Consultation on the Pregnancy and Parenthood in Young People Strategy: Analysis of Responses

2. Delaying Pregnancy in Young People

One of the long-term aims of the Strategy is a “Reduction in teenage pregnancies and subsequent unintended pregnancies”. The proposed associated actions for this strand of the Strategy explore ways of delaying pregnancy in young people. They focus on providing young people with the knowledge and services they need so they can make informed choices; and preparing young people for potential parenthood.

Question 1: What ways of working, within and between agencies, will help ensure that there is a co-ordinated approach to take forward the actions in section one in your area?

Forty-four respondents addressed this question. Four main themes emerged from their responses.

Ensuring all parties provide consistent messages

Respondents across a range of sectors highlighted the importance of all relevant parties from strategic groups and multi-disciplinary networks such as Joint Health Improvement Teams, to frontline staff such as teachers and health visitors, sharing the same understanding of the issues and being aware of the key messages to transmit. Several respondents emphasised their view that consistency in approach and communication is crucial to aid a co-ordinated approach within and between agencies.

The wide range of organisations and personnel coming into contact with young people and with the potential to play significant roles in taking forward the actions was acknowledged by many respondents, with some advocating joint training across different disciplines to help ensure standardised approaches. Training relating to delivering RSHPE was highlighted specifically in this regard.

Effective delivery of sexual health education in schools

Delivery of sexual health education in schools was identified by a few respondents as an area with potential for improvement in terms of content and consistency. One respondent (NHS) suggested that teachers require more knowledge and confidence in this area; another commented that education frameworks for RSHPE in their area have been beneficial in guiding teaching staff to learning outcomes (Joint). Despite a general agreement that consistency in delivery is important, a few respondents cautioned that sensitivities associated with the beliefs and faiths of different groups exist and these need to be addressed if consistency is to be achieved.

One respondent (NHS) argued for local authority Directors of Education to be tasked with ensuring a co-ordinated and standardised approach to the delivery of RSHPE, allowing for age and stage appropriate discretion to be applied.

Examples were provided by local authority and NHS respondents of current effective joint working between NHS and education colleagues (e.g. in NHS Tayside). One local authority respondent referred to the involvement of guidance teachers in signposting to relevant NHS services, such as their pop-up clinics.

Although supporting an emphasis on school contexts for delivery of messages, one respondent (Prof Rep) urged that consideration is also given to engagement with and delivery of messages to those attending school infrequently.

Joint working and planning between agencies

Another common theme to emerge was that multi-agency working in a collaborative manner will help ensure that there is a co-ordinated approach to taking forward the Strategy actions. Mention was made of existing joint working by CPPs, Integrated Children’s Services Plans, GIRFEC groups and Sexual Health Strategy Groups.

Whilst the existence of these groups was acknowledged as providing potentially effective frameworks for co-ordinating approaches, several respondents emphasised the need for the groups to communicate and liaise in order to work efficiently in relation to delivering the actions. Examples were provided of a sexual health strategy group reporting to a Children’s Services Executive Group; and the inclusion of the Children’s Health and Social Care Services in North Ayrshire’s Health and Social Care Partnership which was viewed as:

“…a key strength to us in taking forward the actions of section one as it enhances opportunity for joint working, increased accountability, integrated planning and co-ordination of actions which are young people centred” (North Ayrshire Health and Social Care Partnership).

One individual respondent suggested that groundwork, including mapping of relevant local services and agencies, should precede the establishment of collaborative networks. Joint planning and multi-agency working were viewed as enabling joint plans and shared commitment towards agreed goals and vision.

A few respondents highlighted what they perceived to be the need for a communication strategy to be developed alongside multi-agency working to strengthen and underpin its effectiveness.

Involvement of young people

Nine respondents across a wide range of sectors specifically recommended involving young people in aspects of multi-agency working, such as planning strategy or providing feedback. One respondent (Joint) referred to their strategic plans containining explicit commitment to working with young people. Another (NHS) advocated local authorities developing ways of enabling young people to have an input into how RSHPE is delivered in the classroom. One local authority body commented:

“NHS Borders has an excellent working relationship with the voluntary youth sector and are proactive in our approach to improving outcomes for young people who may be more at risk of poor sexual health outcomes or unwanted pregnancy. The Joint Health Improvement Team have a Service Level Agreement with YouthBorders to deliver some of the more operational aspects of this work which enables us, in partnership, to capitalise on the relationships that the youth work organisations have with the young people who engage with them. Often these are young people who do not engage with services through more formal methods and enables us to take a more targeted approach” (Scottish Borders Children and Young People’s Leadership Group).

