Current interventions

Sex and Relationship Education (SRE) is a non-assessed subject within British schools and as such remains inconsistent (UK Department of Education and Employment, 2000). Currently it is only compulsory for local authority maintained schools to teach basic biology and reproduction. Academies and free schools do not have to teach this as they do not have to follow the national curriculum. However, this is due to change in 2019, with the introduction of Relationships and Sex Education which will be compulsory for all secondary schools, including academies and maintained schools (Schulkind, Hurst, Biggart, & Bowsher, 2015;

Sellgren, 2017). In a 2002 review, it was found that over a third of SRE in schools was outdated and needed improving (OfSTED, 2002). An example of the narrow perspective of current Sex and Relationship Education was highlighted by a recent study that found 4 out of 10 schoolgirls in England aged 14–17 years reported having experienced sexual coercion (Barter et al., 2016), yet the girls did not understand coercion as they are currently not taught basic information such as consent.

Sex and Relationship Education in schools is provided primarily by teachers (Westwood 2001), yet teachers often report having insufficient sexual health knowledge about STIs and emergency contraception to effectively teach the subject (Westwood & Mullan, 2007). Sexual health professionals have better knowledge of SRE, however pupils have less positive attitudes towards them as they do not see them frequently (Westwood & Mullan, 2009). As teachers do not have sufficient knowledge to teach SRE, it is not clear what sexual information teenagers are provided with and SRE remains inconsistent.

Therefore, it is important to review sexual health interventions outside of schools. Ingram and Salmon (2007) reviewed the ‘no worries clinics’. These are sexual health clinics designed for teenagers inside existing GP surgeries and health clinics. These exist in the South West of England and cover all areas of sexual health advice and screening. Ingram and Salmon concluded that teenagers who attended these clinics felt more confident about sex, were informed about sex and reported less intention to take risks.

There are also the adolescent pregnancy prevention clinics, which are privately funded clinics for adolescents and young adults (Yoost, Hertweck, & Barnett, 2014). These clinics provide female family planning and sexual education to females aged 11-24 years. They concentrate on contraception methods and sexual health information and work on building a positive relationship between the patient and health care provider so that confidential information and

37 advice can be sought. A review of these clinics found that they had a significant influence on knowledge and sexual intentions in younger adolescents 11-16 years. However, they had less of an effect on older adolescents.

Yet even though these clinics are more effective for younger adolescents, the majority of younger adolescents do not feel comfortable accessing these types of clinics and worry about confidentiality and judgement when visiting (Mulholland & Wersch, 2007). The biggest worries for teens are confidentiality and anonymity as well as staff members being unfriendly or critical (Iyer & Baxter-MacGregor, 2010). Also, teenagers are only likely to access these clinics when they are already sexually active (Jones & Biddlecom, 2011). Only a third of young people use a service prior to having first sex (Stone & Ingham, 2002). As early sex is linked with more risky behaviours (Zimmer-Gembeck & Helfand, 2008), it is important to target teens at age-appropriate times. While drop-in clinics are effective there also needs to be a way to ensure that teens can feel comfortable accessing information before they become sexually active. Ingram and Salmon (2010) found that delivering services within schools and communities make them more accessible. However, many low SES schools and areas cannot afford to have these types of drop-in services available.

The recommended standard for sexual health provision in the UK is to provide individuals with safe sex information and access to free contraceptives (Recommended standards for sexual health services, 2011) , and for teenagers to have access to free contraceptives throughout the UK. Yet as mentioned, many teenagers are uncomfortable visiting sexual health professionals.

Previous sexual health interventions that have been underpinned by theoretical models such as the theory of planned behaviour have tried to increase the number of teenagers visiting sexual health clinics. The Department of Education in the UK ran a national campaign called ‘Sex.

