Chapter 3: Respect and Responsibility: Sexual Health and Wellbeing
Unlike the other three topic chapters in this Framework, each of which deals with a single disease, this chapter relates to a range of sexual health and wellbeing issues. The sexual health chapter of the Framework is, therefore, necessarily broader in scope.
Where we are now
Respect and Responsibility (Scottish Executive, 2005), the first national strategy for sexual health in Scotland, has been in place since 2005. Following a review in 2008, the Scottish Government, NHS Boards, Third Sector agencies, Local Authorities and other stakeholders worked towards the Respect and Responsibility National Sexual Health Outcomes 2008-2011 (Scottish Government, 2008b ).
Respect and Responsibility has three broad aims:
- to improve the quality, range, consistency, accessibility and cohesion of sexual health services from primary care to GUM services, in line with the principles of providing services that are safe, local and appropriate;
- to support everyone in Scotland, including those who face discrimination due to their life circumstances or their gender, race or ethnicity, religion or faith, sexual orientation, disability or age, to acquire and maintain the knowledge, skills and values necessary for good sexual health and wellbeing; and
- to positively influence the cultural and social factors that impact on sexual health.
The strategy recognised the diversity of lifestyles in the population of Scotland. Its approach, based on the principles of self respect, respect for others and strong relationships, continues to be relevant.
Much has been achieved through Respect and Responsibility and the National Outcomes. In particular, the majority of NHS Board areas now offer high quality integrated sexual health services. Quality Standards for sexual health services have been developed by NHS Quality Improvement Scotland ( QIS) and NHS Boards are working to meet these standards with support from Healthcare Improvement Scotland (formerly QIS). The type of service provided in Primary Care, however, remains inconsistent.
In many areas of Scotland young people also now have access to general health advice, chlamydia testing, pregnancy testing and condoms in or within walking distance of schools. There is improved availability of sexual health and relationships education in schools and other settings, although this is not consistent throughout Scotland. The Reducing Teenage Pregnancy Guidance and self-assessment tool ( LTS, 2010) has been produced but has not, as yet, been uniformly implemented.
In terms of communication the Sexual Health Scotland website ( http://www.sexualhealthscotland.co.uk/) has been an important development. It provides non-judgemental advice and information about sexual health, relationships and service provision. There has also been the delivery of national social marketing campaigns Sex: It's Healthy to Talk About It (promoting communication); Giving You More Choice (raising awareness of Longer Acting Reversible Contraception ( LARC); and HIV Wake Up (raising awareness of HIV testing, aimed at men who have sex with men).
Sound leadership and co-ordination has been provided through the Ministerial National Sexual Health and HIV Advisory Committee ( NSHHAC) and, at local level, through multi-agency sexual health strategy groups and sexual health leads. Some areas have been more successful than others, however, in getting the necessary buy-in and support of non- NHS statutory organisations and agencies.
Where we want to be
The sexual health and wellbeing element of the Framework intends to support and promote ongoing delivery of the key elements of Respect and Responsibility. Specifically, for 2011-2015 the intention is that:
- the aims and principles of Respect and Responsibility, should continue to be delivered, taking into account the progress already made; and
- key areas for further action to improve sexual health and wellbeing in Scotland should be identified, informed by up to date evidence and, in particular, a focus on those who are considered to be most at risk of poorest sexual health and wellbeing.
The Framework translates this agenda into the high level Framework Outcomes:
Framework Outcomes: Sexual Health and Wellbeing
- Fewer sexually transmitted infections; fewer unintended pregnancies
- A reduction in the health inequalities gap in sexual health
- People affected by blood borne viruses lead longer, healthier lives
- Sexual relationships are free from coercion and harm
- A society and culture whereby the attitudes of individuals, the public, professionals and the media in Scotland towards sexual health are positive, non-stigmatising and supportive.
The Multi-Agency Approach
As highlighted throughout the Framework, improving sexual health and wellbeing is a multi-agency responsibility. It cannot be addressed through interventions delivered in specialist sexual health services alone. Each area has already established a multi-agency sexual health strategy group and these groups should continue their role in promoting and delivering partnership working to enable local progress and improvement in sexual health and wellbeing.
