The problem of teenage pregnancies in the UK led to the development of a National Teenage Pregnancy Strategy (NTPS) to combat it. Despite efforts put into this strategy, the UK still ranks as the highest in Europe and the lofty targets of 50% reduction is yet to be met as recent statistics show only an overall of 4.9% in reduction in rates since inception of the programme (ONS 2009).
The NTPS highlighted four key areas to be used as the basis for LA programmes which include; the use of mass media and campaigns to increase awareness, Sex and Relationship Education (SRE) in schools and community settings, easily accessible services and information on sexual health and improved assistance to young parents to reduce social exclusion (DCFS 2009). On this note, The last 10 years have seen the implementation of different programmes in the local authorities (LA) in an attempt to reach the national target of halving the rates of teenage pregnancy in the UK as well as providing means to increase by at least 60% the number of teenage mothers returning into gainful employment or education as the case may be (DCSF 2009).
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Different LAs have experienced both negative and positive changes in the teenage pregnancy rate with areas characterised by social and educational deprivation having a steeper rate of decline than others (DCSF 2005). Despite this steep decline, the Spearhead areas which face the greatest challenges in terms of health inequalities still have higher rates of pregnancies than others (DCSF 2009b) and Southwark belonging to this group has been worse-off than other areas in Britain. This essay attempts to highlight the process of impact assessment of the SRE programme adopted by Southwark and is intended to map the needs and examine demands of the teenagers and assess services providing SRE so as to check the gaps between these factors which are responsible for the high teenage pregnancy rate in this area despite the strategies applied in keeping with the NTPS.
SRE Programme Summary and Analysis
In 2000, the Department for Children, Schools and Family (DCSF) issued guidance on all schools to improve and ensure effectiveness of SRE in schools which is targeted at influencing young people to make responsible and well-informed choices about their lives (DCSF 2009c). SRE is meant to educate young people on sex-related issues and on making conscientious choices about their lives thereby reducing risky behaviour which might lead to unintended pregnancy. It involves mainly schools, the parents and the community at large. This is meant to be with support from the LA to ensure inclusion of comprehensive SRE programmes into PSHE in all schools (DfES 2006).
Southwark LA took the following approaches towards administering SRE which would raise the ambition of teenagers in the LA. It extended the services of sexual health professionals to beyond clinical settings to include schools and community settings. Programmes were developed outside school settings to teach teenagers about the realities of parenting and the advantages of wise choices for example: Choose your Life, L8R, Body Tool Kit, Teens and Tots, Virtual Doll Programme. Diverse needs of different ethnicities, religions and abilities were considered with programmes to meet them. In the school settings, the schools were made to develop SRE guidelines which involved parents, teachers, school nurses and teachers and vanguard staff especially those working with high risk teenagers in the schools and community were trained (NHS Southwark 2007). By this means, the Southwark LA seeks to improve the knowledge of young people on early pregnancies, direct them to making credible decisions and in turn reduce the rate of teenage pregnancies (Fullerton et al 1997).
The measures taken were in line with the aims and objectives of the programme as studies have shown that teenagers appreciated a forum to discuss sex and relationship issues and these forums were advantageous as they reduced the chances of earlier intercourse (Allen et al 2007; Fullerton et al 1997) however some local disputes existed that interfered with optimal delivery of SRE in the schools in Southwark. Not all schools had included SRE in the teaching curriculum, some of the teachers were unclear of the extent to teach and were either embarrassed or awkward about young peoples sexual issues, some schools had a curriculum that did not include social or emotional issues which play a significant role (Chambers 2002), mixed gender classes discouraged the teenagers especially females from asking questions (Stephenson et al 2004) and some parents were not totally cooperative as they withdrew their children from SRE classes (Lanek 2005).
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In response to these problems recommendations by Health & Social Care Scrutiny Sub-Committee (2004) were made. The committee advised that the obligation of all schools especially faith schools towards inclusion of SRE into school curriculum should be encouraged and advocated for further training of teachers on undertaking sexual health issues with teenagers and use of different techniques that will include social aspects. They also recommended that schools attempt to increase parents' awareness on the proactive nature of sexual health education (NHS Southwark 2004).
Health Impact Assessment Process
A Health Impact Assessment (HIA) is a blend of processes through which a project , policy or programme can be evaluated and assessed so as to identify the influence it has on the health of the population (WHO, 1999). It is a systematised way of assessing the effectiveness of a project involving different stakeholders in order to make evidence-based decisions towards improvement of the project where necessary (Lock 2000). A HIA is the ideal approach to use in assessing the effect of the SRE on Southwark teenagers as it identifies the health and inequality impacts (NHS Southwark 2004) considering the diverse nature of the young people in Southwark. Bearing in mind that this programme has been on-going, this process is regarded as a concurrent health impact to expose strengths and weaknesses in the project while making recommendations in tune with the gaps to further enhance its progress in the most cost-effective way (Bos 2006; WHO 2002).
