptions. Young people described the majority of teenage pregnancies as unplanned, with outcomes for young parents and their children disproportionately poor. The numbers of young people having sex under 16 was not disproportionate to national figures (approximately one third of under-16’s reported having had intercourse) however numbers of under-18’s accessing local contraception services was low, as was uptake of LARC. Prior to implementation of the local strategy, services offered an adult, medical model which was consultant-led and there was a lack of consistent provision of quality Sex SRE and Relationship Education and access to contraception services by young people. There was little targeted provision of services with the majority being non-agespecific and based within clinical settings. Contraception was seen as a female issue and teenage pregnancy as an issue for social services. There was no community based support on safer sex and relationships and no support for parents. There was a lack of understanding of local need and the barriers which restricted access to services. Table 1 sets out the changes made to deliver an effective strategy to reduce under-18 conceptions.14
Moving Forward Throughout the strategy a question regularly posed was: “what is the one thing which delivered the most significant decrease?”. However it is not one specific service but a combination of changes to create a whole system approach across services, made possible due to effective leadership across commissioning and provider organizations. The most significant change has been the cultural change in attitudes by services working with young people in how they approach and address the issue with the focus on prevention and early intervention rather than crisis management. Improving young people’s sexual health and reducing teenage pregnancy is now seen as “everybody’s business” not just a health issue. There has been change in the delivery model from a consultantled medical model to nurse/youth worker delivery with the access to condoms predominantly provided through non-clinical services (as well as some pregnancy testing and Chlamydia testing). Increasingly outreach nurses are undertaking the provision of contraception in partnership with other young people’s services. Both of these initiatives have led to increased access and a holistic provision, covering issues including relationships and sexuality, not just contraception. Workforce development has also been an effective method of improving access and
information by ensuring staff across a range of providers are giving consistent messages and have the skills and confidence to support young people. Collectively this has supported a change in attitudes and behaviour in young people which includes accessing services before they have sex rather than after, so contraception can be planned. Building on the learning from this strategy the new local commissioning model will further embed the preventative and early intervention approach with a balance between clinical and non-clinical provision and continuing workforce development. For the first time there is also investment in adult sexual health promotion which will focus on improved knowledge, health improvement and access to services, mirroring the young people’s model. This will include workforce development for staff in adult services and targeted clinical and non-clinical outreach for hard to engage groups (those with learning disabilities, mental health issues, LGBT, older people, etc). This will ensure that we do not see a reversal of the achievements in reducing under-18 conceptions and will also begin to improve sexual health outcomes within the adult community. The model is also being used to develop strategies to address other young people’s health issues.
References 1. 2.
3.
4.
5.
Social Exclusion Unit Teenage Pregnancy Report. London: Social Exclusion Unit. 1999 Department of Health. Guidance for youth workers on providing and referring young people to contraceptive and sexual health services. 2001 Department of Health. Guidance for developing contraception and sexual health advice services to reach boys and young. 2000 Health Education Authority. Teenage pregnancy: an overview of the research evidence. 2004 Department for Education and Skills. Teenage Pregnancy Next Steps: guidance for local
6.
7. 8.
9.
Authorities and Primary care trusts on effective delivery of local strategies. 2006 Department for Education and Skills. Teenage Pregnancy: Accelerating the Strategy to 2010. 2006 Department of Health. Teenage Pregnancy Strategy: Beyond 2010. 2010 Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Diseases. 2007. Washington DC: National Campaign to Prevent Teen and Unplanned Pregnancy. Santelli J et al. Explaining recent declines in adolescent pregnancy in the United States: the
296 Perspectives in Public Health l September 2014 Vol 134 No 5 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 17, 2015
10. 11. 12. 13. 14.