Primary Care has an important role to play, particularly in remote and rural areas where access to specialist services may be difficult and challenging. A well-informed, responsive and supported Primary Care sector can fulfil the essential sexual healthcare needs of the majority of the local population, enabling sexual health services to focus on the provision of specialist care. Universal women's, men's and children's health services also play their part. Importantly, Local Authorities have responsibility for key policy areas which impact on sexual health outcomes, including education and social work.
- Multi-agency sexual health strategy groups should ensure that Primary Care is engaged and supported in the development and implementation of local sexual health strategies, including the development of cost-effective models of care, with clear care pathways for the individual.
- Those heading up multi-agency sexual health strategy groups should ensure that membership is relevant, pro-active and at a sufficiently senior level to ensure appropriate and timely decision making. Roles and responsibilities should be clear and explicit.
- There should be strong links between multi-agency sexual health strategy groups, Blood Borne Virus MCNs, Alcohol and Drug Partnerships and Community Health Partnerships which, in turn, will feed into the Community Planning process.
- Where relevant, Local Authorities should link progress against Framework Outcomes to Single Outcome Agreements, in conjunction with local partners.
Delivering the Outcomes
The following section details the recommendations and strategies that multi-agency partners should adopt to contribute towards delivery of each of the Framework Outcomes. Progress against outcomes will be measured through the agreed set of national indicators (see Appendix 1).
Outcome 1: Fewer newly acquired blood borne virus and sexually transmitted infections; fewer unintended pregnancies.
Outcome 2: A reduction in the health inequalities gap in sexual health and blood borne viruses.
Children and Young People
Getting it Right for Every Child (Scottish Government, 2006) provides the methodology for delivering the Early Years Framework (Scottish Government and COSLA, 2008a,b), Equally Well and Achieving our Potential: A Framework to tackle poverty and income inequality in Scotland (Scottish Government 2008e). Strong partnership working should be taking place locally across all agencies, at both practitioner and strategic organisational level, to improve outcomes for all children and young people. This work should take an early intervention approach and deliver streamlined and co-ordinated help that is appropriate, proportionate and timely. This work, combined with the other values, principles and core components of Getting it Right for Every Child, is key to addressing some of our most entrenched problems in society, including the need for improvement in sexual health and wellbeing.
- Improving sexual health and wellbeing should be integrated into wider work streams at local level which aim to address health and social inequalities and risk taking behaviours and which focus on prevention, including building resilience, aspiration and self-esteem.
Whilst pregnancy and parenthood are positive choices for some young people, for others they are associated with negative social and psychological consequences.
Local Authorities have the lead role at local level in delivering national strategies which address disadvantage in Scotland and breaking the intergenerational cycle of inequalities. They are, therefore, best placed to assume a leadership role in delivering reduced teenage pregnancies in partnership with NHS, Third Sector and other local partners. Where relevant, Local Authorities should ensure the inclusion of a teenage pregnancy Single Outcome Agreement indicator.
In addition, Local Authorities and other statutory and Third Sector organisations are asked to work together to implement Reducing teenage pregnancy - Guidance and self-assessment tool, published by Learning Teaching Scotland ( LTS) in 2010. This brings together the range of current evidence and advice on the partnerships, strategies and interventions that need to be in place locally if teenage pregnancy rates are to be reduced ( LTS, 2010). By reviewing this evidence and using the self-assessment tool on an annual basis, Local Authorities and their partners can build on existing good practice to address teenage pregnancy in the long term.
- Local authorities should take a leadership role in addressing teenage pregnancy and should play a key role in implementing the 'Reducing teenage pregnancy' self assessment tool ( LTS, 2010).
It is more effective and cost effective to focus efforts on those known to be most at risk; this is supported by Healthcare Improvement Scotland Sexual Health Standard Criteria 3.6 .
Local needs assessment will inform multi-agency sexual health strategies but high risk groups are likely to include young people aged under 25 and men who have sex with men ( MSM). Within these groups, higher-risk populations include young people not in school, young offenders and those who are looked after or accommodated. Those with alcohol and/or drugs problems are also at risk of poor sexual health outcomes.
Pregnancy and parenthood are positive choices for many; many unintended pregnancies lead to positive experiences for mother and child. However, some women may be at risk of harm due to unintended pregnancy and should therefore be targeted for supportive and preventative action. Those who are most at risk include women who have had a previous termination, young women who have had repeat pregnancies in adolescence and some women in areas of deprivation. They will also include other vulnerable women such as those who misuse substances and/or who are involved in prostitution.
