Priority Area Overview – Sexual Health This report has been prepared to support the Review of Health Improvement Programmes. A series of priority areas have been identified for the review derived from policy and strategy documents . The Review has a number of identified outputs, one of which is a high level summary of each priority area which highlights, based on current evidence of effectiveness, which interventions have the greatest potential to improve health in each priority area. Methodology The Review is being conducted within a limited timeframe, as a result an extensive review of the literature across all of the priority areas and initiatives is not feasible. The review team has adopted the following approach: Evidence from systematic reviews or reviews of reviews Guidelines derived from an assessment of the available evidence Reviews from sources which have a clearly defined methodology and quality assurance process that is nationally or internationally recognised. The Library and knowledge management service of Public Health Wales has undertaken an initial search of the following sources using agreed search terms: NICE Guidelines Cochrane Database of Systematic Reviews (Cochrane Reviews Only) Campbell Collaboration Reviews EPPI Centre Reviews The Community Recommendations Where limited material was identified, or specific information gaps, or where the reviews or recommendations are more than 5 years old, a further search has been undertaken of DARE and Health Evidence Canada for reviews conducted within the last five years, which are rated as moderate to good quality. Reviews have been screened for inclusion based on agreed criteria e.g. health promotion interventions, interventions which involve clinical
Priority Area Sexual Health Sub Division Teenage pregnancy Study Details Outcome measures Main findings Results Current Wales Evidence Grading NICE, 2007 STI/teenage conception prevention (one to one interventions) National Institute for Health and Clinical Excellence. Individual behavioural counselling Children and young adults Reduce transmission of HIV and STIs; reduce prevalence of undiagnosed HIV and STIs; reduce stigma associated with HIV and other STIs. Reduce unintended pregnancy Summary of the recommendations (refer to full guidance for detail): PCT commissioners should: • Ensure that sexual health services, including contraceptive and abortion services, are in place to meet local needs. All services should include arrangements for the notification, testing, treatment and follow-up of partners of people who have an STI (partner notification). • Ensure staff are trained. • Ensure is an audit and monitoring framework in place. GPs, nurses and other clinicians working in a variety of healthcare and settings should: Where appropriate, provide one to one sexual health The recommendations in this guidance are on three reviews of effectiveness and their evidence statements – refer to the Full guideline and NICE website for details. Elements of the intervention are funded for national but monitoring information is not available to confirm widespread or information suggests is A. This intervention is supported by good evidence of its effectiveness and is for use in the UK trial
social exclusion EPPI. Childhood and youth development programmes (policy initiatives) Children and adults repeat pregnancy rates. unintended teenage pregnancy rates. Happiness, enjoyment of school and ambition can all help to delay early parenthood. The available research evidence also points both to day care and to education and career development programmes as promising ways of supporting young parents. Holistic support programmes appear to be appropriate but have not yet been shown to be effective. However, studies of young people's views suggest many important research gaps. These include the development and evaluation of policies to promote young people's involvement in schooling, further education and training, and to support families experiencing problems linked with social disadvantage and poverty. in the USA. Six of the intervention studies provided sound evidence of the value of two particular approaches to targeting the social exclusion associated with unintended teenage pregnancy: early childhood interventions consisting of preschool education, parenting support, and social skills development; and youth development programmes combining community service and student learning, or providing a programme of academic and social development. The overall pooled effect size showed that teenage pregnancy rates were 39% lower among individuals receiving an intervention than in those receiving standard practice or no intervention (Relative Risk = 0.61, 95% CI 0.48, 0.77). Three main themes associated with early parenthood emerged from the national but monitoring information is not available to confirm widespread or information suggests is to good quality evidence of its effectiveness
