The Scottish Government

« Previous | Contents | Next »

Listen

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

Key findings to inform policy and service

In this section the implications of the findings of the evaluation for the development of policy and practice on sexual health issues are explored.

Overall

• As yet there is little evidence indicating improved sexual health outcomes for young people in Lothian following the Healthy Respect intervention. This may be because Healthy Respect activity to date has centred on professional training and networking and the project has not yet delivered a focused intervention aimed at young people.
• Healthy Respect has, however, used its critical mass to push forward partnership working on sexual health and to widen the professional responsibility for young people's sexual health, though much remains to be done.
• There are caveats in any generalisation about the implementation and evidence of best practice derived from the diverse range of component projects. However, there were some challenging findings in the process evaluation. For example, the low levels of active participation by young people, the lack of information on the impact of the professional training, and that, in the absence of proper results to share as findings from full analysis of completed work, much dissemination activity was simply awareness_raising about the need to re-conceptualise the issue or explore new ways of working.

Sexual health outcomes

• Data on trends in sexual health outcomes (conceptions, births, abortions) during the period of the Healthy Respect are incomplete and require longer monitoring and methodological development in testing for temporal association.
• Unlike some other public health interventions, where there is a long lag time between intervention and noted health outcome, the lag time between the Healthy Respect intervention and changes in conception rates should be relatively short, and is therefore worth monitoring.
• Aggregated regional comparisons highlight the well-recognised relation between deprivation and teenage conception rates. Moreover, small area data also show substantial geographic variation within both regions (Grampian and Lothian). Focusing interventions in more deprived localities could clearly yield bigger health gains and is more likely to achieve the policy goal of reducing health inequalities, though the dangers of targeting and stigmatisation of sub-populations are acknowledged.
• Chlamydia laboratory data in this report includes the selective testing of high-risk groups (including testing undertaken in relation to other research studies in both regions in this time period). This bias was expected to inflate numbers of positive cases detected; clearly rates in high-risk groups will be higher than general population rates.
• Data presented suggest that primary health carers play a major role in sexual health services provision, but audit findings overall suggest a fragmented sexual health service, with poor continuity, and some delay in referrals in both regions. There is a lack of available data to monitor routinely the quality of referrals, treatment, and the effectiveness of care in partner tracing and re-infection rates.

Knowledge and behaviour outcomes in sexual health

• SHARE is a high quality and theory-based school sexual health education programme. However, our results show few improved knowledge and behavioural outcomes amongst young people exposed to the Healthy Respect SHARE programme compared with Grampian non-SHARE programmes. Our results are similar to previous reports that school-based educational interventions may demonstrate some increased knowledge, but have little or no success in changing attitudes and behaviour.
• Some pupils reported having first sexual intercourse at a young age. Information from our study is sparse to explore the sexual health education received in earlier years of schooling. For some of the most vulnerable pupils any sexual health education starting in S2 may have been too late.
• Despite the emphasis given in SHARE to multidisciplinary training of staff, young people continue to demonstrate marked reluctance about discussing personal issues with teachers. Despite the fact that schools may provide access to a large number of young people, attempts to provide better support for young people must weave in the provision for communication and advice from non-school staff to the educational input. The promise of SHARE with the introduction of multi-professional training was not uniformly carried through in the field. Existing partnership links between education and the other services need to be strengthened at strategic and managerial levels to allow this to happen routinely.
• Similarly, given the new public health role for school nurses, further exploration is required for a better understanding of the apparent lower popularity of school nurses for giving advice and support on sexual health issues in Lothian compared to Grampian. Tentative explanations may include the length of time nurses were on site in Lothian schools, possible lack of provision or limited continuity due to school nurse staff turnover in Lothian, or that the relocation of some Lothian school nurse sessions to drop-in centres resulted in pupils no longer identifying those drop-in service providers as "school nurses".
• Healthy Respect SHARE schools operated associated drop-ins on or near school premises. The drop-ins proved popular with many pupils where they were available. Systematic evaluation of the drop-ins was impossible however, given their very different timelines, operating procedures, service offerings, staffing arrangements and varied forms of record keeping. More evidence is required about throughput, effectiveness and cost effectiveness, and more work is needed to identify which ages and types of young people utilise which aspects of the drop-in services.

Schools as appropriate hubs for service delivery on sexual health?

• Poor knowledge and behaviour outcomes from the SHARE schools must lead to questions of whether schools are the most appropriate venues for the delivery of interventions aimed at improving sexual health. A clear attraction for those wishing to influence young people's behaviour is the fact that education is a mass service delivery system _ children move through in age cohorts regardless of emotional and physical maturity. But in sexual health education a proportion of any class must either hear the message too late or too early for them. It might be irresponsible to give no sex education at all, but from evidence it appears unrealistic to expect even the best curriculum to deliver significant changes in behaviour.
• Schools, given their own educational priorities and constituencies, are often reluctant to participate in sexual health interventions. Schools may also believe that an 'up-stream approach', that raises pupils' expectations, achievements and aspirations is a better investment against the links between deprivation and poor sexual health outcomes and may solve the 'problem' by raising young people out of a lifestyle characterised by low expectations.
• The issue of confidentiality versus child protection remains an unresolved but central dilemma for school-based interventions. This is evidenced, not only in non-medical vs medical agencies' conflicting guidelines following disclosure, but also, for example, in imposed filters on internet sources of information that bar access to sexual health education sites in schools. Young people are aware of mixed messages about openness and sexual health issues.

Access to and acceptability of sexual health services

The complexity of attitudes to sexual health services by gender, age and presence or absence of reported sexual activity suggest that approaches that treat young people as one homogeneous group are unlikely to succeed.