- In order to support a more targeted approach multi-agency partners should be working together to ensure:
- the provision of drop-in services for young people in, or close to, schools, particularly in areas of greatest need ( e.g. areas of high prevalence, remote/rural areas where there are fewer specialised sexual heath services), which provide both general and sexual health advice, pregnancy testing and condoms;
- that women who attend for termination are made aware of the availability of local sexual health services, where this is appropriate;
- the provision of Longer Acting Reversible Contraception ( LARC) to vulnerable women most at risk of unintended pregnancy, where appropriate, including in termination and maternity services, prior to discharge. This is supported through NHS Quality Improvement Scotland Sexual Health Standards 6  and 8 ;
- targeted provision of sexual health and HIV prevention services to support MSM. This work should be delivered in partnership through both the statutory and Third Sector.
Sexual Health and Drug or Alcohol Use
It is recognised that being under the influence of alcohol and drugs can affect an individual's judgement and make them vulnerable to engaging in risk-taking behaviour, such as unprotected sex. This includes both those who drink socially and those with a drug or alcohol problem. Work to encourage and support people to make responsible decisions around alcohol and drugs will therefore contribute to fewer poor sexual health outcomes, such as unintended pregnancies and STIs. It is therefore important that there are strong operational links between sexual health and alcohol and drug services and strong strategic links between Multi-Agency Sexual Health Strategy Groups and Alcohol and Drug Partnerships.
Providing drug and alcohol harm reduction, treatment and rehabilitation services should involve a sexual health assessment, with appropriate advice given and contraception needs met. This should be revisited when staff become aware that clients are in a relationship. Similarly, those undertaking needs assessment in sexual health services will need to take into account drug and alcohol use, without the individual being judged or stigmatised. Staff should also be aware of how and where to refer people on to appropriate local services. This has education and training implications to ensure that drug and alcohol staff feel confident and skilled to discuss sexual health issues and sexual health staff feel confident and skilled in specific issues for people with drug and alcohol problems. For those at particular risk of poor sexual health outcomes, contraception needs may include the provision of LARC. Particular support is required for pregnant women with a drug or alcohol problem, and their partners, throughout pregnancy and in bringing up their child in the future.
- There should be strong partnership working between Multi-Agency Sexual Health Strategy Groups and Alcohol and Drug Partnerships.
- There should be clear links between sexual health and drug and alcohol services, with sexual health issues addressed as part of the assessment process, including advice on contraception for both men and women and, where appropriate, the provision of contraception including LARC.
Relationships, Sexual Health and Parenthood ( RSHP) Education
Local Authorities are responsible for ensuring that Relationships, Sexual Health and Parenthood Education ( RSHP) is delivered to all young people, both in school and wherever learning takes place. Looked after and accommodated young people and young offenders are most at risk of poor sexual health outcomes and should therefore be prioritised for such education.
The delivery of RSHP within the Health and Wellbeing component of Curriculum for Excellence provides the opportunity for linkages with other health improvement issues and risk-taking behaviours such as blood borne viruses, alcohol and drug misuse, smoking and mental health. Local Authorities must ensure that the delivery of such education meets their equality and diversity legal obligations.
Parents and carers have an essential role to play in the provision of age appropriate RSHP. Local Authorities, in partnership with NHS Boards, must play a key role in supporting and facilitating parents and carers to discuss relationships and sexual health with children and young people.
- Relationships, Sexual Health and Parenthood education should be provided to all young people, including those not in school, with delivery in line with equality and diversity legal obligations.
Sexual Health Services
As highlighted throughout the Framework, the provision of sexual health services should be a multi-agency and multi-disciplinary responsibility, based on local epidemiology and need. All sexual health and blood borne virus consultations, whether carried out in primary or secondary care, should begin with a risk assessment. Critical issues to be addressed include the use of an effective method of contraception, STI and blood borne virus testing tailored to individual risk, as well as alcohol and drug use (see Chapter 1). Specialist services should be set up in such a way that they can provide holistic care, based on the needs of the individual, including, for example, a focus on tackling non-sexual health issues such as drug and alcohol abuse or gender-based violence.
In addition, specialist services for those with specific sexual health needs ( e.g. sexual dysfunction, transgender issues etc) should be accessible throughout Scotland. This is supported by NHS Quality Improvement Scotland Sexual Health Standard 1 .
