Sexual health is "a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity” (World Health Organisation (WHO), 2006: Defining sexual health).
Under 18 year old conceptions, chlamydia diagnoses (in 15-24 year olds) and people presenting with late stage Human Immunodeficiency Virus (HIV) are used as measures for the improvement in sexual health in the Public Health Outcomes Framework (2012).
Those at risk of under 18 year old conception are mostly vulnerable and socially excluded young people. Nearly half of teenage conceptions and one fifth of all conceptions end up in abortion. This means we can still do more to prevent unwanted conceptions.
Sexually active individuals are at risk of acquiring a range of Sexually Transmitted Infections (STIs), such as Chlamydia. The populations at the greatest risk of HIV, in the UK, are men who have sex with men (MSM) and the Black African population. 13% of people estimated to be living with HIV are unaware of their infection.
The local picture
The teenage conception rate in Calderdale is the lowest it has been since records began, as it is in England. During 2014, there were 92 conceptions in 15-17 year olds in Calderdale, a reduction to 24.5 per 1,000 females in 2014, and from 28.8 per 1,000 females in 2013 (Public Health England (PHE) Public Health Outcomes Framework (PHOF) 2.04: Under 18 conceptions). The Calderdale rate is similar to the regional and national averages.. It is also similar to the Chartered Institute of Public Finance and Accountancy (CIPFA) family group average (based on areas similar to Calderdale or Calderdale's nearest neighbours in terms of socio-economic indicators).
A number of wards are significantly above the Calderdale average for teenage conceptions (2012-14). These wards are: Ovenden, Illingworth and Mixenden, and Elland, see Figure 1.
Figure 1: Under 18 conceptions by ward 2012-2014
Abortion rates for all women (aged 15-44 years) in Calderdale have overall reduced in the last few years. In Calderdale in 2015, 15.4 per 1,000 of all conceptions still ended in abortion, as did 47.8% of all teenage conceptions. The abortion rate for all women in Calderdale is statistically similar to the England abortion rate of 16.7%, but above the Regional rate of 14.4%. The number of repeat abortions in women under 25 in Calderdale has reduced over the past four years and is not significantly different from the regional and England rate (Office for National Statistics (ONS) Conception statistics for England and Wales 2015 and Public Health England (PHE) Sexual health profiles - abortion).
Data is not routinely collected on Refugees and asylum seekers. However, the recent Health needs assessment: refugees and asylum seekers (Corner, 2016) indicates poor uptake of Family Planning:
In Calderdale, in 2015, the rate of chlamydia diagnoses was 3,023 per 100,000 young people aged 15-24 years, with the diagnosis rate increasing year-on-year from 2012 to 2014, but then falling in 2015 (PHE PHOF 3.02: Chlamydia detection rate (15-24 year olds) (Male)). This detection rate is above the regional and England detection rate. PHE recommend a detection rate of at least 2,300 per 100,000 15-24 year old resident population, to detect and treat sufficient asymptomatic infections to effect a decrease in incidence. The proportion of 15-24 year olds screened for Chlamydia in Calderdale is 20.5%, compared to 21.2% within the region and 22.5% in England. The Chlamydia screening figures indicate that screening coverage needs to increase to the recommended 25% of the 15-24 year old population and detection rates assessed accordingly.
The overall STI rate (excluding Chlamydia for people aged under 25 years old) in Calderdale in 2015 was 730 per 100,000. The rate was 758 per 100,000 in 2012 rising to 851 per 100,000 in 2014, then in 2015 the rate reduced. This trend mirrors the STI rates across the region and in England, where STIs increased from 2012 until 2014 and then reduced. It is important to note that Sexual Health Service provision, in Calderdale, fully integrated in 2012, which means all people attending for contraception are now screened appropriately for STIs, without the need for onward referral. This may have impacted on the STI rates, with high rates being, at least in part, reflective of high rates of testing following the integration. Rates of Gonorrhoea diagnoses in Calderdale have increased consistently between 2009 and 2014, in line with the national trend, but fell sharply in 2015 whereas regionally and nationally, in 2015, rates of Gonorrhoea diagnoses continued to increase (Sexual and reproductive health profiles - Gonorrhoea diagnostic rate).
Figure 2: Rates of new STIs and deprivation by Lower Super Output Area (LSOA) in Calderdale (Integrated Sexual Health Service (ISHS) diagnoses only): 2014
Rates of Syphilis have remained small and stayed the same between 2014 and 2015. Rates of genital warts have decreased between 2011 and 2015 overall. Rates of herpes has increased, which is not in keeping with national trends.
Of all those diagnosed with a new STI in Calderdale (2015), 47% were men and 53% were women. Of those diagnoses with a new STI, 60% of those are aged between 15 and 24 years old. This may be as a result of a targeted Chlamydia screening programme at this age group. Where sexual orientation was known, 10.9% of new STIs were among men who have sex with men.
