Social and Community DevelopmentWhat factors affect young people’s engagement in sexual health services?

 

Word count: 9142

Content

Acknowledgments 2
Abstract3
1: Introduction 4
– What arethe different influences on sexual behaviour?
2: Method Section12
3: Results 15
4: Discussion 20
5: Conclusion 32
6: References 35
Acknowledgments
I would like to express my special appreciation and thanks to_________, for the sacrifices she made in order for me to achieve and to strive towards my goal. There are not enough words to express how grateful I am for theexceptional support she gave to me through this period.

Abstract
This research investigates young adults between the ages of 10 and 24 and seeks to understand their engagement with sexual health services and in particular, what are the factors that prevent their engagement and involvement with such services. A literature search was conducted and out of the chosen studies key themes were identified; Accessibility and availability, privacy and confidentiality, Informal service and staff characteristics. These key themes helped to understand why young people refrain and/or put off accessing sexual health services. It also helped to draw some conclusions as to what improvements could be made in order to encourage young people to engage with a service that contributes to not only their sexual wellbeing but ultimately also on their physical, mental, emotional and social well-being. The research concludes that in order to encourage young people to actively engage with sexual health services, they have to be at the forefront of designing services.
1: Introduction
Sexual health contributes to an individual’s physical, mental, emotional and social well-being therefore, it is important for one to take care of this particular aspect of their health (NI Direct, 2014).This literature review will focus on young people and their well-being in relation to sexual health. This review will use the term ‘young people’ to refer to those in between the ages of 10 and 24 (International Planned Parenthood Federation, IPPF, 2014). The terms ‘young adults’, ‘young people’ and ‘teenagers’ will be used interchangeably throughout this review.

Sexual health covers a wide range of areas and facilities to help individuals safely manage their sexual relationships. This includes advice on contraception, abortions, and sexually transmitted infections or diseases (STIs/STDs). The World Health Organization (WHO, 2015) and the National Health Service (NHS, 2013) define sexually transmitted infections (STIs) as infections that are passed onfrom one person to another as the result of unprotected sex or genital contact. There are as many as thirty different sexually infectious bacteria, viruses and parasites. The most common within young adults are chlamydia, genital warts, gonorrhoea, herpes and syphilis (NHS, 2013). Individuals may seek sexual advice and services from a number of providers within the community and hospitals, as well as the voluntary, charitable and independent sectors (Department of Health, 2013).

Sexual health services are free and are available for everyone no matter their sex, age, ethnic origin and sexual orientation. Services and advice can be accessed through ‘General Practitioners (GPs), contraception clinics, sexual health clinics, STI testing clinics, genitourinary medicine (GUM) clinics, pharmacies, sexual assault referral centres and young people’s services’.However, all those listed above may offer not offer the full selection of sexual health services and for that reason, it is best for individuals to check what is on offer in advance (NHS, 2013).

As shown above, the UKhas a number of settings in which young adults can effectively access help and advice in relation to their sexual health needs. However, statisticsdemonstrate that there are a large proportion of young adults contracting STIs. In 2013, chlamydia was the most commonly diagnosed STI amongst young people in England. Over 139,000 young adults, aged 15 to 24 were diagnosed with chlamydia in the same year (Public Health England, 2014). One possible explanation for this is given by the Department of Health (DH, 2013), who highlighted that because of stigma and discrimination, individuals may feel reluctant to acquire help and attend services, in order to receive an early diagnosis and obtain treatment for their symptoms.

It would appear that WHO (2015) has made some attempt to combat the stigma that may be felt by young adults, for example,within WHO’s (2015) definition of sexual health, the importance of an individual’s sexual right is emphasized, as it states that each individual should be respected, protected and fulfilled.

Most young adults between the ages of 16 and 24become sexually active and may begin to form relationships. Statistics from the Department of Health (2013) show thatthere are ‘higher rates of poor sexual health, including STIs and abortions’ in these age groups, in comparison to older people.As well as heterosexual couples, high rates of STI’s also occuramongst gay and bisexual men in the younger age groups.Possible explanations as to why this specific age group have high rates of STIs will be discussed in further details below.

In addition to the statistics of chlamydia given above,The Family Planning Association (2010) highlights that second to chlamydia, genital warts are also common, with high rates of occurrences in young adults.In 2013, the diagnosis of gonorrhoea accounted for 8,122 cases amongst young people (GOV.UK, 2014). The Family Planning Association(FPA, 2010) stated that in 2009, genitalherpeshad the highest rates in young adults, particularly in females. Recent reports show that although syphilis is one of the less common STI’s in the UK, ‘there have been several small outbreaks across Britain in heterosexual teenagers’ (NHS, 2014; Brimelow, 2011). The data for human immunodeficiency virus (HIV), showed that in 2013 there were 736 diagnosis in people aged 15 to 24 (Public Health England, 2014). AlthoughHIV diagnosis is not the highest in young adults, it is warned that this particular age group are unaware of the risks of HIV (BBC, 2009).In relation to abortions, the rate was highest for women aged 22 years, in 2013 (NHS, 2014).

As mentioned by Public Health England (2014), it is known that young adults continue to be the age group that are most at risk of contracting STI’s in England.Boseley (2010) presents one possible explanation for this and argues that young adults ‘lack the confidence to negotiate relationships’. Similarly, Bekaert (2005, p.232) discusses that what young people lack is the ‘knowledge or skills to negotiate boundaries and prevent STIs and pregnancy.’In actual fact, it is likely that young people would postpone sexual activity if they are presented with precise information concerning sex and contraception.