• For the youngest people with low or non-existent levels of independent income, and reduced autonomy of movement because of school hours and so on, localised services like the SHARE drop-ins may be the best solution in terms of offering accessible, low threshold services. They may also be the solution for those who are merely curious. They may not be appealing for older teenagers who are more likely to be sexually active, require a guaranteed confidential service, and who may have more disposable income and freedom of movement.
• Older teenagers may be more likely to use family planning or GP services, but continued barriers to using such services include location, restricted opening times, embarrassment, and fears of judgmental staff attitudes.
• Not all young people want counselling or advice _ they simply want the availability of contraceptives.
• Young people may also want to access information anonymously, or handle the paraphernalia of contraception and STI testing privately. This would account for the rapid disappearance of the postal testing kits experimentally left in record shops by the Chlamydia project, most of which will have been taken by the merely curious, rather than the explicitly needy. But the point has already been made that information on sexual health topics may be difficult to access anonymously even in this information-rich age, because of the filters on many school, library and home computers.

Building strategic and facilitative partnerships and networks

• It is in the area of building strategic partnerships and professional networks that Healthy Respect demonstrated most success . Fortunate in building on a legacy of multi-agency work in many areas of the Lothians, Healthy Respect consolidated this position and drew a whole range of partners into the intervention.
• Partnership at a strategic level was not particularly difficult to implement, and Healthy Respect forged ahead, playing a major part in the development of sexual health strategies at both national and regional levels.
• Facilitative partnerships where agencies work together to deliver service was a more difficult challenge however. Informal networking developed quickly within the Healthy Respect components and beyond, through training and personal contacts, dissemination activities and so on. More problematic was the fact that such informal networking was more likely to involve those directly delivering service, but not their line managers. Middle management was largely ignored in training and dissemination activities, and some initiatives were stifled by lack of professional support.
• Not building proper contractual partnerships between the 'giants' of local authority education services and health boards left a problem that remained to the end. Partnerships are starting to develop, but will take time to build.
• Healthy Respect was particularly successful in drawing voluntary groups into partnership and using their rootedness in the communities to good effect. This was a symbiotic relationship, however, with the voluntary agencies using the Healthy Respect platform to build their activity base and profile. The extent to which these agencies subsidised their own involvement does raise questions about the long term sustainability of these relationships.
• Partnership working may also cause tensions where it appears to involve subjugation of separate identities under a partnership banner or brand. Professional reputations or hard-won identity for a named organisation and its work are hard to give up, and ownership issues may arise.
• Healthy Respect had to work hard at supporting alliances between partner organisations and maintaining impetus. The need to monitor, and very early requests for assessments of what is working and what is not, was often in conflict with the need to keep morale high in such a contentious demonstration project.
• The end product of partnership has to be improved service for young people (in this instance) and this needs to be the focus and yardstick against which partnership work is constantly measured. In the case of Healthy Respect, partnership working allowed innovative low threshold services to be developed, encouraged services to network and think of more imaginative ways of training, and of framing youth issues. It also enabled access to more vulnerable and hard to reach groups, and drew more professional groups into accepting responsibility for young people's sexual health and overall wellbeing.

The process of implementation of Healthy Respect

There are issues about the process of establishment of Healthy Respect which impeded progress at the start and left weaknesses which could not be remedied.

Commissioning and establishment

• Many of the components were clearly in a pre-demonstration rather than demonstration phase _randomly experimental, with poor evidence base etc.
• The demonstration project advanced on all fronts, rather than concentrating effort in some areas or on some styles of working which could have established an effective test bed for work on young people's sexual health.
• More attention needs to be paid at commissioning to the capacity, required funding (and willingness) of partner agencies that will host the projects.
• None of these errors are attributable to the current management team or to the component project workers within Healthy Respect, and both groups have worked very hard to reverse some of the earlier mistakes.

Being a demonstration project

• Demonstration project funding and status gave Healthy Respect the sort of critical mass and synergy where the whole could be more than the sum of its parts. Many individual projects and their host organisations felt they had gained from working together.
• Being part of something much bigger gave component organisations some protection against the hostile groups ranged against this type of work.
• The size of the intervention exposed but did not resolve a number of important issues where there is ambivalence and lack of consistent guidance at both national and local levels on young people and sexual health.
• The organisations selected for involvement had strongly-developed practice skills but not necessarily demonstration project skills. More support was required if these functions were not going to be carried out centrally within the management of the project.
• Training on consultation with young people needs to become a central concern.

Working on young people's sexual health

The process study revealed many individual examples of competent people extending themselves to develop new work. What does the demonstration project teach about ways of working with young people on contentious sexual health issues?

• Healthy Respect demonstrated that it is possible to redefine work on young people's sexual health through creating a brand that focuses on respect for self and others in tandem with extension of clinical services. But clarity and understanding of brand values needs to be strengthened.
• Healthy Respect helped define new issues and identify new target groups for concern. Some other neglected and vulnerable groups (e.g. ethnic minorities, excluded schoolchildren) still need to become the focus of attention.
• Healthy Respect demonstrated that there are some positive service outcomes that can accrue when service providers work together, but, crucially, there is a need now to deliver, achieve sustained levels of delivery, and further test impact on young people.
• Healthy Respect largely failed to explore and therefore to demonstrate the value of young people's active participation beyond anything other than first level consultation.
• Close consideration needs to be given to design/targeting of the intervention to ensure that it allows systematic exploration and evaluation.
• We know that staff appreciated the training that they received within Healthy Respect. We know too little about impact on practice and sustainability however, and suspect that more field support is needed to make staff feel confident to tackle difficult issues.

« Previous | Contents | Next »