Reinfection with an STI is a marker of persistent risky behaviour. In Calderdale (2015) an estimated 9.6% of women and 8.1% of men presenting with a new STI at a specialist Sexual Health Clinic between 2011 to 2015, became re-infected with a new STI within 12 months. Nationally during the same period of time, an estimated 7.1% of women and 9.3% of men presenting with a new STI became re-infected within 12 months (PHE, 2015). Re-infection rates are higher in 15-19 year olds.
Figure 2 illustrates the distribution of STI diagnoses and deprivation in Calderdale. Generally where there are higher rates of newly diagnosed STIs, these sit within LSOAs which are the most deprived areas within Calderdale.
HIV prevalence in Calderdale is low at 1.03 per 1,000 of the population compared to England’s rate of 2.26 per 1,000 (PHE Sexual and reproductive health profiles - HIV diagnosed prevalence rate 2015). 7.7 % of the middle super output areas (MSOAs) in Calderdale had a prevalence rate higher than 2.00 per 1,000 of 15-59 year olds. No ward has a particularly high prevalence rate, as the rate is not above 2.00 per 1,000 of the population aged 15-59.
Among those known to have HIV, 66.7% are white, 23.3% Black African and 6.7% known as other and 3.3% stated as unknown ethnicity (HIV and AIDS reporting system (HARS)). With regards to exposure, the probable route of infection is 44.8% through sex between men, 41.1% through sex between men and women, 3.4% through injecting drug use, and 10.3% is stated as unknown route of infection (HARS).The prevalence of HIV in the asylum seeker population is difficult to obtain. However, there is a desire amongst the local asylum seeker population to be tested for HIV (Refugees and asylum seekers).
In 2015 there were 9 adults newly diagnosed with HIV in Calderdale. In Calderdale between 2013 and 15, 57.7% of people presenting with HIV were diagnosed at a late stage. People presenting with HIV at a late stage of infection in Calderdale has decreased overall, since this became a Public Health outcome indicator in 2012 (PHE Public Health Outcomes Framework (PHOF) HIV late diagnosis). However, Calderdale’s rate remain significantly higher compared to the Yorkshire and Humber rate of 48.2% and England’s rate at 40.3%. These figures must be interpreted with caution due to the relatively small numbers of HIV in Calderdale.
The consequence of late HIV diagnosis is increased short-term mortality, poor prognosis, increased risk of onward transmission and higher healthcare costs. HIV late diagnosis is used to evaluate the success of local HIV testing efforts.
HIV testing coverage (2015), which is the proportion of eligible new GUM attendees (or Integrated Sexual health Service [ISHS] attendees) who accept a HIV test is 70.9% in Calderdale. This compares well to the Regional (62%) and National figure (67.3%). The Calderdale HIV testing coverage is the highest it has been since 2009. Following the integration of the Genitourinary medicine (GUM) and Contraception and Sexual Health Service (CASH), the providers have worked hard to increase testing coverage.
Current provision
The Sexual Health Risk and Resilience Group bring sexual health stakeholders together, to agree priorities and address sexual health needs in Calderdale. The group are currently reviewing the Outcome Based Approach for sexual health.
Condom distribution takes place through sites identified by service users and stakeholders, including sports venues, barbers, bars and clubs, social media alerts, condoms by post, and at public sex environment (PSE) sites. Calderdale has a C Card scheme to distribute condoms to young people, which additionally provides information, advice and guidance to young people to enable them to have safe and respectful relationships. Children Looked after (CLA) have priority access to sexual health services. In addition all Children Looked After nurses are able to distribute condoms in environments that the young people have deemed appropriate.
School pupils have received a number of sexual health education interventions, as have children in care. More work is required to ensure there is a consistent good quality approach to sex and relationships education in schools, including the Pupil Referral Unit (PRU).
Access to Long Acting Reversible forms of Contraception (LARCS) in Calderdale has increased through recent years, as they are more reliable than oral methods, even at one year of use (2014). LARC prescribing figures in Calderdale in primary care and sexual health services compare very well against national and regional rates, but we need to ensure good access and information are available to young people and other vulnerable groups.
Access to Emergency Hormonal Contraception (EHC) has been extended to cover 120 hours after sexual intercourse, which includes provision and good coverage in community pharmacies. Commissioning EHC via community pharmacies has improved the geographical availability and provision into the evenings and weekends.
Teenage conception rates have reduced, since records began, as a result of these changes, as have abortion rates for all ages (since 2013). However, the local abortion picture illustrates there is still room for improvement.
The main Sexual Health Service have reviewed sexual health clinic provision, in line with the engagement and STI / teenage conception hotspot areas, the major towns and deprived wards. The ISHS is now open in the evenings and on a Saturday. 'Spoke' clinics will be developed in hotspot areas where there is currently no provision. Pop up clinics will begin to occur accordingly. The ISHS are currently developing a monthly clinic to provide contraception, sexual health advice and screening to Refugees and asylum seekers at the St Augustine’s centre. There is also a variety of screening options now available, where screening is available at other services / venues. These include Point of Care testing, and screening (which can be requested online) by post. Most (approximately 86%) residents of Calderdale attend the local sexual health service, rather than out of area, which suggest that local access and service quality provision is good.
