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Nursing Practice Keywords: Teenage /STIs/ Sexual health Discussion ●This article has been double-blind Sexual health peer reviewed Despite improvements in sexual health and services for young people, pregnancy rates and sexually transmitted infections among this group remain high Teenage pregnancy and sexual health

In this article... 5 key Statistics on teenage and sexually transmitted points The under-18 infections in young people 1conception rate Steps being taken to enhance young people’s sexual health in England is at its The role of nurses in reducing teenage pregnancy lowest level since 1969 Rapid access Author Alison Hadley OBE is director of reduction. The majority of teenage preg- 2to sexually the Teenage Pregnancy Knowledge nancies remain unplanned, with at least transmitted Exchange, University of Bedfordshire; 50% ending in a termination. Outcomes infection screening David T Evans is senior lecturer in sexual for young and their children, has improved health, University of Greenwich. although improving, remain dispropor- significantly Abstract Hadley A, Evans DT (2013) tionately poor. Continuing to Teenage pregnancy and sexual health. In addition, despite improvements in 3reduce teenage Nursing Times; 109: 46, 22-27. rapid access to sexually transmitted infec- pregnancy and The under-18 conception rate in England is tion screening and treatment, STIs are improve young at a 40-year low but a further reduction is common among young people, with chla- people’s sexual needed to reach levels in comparable mydia being the most prevalent sexual health remains a western European countries. Sexually infection in the UK (Public Health Eng- government public transmitted infections are common among land, 2013). health priority young people, with chlamydia the most A fear of open prevalent STI in the UK. A continuing priority 4discussion To challenge this, a multi-agency These statistics explain why teenage about sexual health approach is needed, with high-quality sex pregnancy and sexual health continue to continues to be a and relationships education, easy access to be prioritised in new policy of the coalition barrier to providing contraception and sexual health services government. young people and an open culture around relationships The Public Health Outcomes Framework with accurate and sexual health. Nurses play a crucial 2013-16 (Department of Health, 2013a), information role in supporting young people within against which national and local govern- Nurses in all both contraception and sexual health ment will monitor improvements in 5settings have a services and as trusted practitioners in a public health, includes reducing under-18 role in supporting range of settings. conception rates and late diagnosis of HIV, young people to and increasing chlamydia diagnoses prevent pregnancy n a recent public opinion poll, teenage among 15-24-year-olds as key sexual health and STIs pregnancy rates were estimated to be indicators. Alongside this, the Framework 25 times higher than official govern- for Sexual Health Improvement in England Iment statistics (Ipsos Mori, 2013). In highlights reducing rates of under-18 con- fact, rates in England are at the lowest level ceptions and STIs as two of the five priority since 1969. As a result of the previous gov- areas for improvement (DH, 2013b). ernment’s Teenage Pregnancy Strategy (Social Exclusion Unit, 1999) and con- What works? certed efforts by individual services and The teenage pregnancy (SEU, 1999) and practitioners between 1998 and 2011 the sexual health and HIV strategies (DH, under-18 conception rate fell by 34% (Office 2001) were based on the best international for National Statistics, 2013). Nurses have evidence on what helps young people both played a major role in this success. to prevent early pregnancy and to look However, we are only two-thirds of the after their sexual health. Young women need to be well informed

Alamy way towards the original goal of a 50% High-quality sex and relationships and confident about using contraception

22 Nursing Times 20.11.13 / Vol 109 No 46 / www.nursingtimes.net For a Nursing Times Learning unit on contraception, go to www.nursingtimes.net/contraception