contribution of abstinence and improved contraceptive use. 2007. American Journal of Public Health; 97; 1, 150-156. Cornerhouse, Hull. Mind the Gap. 2005 Cornerhouse, Hull. Men, Masculinity and Mayhem. 2006 University of Hull. Factors underlying unintended pregnancy in young women in Hull. 2007 University of Lincoln. Evaluation of the Hull Teenage Pregnancy Support Service. 2007 Teasdale G.M. Improving Sexual Health Outcomes for Young People. Paper presented at Public Health England Conference; Warwick. England, September 2013.
in children were highly correlated with the levels in their mothers. The feasibility of an EU-harmonized approach has been demonstrated and using the lessons learned, policy-makers can now start to envisage a European survey programme. The third speaker demonstrated the multi-agency efforts required to assess the health risks from discrete radioactive objects found in several outdoor environments. The example focussed on the public health implications of radioactive objects found during beach monitoring in the vicinity of the Sellafield site in Cumbria. Finally, the potential risks of human exposure resulting from the radioactive release from the Tokyo Electric Power Company’s Fukushima Daiichi nuclear power plant after the earthquake and tsunami in Japan on 11th March 2011 were presented. PHE contributed to the
WHO’s risk assessment applied to the general population groups in Fukushima prefecture, neighbouring prefectures, the rest of Japan, neighbouring countries and the rest of the world. The results showed that the lifetime risks for some cancers may be somewhat elevated above baseline rates in certain age and sex groups in the areas most affected. For the less affected areas of Fukushima Prefecture, the rest of Japan and the rest of world, the excess cancer incidence risks for all the cancer sites under consideration are estimated to be much lower than the expected natural variation in background cancer rates. Professor Anthony Kessel Miss Emmeline Buckley Dr Ann Hoskins Dr Sam Bracebridge Dr Isabel Oliver
Dr Naima Bradley Public Health England Professor Fiona Brooks University of Hertfordshire
References 1. Hagell A, Coleman J, Brooks F. Key Data on Adolescence 2013: 8th Edition. 2013. London: Association for Young People’s Health (AYPH). 2. Viner R, Barker M. Young people’s health: the need for action. BMJ 2005: 330, 901-903. 3. MacDonald D. Affordable Warmth Interventions in North Lancashire. Perspectives in Public Health 2014: 134(5) 4. Teasdale G. Achieving Success in Reducing Teenage Pregnancy in Hull. Perspectives in Public Health 2014: 134(5) 5. McCulloch J, Bracebridge S, Thompson M, van de Venter E, Oliver I. Developing capacity in field epidemiology in England. Perspectives in Public Health 2014: 134(5) 6. Exley K, Aerts D, Biot P, Casteleyn L, KolossaGehring M, Schwedler G et al. Human biomonitoring to assess environmental chemical exposures: work towards a UK framework. Perspectives in Public Health 2014: 134(5)
Achieving success in reducing teenage pregnancy in Hull There are disproportionately poor outcomes for those who become teenage parents. Gail Teasdale, Integrated Services Manager for Children and Young People’s Health, Hull City Council, looks at the success of the local teenage pregnancy strategy in Hull, and how this success can be furthered in the future.
Teenage pregnancy is a complex issue with a range of contributing risk factors including poverty, low educational attainment, truancy, not being in education, employment or training (NEET), low self-esteem, early sexual activity and poor contraception use. There are disproportionately poor outcomes for those who do become teenage parents. At age 30, teenage mothers are 22% more likely to be living in poverty, 20% more likely to have no qualifications than mothers giving birth aged 24 or over and are much less likely
to be employed or living with a partner. Research and evidence-based practice has shown this issue cannot be addressed through a single intervention or service as the majority of teenage pregnancies are unplanned. Instead a consistent and co-ordinated partnership approach at a strategic and operational level across schools, health, youth services, social care and voluntary sector organisations is required to deliver improved outcomes. An early intervention and prevention approach which aims to reduce risks and build
292 Perspectives in Public Health l September 2014 Vol 134 No 5 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 17, 2015
resilience, along with effective use of local data and performance management is vital to maximizse impact and ensure those areas/groups of young people most at risk are reached and supported. This paper aims to summarize the successful implementation of the National Teenage Pregnancy Strategy1 at a local level. It aims to inform future commissioning and policy and build on the evidence base to sustain the current downward trend, maximize impact and continue to deliver positive outcomes in a cost effective way for young people on this and other health issues.
