Summary of the impact

Research at Coventry University has produced innovative approaches to addressing sexual health and wellbeing issues, sexual health promotion and sex education. The research has resulted in:-

• Impact on health and wellbeing (UK), an increase in self-reported use of sexual health services (supported by an increase in STI screening rates in some services) and increases in chlamydia screening and detection rates (with the programme now being rolled out nationally). Beneficiaries include young people, parents, GPs, Warwickshire County Council and Coventry City Council.
• Impact on society, culture and creativity through public understanding and public debate (International), with more than 150,000 visitors from over 20 countries accessing the sexual health resources, 30% of visitors returning to the website and an average of 6000 visits per month to the site, one year after launch. These resources benefit young people (primarily 13-25 age group).
• Impact on practitioners and services (International), with training courses and tools facilitating the adoption of best practice, with resources benefitting health practitioners and teachers and being used as evidence of harmful cultural practices in the Asylum Appeal Court.

Underpinning research

The underpinning research, which started in 2000, was developed by members of the Studies in Sexual Health research group, including Wallace (Professor employed at Coventry since 1998), Brown (Reader employed since 2004), Newby (Research Fellow employed since 2002) and Bayley (Senior Research Assistant employed since 2003).

Wallace et al [1] conducted one of the first theory-driven large-scale sexual health surveys of young people. This was in collaboration with the psychologists who developed the most widely applied psychological theory of health behaviour change, the Transtheoretical Model (TTM). The survey monitored 3820 young people, aged 13-16 years, in 10 schools across England between 2000 and 2003. Findings highlighted important psychological predictors of condom use and motivation to use condoms in the future among virgins and non-virgins; contributing to literature about relevant targets for intervention design. Similarly, qualitative research identified barriers to contraceptive use, useful for informing sexual education intervention design [2].

As a result of their research the team developed `What should we tell the children', a group intervention in collaboration with Coventry PCT's Teenage Pregnancy team and the Mother's Union, to help parents communicate with their children about sex and relationships [3]. Research into how to engage parents [4], particularly fathers, created the evidence base for translating the programme into a serious game format to engage fathers and those unlikely to attend a `parent' programme and also supported the development of a `Respect Yourself' campaign [5].

Another focus of sexual health research has been in support of chlamydia screening. Incidence of the disease has been rising steadily over the past decade, with approximately one in ten 15-24 year olds infected. In recognition of this significant public health problem, the Department of Health launched the National Chlamydia Screening Programme (NCSP) to increase detection and treatment of infection. Currently the number of chlamydia diagnoses is short of the target required to bring about a reduction in the prevalence of this infection. In 2008, the team worked with the Health Protection Agency (now Public Health England) to develop a theory-based intervention to increase offers of chlamydia screening to sexually active 15-24 year olds within general practice.

Specifically Wallace advised on the theory-based content, specifying evidence-based techniques most likely to be effective in increasing the motivation of clinicians to offer screening. The intervention was tested in a cluster randomised controlled trial (RCT) and was shown to be effective (see p3). To September 2013, 70 local authorities have signed up to roll out the intervention in their areas and 351 GP practices have agreed to receive workshops (as of 4^th October 2013). The intervention, being rolled out across England in 2013/14, includes the principles and theoretical approach used in the trial in which Wallace et al were involved, but has been modified to include a broader sexual health offer including offer of condoms and contraception as well as chlamydia and in some areas HIV screening.

Extending the sexual health research into Female Genital Mutilation (FGM), Brown and Barrett have developed targeted sexual health interventions which have led to significant international research focused on addressing these harmful cultural practices [6]. This work is interdisciplinary in nature (Barrett is submitted to UoA21). FGM adversely affects the mental, sexual and reproductive wellbeing of thousands of women; European Parliament indicated that as many as 500,000 women in the EU could be living with the consequences of FGM, and that over 180,000 women and girls are at high risk of falling victim to the practice each year. In 2010, Brown and Barrett led an international, multidisciplinary team (with partners from Belgium, Netherlands and the UK) in an EC Daphne III funded project (£93,607) to tackle FGM. The team used highly innovative twin-track participatory and behavioural change approaches to developing interventions with Somalian communities in Bristol (UK) and in Amsterdam (Netherlands). Follow-on funding from the EC (£485,602) was secured in 2013, extending the original international research team to include partners in Italy (CESIE), Portugal (APF) and Spain (Gabinet) to further develop the research and evaluate the effectiveness of the toolkit developed in the pilot scheme.