Table 1. Ways in which nurses can make a difference What you need to do/know Where to find help Understand how youth-friendly services can make it easier for tinyurl.com/DH-young-people-services young people – boys as well as – to obtain early advice and the importance of welcoming, friendly and non-judgemental staff Get up to date with basic information on the 15 methods of tinyurl.com/FPA-contraception-advice contraception, particularly the four methods of long-acting reversible contraception (LARC) Find out about the most common sexual infections and how you tinyurl.com/FPA-STI-advice can help the young people you see protect themselves Find out details of local services where young people can obtain: Search local council and health organisation websites, ● Full range of contraception methods for example for sexual health services, GUM (genito-urinary ● Free emergency contraception ) clinics, contraception, , C-card or free ● Free , for example through a C-card scheme or similar schemes ● Pregnancy testing and unbiased advice on options PEP is available at A&E departments, sexual health clinics and ● Chlamydia screening often at 24-hour health services. See: ● Full sexual health screening ● www.nhs.uk/chq/Pages/1840.aspx ● Urgent (within 72 hours) post-exposure prophylaxis (PEP) if at ● SXT – find sexual health information in under a minute at risk of HIV infection www.sxt.org.uk/ ● Specialised services for sexual assault, abuse, , child www.rapecrisis.org.uk/Referralcentres2.php protection, drug/-assisted sex and dependency Help foster a friendly and open culture to support young people tinyurl.com/Brook-positive receiving early help by: ● Having relevant and appropriate leaflets, posters or website information about the local contraception and sexual health services and any additional services for gay, lesbian or bisexual young people easily accessed ● Routinely asking young people if they know where to go for advice if they need it ● Ensuring colleagues know where to refer young people to ● Ensure you understand the Fraser guidelines on consent and ● www.brook.org.uk/index.php/information/sex-and-the- how to apply these to young people under the age of 16. Be aware law/239-consent-to-medical-treatment of local policies on safeguarding and sexual exploitation and ● www.brook.org.uk/index.php/sex-relationships/harmful- persons to contact if you are concerned about a young person situations Emphasise the importance of condoms to help prevent sexual Evans (2005) infections and HIV, as a “double Dutch” method used with contraception, and for different sexual practices and for non- vaginal intercourse, such as anal. education (SRE) is essential. This should people will be sexually active so they all » Alcohol use and misuse; be regular and continuous, not a one-off need effective SRE and access to contra- » Having had a previous pregnancy. condom teaching session or single day at ceptive and sexual health services to help In England, an estimated 20% of births the end of year 11, and should be delivered them look after their sexual health. conceived to under-18-year-olds are to by trained educators, building knowledge Nurses and other practitioners, such young women who already have a baby, and skills to help young people develop as SRE teachers, need to be alert to identify and 11% of terminations to under-19s are healthy and safe relationships (Kirby, young people who are at increased risk young women who have had one or more 2007). Comprehensive SRE also needs to be of unprotected sex and who may need terminations before. combined with easy access to free youth- extra support. A recent study found the Although data on boys and young friendly contraceptive and sexual health girls most at risk of pregnancy before fathers is not routinely collected, indi- services and free condoms (Santelli et al, 18 were: vidual studies have found similar vulnera- 2007). There is no good evidence that » Eligible for free school meals; bilities (Fatherhood Institute, 2013). “abstinence only” programmes or cutting » Persistently absent from school; The risk factors for unplanned and social for teenage parents are effec- » Making slower than expected academic teenage pregnancies also affect the moti- tive methods of reducing rates of teenage progress between key stages 2 and 3 vation and sense of self-worth young pregnancy or STIs. (ages 11-14) (Crawford et al, 2013). people need to consistently use condoms To be effective, prevention needs to Other risk factors are: to prevent STIs. reach all young people, with more inten- » Being in care or a care leaver; With all young people, but particularly sive prevention for those at greatest risk. » Experiencing and those with risk factors, nurses need to be By the age of 20, around 90% of young exploitation; vigilant for signs of sexual exploitation

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and abuse. Brook, a sexual health charity perceived to be for “family planning”). for under-25s, has an online traffic light Box 1. sources of Some nurses and professional carers may tool that provides a helpful guide to information have unwelcoming beliefs about non-het- assessing sexual behaviours (Brook, 2012). erosexual people or may be unaware of ● Teenage pregnancy and sexual health the sexual health needs of young LGBT Sexual health improvement in your area: check your local authority people, especially safer sex for STI and HIV framework joint strategic needs assessment prevention (Evans, 2013; Royal College of The sexual health improvement frame- ● Sex and relationships education, Nursing, 2012). work (DH, 2013b) builds on the evidence working with parents and examples of The wider health workforce from the teenage pregnancy and sexual good practice: visit the Because teenage pregnancy and sexual health and HIV strategies. It sets out clear Forum www.sexeducationforum.org.uk health are complex lifestyle issues, the ambitions across a person’s “life-course” ● All methods of contraception and sexual health framework asks local that require local authorities and clinical common STIs: www.fpa.org.uk authorities to include the preventive role commissioning groups to make further Brook’s Sex Positive campaign: www. of the wider health and non-health work- progress. brook.org.uk force in commissioning and to join up A main objective of the framework is to ● The School Nurse Development sexual health services with other local sup- build an open and honest culture around Programme: tinyurl.com/DH- port services. These can include drugs relationships and sexual health, some- schoolnurse and alcohol, mental health and sexual vio- thing that is common in comparable coun- ● The Teenage Pregnancy Knowledge lence services. tries with low teenage pregnancy rates. Exchange, University of Bedfordshire: Making every contact between a young Despite strong evidence that effective SRE www.beds.ac.uk/knowledgeexchange person and a professional count and cre- delays sexual activity and protects chil- ating a seamless care pathway helps to dren and young people, a fear of open dis- ensure that young people access help early cussion continues to be a barrier for some stigma around sexual health can be even and reduces healthcare costs (Brook and schools to providing even the basic foun- more acute (Burrows, 2011). This may lead fpa, 2013). dations of SRE as well as new challenges to homophobic bullying, from schools and such as pornography and social media. institutions as well as individuals, which How can nurses help? Embarrassment deters many parents and ultimately contributes to higher levels of Nurses have been essential to achieving a their children from discussing sex and mental health problems, unprotected sex significant reduction in the UK’s teenage relationships, and many teenagers still and suicide risk in these groups. pregnancy rate and improving access to report a sense of stigma and disapproval if For many young LGBT people, the sexual health services. they ask for sexual health advice. “invisibility” of their lifestyles and needs is Their contributions include the For lesbian, gay, bisexual and another barrier that prevents them from following: transgender (LGBT) young people and accessing sexual health services (espe- » Nurse-led contraceptive and sexual other marginalised groups, the silence and cially, for example, if such services are health services;

