Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Sex education at the appropriate age
- caroline scherf (24 November 2006)
-
Systematic review to address socioeconomic inequalities associated with teenage pregnancy
- Ginny Brunton, Ann Oakley, and Angela Harden. (2 December 2006)
-
What this study adds
- David J Torgerson (19 December 2006)
-
Re: What this study adds
- Gillian M Raab, Daniel Wight, Marion Henderson (21 December 2006)
-
Re: Re: What this study adds
- David J Torgerson (22 December 2006)
-
SHARE has changed since study
- D Graham Mackenzie, John Taylor (19 January 2007)
-
Impact
- Jose J De Murtinho-Braga (22 January 2007)
-
Social Inclusion for Relationship and Sexual Health
- Robert J Reynolds (23 January 2007)
-
Sex or Social Education?
- Nina Champaneri, B71 4NH (26 January 2007)
-
SHARE and Reconfiguration
- Robert J Reynolds (26 January 2007)
|
|
|||
|
caroline scherf, consultant Sexual & Reproductive Health Cardiff CF64 2XX
Send response to journal:
|
Sir, The disappointing findings by Henderson et al of no reduction of conceptions among women who had specially designed Sex Education Sessions were wholly predictable. Such a study is likely to be exploited by those opposing sex education in schools as proof of it’s inefficiency. Such a conclusion would be totally incorrect, despite the findings of Henderson’s well designed study. Both the study group and the control group were exposed to the different types of Sex-education in Secondary school at age 13 – 15 years. At this age, between 20-30% of them will have experimented with Sex already and thus present a classic case of ‘missing the boat’. Teenagers are exposed to a multitude of Sex ‘education’ run by TV, internet, radio and magazines aimed at young people. They have drawn their own conclusions which are very difficult to challenge once established. This may be due to 13 - 15 being a quite rebellious age at which children are very unlikely to face uncomfortable facts – such as the need for organising contraception prior to having sex. At this age, the hedonistic ‘it won’t happen to me’ prevails, leading to unsafe experiments with Sex. Teenagers from other countries in Northern Europe with lower rates of unplanned pregnancies and STI’s have been educated about mammal reproduction including humans since nursery school age and know a whole lot more about contraception and how to find it by the time they reach this ‘risk-taking’ age. The most powerful barrier to overcome is the completely untrue myth that Sex Education in nursery and Primary School age will encourage children to be sexually active. The opposite is true: sex can be seen as part of normal reproduction and will become greatly de-mystified. CHildren will thus become empowered to make important decisions. Human reproduction must be included into the nursery and primary school curriculum with no opt-out options for parents. It should be taught alongside Literacy and Numeracy with material appropriate for young children. It must not be left to parents as this approach has proven ineffective with the Sexual Health of Teenagers in this country deteriorating. The department of education has made a plea to reduce teenage illiteracy – and the expense and effort invested is remarkable. The Government's plea to reduce teenage pregnancy must be taken up by the Department of Education to intiate Sex Education before the child can read and gather his/her own information. Such an approach would enable teenagers to behave more responsibly and be less likely to regret their first sexual experience or suffer morbidity from it. Ref M Henderson, D Wight, G M Raab, C Abraham, A Parkes, S Scott, and G Hart Impact of a theoretically based sex education programme (SHARE) delivered by teachers on NHS registered conceptions and terminations: final results of cluster randomised trial BMJ 2006; 0: bmj.39014.503692.55v1 Ejidokun O, McNulty D, Linnane J, Ramaiah S; Sex Education should begin in primary school; BMJ. 1999 Jan 2;318(7175):57 Wellings K et al.; Sexual Behaviour in Britain: early heterosexual experience; Lancet 2001; 358:1843-50 Competing interests: None declared |
|||
|
|
|||
|
Ginny Brunton, Research Officer EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, Ann Oakley, and Angela Harden.
