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Sexual Health

Introduction

The World Health Organisation (WHO) defines good sexual health as ‘a state of emotional, mental and social wellbeing related to sexuality, not merely the absence of disease, dysfunction and infirmity’. Prompt diagnosis and treatment of individuals with a Sexually Transmitted Infection (STI) and the identification and treatment of infected sexual partners (partner notification), reduces the duration of infection, the likelihood of infecting others and the possible complications associated with untreated infections.  Unintended pregnancies and STIs can have a long lasting impact upon people’s lives; good sexual health is important to individuals and society therefore being able to access the right support and services and promoting good sexual health is essential (DH, 2013).

Building upon the first National Strategy for Sexual Health and HIV (DH, 2001), A Framework for Sexual Health Improvement in England was launched in March 2013. The Governments ambition for this framework is to improve the sexual health and wellbeing of the whole population by:

 

  • Reducing inequalities and improving sexual health outcomes
  • Building an honest and open culture where everyone is able to make informed and responsible choices about relationships and sex;
  • Recognising that sexual ill health can affect all parts of society. (DH 2013)

 

Corporate / Organisational Indicators & Performance Measures

The Framework should support the achievement of the Public Health Outcomes Framework indicators:

  • To reduce the number of people presenting with HIV at a late stage of infection
  • To reduce rates of teenage conceptions amongst under 18’s
  • To increase the detection  rate for Chlamydia among those aged 15-24 years
  • To reduce the rate of STIs, excluding chlamydia
  • Performance against these indicators is monitored on a monthly and quarterly basis through the following:
  • Public Health Senior Management Team
  • Bedford Borough Corporate Performance
  • Bedford Health Protection Committee

 

What do we know?

 

Chlamydia

Chlamydia is the most common curable STI with 200,288 diagnoses made in 2015, of these 129,000 were diagnosed in young people aged 15-24 years (PHE,Laser Report 2016). Chlamydia is most often asymptomatic and if left untreated can lead to serious reproductive health consequences, including infertility in both men and women. Public Health England recommend that local areas screen to achieve a diagnostic rate of at least 2,300 per 100,000 resident 15-24 year olds, to contribute to a national reduction in Chlamydia prevalence.

 

Local Picture 

The aim of an effective screening programme for Chlamydia is to achieve a detection rate of at least 2,300 per 100,000. This ensures that the programme is effectively targeting those young people at highest risk of infection. The detection rate for Chlamydia in Bedford Borough has exceeded the recommended rate in 2013, 2014 and also in 2015 with a detection rate of 2671.4 per 100,000. Areas achieving this rate should aim to maintain or increase it. Such a level can only be achieved through the ongoing commissioning of high volume, good quality screening services across sexual health services and primary care.

Figure 1 Chlamydia detection rate per 100,000 population in 15-24 year olds in Bedford local authority, East of England PHE Centre and England 2015

Sexual Health

 

Table 1 Chlamydia testing data in 15-24 year olds in Bedford: 2015

Number of chlamydia tests in SHCs

Number of chlamydia tests in other settings

Total number of

tests

Number of positives (all settings)

Percentage of population tested (all settings)

1418

3860

5278

537

26.3

*Repeat tests are not excluded

Source: Data from specialist sexual health clinics and community settings

 

In 2015 the percentage of all those screened who tested positive for Chlamydia in Bedford Borough was 10.17%, which is significantly higher than the England percentage of 8.3% and the East of England percentage positive of 7.93%, confirming an effective approach to screening locally and targeting an appropriate cohort whilst retaining open access.

 

Focusing on treatment and partner notification will not only prevent re infection and possible onward transmission but will also increase diagnosis rates (NCSP 2012). Evidence shows that treatment rates of at least 95%, together with a partner notification rate of at least 0.6 per index patient, will contribute to the reduction in the prevalence of Chlamydia. There should also be an emphasis on the need for repeat screening annually and on change of partner, as well as the need for re-testing after a positive diagnosis within 3 months of initial diagnosis.  Sexual health services across Bedford Borough are performance managed on a quarterly basis against targets for treatment and partner notification.

 

HIV Infection

An estimated 101,200 people were living with HIV in the UK in 2015. The overall prevalence was 2.3 per 1,000 population aged 15-59 years. Men who have sex with men (MSM) and black Africans are the groups most affected by HIV infection. The majority of infections are acquired sexually (>95%) . The number of infections acquired through injecting drug use and mother to child transmission remains low.

