Use of a staff administered structured questionnaire to identify relevant life-style issues and social-health determinants in a sexual and reproductive health service.

OBJECTIVE: To evaluate a staff-administered questionnaire to identify life-style issues and social-health determinants. DESIGN: Structured questionnaire administered by a health professional after dealing with the primary reason for attendance. SETTING: Community-based UK sexual and reproductive health service. POPULATION: First 1329 selected clinic patients comprising 1018 women attending Family Planning and 161 women plus 150 men attending Genitourinary Medicine; 47% were aged under 25. MAIN OUTCOME MEASURES: Identification of relevant health-risk taking, life-style issues, and unaddressed health concerns. Participants were offered appropriate support, information and referrals. RESULTS: Two hundred and sixty-four (23%) of the Family Planning women and 83 (52%) of the Genitourinary Medicine women [plus 103 (69%) of the men] reported two or more sexual partners in the last year. A third of participants denied regular condom use. Six per cent of women and 5% of men questioned had previously been forced to have sex. Eleven per cent of men admitted to having paid for sex and 9% of women disclosed physical assault (one-quarter in the home). Eight per cent of women and 7% of men had unresolved issues relating to previous miscarriage, termination, or stillbirth. CONCLUSIONS: It is possible to identify relevant life-style issues and social determinants of health during routine practice using a staff-administered questionnaire. The resulting information may not otherwise have been disclosed and may impact significantly on health and care delivery. The information collected provides opportunities for both individuals and service planners to address wider health needs.

A comparative study on the effects of a contraceptive vaginal ring NuvaRing and an oral contraceptive on carbohydrate metabolism and adrenal and thyroid function.

OBJECTIVES: To compare carbohydrate metabolism, adrenal and thyroid function during use of a combined contraceptive vaginal ring (NuvaRing, NV Organon, Oss, The Netherlands) with those of a combined oral contraceptive. METHODS: Healthy women aged 18-40 years used either the vaginal ring, delivering 15 microg ethinylestradiol and 120 microg of etonogestrel per day, or a combined oral contraceptive containing 30 microg ethinylestradiol and 150 microg levonorgestrel, for six cycles. Each cycle comprised 3 weeks of use of the ring or the pill followed by 1 ring- or pill-free week. The following parameters were measured at baseline and at the end of cycles 3 and 6: carbohydrate metabolism (glucose, insulin, glycosylated hemoglobin); adrenal function (total cortisol, cortisol binding globulin, dehydroepiandrosterone sulfate); thyroid function (thyroid stimulating hormone, free thyroxine). RESULTS: Small and similar increases in insulin were seen in both groups. Concentrations of cortisol binding globulin and total cortisol rose significantly less during ring use than during combined oral contraceptive use (cycle 3, p= 0.0002; cycle 6, p < 0.0001). Levels of dehydroepiandrosterone sulfate did not change in either group. Thyroid stimulating hormone levels increased significantly more in the ring group at cycle 3 (p = 0.0016) but free thyroxine levels were unchanged in both groups. CONCLUSIONS: Both the vaginal ring and the oral contraceptive have no clinically relevant effects on carbohydrate metabolism, adrenal or thyroid function.

Client and staff views on facilities and services, before and after the convergence of sexual, reproductive and women's services.

OBJECTIVE: To evaluate client and staff views on existing facilities and services, before and after the convergence of sexual, reproductive and women's services. METHODS: Evaluation involved questionnaire survey of clients and staff, one-to-one interviews with staff and review of routinely collected clinical activity data. RESULTS: The integration of the three services led to a reduction in stigma associated with attending sexual health services. Despite some staff concerns, the number of men attending the services did not decrease. There was increased satisfaction with the new service, especially the quality of facilities. There were increased numbers of referrals between clinical services in the Sandyford Initiative. CONCLUSIONS: Sexual, reproductive and women's services can be integrated to provide improved facilities for clients.

Public and private collaboration in establishing a young person's sexual health clinic in a commercial setting.

