Summary of the impact

Edinburgh Napier University led on a large quasi-experimental study which evaluated a National Health Service (NHS) Demonstration Project called Healthy Respect. Healthy Respect was a complex public health intervention based on the latest evidence and theory, which combined school sex education with sexual health drop-in clinics in or near to schools, and was supported by large media and branding campaigns. The research was commissioned by the Scottish Government (2006-2010). Our findings were reported directly to Government and the NHS and were synchronized to fit their policy-making cycles. It shaped Government policy and steered service provision in the NHS.

Underpinning research

Background
The poor sexual health of young people, including unplanned pregnancy, sexually transmitted infections and poor quality relationships, is of concern in many countries including the United Kingdom. In 2005, the Scottish Government launched its sexual health policy (Respect and Responsibility), which aimed to improve the sexual health of the population, including a flagship intervention for young people called Healthy Respect.

A team led by Professor Lawrie Elliott (Edinburgh Napier University, 2005-present) was commissioned at a cost of £670,000 by the Scottish Government to evaluate the impact of Healthy Respect (3.1). The team comprised researchers with expertise in sexual health, randomised controlled trials (RCTs) and quasi-experimental research, Professor Lawrie Elliott (Edinburgh Napier University), Dr Marion Henderson and Professor Danny Wight (Medical Research Council, Social and Public Health Sciences Unit), statistics Professor Gillian Raab (Edinburgh Napier University, 2000-2010), qualitative research Dr Markus Themessl-Huber (University of Dundee) and mixed methods Dr Claudia Martin (Scottish Centre for Social Research).

Members of the team have a long track record in evaluating sexual health interventions. For example, Professor Elliott has conducted sexual health research since the acquired immunodeficiency syndrome (AIDS) epidemic in the 1990s. Professor Wight and Dr Henderson have published widely on the sexual health of young people for almost 20 years including a large RCT on a school-based sex education intervention which was incorporated into Healthy Respect.

The evaluation of Healthy Respect spanned five years (2006-2010) and comprised a number of studies including a quasi-controlled trial which compared over 2,000 young people in the intervention area to over 3,000 in a non-intervention comparison area. We assessed the quality and impact of collaborative links between the agencies and over 300 professionals involved in its delivery. We also assessed the uptake and experience of Healthy Respect among young people and their parents.

Key findings and conclusions
Healthy Respect was successful in encouraging organisations to work collaboratively and, in so doing, improved access to more specialist services. It also improved professionals' ability to work with young people (3.2). However, it had a limited impact on the sexual health outcomes for the majority of young people (3.3). Furthermore, it had a limited impact on those who had poorer sexual health (3.3) including those from areas of social and economic deprivation who incidentally made more use of the Healthy Respect services. Thus sexual health inequalities remained.

Our work indicates that collaborative partnerships, which are the fundamental basis of many complex public health interventions, improve the way services work. This may help relatively healthy young people to maintain their health status but, population-based interventions, such as Healthy Respect, are unlikely to result in better outcomes for those young people with already poor sexual health. Interventions which aim to address the underlying causes of poor sexual health, such as inadequate parenting and detrimental social relationships, may prove promising and these should be delivered earlier in life. Our work has led to a new grant, led this time by the Medical Research Council (MRC), Social and Public Health Sciences Research Unit (collaborator Edinburgh Napier University) for a trial at a cost of £914,000 evaluates the effectiveness of a public health primary school intervention that aims to improve well-being and social relationships among younger people (NIHR 212) (3.4).

References to the research

3.1. Evaluation of the National Demonstration Project Healthy Respect Phase 2. Elliott L, Raab G (Edinburgh Napier University), Themessl-Huber M (University of Dundee), Henderson M, Wight D (MRC Social and Public Health Research Sciences Unit, University of Glasgow), Martin C, Ormston R (Scottish Centre for Social Research, Edinburgh), Burtney L. Funder: Scottish Government, £670,000, 2006-2010.

3.4. Social and Emotional Education and Development (SEED): a Stratified, Cluster Randomised Trial of a Multi-component Primary School Intervention that follows the Pupils' Transition into Secondary School. Funder: National Institute for Health Research, Public Health Research Programme, £914,000, 2012-2017. http://www.phr.nihr.ac.uk/funded_projects/10_3006_13.asp.

Details of the impact

Impact on Policy
The results of our evaluation began to emerge in 2008 and were fed back regularly to the Healthy Respect team and Government, including the two research papers published in 2013 (3.2, 3.3). We also published two reports: an interim report in 2008 (5.1) and a final report in 2010 (5.2). All were designed to synchronise to the policy-making cycles of Government and the NHS.

For example, our final report was peer-reviewed by members of the Healthy Respect team and Government representatives (5.3). Two of the research team, Dr Henderson and Professor Wight, sat on the Scottish Government Health Department, National Sexual Health & HIV Advisory Committee which advised on the Scottish Government's new sexual health strategy published in 2011 entitled: `Sexual Health and Blood Borne Virus Framework 2011-2015'. The results of our evaluation directly shaped this policy which emphasises the need for early intervention (5.4).