One respondent (Third) recommended exploring communication tools such as social media as a means to engage with young people and their representative organisations.

Other themes

Several other suggestions were made for ways of working to enable a co-ordinated approach across agencies:

• Strong leadership (3 mentions).
• Articulation of the precise role of the Third Sector in multi-agency working, for example, which organisations would be involved and would new ones be required. Strengthen the partnership between the Third Sector and statutory organisations (2 mentions).
• More explicit links to be made with related legislation and policies (e.g. Children and Young People (Scotland) Act 2014 and the new Looked After Children’s Strategy) (2 mentions).
• Greater use of websites/forums/public information (e.g. to raise awareness of pharmacist expertise) (2 mentions).
• Ensure a joined-up approach with the Named Person service (2 mentions).
• Physically co-locate senior managers across relevant disciplines such as education, health and social services in order to provide greater opportunity for planning; ensure access to relevant records is shared across agencies (1 mention).

Question 2: Are there local systems in place to take forward these actions?

Thirty-four respondents addressed this question. Whilst one respondent (Prof Rep) commented that the existence of local systems to take forward these actions will vary according to Health Board and local authority priorities and budget, several others considered that national frameworks such as Curriculum for Excellence, the Children and Young People (Scotland) Act 2014 and GIRFEC provided overarching structures within which local systems could develop. Two respondents (both Joint) highlighted CPPs as supporting the existence of local systems; mention was also made of the newly formed Health and Social Care Partnerships in this regard.

Partnership working

Several respondents provided examples of what they considered to be effective partnership working in their area which provided vehicles to deliver the actions. One respondent remarked:

“Dumfries and Galloway has a long history of good partnership working and links are well established” (Dumfries and Galloway Teenage Pregnancy Working Group).

Included amongst more specific examples of integrated partnership working were: Lanarkshire’s Sexual Health Service (Third); NHS Tayside’s Sexual Health and Blood Borne Virus Managed Care Network (BBVMCN) and its subgroups (NHS); Perth and Kinross Sexual Health and BBV Strategy Group which reports to and is guided by NHS Tayside’s Sexual Health and BBVMCN (NHS); East Lothian’s Children’s Services Partnership (LA); and The Corner (jointly funded by Dundee City Council and NHS Tayside) (Joint).

A few respondents made especial mention of existing links between education and NHS in the context of local systems. One individual respondent highlighted Local Learning Community Partnerships, comprising local council, primary and secondary school, voluntary and NHS partners. A local authority body also cited NHS and school links as effective in their area.

Specific initiatives

Several respondents identified specific initiatives and organisations within their areas which they considered had potential to support implementation of the actions and which might offer models for others to look to. Examples included:

• Moray Parenting Model (to be reviewed by Wave Trust with discussions about how to take this forward).
• Sandyford Services in NHS Greater Glasgow and Clyde.
• Children and Adolescent Mental Health Services (CAMHS).
• Funding of two dedicated nurses to work with the most chaotic and vulnerable young people across North and South Lanarkshire.
• West Lothian Supporting Young People Service (the “Chill Out Zone”).
• Roll-out of the Sexual Health and Relationship Education plan in Glasgow, a sex education programme delivered to pupils from P1 to S6.
• Programmes offered in Scotland’s Catholic schools (“God’s Loving Plan” in primary schools and “Called to Love” in secondary schools).

Systems which engage with young people

Many respondents highlighted local systems which aim to engage with young people. Mention was made of initiatives supported by partnership working between the local council and Save the Children (Joint). Joint work between the National Society for the Prevention of Cruelty to Children (NSPCC) and Barnardo’s with young offenders in HMP Polmont was described as “inspiring” (Prof Rep). One individual identified the local Youth Strategy Implementation Group which brings together a wide range of local partners. The involvement of young people in delivering NHS Lanarkshire’s Sexual Health Service was mentioned as was the CPP Youth Alliance (Third).

Joint working with young people in development of the relevant curriculum was identified (Joint); another respondent (Third) reported the involvement of young people in decisions on how to approach RSHPE teaching in schools.

One local authority described a pilot in two West Lothian schools in which staff have been trained to deliver a primary programme of study for RSHPE. The programme is now ready to roll out to all primary schools, with a secondary school programme also developed.

Another respondent (NHS) outlined joint working between the Dumfries and Galloway Health and Well Being Unit and education colleagues to support RSHPE.

