SHNA : Sexual Health in Wirral from epidemiological data

Transcription

1 SHNA : Sexual Health in Wirral from epidemiological data The report presents some facts and figures that help describe sexual health in Wirral s population. All the key areas are covered: diagnoses of sexually transmitted infections (STIs), uptake of testing and screening, contraception, pregnancies in women aged 17 and under, and terminations of pregnancy. At the end there is also some information on factors that are known to influence sexual health and behaviour. Summary boxes are included throughout to give a succinct and simple interpretation of what the data represents and might mean for future work to improve sexual health locally. Data sources and interpretation There are limitations with the data that are available and where there are important issues to bear in mind these are highlighted. It is also important to remember that when sexual and reproductive health statistics are presented for the whole of Wirral they are likely to conceal underlying inequalities, both in prevalence and also in uptake of screening, testing, vaccination and treatment completion i. Selected source data is provided by Public Health England from two key sources: Public Health England, 2014 Genito-urinary Medicine Clinical Activity Dataset (GUMCAD2) and Local Authority Sexual Health Epidemiology Reports (LASER) (publicly accessible data is on the Fingertips Sexual Health profiles website). Data mostly relates to the year up to 8 th April The population represented in the chlamydia data was changed in 2011, which affects the availability of time-trend data for statistics that include chlamydia cases. Since 2012, information about sexual health diagnoses is collected from genito-urinary medicine (GUM) clinics and other community settings where testing takes place. Wirral residents are counted in these figures even if they use services further afield. The aims of this report are to: 1. Give a clearer picture of how many people in Wirral are being diagnosed with sexually transmitted infections, using different contraception options, becoming pregnant at a young age and experiencing unwanted pregnancy. Looking at how Wirral compares to the situation in England and elsewhere helps clarify priorities. 2. Understand how sexual and reproductive health issues are changing over time what do we see more of, and what is less common? 3. Understand more about the population groups who are most likely to be affected by less good sexual and reproductive health 4. Give a clearer picture of how risk factors or social determinants such as harmful drinking, or low educational attainment are distributed across Wirral 1

2 Population structure of Wirral Figure 1, below shows the numbers of men and women living in Wirral, grouped by age. Sexual Health services are open access, but the biggest users of these services and the age group most likely to acquire sexually transmitted infections (STIs) are year olds ii (DH, 2013). When looking at the number of cases of STIs, under 18 conceptions and terminations, it is important to understand this information in the context of this target age group. Other target groups with higher rates of STIs than the general population are men who have sex with men and people from some ethnic backgrounds, notably Black Caribbean and Black African. Figure 1: Histogram to show numbers of men and women in Wirral, by age group 25,000 Numbers of men and women in Wirral in 2011, grouped by age 20,000 15,000 10,000 Females Males 5,000 0 Source: National census, 2011 Note: the age groups which have the highest rates of new STIs are coloured in pink and dark blue. Altogether, men and women in this age range number Sexual health need is known to be higher in year olds, men who have sex with men and Black African and Afro-Caribbean groups - These groups should not be the sole focus of efforts to improve sexual health 2

3 2. Sexually transmitted infections 2.1 Total number of sexually transmitted infections diagnosed in Wirral residents Figure 2 shows that chlamydia is the most commonly diagnosed STI in Wirral, followed by genital warts, herpes, gonorrhoea, and a number of other less common infections, including HIV and syphilis which are grouped as other. It is important to remember that chlamydia diagnosis is supported by a national screening programme for year olds. In 2013, the total number of new diagnoses in all Wirral residents was % of the diagnoses were in men and 51% in women. Almost six out of every ten diagnoses were made in people aged Compared to the previous year, overall numbers of new diagnoses have increased slightly. When compared to other English local authorities overall STI rates, Wirral ranks 111 th out of 326. This means that 110 local authorities have rates that are higher than ours and 215 have rates that are lower. Compared to the North West, Wirral has significantly fewer STIs per head of population, but still ranks third highest in Cheshire and Merseyside behind Liverpool and Knowsley. More detailed information relating to each of the individual infections, including HIV and cervical cancer, which is mostly sexually transmitted, is provided below. Figure 2: Numbers and frequency of sexually transmitted infections in Wirral, 2013 Sexually transmitted infections in Wirral, 2013 Chronic STIs diagnosed pre Other new STIs 436 Chlamydia 1299 Herpes 161 Warts 336 Gonorrhoea 95 Source: Public Health England, 2014 GUMCAD2 and Local Authority Sexual Health Epidemiology Reports. Data relates to the year up to 8 th April