There are many positive and negative views with regards to whether sex education should be taught in schools, with many viewpoints maintaining that it is harmful and affects the innocence of children. However, according to Carroll (2013, p.196), sex education is important and reduces “ignorance” and “curiosity” that may be harmful. Furthermore, she argues that if institutions fail to educate children, then often the media does, with music, lyrics and images that often portray negative aspects of sex. Whereas, accurate knowledge about sex, can lead to more positive and accurate ideologies about sex.

Linsleyet al., (2011, p.216), take the above concept further and discuss the importance of sexual health promotion and it being accessible to vulnerable groups. They highlight “young people” as one of the vulnerable groups requiring targeted health promotion and prevention, arguing that they are ‘disproportionally affected by sexual ill health’. One of the welcomed suggestions put across by Linsleyet al.,(2011, p.216), is for an allocated nurse to be present in schools and colleges, so that young people can be educated about sexual health matters and furthermore, informed of where they can obtain emergency contraception.

Conversely, Fishbein and Ajzen’s (1975)Theory of Reasoned Actionor Theory of Planned Behaviour has been used to explain the reasons why people, in general, make decisions to engage in a wide range of behaviours. These theories have also specifically been used to explain and understand the trends of young people and their sexual behaviours.
Fishbein and Ajzen’s (1975) theory of reasoned action relates to the link between beliefs, attitudes, intentions and behaviour (DiClemente and Peterson, 1994,p.187). McKenna (2000, p.273) explains that the theory recognises that the cause of an individual’s actions is predicted by their intentions. In turn, their intentions are influenced by what they view as expectations of them by others. In terms of sexual health and young adults, the Theory of Reasoned Action mayexplain why someyoung peoplefail to use condoms or contraception.

An attempt was made to extend the theory of reasoned action, in circumstances where a person’s behaviour is not entirely under their control.When putting this into the perspective of sexual relationships, as it takes two people to partake in the act, it is possible and not uncommon for one person to play a dominant role in coercing the other to partake in a sexual act. From this perspective,Ajzen (1988) proposed The Theory of Planned Behaviour. This theory explains that an individual’s intentions functions on three basic factors, ‘one personal in nature, one reflecting social influence, and a third dealing with issues of control’ (Ajzen, 2005).

Gibbons and Gerrard took this notion further and developed the Prototype Willingness model. Sanderson (2009, p.194) explains that as well as the role that social norms and intentions play in the prediction of behaviour, the prototype willingness model focuses on the role of prototypes, which is ‘social images of what people who engage in the behaviour are like’. In addition, the model describes the extent in which a person is likely to engage in the behaviour in a given situation. For example, applying this model to young adults andrelating it to sexual health in young adults, the prototype willingness model may provide an explanation of young people and theirwillingness to engage in risky sexual behaviour.

The above models have given emphasis to the different influences of sexual behaviour. There are some common themes that can be extracted from them which provide a general view of different influences on sexual behaviour.

What are the different influences on sexual behaviour?
Person attitudes and beliefs
This includes the awareness of risk, for example, the ‘degree of perceived risk of catching an STI’ or pregnancy, in addition to the attitudes towards condoms, for instance, whether an individual believes condoms lessens sexual pleasures, or the common mistaken belief that there is a link between the use of hormonal contraceptives and weight gain. The behaviour change models mentioned above contrasts in the emphasis given of the influence of personal attitudes and beliefs. Whilst personal attitudes and beliefs are a key element in the theory of planned behaviour, in the prototype willingness model, the role of attitudes is less predominant, mainly for the younger/less experienced young people (DH, 2013 & 2009).

Social norms and peer pressure
There have been surveys that illustrate that both parents and young people agree that,around the age of 16 and 18 is the ideal age to first have sex.

Although there is evidence that peer pressure has an effect on an individual’s sexual behaviour, it is not clearly pointed out the form in which peer influence works. However, it has been suggested that in regards to gaining information based on sex and relationships, friends are those to receive this information from.

Being influenced by a peer is predominantly strong in a situation where, for example within a gang, the younger, less confident youth may be influenced by a more dominant older youth.

Is has been indicated that with peer influences, there may be some gender differences. For instance, some research undertaken suggests that in boys, peer pressure has a tendency to negatively influence them. This can be the case when they may be pressured into losing their virginity at an early stage and have ongoing sex from then on. Whereas amongst girls, peer influences tend to have a strong positive effect. For example, making choices based around contraception (DH, 2009).
Behavioural willingness
In Gibbons and Gerrard’s Prototype Willingness Model, they identify that behavioural willingness acts as a significant influence on the behaviour of young andinexperienced young individuals. For example, if it was believed by an individual that those who do not use contraception gain status through their behaviour, it is of high possibility that they will adopt those practices (DH, 2009). Gibbons and Gerrard have illustrated that behavioural willingness best predicts the behaviour amongst young and inexperienced young people than intention.
Past Behaviour
Furthermore, Gibbons and Gerrard’s model predicts that ‘past behaviour has a strong influence on future behaviour (DH, 2009). An example of this is the use of condoms.If it has been used in the past, it is more like it would be used in the future.

