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Section three: Preventing STIs and unintended pregnancy
Key points
- Preventing STIs and unintended pregnancy requires a holistic approach involving a number of agencies and individuals and action at a local and national level
- Progress is being made in ensuring sex and relationships education, information and advice, backed by good quality services, is available to everyone.
Preventing STIs
Scotland's record on STIs is not enviable (see statistics on page 3). Tackling this is not only a matter for health services, however, but for a variety of agencies and organisations, including schools, local authorities, individuals, parents and carers. During 2006-2007 work was stepped up to improve access to sex and relationships education and advice in schools and other settings.
'Mystery shoppers' test access to sexual health services
A 'mystery shopper' process has been used to test how quickly patients with symptoms of an acute STI can access services.
The project involved healthy people contacting 21 GUM and 14 family planning clinics giving symptoms of STIs and finding out when they could be seen. Overall the experience was positive, with most meeting national standards.
Under British Association of Sexual Health and HIV ( BASHH) guidelines, patients displaying symptoms should be seen within 48 hours. Scotland's key clinical indicator ( KCI) on access also says people with priority sexual health conditions should be seen by specialist services within two working days of contacting the service.
The female shopper contacted each clinic with symptoms of either chlamydia or genital ulcers while the male called the GUM clinics with symptoms of either genital ulcers or urethral discharge.
Of the GUM clinics, 71 per cent could see the female who called with possible chlamydia within 48 hours and 76 per cent could see the female with possible genital ulcers. The male with symptoms of genital ulcers could be seen in 71 per cent of clinics within 48 hours and 76 per cent with urethral discharge.
Six of the 14 family planning clinics could see the female caller with chlamydia within 48 hours, with two advising contacting GUM and one advising contacting a GP. Dean Terrace in Lothian offered a postal testing kit.
Four out of 14 could see the caller with suspected genital ulcers within 48 hours, which was not unexpected as few family planning clinics test for this. One clinic referred the caller to her GP and five to GUM.
The results of the research, which took place in March 2007, were published in July.
'Although clinics are busy and often working at full capacity, the high percentages of GUM clinics able to offer callers an appointment within 48 hours illustrates a good level of service access nationally,' says the report of the research findings.
More information can be found via www.isdscotland.org
Case study
Chlamydia testing in schools
Year-group testing programmes are underway in schools in the Dumfries & Galloway area to raise awareness and to find and treat cases of chlamydia.
The screening day is a good opportunity to raise awareness of sexual health issues and services and can be delivered as part of a programme of sexual health and relationships education provided by the sexual health team in co-operation with the area's secondary schools.
So far screening has been carried out in four schools with pupils ranging from S4 (15-year-old) to S6.
'We've found different rates of chlamydia infection, ranging from nil to 12 per cent,' says Dr Maggie Gurney, lead clinician in sexual health.
'Pupils can opt out if they want and there's no pressure for them to take part. But what we're finding is that most of them are happy to be tested as part of the wider sexual health and relationships education programme.'
Pupils are also tested for diabetes and for protein in their urine and any positive results for these are given to them by the end of the day along with advice to visit their GP.
Positive results for chlamydia are given by mobile phone within a week and treatment and contact tracing are initiated.
Healthy Respect
Healthy Respect, the Lothian-based national health demonstration project on sexual health, is more than half way through phase two, which runs until March 2008. In 2006-2007 it made progress against all its objective areas, which include sex and relationships education in schools, young people at risk, access to services and improved attitudes to sexual health and relationships using communication.
Here is a small snapshot of some of Healthy Respect's work in 2006-2007:
- Held six multi-disciplinary SHARE training events, with 102 frontline educators being trained in the programme
- In association with Caledonia Youth, held an event on sex and relationships to support young people with learning disabilities, attended by 42 young people and 11 workers
- Continued to increase the number of drop-ins in a variety of locations across Lothian - there are now 23 drop-ins available to young people aged 13-18
- Delivered a Parents campaign, which highlighted the value of 'quality family time' in reducing risk-taking behaviour for young people.
Case study
Word-of-mouth helps young people access services
An anxious 15-year-old attended the Healthy Respect drop-in at her local health centre with a friend, having heard about it from other friends locally. She had also just started SRE in school, which had included a session led by the school nurse on services for young people.
At the drop-in, the school nurse did a pregnancy test for the girl, which was negative and offered a follow up test and a c:card so that she could access free condoms. She also initiated discussion on healthy relationships and safer sex issues.
When the girl returned the following week, with a different friend, the second test was also negative and a urine sample was sent for Chlamydia testing. The girl was keen to start the oral contraceptive pill, so received detailed information and a leaflet from the school nurse. Her friend also requested a c:card.
Both girls said it was easier to access the local service as friends had previously used it and felt it was a young person-friendly service.
Case study
HIV Comeback Tour in Lothian
A multi-agency group in Lothian developed a campaign in response to increasing rates of HIV in men who have sex with men ( MSM). The HIV Comeback Tour, launched in September 2006, involved NHS Lothian, Gay Men's Health, Healthy Gay Scotland, LGBT Youth, Harm Reduction Team, GUM, Waverley Care and Positive Voice.
The three-year campaign aims to raise awareness of HIV among MSM, encourage regular testing and urge use of condoms and negotiated safety strategies, and has been based on international evidence as well as extensive local research, involving MSM. It is being formally evaluated to assess impact and effectiveness and to see if it has potential to be applied nationally.
Clinical data has shown that the number of people attending the specialist MSMGUM clinic rose between 2005-2006 and 2006-2007. The number of new patients almost trebled from 132 to 388 while return visits rose from 253 to 729.
Targeting help at vulnerable young people
Strenuous efforts are also being made to engage with young people, particularly those who are most vulnerable.