The Lead Clinicians for Sexual Health have been key in driving forward the agenda on sexual health locally and nationally. Every NHS Board should ensure that this role is fulfilled and recognised in job-planning processes. The Lead Clinician role is clearly set out in Respect and Responsibility (Scottish Executive, 2005).
- Sexual health consultations, undertaken in primary or secondary care, should begin with a risk assessment, with testing and treatment and care tailored to individual needs.
- High quality, integrated sexual health services should be available throughout Scotland.
Training and Education
Regular training, education and continuing professional development is vital to ensure the confidence and competence of the workforce.
- Local multi-agency strategies should detail clear action to ensure a competent and confident workforce for both health and non-health staff through regular training, education and continuous professional development. In NHS Boards, this is supported by NHS Quality Improvement Scotland Sexual Health Standard 9 .
Sexual Health Improvement Interventions
In January 2011, the Chief Medical Officer for Scotland set up an Expert Advisory Group to review the evidence base underpinning opportunistic chlamydia testing, with a view to further advice being provided to the NHS in Scotland to augment SIGN Guideline 109 ( SIGN, 2009) on the management of genital chlamydia trachomatis infection. The Group are due to report in summer 2011. The Scottish Government will consider carefully the findings from the review and the potential impact on current policy and practice, taking forward work with stakeholders as part of the implementation of this Framework.
- The Scottish Government will consider carefully the findings from the Report of the Expert Advisory Group on chlamydia testing and its impact on current policy and practice, working with stakeholders as part of the implementation of the Framework.
A report on a systematic review of reviews on effective interventions to improve sexual health and wellbeing and three short evidence briefings covering Children and Young People, Adults and Service Delivery ( NHS Health Scotland, 2010a,b,c) were published by NHS Health Scotland in September 2010. The findings, and the outcome of a service mapping exercise across Scotland, published in June 2011, will assist with the implementation of interventions which have a sound or promising evidence base.
Monitoring and evaluation should be integral to service provision, with findings shared to promote best value and to inform local priorities and future planning.
- Sexual health improvement interventions should have a sound or promising evidence base and should be monitored and evaluated.
Sexual Health and the Prison Service
In Scotland, some of those most vulnerable to poor sexual wellbeing are those who are, or have been, in prison or young offender services.
Sexual health work in prisons should prioritise those most in need. Young offenders, their partners and women are particularly vulnerable to poor sexual health and wellbeing and may also be perpetrators or victims of coercive and harmful sexual relationships.
Examples of good practice are already in evidence and the transfer of prison health services into the NHS in 2011 offers an opportunity to further support improvements in sexual health for these key populations.
Supporting these vulnerable populations requires input both during their time in prison and following release. Scottish Prison Service and NHS Boards have a duty of care to ensure that people are adequately signposted to services following release. It can be challenging for these populations to link with services. Many people leaving prison will also have drug and alcohol problems. The linkage between sexual health and drug and alcohol services will again, therefore, be important.
- The Scottish Prison Service and NHS Boards should work in partnership to ensure that:
- the sexual health and wellbeing needs of prisoners, and their partners where possible, are addressed, including the provision of contraception, which may include LARC, where appropriate; and
- sex and relationships education is prioritised; in the first instance to young offenders and women.
Outcome 3: People affected by blood borne viruses lead longer, healthier lives.
There is evidence of the impact of STI and blood borne virus co-infection with a number of studies indicating a strong association between STIs and increased risk of HIV acquisition. Co-infection of HIV and other STIs is common, particularly amongst MSM; co-infection of hepatitis C and HIV accelerates the development of advanced liver disease and can create complications for those living with blood borne viruses. Services should therefore be alert to issues of co-infection, develop cross-condition measures to tackle the problem and, when appropriate, provide long-term care and support.
- Sexual health services should be alert to issues of co-infection and, where possible, develop cross-condition measures to tackle the problem.
Accessibility of Sexual Health Services
As set out in NHS Quality Improvement Scotland sexual health Criteria 1.4  and Standard 5 , there should be targeted services for communities or individuals with specific needs. This includes not only people living with HIV and hepatitis B, but also those affected by hepatitis C, where new infection is being seen in some HIV positive MSM. Services should ensure that both men and women living with, or at risk of, blood borne viruses have access to sexual health care, including contraceptive advice and provision, where relevant.