‘Informants’
DH (2009) states thatinformants relate towhere young people acquire information from, which in turn, may influence their decisions. This includes the media, internet, friends, parents, schools as well as health care practitioners. These informants are likely to form an individual’s attitudes and beliefs, on the other hand can initiate other factors which influence behaviour, for instance norms and behavioural willingness.
Religion
Religion can play a great influence of attitudes and behaviour. For example, as illustrated by Carroll (2013, p.194), religion can have a major impact on sexual activity in religious heterosexual youths. Carroll (2013, p.194) argues that those with religious backgrounds are more likely to postpone their first sexual experience, less likely to partake in sex before marriage and also less likely to have fewer sexual partners. All of which is likely to decrease the likelihood of this section of society needing to access sexual health services.
Despite the above, Carroll (2013, p.194) also identifies that once a young person has initiated sexual contact, then religious attendance and association has little impact on sexual behaviour. Given the above information and scenario, it is a possibility that in such a situation, where there is religious affiliation, accessing sexual health clinic’s may have even more negative connotations, as it is more likely to cause feelings of guilt, shame and stigma.
According to the UK Young Parliament (UKYP, 2007), the matter of Sex and Relationships Education (SRE) in schools are of concern to young people. The SRE that is being received in schools is believed to be ‘too little, too late, too biological and does not provide enough information on relationships.’ It is also discovered that teachers, governors and parents have received insufficient guidance and support to help in talking to young people surrounding sexual health issues. Similarly, an Ofsted (Office for Standards in Education) reportfound that SRE was inadequate in 40% of schools (Weale, 2015).
The Framework for Sexual Health Improvement in England claims that it is a statutory requirement to provide sex education in maintained secondary schools. It is also contained within The Education Act (1996) thatsex education is part of the National Curriculum Science and therefore must be taught to all pupils who are of the primary and secondary age. In addition to this, the Secretary of State for Education’s Sex and Relationship Education Guidanceensures pupils know the benefits of healthy relationships and delaying sex, and raises awareness of how pupils cangain access to confidential sexual health advice and support (DH, 2013;Education Act, 1996; FPA, 2011).
The Local Authorities Regulations 2012 declares that each local authority ‘shall provide, or shall make arrangements to secure the provision of, open access sexual health services.’ This means that each individual should be able to gain access to a local service. The functions of these services are to prevent the spread of STIs and treat, test and care for individuals with such infections (The Local Authorities Regulations, 2012).
Although there have been progress in the last years of improving sexual health, such as rapid access to genito-urinary medicine (GUM) clinics and other services within the community, reduced pregnancy ratesand more use of contraception’s, there is still a case for change. The goals for the Department of Health for young adults are to build their knowledge and resilience, ensure that their sexual health needs are met and make certain that they all have an easy and rapid access to sexual and reproductive health services.
The above arguments have led to a particular interest in researching further the factors that are currently affect young people’s engagement and involvement in sexual health services. As such, further details of the method used to select articles will be discussed, following a review of the literature found.

2: Method Section
The literature search undertaken was conducted through specific electronic database searches as well as citation searches.

Thekey terms that was extracted from the research question to search the databases was sexual health services and young people.In addition to this, more specific terms surrounding sexual health were used such as: sexual and reproductive health services, sexual health services accessibility, sexuality, family planning clinics. However, throughout the search, majority of these terms were excluded as it did not provide appropriate research pieces related to the question being explored.

With the use of these key terms, I began by searching, using the following databases:, AMED (The Allied and Complementary Medicine Database),ASSIA (Applied Social Sciences Index and Abstracts),EBL ebook library,EBSCOhost, CINAHL (Cumulative Index to Nursing and Allied Health Literature) plus with full text, Cochrane Library, Ingenta Connect, Internurse,NELSON (Northampton Electronic Library Search Online), MEDLINE, PubMed Central, Sage Journals Online, Science Direct, SpringerLink, Social Care Online and Wiley Online Library.

During the search, majority of the research articles found, in the various databases used,tended to be either the same, or in a few no articles were found based on the search terms used. Although the above databases were searched, some did not produce relevant articles related to the research question, therefore, were excluded. It will be explained further, howthe main databases in which the articles were found, were thoroughly searched.

EBSCOhost database was searched, using the terms sexual health services and young people. This initially generated over 1,500 hits. By using the ‘advanced search’ the terms young people and UK were included. From this, the hits were reduced to 94, which created a controllable sample size and articles more related to the dissertation question. To bring this down further, the tab for ‘scholarly (peer reviewed) journals’ was selected. In reading the abstracts of the articles found, in order to see the relevance of it in answering the research question, 2 main articles were obtained.

Using the Sage Journals Online database, again, sexual health services was the key term used to search. From obtaining smaller sample sizes and relevant articles from the above database, the ‘advanced search’ was used throughout the searches. With the inclusion of ‘young people’ and ‘UK’, the articles were reduced to 89 from 41,175 without those terms. Similarly, the abstracts of these 82 articles were read, but only one relevant article was attained from this database.

When searching the Science Direct database, in the same way the ‘advanced search’ was used. However, this database had restrictions as to how many search terms could be used. As a result, only sexual health services and young people were used. A broad, general set or research were found, producing a high number of results, and for that reason, the search was narrowed down to articles written between the years 2005 and 2015. Nevertheless, results were still a large number. As an alternative, the term ‘sexual and reproductive health services’ was used, with the limitations of only journalarticles written within the last 10 years. Yet, around 2,700 results were produced. To further narrow this down, the ‘topic’ that was included were reproductive health and sexual, which then created 302 results.However, only reading the titles of these 302 results, appropriate articles were picked up and were then narrowed down to 2 relevant pieces of work, from reading the abstract.

Citation searches were used in addition, when research articles found were considered to be relevant pieces of research. It was found that citations had a considerable amount of literature related to the chosen topic. However, were not based on the basis of recent publication written within the last 10 years.
Having obtained a suitable set of research data, the next process was to analyse them and identify key themes. The key themes were able to be identified in firstly, reading the conclusion/discussion of the articles. From here, reading each article thoroughly was done in order to find out what each piece of research was trying to discover.

