Summary of the impact

This case study is based on two areas of research, both focused on young women's sexual health, conducted by Hoggart and Newton between 2009 and 2013. The first concerns abortion, and the second concerns long-acting reversible contraception (hereafter LARC). The research has had the following impacts: sexual health policy has been influenced; the delivery of sexual health service has changed; guidelines have been informed; practitioners have used the research findings; new clinical processes have been adopted; professional training has been influenced by the research; and industry has invested in research.

Underpinning research

In recent years, young women's contraceptive and abortion behaviour has been the subject of policy developments and academic research. In 1999 the Labour Government launched the Teenage Pregnancy Strategy and set a target of halving conceptions among the under-18s by 2010. There has been significant focus in recent years, in the UK, on LARC and its potential to reduce rates of unintended pregnancy. The research underpinning this case study has had an impact on policy and clinical practice with respect to young women and sexual health in the areas of contraceptive provision and abortion policy and services.

The research on abortion began with an empirical study investigating teenage abortion in London. This was originally commissioned by the Government Office for London in 2008, in partnership with the London Sexual Health Commissioning Programme. Lesley Hoggart began the research at the Policy Services Institute; the data analysis, which began in 2009, and rest of the project were carried out at the University of Greenwich where Hoggart held the post of Reader in Social Policy. A full research report¹ and a peer-reviewed publication² were produced. Hoggart then conducted a further piece of research in 2011³. This comprised secondary analysis of three of her previous projects on teenage pregnancy decision-making undertaken between 2003 and 2010 (including the teenage abortion in London study). The three previous projects were all concerned with the pregnancy/abortion decision-making processes of pregnant teenagers.

Two original insights have come from this body of research: young women may be committed, but ineffective, contraceptive users primarily relying upon user-dependent methods; and young women's contraceptive behaviour following an abortion may be influenced by a number of complex factors, including their own emotional response to the abortion. These and other findings led to a number of implications for sexual health policy and practice:

The London report¹ recommends:

• introducing post-abortion follow-up for young women;
• developing more coherent abortion pathways;
• improving young women's access to all forms of contraception (including LARC), and
• improving pregnancy support and counselling.

The publication on teenage pregnancy decision-making³ emphasises:

• the importance of practitioners giving non-judgmental advice to pregnant teenagers.

The LARC research, conducted by Hoggart and Newton, was commissioned in 2010 by the London Sexual Health Commissioning Programme as a follow-up to Hoggart's research on abortion. Policy makers wanted to improve young women's access to all forms of contraception, but were concerned about low retention rates of the implant, one form of LARC. The research had two main research aims: first, to gain an in-depth understanding of why young women have their implants removed and second, to understand what might help them maintain this method of contraception. This research contained original insights, some of which have attracted the attention of sexual health professionals, namely:

• young women feel they are given very little support when they experience unexpected side effects associated with the implant;
• if they encounter resistance to removal of their implant, they may become exasperated and disengage from sexual health services.

The report⁶ recommends:

1) practitioners should inform women about all possible side-effects, and how they may be treatable, at the initial contraceptive consultation;

2) clinics should have an `open-door' policy and encourage women to return to the clinic for help, at any time;

3) practitioners should offer therapeutic interventions to manage bleeding irregularities, and

4) removal (combined with further contraceptive advice) should be readily available at any time.

References to the research

Abortion research

LARC research

Details of the impact

This body of research has led to changes in policy and clinical practice in the UK. These impacts are in line with the research recommendations summarised in section 2. For clarity of exposition, the two areas of research are discussed separately: abortion, followed by LARC.

Research on abortion

Policy debate has been informed by the research evidence. The 2010 report is extensively quoted and referenced in the 2013 Department of Health policy document, A Framework for Sexual Health Improvement in England. This has had onward impact on the work of the Department of Health, the Department of Education, Public Health England, and several charitable bodies. Further, on the basis of the abortion research, Hoggart was engaged as an expert adviser to the Department for Education on an IFS/DfE project to examine the characteristics associated with teenage pregnancy.

The delivery of a public service has changed. New abortion care pathways have been developed in London in response to the London abortion research recommendations. Brook advisory service has also developed its service as a result of the abortion research: when they refer a young person for an abortion they now contact them following their abortion in order to discuss their contraceptive needs. In terms of wider reach, Lisa Hallgarten, formerly of Education for Choice and latterly of Brook, believes that the 2010 recommendations on abortion, sexual relationship education and counseling were taken up universally and certainly across the London boroughs, with strong evidential links into policy and advocacy documents throughout London. She believes it is evident that policy has become practice, and that virtually all people who engage with target groups are well aware of the abortion research mainly because the work is written from a practitioner's point of view, is very implementable and has sensible recommendations. A number of key stakeholders involved in the implementation of the Sexual Health Strategy believe that although there has been similar research in this area, this work has without doubt had a major impact and has provoked actions more immediately than any other similar piece of research. Adrian Kelly noted that the Greenwich research was passed down to the 32 London boroughs, which allowed each individual borough to create locally tailored action plans. A typical action (in Hackney) was to recruit a dedicated nurse to follow up young women after abortion to encourage the uptake of contraception. Two boroughs, Enfield and Hackney, made key decisions, following which repeat abortion dropped dramatically.