Women involved in prostitution are extremely vulnerable to blood borne viruses, STIs and poor sexual and reproductive health. It is therefore important that these women are able to easily access high quality sexual health services.
NHS Quality Improvement Scotland Sexual Health Standard 5 supports the accessibility of high quality sexual healthcare to those attending services for ongoing HIV care, to improve their personal wellbeing and to minimise the risk of transmission.
- High quality sexual health and support services should be accessible to all, including those affected by blood borne viruses, through both NHS and Third Sector services.
Outcome 4: Sexual relationships are free from coercion and harm
Information for Young People and Other Vulnerable Groups
Self-esteem and aspiration have an important role to play in ensuring that sex takes place within a safe, respectful and mutually supportive environment and that sexual experiences are not coerced or regretted. It is important that all young people, but in particular young women and young MSM, should be supported through programmes of confidence, self-esteem and aspiration building.
Parents and carers also play an extremely important role in this area, for example through fostering openness and discussion opportunities with their children, looking at family cultural issues and supervision of young people. Their role should be acknowledged and facilitated, where it is considered appropriate.
People with learning disabilities can be vulnerable to coercion and harm, including sexual abuse. It is important that appropriate information explaining what sexual abuse is, how to protect oneself and where to get help if required, is made available to those with learning difficulties. Family carers and support workers also need information to address issues such as how to recognise, support and respond to abuse, legal issues and where to go for further information and help.
- Local Authorities should work with partners to ensure that all young people, parents and carers, have access to high quality and consistent information on sexual health and wellbeing.
- Appropriate information should be available to those with learning difficulties, their carers and support workers.
All services and professionals should be comfortable promoting good communication as central to better sexual health and wellbeing and better relationships.
- There should be continued action to encourage good communication for better sex and better relationships, including same sex relationships, including action to:
- encourage communication and confidence both before and during sexual relationships;
- provide support to ensure that no-one feels coerced into an unwanted sexual encounter whether through force, abuse of alcohol or drugs or through pressure from peers and/or the media;
- recognise that body image has a strong impact on individual's and society's perceptions of sexual relationships;
- support positive sexuality for people with physical disability; and
- challenge the negative assumptions attributed to the sexuality of people with learning disability.
Gender-based violence comprises a range of abusive and controlling behaviours that can include sexual assault and forced sex, as well as more hidden forms of victimisation that interfere with a person's choices about sexual activities, contraception, safer sex practises, pregnancy and the ability to negotiate around these issues.
Whilst sexual abuse and coercion can happen to anyone, young people (particularly young women) and women and men involved in prostitution have heightened vulnerability. Evidence indicates that experience of gender-based violence is consistently associated with unplanned pregnancies, sexual risk taking, STIs, terminations of pregnancy and sexual dysfunction and can be a barrier to adults and young people accessing sexual health care.
The NHS has a pivotal role in the appropriate identification and management of gender-based violence, since virtually all survivors of abuse will interact with health services at some point, either on their own or on their children's behalf. The implementation of Routine Enquiry of Sexual Abuse is currently underway. This will lead to increased detection and will afford survivors the opportunity to access support and services, allowing for earlier intervention and improved health outcomes. It also necessitates strong partnership working between all relevant services.
- Those working in sexual health services should be sensitive to the impact of gender-based violence on sexual health and be aware of support services for individuals who have been abused and how to refer onwards.
- NHS Boards should review sexual health service provision for those who have suffered from sexual assault to identify how this can be improved or strengthened.
Many women who are, or have been, within the prison service are victims of coercive, harmful or abusive relationships, whether through their partner, childhood sexual abuse and/or prostitution.
The Scottish Prison Service, and from November 2011 NHS Boards, have an important role in offering advice, education and support to such vulnerable women to help empower them to remove themselves from coercive and harmful relationships. Many of these women may also have drug or alcohol problems associated with abusive sexual relationships and supporting recovery will be an important factor.
- Scottish Prison Service and NHS Boards should work in partnership to provide advice, education, and support to women in prison who are, or who may be, subject to coercive and harmful relationships.
Outcome 5: A society whereby the attitudes of individuals, the public, professionals and the media in Scotland towards sexual health and blood borne viruses are positive, non-stigmatising and supportive.
Relationships, Sexual Health and Parenthood ( RSHP) Education
- Relationships, Sexual Health and Parenthood education should be provided to all young people, with delivery in line with equality and diversity legal obligations.