Worth Talking About’ (SWTA) (Goodwin, Smith, Davies, & Perry, 2011). Although this campaign was not based on the TPB, it was developed from extensive evidence of the role of health communication on behaviour change ( Brown, Burton, Nikolin, & Crooks, 2012; NHS Choices, 2012). This intervention was aimed at sexually active adolescents under the age of 25, using posters and television advertisements (Ajzen, 2006). Brief health messages were provided in speech bubbles, which directed the reader to a website with further contraception information. Research investigating the impact of the campaign found that the number of young adolescents requesting sexual health appointments increased (NHS Choices, 2012). Therefore, brief messages can have an impact on changing behaviour, but the content of the message (DiClemente, Marinilli, & Singh, 2001), and mode of delivery, need to be carefully considered

38 (Abraham & Michie, 2008). Using this approach, teenagers are encouraged to make informed decisions about health behaviours, and be aware of negative consequences of not performing these behaviours (Broadstock & Michie, 2000). However, nudging a person to change their behaviour by increasing their knowledge about safe sex and providing free condoms only has a modest effect on changing an individual’s behaviour (Ajzen, 2011; Marteau, 2011).

Other interventions widely discussed in the literature are Positive Youth Development programs (PYD). The aim of PYD programs are to provide teenagers with the confidence to be able to refuse sex or practise safer sexual behaviours (Gavin et al., 2010). This is achieved by helping teenagers strengthen their relationships and skills and develop a more positive view about their future (Mji, 2016; Turner, 2017). PYD programs aim to provide a holistic view of adolescent development that then aims to reinforce skills needed for safer sex (Schwartz et al., 2010). Bonding and relationships are an important part of PYD programs and so the atmosphere is supportive so that the program staff and teenagers can connect and a sense of belonging with the other program participants can be achieved (Eccles & Gootman, 2007). In this format prosocial behaviours are encouraged and peer pressure towards problem behaviours is minimised, with positive and safe behaviours being actively promoted.

There have been mixed results from PYD programs. There have been significant gender differences, with male students reporting less sexual intercourse and more condom use after a PYD program, but no significant differences in sexual behaviour for females (Clark, Miller, Nagy, Avery, & Roth, 2005; Flay, Graumlich, & Segawa, 2004). However, another study found that female participants were significantly less likely to have sex or get pregnant than the control group, yet there were no differences for males (Quinn & Fromme, 2010). A further study found similar results with no significant differences for males but females were significantly less likely than controls to have sex under pressure, to have ever had sex, and to have a pregnancy or birth. Female participants were also significantly more likely to use hormonal contraception than those in the control group, but the groups did not differ significantly on condom use (Philliber, Kaye, Herrling, & West, 2002). Furthermore in a longitudinal study on PYD youth, PYD teens were significantly less likely to be parents at age twenty than the control group (Campbell, Ramey, & Pungello, 2002). A further two studies found no significant differences on sexual behaviour and pregnancy rates between the PYD teens and control group (Melchior, 1998; Piper, Moberg, & King, 2000). However, a large systematic review of the literature concluded that overall PYD programs do significantly improve condom use and frequency of sex (Gavin et al., 2010).

39 Thus, there are contrasting results found from positive youth development programs, with some studies concluding they are effective for males but not females (Clark et al., 2005; Flay et al., 2004), and other studies concluding they are effective for females but not males (Quinn &

Fromme, 2010). Also, studies have concluded that PYD programs have no significant effects on sexual behaviours (Piper, Moberg & King, 2000). Yet large systematic reviews have found significant effects on contraception use (Gavin et al., 2010. One of the reasons for these contrasting results might be the definitions used to describe PYD programs. PYD programs have many different definitions developed by academic researchers, program providers and funding organisations who have worked in the area. A literature review of PYD programs identified 15 different definitions; ranging from specific goal setting to spirituality and volunteer work (Catalano, Berglund, & Ryan, 2004). It is difficult to assess how these programs work due to the difference in definitions. It is also difficult to assess whether each program is targeting the same behaviours and skills. Consequently, it is not clear if all of the programs discussed are actually positive youth development programs.

Another issue with PYD programs is that they tend to be long-lasting for an entire school year or longer, so that teens have adequate time to benefit from the program (Gavin et al., 2010).

Because of their heavy emphasis on human resources and length of program, they have a large upfront cost (Schulman & Davies, 2007). Therefore, these types of programs are not appropriate for low SES areas and schools do not have the funding in England to incorporate a yearlong program. Therefore, as these kinds of face-to-face, time and labour intensive programs may not be feasible in low SES areas in particular, then it must be considered whether different more cost-effective mechanisms, such as online delivery, needs to be developed for delivering sexual health intervention messages to groups such as low SES teenagers.