• greater parental involvement in secondary school to encourage young people's ambition • work experience opportunities, volunteering, and out of school activities to foster success and ambition • support for children and young people experiencing family breakdown and conflict • Parent training in conflict resolution Policy-makers should also continue to implement wider measures to tackle social disadvantage and poverty among young people as a route to lowering teenage pregnancy rates. HDA, 2007 Teenage pregnancy Health Development Agency. Education/youth development Reduce the rate of teenage pregnancies See section on "What Research findings and implications for practice". Some aspects of people’s behaviour can be successfully addressed through risk-reduction interventions. Patterns of behaviour that from Recommendations: The provision of sex education should be linked to access to contraceptive services. Interventions on sex education should aim to empower people, promoting sexual This intervention is implemented locally in some areas but does not have a consistent national C. There is some evidence supporting the use of this intervention but it is not conclusive
programmes. Contraceptive services. Children and young adults wider ‘structural’ forces, such as socioeconomic disadvantage and social exclusion, may be more difficult to address in a service setting, although these factors are likely to be key in effecting long-term change. However, interventions to improve the quality and responsiveness of services with the aim of preventing adverse outcomes demonstrate effectiveness. General strategies are likely to have a longer term influence on conception rates, but teenage pregnancy and parenthood is a highly complex area and recent evidence indicates that programmes to address it need to be addressing the individual, social and economic factors involved. and a positive and open view of sex and sexuality. Sustained programmes should: • when focusing on a single aspect of sex education, such as information about contraception, provide links to relevant support services (e.g. family planning services); • be clearly thought through, based on theory, evidence of effectiveness and local needs assessment; • improve mainstream provision, as well as identify and target local vulnerable groups, such as school or teenagers in low-income families; • know and use the local context to inform work; • include active learning techniques, such as groupwork, discussion and role play; programme or a co-ordinated approach OR is nationally on an ad-hoc basis
Systematic Reviews. Multiple interventions (educational, self-help, contraceptive distribution) Children and young adults attitudes about the risk of unintended pregnancies; initiation of sexual intercourse; use of birth control methods; abortion; morbidity & mortality related to pregnancy, abortion or childbirth; Sexually transmitted infections (including HIV) interventions preclude a definitive conclusion regarding which type of intervention is most effective. Overall the evidence remains inconclusive and could not be the basis for recommending the use or discontinuation of any of these interventions where they are already in use. outcomes (initiation of sexual intercourse, use of birth control methods, abortion, childbirth, sexually transmitted diseases) is not conclusive. The variability in populations, interventions and outcome of included trials and the paucity of studies directly comparing different interventions preclude a definitive conclusion regarding which type of intervention s most effective. dependent on local components which are variable Lopez LM et al, 2012. Contraceptive Education after childbirth Cochrane Database of Unplanned pregnancies; choice or use of contraception The overall quality of evidence was moderate. Half of these postpartum interventions led to fewer repeat pregnancies or births or more contraceptive use. However, the evidence of intervention effectiveness was of low to moderate quality. Trials with evidence of Six trials provided multifaceted programs with many contacts. Three showed evidence of effectiveness. Of those, two USA studies focused on adolescents: Adolescents in a program were less likely to have a second birth U status is unknown D. The evidence is inconsistent and it is not possible to draw a conclusion but there is