Initially, it was intended for this literature review to focus on young adults aged 16 to 24. However, following the literature search, it proved difficult to find information on this specific target group. Therefore, the age group was broadened in order to incorporate more information.
3: Results
A number of studies into the area of young people accessing sexual health services explored factors that may contribute to why this specific age groupare not using the services available to them. These studies also suggest ways to make the services more youth friendly. For example:

Literature one: Reeves, C., Whitaker, R., Parsonage, R.K., Robinson, C.A., Swale, K. and Bayley.L (2006) Sexual health services and education: Young people’s experiences and preferences. Health Education Journal.65(4), p. 368-379.
This was a qualitative study which had the intentions of discovering what students require at sexual health services and their perceptions of it. There was a total amount of 360 year 11 students (15 and 16 year olds), in secondary schools being studied. The questionnaire based study found that what the respondents felt were the most important aspects of sexual health service provision wereconfidentiality and a friendly atmosphere with staff that are easy to talk to. Reeves et al,.(2006, p.378) also concluded that services need to be informative andoperate around young people’s everyday lives, in terms of the services being located near their home or school and the opening hours of these services.

A specificstrength of this study wasthe questionnaire design the researchers had used to carry out their investigation. Reeves et al., (2006, p.370) had adapted a questionnaire used previously in a similar research study. This increases the trustworthiness between the reader and the author. According to Browne (2006, p.434), questionnaires can be affected by the imposition problem. This refers to the researcher asking questions based on their own views, decisions and assumptions on the topic, and/or the people being researched, instead ofaiming to find out what the participants really think. Therefore, disregarding what may be of importance. However,this study seeks to eliminate this as it used a previous questionnaire as a template,in order to guide their research.
A potential limitation of this study was the small number of schools that took part in the research. Only three Secondary Schools, within the same area, were included. Findings may vary from area to area, for that reason a variety of areas should have been examined to see whether attitudes and trends are consistent within young adults in different locations. Overall, the aim of this study was clear and the methodology chosen of questionnaires allowed the researchers to gain an understanding into the thoughts young people have when accessing sexual health services.

Literature two: Perry, C. and Thurston, M. (2007) Meeting the sexual health care needs of young people: a model that works? Child: care, health and development. 34(1), p.98-103.
This quantitative study aimed at exploring whether two services that were set up, successfully engaged the target group, of young people. Short questionnaires were also given to those who accessed the services to indicate how happy they were with the features of the services, such as the attitudes of staff, confidentiality and the opening hours.The mean age for those who used service one was 14 years, and for service two was 16.8 years. The study found that what has been emphasized as important, by young people, when providing sexual health services are friendliness of the staff, confidentiality and information, help and support that are given.

A particular strength of this research study was the combination of both quantitative and qualitative research used by the author’s. As stated by Teddlie and Tashakkori (2003), cited in Liebenberg and Ungar (2009, p.201), the use of mixed methods can ‘support stronger inferences because of their ability to provide greater depth and breadth.’ Perry and Thurston (2007, p.99) were able to explain their findings in detail based on the short questionnaire distributed to the young people who used the service.
A possible limitation of this study, which was acknowledged by the researchers, was that young people, who did not use the services, could have also been surveyed. This would have determined whether there were features of sexual health provision that prevent young people in attending. Additionally, the researchers would have gained a greater insight into what young people prefer when accessing these services.

Literature three:Jerome, S., Hicks, C. and Herron-Marx, S. (2009) Designing sexual health services for young people: a methodology for capturing the user voice. Health and Social Care in the Community. 17(4), p. 350-357.
Evidently, from the articles found, concerns based on confidentiality and whether the service would be informal are the barriers young people face when intending to access a sexual health service. Similarly, this thematic review, focus group and questionnaire based study undertaken by Jerome et al., (2009, p.355), revealed that privacy and confidentiality are ‘critical components of an effective sexual health clinic’ for 12 -24 year olds.Furthermore, what was utmost important to users were the proximity of the service and a dedicated service. What was a least priority for young people in service provision, in this study, was the need for an informal service.

Although the sample size for this study was small, a particular strength of this research was the methodology used. In order to maximise validity, the researchers collected information by using two sources, which were a thematic review of literature and focus groups. In addition, for the thematic review of the literature, they used a combination of electric databases to gain insight of the topic.

Literature four: Braeken, D. and Rondinelli, I. (2012) Sexual and reproductive health needs of young people: Matching needs with systems. International Journal of Gynaecology and Obstetrics.119, p. S60-S63.
This article was based onan expert opinion piece from a member of The International Planned Parenthood Federation (IPPF). In contrast to the studies above, Braeken and Rondinelli (2012, p.S60) explained the sexual rights of young people, in addition to what specific barriers should be taken into account before young people get to the service, whilst they receive the service and after leaving the service.

It was detailed in this review piece that the hurdles young people face before reaching the service delivery point are inconvenient hours, confidentiality concerns, alongside the fear of discrimination. The authors came to a conclusion that there are urgent needs for services to be more efficient, high-quality, provide interdisciplinary collaborative care, and have greater access. As a whole, this review went in depth of the sexual and reproductive health needs of young people.

Literature five: Braeken, D., Otoo-Oyortey, N. and Serour, G. (2007) Access to sexual and reproductive health care: Adolescents and young people. International Journal of Gynecology and Obstetrics [online]. 98, p. 172-174.
The aim of this report was to deliberate the roles of clinicians and to make recommendations for obstetricians,in order to uphold the sexual and reproductive health rights for young people. It was discussed that as clinicians, they should continuously reflect on their attitudes towards adolescent sexual and reproductive health.

