A SUMMARY OF SEXUAL HEALTH DATA: NHS TAYSIDE NOVEMBER 2008 Phyllis Easton Health Intelligence Manager NHS Tayside Caroline Snowdon Public Health Intelligence Officer NHS Tayside Tel: 01382 424191 Email: phyllis.easton@nhs.net Tel: 01382 596973 Email: caroline.snowdon@nhs.net Introduction This document sets out the data in relation to the sexual health issues and challenges for NHS Tayside. Currently, the clinical data relies on manual processing but the development of the new NHS Scotland National Sexual Health System (NaSH) will provide more robust and accessible electronic data. For each topic, the latest available data is presented here. Sexual activity in young people While it is difficult to estimate the levels of sexual activity in young people, particularly those under 16, the following points highlight issues of concern with this age group. A recent conference reported that around one-third of Scots are sexually active when they are under 16 years old.1 Research from the East of Scotland, including Tayside, has reported that, at first sexual intercourse, the age of young people and their partners and non-use of contraception are most strongly associated with pregnancy.2 The uptake of pregnancy testing and emergency contraception in young people across Tayside suggests high rates of unprotected sexual activity, with associated health risks. The incidence of sexually transmitted infections, particularly in young women is rising. Many more young people may be suffering from infections which show no symptoms. The effects of untreated Chlamydia can include pelvic inflammatory disease and subsequent infertility, potentially serious outcomes from an infection which is easily treated if diagnosed early. In research carried out with young people under 15 in Scotland, 45% of girls and 32% of boys who had had sexual intercourse expressed regret, the majority stating that it had happened too early and a proportion (13% of girls, 5% of boys) stating that it should not have happened at all. 60% of respondents who had experienced intercourse reported using a condom, which meant that 40% did not.3 Teenage conception NHS Tayside has shown consistently higher conception rates in the under 16 age group than Scotland. The chart below illustrates this over time. The Tayside trend decreased between 1999 and 2004 and has shown a slight rise since then. 2 Conceptions in women age <16 Rate per 1000 14.0 12.0 10.0 8.0 6.0 4.0 2.0 1998 1999 2000 2001 2002 2003 Scotland 2004 2005 2006 p 2007e Tayside Source: ISD Online p 2006 data are provisional e 2007 point is an estimate from data for the first three quarters of the year Includes pregnancies in women aged 13 to 15 years old (at the time of conception) ending in a live or stillbirth and pregnancies resulting in a therapeutic abortion or miscarriage which required hospital inpatient or day-case treatment. Excludes home births and births at nonNHS hospitals. The table below shows the pregnancy rates in those aged under 16 for three year periods from 1998 to 2006. When individual areas are considered, there are vast differences. Dundee City has by far the highest rate in Scotland and has been consistently much higher than the other two areas in Tayside. Rates of pregnancies per 1,000 females aged <16 years Area of Residence Scotland Tayside NHS Board Angus Dundee City Perth & Kinross 1998/00 1999/01 2000/02 2001/03 2002/04 2003/05 2004/06p 7.6 7.1 7.1 7.0 7.3 7.2 7.6 12.2 9.4 16.5 5.8 11.6 9.6 13.9 5.5 10.6 9.1 11.1 6.1 11.6 8.5 11.3 5.9 13.2 6.2 12.0 5.8 12.0 4.9 14.2 5.3 10.5 5.3 15.3 5.3 Source: ISD Online. P 2004/06 data are provisional 3 Although pregnancy rates are high, particularly in Dundee City, the actual numbers of pregnancies are fairly small as shown in the table below. Again, due to small numbers and issues of confidentiality, the data are presented in three year totals according to national practice. Numbers of pregnancies per 1,000 females aged <16 years Area of Residence Angus Dundee City Perth & Kinross 1998/00 1999/01 2000/02 2001/03 2002/04 2003/05 2004/06p 58 59 55 51 37 29 32 131 112 88 87 90 106 115 46 44 49 46 44 40 41 Source: ISD Online P 2004/06 data are provisional The next chart compares the under 16 conception rates for the three local authority areas in NHS Tayside with Scotland. A considerable decrease in the rate for Dundee City was shown in 2001 but an increasing trend is shown since then. Over time, Perth and Kinross has been just below the Scottish average rate, while the Angus rate has decreased from one that was above the Scottish average to one similar to Perth and Kinross. Conceptions per 1000 females aged 13-15yrs Rate of teenage conceptions per 1000 females age <16 years 18 16 14 12 10 8 6 4 2 0 1998/00 1999/01 2000/02 2001/03 2002/04 2003/05 2004/06p Year Scotland Tayside NHS Board Angus Dundee City Perth & Kinross Source: ISD Online Includes pregnancies in women aged 13 to 15 years old (at the time of conception) ending in a live or stillbirth and pregnancies resulting in a therapeutic abortion or miscarriage which required hospital inpatient or day-case treatment. Excludes home births and births at non-NHS hospitals. 