National context The Labour Government’s Teenage Pregnancy Strategy for England1 had a national target to reduce under-18
Current Topic & Opinion Figure 1
conceptions nationally by 50% by 2010. All local authority areas agreed on a local reduction target ranging between 40% and 60%. If all areas had met their targets then the national 50% target would have been achieved. However impact varied with some areas seeing significant reductions while others saw smaller reductions or even, in some cases, increases. Differing outcomes related to a range of local factors highlighted in this article including level of investment and prioritization of the issue at a senior and political level. The national strategy1 was informed by an international evidence review which identified thirty key action points categorized under four main themes: •• joined up action, nationally, regionally and locally; •• improved sex and relationship education; •• access to youth friendly contraception and sexual health services; and •• improved support for young parents to improve the disproportionately poor outcomes for them and their children. There was also a national campaign to reach young people and parents. Over the course of the strategy, further national guidance and updated strategies were published nationally and implemented locally. 2-7. These were informed by emerging evidence which
underpinned the importance of key aspects of the strategy including high quality sex and relationships education (SRE)8 and the importance of improving access to and increasing the uptake of contraception.9 Furthermore the guidance was informed by “deep dive” reviews which compared similar areas (statistical neighbours) with contrasting progress which showed reductions associated with all elements of the strategy being in place.
Progress made in Hull Reducing under-18 conception rates was identified as a key issue for Hull following the launch of the National Teenage Pregnancy Strategy in 1998. As the strategy developed locally it was further informed by local consultation and research to address gaps in provision and enable service redesign to meet need, including understanding local barriers to accessing services,10 the sexual health needs of boys and young men,11 barriers to preventing unplanned conception,12 an evaluation of support for teenage parents13 and the local biannual Young People’s Health and Lifestyle survey. In Hull the local strategy was launched in 2001, applying national guidance to local context. This became a key performance indicator for both the local authority and the NHS. This shared target enabled joint commissioning of services which improved costeffectiveness. A local multi-agency
Reducing Teenage Pregnancy Strategic Partnership was established with themed operational working groups. This strategic group reported to the Children’s Trust board, ensuring progress was monitored at a senior level. Over the course of the strategy (1998-2012) Hull has seen a reduction of 53.5% in under-18 conceptions (from a rate of 84.6 per 1,000 to 39.3 per 1000). This reduction occurred across both births and terminations with births reducing from 57.3 per 1000 to 28.6 per 1000 and terminations from 27.3 per 1000 to 10.7 per 1000. This is a larger reduction than achieved nationally (a 40.6% reduction over the same period). Hull has also achieved a larger decrease than most of its statistical neighbours. In addition, Hull has seen significant reductions in repeat conceptions from 17.66% in 2008 to 13.79% in 2011. With regards to the current age profile of under-18 conceptions in Hull, approximately 80% now occur in 16 and 17 year olds with none under 13, illustrating that not only has the overall rate reduced but that young people who do become pregnant do so later. This suggests that the delay strategy promoted through SRE and media campaigns has had an impact. There is no strong evidence that an abstinence only approach is effective and all services locally were commissioned with a pro-choice, empowerment ethos. This is evidenced by Kirby8 who concluded
September 2014 Vol 134 No 5 l Perspectives in Public Health 293 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 17, 2015
Current Topic & Opinion Table 1 2001
2012
Sex education varied from school to school. Mainly focused on biology and some schools only delivered though annual health days. No SRE post-16.
