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External Evaluation of Healthy Respect
A NATIONAL HEALTH DEMONSTRATION PROJECT: FINAL SUMMARY REPORT

I. Sexual health and behaviour outcomes

A: to evaluate the effect of Healthy Respect in improving sexual health attitudes and behaviour in young people in Lothian compared to Grampian.

Hypotheses

In relation to the timed implementation of theHealthy RespectDemonstration Project, in Lothian compared with Grampian:

1. There will be an increased proportion of young people who report better communication with parents on sexual health issues.

2. There will be an increased proportion of young people who report better communication with teachers/tutors on sexual health issues.

3. There will be a reduction in the proportions of young people who report having had sexual intercourse at ages <16 years.

4. There will be increased knowledge and improved attitudes and intentions about using condoms among young people.

A before-and-after survey of young people's sexual health knowledge, attitudes and behaviour was used to test Healthy Respect's Sexual Health and Relationship Education (SHARE) programme in 10 Lothian schools, compared with five non-SHARE Grampian schools. ¹

Main Findings

• Before Healthy Respect's SHARE intervention, Lothian pupils in 2001 consistently demonstrated significantly less knowledge, less positive attitudes and behaviour relating to sexual health, compared with pupils in Grampian.

Communication about sexual health issues

• Around half of pupils can talk to mothers whereas only one fifth can talk to fathers on these issues. Boys were less able to talk to mothers and girls less able to talk to fathers. After Healthy Respect and SHARE (2003) the proportion of pupils in Lothian (particularly the few boys feeling able to talk to their fathers) increased so that the difference with Grampian was no longer evident.
• Other results indicate no increase by 2003 in the low proportions of pupils in Lothian who report better communication with teachers on sexual health issues and advice, and Lothian pupils appeared only half as likely to approach school nurses compared with Grampian pupils (20% of pupils in Lothian vs. 38% in Grampian (2003)).

Sexual intercourse at ages<16

• Around 1 in 5 pupils reported having had sexual intercourse at age<16.
• Significantly more Lothian (~24%) than Grampian (~19%) pupils report having had sexual intercourse, both before and after the intervention, with no evidence of any reduction in Lothian by 2003.

Knowledge, attitudes and intentions in relation to condom use

• By 2003, the proportion of pupils in Lothian feeling confident (self-efficacy) about getting condoms, and using condoms properly, increased. Also more Lothian pupils (particularly boys) agreed by 2003 that sexually transmitted infections (STIs) are likely to be contracted unless condoms are used.
• However, no further evidence of narrowing of the regional gap was detected in improving other attitudes about condom use by 2003. Pupils in Lothian were more likely to feel embarrassed (especially girls) and more likely to think condom use would reduce sexual enjoyment (especially boys).
• Lothian pupils' intentions about condom use (as closer predictors of actual behaviour change) showed no sign of improvement despite the above noted improvements in
  self-efficacy and knowledge.
• Finally, clear differences in attitudes to condom use by gender were noted. These differences are shown below to better inform practice and gender-specific approaches to attitude change:

B: To evaluate Healthy Respect's effect on access, acceptability and uptake of contraceptive and sexual health services in Lothian compared to Grampian

Hypotheses

In relation to the timed implementation of theHealthy RespectDemonstration Project, in Lothian compared with Grampian:

1. There will be increased provision of sexual health services and contraceptives for young people. (see II, mapping services and I-C, trends in sexual health outcomes)

2. There will be a reduction in young people's perceived barriers to sexual health services.

3. There will be increased access to sexual health services and contraceptives by young people.

4. There will be increased intentions to use sexual health services and contraceptives by young people. (see also section I-A)

5. There will be higher rates of uptake of sexual health services and contraceptives by young people. (see II, mapping services and I-C, trends in sexual health outcomes)

Findings from the questionnaire survey and focus group interviews in Lothian and Grampian evaluate the impact of the Lothian's Healthy Respect and SHARE programme on young people's preferences for and perceived barriers to sexual health services, advice and obtaining contraceptives.

Main Findings

Access and barriers to advice and sexual health services

• In both Lothian and Grampian the most popular services for pupils were drop-in centres, family planning clinics and family GPs.
• After Healthy Respect, the popularity of drop-in centres increased further in Lothian (49% to 60%), and decreased for family planning clinics and GPs compared with Grampian. There is little indication that barriers to other services (telephone helplines, internet, school-based staff) decreased in Lothian.
• School-based staff, and teachers in particular, were the least favoured source of advice. Focus group interviews revealed concerns about lack of confidentiality, embarrassment and the possibility of being treated differently by a teacher after disclosure of personal information.
• Pupils in the Lothian focus groups after the intervention said there were no specific sexual health services in their locality, especially in rural areas. Where services did exist, they were often judged unsatisfactory because of severely restricted opening hours.
• The kind of advice services preferred vary according to gender and whether or not young people reported already having sexual intercourse. Boys were more reluctant to seek advice from drop-in centres and family planning clinics, and girls were no more likely than boys to access GPs. Those who reported previous sexual intercourse were less likely to use GPs.