4 Notes: i) data includes that collected from genito-urinary services and community settings, and includes any Wirral resident regardless of whether they presented to a service in Wirral or elsewhere. ii) These numbers represent individual diagnoses rather than people. One person may have contributed several new diagnoses of different infections to these figures - Wirral is about a third of the way down national ranks for its overall STI rate, with a slightly increasing trend - In the North West Wirral ranks third highest behind Liverpool and Knowsley - Diagnoses in men and women are split equally - Chlamydia is by far the most commonly diagnosed sexual infection 2.2 Chlamydia Half to three quarters of people with chlamydia do not experience symptoms, but if left untreated chlamydia can lead to infertility. Because chlamydia is common, often silent and potentially serious England has a national chlamydia screening programme for year olds, which uses a simple swab or urine test. Positive cases are treated with antibiotics. Local screening programmes aim to achieve 2300 or more diagnoses for every year olds. Diagnosis and treatment on this scale should bring down the amount of chlamydia infection in the population so fewer people become infected. Screening tests take place in various community venues, but anyone can also get a test at a sexual health clinic or GP surgery iii. The graph below (fig 3) shows that Wirral exceeded the recommended diagnosis rate in year olds in 2013 and In 2013, just over quarter of Wirral year olds were tested, totalling 9571 tests (1232 in GUM clinics and 8339 in other settings); one in ten tests was positive (863), and two thirds of positive tests were in women. This number of positives reflects the volume of testing taking place and the proportion of young people who are infected. Wirral s testing rate ranks top in Cheshire and Merseyside. Positive results in year olds accounted for just over two thirds of all the positive chlamydia tests in Wirral. For the overall chlamydia rate, Wirral is in the top quarter of all local authorities (80th out of 326), showing that chlamydia is a significant sexual health challenge in this area. 4

5 Rate per 100,000 population Figure 3: Bar chart to show the number of Chlamydia diagnoses per Wirral residents aged in 2012 and 2013, with comparison rates for the North West and England Chlamydia Diagnoses Rate, per 100,000 population Wirral North West England Source: Public Health England, 2014 Fingertips sexual Health Profiles, October Chlamydia is Wirral s most common STI. Three quarters of local authorities have lower rates than Wirral - Wirral has an effective national screening programme for year olds that accounts for around two thirds of positive tests - Two thirds of positive tests are in women. Undiagnosed Chlamydia can lead to infertility so this is an important priority for the local sexual health system 2.3 Genital warts Genital warts are spread by skin to skin contact and infection with Human Papilloma Virus. Having genital warts is not thought to affect fertility, but they are unsightly and so people are likely to seek treatment when they notice the warts. Using a condom does not give complete protection from HPV infection, and reinfection or reoccurrence is common. In England the most usual age to get genital warts is for women and for men iv As figure 4 shows, there were 336 diagnoses of genital warts made in 2013; six out of ten were cases in men. The graph also shows that in Wirral there are fewer cases of genital warts year on year, and the rate is falling faster than in the North West or England. Some of this change over time may be attributable to the effect of widespread HPV vaccination in girls aged since Wirral has the lowest rate of genital wart first infections in Cheshire and Merseyside and three quarters of English local authorities have higher rates. 5

6 Rate Per 100,000 population Figure 4: Line graph showing fall in first cases of genital warts per population in Wirral, North West and England, Genital Warts Diagnosis Rate, Wirral North West England Genital wart diagnoses are falling faster in Wirral than elsewhere in the North West - Good uptake of HPV vaccination may have contributed to this positive trend, with more than 90% of local year olds being vaccinated 2.4 Genital herpes Genital Herpes is the third most commonly diagnosed STI in Wirral. It is caused by the same virus that causes cold sores, Herpes Simplex Virus (HSV). Condoms do not provide complete protection from HSV infection. Once infected, sores come back every few months, but become less severe and more infrequent over time. Herpes is controlled using anti-viral drugs, and people with sores are advised not to have sexual contact until they resolve. HSV can be dormant in the body for months or years before becoming symptomatic and prompting the person to contact sexual health services. HSV can still be passed on, even when there are no sores. In England, two thirds of diagnoses are in women. The most common age to be diagnosed is for women and in men. iv Methods for testing for genital herpes have improved in recent years, and partly as a consequence of this England, The North West and many other areas have seen a rise in diagnoses v. Figure 5 shows that Wirral has bucked this trend with 161 cases last year, although half of local authority areas have lower rates. 6