The number of people living with diagnosed HIV infection in the UK has continued to increase, while the number of new HIV diagnosis remains stable at approximately 6,000 per year in recent years. People diagnosed late have a tenfold increased risk of death in the first year following diagnosis compared to those diagnosed early. It is estimated that 13% of people are living with HIV and unaware of their infection and remain at risk of passing it on if they are having unprotected sex. Reductions in undiagnosed infection can be achieved through increased HIV testing in STI clinics and in a variety of different medical services, in addition to primary care and community testing, including self-sampling. (PHE Laser Report 2015)

 

Local Picture

In 2015 the diagnosed HIV prevalence rate for Bedford Borough was 2.4 per 1,000 population aged 15-59 years, compared to 2.26 per 1,000 in England.  This indicates that Bedford Borough is a higher prevalence area for HIV.

 

In England, of those diagnosed with HIV infection in 2015, 79% had residence information available.

Where residence information was available in 2015, 16 adult residents of Bedford were newly diagnosed with HIV. The rate of new HIV diagnosis per 100,000 population among people aged 15 or above in Bedford was 11.9, compared to 12.1 in England.

 

Figure 2. Rate of new HIV diagnosis per 100,000 population among people aged 15 or above by year in Bedford compared to rates in areas of East of England PHE Centre (PHEC) and England: 2011-2015.

 

Sexual Health

 

Late diagnosis of HIV is the most important factor of HIV related morbidity and short term mortality. It is a critical component of the Public Health Outcomes Framework and monitoring is essential to evaluate the success of local HIV testing efforts. Between 2013 and 2015 68.2% of HIV diagnoses were made at a late stage of infection, which equates to 30 people. The late diagnosis rate for England is 40.3% per 1,000.

 

Figure 3 shows the proportion of HIV late diagnoses in Bedford Borough compared to the rest of the East of England. The rate of late diagnosis in Bedford Borough is significantly higher than the national average of 42.2%.

Sexual Health

 

Source PHE 2015

 

Unfortunately due to small numbers in many local authorities it is not possible to present a break-down of new HIV diagnoses by route of transmission in this report. In England in 2015, 48% of new HIV diagnoses were in MSM, 15% in male heterosexuals, 19% in female heterosexuals; 53% of new HIV diagnoses were in white and 20% in black African populations.

Increasing access to HIV testing can reduce the number of people being diagnosed late through earlier identification. In 2015 among specialist sexual health clinics 92.9% residents from Bedford Borough were eligible to be tested for HIV and were offered, an HIV test was done in 79.0% of these attendances.

Nationally, an HIV test was offered at 80.4% of eligible attendances at specialist SHC and, where offered, an HIV test was done in 76.2% of these attendances. Increasing the uptake of HIV testing remains a priority for Bedford Borough in order to improve health outcomes following diagnosis and therefore contributing to the achievement of the Public Health Outcomes Framework indicator to reduce late diagnosis. . The offer and uptake for Bedford Borough residents will be monitored against performance through the Integrated Sexual Health Contract performance.

 

Other Sexually Transmitted Infections

Local Picture

Figure 4 shows the National trend in all acute STIs new diagnoses of Syphilis, Gonorrhoea, Genital Herpes and Genital warts.

Bedford Borough is ranked 91 (out of 326 local authorities in England; first in the rank has the highest rates) of new STI diagnosis excluding chlamydia diagnosis in 15-24 year olds with a rate of 751.1 per 100,000 residents compared of 815 per 100,000 in England.

Bedford Borough is ranked 131 out of 326 local authorities in England for gonorrhoea, which is a marker of high levels of risky sexual activity. The rate of gonorrhoea diagnosis per 100,000 in 2015 was 39.7, compared to 70.7 per 100,000 in England.

Sexual Health

 

Prevention messages should be promoted to all sexually active young people and adults, highlighting that individuals can significantly reduce their risk of contracting  or passing on an STI or HIV by:

  • Always using a condom correctly and consistently when having sex with casual or new partners, until all partners have had a sexual health screen.
  • Reducing their number of sexual partners and avoiding overlapping relationships.

 

Reducing the burden of STIs requires a sustained public health response based around early detection, successful treatment and partner notification, alongside promotion of safer sexual health behaviour.