Access and barriers to obtaining condoms

• The most popular way to obtain condoms in both Lothian and Grampian was through vending machines in public toilets (~60%). Local chemists were regarded favourably (~40%), and family planning clinics appeared more popular in Grampian (~40%) than in Lothian (~25%). After Healthy Respect there is little evidence of any reduction in perceived barriers to these and other services which supplied condoms for Lothian pupils compared to Grampian pupils, except that the recognised availability of condoms at drop-in centres in Lothian did increase after the intervention (20% to 32%).
• Again, results show clear differences by gender and sexual activity. Boys were more likely to use vending machines than other methods to obtain condoms, probably due to the anonymity offered in this method.

Access to specific regional sexual health services

• Pupils still appear poorly informed about the availability of sexual health services in their region. After the intervention, increased proportions of pupils in Lothian had heard of Healthy Respect, and the c:card service (>65%), but only a minority of pupils had heard of other specific regional services presented to them (<30%) and few had used them (<10%).
• Although the Healthy Respect logo was well identified in focus groups in Lothian by 2003, few pupils were able to say what Healthy Respect signified, thus raising some doubts about the delivery of values associated with the brand.
• Grampian pupils were most likely to identify the Health Promotions shop in the main street of Aberdeen as an available sexual health service in their area (~60%), but, again, very few pupils recognised or used the other services listed.
• Boys were less likely than girls to access sexual health services, but those who were sexually active tended to show greater awareness of services available and to be more likely to use them.
• Whereas the younger pupils in focus groups commonly identified the Internet as a potential source of advice, older pupils noted that, in reality, restrictions on search terms and website contents on school premises (applying also to the Healthy Respect website) mean that potentially valuable sources of sexual health information remain unavailable.

Reported contraceptive use of sexually active pupils

• The survey findings showed that only around half of pupils who reported having had sexual intercourse said they had used a condom at first sexual intercourse.
• Before and after Healthy Respect and SHARE, there were no significant regional differences in the reported use of condoms, the contraceptive pill or the morning after pill at first sexual intercourse. By 2003 there was an indication of increasing reported use of all three methods in both regions.

C: To evaluate, in relation to the timing of Healthy Respect, longitudinal trends in teenage conception and abortion rates, and screening for STIs in Lothian compared with Grampian, and with Scotland as a whole.

Hypotheses

In relation to the timed implementation of the Healthy Respect Demonstration Project in Lothian:

1. Teenage conception rates will fall in Lothian. The rate of fall will exceed that in Grampian and in Scotland as a whole.

2. Teenage abortion rates will fall in Lothian. The rate of fall will exceed that in Grampian and in Scotland as a whole.

3. The number of tests for Chlamydia trachomatis undertaken in teenagers will rise in Lothian. The rate of testing among young people will exceed that in Grampian and in Scotland as a whole.

4. Compliance with national recommendations for the detection and management of genital Chlamydia trachomatis infection (SIGN Guideline 42) will be higher in Lothian than in other regions of Scotland.

This section compares sexual health outcomes (conception and abortion rates) for young people in Lothian and in Grampian and in Scotland as a whole in relation to the timed intervention of Healthy Respect in Lothian. Adjusted comparisons for Lothian and Grampian are presented. It also compares the performance of healthcare professionals in the detection and management of genital Chlamydia trachomatis infection. At time of reporting, complete teenage conception data for 2003 were unavailable.