7 Rate Per 100,000 population Figure 5: Line graph showing changes in first cases of genital herpes per population in Wirral, North West and England, Genital Herpes Diagnosis Rate, Wirral North West England Genital warts are Wirral s third most commonly diagnosed STI - Diagnosis is falling in Wirral despite improved diagnostic techniques - Half of local authorities have lower rates of genital warts 2.5 Gonorrhoea Gonorrhoea is spread through unprotected vaginal, oral or anal sex. A pregnant woman who has gonorrhoea can pass it on to her baby during vaginal birth; this can to lead to a severe eye infection that can cause sight loss. Most people develop symptoms of discharge, but one in ten men and half of women with gonorrhoea infection do not have any symptoms. This is important because gonorrhoea can cause infertility. Three quarters of gonorrhoea diagnoses are made in men, and the most common age for diagnosis is in men and women. iv Gonorrhoea infection illustrates the importance of having effective follow-up treatments for partners of people diagnosed with STIs. Gonorrhoea is treated with antibiotics, but this is becoming less effective as some strains of gonorrhoea have become resistant, meaning they are no longer killed. v Gonorrhoea is rare in Wirral; 95 cases were diagnosed in As figure 6 shows, rates in England are rising, which partly reflects the impact of more resistant strains and also improved testing techniques. v Over the last one to two years the North West and Wirral have shown a downward trend. However, the numbers of cases involved is small and varies quite widely from year to year. Wirral is middle-ranking in England for gonorrhoea; in the North West the highest rates are concentrated in the urban centres around Manchester, Liverpool and Blackpool. Gonorrhoea is considered a red flag for high levels of risky sexual behaviour. v 7

8 Rate Per 100,000 population Figure 6: Line graph showing changes in gonorrhoea diagnosis per population in Wirral, North West and England, Gonorrhoea Diagnosis Rate, Wirral North West England Gonorrhoea is a rare but serious infection, signifying risky sexual behaviour - It is becoming harder to treat with antibiotics - Elsewhere rates are rising, but Wirral has seen a slight downward trend 2.6 HIV Background Human Immunodeficiency Virus (HIV) is a virus that infects and destroys cells needed for combating infections, leaving the body susceptible to diseases it would normally be able to fight off. It is a life threatening illness for which there is no cure. However, given advances in drug treatment individuals can have a near normal life expectancy if HIV is diagnosed early enough and well managed. Without treatment, the immune system can become lowered and rare infections or cancers develop. When these are particularly serious, the person is said to have AIDS (Acquired Immune Deficiency Syndrome). Antiretroviral therapy (ARV) is used to combat the virus to protect immunity. ARVs must be taken as prescribed to be effective. HIV can only be passed through infected blood, semen, vaginal fluids or breast milk. HIV is mainly transmitted through vaginal or anal intercourse without a condom or by sharing a needle or syringe with someone who is infected with the virus. 8

9 People living with HIV experience significantly higher rates of depression and other psychological problems than the general population. This has a major impact on quality of life, complicates clinical care, compromises physical health and increases the risk of onward infection. Access to appropriate emotional, social and peer support services is therefore particularly important for people as they adjust to their diagnosis. It also has an important role to play in the prevention of onward transmission of HIV. vi Testing recommendations HIV testing is recommended as follows: vii 1. When a doctor or other healthcare worker suspects HIV based on clinical signs and symptoms 2. All patients diagnosed with an sexually transmitted infection 3. All sexual partners of HIV positive men and women 4. All men who have disclosed sexual contact with men 5. All female sexual contacts of men who have sex with men 6. All patients reporting a history of injecting drug use 7. All people from countries where more than 1% of the population is HIV positive 8. All people who report sexual contact with someone from a high prevalence country 9. Universal testing in GP practices where the local prevalence is 2 or more per Men who have sex with men and injecting drug users should be tested at least annually. The emphasis on testing is because early diagnosis makes HIV easier to treat, increases life expectancy, and costs less. Diagnosis is also a form of prevention, reducing onward transmission and enabling partners to come forward for testing. Nationally, it is estimated that between one-fifth and one-quarter of all those who have HIV are unaware of their infection. This could mean there are an extra 34 to 42 people in Wirral who have HIV/AIDS, but do not know it. The statistics for Wirral have been supplied by Liverpool John Moores University and Public Health England viii. Wirral has a strikingly low proportion of people in GUM clinics who were eligible for an HIV test and then went on to have one - 21% (range: 21-86%, English average 69%). This may reflect a coding error and thus an underestimate, but the figure for 2012 (54.4%) suggests that half of eligible GUM attendees did not accept an HIV test. 52.9% of people who are diagnosed with HIV in Wirral should already have started treatment. Encouragingly, the late diagnosis rate fell by 15% between 2011 and 13. People living with HIV in Wirral The numbers of people living with a HIV positive diagnosis in Wirral has increased from 59 in 2000 to 169 in In 2010 Wirral had 20 new cases of HIV, 21 new cases in 2011 and 13 new cases in The 2010 prevalence rate was 0.85 per 1000 population of 15 to 59 years olds. In 2013 this has risen slightly to Pooling the three years data between 2010 and 2012 for Wirral, there are more men living with HIV than women at an approximate ratio of 5:2. The majority of people are aged 40 years or over. The most common age category was 45 to 50 years, reflecting that HIV is a 9