Reinfection of STIs

Reinfection with and STI is also a marker of persistent risky behaviours. In Bedford Borough an estimated 7.8% of women and 10.7% of men presenting with a new STI at a sexual health clinic during a 5 year period from 2011 to 2015 were re-infected with a new STI within 12 months with a new STI within 12 months. Nationally over the same period, the figures are estimated as 7.1% of women and 9.3% of men. There is still a need to continue with health promotion messages in order to provide guidance around safer sex and promotion of the integrated contraception and sexual health services providing up to date information and free contraception, and testing.

Abortion

Abortion,( termination of pregnancy) is a healthcare need as well as a public health intervention (RCOG 2011). Unintended pregnancy knows no cultural or religious bounds and women of every faith and from all walks of life the world over access abortion services (Education for Choice 2008).

 

Local Picture

The total number of abortions in 2015 in Bedford Borough was 507. The percentage change from 2014 was -1.63%

Figure 4: Shows a breakdown of ages (* indicates <50)

 

Age

Under 18

18-19

20-24

25-29

30-34

35+

Total

Number of Abortions

 

*

 

*

 

139

 

115

 

78

 

96

 

507

 

Source: DH 2015

  • The total abortion rate per 1,000 female population aged 15-44 years was 16.0, while the England rate was 16.7 per 1,000. Bedford Borough is rated 81for the total abortion rate (out of 147 local authorities; first has the highest rating)
  • Among women under 25 years who had an abortion in 2015, the percentage of those who had a previous abortion was 21.1%, the England percentage is 26.5%, and this is slightly lower than the England and East of England percentage of 24.8%
  • The percentage of abortions for women over 25 years per 1,000 female population  aged 24-44 years was 39% while in England the percentage was 46.2%,  and the East of England percentage of 45%
  • Of the NHS funded abortions, which accounts for the majority, the proportion of those under 10 weeks gestation was 79.5%, the England rate was 80.3%. Although there is another provider, for patient choice, the data indicates the  local  preference is the Acute Trust.

 

The choice of early medical abortion is likely to have contributed to the increase in the overall England percentage of abortions performed under 10 weeks gestation, although the local figures and national figures have remained stable for 2014/15.  Early medical abortion is less invasive than a surgical procedure and carries less risk as it does not involve instrumentation or the use of anaesthetics. Medical abortions are also cheaper than surgical interventions.(PHE LASER, 2015)

The highest numbers of unplanned pregnancies occur in the 20 to 35+ years age group. Unplanned pregnancies can end in abortion (planned or spontaneous) or a maternity. Many unplanned pregnancies that continue become wanted. However, unplanned pregnancy can cause financial, housing and relationship pressures and have impacts on existing children. Therefore it is important to offer universal and easy access to contraception.

 

Long Acting Reversible Contraception (LARC)

The effectiveness of long-acting reversible contraceptives (LARC) is not dependent on the individual remembering to use them, and so they are one of the most effective methods of contraception.

Figure 5 illustrates the rate of LARCs prescribed in a primary care setting between 2011 and 2014. In 2014, Bedford was ranked 151 out of 326 local authorities in England for the rate of GP prescribed LARCs (1st has the highest rate), with a rate of 38.4 per 1,000 women aged 15 to 44 years, compared to 35.9 in East of England and 32.3 in England.

Rates per 1,000 women aged 15 to 44* years of LARCs (long-term) prescribed in primary care for Bedford local authority, East of England PHE Centre and England: 2011 to 2014 (PHE Laser Report 2014)

Sexual Health

 

 

Current activity and services  

Sexual health and contraceptive services (CaSH) are delivered in a variety of settings. The main provider of contraceptive and sexual health services is   Cambridgeshire Community Services (iCaSH) who subcontract Terence Higgins Trust and Brook.  These services have recently moved to an integrated model where contraception, sexual health and psychosexual services are managed by one provider and where possible delivered from one hub. Some services are available through GPs and Pharmacists. These services are free, open access and confidential.