References to the research

Selected Grant Funding

• Bayley, Brown and Newby received funding from the West Midlands South Health Innovation and Education Cluster (HIEC) to further develop the `What should we tell the children' intervention, the PR:EPARe serious game and the "Respect Yourself" website (£122,000).

• Brown and Barrett received two grants from the European Commission to research FGM (JLS/2008/DAP3/AG/1193 and JUST/2012/DAP/AG/3273) totalling £579,209

Details of the impact

This research has had direct impact on health and wellbeing; society, culture and creativity, and practitioners and services.

Impact on health and wellbeing — measure of improved clinical outcomes, public behavior and health services
A rigorous intervention mapping approach was used to develop the parents' sex and relationships group programme `What should we tell the children' [3], with 400 parents benefitting since 2006. Feedback collected in December 2010 showed that parents' confidence in discussing sexual health matters had increased as a result of undertaking the course (97% of attendees thought that, as a result of the course, they were more likely to talk to their children about relationships and sex) [a]. Subsequent feedback from parents has shown that the programme has had a significant impact on the way they interact with their children regarding sexual health matters [b].

As a result of the programme, Coventry City Council continued to work with the research team to launch a new web-based campaign `Be Savvy' (www.besavvy.org.uk) to promote sexual health and wellbeing to teachers, parents and young people. The website hosts a serious game version of `What should we tell the children'. The team have also developed and promoted an interactive PR:EPARe serious game for relationships and sex education (RSE) [5]. The game is used by teachers as a resource to aid sex education; tackling pressure and coercion in teenage relationships (see section below on impact on practitioners and services).

Using the same rigorous intervention mapping approach, the research was extended, in collaboration with Warwickshire Council, to redevelop their `Respect Yourself' campaign website and develop a new web app (www.respectyourself.info). The campaign is aimed at young people in Coventry and Warwickshire to provide them with information about locally available resources. Brown and Newby's research contributed to the successful `Respect Yourself' campaign, which resulted in a decline in under-18 conceptions in Warwickshire. Evaluation data indicated that the website and web app were successful in increasing the uptake of sexual health services by young people in Warwickshire, specifically amongst males. Involvement in the development of the website and web app also had a positive impact on young people. This is confirmed by written feedback from the young people sitting on the project's consultancy board, e.g. "...this has been a very beneficial experience for me, in the way that it has expanded my knowledge and confidence" [c]. Amy Danahay, Respect Yourself campaign manager, said: "These results prove we are giving young people the power to make positive and informed choices about their relationships and sexual health and the courage to speak out if they don't feel comfortable and safe."

The impact of the chlamydia screening intervention was evaluated between 2009 and 2011 in a prospective, cluster RCT with a modified Zelen design, in which participating practices did not know that the intervention was being evaluated. During this period, testing in intervention practices was 1.76 times greater than in the control practices and this persisted for nine months post intervention. The number of chlamydia infections detected increased within the intervention practices, from 2.08 per 1000 registered 15-24 year olds prior to the intervention, to 2.45 during the intervention. Due to this evidence of substantial efficacy, the findings have been widely discussed by Local Authority commissioners and public health teams across England. Furthermore as a direct result, in April 2012 the NCSP commissioned the roll-out of the intervention across all GP practices in England using a network of trainers. Training of the trainers commenced in July 2013 and 70 upper-tier Local Authority areas in England have elected to participate.

Impact on society, culture and creativity — impact on public understanding and public debate
Although the `Respect Yourself' and `Be Savvy' websites were set up for use within the West Midlands, they have had significant international reach. In the 9 months between July 2012 and March 2013 the `Respect Yourself' website was visited 164,463 times (data from Google analytics), with visitors from over 20 countries worldwide. The significance of the resource is demonstrated by good repeat use of the site, with 30% of unique users having visited the site previously. One year after its launch the resource is still attracting more than 6000 visitors per month (data from Google analytics August 2013). On average 2-3 questions are submitted to the site each week, proving the ongoing value of the website and the continued engagement of young people in the resource. Similarly, the `Respect Yourself' app has been accessed 20,000 times by 11,042 users (data from Diva Creative Ltd). There are 22,000 visits a year to the `Be Savvy' website, on which the PR:EPARe and `What should we tell the children' serious games are both hosted [d].