Box 2. Case study: School and practice nurses integrated prevention network, Wiltshire County Council

Wiltshire County Council has a plan in local No Worries service. This community- young people who may be concerned place to reduce sexual ill health in young based contraception and sexual about confidentiality. people and prevent unplanned health service is provided in Wiltshire The No Worries service is coordinated pregnancy. Ensuring easy access to through accredited GP surgeries and by the public health team in Wiltshire services in a large rural county with pharmacies. County Council, which helps to ensure limited public transport, the council There are 20 No Worries surgeries young people have a consistent involves a multidisciplinary team to across the county, which offer a full young experience regardless of the service provide young people with supportive people’s sexual health service. Some are they visit. and confidential services in a range of commissioned to provide an enhanced Wiltshire has also introduced a sexual convenient locations. School and practice service that links them directly to a health risk assessment protocol, with nurses play a key role. , where the practice training for frontline staff, to promote a To support health and wellbeing in nurse will support the school’s consistent approach to safeguarding and schools, the school nursing service relationships and sex education joining up between services. If a No delivers a core offer in all secondary programme and deliver sexual health Worries service or chlamydia screening schools of one hour a week – usually assemblies. This helps pupils get to know programme is concerned about a young in the form of a drop-in session for pupils. a member of staff from a service they person, they can easily make a referral to The type of service offered by the may need to access and encourages the relevant school nurse or the public school nurse is discussed and agreed them to seek early help before problems health young people’s nurse, who will with the individual school, with some escalate. undertake a sexual health risk assessment providing condoms and pregnancy Young people can access the No to find the most appropriate support testing. None offer emergency Worries service from any surgery, not just pathway. contraception on site but each school the practice at which they are registered. ● For more information contact: Tracy. is able to make a swift referral to the This is particularly important for some [email protected]

26 Nursing Times 20.11.13 / Vol 109 No 46 / www.nursingtimes.net For more articles on sexual health, Nursing go to nursingtimes.net/sexualhealth Times.net

Box 3. Case study: Post pregnancy contraception outreach nurse, London Borough of Hackney

Hackney was one of four sites in England agencies: the local termination provider; up-to-date information and dispelling that took part in the Department of and maternity services; myths, so young women are well Health’s teenage health demonstration looked-after children, social care and informed and confident in using the site programme to improve young youth services; young support method they choose. This is important people’s access to local health services, services; school nurses; health visitors; for all methods, particularly the including a focus on reducing repeat and community sexual health services. , as requests for unplanned conceptions to under-18s. Young women referred under the removals are much less likely if women In Hackney, a new post of an assertive scheme are offered an appointment at a are well informed about its temporary outreach sexual health nurse was time and location convenient to them, side-effects. developed to support pregnant teenagers which can be in their home, school or The method of choice is provided in and young women who had given birth or college, local children’s centre, health one of the young people-friendly had a termination to choose a centre or even a local cafe. CHYPS Plus service hubs located across contraceptive method they felt happy The outreach nurse establishes a the borough. Since the appointment of with and confident to use after the trusted relationship with the young the assertive outreach nurse, the number pregnancy. women, talks through all methods of of repeat terminations in under-19s in To initiate early contact with the young contraception and helps them develop a Hackney has more than halved. women the outreach nurse established contraceptive plan. Much of the ● For more information contact: Charity. referral pathways with a range of partner discussion focuses on providing accurate, [email protected]