Examining sexual health services as a whole, Braekenet al., (2007, p.173), emphasised on the elements of good practice. This included the importance of having staff that have skills in being knowledgeable, non-judgemental and approachable. Also mentioned was the barriers in which young people face when accessing services, which were inconvenient hours and concerns about confidentiality and discrimination.
Though this article was based on an expert opinion piece, rather than research studies similar to the previous articles used, the writer has written more pieces on this subject matter, therefore, has background knowledge on the topic. In addition, unlike the previous research presented, Braekenet al., (2007, p.173), proposed recommendations for professionals. This ensures that health care professionals are fulfilling their role in order to improve access to these services.

There are key themes that can be extracted from the chosen studies that give possible explanations as to why young people are not engaging in sexual health services. These themes areconfidentiality and privacy; accessibilityand availability; staff characteristics and informal Service

When initially undertaking this research, it was expected that issues such as stigma and discrimination would be a key features that affects young people’s engagement in sexual health services. However, these themes were only mentioned in one of the articles. There may be a number of explanations for this outcome.For example, it may not be something that young people consider as effecting their engagement in these services. However, as documented in the introduction, DH (2013) highlight that this was a major contribution for young people not accessing sexual health services. Alternatively, another possible reason may be that the chosen articles did not have this as a main focal point, or it can come under the umbrella of confidentiality and/or privacy.
4: Discussion
It has been identified that young people have particular difficulties with accessing sexual health care, putting them at high risk of becoming infected with STIs. A few of these factors have been highlighted by the articles above, and includes confidentiality and privacy, restrictions associated with proximity and opening hours of the service, the attitudes and behaviours of staff and the need of providing aninformal service. On the other hand, what has been least recognised in the above articles is the importance of providing sex education to young people.

Young people have been recognised as ‘a particularly vulnerable group whose knowledge about sexual health affects their sexual behaviour and risk taking’ (Reeves et al., 2006, p.369).Nevertheless, it has come to the attention that the subject of sex education is insufficiently taught in a third of schools (Burns, 2014). The Government have put emphasis on the need of sexual health services being accessible from schools and exposed within them.Secondary schools, in particular, have a responsibility in promoting the health and well-being of their pupils (Mullinar and Martinez, 2007).Schools are being supported by The Department for Education and Skills (DfES) to promote service provision within the teaching and learning of Personal, Social and Health Education (PSHE). From this, young people would have knowledge on where to access sexual health services and advice, whilst feeling confident in doing so, as well as being provided with accurate details of the local services.

Also, through the learning of sex and relationship education, it should ‘meet the education and emotional needs of all young people (FPA, 2011). This includes vulnerable groups of young people such as lesbian, gay, bisexual and transgender (LGBT) young people and disabled young people (Emmerson and Levene, 2010). Department of Health (2007) have indicated that through the education of sex and relationships, sexuality is often a subject that gets left out. LGBT young people have expressed their concerns that they feel excluded from sex education as well as sexual health services. They have pointed out that they ‘would like their needs to be acknowledged by service providers (DH, 2007). Although some sexual health services monitor their use by male and female individuals, less is acknowledged about the sexuality of young service users. Many of these users conceal their sexuality because they fear that they may be negatively judged by professionals. To deal with this issue, LGBT groups are being set up. Additionally, by ‘creating links with local service and making information visible,’ the inequality that LGBT young people face can be acted upon.

Mullinar and Martinez (2007) suggest ways in how schools can promote access to these services, some of which includes: publicising services, with the use of posters around the school premises;requesting visitors from sexual health services to take part in classroom sessions; arranging pupils to visit the services; maintaining an up-to-date and accurate directory of the services and the use of local videos/DVDs showing the location of the services and how to access them. Furthermore, schools should lay emphasis on the confidential nature of these services. As a result, young people will feel more encouraged to use the services available to them.

In similar opinion, Enson (2012, p.341) identifiedthat advertising services is directly linked to improved service, therefore, may lead to lower rates of STIs and teenage pregnancies. She also expressed that with advertising goes ‘hand in hand with good communication,’ which allows young people to be aware of where and how to access the services, and re-affirms aspects of confidentiality and trust, whilst being able to build a rapport with the health professionals within the services. Moyse (2009, p.329) explains further that advertising must be clear and also written in language that young people are able to easily read and understand. Additionally, information should be written in other languages for those who do speak English.

It has been acknowledged that schools provide several means of individual support, on the other hand service provision is yet often inadequate and young people’s concerns based on confidentiality and privacy can discourage them from seeking help and advice (Ofsted, 2002 cited in Thistle, 2003).

Confidentiality and privacy
Young people, particularly those who are under the age of 16, are less likely to accessadvice based on contraception and sexual heath, ‘both before their first sexual experience and when they do become sexually active’ (Department for Education and Skills, 2007). The fear of confidentiality and privacy being broken is the major reason for this and have appeared to be re-occurring themes throughout the articles. It is mentioned that there is a link between the low uptake of sexual health services and the suspicion of confidentiality issues (Jerome et al., 2009, p.355). Shepherd (2008), cited in Jerome et al.,(2009, p.355), describethese qualities as ‘critical components’ of an efficient sexual health service. Reeves et al., (2006, p.376) andBraekenet al., (2007, p. 173) also highlight and discuss the importance of confidentiality being vital in service provision to young people. What teenagers are most worried about are parents being informed, ‘gossipy receptionsand confidential information being intercepted by parents or carers’ (Royal College of General Practitioners, 2011). Therefore it is important to reassure young people about the policies based around confidentiality.