4 Teenage conception and deprivation There is an association between deprivation and the teenage conception rate. The chart below shows pregnancy rates by deprivation quintile of the Scottish Index of Multiple Deprivation (SIMD). In the most affluent quintiles, 1 and 2, numbers of pregnancies in Tayside are very small and are suppressed in the published data. As deprivation increases to the most deprived quintile, 5, so do pregnancy rates in this age group. The chart below shows similar patterns for both Tayside and for Scotland, with Tayside rates being higher for SIMD quintiles 3 to 5. Pregnancy rate per 1000: age 13-15 by deprivation: Tayside 2005 50 40 30 10 22 20.5 20 3 8.8 6.1 4.1 13 9.2 0 1 2 3 4 5 SIMD quintile (1=most affluent) Scotland Tayside Source: ISD Online As well as demonstrating lower pregnancy rates, those in the most affluent areas as measured by SIMD show different outcomes when a conception does occur. A much higher rate of young women in more affluent areas terminate their pregnancy. 5 Pregnancy outcome (%) by deprivation quintile age 13-15: Scotland 2005 140 120 100 79 80 72 64 60 49 40 51 50 50 36 21 28 20 0 1 2 3 4 5 SIMD quintile (1=most affluent) Delivered Aborted Source: ISD Online Abortions Abortion rates in women aged 15-44 have been consistently higher in Tayside than in Scotland over the last 10 years, shown in the next chart. Abortion rates per 1000 women aged 15-44 Rate per 1000 women age 15-44 20 16.8 16 12 15.6 14.4 11.5 11.1 15.7 15.2 14 11.2 17.1 16.4 15.4 14 11.1 10.8 11.6 12.0 11.8 12.5 13.0 8 4 0 1998 1999 2000 2001 2002 Tayside 2003 2004 2005 2006 2007 p Scotland Source: ISD Online Notes: Refers to therapeutic abortions notified in accordance with the Abortion Act 1967 6 Abortion rates vary within Tayside, with Dundee City showing the highest rates over time. The chart below shows abortion rates in each area for the years 2003 to 2007. Rate per 1000 women aged 15-44 Abortion rates per 1000 women aged 15-44 by local authority area 25.0 19.8 18.6 20.0 15.8 15.0 14.1 14.7 19.0 21.1 18.7 14.9 14.9 13.9 13.2 14.0 13.6 11.7 10.0 5.0 0.0 Angus Dundee City 2003 2004 2005r Perth & Kinross 2006r 2007p Source: ISD Online Notes: 2007 figures are provisional Refers to therapeutic abortions notified in accordance with the Abortion Act 1967 The chart below shows that, in those under 16, conception is considerably more likely to end in a termination and in recent years, over two thirds of pregnancies in this age group have been aborted. No. deliveries or terminations Outcome of pregnancy in under 16 age group: Tayside 60 40 46 38 46 40 47 41 40 38 34 24 24 32 29 20 47 19 19 20 2003 2004 2005 23 0 1998 1999 2000 2001 2002 2006 Year Delivered Aborted Source: ISD Online 7 Among all teenage women (aged less than 20), the proportion of conceptions ending in termination has risen over time as the table below demonstrates. Pregnancy outcomes in Tayside women aged <20 years Total Year Delivered Aborted pregnancies 1998 488 311 799 1999 486 317 803 2000 487 313 800 2001 446 305 751 2002 416 310 726 2003 470 371 841 2004 473 340 813 2005 484 374 858 2006 456 373 829 Percentage aborted 38.9 39.4 39.1 40.6 42.6 44.1 41.8 43.6 45.0 Source: GRO online Repeat abortions Figures for 2006 and 2007 show that of all abortions, 30.1% and 29.6% respectively, are to women who have had one or more previous abortions. Sexual and Reproductive Health Services The numbers accessing family planning services have been rising over recent years as the chart below shows. Number of family planning clinic attendances: New and Return Num be r o f at t e ndance s 25000 20000 15000 10000 5000 0 2004 2005 2006 2007 2008 Ye ar Note: 2008 figure is based upon the first two quarters of 2008; Source: Tayside Family Planning Service data 8 Emergency hormonal contraception The uptake of emergency hormonal contraception (EHC) is shown below. To t al di spe nse d Uptake of Emergency Hormonal Contraception 1800 1600 1400 1200 1000 800 600 400 200 0 2006 2006 2006 2006 2007 2007 2007 2007 2008 2008 2008 2008 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Qtr 1 Qtr 2 Qtr 3 Qtr 4 Ye ar Note: 2008 figures are based on January - June 2008 Source: Ascribe and Prisms Long acting reversible contraception The next chart shows the uptake of long acting reversible contraception (LARC) Uptake of Long Acting Reversible Contraception Total dispensed 20000 15000 10000 5000 0 2005 2006 2007 2008 Year Note: 2008 figures are based on January - June 2008 Source: Ascribe and Prisms 9 Sexually Transmitted Infections