Comprehensive and regular SRE to build knowledge and skills to support young people to develop healthy, safe relationships as part of a whole school approach across primary and secondary schools. (APAUSE programme in secondary schools (2005-2009). Christopher Winter Programme across primary and secondary schools (2010 to present)). This is delivered by trained educators (as part of the national CPD programme). Development of post-16 SRE sessions in 6th form colleges.
Development of a peer education programme in secondary schools and colleges which complemented core SRE delivery.
Shift of focus from biology only to a risk and resilience approach including improved communication and negotiation skills, healthy relationships, access to services and resisting peer pressure.
Services focus on clinical provision only – medical model
Complimentary, non-clinical services developed to support young people to reduce risks and build resilience, e.g. boys and young men’s project, peer education, streetbased outreach. Services broadened to include relationships and sexuality. Joint delivery between clinical and non-clinical young people’s provision.
Contraception accessed through traditional adult Easy access to free youth-friendly sexual health services including: family planning services in clinical settings or GP.
• City centre young people’s sexual health services
• Outreach nurses providing a contraception in schools, colleges, youth centres etc.
• Teenage mothers offered contraception visit at home within four weeks of birth.
• Improved access to condoms through youth services, school nurse drop-in etc.
• Services designed and commissioned in line with ‘You’re Welcome’ quality standards.
Lack of workforce training in place for all services working, with young people e.g. youth workers, social workers, etc.
Comprehensive training program open to all services across the partnership. This included training on condom distribution and also pregnancy options for non-clinical staff (Education for Choice training).
Focus of strategy aimed at girls only.
Gender-specific services to target work with boys and young men and training for generic staff to improve work with boys and young men.
Distorted perception of peer norms.
Research and campaigns which challenge perceived peer norms and give clear consistent messages on delay and access to services.
No work with parents on issue.
Implementation of the national Family Planning Association Speakeasy program to support parents to discuss sex and relationships with their children in an age appropriate way.
Teenage pregnancy seen as a social services issue.
Initially part of the National Sure Start Plus programme, Hull developed the Teenage Pregnancy Support Service, a holistic support service for young parents. This improved early access to maternity services as well as improved outcomes for pregnant teenagers, fathers to be and teenage parents on education, employment, health, parenting and prevention of repeat conceptions.
City wide data only available. Lack of data to Effective dataset in place to evidence impact and improve targeting of services. inform targeting of provision to maximize impact. Lack of a joined up multi agency (strategic or operational) approach.
Strategic board established with operational themed working groups. Annual action plan.
294 Perspectives in Public Health l September 2014 Vol 134 No 5 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 17, 2015
Current Topic & Opinion Figure 2 The Hull Model14
Effecve use of peer norms to change culture and behaviour
Improved SRE/Health Literacy in Schools and Colleges
Early Intervenon through exisng services
Consistent messages to young people parents and praconers
Holisc support to teenage parents
Effecve Strategic Leadership and Governance
Targeted work with boys and young men
Workforce Development and Training across the partnerships
Targeted services and support for young people at risk
Ongoing engagement, evaluaon and research
Effecve use of data for local performance management
that a dual message of delaying early sexual activity while providing information about contraception and safer sex is most effective in supporting young people. In addition to the strategic impacts the following operational impacts have also been delivered: •• Improved knowledge and ability of young people to make informed health choices (Hull biannual Health and Lifestyle survey); •• improved access to contraception including long acting reversible contraception (LARC) (local service data shows an increase of approximately one third);
Support for parents to discuss sex and relaonships
Young people friendly, accessible clinical services
•• improved engagement and access to services by vulnerable and hard-toengage groups through delivery in non-clinical settings through youth services; •• improved access by boys and young men (in 2001 less than ten young men under-18 accessed local sexual health services annually compared to 1800 girls. Now access has increased to approximately 8,000 with 50% being boys and young men. In addition 1005 one-to-one support sessions were delivered to boys and young men on issues relating to sex and relationships; and •• reduced need for social care interventions in teenage parents (the
teenage pregnancy support service prevented the need for social care intervention in 165 cases in one year due to early intervention and support). Over the last ten years, local and national research, consultation and evaluation as well as evidence-based best practice from other areas has been used to adapt and revise the local strategy to maximize impact.