`The evaluation of Healthy Respect also highlighted that poor outcomes in teen years, including sexual risk-taking, are best tackled in the early years of a child's life; that there is a need to work more intensely with young people to help them address underlying issues which shape sexual health; that the most vulnerable young people should be targeted for interventions; and that generic aspects of parenting are more important than communication about sexual matters.' Sexual Health and Blood Borne Virus Framework 2011-2015, P19.

The Health Improvement Programme Manager (NHS Health Scotland) was a key link between the Government, the NHS and other stakeholders on sexual health and stated in May 2013: "The Healthy Respect evaluation helped to shape policy on the sexual health of young people". NHS Health Scotland used the evaluation reports to inform current policy including the `Sexual Health and Blood Borne Virus Framework 2011-2015'. (5.5).

The Specialist in Public Health Scottish Government, Healthy Respect Lead, and now Deputy Director of Public Health NHS Lothian stated in March 2013: "The iterative feedback throughout the evaluation process allowed us to make early changes to the Healthy Respect intervention. The evaluation results also informed Government sexual health policy including the Respect and Responsibility Sexual Health Outcomes Plan 2008-2011 and the Sexual Health and Blood Borne Virus Framework 2011-2015. It also influenced thinking around broader policies such as the report of the Ministerial Task Force on Health Inequalities 2008". (5.6).

In 2013, Professor Elliott was invited, on the basis of the evaluation of Healthy Respect, to present evidence to the Scottish cross parliamentary Health and Sport Committee's Inquiry into Teenage Pregnancy which was held on 26th February 2013 (5.7). The aim of the committee was to initiate a new round of policy thinking. In October 2013, the Scottish Minister for Public Health Michael Matheson MSP, responded by letter to the findings of the Inquiry. He welcomed the recommendation to address the determinants of poor sexual health (which are wider than health) and intervening early in life to break the intergenerational cycle of health inequalities (5.8).

Impact on Service Provision
Our research findings emphasised the importance of collaboration between agencies (3.2) and these influenced operational policy on sexual health service provision, particularly that which improved access for young people to a wider range of health and other services.

In March 2013, the Specialist in Public Health Scottish Government, Healthy Respect Lead, and now Deputy Director of Public Health NHS Lothian stated "The research has helped Healthy Respect to improve current health care pathways for young people particularly those from disadvantaged backgrounds" (5.7).

In June 2013, the Programme Leader for Sexual Health and Healthy Respect Manager (NHS Lothian) and the Senior Sexual Health Promotion Specialist, Healthy Respect (NHS Lothian), stated "The outcomes paper (3.3), confirmed that Healthy Respect, as a demonstration project, had some way to go to improve the sexual health of young people. The partnership paper (3.2) suggested we should build on our success in service collaboration particularly with a view to connecting with the broader health agenda. Our approach has always been to respond to emerging evidence and practice. For example, our drop-in clinics now offer young people the opportunity to address a range of health issues including drug and alcohol use, social, emotional and mental well-being and on-line safety. We are also collaborating on approaches to teenage pregnancy which recognise its complexity and the need to work together to effect a sustained reduction, as well as to improve other health and educational outcomes for young parents and their children" (5.9).

Sources to corroborate the impact

5.1. Elliott L, Henderson M, Wight D, Nixon C, Claveirole A, Raab G, Pow J, Martin C, Miller M, Storkey H, Birch A, Rowlands B, Burston A, Themessl-Huber M, Burtney L (2008) Evaluation of Healthy Respect Phase Two: Interim Report. NHS Health Scotland.
http://www.healthscotland.com/documents/3084.aspx.

5.2. Elliott L, Henderson M, Wight D, Nixon C, Claveirole A, Raab G, Pow J, Martin C, Miller M, Storkey H, Birch A, Rowlands B, Burston A, Themessl-Huber M, Burtney L (2010) Evaluation of Healthy Respect Phase Two: Final Report. NHS Health Scotland.
http://www.healthscotland.com/documents/4122.aspx.

5.3. E-mail from NHS Health Scotland 14 October 2009: meeting of stakeholders on the final report.

5.4. Scottish Government `Sexual Health and Blood Borne Virus Framework 2011-2015' published 2011. http://www.scotland.gov.uk/Publications/2011/08/24085708/16.

5.5. Interview with contact from NHS Health Scotland conducted by Professor Elliott 2 May 2013.

5.6. Interview with Specialist in Public Health Scottish Government, Healthy Respect Lead, and now Deputy Director of Public Health NHS Lothian, conducted by Professor Elliott 19 March 2013.

5.7. Invitation from the Health and Sport Committee, Scottish Parliament 18 February 2013 and transcript of the meeting (26 February 2013).

5.8. Letter from the Scottish Minister for Public Health, Michael Matheson MSP to the Duncan McNeil, Convenor Health and Sport Committee 12 September 2013
http://www.scottish.parliament.uk/S4_HealthandSportCommittee/Inquiries/Minister_for_Public_Health_-_Response_to_Teenage_Pregnancy_Enquiry.pdf. Copy of annex C cited in the letter can be provided, specifically page 1 and 2, which highlights early interventions that address the wider determinants of sexual health.

5.9. Interview with Programme Leader for Sexual Health and Healthy Respect Manager NHS Lothian and Senior Sexual Health Promotion Specialist conducted by Professor Elliott 17 June 2013.