Integrated Contraceptive and Sexual Health Services (iCaSH)

Cambridgeshire Community Services iCaSH together with Terence Higgins Trust (THT) and Brook provide a range of contraceptive and sexual health services, for all ages, for the population of Bedford Borough.  The services are based on a hub and spoke model, with the hub located in Bedford Borough and spokes in Central Bedfordshire. The services include: 

 

  • STI and HIV testing
  • Comprehensive contraceptive services
  • Treatment and partner notification for a full range of sexually transmitted infections
  • A range of sexual health information and health promotion
  • Psychosexual Therapy
  • Outreach testing and promotion and one to one intervention

 

The clinics aim to offer easy access to services including both drop in and pre-booked appointment clinics. There is a website providing advice and information and a single telephone number to book an appointment http://www.icash.nhs.uk/ . The appointments include early and late appointments and specific clinics for young people under 25 years.

School based CaSH services are available in the majority of upper schools in Bedford Borough, however, in recent years the number of attendances has decreased and therefore, these will be under review to see if there is a preferred venue young people would like to attend to access services. Targeted outreach work is delivered to those young people identified as vulnerable, such as looked after children, young people from areas of higher teenage pregnancy rates and young people not in employment, education or training (refer to the Teenage Pregnancy JSNA Chapter for more detail).

 

Psychosexual Service

Psychosexual counselling is designed to help people who may be suffering with sexual difficulties such as pain during sex for women and erectile dysfunction for men. However, more complex issues such as gender identity, sexual abuse/assault, and sexual addictions can be addressed. Referrals into the integrated service can be made from any health/social care professional or in some situations self-referral. 

Sexual Health Services in Primary Care 

Most Primary Care Practices offer access to long acting reversible contraceptives for their registered practice population. In addition, a small number of practices are commissioned to offer enhanced sexual health and contraceptive services, providing clinics which are free, confidential and open to anyone in Bedford Borough even if they are not registered to that practice. These services include sexual health information, testing and advice, a full range of contraceptive service, and treatment and partner notification for sexually transmitted infections.  For further details of these clinics visit http://www.icash.nhs.uk/

Condom Card Scheme

There are free condoms available for young people up to 25 years in a variety of settings, easily accessible for young people and managed and co-ordinated by the current sexual health provider. Free condoms are available for all ages throughout iCaSH services and from some GP practices and pharmacies when being provided with emergency hormonal contraception or tested for a sexually transmitted infection.

Sexual Health Services in Pharmacies

Emergency Hormonal Contraception (EHC), Chlamydia screening and treatment are available from a number of pharmacies across Bedford Borough. Those pharmacies that sign up to the enhanced sexual health contract receive an annual update on sexual health which also includes pathways and information on safeguarding.

Abortion Services

Termination for pregnancy services are provided by Bedford Hospital, Luton and Dunstable Hospital and BPAS (British Pregnancy Advisory Service) for Bedfordshire residents. In agreement and joint working with Bedford Hospital, an  iCaSH outreach nurse runs  an  outreach contraception clinic for those under 25 years alongside the termination clinics twice a week and arranges an appointment with the sexual health and contraceptive services for those over 25.

Sexual Assault Referral Centre

The Emerald Centre is a dedicated Sexual Assault Referral Centre providing a comprehensive service to anyone who has reported a rape or sexual assault to the police and is also open to self-referral. The centre is based in Bedford and serves several local authorities including Bedford Borough. Independent Sexual Violence Advisors (ISVAs) provide on-going care and support to victims and assist the victim in accessing a range of support.

National Chlamydia Screening Programme

The National Chlamydia Screening Programme provides sexually active young people aged 15-24 with access to Chlamydia screening and treatment through a variety of settings including contraceptive and sexual health services, GPs, pharmacists and termination of pregnancy providers. Young people can also request a screening kit anonymously via ‘free test me’, an online Chlamydia screening test site.

HIV Free Postal Self- Sampling Kits

This initiative was launched in November 2015 in readiness for HIV testing week, initially supported and funded by Public Health England with local Authorities funding their own area from January 2016. People can order a free HIV sampling kit to be sent to them at http://www.freetesting.hiv/ . In order to be eligible for a self-sampling kit there are a number of questions which identify those who have been at increased risk of contracting HIV. Those who do not meet the criteria can access a free HIV test at any of the sexual health clinics. If the result is positive the individual is referred to specialist HIV Care and Treatment Services for support and treatment.