Teen sexual activity & pregnancy Campbell Collaboration. educational School (ever-having had intercourse), Pregnancy risk (not using effective method of contraception) and pregnancy programs evaluated rigorously to date will alter in intended ways the sexual activity or pregnancy risks of youth. However, this overall pooling of studies mixes results of different program types serving different populations of adolescents. (see under Results) studies that reported on a total of 38 randomized trials of interventions aimed at reducing teen sexual activity and pregnancy. When looking more specifically by intervention type, the following results were found: • Too little evidence to make specific judgments consultations. • Limited evidence regarding sex education programs with an abstinence focus. Studies evaluated rigorously showed pooled statistically significant effect favouring the control group on pregnancy rates. However, none of the rigorously evaluated programs is representative of abstinence-only programs that have grown in popularity over the course of the past decade, and thus these results cannot be used to generalize to the broader set of abstinence focused interventions currently in operation. status is unknown inconsistent and it is not possible to draw a conclusion but there is some evidence of effect
multi-component youth development programs serving higher risk adolescents. Moreover, within this category, the results tend to be most favorable for females. However, there is a paucity of rigorous evaluations of such programs, and further replication and evaluation is warranted. Swann C et al 2003 Teenage pregnancy and parenthood HDA Children & young adults Teenage pregnancy rate & outcomes of teenage pregnancy There was some consensus about what works to reduce teenage pregnancy rates. Good evidence was found for the effectiveness of the following: School-based sex education, particularly linked to contraceptive services Community based education development & contraceptive services Youth development programmes: although the evidence base for this was small, reviews indicate that programmes focusing on personal development, education & vocational development may increase 21 reviews undertaken primarily in the US and UK. See full report for detailed discussion of evidence. U status is unknown C. There is some evidence supporting the use of this intervention but it is not conclusive
programmes including abstinence messages only seem to be effective if messages about contraceptive services and other practical issues are included. Trivedi D et al. 2007 Teenage pregnancy and parenthood (update of Swann et al. 2003) HDA Children & young adults Teenage pregnancy rate & outcomes of teenage pregnancy In this update (of et al 2003) little new evidence found, and most findings overlapped with the first briefing. However, one recent review evaluated research relating to policy initiatives to tackle social exclusion associated with unintended teenage pregnancy and parenthood. This review contributes a new focus within the context of social disadvantage and exclusion (Harden et al 2006) see 6. above Five (category 1 and 2) reviews evaluated the effect of interventions such as school-based programmes, access for youth services, counselling and skills-based education, and programmes among those who are socially disadvantaged on teenage pregnancy, sexual risk behaviour, access to services, and contraceptive use and knowledge. Elements of the intervention are funded for national but is dependent on local components which are variable C. There is some evidence supporting the use of this intervention but it is not conclusive NICE, 2007 STI/teenage conception prevention (one to one interventions) Reduce transmission of HIV and STIs; reduce prevalence of undiagnosed HIV and STIs; reduce stigma associated with Summary of the recommendations (refer to full guidance for detail): STIs The recommendations in this guidance are based on three reviews of effectiveness and their evidence statements – refer to the Full guideline and NICE website for details. status is unknown A. This intervention is supported by good evidence of its effectiveness and is recommended for use in the UK
structured on the basis of behaviour change theories. They should address factors that can help reduce and improve and motivation. Ideally, each session should last at least 15–20 minutes. The number of sessions will depend on individual need. • For details of a of behaviour change theories see ‘Predicting health behaviour’ (Conner and Norman 2005). Health professionals and Specialists with responsibility for helping to contact, test and treat partners of patients with an STI (partner notification) should take action to: • Help patients with an STI to get their partners tested and treated (partner notification), when necessary. This support should be tailored to meet the patient’s individual needs.