Promoting Sexual Health and Wellbeing
National and local awareness raising is key to promoting knowledge, understanding and communication around sexual health and wellbeing and in particular to a broader understanding beyond 'safer sex'.
Challenging cultural and commercial messages which reinforce negative stereotypes of gender identity and sexual orientation are essential to promoting positive sexual health and wellbeing. Gender stereotypes of both men and women perpetuate assumptions of male power and control over a sexual partner, are often founded on misinformation and can inhibit and limit both men and women in developing meaningful relationships and emotional maturity. These stereotypes can be reinforced by both written and electronic media and through, for example, advertising. These rapidly developing influences should be counteracted with positive local and national action.
- Work to promote the positive and life enhancing aspects of sexual wellbeing and sexual relationships should continue locally, regionally and nationally.
- Efforts to promote a positive approach to sexual health and relationships in the media should continue, nationally and locally, through linking in with media groups such as the National Union of Journalists and national broadcasting regulators.
The Scottish Government will monitor progress on delivery of the outcomes through the Framework Indicators detailed in Appendix 1.
The Scottish Government, including the National Co-ordinators, Special Health Boards and other national organisations will have key roles in progressing the achievement of the Framework Outcomes and supporting multi-agency partners. These roles are set out in Chapter 7.
Table 3.1 - Outcome 1: Fewer newly acquired STIs; Fewer unintended pregnancies
Sexually Transmitted Infections
- The overall trends for the four main sexually transmitted infections (genital chlamydia, gonorrhoea, genital herpes and genital warts), show a general increase in diagnoses - although much of this increase is related to increased access to services and increased testing in recent years.
- Young people aged less than 25 and men who have sex with men are most at risk of infection.
- The teenage pregnancy rate in Scotland has remained steady over the last ten years, but the most recent data has shown a very slight decrease across all age groups. ( ISD, 2011a)
- There is a strong association between deprivation and rates of teenage pregnancy. Those living in Scotland's most deprived areas have approximately four times the rate of teenage pregnancy (91.3 per 1,000 compared with 22.2 per 1,000) and ten times the rate of delivery as the least deprived (65.3 per 1,000 compared with 7.6 per 1,000) ( ISD, 2011a).
Termination of Pregnancy
- In 2009 and 2010, there was a reduction in the number of terminations of pregnancy performed. 28% of those women had had at least one previous termination. ( ISD, 2011b)
- The rate of terminations in 2010 was highest in younger women 16-19 (21.4 per 1,000) and those aged 20-24 (22.4 per 1,000). ( ISD, 2011b)
- Termination rates show a clear link with levels of deprivation. Rates in areas of high deprivation (16 per 1,000) are nearly double that seen in the most affluent areas of Scotland (9.2 per 1,000). ( ISD, 2011b)
Table 3.2 - What the evidence tells us
- Evidence indicates that interventions in the early years of a child's life are most effective in supporting positive sexual health outcomes ( NHS Health Scotland, 2010a). In particular, the Family Nurse Partnership and Abecedarian Projects have provided high quality evidence on the effectiveness of early intervention in achieving positive sexual health outcomes in young people, including reductions in unintended pregnancy.
- The evaluation of Healthy Respect Phase Two ( NHS Health Scotland, 2010d) also highlighted that poor outcomes in teen years, including sexual risk-taking, are best tackled in the early years (pre-birth to age eight) of a child's life; that there is a need to work more intensely with young people to help them address underlying issues which shape sexual health; that the most vulnerable young people should be targeted for interventions; and that generic aspects of parenting are more important than communication about sexual matters.
- Sexual health and relationships education remains critically important. It is now well established that providing accurate age and stage appropriate information can support young people to avoid sexual activity until they are physically and emotionally ready (Currie et al, 2008).
- The availability of comprehensive and integrated sexual health services remains key to sexual health and wellbeing.
- Socio-economic influences have a clear impact on sexual health outcomes.
- Early evidence indicates the strong impact of the media on young people's approaches to sex and sexual relationships.
- Data suggests that healthy sexual attitudes are understood by a significant majority, but significantly fewer act on these healthy attitudes. (Progressive Partnership Ltd. 2008)
- Recent findings suggest that young people in alternative educational settings have poorer health-related behaviours compared with their peers in mainstream education and are more vulnerable than their mainstream peers in terms of sexual activity, condom and contraception use. (Henderson et al, 2011)