Confidentiality isperceived to be a fundamental ethical principal, and all healthcare professionals have a duty to ensure that confidentiality of information concerning clients in their care is safeguarded (UK clinical ethics network, 2015). In a similar point of view,Braeken and Rondinelli (2012, p.S63) state that‘confidentiality is at the heart of the code of ethics.’ They further explain that within any given situation, there should never be an involvement of a third party, without the consent of the young person. Although it is important to encourage young people to maintain communication between themselves and their parents concerning their sexual health, it is also important to make certain that there are procedures put in place for individuals who do not wish to share their information with a third party. As a whole, all healthcare professionals have a liability not to share any information, regardless of service user’s age or maturity (Royal College of General Practitioners, 2011). In support of this is the standard statement on client’s rights to confidentiality. For example, the Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists (2012), points out that each individual have the right to be sure that information about them will be held in confidence. They must be fully informed on how their information is used.

In addition, the Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists (2012) also highlight the three areas of law that support the processing of service user’s information: Human Rights Act 1998, The Data Protection Act 1998 and The Common Law of Confidentiality. The Human Rights Act 1998 (article 8) establishes a right to ‘respect for private life.’Although private life has a broad meaning, in relation to sexual health services, this act covers how ‘personal information is held and protected’ (Citizens Advice, 2015).

The Data Protection Act 1998 sets out how data, based on the service user, may be processed.While this legal standard consists of eight principles, the most significant within this context are: principle 1 which entails the processing of data to be fair and lawful in terms of wider UK law; principle 7 states that those liable, which includes secretaries, practice managers and receptionists, as well as healthcare professionals,are obligated to protect personal data against ‘unauthorised or unlawful processing and against accidental loss, destruction or damage’ and section 55 of this act expresses that where personal data is obtained or is disclosed unlawfully is a criminal offense (Royal College of General Practitioners, 2011; Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists, 2012).

Lastly, The Common Law of Confidentiality (although not codified in an Act of Parliament), sets out that information on the patient ‘should not be processed for other purposed except in circumstances where the law permits or requires it’ (Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists, 2012).

Although it is unlawful for young people under the age of 16 to be involved in sexual activity (according to The Sexual Offences Act 2003), it has been established that health professionals must still respect the young person’s wishes in keeping their information confidential. However, circumstances where a young person’s health is at high risk of significant harm outweighs the right to privacy,is where confidentiality may be broken. In this case, it should be communicated and informed first to the individual that their information will be disclosed (DH, 2013; British Medical Association, 2014; Royal College of General Practitioners, 2011).

Reassuring young people that the sexual health services have a clear policy on confidentiality means that they are more likely to trust the professionals and continue using the services they are entitled to. The ways in which this can be done is by expressing the practice’s confidentiality policy through leaflets, notes and posters in the practice and talking about confidentiality during the consultation (Royal College of General Practitioners, 2011).

Alongside confidentiality, privacy is also an important feature of a sexual health service (Downing and Cook, 2006).Research undertaken in Knowsley, England, found that what was of most concerns to young people were the likelihood of being overheard on their reasons for their visit and the fear of being seen by others at these services, hence stigmatisation. DfES (2007) recommended the ‘development of broad-based health advice services’ with advice on contraception and sexual health acting as one component, in tackling stigmatisation. A broader health advice service would be able to offer support on a variety of health problems, such as diet and exercise, alcohol and drug education, emotional health and well. As a result, without the feeling of embarrassment, young people can access advice.

It has also been suggested that how service provision could be improved that would encourage young people to access sexual health services, is by minimal waiting,having a separate waiting area for men and women, and including a private and soundproof area ‘so that information gathering and history taking can be done confidentially’ (Braekenet al., 2007, p.S62;Jerome et al., 2009, p.355).

Accessibility and availability
The articles presented were able to recognise and highlight that location is crucial when providing sexual health services. Jerome et al., (2009, p.355) recognised that the reason for proximity being a ‘function of access problems’, is because users of the services are not likely to have their own transport. Whilst Reeves et al., (2006, p.376) acknowledged that young people may find it difficult to travel long distances without notifying their parents (for this reason, centres should be located near home or schools), they also linked accessibility with the issue of preferred opening times.

Moyse (2009, p.329) gives the ‘essential elements for a successful service’ and illustrates this through the five A’s: awareness, attitude, approach, availability andaccessibility.She underlined that the young person’s choice to access the service is influenced by the distance they would have to travel. It was also pointed out that if the services are within 1km of the individual’s home, they are more likely to access them. The reasons why services must be near their home, or school is because it is unlikely that this particular age group have their own transport and may not have the funds to travel far. In addition to this, they may not have the time, especially if they do not wish to let their parents/carers know.What has been suggested to tackle the obstacle of this by offering drop-in sessions in locations where young people spend their time, for instance youth clubs, leisure centres, schools, as well as providing community based services.

Reeves et al., (2006, p.377) and Braekenet al., (2007, p.173) found in their studies that oneof the greatest barriers to accessing services for young people is the inconvenient hours.This is where, in particular, young people’s engagement in sexual health services is affected. It was mentioned that young people feel services are tailored to fit what health professionals think as best opening times, rather than the young people attending them. For this reason, attention has been drawn to the need for a flexible service that fit ‘the patterns of young people’s social activity’.Moyse (2009; p.329) gives further details and explains that young people may have to access the services when their parents or carers are not suspicious of their whereabouts, therefore appropriate times would be between 3pm until 6pm and Saturdays and Sundays.