In Tayside, rates of Chlamydia and other sexually transmitted infections (STIs) are increasing. The highest rates are found in the age 16-25 group in both genders. The increasing rates can be partly explained by the increase in clinical activity and higher rates of case finding. Uptake of Genitourinary Medicine Services The uptake of clinical services within Genitourinary Medicine (GUM) is increasing over time as shown in the chart below. Recording has changed over the period and current figures show number of cases while previous data has counted consultations with different professionals at the same visit as separate contacts. The increase in attendance is therefore greater than the chart suggests. Attendances at NHS Tayside Sexual Health Clinics Num be r o f at t e ndance s 12000 10000 8000 6000 4000 2000 0 2005 2006 2007 2008 Ye ar 2005 - 2007 figures from PRI are estimates based on quarterly averages for each year 2008 figure is based on Ninewells and PRI January - August 2008 data Source: Tayside Clinic data Chlamydia testing The chart below shows the number of Chlamydia tests performed in Tayside and that numbers are much higher in women than in men. 10 Num be r o f t e st s Number of Chlamydia tests performed: Tayside 8000 7000 6000 5000 4000 3000 2000 1000 0 2005 2006 2007 Ye ar Men 15 to 24 years Men 25 to 49 years Women 15 to 24 years Women 25 to 49 years Source: Population based Key Clinical Indicators for Sexual Health 2005 - 2007 Positivity rates vary across gender and age groups and are highest among young men, mainly because those accessing services are a higher risk group and are, for example, more likely to attend after contact tracing. Positivity rates are fairly low in women aged 25 and over. 25 20 t e st s P e r ce nt ag e o f po si t i ve Proportion of Chlamydia tests which are positive: Tayside 15 10 5 0 2005 2006 2007 Ye ar Men 15 to 24 years Men 25 to 49 years Women 15 to 24 years Women 25 to 49 years Source: Health Protection Scotland - HIV reports database (as at 31st March 2007) 11 HIV Numbers of HIV reports per year are small but, as shown in the chart below, the number of cases occurring through heterosexual contact is showing an upward trend. Number of reports 30 25 20 15 10 5 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year Sexual intercourse between men Sexual intercourse between men and women Injecting Drug Users NHS Tayside Source: Health Protection Scotland - HIV reports database (as at 31st March 2007) Overall, HIV reports in Scotland are increasing and while there were 171 reports in 2001, the number in 2006 was the highest recorded for a single year at 453. There is considerable variation in the incidence of HIV between the different Community Planning areas in Tayside. The number of people with HIV is much higher in Dundee City, and accounts for 68% of the current HIV population (where the Local Authority area is recorded). Access to services Lesbian, Gay, Bisexual Or Transgender Population National research has highlighted issues for people who are lesbian, gay, bisexual or transgender, mainly in terms of barriers to accessing sexual health services. Work carried out locally in a survey with 95 respondents confirmed that, although many reported positive experiences with healthcare services, 13% had experienced difficulties. Of particular importance were issues in relation to cervical smear testing and assumptions about heterosexual relationships when asking for any advice related to sexual health. 12 Ethnic minorities The non-white ethnic population in Tayside forms 1.9% of the total population. Cultural beliefs in relation to sexual behaviour and sexual health may be in conflict with the prevailing social norms and this needs to be acknowledged in addressing the sexual health needs of this population. Conclusion This document has presented data in relation to the main issues and challenges for NHS Tayside. In young people in particular, pregnancy and sexually transmitted infection rates are measured against an increasing sexually active population. The rising trends in accessing clinical services can show an increase in some indicators, such as higher rates of sexually transmitted infections due to case finding. The available data is regularly updated and monitored across the range of indicators presented here. References 1. Does the law matter? Young people, sex and relationships. Report of conference held by Children 1st and Childline, Edinburgh 17th June 2008. 2. Buston K, Williamson L, Hart G. Young women under 16 years with experience of sexual intercourse: who becomes pregnant? J Epidemiol Community Health 2007; 61: 221-225. 3. Wight D, Henderson M, Raab G, Abraham C, Buston K, Scott S, Hart G. Extent of regretted sexual intercourse among young teenagers in Scotland: a cross sectional survey. BMJ 2000; 320: 1243 – 1244. 13