The process of HIA involves a stepwise approach and has five core steps which would be applied towards the SRE in Southwark and any other HIA (Cameron 2000; WHO 2002). These steps which include; screening, scoping, appraisal, report and recommendation, and monitoring and evaluation may be adapted to suit the community or project being assessed (Breeze et al 2001; WHO 2010).
This process which is the first step in a HIA is aimed at exploring the feasibility and importance of the assessment, the department of health instructs on some questions to be answered to check viability of the HIA process, and the questions put into consideration the wider determinants of health which play a role in the problem of teenage pregnancy in southwark (DH 2007).
Based on the screening tool, a HIA is necessary on the SRE as Southwark LA ranks highest in teenage pregnancies in Britain despite its adoption of the programme like other LAs. In accordance with the NTPS, Southwark LA goals were to reduce teenage conception by 15% in 2004 and 60% by 2010 (NHS Southwark 2004) however the rate is still at 76.7 per 1000 and a change of 12% only has been seen since the start of the programme in 1999 (DCSF 2009a). Like the rest of Britain, Southwark included the SRE programme in its teenage pregnancy strategy and as the general consensus holds sex education has contributed greatly to the reduction of teenage pregnancies. The impact assessment will provide information and evidence on category and substance of change of the SRE programme where needed for policy makers to guarantee set targets of reducing teenage pregnancy rates are met (NHS 2007) .
A steering group is appointed to supervise the process and also to set the geographical boundaries and profile of the population affected by the programme in agreement with the stakeholders. (Cameron 2000; Metcalfe et al 2009). As the HIA is based on Southwark SRE the geographical boundary is limited to Southwark borough and the population profile consists of about 20,000 teenagers with 37% from Black and Minority Ethnic groups (BME), blacks make up 26%, 4% are Asians, 3% are Chinese, 4% mixed (ONS 2004; Southwark Vital Statistics 2007). Issues relevant to the needs of young people in Southwark in relation to the SRE are identified and discussed to direct the appraisal step of the HIA (WHO 2002). Background information on SRE in Southwark showed the problem with the programme was multifaceted (NHS Southwark 2004). Using this information in addition to information on the SRE in other LAs where successes have been registered, proposals can be set towards addressing the issues (Joffe et al 2005).
"Appraisal is the 'engine' of health impact assessment, moving the whole process along towards practical outcomes" (Cameron 2000). This appraisal can be regarded as intermediate as the method of information collected is based on a collaboration of stakeholders, health care professionals, the teenagers and a semi-extensive literature review on the effects of sexual education on teenagers. The negative and positive impacts of the SRE on reducing teenage pregnancies in Southwark is explored by this process (Parry et al 2001) using both qualitative and quantitative data for completeness. Considering this is a concurrent HIA the past impacts are evaluated with a vision to enhance future progress. It is a multidisciplinary step as it involves all the people involved in the SRE programme (WHO 1999). Workshops organised should include the health workers, school-teachers, school nurses, community programme co-ordinators, peer-health educators, youth representatives from schools and community programmes, representatives from faith-based organisations and representatives from the LA who will provide local views of the programme (Mindell et al 2004) . The information collected from this exercise will help define the understanding of SRE amongst the different groups, inequalities existing between these groups may also be recognised and aspects of the programme which are not advantageous may be brought to light. It will also help to assess long and short-term impacts of the programme (Joffe et al 2005). Considering that data collected from this exercise are likely to be biased, robust methods are needed to contribute validity to the predictions derived from the data (Parry et al 2001). Other information should be collected by secondary analysis of existing data from the youth centres, school reports, NHS Southwark databases, and Office for National Statistics. This data collected will supply the sociodemographic and health profile of the teenagers in Southwark, and also report on already experienced impacts of the SRE.
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Some challenges are expected in this stage as evidence-based information regarding the determinants of health for the different groups of teenagers may not be readily available or easily accessible. This may be daunting but should not deter continuation of the assessment rather the best available data should be used while recognising the significant gaps in the evidence used (Joffe et al 2002, Mindell et al 2003).