 

Local views 

The Sexual Health Needs Assessment 2015 included both staff within local sexual health services and patients/client feedback which was used to inform the needs of future sexual health service provision (Hall, V., et al 2015)

The integrated sexual health services iCaSH, capture feedback from young people attending their clinics via an anonymous comment box. The iCash website was developed based upon consultation with young people and service users.

The new integrated services ask service users to complete a Patient Reported Experience Measures (PREMs) questionnaire. This will be given to patients on a quarterly basis and findings will be reported through the performance monitoring of the sexual health contract.

 

Anonymous Service User- January 2017

‘I had a fantastic experience with iCaSH at a time when I was very distressed. They were welcoming discreet and supportive. I was given appropriate treatment on the day and received my results quicker than expected’

The psychosexual service offers all patients a client feedback form, 98% (n= 90) of those that completed the form in 2015 said they would recommend the service to friends or family.

As detailed in the introduction, The Department of Health released A Framework for Sexual Health Improvement in England in March 2013 .

In addition to the framework, the Department of Health developed Commissioning Sexual Health services and interventions: Best practice guidance for local authorities in March 2013.

 

The Public Health Outcomes Framework sets out key indicators for local areas. The three specific indicators related to sexual health are;

  • Under 18 conceptions
  • Chlamydia detection rate (15-24 year olds)
  • People presenting with HIV at late stage of infection
  • Reduce the rates of STIs, excluding chlamydia

 

The further related public health indicators are;

  • Violent crime (including sexual violence)
  • Employment for those with long term health condition including those with learning difficulty/disability or mental illness- includes those with HIV
  • Access to non-cancer screening programmes- includes ante natal HIV screening

 

National and local strategies

.1 National

The Department of Health released A Framework for Sexual Health Improvement in England in March 2013. The framework builds upon the 2001 National Sexual Health Strategy in order to;

  • Reduce inequalities and improve sexual health outcomes
  • Build an honest and open culture where everyone is able to make informed and responsible choices about relationships and sex; and
  • Recognise that sexual ill health can affect all parts of society.
  • (Department of Health 2013)

In addition to the framework, the Department of Health developed Commissioning Sexual Health services and interventions: Best practice guidance for local authorities in March 2013.

 

The Public Health Outcomes Framework sets out key indicators for local areas. The three specific indicators related to sexual health are;

  • Under 18 conceptions
  • Chlamydia detection rate (15-24 year olds)
  • People presenting with HIV at late stage of infection

 

Local

Following a comprehensive sexual health needs assessment looking at all sexual health service provision across Central Bedfordshire and Bedford Borough the recommendation was to move towards an integrated model of delivering sexual health services, which has been implemented locally from 1st November 2016. This model has been adopted nationally and regionally and evidence suggests it will increase patient access to the full range of contraception and sexual health services from a single location. Benefits will include; better integrated pathways, increased opportunities for joint working and increased opportunities for co-ordinated work with GPs, Pharmacy and the third sector (HNA, 2015).

 

Cost effectiveness

The following strategies have been identified as cost saving:

 

The ‘Economics of Sexual Health’ study (2005,fpa) found that ‘It is absolutely clear that contraception services, in themselves, result in reduced cost and increased benefit overall. ’It also found that ‘there is evidence that access to emergency contraception, both the emergency contraceptive pill and the IUD, is beneficial. Investing in HIV prevention strategies should be a priority because of its potential for cost savings. It is estimated that each infection prevented would save between £280,000 and £360,000 in lifetime treatment costs. If the 3,640 UK-acquired HIV diagnoses made in 2010 had been prevented, between £1bn and £1.3bn lifetime treatment and clinical care costs would have been saved (HIV in the United Kingdom: 2014 Report HPA).

 

What are the key inequalities?

  • Sexual health problems disproportionately affect those experiencing poverty and social exclusion. Individuals and groups who find it most difficult to access services include, asylum seekers and refugees, sex workers and their clients, those who are homeless and young people in or leaving care. The highest burden is borne by men who have sex with men and some black minority ethnic groups (NICE 2011).
  • Young people aged between 16 and 24 account for nearly half of all STI diagnoses (PHE Laser Report 2015 ), therefore normalising and improving access to sexual health services is imperative in reducing this stark health inequality experienced by this group.
  • HIV diagnoses are higher among individuals from the black African community and evidence from a Health Needs Assessment across Bedfordshire in 2015 suggested that men from this group are less likely to access sexual health services. (HNA 2015).
  • Men who have sex with men (MSM) continue to experience high rates of STIs and remain a priority for targeted HIV and STI prevention and health promotion work.