The reduction in teenage conceptions, but increase in STIs could be as a result of poor condom use, which suggests we need to implement work on changing the behaviour of condom use in Calderdale. However, we must take into consideration the change in sexual health provision in Calderdale, where more people are being screened for STIs (which may have impacted on STI diagnoses rates of late) and the increase in LARC use, may have impacted on condom use. Utilising the recent Chlamydia screening figures, Calderdale need to increase testing coverage in line with the PHE recommendation of screening 25% of the population aged 15-24 year olds for Chlamydia and then review the detection rate accordingly.
HIV testing is now a blanket offer to all attendees of the sexual health service. Point of Care HIV Testing (PoCT) in community settings has been introduced by the HIV prevention and support provider, particularly focusing on priority groups, such as Refugees and asylum seekers at the St Augustine’s centre. Remunerating priority groups to take a HIV test, has increased testing coverage. The HIV prevention and support provider is a Local Activation Partner with HIV Prevention England (PHE), which means Calderdale can access National campaign materials targeted at our priority groups. HIV postal testing is currently being piloted and is due to be evaluated with a view to implementing this long-term. Although prevalence of HIV in Calderdale is below the national average (and therefore likely not to feature on the priority list of General Practitioners (GPs)), HIV action to target late diagnosis will continue to focus on priority areas, utilising the data in the Local Picture: figure 3.
A HIV late diagnosis will now be treated as a Serious Untoward Incident (SUI) and therefore in Calderdale this will warrant a thorough investigation and learning from this incident across the system, to ensure we can prevent this happening in future.
User views
A local patient and public engagement (PPE) exercise during 2013-14 identified that people in Calderdale want to receive better sexual health information from the internet, their own GP or nurse.
Most of those engaged in the consultation exercise wanted to receive sexual health services from the main sexual health service, their GP or pharmacist. There was a preference for weekend and evening access to these services and a desire not to have to travel for longer than 30 minutes to receive the service, and to be dealt with sensitivity and confidentiality.
The views of children and young people were identified through the electronic Health Needs Assessment (electronic Health Needs Assessment (eHNA) survey: key findings) school pupil survey in 2016. Around 1 in 3 pupils still want information about contraception, delaying sex or safer sex, which is not significantly different to previous surveys.
Unmet needs
Vulnerable young people do not access services and information in the same way as their peers (Sex Education Forum, 2010). Young people want access to information in school. Around half of teenage conceptions end in abortion indicating unplanned conceptions. Estimated STI re-infection rates at the ISHS, are higher for men, but lower for women compared against England re-infection estimates, which again supports the need to conduct behaviour change work, particularly with men. 13% of people living with HIV are not aware of their status (PHE, 2016) and remain at risk of passing it on.
The refugee and asylum seekers health needs assessment (Comer, 2016) identified the lack of data collected surrounding the needs of this group, which is required in order to begin to address their health needs. The ISHS in particular will ensure information is collected around sexual violence and female genital mutilation alongside demographics of all attendees.
There has been a steady increase in the number of unaccompanied asylum seeking children in Calderdale and these complex young people will need a culturally sensitive targeted approach to their sexual health need.
Projected future need
The population in Calderdale will increase (currently approximately 208,400 according to Mid year sub national population estimates 2015), with increases in both children and older people. It is anticipated that there will be a more diverse population with complex variation in the range of needs in different communities and ethnic groups. There will be a need to enhance geographic access to services as well as addressing deprivation and inequality and ensuring inclusiveness of services for ethnic groups, different age groups, all sexual orientations and abilities.
The use of the internet and dating apps, for all ages, has increased the opportunity for people to meet to take part in sexual activity. This may lead to an increase in STIs and unwanted pregnancy for all ages and highlights the need to maintain the focus on safeguarding (Safeguarding adults and Safeguarding children and young people ). Communications in sexual health must continue to adapt to developing digital communications.
Key considerations linked to the known evidence base (what works?)
The content and quality of sex and relationship education in schools must be addressed using a consistent partnership approach, by utilising the Public Health in Schools coordination role and ISHS contract with embedded preventative work. Access to information and support for young people should be extended, with information from parents, schools and other professionals.
The availability of local information around sexual health services and information, in particular digital communication should be improved. A targeted communications campaign should be conducted to change behaviour around condom use, particularly focusing on men.
The access and reach of services to potentially at-risk groups such as young offenders, children looked after, young people at PRU and NEETs (Not in education, employment or training), LGBT (Lesbian, Gay, Bi-sexual and Transgender) young people, and unaccompanied asylum seeking children should be extended. A targeted approach for teenage conception ‘hotspots’ and HIV higher prevalent areas must be continued. The promotion of community POCT testing should be continued, and an evaluation of the postal HIV test should be reviewed and implemented accordingly.
References and more information
References
- WHO (2006): Defining sexual health .
- Public Health England: Calderdale local authority HIV, sexual health and reproductive health epidemiology report (LASER)) 2015.
More information
For a number of Calderdale sexual health indicators, visit: Sexual and Reproductive Health Profiles (PHE).
A guide to local and national data on sexual health was published by PHE in December 2015.
For more on indicators of child health, visit:
For more on the health of refugees and asylum seekers, read: