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Preventing teenage pregnancy through home-based sexual healthcare: a qualitative study of practitioners’ experiences

Catriona Jones and her colleagues use practitioners’ perspectives to evaluate a sexual health service designed to prevent second unplanned teenage pregnancy.

Web conversation

Catriona Jones, RM, MSc, BSc (Hons), PGCE, Senior Research Fellow in Maternal and Reproductive Health Professor

Mark Hayter, PhD, RN, MMed. Sci, BA (Hons), Cert. Ed, FAAN, Professor of Sexual and Reproductive Health

Dr Jenny Owen, PhD, BA (Hons), PGCE, Honorary Senior Lecturer, University of Sheffield

Ritah Tweheyo, PhD, MPH, PGD. DS, BSc.Ed, Research Associate, Faculty of Health, University of Hull

Christina Harrison, RGN, MSc, Assistant Director for Children Young People & Families, Doncaster Community Integrated Services, Rotherham Doncaster and South Humber NHS Foundation Trust

Sally Coleman, Contraceptive and Sexual Health Nurse, Doncaster Community Integrated Services, Rotherham Doncaster and South Humber NHS Foundation Trust Coleman.

This article presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0711-25014). REC ref: 13/YH/009.The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

 

Key points

  • Be flexible in providing the service to meet the needs of as many clients and potential clients as possible
  • Have a willingness to communicate in the way that suits the clients. Speaking on the phone may be a more traditional means of making contact, but 
  • the client group may prefer to text
  • A successful service needs to be able to respond to a referral quickly
  • Healthcare professionals involved may be less interested in the outcomes in statistical terms and more focused on providing access to the client group
  • An effective service will require an element of awareness-raising among other healthcare professionals.

Abstract

Practitioners’ perspectives were used to evaluate a sexual health service designed to prevent second unplanned teenage pregnancy. The service is called Preventing Second Pregnancy (P2P).

According to the Family Planning Association (FPA), the UK has the highest teenage pregnancy rates in Western Europe (FPA, 2016). One fifth of births among under 18 year olds are repeat pregnancies (Teenage Pregnancy Independent Advisory Group (TPIAG), 2010; Aslam et al, 2015). The use of outreach contraception and sexual health services aimed at adolescents is one way in which easier access to support and advice on sex, relationships, contraception and sexually transmitted infections is facilitated (Hadley and Evans, 2013). The responsibility for the design and implementation of such programmes rests with local authorities, but little is known about what makes them a success or failure in preventing secondary pregnancies in teenagers (Hayter et al, 2016).

Qualitative evaluation was conducted using three focus groups with nurses, midwives and health visitors involved in the referral to, and delivery of, the P2P sexual health service. Analysis was guided by Ritchie and Spencer (1994). This paper presents four characteristics emerging from the analysis that were perceived by health professionals to be important for the effectiveness of P2P.

Key findings from previous research indicates that for some young mothers, outreach contraception and sexual health services have a role in the prevention of an unplanned second pregnancy (Hayter et al, 2016). Findings from this study indicate that aspects of the P2P service that practitioners felt contributed to its effectiveness were: flexibility and responsiveness, a commitment to breaking down barriers to accessing contraception, maintaining the initial impetus, and timely service provision.

Keywords: teenage pregnancy; contraception; health practitioners; sexual health; enablement


What is known already:

  • The UK has the highest teenage pregnancy rates in Western Europe (FPA, 2016). Approximately one fifth of births among under 18 year olds are repeat pregnancies (Aslam et al, 2015; TPIAG, 2010).
  • Research suggests that the use of outreach contraception and sexual health services aimed at adolescents is one way in which easier access to support and advice on sex, relationships, and contraception is facilitated (Hadley and Evans, 2013).
  • Previous research indicates that for some young mothers, outreach contraception and sexual health services have a role to play in the prevention of an unplanned second pregnancy (Hayter et al, 2016).

 

This paper adds:

  • According to the professionals who work within and around P2P, the features of effective an service include flexibility and responsiveness, a commitment to breaking down barriers, maintaining the initial impetus, and timely service provision.
  • Utilising young people’s preferred communication styles can facilitate greater engagement of young people; use of text messaging, call back and other ways are crucial.

Introduction

The UK has the highest rates of teenage pregnancy in Western Europe (FPA, 2016). The impact of pregnancy in adolescence on the health of mothers and their babies is well documented: teenage pregnancy is associated with higher neonatal morbidity and mortality, low birth weight babies, and a higher risk of some obstetric complications (Azevedo et al, 2015). In the UK, around three quarters of teenage pregnancies are unplanned and half end in abortion (Local Government Association (LGA), 2013). Providing effective support to young people in relation to sexual health and risk-taking, particularly in the face of increasing levels of inequality, is a priority action plan for the health service (Independent Advisory Group on Sexual Health and HIV, 2007).

Current estimates suggest that approximately one fifth of births among under 18 year olds are repeat pregnancies (Aslam et al, 2015; TPIAG, 2010). Repeat births come at a great cost to teenage mothers, their children and society. The problems associated with teenage motherhood are more severe for teenagers who are parenting more than one child (Rowlands, 2010). In addition to exacerbating the cycle of poverty and lack of an education, teenage mothers pass on risk to their babies (LGA, 2013). These children may be more likely to suffer from child abuse or placed in foster care (Rowlands, 2010). The risks of low birth weight, increased mortality rate and poor health outcome increase for babies born to teenagers who already have a child. As such, services designed to reduce second unplanned pregnancies are an important element in promoting teenage sexual health and the safeguarding of children (Viner et al, 2012).

Whilst the data on preventing repeat teenage conceptions is limited (Hayter et al, 2016), Hadley and Evans (2013) suggest that secondary prevention programmes are more likely to be successful if they include individualised counselling, home visits, a multidisciplinary youth-oriented approach, contraception teaching and easy access to services. The UK has seen major changes in sexual health services provision, including service integration and innovation. Local authorities (LAs) are being mandated to take the lead in reducing teenage pregnancies, having been given the ‘freedoms and flexibilities to do what fits to reduce teenage pregnancies in their area’ (DH, 2013: 38). Whilst the responsibility for the design and implementation of such programmes rests firmly with LAs, the features of successful initiatives aimed at preventing secondary unplanned pregnancies in teenagers remain relatively unknown. Primary research focusing on the delivery, uptake, and the effectiveness of these services is limited. Furthermore, the ways in which outreach nurse practitioners help teenagers develop responsible social and sexual relationships is under researched.

NICE guidance (2007) calls for more evidence of rigorous evaluation of the effectiveness of one-to-one interventions in outreach settings. Exploring the experiences of health professionals directly involved in P2P service delivery, and those who play a part in the referral processes, will provide evidence on features of an effective intervention especially designed to prevent unintended repeat pregnancies to inform the future of NHS sexual healthcare.

This study was conducted in the North of England, with a view to evaluate the effect of a home-based sexual health outreach service for young people.

The Preventing Second Pregnancy (P2P) service has been described elsewhere (Hayter et al, 2016) but, briefly, within the first few weeks after childbirth, new teenage mothers are informed about P2P by a visiting health professional, either a midwife, health visitor or family nurse partnership worker. If agreeable, a referral is made for a home visit from a P2P nurse. When the P2P nurse attends the home, information on contraception and safe sex are provided. Contraception can and, in most cases, is provided during the visit.

Although there are some emerging services in the NHS that have been modelled on the P2P approach, no guidelines for the delivery of this type of patient care exist, to the best of our knowledge. Drawing on the experience of outreach nurses and other health professionals will contribute significantly to the development of similar services in the NHS. It will also increase confidence in other workers undertaking P2P approaches.


Aims of the project

The overall aims were to explore the views and experiences of professional stakeholders who work with teenage mothers. It also sought to find out about young mothers' (16 to 19 years) experiences of P2P, an alternative sexual health service for teenage mums that includes nurse-led contraceptive home care, though these findings are not reported in this paper. The study was designed with the additional aim of informing guidelines for the development of services that provide contraceptive care for new teenage mothers.

Given the exploratory nature of this work, a qualitative design was selected to gain an in-depth understanding of the experiences of using, and referring into the service. Firstly, 40 young mothers (aged 16 to 19 years) who had given birth and used the service within the previous two years were recruited to the study by a P2P nurse, and interviewed in their own homes by an experienced researcher. Key findings indicated that for some young mothers, P2P was instrumental in preventing an unplanned second pregnancy. More details of the findings from the interviews with young mothers can be accessed in a separate paper (Hayter et al, 2016).


Method

The part of the study being reported in this paper utilised Focus Group Discussions (FGDs) because the strengths of this method include the promotion of discussion and exchange of views and experiences while illuminating complex issues (Barbour, 2014). Health professionals referring into or delivering the service were recruited through the clinical lead of the P2P service. Participants were informed about the research and provided with a participant information sheet. After a week, staff interested in taking part in the study were invited to attend one of three FGDs, which were conducted at the sexual health clinic, facilitated by a member of the research team. A semi-structured interview schedule, guided by the aims of the study, was used to inform the discussions.

 

Ethics

This study was reviewed and approved through NHS Ethics and research governance prior to project commencement. Informed written consent was obtained after all participants had read the study information sheet. Participants were assured of confidentiality and voluntary participation emphasised.

 

Data collection

Data were collected by three focus groups consisting of six, eight and nine participants respectively. A combination of P2P nurses, health visitors and midwives took part in each of the FDGs. Data were audio-recorded and transcribed, and analysed by the research team.

 

Data analysis

This study used the Framework Analysis approach developed by Ritchie and Spencer (1994), which is ideally suited to this study. This is because it allows for multiple researchers to work on a project while enabling clear track and comparison of large volumes of data by use of a systematic matrix of case and codes (Gale et al, 2013).

Transcripts were read and reread by three researchers separately, to identify significant comments and emergent themes. The resulting matrix was then discussed and refined with the research team with a focus on drawing out the elements of the service, which could be associated with effectiveness.


Findings

Analysis identified four characteristics perceived by key health professionals to be important for effectiveness.

 

A flexible and responsive service

The flexibility within the roles and responsibilities of P2P nurses is crucial to effective delivery and uptake. Staff used other services as a platform to achieve the service aim and clients were able to access contraception and sexual health advice whilst visiting friends who were being visited by a P2P nurse:

Used to be the baby weighing clinic, didn’t it? Everybody comes to get their baby weighed. We’d go for two hours and if anybody wanted to come and get their Depo injection or start on something or they were having problems we were there as well. (FG 2: P2P Nurse 3)

I can sometimes manage to get more than one person covered for contraception in one visit, if they are in the same house and they ask for it, and I’ve got the right contraception with me. (FG 3: P2P Nurse 3)

Respondents highlighted a desire to help those disadvantaged by present services. In many cases, they felt a sense of responsibility to all women in need of sexual health services, despite changes to the workforce.

I think it needs to change. I think it needs to be evaluated and go more towards the vulnerable mums regardless of age. That’s what I believe. (FG 1: Midwife 1)

I think you’re right there because I can see a lady out at [name of place] who’s quite capable of going to her GP, she’s not vulnerable, but she wants the service. And that’s fine and that’s been fine but there’s only going to be me and [name of nurse] soon. (Laughs) (FG 1: P2P Nurse 2)

 

A commitment to breaking down barriers

It was discussed that contraception and sexual health remain sensitive topics for many women. Practitioners explain how this creates barriers to seeking contraception especially for young people, but the existence of P2P helped to break down these perceived obstacles;

I think for a lot of them, the P2P nurse comes in … we know that they’re having sex because they’ve had a baby, they don’t have to tell anybody ‘I’m going to have sex again’, because we’ve sorted it for them. Whereas it’s quite hard, isn’t it, to ring the GP and then you’ve got the receptionist saying, ‘Oh, what do you need to see the doctor for?’ (FG2: P2P Nurse 1)

Many P2P nurses tried to contact their referrals by telephone. However, it emerged from the discussions that barriers often existed if young mothers were unsure of who was trying to make contact - there was often a reluctance on the part of the women to answer to an unknown number. P2P nurses generally agreed that they employed strategies to reduce communication barriers and improve engagement with the referrals;

The problem sometimes is, they’ve been referred and we can’t get hold of them… they’re not picking the phone up. (FG1: P2P Nurse 3)

Lots of girls like to text, they do like to text… Because they’ll see your number on the phone, they don’t recognise it, so they don’t pick it up. But then if you text them and say who you are… they’re quite happy to text. (FG1: P2P Nurse 1)

 

Maintaining the initial impetus

Getting the word out to others, particularly to other professionals and service users, is seen as key to the success of P2P. In addition, respondents stressed the importance of maintaining the initial impetus of ‘getting the word out’, and ensuring that there was a sustained commitment to maintaining awareness;

It [P2P] was quite well-documented, and sort of everybody was aware of it. I think it’s fallen off a little bit, that information-sharing, that information-giving. (FG1: Health Visitor)

…they used to get the packs that had got the information in, some condoms, information about contraception as well as the P2P service. But then it became an issue about funding, so then obviously that was then withdrawn. (FG1: Midwife)

We used to have really good leaflets… things with your names on and numbers… I know it’s a cost thing, but now people are photocopying those, it’s not very professional-looking, is it? They’ll just throw it away. (FG1: P2P Nurse)

Keeping others informed through updating was recognised as key to an effective P2P service;

It might be an idea to restart the 6 month updates to midwives and HV to keep them up to speed with any changes. (FG 3: P2P Nurse)

Attempts by P2P staff to keep midwifery and health visiting services aware were affected by changes to the service, including increased workloads and reorganisations, which were seen as potential barriers to an effective service;

But there is talk about us going up to a Community Midwives meeting to update about contraception. That’s on hold at the moment because they must be having some more changes. (FG 1: P2P Nurse)

Timely service provision There was recognition by midwives and health visitors of the importance of a speedy, efficient service. Overall, there was a positive response to the process of referral and P2P nurses were praised for the speed at which they respond to women who are referred:

Well my role is, well, I just make a referral really and then I can just step back and let them [P2P] get on with it from there, and that seems to be it really. (FG 3: Health Visitor)

They, [the P2P nurse to whom you have made a referral], usually get back to you quite quickly … and they [client] have received a really good service. (FG 2: Midwife)

In addition, collaborative working was identified as a cornerstone to service uptake. Participants identified specific difficulties with some primary care services. Those unaware of P2P did not refer and these services seemed to have inadequate services for young women in need of contraceptive cover;

I always tell them [clients] to come here because … GP services give them appointments for weeks in advance when they can have it done much quicker, you know, could come here straightaway and have it done. Because GPs still think you have to wait six weeks before you can have an implant. (FG2: Health Visitor)

Some girls are waiting up to 3 weeks for contraception through the surgery. (FG 3: Health Visitor)

Even when referral systems did not work well, collaborative working ensured that the breakdown did not result in a client being left without contraceptive cover: By the time we [P2P] are picking it up, it’s because somebody’s already been through that process with the client. So usually the community midwives have been brilliant and they’ve done everything. (FG2: P2P Nurse)


Discussion

Health professionals who provide and refer into the contraceptive and sexual health service identified four characteristics that they perceive to be central to its effectiveness: flexibility and responsiveness; a commitment to breaking down barriers; maintaining the initial impetus of service provision; and timely service provision.

Data from the focus group discussions indicates that the health professionals involved are committed to reducing unintended conception rates through enablement of teenage mothers. Nurses, midwives and health visitors of the P2P service strive to be flexible and inclusive, tailoring their approaches to meet the needs of the service user. The proactive efforts they make in reaching the most vulnerable young mothers are necessary to significantly reduce the risk of unintended pregnancy – a key priority identified in the Framework for Sexual Health Improvement in England, (DH, 2013). However, data here indicates that there is more to the service than preventing repeat pregnancy.

Effective services from a P2P health professional’s perspective appear to be based around accessibility, particularly in terms of speed and confidentiality. Previous research of this service indicates the aspects of the service that were found to be most satisfying to young women were the confidential nature of the encounter between client /health professional, convenience of access, the flexibility of health professionals alongside the non-judgemental attitude of staff and the on-going support (Hayter et al, 2016). From both a service user and stakeholder perspective, the service appears to be effective in terms of meeting the contraceptive needs of the young mothers. Yet, during the FGDs, there was very little evidence of numerical detail of the effectiveness at reducing unplanned pregnancies within the local area. This suggests that the prevention of unintended pregnancies is of less important to staff and service users – what seems to be more of a priority in terms of measuring effectiveness is the access to sexual health advice in a discreet and timely manner.

Research by Regmi (2012) suggests that ‘effectiveness’ of health services is complex in nature as it can be difficult to measure, with different stakeholders having different interpretations of what makes a service effective. Data presented here reflects this complexity.

Teenage pregnancy and parenting in adolescence is also complex, and has been found to be associated with a variety of broader social, economic, cultural, and psychological factors, including poverty, school failure, and sexual abuse (Davies, 1996).

Findings from research into sexual risk-taking behaviour and adolescence highlight a need for the integration of health services for young people (Elkington et al, 2012; 2011; Lavikainen et al, 2009; Independent Advisory Group on Sexual Health and HIV, 2007; Bailey et al, 1999). There is a growing call from policy and research for services to adapt themselves appropriately to support young people seeking sexual health care. Interventions are expected to include behaviour change and health promotion activities, which address other determinants of ill health, such as smoking, drug use, and alcohol abuse (Slater and Robinson, 2014). Reducing rates of unintended conceptions was initially key to commissioners and policy makers, but the model adopted by P2P – as well as the ongoing support provided by the workers and their commitment to providing services to those who are less likely to engage with sexual health professionals – indicate a service that is adapting itself to support young people in a broader sense.


Conclusion

Good sexual health is important to individuals and society (Slater and Robinson, 2014). P2P provides a flexible enablement approach to service delivery, which in turn facilitates positive engagement through reducing barriers to a young person’s face-to-face access to sexual health services. The data illustrates the aspects that contribute to the efficiency of P2P service delivery. The key elements of an effective service have been found to be flexibility and responsiveness, a commitment to breaking down barriers to accessing contraception, maintaining the initial impetus and timely service provision. Staff have been key to adapting the service so that it meets the needs of young people more broadly in terms of the social, economic, cultural, and psychological factors, which impact upon the rates of unintended conceptions.

 

Implications for clinical practice

  • Rapid access to, and delivery of a timely home-based sexual health services for teenage mothers is best facilitated by a confident, flexible and resilient workforce, that work around the challenging landscapes of health care changes.
  • Sexual health service to teenagers following childbirth should be timely, streamlined and home based.
  • Utilising young people’s preferred communication styles when offering services is cornerstone to reaching to vulnerable young people; use of text messaging, call back and other ways are crucial.
  • Processes that facilitate regular updating to provide clarity around referral pathways are necessary to ensure that all practitioners involved in the care of teenage mothers are proactive in offering or referring them for the service.

 

Strengths and limitations

The study is limited by not soliciting the views of professionals who did not refer into the service, as they could have highlighted gaps in the reach of P2P. Nevertheless, this study presents important facets of an effective sexual health outreach service. The strengths of this study are the interdisciplinary nature of the focus groups, high attendance (six to nine practitioners) in each of the three FGDs, and specific features contributing to P2P effectiveness identified.

Credibility of the findings was facilitated by the emergent themes from the FGDs being fed back into and discussed with the project advisory group (PAG). Membership to PAG included two young mothers, who had previously used the sexual health service, a midwife, a health visitor and a P2P nurse.

The aims of exploring the views and experiences of professional stakeholders who work with teenage mothers were achieved. Whilst the additional aim of informing guidelines for the development of nurse-led home-based contraceptive care for new teenage mothers has been less formally achieved, the authors believe that the dissemination of findings in peer reviewed journals such as Community Practitioner and through conference goes some way to providing an evidence base which can inform the future development of services.


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