Evans DT (2013) Promoting sexual health and » Sexual health outreach nurses contraception and the sexual health of wellbeing: the role of the nurse. Nursing Standard; providing targeted support for at-risk young people and how nurses in various 28: 10, 51-58. young people; fields of practice can support young people. Department of Health (2001) National Strategy for Sexual Health and HIV. London: Department of » School nurses working as part of Health. multi-agency school and college-based | Department of Health (2012) Getting it Right for || || | || | clinics (Box 2); | | 34% Children, Young People and Families. Maximising | |

| Amount the under-18

| the Contribution of the School Nursing Team: QUICK |

Postnatal and post-termination | » |

| conception rate fell

| Vision and Call to Action. London: DH. tinyurl. |

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| between 1998 and 2011 contraception nurses helping young | | | | | com/DH-SchoolNurse women prevent repeat pregnancies Department of Health (2013a) Public Health (Box 3); Outcomes Framework 2013-16. London: DH. tinyurl.com/DH-PublicHealth-2013-16 » Practice nurses offering drop-in Department of Health (2013b) A Framework services in primary care and The aim has been to raise awareness of for Sexual Health Improvement in England. contributing to SRE programmes. some of the key issues involved in sexual London: DH. tinyurl.com/DH-SexualHealth- However, even without formal courses health for young people and to point you Framework Evans DT (2005) Clever dicks do it in a condom. in aspects of contraception and sexual to further resources if you wish to con- Practice Nurse; 14 October 2005: 27-34. health, nurses can still make a valuable tinue your personal and professional Fatherhood Institute (2013) Fatherhood Institute contribution. Table 1 outlines a few key development. The article is based on a Research Summary: Young Fathers. Savernake: Fatherhood Institute. tinyurl.com/FI-YoungFathers areas to consider. study day developed for health and non- Ipsos Mori (2013) Perceptions are not reality: a As part of the school nurse develop- health professionals working with young poll conducted with the Royal Statistical Society ment programme (DH, 2012), the Depart- people and delivered in local areas by and King’s College London. tinyurl.com/ IpsosMori-Perceptions NT ment of Health England is planning to Alison Hadley and David Evans. Kirby D (2007) Emerging Answers 2007: publish a Sexual Health Professional Research Findings on Programs to Reduce Teen Pathway to help school nursing teams, col- ● For more information, contact Alison. Pregnancy and Sexually Transmitted Diseases. lege and sexual health nurses provide [email protected]. Washington DC: National Campaign to Prevent Teen and Unplanned Pregnancy. tinyurl.com/ high-quality teenage pregnancy preven- NationalCampaign-Emerging tion and sexual health promotion for Office for National Statistics (2013) Conceptions References in England and Wales 2011. London: Office for young people. The DH will also produce a Brook (2012) Sexual Behaviours Traffic Light Tool. National Statistics. tinyurl.com/ONS- A Guide to Identifying Sexual Behaviours. Brook: new practice nursing model that will Conceptions2011 London. www.brook.org.uk/index.php/traffic- include suggestions on how practice Public Health England (2013) Sexually Transmitted lights Infections Annual Data. London: PHE. tinyurl.com/ nurses can support young people in Brook and fpa (2013) Unprotected Nation: the PHE-STI2012 looking after their sexual health. In spring Financial and Economic Impacts of Restricted Royal College of Nursing (2012) The Nursing Care Contraception and Sexual Health Services. 2014, the DH will publish a compendium of Lesbian, Gay and Bisexual Clients – Guidance London, Brook and fpa. tinyurl.com/Book- for Nursing Staff. London: Royal College of of school nurse good practice examples in unprotected Nursing. tinyurl.com/RCN-LGBT-guidance order to help share effective local work, Burrows G (2011) Lesbian, gay, bisexual and Santelli J et al (2007) Explaining recent declines transgender health: part 1 – ; including examples of male school nurses. in adolescent pregnancy in the United States: the Practice Nurse; 41: 3, 23-25. contribution of abstinence and improved Crawford C et al (2013) Teenage Pregnancy in contraceptive use. American Journal of Public Conclusion England. Centre for Analysis of Youth Transitions Health; 97; 1, 150-156. Impact Study 6. Sheffield, Institute for Fiscal This discussion article has taken a broad Social Exclusion Unit (1999) Teenage Pregnancy Studies. tinyurl.com/SIFS-pregnancy approach to preventing teenage pregnancy, Report. London: Social Exclusion Unit.

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