The Programme Development Group (PDG) took account of a number of factors and issues when developing the recommendations.
Most of the evidence considered for the reviews of effectiveness is from the USA. The UK healthcare system differs from the US system in its organisation, use of resources and access. Furthermore, the ethnic composition of the UK population differs in a number of respects. There was little direct evidence about young people from socially disadvantaged groups. In addition, the PDG had to consider, on a case by case basis, whether it was reasonable to apply evidence derived from the USA (for example, on African Americans) to socially disadvantaged young people in the UK.
The PDG was clear that service providers should not be discriminating and judgmental, and should respect young people's choices and way of life. Attitudes that could be perceived as critical might deter young people, particularly socially disadvantaged young people, from attending services again. Services must be fully accessible for young people with disabilities and should prioritise individual needs.
The local pharmacy has a vital role in meeting the needs of diverse communities, particularly the needs of young people who may be anxious about approaching contraceptive services. Pharmacists, including those working for private retail chains, are part of a local primary care and wider health service network. The pharmacy section in a large supermarket may be the only service that is easily available and accessible within some rural areas. The PDG recognised that all health professionals and service providers have the right to refuse to provide or prescribe contraception, if doing so is contrary to their personal or religious beliefs. However, the PDG did not think it acceptable that provision of contraception, including emergency contraception, should depend on whoever happens to be on duty. If, for any reason, there is limited or variable provision in the local pharmacy, young people requiring urgent treatment, for example emergency contraception, may find it difficult to reach alternative services. This was a cause of concern.
The evidence shows that advance provision of oral emergency contraception does not encourage risky sexual behaviour among young people. Evidence also shows that women who have emergency contraception in advance are more likely to use it, and to use it sooner after unprotected sex. Having emergency contraception on hand does not affect the use of other kinds of contraception (Polis 2007).
The PDG felt that advance provision of free oral emergency contraception could fulfil an unmet need for some young people. It might also provide an early opportunity to discuss contraception and broader sexual health issues and needs.
The focus of the guidance is on the provision of effective contraceptive services, but not all methods of contraception are designed to protect against STIs. Young people may not always realise that the most appropriate contraceptive method for them may offer no protection against STIs. Only the condom is effective against STIs, including HIV.
The PDG recognised that sexual health is an important aspect of the physical and mental wellbeing of young people, and that contraceptive services should be delivered in the broader context of sexual, physical, emotional and mental health and wellbeing.
Self-referral to contraceptive services through GP services, young people's services, community contraceptive services and 'one stop shops' is valuable. Assumptions about where young people prefer to get their services must be avoided, and a range of 'young-people friendly' contraceptive services will continue to be required. Young people's needs for information and demands for services may differ according to their age, way of life and cultural background.
It is important that contraceptive services are available for all young people. A universal service does not imply that every young person has the same needs. Socially disadvantaged young people are likely to need more support than others. Some may need more personalised and tailored advice and support. The guidance applies to all young people but there is a greater focus on young people who could be considered to be socially disadvantaged, and those from areas with a higher concentration of socially disadvantaged young people.
The PDG acknowledged that the term 'socially disadvantaged young people' covers a range of people who may not be easily identified, that those considered to be socially disadvantaged might vary in different local areas, and that people may move in and out of social disadvantage at different points in their lives.
There are some socially disadvantaged groups who have very limited access to contraceptive services, for example asylum seekers or Gypsy and traveller communities.
Some socially disadvantaged young people may have multiple health and sexual health needs. They may also need or be receiving support from social, voluntary or children's services, which is often fragmented or inconsistent. Information and advice about contraception and sexual health may be provided by different teams and different provider organisations.
In the economic modelling undertaken for this topic, it was argued that the savings in government-funded benefits to young mothers having fewer teenage births was a real saving to the community. In most cases, transfers of money from taxpayers to recipients (known as 'transfer payments') are not counted as either costs or benefits from a societal perspective because they cancel out, and involve simply a redistribution of existing wealth. However, in the case of government-funded benefits to single mothers, the need for paying the benefits is removed if there is no baby. The funds that would have been used for this purpose can be used for something else. The PDG considered the argument that reductions in government-funded benefits were a saving of costs and concurred with it. The modelling considered cases in which increased use of contraception delays pregnancy until the woman reaches her 20s, and those in which it results in the absence of a pregnancy altogether.
Good quality contraceptive services for young people depend on doctors and nurses who not only are sensitive to their needs but properly trained. The PDG believes that all doctors and nurses need access to high quality pre- and post-registration contraception and sexual health training modules and courses and clinical placements without delay.
There are unseen barriers to contraceptive use for some socially disadvantaged young people. For example some hormonal methods may not be suitable for women on highly active antiretroviral therapy (HAART). In addition, some young women might be worried if their periods stop or become irregular as a result of some forms of contraception.
There was no evidence on the effectiveness of national media campaigns. It would be beneficial for any future national media campaigns to be planned with involvement of local organisations.
There is variation in practice across the country in terms of meeting the standards set out in 'You're welcome' (DH 2007). Some services will surpass the standards, whereas others will not yet have met them.
The high rates of unwanted and unintended pregnancy among women aged 19–24 years is a cause for concern. There was little evidence about their attitude towards contraception and their use of contraceptive services. Service providers have focused on targets and priorities related to the Teenage Pregnancy Strategy, yet the needs of those who are slightly older, particularly those who are socially disadvantaged, are not well understood and are not being met.
The PDG acknowledged that there are many myths surrounding contraception, for example, the idea that using 2 condoms is better than using 1, or that you cannot get pregnant the first time you have sex. Lack of knowledge and misinformation about pregnancy risk and contraception is likely to prevent young women from seeking advice and support when they most need it.