notification (including referral pathways). • Ensure are trained. • Ensure there is an audit and monitoring framework in place. GPs, nurses and other clinicians working in a variety of healthcare and settings and midwives and health visitors who provide antenatal, postnatal and child development services should: Where appropriate, provide one to one sexual health advice to vulnerable young people under 18 on: − how to prevent and/or get tested for STIs • Provide supporting information on the above in an appropriate format • Discuss with vulnerable aged under 18 who are pregnant or who are already mothers and their partners
(where appropriate) how to prevent or get tested for STIs. • Provide supporting information in an appropriate format. NICE, 2011 HIV testing - MSM National Institute for Health and Clinical Excellence. Education: campaigns, promotional materials, counselling. Adults Children & adults Reduction (prevention) of HIV transmission. Seven recommendations are made in this guideline. Six relate to strategy and service provision; one recommendation relates to health improvement: Promoting HIV testing among men who have sex with men (MSM) Ensure interventions to increase the uptake of HIV testing are hosted by, or advertised at, venues that encourage or facilitate sex between men (such as some saunas or websites). This is in addition to general, community-based HIV health promotion (for example, at GP surgeries and in other locations such as bars). The guidance is based on a series of evidence reviews and evidence statements – refer to the Full guideline and NICE website for details. Elements of the intervention are funded for national but is dependent on components which are variable A. This intervention is supported by good evidence of its effectiveness and is for use in the UK
Systematic Reviews. Behavioral or social interventions designed to promote sexual risk reduction either delivered to individuals, small groups, or communities. Adults or communities. Therefore the inclusion of studies where assignment of groups or communities was by convenience did not exaggerate the summary effect. The greater effectiveness of interventions including more than 25% identifying MSM suggests that when they can be reached, these men may be more responsive than men to risk reduction efforts. Non-gay identified MSM may have had less exposure to previous prevention messages, so their initial exposure may have a greater impact. The greater effectiveness of interventions that include efforts to promote personal skills such as keeping condoms available and behavioral indicates that such content merits strong consideration in development and delivery of new interventions for MSM. measured against minimal to no HIV prevention intervention reduced occasions of or partners for unprotected anal sex by 27% (95% confidence interval [CI] = 15% to 37%). The other 18 interventions reduced unprotected anal sex by 17% beyond changes observed in standard or other interventions (CI = 5% to 27%).Intervention effects were statistically homogeneous, and no independent variable was statistically significantly associated with intervention effects at alpha=.05. However, a multivariable model selected by backward stepwise elimination identified four study characteristics associated with reduction in occasions of or partners for unprotected anal sex among small group and interventions at alpha=.10. The most favorable reductions in episodes of or partners for unprotected anal sex (33% to
interpreting the effectiveness of these interventions. Ojo O et al, 2011. HIV risk reduction – setting) Cochrane Database of Systematic Reviews. Voluntary counselling and testing; education. Working age adults Incidence of HIV and STIs, uptake of VCT, indicators of high risk sexual behavior. Workplace interventions to prevent HIV are feasible. There is moderate quality evidence that VCT offered at the work site increases the uptake of testing. Even though this did no lower HIV-incidence, there was a decrease in self-reported sexual transmitted diseases and a decrease in risky sexual behaviour. There is low quality evidence that educational interventions decrease sexually transmitted diseases, unprotected sex and sex with commercial sex workers but not sex with multiple partners and the use of alcohol before sex. More and better randomised trials are needed directed at high risk groups such as truck drivers or workers in areas with a very high HIV prevalence. Risky sexual behaviour should be measured in a standardised way. 8 RCTs found with 11,164 participants but one study did not provide enough data. Studies compared Voluntary Counselling and Testing (VCT) to no VCT and education to no intervention and to alternative education.VCT uptake increased to 51% when provided at the workplace compared to a voucher for VCT (RR=14.0 (95% CI 11.8 to16.7)). After VCT, STI decreased (RR = 0.10 (95% CI 0.01 to 0.73)) but HIV incidence (RR=1.4 (95% CI 0.7 to 2.7)) and unprotected sex (RR=0.71 (0.48 to 1.06)) did not decrease significantly. Education reduced STDs (RR = 0.68 (95%CI 0.48 to 0.96)), unprotected sex (Standardised Mean Difference (SMD)= -0.17 (95% CI -0.29 to -0.05), sex with a commercial sex worker (RR = 0.88 (95% CI 0.81 to 0.96) but not multiple sexual is not currently taking place D. The evidence is inconsistent and it is not possible to draw a conclusion but there is some evidence of effect reported