Case study
Helping vulnerable young people in Tayside
In Tayside, the WEB project, a local voluntary sector organisation which works with disadvantaged and socially excluded young people, was commissioned by NHS Tayside to provide a tailored programme of sex and relationships education aimed at the needs of some of the most vulnerable young people across the region. The programme started in April 2006 and in its first year 39 organisations across Tayside hosted sessions with more than 600 young people participating.
The WEB project is also developing a programme to work with 16-25-year-olds who are sexually exploited, targeting both indigenous and migrant young people.
NHS Tayside has also set up a pilot Young People's Clinic in GUM that offers a tailored one-stop shop aimed at meeting the needs of young people. Ann Eriksen, Head of Social Inclusion, says: 'The clinic is jointly provided by doctors and nurses from both sexual health and paediatrics and has strengthened the arrangements to protect and support some of the most vulnerable young people.'
The evaluation of the first year's data will be published in 2008.
Child Protection
During the past year there has been progress at a national and local level in tackling child protection issues, particularly in relation to sexual health and wellbeing. A number of local protocols and training initiatives have been developed to provide guidance and support to professionals working with young people who are sexually active, including those who may be under the age of 16. It is important that protocols support a proportionate response to sexually active young people, ensuring that those in need of protection are referred appropriately whilst also ensuring that young people's clinical needs are met.
National guidance in the area of disclosure of under age sexual activity is under consideration and will support work underway following the 3-year Child Protection Reform Programme, which was recently very positively evaluated in an independent review.
Case study
Pharmacists in Ayrshire & Arran trained in child protection
Community pharmacists in Ayrshire & Arran are being trained in child protection issues to allow them to extend sexual health services.
The pharmacists are being trained in the issues which have to be considered when dealing with requests for sexual health services from young people.
The move will allow the area's pharmacy-based service for emergency hormonal contraception ( EHC) to be extended to include girls aged 14 and 15 where clinically and professionally appropriate.
It will also allow them to give other sexual health messages, such as options for long-term reversible methods of contraception and ways of avoiding STIs.
Ayrshire & Arran's community pharmacy-based EHC service involves 79 pharmacies in all urban and most rural areas and is intended to widen access, particularly because they are open in evenings and at weekends.
In 2006-2007 there were 4,943 consultations, with EHC being supplied in 98 per cent of cases, along with written and verbal advice on contraception and avoiding STIs.
NHS Ayrshire & Arran decided to lower the current age limit for the service from 16 to 14 in light of high teenage pregnancy rates in 13-15-year-olds.
Case study
Feel, Think, Do programme for primary school children in Forth Valley
An innovative sexual abuse prevention programme is being rolled out in Forth Valley.
Feel, Think, Do is an interactive resource designed to be used with pupils in primaries six and seven.
Delivered over eight lessons, the programme includes a DVD which uses a live theatre in education performance to create situations, exploring issues such as emotional literacy, risk-taking, personal safety and sexual abuse.
Throughout the DVD there are opportunities to pause, encouraging discussion and providing links to the lesson plans.
Feel, Think, Do was launched in January 2007 and was rolled out to Forth Valley primary schools in October.
The programme was developed by the Sexual Health and INTER- ACT teams from Health Promotion at NHS Forth Valley, in partnership with Health Scotland, Stirling Council, Clackmannanshire Council and Open Secret.
Dr Chris Kelt, lead clinician, says: 'This initiative is important not only because it encourages personal safety in children and young people but it helps put over the importance of respect for self and others and positive relationships, and will hopefully help prevent sexual abuse and coercion and subsequent sexual problems.'
Preventing unintended pregnancies
The strategy as a whole is based on an overarching aim of achieving improved sexual health and wellbeing. This involves a number of factors including education and tackling economic and societal factors. Meanwhile, however, NHS Boards, schools, local authorities and other organisations across Scotland are taking practical steps to prevent unintended pregnancies. These include ensuring access to condoms, widening the availability of emergency hormonal contraception ( EHC) and improving access to long-acting reversible contraception. For example, in the Western Isles, four additional condom machines have been installed in local premises, one of them on an island where previously there had been no public condom machine while in Aberdeen the Terence Higgins Trust office now makes condoms available free to everyone, not just gay men. Education programmes are also being delivered across the country to young people in particular to give a better idea of the consequences of unintended pregnancies.
Case study
Work to improve access to long-acting reversible contraception in Lothian
NHS Lothian's Family Planning and Well Women services ( FP/ WWS) have taken action to improve access to long-acting reversible contraception, such as intra-uterine devices ( IUD) to meet patient demand. Only a small number of GP practices provide the service, with most referring women to the specialist services.
To help meet demand, the FP and WWS have doubled the number of IUD clinics held in the central Edinburgh clinic while a dedicated IU contraception clinic is now held once a fortnight in East Lothian. From Summer 2007, an additional IUD clinic is taking place each week in West Lothian.
'We realised we had to do something to meet demand because, in reality, very few GPs in Lothian offer this service so most women come to us,' says lead clinician Professor Anna Glasier.
The Family Planning Service is also working with GPs to encourage more practices to help meet the need.
In addition, the service continues to provide outreach clinics in some of Lothian's most deprived areas and a clinic has been established with NHS Lothian's Substance Misuse Directorate to deal with complex contraceptive needs and to encourage the use of long-acting reversible contraception amongst female drug users.
A fast-track appointment system has also been set up for women who have had a pregnancy terminated and who wish an IUD.
The number of patients who received IUD insertions rose considerably from 788 in 2005-2006 to 1,224 in 2006-2007 while the number attending for Implanon insertion rose from 658 to 1,028.
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