Send response to journal:
|
Sir – Henderson et al. have indicated that their enhanced sex education programme did not reduce conceptions, and that longer-term interventions that address socioeconomic inequalities should be developed and rigorously evaluated. Although sex education is an important part of young people's preparation for adulthood, the evidence to date is that it is not, on its own, an effective strategy for encouraging teenagers to defer parenthood. It will be interesting to see the results of the comparable English RIPPLE trial (though of peer led not teacher delivered sex education), expected early next year(1). Social disadvantage and teenage pregnancy are strongly associated(2,3). In countries where teenagers have a reasonable expectation of inclusion in the opportunities and advantages of living in an economically advanced society, they are more likely to avoid early parenthood(4). Teenage parenthood is not in itself a social problem, and some young people make positive choices to become parents early. The problem is the social disadvantage and exclusion that in some societies, especially the UK, are linked to young parenthood both as consequences and as contributing factors. We have grappled with these issues in our recent systematic reviews evaluating the effectiveness and appropriateness of interventions to reduce the social exclusion associated with teenage pregnancy(5). As Henderson et al. postulate, we found that programmes aiming to change life opportunities for young people have a considerable positive effect on reducing pregnancy in this group. Our meta-analysis of high quality controlled trials indicated that pregnancy rates could be reduced by 39% in young people who themselves were recipients of day care as children and/or received youth development programmes in American studies. However, studies of young people's views also suggested important research gaps. These include the development and evaluation of policies to promote young people's involvement in schooling, further education and training, and to support families experiencing problems linked with social disadvantage and poverty. It appears that happiness, enjoyment of school and ambition can all help to delay parenthood in young people. The available research evidence also points both to day care and to youth development programmes as effective and appropriate ways of supporting children and young people. These findings suggest a need for further research into the socioeconomic and cultural influences that shape young people's choices about when they become parents, and what other options are open to them for a happy and satisfying life. References 1 Stephenson JM, Oakley A, Johnson AM (2001) A Randomised intervention trial of peer-led sex education in schools in England (RIPPLE). Lancet protocol 01 PRT/6. 2 Dickson R, Fullerton D, Eastwood A, Sheldon T, Sharp F (1997) Preventing and reducing the adverse effects of unintended teenage pregnancies. Effective Health Care Bulletin 3: 1-12. 3 Social Exclusion Unit (1999) Teenage Pregnancy. London: HMSO. 4 United Nations International Children's Emergency Fund (2001) A league table of teenage births in rich nations. Innocenti Report Card No. 3. Florence, Italy: UNICEF Innocenti Research Centre. 5 Harden A, Brunton G, Fletcher A, Oakley A, Burchett H, Backhans M (2006) Young people, pregnancy and social exclusion: A systematic synthesis of research evidence to identify effective, appropriate and promising approaches for prevention and support. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London. Competing interests: None declared |
|||
|
|
|||
|
David J Torgerson, Director, York Trials Unit University of York YO10 5DD
Send response to journal:
|
The RCT of reported by Henderson and colleagues appears to be a high quality study of a high quality sex education intervention. The results of the main outcome show that there is a 14% increased risk of termination among women in the intervention group. The p value of 0.26 is not 'statistically significant' in the conventional sense; however, the balance of probabilities would suggest that the programme under evaluation increases terminations. It seems odd, therefore, that the authors in the section of the paper "What this study adds" state that "High quality sex education should be continued". One assumes they do not mean the programme they evaluated, which as they state costs £900 per teacher compared with the alternative, that has a lower termination rate, of between £20 to £180 per teacher. One hopes if the Scottish Executive respond to the rigorous evidence presented in this trial that they will now withdraw this programme and change back to the cheaper and possibly more effective alternative. Competing interests: None declared |
|||
|
|
|||
|
Gillian M Raab, professor of applied statistics Napier University, Comely Bank, Edinburgh EH4 2LD, Daniel Wight, Marion Henderson
Send response to journal:
|