On the other hand, Wellings and Mitchell (2012, p.186) acknowledged that accessibility can be determined by a range of factors, one of which includes cost. The costs of ‘consultations, medicines and condoms can act as a barrier to access.In return, places young people at higher risks of contracting STIs as well as teenage pregnancies.

A current issue in sexual health is the ‘short-sighted reforms to vital contraception and other sexual health services’ (FPA, 2013). Whilst NHS are efficiency saving, the result of this is undercutting the quality of available services through restrictions on the basis of place of residence and age, inadequate services offered by primary care trusts (PCTs) and alterations to commissioning structures. The Unprotected Nation report, commissioned by Brook (UK’s prominent provider of sexual health services and advice for the under 25’s) and FPA predicts ‘a bleak future’ being a result of the continuation of restrictions placed on these sexual health services through the changes of commissioning structure and the cut in budgets (FPA, 2013).

Currently, local authorities (commissioned to open access of sexual health services) are said to be victims of the cut. Because of their lack in investments and a higher demand for their current resources, they are progressivelybecoming harder to access. In addition, as a consequence of the cuts, a number of staff has been made redundant(Williams, 2012).

According to FPA (2013) and The Guardian (2013), NHScuts of sexual health and contraception services have resulted in restricted choice and access, in turn increasing the rates of STIs.If this is to continue, there would be a rise of abortions and STIs by 2020, due to limited access and fragmentation of services, costing the UK an amount of £136.7 billion on the future spendingof health and welfare. Brook’s chief executive added that young people would be the ones to suffer due to these cuts, in addition to the lack of sex and relationships education programmes (Guardian, 2013). Furthermore, the harsh cuts on youth work provision, where SRE takes place, would have an impact on young people having the knowledge and confidence to access the services available to them (Williams, 2012).

The Framework for Sexual Health Improvement in England (2013, p.39) suggest ways in tackling this issue by effective commissioning. It is evident that investing in sexual health provision is cost effective. For example when £1 is spent on contraception, £11 is saved in other healthcare costs. This was able to save the NHS £5.7 billion in healthcare costs, which would have had to be paid if there were no contraception provided. The Unprotected Nation report (2013) also provides ways in which there could be improved access if the restrictions to sexual and contraceptive services are removed. For instance, with the improved access to services, by 2020, £1.1 billion could be saved in the treatment costs of STIs.

Furthermore, Lim et al., (2008), cited in Wellings and Mitchell (2012, p.186) proposed that the use of technology has the potential in improving accessibility. Modern technology being used recently consists of the use of text messaging and online services for the promotion of sexual health and for appointment reminders. The advantage of this includes low cost, good accessibility, and the ability in reaching many people. Similarly, Minichielloet al., (2013, p.2) explained that the enhancement of e-health technology, which refers to internet-based health care provision, will be of most benefit to young people as the internet plays a major role in where young people gain their information from.

Staff characteristics
Braeken and Rondinelli(2012, p. S61)suggest that attitudes and behaviours of staff is what affect young people’s access to services. One of the most significant concerns for young people, found in this study, is the fear of unfriendly and critical staff. Reeves et al., (2006, p.376)and Perry and Thurston (2007, p.101) discussed in further that a friendly atmosphere and staff that are easy to talk to were within the three most important aspects of service provision. Young people value non-judgemental and friendly staff, ‘who gave them information without embarrassing or shaming them’ (Reeves et al.,2006, p.372).

In order to create a right environment within sexual healthcare services, those working in the provision should have the essential skill ofproviding a well-informed approach (Enson, 2012, p.342). It is evident that young people are happy with services where they are given information, help and support. However, Moyse (2009, p.330) expresses that some professionals may hold attitudes, which may come across uncompromisingtowards young people and their sexual behaviour. Therefore, when information is being delivered, staffs are to do this in a non-judgemental way, whilst being sensitive to the young person’s needs.

In similar opinion, Braekenet al., (2007, p.173) indicate that one of the elements of good practice includes the skills and attitudes of providers. It was explained that the main characteristic of a provider is that he or she accepts the young person for who they are. Again, this focuses on staff being non-judgemental, as well as knowledgeable and approachable.Braeken and Rondinelli (2012, p.S62), put forward that the professional taking a sexual history and gathering information about the young person’s need, at a consultation is a way of the setting the scene of allowing the young person to feel that they are being listened to, treated with respect without being judged.

Sexual health services serve ‘a diverse group of young people from a broad range of backgrounds (Enson, 2012, p.339).For this reason, it can also be recommended that there should be a diverse mix of staff within service provision.The outcome of this may welcome more young people to the service, without the fear of being discriminated against because of their race or ethnicity, religion or belief and sex or sexual orientation. Moreover, Jerome et al., (2009, p.356) discovered from their study that a priority for young people accessing sexual health services is to include both male and female staff for their needs to be addressed by a same-sex professional. As a whole, focusing on what the client wants and ensuring client centred practice is put into place will invite young people to engage in sexual health services.

On the other hand, there may be inequality of power when young people access sexual health services. FPA (2013) underlines that one of the qualities that young people value the most in sexual health provision is the guidancegiven to them on all obtainable contraception options. This includes advising other courses of action where the young person is not happy with their current choice. However, instances whereprofessionals are not taking the time to listen to service users,have caused for certain contraceptive methods being ‘pushed’ onto them. This could indicate that professionals are abusing their power between themselves and the service users.Young people are not being empoweredin making their own decisions based on their contraceptive rights, as well as their rights in gaining the correct information. An example of this is given through a case study of a young woman accessing contraception. She stated that when reaching the service delivery point, she waited an hour to see someone, but only took a few minutes to be given the pill (FPA, 2013).