OBJECTIVE: To define the key factors and constraints in public-private sector collaboration in establishing and delivering a young person's sexual health clinic within an existing commercial establishment. CONSULTATION, PLANNING AND IMPLEMENTATION PHASES: Consultations were held between the Health Promotion Department, family planning and commercial outlets, resulting in the establishment of the UK's first sexual health service within commercial premises. Once the clinic had been operational for 6 months, a single researcher carried out semi-structured interviews with 13 staff representing all levels within the partner organisations. POST-IMPLEMENTATION INTERVIEWS: There was agreement by all interviewees on the objectives of the clinic. The problems encountered during the establishment of the service were with the legislation pertaining to pharmacies and the adverse press coverage of a minority public view of the provision of sexual health services to young people. No respondent identified conflict between the aims of the clinic and the strategic objectives of their organisation. RECOMMENDATIONS: Common aims are imperative for successful interagency working. Wider initial consultations may have helped to identify potential problems and confirm common aims at an earlier stage of the development of the project. The involvement of senior management may also have improved the smooth running of the project.

Evaluation of a young person's sexual health service in a commercial setting.

OBJECTIVE: To determine the acceptability and accessibility of a sexual health service for young people in a city centre pharmacy. DESIGN: Prospective qualitative survey of clients attending a new sexual health service, including client characteristics and semi-structured interviews. PARTICIPANTS: Clients attending the service between January and May 1999. MAIN OUTCOME MEASURES: Social demographics, reasons for attendance and consultation outcomes for clients together with their views of the service. RESULTS: A total of 98 clients (average of three clients per session) attended from January to May 1999, ranging from 14 to 39 years of age. Clients came from 41 postcode areas of the city (which has over 80 postcode areas) and neighbouring districts, covering all social strata. Only four clients had never been sexually active; 53 clients attended for emergency contraception, with 26 attending for hormonal contraception. A total of 93% of those asked were either satisfied or very satisfied with the opening times. All clients were satisfied or very satisfied with the clinic location. CONCLUSIONS: The setting of a sexual health service for young people in a city centre pharmacy allows access from a wide area. The timing and location of the service were the most commonly quoted reasons for attendance. All clients were asked to participate in a semi-structured interview, unless the interviewer was already engaged; results were obtained for 66 clients (67% of attendees).

Uterine balloon therapy for menorrhagia: a feasibility study of its use in the community setting.

OBJECTIVES: To determine whether uterine balloon therapy (UBT) for menorrhagia can be performed safely in the community setting, obviating the need for hospital admission or general anaesthesia. DESIGN: Prospective case studies of 20 women undergoing Thermachoice endometrial ablation for menorrhagia. SETTING: Glasgow Centre for Family Planning and Reproductive Health Care, Greater Glasgow Primary Care NHS Trust, Glasgow, UK. PARTICIPANTS: Twenty women with menorrhagia unresponsive to medical therapy. MAIN OUTCOME MEASURES: Pain levels experienced by women during the procedure, measured by visual analogue scores and analgesia requirements postoperatively. RESULTS: Pain scores were in the range 0.1-6.6 (median 1.1) for outpatient hysteroscopy, compared to 0.1-9.8 (median 4.0) for uterine balloon therapy. No procedure was abandoned due to pain. CONCLUSION: UBT performed under local anaesthetic is tolerated well by patients. It is an effective treatment for menorrhagia, which is safe and easy to perform in the community setting.

Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening.

OBJECTIVES: To investigate the psychosocial impact for women of a diagnosis of Chlamydia trachomatis and discuss the implications for the proposed UK chlamydia screening programme. DESIGN: Qualitative study with semistructured interviews. Interview transcripts analysed to identify recurrent themes. PARTICIPANTS: Seventeen women with a current or recent diagnosis of chlamydia. SETTING: A family planning clinic and a genitourinary medicine clinic in Glasgow. RESULTS: Three themes were identified: perceptions of stigma associated with sexually transmitted infection, uncertainty about reproductive health after diagnosis, and anxieties regarding partner's reaction to diagnosis. Most women had not previously perceived sexually transmitted infections as personally relevant; this was a function of stereotypical beliefs about who was "at risk" of sexually transmitted infection. These beliefs were pervasive and negatively affected reactions to diagnosis and produced anxiety about disclosure of the condition to others (particularly sexual partners) and future reproductive morbidity. This anxiety, given the uncertain natural history of chlamydia, may prove difficult to dispel. CONCLUSIONS: There are three primary areas of concern for women after a diagnosis of chlamydia which need to be examined in the proposed screening programme. Information provided should normalise and destigmatise chlamydial infection and positively promote genitourinary medicine services. Support services should be available because notification of partner can cause anxiety. Uncertainty about future reproductive morbidity may be inevitable; staff providing screening will require guidance in providing advice under such conditions.