The result cited by David Torgerson about the effect of the sexual health education programme (SHARE) on the risk of a termination could be quoted as an estimate of a 14% increase. This is not a change in the absolute rate of abortions, but the increase for the SHARE arm of the trial compared with the control, after adjusting for social factors. The rate of 127 abortions per 1000 pupils followed up from the SHARE arm was almost identical to the rate that would be expected from Scottish national data (1), while that in the control arm was somewhat lower. Since the trial results are based on a relatively small number of events they are subject to considerable uncertainty when they are interpreted as the effect of the intervention. In particular, the 95% confidence interval around the rate of 14% quoted by Torgerson is from -9% to +37%. This means that the ‘balance of probabilities’ to which he refers to is one that could go either way, given this evidence. (1) Scottish Health Statistics, Teenage Pregnancy, accessed from http://www.isdscotland.org/isd/3348.html accessed 21/12/2006 Competing interests: None declared |
|||
|
|
|||
|
David J Torgerson, Director, York Trials Unit University of York YO10 5DD
Send response to journal:
|
Professor Raab is quite correct in that their study showed a 14% relative increase in terminations not an absolute increase. However, the point estimate still favours the control group and within any trial the point estimate is the most likely value of the 'true' population estimate. In this instance the confidence intervals and the p value do not reach statistical significance using 'conventional' values: because the confidence intervals are wide this indicates the need for futher research before this programme is widely adopted. However, because policy makers HAVE to adopt a programme, even if it is a do nothing option, then given the results of this trial we should adopt the control intervention as it is of lower cost and the point estimate also favours the control group. If the authors were to calculate 51% confidence intervals then we would almost certainly observe that the bottom and top of these intervals would favour the control group, which supports my previous observation that the on balance the current evidence favours the control group. Competing interests: None declared |
|||
|
|
|||
|
D Graham Mackenzie, Locum Consultant in Public Health Medicine Public Health Department, NHS Fife, Cameron House, Leven, Fife KY8 5RG, John Taylor
Send response to journal:
|
Editor,
Henderson et al have studied sexual health and relationships education (SHARE) delivered between 1996 and 1999 in east Scotland.1 They showed no statistically significant influence on conceptions or terminations by age 20 years. In Henderson et al’s study, SHARE was delivered exclusively by school teachers1, but an earlier study on the same cohort highlighted the limitations of using such an approach.2 Indeed, recent advice to local authorities and NHS organisations reinforces the need for a multidisciplinary approach in working to reduce teenage pregnancies.3 A review of the evidence in preparation for the second phase of the National Health Demonstration Project, Healthy Respect, demonstrates that a multi-faceted approach combining education, information and services has the best chance of improving sexual health outcomes.4 In Scotland, teachers now work alongside youth workers, school nurses and voluntary organisations to deliver SHARE5 with improved access to services for young people. Accordingly, while Henderson et al should be commended for their rigorous analysis, which is likely to accurately reflect the impact of SHARE in schools in the mid to late 1990s, there are good reasons to question how relevant their findings are for current practice. Yours faithfully, D. Graham Mackenzie, locum Consultant in Public Health Medicine, Public Health Department, NHS Fife, Cameron House, Leven, Fife KY8 5RG John Taylor, Development Manager, Blood Borne Virus Task Group, Health Promotion Department, NHS Fife, Haig House, Leven, KY8 5RA References 1. Henderson M, Wight D, Raab GM, Abraham C, Parkes A, Scott S, Hart G. Impact of a theoretically based sex education programme (SHARE) delivered by teachers on NHS registered conceptions and terminations: final results of cluster randomised trial. BMJ 2007; 334: 133. 2. Wight D, Raab G, Henderson M, Abraham C, Buston K, Hart G, et al. The limits of teacher-delivered sex education: interim behavioural outcomes from a randomized trial. BMJ 2002;324:1430-3. 3. Teenage Pregnancy: Accelerating the Strategy to 2010. Department for Education and Skills 2006. 4. Henderson S. Briefing Paper 2. Promoting a Healthy Respect: What does the evidence support. Health Scotland 2006. 5. Respect and Responsibility. Strategy and Action Plan for Improving Sexual Health. Scottish Executive 2005. Competing interests: None declared |
|||
|
|
|||
|
Jose J De Murtinho-Braga, Family Doctor Northdown Surgery, M argate CT9 2TR
Send response to journal:
|
Why bother to reduce the number of terminations? Is this a tacit acknowledgement of the psychological impact of terminations or is it another attempt to save finite health resources? Why were the presumably not inconsiderable number of Catholic schools in the area immediately excluded from this study and not approached for statistics regarding births and terminations? Without the statistics being done I can only speculate that perhaps because they already have a holistic programme of education that has successsfully reduced births and terminations in the target age group and that comparison with the failed intervention in this study would thus have been politically embarassing. There also exists programmes such as "teen star" working in Catholic schools that teach natural family planning and encourage self empowerment and engagement in education and school activities which enhance this trend towards responsibility and planned parenthood even further (see www.teenstar.org.) Competing interests: None declared |