Distance Travelled – Before and After In 1998, Hull had one of the highest under-18 conception rates in England with a rate of 84.6 conceptions per 1000 girls aged 15-17. Approximately two
September 2014 Vol 134 No 5 l Perspectives in Public Health 295 Downloaded from rsh.sagepub.com at UNIV OF PITTSBURGH on March 17, 2015
Current Topic & Opinion thirds continued with the pregnancy and one third accessed a termination. 20% of all under-18 conceptions were repeat conceptions. Young people described the majority of teenage pregnancies as unplanned, with outcomes for young parents and their children disproportionately poor. The numbers of young people having sex under 16 was not disproportionate to national figures (approximately one third of under-16’s reported having had intercourse) however numbers of under-18’s accessing local contraception services was low, as was uptake of LARC. Prior to implementation of the local strategy, services offered an adult, medical model which was consultant-led and there was a lack of consistent provision of quality Sex SRE and Relationship Education and access to contraception services by young people. There was little targeted provision of services with the majority being non-agespecific and based within clinical settings. Contraception was seen as a female issue and teenage pregnancy as an issue for social services. There was no community based support on safer sex and relationships and no support for parents. There was a lack of understanding of local need and the barriers which restricted access to services. Table 1 sets out the changes made to deliver an effective strategy to reduce under-18 conceptions.14
Moving Forward Throughout the strategy a question regularly posed was: “what is the one thing which delivered the most significant decrease?”. However it is not one specific service but a combination of changes to create a whole system approach across services, made possible due to effective leadership across commissioning and provider organizations. The most significant change has been the cultural change in attitudes by services working with young people in how they approach and address the issue with the focus on prevention and early intervention rather than crisis management. Improving young people’s sexual health and reducing teenage pregnancy is now seen as “everybody’s business” not just a health issue. There has been change in the delivery model from a consultantled medical model to nurse/youth worker delivery with the access to condoms predominantly provided through non-clinical services (as well as some pregnancy testing and Chlamydia testing). Increasingly outreach nurses are undertaking the provision of contraception in partnership with other young people’s services. Both of these initiatives have led to increased access and a holistic provision, covering issues including relationships and sexuality, not just contraception. Workforce development has also been an effective method of improving access and
information by ensuring staff across a range of providers are giving consistent messages and have the skills and confidence to support young people. Collectively this has supported a change in attitudes and behaviour in young people which includes accessing services before they have sex rather than after, so contraception can be planned. Building on the learning from this strategy the new local commissioning model will further embed the preventative and early intervention approach with a balance between clinical and non-clinical provision and continuing workforce development. For the first time there is also investment in adult sexual health promotion which will focus on improved knowledge, health improvement and access to services, mirroring the young people’s model. This will include workforce development for staff in adult services and targeted clinical and non-clinical outreach for hard to engage groups (those with learning disabilities, mental health issues, LGBT, older people, etc). This will ensure that we do not see a reversal of the achievements in reducing under-18 conceptions and will also begin to improve sexual health outcomes within the adult community. The model is also being used to develop strategies to address other young people’s health issues.
References 1. 2.
3.
4.
5.
Social Exclusion Unit Teenage Pregnancy Report. London: Social Exclusion Unit. 1999 Department of Health. Guidance for youth workers on providing and referring young people to contraceptive and sexual health services. 2001 Department of Health. Guidance for developing contraception and sexual health advice services to reach boys and young. 2000 Health Education Authority. Teenage pregnancy: an overview of the research evidence. 2004 Department for Education and Skills. Teenage Pregnancy Next Steps: guidance for local
6.
7. 8.
9.
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