Local systems identified as having potential for improvement

A general theme across several responses was that whilst local systems are in place which could support the actions, some need to be strengthened and formalised in order to be effective. Mention was made of weak electronic infrastructure where work is required to join up systems and allow for sharing of information (Third); clearer reporting “pathways” were called for to ensure shared accountability between health, social care and education (Ind); stronger mechanisms for accountability for monitoring work towards the actions were requested (Prof Rep).

Gaps were identified in advising and educating supported carers in providing relationship and sexual health advice to young people staying with them (Joint). One respondent (Third) considered that CPP and local systems do not have the necessary relationship expertise to take forward the actions.

Calls were made for local RSHPE to be based on more standardised information (NHS, Ind). One respondent (Prof Rep) reported the challenges which some NHS Health Boards are having in providing generic and sexual health information and clinical services in or near schools, one issue being acquiring premises for delivery. Another (Third) identified a gap in support which can be offered to vulnerable 16 and 17 year olds who require sexual health services or pregnancy services. It was argued that if they have not previously been engaged with the child protection system this creates a gap in service provision.

Question 3: Do you think the actions meet the outcomes in the logic model?

Thirty-six respondents addressed this question. Overall there was much support for the actions and their relationship with the outcomes in the logic model. Fifteen respondents across a wide range of sectors were clear that they considered the actions do meet the outcomes, however, one respondent (Joint) felt it was difficult to link them directly with each other. Specific praise was given to what was perceived to be the emphasis on inter-agency working as opposed to focusing solely on health (Joint). Three respondents singled out for praise the action for schools, youth work and local authorities to engage young people in the develpment of the RSHPE curriculum in schools.

A few respondents argued for greater national action to underpin local actions towards the outcomes. Calls were made for national level influence over the content of core training content within teacher training courses to embed relevant health topics (two NHS respondents and one Joint respondent). Another respondent (Joint) recommended national leadership around RSHPE and curriculum developments and a stronger national preventative message.

Several respondents across a range of sectors cautioned that the effectiveness of the actions in meeting the outcomes would depend on factors such as leadership, level of support, financial underpinning, robust monitoring, review and enforcement. One commented:

“...we do need to ensure that we have the funding and resources to deliver these objectives in health education, justice and the third sector. The logic model is a fantastic approach but only if it becomes a working model and just not an undeliverable aspiration” (Royal College of Midwives).

One respondent (Joint) urged that allowances must be made for local judgement based on local circumstances and needs.

Three respondents (NHS, Acad, LA) perceived a lack of specificity in the actions to potentially threaten their effectiveness. One commented that many of the activities are:

“....primarily statements, rather than actionable activities that will result in achieving short, medium or long-term outcomes” (MRC/CSO Social and Public Health Sciences Unit, University of Glasgow).

Greater consistency in language across the outcomes framework and strategy was called for by one respondent (Joint) in order to make the actions to outcomes pathway clearer.

Views on ways to improve the actions

Many respondents suggested additions or revisions to the actions which they considered would improve them and their impact on outcomes. The following were documented by three or fewer respondents:

• Actions relating to engaging with young men.
• Acknowledgement that engagement with young people in a school setting should not be exclusive to teaching professionals, but multi-agency teams can also undertake this.
• Action which fully engages parents and encourages conversations between children and adults (the Talk Together initiative in NHS Greater Glasgow and Clyde was mentioned in this regard).
• More information on sexual abuse and domestic violence to be delivered by schools and their partners.
• More action needed relating to tackling stigma.
• Clarity required on the rights of all children and young people to high quality RSHPE regardless of educational setting.
• Greater emphasis on causes and responses needed in the logic model, for example, the importance of mental, emotional, social and physical wellbeing in terms of delaying pregnancy.
• Action on expert training for practitioners so that they can educate and develop young people.
• Clearer recognition and acknowledgement of the contribution of the voluntary sector in prevention and in supporting young parents.
• Action to empower all young people (not just those attending school) to understand the options available.

Question 4: Is there anything missing in this section?

There were 42 responses to this question. Of these, two (Acad, Joint) considered nothing was missing from the section; all but one of the others highlighted general or specific areas which they perceived as either missing altogether or which required to be strengthened or amended; one respondent requested deleting one part of the section.

General views

A few respondents recommended that the Strategy take cognisance of the wider context of social health and health inequality determinants (Joint); wider evolutionary theory (Ind); unconscious bias and influence (as opposed to focusing solely on what the respondent perceived to be a “rational actor” model) (Ind); and broader resilience and protective factors such as access to leisure and culture (NHS). One respondent called for reference to experience and lessons learned from other countries (Joint). Another (Prof Rep) highlighted local and individual factors which they felt could inhibit the implementation of the national Strategy (such as religious views; parental pressures; school and local authority policies) and called for more information on what support may be needed at local level to overcome these.