10 chronic condition. In terms of new cases, the most common age category to be diagnosed was 35 to 39, with the majority of new cases being people aged over 35 years. In terms of ethnicity 76% of all individuals with HIV in Wirral seen between 2010 and 2012 were white, followed by 18% Black African, 6% other BME. The 2010 to 2012 data also showed the most common infection route was heterosexual sex at 53%, followed by men who have sex with men (MSM) at 42%. The remainder was split between injecting drugs users and other rarer routes of transmission. Infection through heterosexual sex showed the biggest increase with 81 cases in 2010 compared to 92 cases in Wirral is in the highest 25% nationally for late diagnosis of HIV - Wirral has seen a dramatic fall in people who are eligible to be tested for HIV in GUM clinics and go on to have a test. 21% is the lowest figure nationally. This persistent low rate for the last two years may well be anomalous but needs to be understood and addressed. - Wirral is considered a low prevalence area for HIV - The number of new cases occurring each year is fairly stable, which means that the number of people living with HIV is slowly increasing, with a predominance of people in their 40s and 50s - More diagnoses are made in men than women and the most common age to be diagnosed is The most common route of infection is heterosexual sex, followed by men who have sex with men - Most diagnoses are in White people, but BME and Black African Wirral residents are disproportionately represented - The priority for Wirral for HIV is targeting of testing opportunities for individuals with risk factors (based on sexuality, ethnicity, as well as recognised clinical indicator conditions) 2.7 Cervical Cancer Almost all cancer of the cervix is caused by infection with Human Papilloma Virus (HPV), which is passed on through sexual intercourse. Only 2% of female cancers affect the cervix, but this is the most frequent cancer type in under 35s. ix All girls aged are now given an HPV vaccine that gives protection against the commonest HPV strains. The national cervical cancer screening programme is for women age and aims to pick up pre-cancerous cervical changes. Important risk factors for cervical cancer are: having a pregnancy at a young age, having multiple sexual partners and smoking x The most up to date data for cervical cancer covers ; over these three years 57 women in Wirral received a cervical cancer diagnosis. Wirral s rate is similar to the rest of England. ix In , 90.4% of year old girls in Wirral completed HPV vaccination, which is in line with World Health Organisation targets viii. There has been a gradual decline in coverage since Figure 7 below shows how the proportion of women who took up their offer of cervical screening in Wirral within has fluctuated over time. Although coverage is above the 70% target, Wirral consistently underperforms in this area compared to the North West and 10

11 Coverage % England. Wirral mirrored the national fall in and coverage now appears to be increasing slowly, but at a faster rate than in the North West as a whole, which is encouraging. Without deliberate action, uptake of screening varies, being highest in the most affluent communities and lowest in the most deprived. i Figure 7: Line graph showing the percentage of eligible women aged who have undergone cervical screening within the recommended time period for Wirral, North West and England, Cervical Screening Coverage, Wirral North West Engalnd Cervical cancer is sexually transmitted - Cervical cancer diagnosis rates are changing in a similar way to the rest of England, and Wirral has closed the gap with the North West average - Screening needs to be promoted in connection with known risk factors and addressing groups who are least likely to accept a screening offer - Protective HPV vaccination hits government targets but shows a downward trend - Screening services are now the responsibility of colleagues in NHS England 2.8 Hepatitis B and C Hepatitis B is a virus that spreads through blood and bodily fluids. Hepatitis B is an uncommon condition in the UK and is mostly confined to particular parts of the population: ethnic groups with links to countries where the virus is much more widespread, e.g. South Asia, China and Africa; men who have sex with men or people who change sexual partners frequently; and people who inject illicit drugs. Very few people who contract Hepatitis B go on to experience serious health consequence and the infection usually resolves over time. In around 1% of cases the virus goes on to cause scarring of the liver or liver cancer. People in high-risk groups are offered vaccination, but there is no specific treatment for Hepatitis B. Health statistics for Wirral indicate that hepatitis B is not a major issue locally. Hepatitis C is more common than Hepatitis B. Hepatitis C is spread in blood and is a common infection in injecting drug users. It can also be spread through unprotected, 11

12 especially anal sex. There is no vaccination for Hepatitis C, but regular testing can pick up an infection and anti-viral drugs are prescribed. Without treatment Hepatitis C can progress to liver scarring, liver failure or cancer. Wirral has a higher than average admission rate for end stage liver disease linked to Hepatitis C, which may suggest a need to increase testing. NICE guidance includes recommendations about testing for Hepatitis B and C in sexual health settings. - Hepatitis B and C can be spread through sex and testing is recommended for some groups in sexual health settings - Deaths from end stage liver disease and cancer due to Hepatitis C in Wirral may indicate a need for more testing in at-risk groups, which includes MSM 3. Individual characteristics and sexually transmitted infections in Wirral The information in this section will look more closely at who is most at risk of becoming infected with an STI 3.1 Age Sexual health services are for anyone who is sexually active or who has contracted an STI. Figures 8 and 9, below, show the ages of men and women from Wirral who received a STI diagnosis at a sexual health clinic between 2011 and They do not show figures for chlamydia, because of the effect of the screening programme; information for HIV is presented in section 2.6 above. Figure 8: Bar chart showing frequency of selected STI diagnosis by age group in Wirral men, Number of STI Diagnoses by age group: Males, Wirral, Infectious Syphilis Gonorrhoea Anogenital Herpes Anogenital Warts Figure 9: Bar chart showing frequency of selected STI diagnosis by age group in Wirral women,