Main Findings

Trends in teenage conception rates in Lothian and Grampian

• Over 1995 to 2002 the overall teenage conception rate was consistently higher in Lothian than the overall Scottish rate, whereas the rate in Grampian was consistently lower.
• Across all age groups (13-15, 16-17, and 18-19) and all years, conception rates are higher in Lothian than in Grampian.
• One Healthy Respect headline target relates to reducing health inequalities in conceptions in the youngest teenagers (13-15 year olds). Numbers and rates of conceptions in this age group are very low (~8 per 1000 women; compared to a rate of ~80 per 1000 for 18-19 year olds). Low rates and random effects make interpretation of trends and detection of significant differences problematic. In Grampian, the conception rate among 13-15 year olds has fallen consistently from 9.7 per 1000 in 1996 to 6.1 per 1000 in 2002. In Lothian, there is greater variation year on year, with no consistent downward trend.
• Using both 2001 Carstairs (7 Categories) and Scottish Index of Multiple Deprivation (SIMD 2004) (deciles), the data demonstrated the well-known association of increasing deprivation with increasing teenage conception rates in these data.
• There was no apparent consistent relation between rurality using Scottish Household Survey (SHS) (6 Categories) and teenage conception rates.
• For 2001 to 2002, the odds ratios for pregnancy for Lothian teenagers (and for different age groupings) were compared to their counterparts in Grampian. Unadjusted comparison showed Lothian teenagers were significantly more likely to have a pregnancy than Grampian teenagers (OR 1.21, 1.14-1.29). Adjustment for deprivation using Carstairs Categories reversed these odds (OR 0.93, 0.87-1.00), while adjustment using SIMD deciles had less effect but reduced the regional difference such that it became non-significant (OR 1.03, 0.96-1.09). This effect is evidence of continuing health inequalities. By taking account of deprivation in different regions, apparent differences in teenage pregnancy rates can be explained in fairer comparisons.
• Unadjusted and adjusted (SIMD) odds ratios for pregnancy for Lothian teenagers (in different age groupings) compared to their counterparts in Grampian were examined for each year from 1995 to 2002. Adjustment reduced or reversed the regional difference in risk of pregnancy.
• Adjusted odds ratios varied year on year and a longer period of monitoring is required to confirm any sustained trends in the difference between Lothian and Grampian in relation to the timing of Healthy Respect.

Trends in teenage abortion rates and abortion proportions in Lothian and Grampian

• Over 1995 to 2002 the teenage abortion rate in Lothian was consistently higher than the rate in Grampian. 2002 data suggest a narrowing of this difference.
• Using abortion proportions, overall ~40% of teenage conceptions end in abortion, with this proportion being only slightly higher in Lothian than in Grampian.
• Using Carstairs (7 Categories), there was evidence of the well-established relationship of increasing deprivation associated with a decreasing proportion of teenage conceptions ending in abortion.
• For 2001-2002, the odds ratios for abortion for pregnant Lothian teenagers (in different age groupings) were compared to those for Grampian. Using unadjusted data, pregnant Lothian teenagers appeared no more likely to have an abortion than pregnant Grampian teenagers (OR 1.03; 95% CI 0.91-1.16). Adjustment for deprivation however, (using both Carstairs Categories and SIMD deciles) indicated that Lothian teenagers were significantly more likely to have an abortion than those in Grampian (Carstairs, OR 1.21, 1.06-1.38; SIMD, OR 1.19, 1.04-1.35). Again longer data monitoring is required, but these findings suggest that the variation between regions is not wholly explained by deprivation. Further associated factors may include decision-making and access.

Comparison of testing for C.trachomatis in teenagers in Lothian compared with Grampian

• Data from microbiology laboratories permitted some comparisons of chlamydia testing in Lothian and Grampian. Between January 2000 and March 2004, quarterly chlamydia tests on teenagers rose by 84% in Grampian (from 539 to 993) and by 121% in Lothian (from 751 to 1661). The rise in Lothian was particularly marked among male teenagers (186%, from 99 to 283).
• In both Lothian and Grampian, the proportion of all chlamydia tests from specialist GU services declined significantly over time (reflecting involvement of a wider range of clinicians in testing). The extent of this fall was similar in the two regions.
• In both Lothian and Grampian, the number of chlamydia positive teenagers detected annually increased over time. The increase from 2000 to 2004 was slightly greater in Lothian (65% increase) than in Grampian (59% increase).
• In both regions, and throughout the period 2000-2004, the rate of detected positive chlamydia tests among selected tested teenagers was consistently around 13%.

Comparative compliance with national recommendations for the detection and management of genital C.trachomatis infection (SIGN Guideline 42) in Lothian compared with Grampian.

• During the period of activity of the Healthy Respect demonstration project, few differences were detected between clinicians in Lothian and Grampian with regard to self-reported chlamydia-related practice.
• In both regions, primary care clinicians (90%) appeared very aware of the need to test for chlamydia in patients with relevant symptoms; but were less likely to offer opportunistic testing to young patients without specific symptoms.
• However, a review of case records was less reassuring with only 26% of relevant general practitioner consultations including initiation of chlamydia testing, and data showed a mixed picture in comparisons between Lothian and Grampian clinical practice.
• Overall, Healthy Respect in Lothian appeared to have little impact on clinicians' practice although the few significant differences that were detected tended to suggest better practice in Lothian.

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