 

What are the unmet needs/service gaps?

There has been an increase in service provision over the last five years and activity data shows that there has been significantly improved access to contraceptive and sexual health services over this time.

These improvements in access must now be built upon to ensure that all sections of society are supported in achieving and maintaining good sexual health. In order to do this, there must be improved access for;

  • Vulnerable groups
  • Men, both heterosexual and men who have sex with men
  • Black African Community who are disproportionately affected by HIV, and in particular Black African women
  • Those who identify as lesbian, gay, bi-sexual, transgender and intersex (LGBTI)

 

Recommendations

1.    Following recommendations from the comprehensive Sexual Health Needs Assessment that was conducted in April 2015 an integrated model of sexual health service provision was implemented from 1st November 2016 across Bedford Borough and Central Bedfordshire. This is in line with National and regional trends.

2.    To continue to maintain performance, quality and safety of service provision through the commissioned integrated sexual health services managed by Cambridgeshire Community Services iCaSH.

3.    To continue to work with Public Health England (PHE) and other regional commissioners to identify any local increase in STIs early and work together to address these, such as joint targeted campaigns.

4.    To reduce HIV late diagnosis, through targeted work with higher risk communities and increase confidential access to HIV testing through a number of testing sites and self-sampling.

5.    To introduce increased provision of HIV testing in Primary Care.

6.    Reduce teenage conceptions- please see the teenage pregnancy JSNA chapter for detail on approaches to reduce teenage pregnancy in Bedford Borough.

7.    Maintain and increase the detection rate for Chlamydia in order to continue to meet the recommended diagnostic target of 2300 per 100,000.

8.    To increase access to the integrated contraceptive and sexual health services (iCaSH) providing a full range of contraception and sexual health services from a single location.

9.    To continue to focus services on women post abortion to reduce the number of repeat terminations across all age groups. This will be monitored via key performance indicators included in Contraceptive and Sexual Health Services contracts.

10. Promote safer sexual health behaviours and key sexual health messages through sexual health services and other services such as substance misuse services, outreach work and relevant cost effective campaigns linked to national events and recommendations i.e. HIV Testing Week.

11. To strengthen the relationships and referrals into other local authority commissioned services linked with other public health outcomes i.e. weight management services.

12. For the integrated sexual health services to continue to identify vulnerable groups, such as victims of Child Sexual Exploitation (CSE) and Female Genital Mutilation (FGM) to refer into safeguarding where appropriate and support services.

 

References

DH 2013 (Department for Health). A Framework for Sexual Health Improvement in England. DH and Cross Government. 

 

DH 2001 (Department of Health) The National Strategy for Sexual Health and HIV. London, DH.

 

DH 2015 (Department of Health)  https://www.gov.uk/government/news/abortion-statistics-england-wales-2011

 

Education for Choice: Best Practice Toolkit, Abortion Education (2008)

National Chlamydia Screening Programme (NSCP) 2012. http://www.chlamydiascreening.nhs.uk/ps/resources.asp

 

Hall, V., et al (2015) Sexual Health Needs Assessment, Public Health Bedford Borough (link)

 

NICE 2011 (National Institute of Clinical Excellence) Increasing the uptake of HIV testing among men who have sex with men (2011) NICE, London.

 

NICE 2010 (National Institute of Clinical Excellence) Effectiveness and Cost Effectiveness: Increasing the Uptake of HIV Testing to Reduce Undiagnosed Infection and Prevent Transition among black African Communities Living in England. NICE, London.

 

PHE- Public Health England ( 2013a) (The Health Protection Agency).  http://www.chlamydiascreening.nhs.uk/ps/data.asp

 

PHE- Public Health England (2014b) HIV in the United Kingdom: 2014 Report. London: Health Protection Services

 

PHE- Bedford Local Authority HIV, Sexual and Reproductive Health Epidemiology  Report (LASER) 2015

 

RCOG (2011) The Royal College of Obstetricians and Gynaecologists.  The Care of Women Requesting Induced Abortion: Evidence-based Clinical Guideline Number 7  (2011).

 

This chapter links to the following chapters in the JSNA:

 

Teenage pregnancy

Health Protection (Adults)

Health Protection (Children)

 

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