|||
|
|
|||
|
Robert J Reynolds, Hospital Doctor North Devon District Hospital EX31 4JB
Send response to journal:
|
Down the ages, most children may have muddled through to adulthood without major medical mishap. despite varying burdens of ignorance and misinformation, with at least eventual reproductive fulfilment but perhaps not always the happiest of possible family and social relationships. Bearing in mind the 'ordinary majority', it was good to learn from Henderson et al (1) that SHARE appreciation by pupils was recorded, and that the Scottish Executive therefore decided to invest further in its use - modified by the involvement of multidisciplinary teachers (2). With respect to the consequences for the perhaps growing minority of teenagers engaging in premature sexual activity, huge international differences, variation with socio-economic status within nations, and the positive impacts of non-specific support programmes, from young childhood to adolescence (3), all direct us to social inclusion as the goal we must share for all our children. The accuracy, detail and deeper insight, deliverable by professional sex education, will always be important, but its own self- affirming content has clearly been too little too late for many in the past. Could it be that consistent helpings of adult time are what our children need, with highlights of one-to-one appreciation, in all of our parallel worlds - home, school, work, even play? Even as adults in fact, do we not feel better - and contribute more - where we are appreciated? Parents cannot always 'be there' sufficiently, and teachers cannot always detect and deal with adverse situations in school. At the very least, each child should have a regular counsellor, access to specialized counsellors as need arises, and involvement in perhaps two or more worthwhile mixed-age teams (not necessarily sporting, musical, theatrical, or school-based), that include adults with topped-up insight on inclusion. At every level of personal growth comes new risk, and fresh anxiety for parents, teachers, governors and politicians. The timing and content of sex education are for some almost too difficult even to think about - whether from personal experience or misapprehension or adopted ideological sensitivity. We are therefore directed towards some degree of compromise, with perhaps considerable reassurance, on all sides, from the self- respect, negotiating skills, and decision-making capacities conferred by credible primary measures for social inclusion and access to help. Publication of the SHARE study comes at a time, at least in England, of threat to the work and prospects of those most clearly fitted to provide or support the counselling above advocated. Group-work may have its place, but we cannot expect even the youngest to raise in groups all of the feelings, on relationships and sexuality, with which they might like help. It is in Family Planning clinics that the broadest and deepest relevant clinical experience is afforded and made available - one-to-one. With open-access for children, adolescents, and adults with worries, contraceptive needs, psychosexual difficulty, and menopausal problems, the doctors, nurses, counsellors and receptionists of our community clinics have established themselves as the very good friends of very many people, not infrequently of people subject to great need and to great disappointment with care elsewhere. There may still be time to keep in place and extend access to the experience of those in specialist Family Planning, but that time is short. We can only hope, with Scherf (4), that misunderstanding from the SHARE results, or a lurch with Stammers (5) into polarization of approach ('save sex' v 'safe sex'), will not add to the 'efficiency savings' that some in government / academia / management seem to think possible at the expense of quality, accessibility and reliability of clinical services. The special tragedy of much current 'reconfiguration’, is that those whose fates make up our headline target statistics, are mainly those least able to benefit from education in class, and least able or willing to reach or trust services from the GPs with whom their families are registered. On the bright side, one school in North Devon has retained the services of an experienced Family Planning doctor for a weekly hour-long advice session. Sadly, though paid for by the school, this provision is thought excessive by NHS managers. The school appears fortunate also in having a Family Planning trained nurse; but again sadly there is insistence by local management that 'confidential' attendances be registered... though this is known to deter from help-seeking. If managers have their way, certain children will choose, or feel obliged, to play the fragmented system, repeatedly accessing Emergency Hormonal Contraception, until they get 'caught' - and then doing the same again. I should say that it will take more than cosmetic measures, and more than mere extension of compulsory 'education', in my view, to bring about 'social inclusion' - for us all, adults, adolescents and children. Our enjoyment of life seems so often to be despite the 'workings' of our alleged 'democracy'. Without real inclusion, raising the school age and extending benefits will see profit for some but truancy for many others. We will not be facing the scale of our 'social problem', if we seek merely better to share benefits that we ‘earn’ at the expense of the future and of the wretched across the world today. (1) Henderson M, Wight D, Raab GM, Abraham C, Parkes A, Scott S, Hart G. Impact of a theoretically based sex education programme (SHARE) delivered by teachers on NHS registered conceptions and terminations: final results of cluster randomised trial. BMJ 2007; 334: 133. (2) Mackenzie DG, Taylor J. SHARE has changed since study. bmj.com Rapid Responses to (1). (3) Brunton G. Systematic review to address socio-economic inequalities associated with teenage pregnancy. bmj.com Rapid Responses to (1). (4) Scherf C. Sex education at the appropriate age. bmj.com Rapid Responses to (1). (5) Stammers T. Sexual health in adolescents. BMJ 2007; 334:103. Competing interests: My wife is a Lead Clinician in Family Planning and a GP. |
