2 Public health need and practice

Sexually transmitted infections

Sexual health in the UK has deteriorated over the last 12 years, with large increases in many STIs. The diagnosis of chlamydia in GUM clinics has increased by over 300% (from 32,288 in 1995 to 104,155 in 2004), and gonorrhoea by over 200% (from 10,580 in 1995 to 22,335 in 2004) (HPA 2005). In addition, the incidence of HIV has increased more than threefold, from 2500 cases diagnosed in 1995 to just over 7000 in 2005 (HPA 2006a).

Overall, the number of STIs and other conditions diagnosed in GUM clinics in the UK increased by 3% between 2004–2005 (from 751,282 to 790,387) (HPA 2006b).

Some of this rise may be due to the greater availability and increased sensitivity of tests and to increased awareness of the services available. It may also reflect significant changes in people's knowledge, attitudes and patterns of sexual behaviour. The second 'National survey of sexual attitudes and lifestyles' (NATSAL 2000) provides the most recent data on sexual behaviour in Britain. Since 1990, first intercourse is taking place at a younger age, a greater proportion of people have multiple partners, and a greater proportion of men report having had a same sex partner (Johnson et al. 2001).

Risky sexual behaviour may be influenced by a number of factors:

  • low self-esteem

  • lack of skills (for example, in using condoms)

  • lack of negotiation skills (for example, to say 'no' to sex without condoms)

  • lack of knowledge about the risks of different sexual behaviours

  • availability of resources, such as condoms or sexual health services

  • peer pressure

  • attitudes (and prejudices) of society which may affect access to services.

    (Ellis et al. 2003)

Under 18 conceptions

England's under 18 and under 16 conception rates have fallen by 11.1% and 15.2% respectively since the introduction of the 'Teenage pregnancy strategy' in 1998. Rates are now at their lowest level for 20 years (TPU 2006). However, the UK still has the highest rate of teenage pregnancy in western Europe. In 2004, there were 39,545 under 18 conceptions in England and 41% ended in abortion. In the same year, there were 7179 under 16 conceptions and 57.6% ended in abortion.

Inequalities

Sexual health problems disproportionately affect those experiencing poverty and social exclusion. Individuals and groups who find it most difficult to access services include asylum seekers and refugees, sex workers and their clients, those who are homeless and young people in – or leaving – care. The highest burden is borne by men who have sex with men, some black and minority ethnic groups and young people.

For some young people, becoming a parent is a positive choice. However, teenage pregnancy is often associated with poor health and social outcomes for both the mother and child. Young mothers are more likely to suffer postnatal depression and less likely to complete their education. Children born to teenage parents are less likely to be breastfed, more likely to live in poverty and more likely to become teenage parents themselves (Botting et al. 1998).

The 'Teenage pregnancy strategy' has highlighted the following risk factors which increase the likelihood of teenage pregnancy.

  • Risky behaviours. These include:

    • early onset of sexual activity

    • poor contraceptive use

    • a mental health problem, a conduct disorder and/or
      involvement in crime

    • alcohol and substance misuse

    • already a teenage mother or had an abortion.

  • Education-related factors:

    • low education attainment or no qualifications

    • disengagement from school.

  • Family/background:

  • living in care

  • daughter of a teenage mother

  • daughter of a mother who has low educational aspirations for them

  • belonging to a particular ethnic group (in the 2001 census, 'mixed white', 'black Caribbean', 'other black' and 'white British' were over-represented among teenage mothers).

    (DfES 2006)

The risk of an STI or an unintended pregnancy is associated with:

  • high numbers of partners

  • high rate of partner change

  • unsafe sexual activity such as unprotected sex.

Sexual health targets

The government set out a number of sexual health targets in the public health white paper 'Choosing health' (DH 2004). These form part of a public service agreement (PSA) with the Department of Health (DH) and include:

  • a reduction in the under 18 conception rate by 50% by 2010, as part of a broader strategy to improve sexual health

  • all patients contacting GUM clinics to be offered an appointment within 48 hours by 2008

  • a decrease in the rate of new diagnoses of gonorrhoea

  • an increase in the percentage of people aged 15–24 accepting chlamydia screening by 2007.

Reducing the under 18 conception rate is a joint PSA for the DH and the Department for Education and Skills (DfES 2004). It is also a national PSA for local government.

Practice

Figure 1 provides a framework to use for sexual health services. It describes the context and desired outcomes. It also highlights the range of interventions (including those carried out on a one to one basis) which are designed to promote sexual health and deliver sexual health services.

One to one interventions are integral to the modernisation of sexual health services.

Figure 2 sets out the relationship and links between different one to one interventions for the prevention of STIs and under 18 conceptions. It places the recommendations (R1–6) in the context of current service provision. This provision is defined in the 'National strategy for sexual health and HIV' (DH 2001) and national guidance documents such as the 'Recommended standards for sexual health services' (MedFASH 2005).

The guidance is aimed at healthcare professionals working in the NHS who have a role in and/or responsibility for sexual health. It will also be relevant to non-NHS professionals and others with a responsibility for sexual health working in local authorities and the education, voluntary, community and private sectors.