A sexual health needs assessment conducted on Southwark showed that high levels of need exist in relation to teenage pregnancies in Southwark and it is evident from the high teenage conception rates, high termination and repeat termination rates (NHS Southwark 2004). Another major finding which can be related to the SRE is that these high rates are disproportionately distributed as the Black and Minority Ethnic groups have higher rates (Berthoud 2001). The needs of this group are peculiar as teenage pregnancy is viewed differently with regards to the culture or religion. Teenagers of Muslim faith had different views from the wider community as younger marriage and parenthood is regarded as the norm (DCSF 2008). It is of importance to note that the ethnic inequalities in teenage pregnancy is an outcome of socioeconomic disparities (Nazroo 2003) which is evident in their representation in number looked after by LAs and in school exclusions (DCSF 2008). On the other hand, the teenagers considered sexual health services aligned to schools with some scepticism which was based on confidentiality issues (NHS Southwark 2007). Some studies carried out on the effects of sex and reproductive education on young people showed that most young people were more satisfied when the education was peer-led than teacher led and females had some inhibitions about discussing sex related issues in the presence of males (Stephenson et al 2004; Seamark et al 2005; Ross 2008). Also, despite the addition of SRE into school programmes, most teenagers cited places other than school as main source of sex related information (Allen et al 2007).
Putting all the information into consideration, the basis for the HIA can be addressed towards the different ethnicities, faiths and socioeconomic groups (Fullerton et al 1997) considering that this has been recognised as the bane of the challenges faced in maximising the impact of SRE to teenagers in Southwark. Appraisal done can relate these needs to the services available and identify the gaps where they exist to make recommendations towards satisfying the needs in the future.
Report and Recommendations
In view of the fact that the problem of teenage pregnancies in Southwark is on-going with about 289 pregnancies in U-18s yearly ( NHS Southwark 2009), it is essential that this process of report writing which will influence decision-making by the stakeholders is not delayed so as to ensure early adaptation of recommendations where implied (Joffe et al 2005). A high level of assiduousness must be assumed by the steering group to guarantee thoroughness in the recommendations proposed.
The Dahlgren and Whitehead (1991) rainbow model of health integrates biological, social and environmental factors into defining the general well-being of an individual. These factors are not constant and the degree of influence each of these determinants of health play varies for different population groups. The decision-making step of the HIA should put this model into consideration while proposing recommendations on the SRE which would adjust the proposal to take full advantage of already established positive impacts while curtailing the negative health impacts (Parry et al 2001).
Consequent upon the findings during the appraisal step of the HIA recommendations towards improving the SRE may include: establishing ethnic and faith -based SRE programmes, which will relate better with the different beliefs held by the diverse groups found in Southwark, stronger collaboration of the community, health sectors and schools in promoting SRE and further training of more peer-educators to increase the impact of the programme and thereby reduce the rate of teenage pregnancies. In addition to this, consideration of same-sex SRE classes should be made (Fullerton et al 2001) There should be a recommendation for future monitoring of the impacts seen after implementation of the revised project which would allow for necessary action towards unexpected outcomes and also contribute to the evidence base for later use (Metcalfe et al 2009; WHO 2002).
Monitoring and Evaluation
The fact that recommendations have been put forward does not guarantee implementation thus monitoring is of necessity to ensure that decision-makers put into effect agreed changes as different factors like lack of resources or political shifts could influence decisions (WHO 2010; Joffe et al 2005). The indicators which should be used in assessing the revised SRE would include rate of teenage pregnancies recorded, teenagers knowledge of sex related issues and ability of teenagers to make well-informed choices to name a few. This can be gauged using qualitative and quantitative methods (Scott-Samuel et al 2001). Long term monitoring can be used to assess accuracy of predictions made during the appraisal and recommendation (Taylor et al 2003; WHO 2002).
Three different forms of evaluation are essential. These include; evaluation of the process which acts as a mechanism of quality assurance (process evaluation), evaluation of acquiescence and execution of recommendation (impact evaluation) and outcomes of subsequent proposal (outcome evaluation) (Parry et al 2001; Scott-Samuel 1988). It is important to note that notwithstanding the extensive nature of the appraisal, the outcome may not be as predicted especially for the groups which have been identified as vulnerable groups which in this case are the BME thus the impacts in this group may be assessed and compared with other groups for more clarity (Joffe et al 2005). Other possible challenges in this stage may be budget related or due to the seemingly endless need for evaluation of a project however a defined stop-point at the onset will help to eliminate this difficulty (Thorogood et al 2000; Taylor et al 2003).
The concept of HIA is fairly new but then its effectiveness is extensive as it has been used in different sectors realeting to health issues and otherwise. The advantages of carrying out a HIA Can be used prospectively, concurrently or retrospectively;
_ Values a social model of health and well-being;
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