Practitioners have used research findings in conducting their work. Although the DoH say they are definitely witnessing a decrease in the number of abortions, which directly presents cost savings to the UK government, there is little or no publicly accessible comparative data to measure robustly how much of this can be attributed to different changes (partly because of the recent re-structuring of the NHS). Nevertheless, two examples are provided of local testimony of the significance of the impact on local practice. In Hillingdon, the Teenage Pregnancy Coordinator implemented a strategy which involved the training of staff and restructuring of abortion and sexual health services to ensure that LARC was offered routinely and appropriately post abortion, and that LARC is the initial method of contraception discussed/offered to all young women under 18yrs (with for example the new post of a Sexual Health Outreach Nurse). This extends to GUM/Sexual Health outreach service. Additionally, abortion rates for under 16yrs and repeat abortions became more of a focus locally than they had been before the research. Abortion providers have used the findings to reinforce to their staff the importance of non-judgmental services: one of the two main providers of abortion in the UK, BPAS, has placed the report on its website.

Professional training has been influenced by the research. Research findings from the abortion research have been drawn upon in the development of Sexual Health Study Days (eg Brighton & Hove, July 2013) being developed by Alison Hadley of the Teenage Pregnancy Knowledge Exchange, Bedfordshire University.

Research on LARC

The delivery of a public service has changed. There has been a change in contraceptive counselling practice in a number of local areas (eg Greenwich, Hillingdon). Women are now given more information about all possible side-effects of the implant, and also advised to return to the clinic as soon as they become concerned about side effects, and that therapeutic interventions can be offered to alleviate bleeding-related side-effects. These changes have been recommended at training workshops conducted by Jane Dickson (consultant in sexual health) throughout the country.

Professional training has been influenced by the research. Hoggart and Newton have worked closely to incorporate the findings of the LARC research into practitioner training and thus maximise the impact of the research in clinical practice. Newton and Dickson developed a workshop for practitioners and commissioners, which was first delivered at a national Sexual Health Research and Practice Conference held at the University of Greenwich in May 2012. This has now been incorporated into practitioner training lectures which are being delivered by Dickson to practitioners and commissioners across the UK. It has also been incorporated into Sexual Health Study Days (eg Brighton & Hove, July 2013) being developed by Alison Hadley of Teenage Pregnancy Knowledge Exchange, Bedfordshire University. Kathy French of the Royal College of Nursing has made presentations which incorporate key findings of this research to more than 1,000 professionals in London; especially emphasising the need to deal with unscheduled bleeding and for all agencies and stakeholders to work together in supporting young women in using LARC.

Practitioners have used the research findings. In London and further afield sexual health practitioners have changed their practice: offering therapeutic interventions for bleeding irregularities; being less resistant to women's requests for implant removal, giving more information about all possible side-effects of the implant, and also advising women to return to the clinic as soon as they become concerned about side effects, and that therapeutic interventions can be offered to alleviate bleeding-related side-effects. West Middlesex University Hospital, for example, has put the educational element of LARC research into practice, training approximately 42 people (sexual health practitioners, doctors, and nurses) to understand the complexity of social/personal issues for vulnerable young women using LARC, and to communicate contraceptive advice effectively on a one-to-one basis so their clients can understand the issues and ask relevant questions.

Industry has invested in research. Bayer has commissioned Hoggart and Newton to undertake further research on long-acting contraception as a result of the high quality of their LARC research.

Sources to corroborate the impact

Impact on national policy (abortion research)
The DoH Sexual health Framework: https://www.gov.uk/government/publications/a-framework-for-sexual-health-improvement-in-england. The IFS/DfE project:
http://www.ifs.org.uk/caytpubs/caytreport06.pdf The following individuals can corroborate claims:
Andrea Duncan, Department of Health; Adrian Kelly, Senior Strategist, Public Health, London Borough of Hackney.

Impact on the delivery of public services (abortion and LARC research)
The following individuals can corroborate claims: Joanna Brien, Sexual Health Counselling Manager, London & South East, Brook; Adrian Kelly, Senior Strategist, Public Health, London Borough of Hackney. Availability of abortion report on the BPAS website as guidance for practitioners: http://www.bpas.org/js/filemanager/files/tpyoungpeopleinlondonabortionandrepeatabortion.pdf

Impact on professional training (abortion and LARC research)
Three individuals who can corroborate claims: Jane Dickson, Consultant in Sexual Health, Oxleas NHS Foundation; Alison Hadley, Teenage Pregnancy Knowledge Exchange, University of Bedfordshire; Kathy French, Sexual Health Adviser, Royal College of Nursing.

Impact on practitioners and their clients (abortion and LARC research)
Abortion statistics from DoH (confidential documents which can be made available by the HEI if audited). Two individuals who can corroborate claims: Carol Page, Public Health Lead for Young People's Sexual Health, Healthy Hillingdon; Dr Kimberley Forbes, West Middlesex, University Hosp.

Industry has invested in research (LARC research)
Documentary evidence of commission by Bayer Pharmaceuticals (confidential documents which can be made available by the HEI if audited).