|||
|
|
|||
|
Nina Champaneri, SHO Psychiatry Hallam Street Hospital, West Bromwich, B71 4NH
Send response to journal:
|
In my heyday as a medical student I had the opportunity to work as and advisor/counsellor on a national free phone sexual health helpline aimed at teenagers. Although this was aimed at the mid/late teens group, the majority of our callers were under 13 years. I was quite shocked at a) how much this age group knew about sex and b) how much they didn’t know about how to practice safe sex. Whilst I agree that delaying first intercourse is recognised as an important outcome measure of sex education programmes, this is proving ever difficult to promote in our modern society where we are surrounded by sex – on billboards, television programmes, advertisements, magazines e.t.c Peer pressure for these kids is high and as the editor mentions, there is a higher rate of single parenthood in the UK, which is bound to influence a young persons behaviour. Sex education should therefore encompass a variety of themes, not just on delaying the act itself and being safe but also addressing the social issues surrounding it. Competing interests: None declared |
|||
|
|
|||
|
Robert J Reynolds, Hospital Doctor North Devon District Hospital EX31 4JB
Send response to journal:
|
It was good to read in the SHARE study that pupil appreciation was recorded, that the Scottish Executive approved continued provision, and that the message is appreciated of need to address ‘socio-economic division’ – for social inclusion. Today we have to draw-in the socially excluded, but today, tomorrow and always, we have to build, within each new generation, knowledge of the value of life for self and others, of shared good from inclusive democracy, and of ‘basic facts’ of relationship, sexuality, health and disease. Within our inclusive culture we will still need such ‘programmes’ as SHARE, and pupil appreciation can guide the evolution of value. A special contribution to demand-led education is found in Family Planning clinics – and in doctor-resourced school advice sessions, as pioneered in South Devon (‘TIC-TAC’). Parents, teachers, doctors, nurses and counsellors, all want to help, but what our children truly need to know may not easily be communicated. Further, what our children really want to talk about may not be readily raised before or within a group. Even as adults, we know our needs for privacy. It follows that as well as cultural change, and programmes of education, we need to afford both regular and on-demand access to trusted advisors, with whom anything can be raised - one-to one. Many in Family Planning have longed to see in every relevant school, a Family-Planning-trained nurse, present daily and backed-up by at least weekly specialist medical input. We would thereby ensure optimum use of nearby specialist clinics, or perhaps GP services where available close to home, for definitive care or timely referral. It is unfortunate that as yet we cannot always count on NHS support for such provision. The idea of ‘sex education for children’ can of course raise concerns. All need to be clear: children should have appropriate understanding of relationship context and of the complementary messages, ‘save sex’ and ‘safe sex’. Support from clinical specialists should ensure programmes with the widest ability to meet varied situations and needs. Unsupported, non-specialist staff will not necessarily appreciate their need of specialist support. I hope that the current debate will encourage response in all senior schools, to the readiness of Family Planning staff to contribute their expertise. We should not wait for NHS guidance / funding. Until we have a government policy, even managers with awareness may in fact ‘have to’ continue Cinderella-service cutting. Change is however likely: the government has a modest target for Genitourinary testing access (<48 hours by 2008); but there is a formidable target for education / contraception / termination, by 2010, to halve <18 pregnancies. Those parts of the country that have been flat-lining for a decade, will need soon to make much more effort, for inclusion, education and service access, if a national average of down to around 22/1000 girls p.a., recorded pregnant, is to be reached just three years from now. Social inclusion and health-care need to be won, of course, irrespective of governing-party readiness and headline targets. We need to challenge any pretended research authority, or implied consensus, for a ‘direction of travel’ that seeks to manage rather than include, and that brings service degradation with sacrifice of experience and educational potential. And the time is now! Competing interests: Writing with spouse - a Lead Clinician in Family Planning |
|||