partners (Mean Difference (MD) = -0.22 (95% CI -0.52 to 0.08) nor use of alcohol before sex (MD = -0.01 (95% CI of -0.11 to 0.08). Ota E et al, 2011. HIV risk reduction – sex workers/ clients Cochrane Database of Systematic Reviews. Behavioural or social interventions designed to promote sexual risk reduction delivered to individuals, groups or communities. HIV/STI incidence/ prevalence. There is limited evidence from randomised controlled trials for the effectiveness of behavioural interventions to reduce the transmission of HIV infection among sex workers and their clients in high-income countries. Further randomised controlled trials are very likely to have important impacts on our confidence in the estimates of the effects, and are likely to change the estimates for effective interventions with outcomes of HIV incidence or prevalence and a variety of different settings among sex workers and their clients in high-income countries. Randomised controlled trials that test for the identification of effective interventions for HIV prevention with outcomes of biological endpoints, such as HIV incidence or prevalence, are needed for these neglected populations. More research is A of four studies were included, comprising two randomised controlled trials and two quasi-experimental pretest-posttest trials with control groups involving 1795 participants. No trials reported HIV prevalence/incidence as outcomes. Overall, the effects of behavioural interventions for sex workers in countries on STI incidence did not differ significantly among two studies using a random effects model (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.11 to 1.98). Only one study found that the STI prevalence in clients of female sex workers was statistically significant (RR 0.09, 95%CI 0.01 to 0.72, P=0.02). There was no significant difference after behavioural intervention for U status is unknown F. The evidence is inconsistent and it is not possible to draw a conclusion but it tends towards no effect reported
Working age adults also needed for male or transgender sex workers and their clients in high income countries. condom use. Two studies demonstrated the effectiveness of intervention for knowledge of HIV transmission among sex workers (RR 1.82, 95%CI 1.55 to 2.14) and clients of sex workers (RR 1.93, 95%CI 1.46 to 2.55). Shepherd J et al, 2011. Sexual behaviour – cervical cancer Cochrane Database of Systematic Reviews. Information and access to free SH services. adults Sexual behaviour, incidence of STIs. Behavioural interventions for young women which aim to promote sexual behaviours protective of STI transmission can be effective, primarily at encouraging condom use. A of 5271 references were screened and of these 23 RCTs met the inclusion criteria. Most were conducted in the USA and in health-care clinics (e.g. family planning). The majority of interventions provided information about STIs and taught safer sex skills (e.g. communication), occasionally supplemented with provision of resources (e.g. free sexual health services). They were heterogeneous in duration, contact time, provider, behavioural aims and outcomes. A variety of STIs were addressed including HIV and chlamydia. None of the trials explicitly mentioned HPV or cervical cancer prevention. Statistically F. The evidence is and it is not possible to draw a conclusion but it tends towards no effect
key data, self-report bias, and analyses neglecting attrition and clustered randomization. Rees R et al, 2004. HIV health promotion - MSM EPPI. Multi-level Adults Sero-discordant or unknown status unprotected anal intercourse Principal recommendations from this review for policy and practice are: Reducing / unknown UAI: Policy makers should consider implementing counselling based upon techniques, or workshops using these techniques, in place of standard counselling for MSM at high risk of engaging in UAI with partners of unknown or sero-discordant HIV status, because it is likely to decrease the proportion of MSM reporting this activity. Any implementation of these interventions should be accompanied by consideration of addressing STIs in the intervention and sound evaluation of impact on sdUAI and STI incidence. Community peer delivered interventions : There is no evidence to support discontinuing community peer delivered interventions. Twenty-six studies met the inclusion criteria for in-depth review: 14 studies focused on the views of specified groups of vulnerable men with data collected in or after 1996; 12 outcome evaluations of interventions delivered in or after 1996 were found that used a comparison group design, six of which were conducted in the UK. Eight outcome evaluations and 10 views studies were judged to be of sufficient methodological quality to go forward into the reviews syntheses. Only four outcome evaluations provided data in a suitable form for statistical meta-analysis. One of two studies, one conducted in the UK, the other in the USA, found that counselling or workshops based on techniques for MSM who are at high risk is not currently taking place D. The evidence is inconsistent and it is not possible to draw a conclusion but there is some evidence of effect