Both the PR:EPARe serious game and `Respect Yourself' website have received significant media attention, promoting and stimulating public awareness. The PR:EPARe serious game received both business and educational media coverage and the `Respect Yourself' campaign was featured in the Guardian [e], on YouTube [f], on Channel 5 evening news, & ITV's `This Morning' programme [g]. International press coverage included China and Mexico [h]. In addition, the website and app were featured in a presentation at the Public Policy Exchange's `6th Annual Sexual Health and Young People Symposium: A New Framework for Tackling Teenage Pregnancy', held in Westminster on 9^th July 2013[i]. The positive early evaluation findings and considerable media attention have meant that a number of other local authorities in the UK have shown an interest in replicating the `Respect Yourself' website and app for their own locality. This has led to the original partners in the project putting together a licensing agreement so that other authorities can purchase the right to replicate it. The research team at Coventry University remain the behaviour change experts and evaluation providers for each new license purchased. Four local authorities are currently in the process of purchasing the license [j].

Impact on practitioners and services — evidence of adoption of best practice
Building on intervention mapping methods, Brown and Barrett applied asset-based approaches to develop FGM research. FGM is a problem that presents locally, within migrant communities in the UK, but stems from traditional, deep-rooted cultural practices in Africa, the Middle East and Asia. The EC-funded REPLACE project resulted in the development of a pilot toolkit promoting the application of community-based participatory and behaviour change approaches to interventions, aimed at ending the practice of FGM within the EU amongst FGM affected diaspora communities. This has had an impact on and been supported by a number of organisations working to end FGM including original partners (FORWARD UK and FSAN (Netherlands)) and organisations from outside the project, such as the European Institute for Gender Equality and the UK Government. REPLACE II has just been funded to implement and evaluate the REPLACE toolkit developed during the pilot phase, working with various FGM affected diaspora communities across five EU countries. The Daphne REPLACE framework, developed as part of the project, is now being used by other practitioners, for example, in a separately funded Daphne [k] project and by Bristol NHS Trust. Brown and Barrett's FGM work has been featured in the national press (The Parliament Magazine — Nov 2011, and London Evening Standard and The Conversation - June 2013) and Barrett has been invited to contribute to a to a government-funding consultation at DFID on FGM prevalence rates and has been part of the "huddle" to inform forthcoming research priorities on FGM. Barrett has been called upon by the Asylum Appeal Court to prepare almost 30 expert reports on FGM in Gambia, and she has appeared as an expert witness in two cases.

The PR:EPARe game has also had impact on practitioners, being available as a resource to teachers in Warwickshire to support their delivery of relationships and sex education. Warwickshire Council ran training courses for teachers every two months and in the first year (2010) 900 completed the course, indicating the reach of the programme. Feedback from teachers stated they found the game to be "...an excellent stimulus for discussion" and "...engaging".

The chlamydia screening intervention has impacted on staff in GP practices, supporting them to achieve a significant increase in opportunistic screening and detection of chlamydia. As detailed previously, this intervention is being rolled out nationally in 70 local authorities.

Conclusion
This case study demonstrates that the Unit's research had impact on health and wellbeing supporting a decline in under-18 conceptions, an uptake of sexual health services and increasing chlamydia screening rates. The materials developed have also had an impact on society, culture and creativity, increasing public awareness on sexual health issues. Internationally, the research has had impact on practitioners and services working to reduce female genital mutilation.

Sources to corroborate the impact

a) Coventry Teenage Pregnancy needs Assessment report, 2012 <RAND appendix 1 PR-522-CU>

b) Item (4) RAND Memo "Addendum to summary impact evidence collection exercise", 9/7/13

c) Appendix 3, RAND Memo Document No. PR-522-CU "Summary of impact evidence collection exercise", 24^th April 2013

d) Google analytics information on `What should we tell the children' programme and Be Savvy and Respect Yourself websites available on request

e) http://www.guardian.co.uk/society/2012/oct/25/early-puberty-growing-up-faster

f) http://www.youtube.com/watch?v=vKMZxl2Sgpw

g) Channel 5 News - 23/10/12 6:30pm and 11/12/12 and This Morning - 24/10/12

h) Mexico http://tinyurl.com/pkm59jw and Chin http://tinyurl.com/nv9zx8b

i) Amy Danahay public policy exchange event http://tinyurl.com/pretx6v

j) Commercially confidential communication from other authorities about interest in app/website technology and the latest information on licence purchases is available on request

k) http://www.change-agent.eu/index.php/about-us/objectives