Recommendations of what could be done to address the above issue of oppression and inequality of power is mentioned previously. More money can be spent on contraception in order to provide service users with a wide variety of options, whilst preventing further issues. Additionally, tackling the matter in the lack of staffing, in order to avoid longer waiting times at the services, as well as service user’s having their needs fully met.

Informal service
The need for an informal service was found to be a low priority in Jerome et al’s., (2009, p.356) study. However, Braeken and Rondinelli (2012, p.S62) detailed that misinformation based on contraception is often a reason that prevents young people from seeking services. Therefore, it is important to provide a service that informs. Also, professionals should not limit the information given to any issues.

It was briefly mentioned by Perry and Thurston (2007, p.101) that young people require services that offers information, help and support. Whereas, Reeves et al., (2006, p.378) explained that in order for services to be developed, they need to be informative. In regards to their study findings, it is more likely that young people would enquire about advice and information from friends and family instead of health professionals. For this reason, not only providing a service that is informative for young people, but also providing information ‘to support parents and friends in their informal role as advisors would be apt.’ In support of this is FPA (2011), who believe that parents, carers, as well as all professionals who interact with young people – including those working in health, education, social services and youth services – should be able to gain access to support, advice, information and training on sexual health issues.

Drawing upon these key themes extracted from the five articles chosen, as well as evidence from sources, have been used to discuss the factors that affect young people’s engagement in sexual health services.Possible solutions to increase young people’s involvement in such services have also been discussed by organisations such as the Department for Education and Skills, The Family Planning Association.
5: Conclusion
The literature review conducted has underlined that young people currently face many factors that affect their engagement in sexual health services.Schools are said to be an ‘informant’ who influence young people’s sexual health decisions (DH, 2013). Because of the lack of sex and relationship education, sexual health promotion and advertising of services in schools, young people are not given the insight into knowing precisely where, how and when to access these services that are entitled to them. Moreover, the PHSE lessons that are taught to them, are not informing young people of their confidentiality and privacy rights, which have been highlighted to be their main fears when accessing sexual health services (UKYP, 2007). Therefore, it is important for schools to firstly promote service provision, secondly, emphasise that these services have the confidentiality and policy rights put in place and lastly, improving better links with other services, in particular GUM Clinics (UKYP, 2007).

In relation to young people who are lesbian, gay, bisexual and transgender, it is important that this vulnerable group are not excluded. Sex education taught in schools should ensure that they acknowledge this group of individuals.

A clear implication of the research analysed in this dissertation found that of all the barriers young people face when accessing sexual health services, confidentiality and privacy are huge issues for young people and the fear of them being broken.For young people, the assurance that what is said to the healthcare professional is kept in confidence is an important factor, as this forms the basis of a trusting relationship (Moyse 2009, p.330). Young people like to access a service knowing that parents would not be notified, their information would not be passed on from one professional to another or to any third party and not being stigmatised for using the services. (Reeves et al., 2006, p.376; Braeken and Rondinelli (2012, p.S63).

It can be suggested that when schoolsrequest for visitors from sexual health services, visitors can use this opportunity to reassure young people that confidentiality and privacy policies are in place at the services. As a result, this can increase the uptake of these services and therefore improve young people’s sexual health and well-being.

Restrictions to services, in terms of the location of them and the opening times, have also been identified within each research as a major barrier of accessing services. Young people have found accessibility, in particular, to be important. The reason for this is because travelling to a longer distance service, without letting their parents know may be difficult. Addressing this issue could be done by the integration of sexual health services, for example, giving young people the opportunity to access drop-in centres within the community, at school and leisure centres.

Young people require services where staff are friendly and non-judgemental, especially those who are LGBT (Perry and Thurston, 2007, p.99, DH, 2007). They value staffs that are patient, understanding, helpful and friendly.Some young people accessing sexual health servicesmay not know what to expect, may not be literate or confident, and some may be incapable of explaining what they need or want. Therefore, it is important that staffs are patient andsensitive to the young person’s need. Braekenet al., (2007, p.173) make recommendations for those who are involved in adolescent sexual and reproductive health. They inform professionals to continuously reflect on their values and attitudes.

Although a few of the articles provided found that the need for an informal service was a low priority for young people, one of the purposes of a GUM clinic is to provide advice and information about sexual health (NHS, 2013). As mentioned, young people would postpone sexual activity if detailed information based on sex and contraception, is given to them. For this reason, the need for an informal service in provision is significant. However, services need to be informative, not only for the young individuals, but also for parents/carers and friends.

In summary, it is evident that young people continue to be those at risk of contracting STIs. A way of tackling this to ensure young people are accessing the services available, to prevent further issues of their sexual health. All young people have a right to high quality, confidential service, including GP’s, GUM clinics, youth advice clinics, and telephone helplines. In order for young people to engage in such services, the provision must be based on the sexual health needs for young people, whilst acknowledging the importance of confidentiality and privacy, the need for services to be accessible and welcoming, whilst operating around their everyday lives (in terms of proximity and preferred opening times), the need of non-judgemental, friendly and approachable staff and the importance of providing a service that will be informative for them. Furthermore, it has been put forward that services should regularly be monitored and evaluated so that it could be understood why young people are accessing the service (DfES, 2007). This way, young people can be more involved in designing and shaping a service that is dedicated in meeting their needs.
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