13 300 Number of STI Diagnoses by age group: Females, Wirral, Infectious Syphilis Gonorrhoea Anogenital Herpes Anogenital Warts Both graphs have a similar outline with most diagnoses in the age group, followed by the age group, tapering to very low numbers at age 65+. These graphs clearly show that adults under 30 are the group most affected by STIs, but is also a reminder that STIs do not go away in older groups; and can also arise in small numbers in children under the age of 16. Diagnosis of an STI in a child under 16 should always trigger a safeguarding investigation and safeguarding and vulnerability or sexual exploitation should be considered in older teenagers as well. - STIs are more likely to be diagnosed in the age group, but sexual health issues can be present in older people as well - Diagnosis of STIs in teenagers should be a red flag for safeguarding issues - Safeguarding procedure is an essential part of sexual health services and sexual health issues should be systematically considered where people are vulnerable whether this is due to age or other factors 3.2 Sexuality In Wirral s integrated sexual health service 99% of attendees declare their sexuality; with around a sixth (17.3%) of men identifying as men who have sex with men. v This proportion is higher than in the general population (around 2-3% xi ), because men who have sex with men are at higher risk of acquiring STIs. Figure 10 shows diagnoses over two years, for heterosexual and homo- or bisexual men in Wirral. Although the former group is six times larger than the latter, the number of cases of gonorrhoea is almost the same, and cases of syphilis are higher in homo-or bisexual men. This reflects the higher rates of these STIs in the homosexual population. Figure 10: bar chart comparing selected STI diagnoses in hetero- and homo- or bisexual men from Wirral,

14 Numbers of selected STI diagnoses in heterosexual and homo- or bisexual men in Wirral, Anogenital Warts Anogenital Herpes Gonorrhoea Infectious Syphilis Heterosexual Homosexual - Rates of less common STIs are higher in homo- and bisexual individuals than in heterosexuals, but because the heterosexual group is larger numbers of cases are similar - Sexual health and wellbeing services and opportunities for testing need extra targeting towards groups who are known to be at higher risk. However, caution must be taken to avoid increasing stigma 3.3 Ethnicity 95% of Wirral s population is White British. xii In 2013, 3.1% of STI diagnoses were made in people from other ethnic backgrounds; and 2.6% of diagnoses were made in people born outside the UK. v Black or Black British individuals accounted for just 0.7% of diagnoses. It is very important that people from non-white ethnic groups know about and feel able to visit Wirral s Sexual Health services and that the needs of this diverse group are met. Changes to the ethnic make-up of Wirral s population in the future may have implications for sexual health services, even when residence in Wirral is transient. - It is essential that people from minority ethnic backgrounds do not encounter barriers to having their sexual and reproductive health needs met - Services should engage with local BME people to understand their needs and address 3.4 concerns. Sexual health This may inequality mean making adjustments to the way some services are delivered - Figure Changes 11: Rates to the of ethnic new STIs make-up and of deprivation Wirral s population in Wirral, in 2013 the future may have implications for sexual health services, even when residence in Wirral is transient. 14

15 The map on the left, above, shows the amount of STIs per head of population for small areas of Wirral: the darker the colour, the higher the rate. On the right is a map showing deprivation, with the darkest colours concentrated on the east showing areas where the quality of employment, education, housing, income, crime, health, and living environment are the lowest. The pattern of STIs approximately mirrors the pattern of multiple deprivation the social inequality is reflected in the sexual health inequality. This is important because social advantage - the benefits of a strong education, dependable income, good health and mental health provide people with the personal power to take control of their sexual health. This includes having healthy relationships based on sexual equality, choice and self-respect and managing situations in which personal power and control can be eroded, for example being drunk. Two obvious conclusions that need to be drawn here: firstly, sexual health services need to be within easy reach in the places where they are most needed, and secondly, sexual health and other services need to pay attention to the root causes of the problems people present with and place an emphasis on preventative actions to help address these. There is more information on the social determinants of sexual health at the end of this section. - Every individual has sexual health needs. Some communities have a greater concentration of sexual health needs than others. This can reflect the age of the population, cultural norms around sex and risk-taking behaviour, e.g. alcohol and drugs, attitudes towards how men and women should act, and the general life opportunities on offer - An integrated sexual health system must offer support to deal with the underlying 3.5 Reinfection issues that lead to poor sexual health, as well as clinical issues - Taking this approach should also lead to reduced inequalities in sexual health across the population 15

16 Reinfection with an STI within a year of treatment is considered a sign of persistent risktaking sexual behaviour. The LASER report for 2013 reports that reinfection affects around one in 20 people visiting sexual health clinics on Wirral. v This is slightly lower than the national figure. In year olds reinfection is more common, affecting one in 13 in Wirral. Reinfection is an important outcome for sexual health services as it highlights when sexual behaviour continues to put a person at risk. - Reinfection signifies persistent sexually risky behaviour year olds are more likely to be reinfected - The reinfection rate is one indicator for how successful preventative care and advice has been 4.0 Factors that influence sexual health and behaviour social determinants The Department of Health s Sexual Health Framework and the findings of the latest national survey of sexual attitudes and behaviour outlines some of the factors that can influence sexual health, behaviour and unplanned pregnancy at an individual and community level xiii. These include: Personal Personal attitudes and beliefs; Peer pressure; Confidence and self-esteem; Misuse of drugs and alcohol, and smoking Coercion and abuse Depression Sex education mostly from a source other than school Early initiation of sexual activity Higher frequency of recent sex and Having more than one partner in the past year Community Social norms; Religious beliefs; Culture; Low educational attainment At a Wirral wide level, figures from Public Health England xiv show that compared to many other areas in England Wirral has high rates of hard drug use, alcohol-related harm, depression in adults, as well as more typical rates of smoking, year olds not in education, employment or training, as well as higher than average levels of attainment at GCSE. Being sexually active in an area where these behaviours and beliefs are more common means sexual and reproductive health is more likely to suffer. Very importantly in Wirral 16

17 these risk factors are not distributed evenly across Wirral neighbourhoods. Without exception they are worse in neighbourhoods with high deprivation (figure 11). xii It is very important to understand how social, cultural and environmental factors shape and pattern sexual behaviour and health in Wirral. This understanding needs to apply at the level of communities as well as individual services users, who may benefit from connecting with support beyond the remit of sexual health, e.g. alcohol, mental health, employment. Putting the right range of services within easy reach of people who are living with the vulnerabilities listed above is essential to strengthen preventative as well as reactive care. Traditional clinic-based services are part of the solution, but can be improved further by considering more innovative options for delivering sexual health messages and services. - A range of personal and community factors influence sexual behaviour - These include beliefs and expectations about sex amongst peers and the local community, confidence and self-esteem, use of drugs and alcohol and the quality of sex education a person receives - Wirral has notably high rates of alcohol-related harm, hard drug use and depression, especially in deprived areas on the east, which could all feed into patterns of poor sexual health - Helping people to become less vulnerable and more empowered when they live in challenging circumstances should be a core preventative aim of a sexual health strategy - Sexual health services need to be networked with other relevant support services - An integrated sexual health system can advocate for improved sex and relationships education for children and adults 5.0 Sexual offences Wirral has the lowest rate of reported sexual offences in the North West, being almost half that of England as a whole. The figure for Wirral s statistical neighbour Sefton is very similar. It is important to note that these figures make no claim to completeness and therefore accuracy can be influenced by diverse, social, organisational and cultural factors. Research suggests that sexual violence is more common in certain groups including; younger people; those who have grown up in care, people with mental health problems, men who have sex with men, those who have already been sexually abused early in life and people with physical disabilities xv. - Poor sexual and reproductive health can often be a red flag for vulnerability - Sexual health needs to be a part of conversations in services that support vulnerable people, - Referral into relevant non-clinical (psycho-social) support services needs to be routinely considered for people presenting with sexual health needs 17

18 Live births per 1000 Wirral women aged Reproductive Health 6.1 Fertility Figure 12: Live births per 1000 Wirral women aged 15-44, General Fertility Rate in Wirral, Year General Fertility Rate Source: Office for National Statistics, 2011 Figure 12 shows the trend in the number of live babies born per 1000 Wirral women of childbearing age (15-44) between 1999 and There were 3560 live births in This profile generally mirrors the pattern in England as a whole. The rising trend is interrupted in 2011, and the rate of live births appears to be falling. It is possible that this change may partly be a reflection of the new, larger estimate of the female population from the 2011 census. The numbers of fertile women living in Wirral is projected to increase in coming years, but the number of children born each year could still stabilise or fall if women tend to have fewer children. xvi Wards in the East of Wirral typically have a higher general fertility rate compared to West Wirral, meaning there are more births per year old women. Births to lone mothers also follow this pattern. This means that the availability of reproductive health services need to be in step with this increased need, so men and women have the right opportunities to obtain contraception and manage their fertility. - Having risen during the number of births per woman aged is now falling - The birth rate in east Wirral is higher than that in the west - The number of women of child-bearing age is projected to increase in the future in Wirral, it is essential all women have the right opportunities to take control over their fertility and avoid pregnancies that later lead to abortion 18

19 6.2 Teenage conceptions There are two national Public Health outcomes xvii related to pregnancy in women aged under 18 (conceptions in year olds, and year olds), against which local authorities are expected to demonstrate improvement. Although not true in every case, becoming a mother at age 17 or less is more likely to lead to less good outcomes for the child, including a higher chance of death in infancy and a higher probability of childhood accidents and behavioural problems. Mothers in turn, are more likely to remain in poverty, stay in poor housing and suffer from poor mental health. v A large national survey of sexual attitudes and lifestyles xiii found that only 11.6% of pregnancies in year olds were planned with almost half (45.2%) being described as unplanned. 47% of unplanned pregnancies in the national survey led to abortion. The survey showed that factors that often go hand-in-hand with unplanned pregnancy are: use of drugs other than cannabis, low educational attainment, sex education mostly from a nonschool based source and current depression. Easy access to contraception, knowledge about how to use contraception effectively and development of the skills and attitudes needed to negotiate its use or decline sex altogether can all help lower the teenage conception rate. Under 16 conceptions In Wirral, 6 in every 1000 young women aged conceived in This rate is comparable to the rates in England and the North West overall. Under 18 conceptions In England, the number of teenage conceptions continues to fall, and has dropped by 40.5% between 1998 and v The rate of decline has been slower in Wirral over the same period (33.8%) and Wirral still ranks just inside the top 25% of English councils, with 195 conceptions in year old women in There is spatial variation in under-18 conceptions which is patterned along socio-economic lines. In the rates in Wirral wards are ranked as shown in figure 13, below. 19

20 Rate per 1000 women under 18 Figure 13: Rate of under 18 conceptions in Wirral wards for Number of under 18 conceptions per 1000 women under aged under 18 in Wirral wards, Seacombe Birkenhead and Tranmere Rock Ferry Bidston and St James Leasowe and Moreton East Liscard Prenton 10 New Brighton 0 Ward Bromborough In Wirral 55.4% of under 18 conceptions in 2013 resulted in abortion, which is slightly higher than the figure in England and the North West. This picture has changed little since Wirral is just outside the worst performing quarter of local authorities for under 18 conceptions - The rate is falling but more slowly than in other areas - Just over half of teenage conceptions result in abortion and this picture has changed little since Factors that are associated with teenage conception are: use of drugs apart from cannabis, low educational attainment, depression and sex education mostly from a source outside of school - Protective factors that lower the risk are: easy to access contraception, knowledge about how to use it effectively and developing skills and attitudes that make it easier to negotiate safe sex and recognise and avoid coercive situations - Together these lead to inequalities in under 18 conceptions that are socially and spatially patterned - Bringing down under 18 conceptions is a complex problem and requires support and effort from a wide range of stakeholders that work with young people, including parents, schools and other support services, particularly those that work with already vulnerable young people 20

21 Abortion rate per 1000 women by age group 6.3 Termination of pregnancy Abortion rates can provide some indication of how readily people in an area are able to obtain suitable contraception and how effectively they use it. It is important to note that while a well-functioning system that puts contraception within reach of anyone who may need it is essential, contraceptive failure, or not using contraception at all resulting in unplanned pregnancy raises wider cultural questions about women s knowledge and personal empowerment to consciously take control of their fertility. Total abortion rate Figure 14 shows that Wirral has higher rates of abortion than the North West or England across all age groups except 35+, and that the rate of abortion peaks in the age group 37 out of every 1000 women aged had an abortion in 2013 in Wirral. The overall rate for Wirral is the 40 th highest in England v. In the North West six, mostly urban local authorities have higher rates (Knowsley, Manchester, Liverpool, Blackpool, Halton and Salford). Figure 14: Abortion rate in Wirral, the North West and England by age group in Legal abortion rate by age group, 2013 Under All ages Wirral North West England Source: Wirral compendium of Statistics, 2014 Abortion less than 10 weeks Abortion before the tenth week of pregnancy is linked to fewer complications and suggests a system that is accessible and responsive. In Wirral in 2013, almost 8 out 10 abortions took place before ten weeks, which is similar to England and the North West, although 15 of 23 North West local authorities perform better on this indicator. 21