There was a shared view amongst a few individual respondents that the Strategy presented a negative view of pregancy amongst young people and missing was consideration of the potentially positive aspects for some, such as personal choice (perhaps underpinned by local culture or religion), access to services and help. Two respondents (LA, NHS) referred to the need to challenge myths which arise, for example, from the way young parents may be portrayed in the media. One respondent (NHS) argued for better use of social media to deliver the Strategy’s messages.

Other views on general aspects of the Strategy which could be strengthened at this point were:

• Mention of methods of communication for vulnerable groups of young people such as those with disability, cultural and language differences, looked after children, lesbian, gay, bisexual and transgender (LGBT) young people, those with mental health concerns (NHS, LA).
• Information on how the actions will be resourced (particularly by Third Sector organisations) (Prof Rep, Joint).
• Greater recognition that preventative work should be a high priority (NHS).
• Evidence of clear, cross-department leadership from the Scottish Government (Joint).

Identification of general aspects missing from the section

A few respondents identified topics which they considered had been overlooked in the draft and required inclusion in the section on delaying pregnancy. These included:

• Tailored sexual education for young people in alternative educational settings and looked after young people (Acad, Joint).
• Consistent and appropriate advice about contraception for young people who are in faith schools or independent school settings (LA, NHS).
• Highlighting early in the section the association between sexual behaviour and current/previous sexual abuse and exploitation in order, for example, to inform age and stage appropriate conversations (Acad).
• Acknowledgement and information on the role of grandparents as role models and educators (Third).
• Awareness raising of Foetal Alcohol Spectrum Disorder (Third).
• Importance of marriage and relationship stability and impact of family breakdown (Third).
• Actions around preventing and tackling gender-based violence (NHS).
• Role that faith communities and wider values education can play in reducing teenage pregnancy (Third).

A few respondents requested clarity on concepts and terms used in the section with “sexual competence”, “creating a positive culture” and “youth friendly” the key ones highlighted. Their view was that elaboration on these terms was missing at present and the Strategy should provide greater meaning in order to strengthen their use.

Where more detail is required

A recurring theme was that the section needs to recognise more explicitly the role of parents as key educators of children and young people and the implications this has for delivering preventative messages. Calls were made for parents to be involved in discussions about RSHPE, included in conversations about their children’s risky sexual behaviour, and for the potential of parents to deliver preventative messages to be explored further. One respondent (NHS) recommended that the section identify potential wider influencers on young people, for example, adults within sports contexts. A few (NHS, Joint) suggested that the role of the voluntary sector in prevention and supporting the Strategy required more detail overall as this did not appear to be sufficiently recognised in the current draft. Two respondents (Prof Rep, NHS) requested that more be made of the place of General Practice in delivering educational messages and collaborative working with others.

Another repeated theme emerging from respondents across a range of categories was that the Strategy needs to place greater emphasis on ensuring consistency in school RSHPE delivery and quality of message. Some requested more information on training of teachers to delivery this education, particularly those still undergoing teacher-training and those attending Continuing Professional Development (CPD). One respondent (Third) recommended RSHPE delivery training for those who come into regular contact with young people but who are not sexual health professionals.

Three respondents (Joint, Ind, Third) identified links to mental health and wellbeing as lacking in the section. Another (Third) recommended more emphasis on those at risk of early pregnancy (e.g. care leavers, those not in education, and so on). One respondent (Oth) suggested that greater focus on the link between early pregnancy and grooming/sexual exploitation and abuse as underlying factors would be appropriate for the Strategy. One Academic highlighted that children and young people who have experienced such adversity will require sensitive handling by professionals and carers and the delivery of standard RSHPE in this context could be challenging.

Recommendations for stronger links

It was considered that more explicit links between the draft Strategy and the Sexual Health and Blood Borne Virus Framework should be made (Joint). Clearer links were also requested with community pharmacy, particularly in the context of developing a national youth friendly charter with a role for community pharmacy to provide information and to link with schools (Prof Rep). Others recommended more emphasis on links with:

• Universal maternal and child services around perinatal mental health and wellbeing (Joint).
• Drugs and alcohol policy frameworks (Ind).
• Third sector and community youth services (NHS).

Recommendations for removal from the section

One respondent (Faith) disputed what they perceived to be the assertion that it is necessary to combine RSHPE with the provision of sexual health services and emphasised their view that Catholic schools cannot be required to offer such services or to signpost young people towards them. On that basis, they requested that the proposal that sexual health service drop-in centres be situated “in or close to” schools be removed from the final Strategy.