22 Repeat abortion In 2013, 33.2% of Wirral women aged under 25 who had an abortion had already had at least one previously. This is the highest rate in the North West, and nationally Wirral ranks 16 th highest on this indicator out of 129 upper tier local authorities. In women aged 25 and over the rate is even higher over half had experienced previous abortion (53.2%), placing Wirral 7 out of 146 English local authorities. Taken together, this information about termination of pregnancy reflects a higher number of women undergoing abortion than in many other parts of England and the North West. Abortion for termination of unplanned pregnancy takes place at an early stage (less than 10 weeks) for the large majority of Wirral women. So why are Wirral women experiencing more unplanned pregnancies than elsewhere? These figures suggest that contraception is either missing from the picture entirely, being used ineffectively, or in the case of condoms going unused even when no other form of contraception is in use. The underlying causes of these patterns of contraceptive use and non-use are discussed in the next section. The high numbers of repeat abortions suggest that contraception services across the integrated sexual health system need to work harder and differently to enable and empower women to take control of their fertility and sexual health through means other than abortion. - The peak age for abortion in Wirral is A third of women under 25 who present for abortion have previously had an abortion. Wirral has one of the highest rates in the country - Most abortions happen at less than 10 weeks, suggesting that the system is capable of responding to women s needs promptly when they decide to terminate a pregnancy - Abortion and repeat abortion should be a trigger for services to look upstream and address underlying issues which may have made unprotected sex more likely, e.g. poor mental health, coercion, drugs or alcohol etc - An effective sexual health system needs to make it easy for women to access contraception and contraception pathways must link in seamlessly with abortion services - Prescribers and others need to have the skills to help women decide what is right for them and to help them learn how to use it effectively - Women should see using contraception to control their fertility as an empowering, positive choice. And men should be supported and enabled to share this view - Affecting this kind of change in normative attitudes is a challenging and long-term endeavour and requires at a minimum the collective efforts of diverse stakeholders and probably recognition as a strategic priority 6.4 Contraception The full range of contraceptive options is available free of charge to anyone who needs it from general practices, sexual and reproductive health services and young peoples clinics. Walk-in centres, sexual assault referral centres, genitourinary medicine clinics (GUM), and pharmacies with patient group directives in place, also provide emergency contraception. Abortion services can also offer contraception as part of the care they provide. People can also buy condoms in shops and emergency hormonal contraception can be purchased in some pharmacies and private clinics v. 22

23 If we want men and women to take control of their fertility it is essential that there is accessible information about what is on offer and where at a local level. Contraception providers must also be skilled at helping clients select a form of contraception that they can use effectively and that suits individual needs. Contraception advice needs to be accompanied by positive messages about the use of condoms to provide protection from STIs. Data sources and interpretation Our understanding of patterns of contraceptive use in Wirral comes mainly from Public Health England s annual Local Authority sexual health epidemiology report contraception appendix v. This report is supplied to commissioners of sexual health services and sensitive information that might risk identifying individuals is not included in the information below, as stipulated by PHE. Data is collected from dispensed prescriptions from General Practice and activity in sexual health services. Unfortunately, this means that not all contraceptive use in Wirral has been captured here. Contraception choices in Wirral Contraceptives are grouped into two categories according to how much their effectiveness depends on the user. Long-acting reversible contraception (LARC) includes hormonal implants, long-acting injectable contraception and inter-uterine devices and systems. Locally these are sometimes referred to as the rod, depo and the coil respectively. LARCs prevent conception very reliably once they are in place, with no need for the user to do anything except to attend for scheduled replacements. User-dependent methods (UDMs) include oral contraceptives ( the pill ), condoms, hormonal patches and natural family planning methods. The effectiveness of these in preventing unwanted pregnancy depends on users using them correctly, e.g. fitting a condom properly, taking the pill as prescribed; therefore these tend to be slightly less effective overall. When it is well tolerated LARC is considered a good choice for women who may have difficulty using UDM methods effectively. Figure 15 shows the breakdown of LARC and UDM contraception in Sexual Health services in Wirral and England. This shows that and year olds account for over half (54.9%) of LARC prescribing in sexual health services and the overall pattern of prescribing within age groups is similar to that in England as a whole. For user-dependent methods there is a slightly more even spread including younger women, with a third prescribed for year olds and half going to year olds. 23

24 Figure 15: Proportion of long-acting reversible contraception and user-dependent methods in Wirral and England in Sexual Health Services, in 2013 Source: Data supplied by Public Health England from sexual health services in Wirral Figure15 below affirms that in sexual health services UDM methods (oral contraception, female condom, patch, natural family planning) outstrip male condoms and LARC in every age group with the proportion of LARC increasing with age. This pattern contrasts with what we might expect, i.e. younger women opting for more dependable options that are less prone to user failure and the chance of unwanted pregnancy. 24

25 Number of dispensed prescriptions Figure 16: Prescriptions for LARC and UDM contraception by age group in Wirral Sexual Health services, % 90% Contraception prescriptions by age in Wirral Sexual Health services in % 70% 60% 50% 40% 30% Male condom UDM LARC 20% 10% 0% < and over Source: PHE LASER report, 2013 Note: male condom is shown separately from other forms of UDM In General Practice prescribing data does not include male condoms and is not available by age. Most contraception prescribing takes in General Practice in Wirral. Figure 17, below compares the total UDM and LARC prescribing in Sexual Health Wirral services and GPs. As the percentages show, the proportion of prescriptions for LARC in sexual health services is two and a half times higher than that in GP. UDM methods dominate in both services. Looking at regional and national GP data, Wirral s LARC prescribing is quite similar to the overall figure for Cheshire and Meseyside, but is almost a third lower than the national figure of 15.3%. Conversely, the rate of LARC prescribing in Sexual Health Wirral is two thirds higher than the national figure (53.7/1000 vs 32.3/1000). Understanding the effectiveness and acceptability of LARC in Wirral is hampered because data does not connect insertions with subsequent removals. 25