The Sandyford Initiative: creating added value to health and health care.

The Sandyford Initiative in Glasgow brings together Family Planning, Genitourinary Medicine and the Centre for Women's Health in a new partnership which aims to provide integrated health and social care in a manner which reflects a social model of health. The Steve Retson Project for Gay Men's Sexual Health is also situated within the Sandyford, providing clinical services within the context of a social model of health. The Initiative is managed by the Greater Glasgow Primary Care NHS Trust but has been developed as a result of joint working between three main services, Greater Glasgow Health Board, Glasgow City Council and a number of voluntary organisations. By working to a social model of health, the intention is to ensure that the detection and management of health problems takes into account the social and economic determinants of health and that the provision and practice of health care reflects the social needs of the user. As such the Initiative is expected to make a significant contribution to the sexual health of men and women and the general and reproductive health of women in the Greater Glasgow area and beyond. The core of the Initiative is housed in premises tailored to the needs of the services and their users although satellite services are being planned. In addition to the core clinical and non-clinical care there are services designed to respond to the needs of specific groups such as young people, black and ethnic minority communities and disabled people, in order to improve access and uptake by previously marginalised groups. It is recognised that often the relationship between health and social service providers and their users becomes strained. Implementation of the Sandyford Initiative is intended to inspire confidence and contribute effectively to improving health and managing complex health problems.

Pill knowledge amongst oral contraceptive users in family planning clinics in Scotland: facts, myths and fantasies.

OBJECTIVES: To document the extent of understanding about the combined pill amongst oral contraceptive users in Scotland. METHOD: A questionnaire was distributed to 2700 pill users in Scottish family planning clinics prior to their consultation with a clinician for a repeat prescription. RESULTS: Knowledge was patchy and usually incomplete in any given area. CONCLUSION: Counselling and teaching about oral contraceptives are important parts of the clinical consultation; even if the user appears knowledgeable about their contraceptive method, there are likely to be some areas where their knowledge could be improved.

Depo provera discussion paper on clinical care, effectiveness and side effects

Recent changes to the health services have led to an increased provision of clinical care in family planning clinics. While some women may only require contraceptive services, others may demand advice on a breadth of lifestyle issues, including diet and nutrition. Obesity affects 17% of women of childbearing age in Scotland and being overweight during pregnancy has significant health risks. A postal survey of 227 nurses identified as working in family planning clinics in Scotland was conducted in 1998. After a mail shot and one reminder, a net response rate of 64% (n = 145) was achieved. Overall, it was found that obesity was perceived as the most extensive problem in women of childbearing age. Seventy nurses (48%) reported that, in addition to offering family planning services, they gave dietary advice 'frequently' or 'always' to their clients without being asked. There were differences in nutrition-related activities in consultations between nurses offering family planning services only and those who routinely offered nutritional advice. Over half (61%) of the nurses reported that they would give advice regarding weight management even if the patients were not seeking help, although there was no significant difference between the two comparison groups. In some cases, the nutritional advice offered to clients highlighted a deficit in training. Most nutrition education came from diploma and/or training courses and scientific literature, followed by 'experience'. Those nurses already embracing a nutritional advice and guidance role were more interested in further nutrition training (p = 0.018) than the other nurses. However, overall, 67% of the nurses wished to train further in nutrition and weight management. The findings suggest that family planning nurses should be supported to develop nutritional advice and guidance skills, and that there is a pressing need for training in public health nutrition and weight management for nurses working in family planning services.

Are computers of any use in a family planning clinic?

PIP: The Family Planning Directorate in Glasgow received trust financing at the end of the financial year 1994-95 to purchase computer hardware and software to update the family planning appointment system at the central clinic and to introduce electronic clinical records for clients attending the clinic. The system was expected to improve the efficiency of clinic administration and raise standards in the clinical areas of management, communication, audit, and information. This paper discusses the use of information technology (IT) within the clinic and considers how far the objectives have been achieved. Over the years, the system has embedded itself in the culture of the central clinic. In the clients¿ viewpoints, taken in 1997, the majority thought that the computers were necessary and were not more time-consuming during the clinical consultation. In addition, most clients thought enough care was taken with confidentiality of their personal records and they were happy with the personal details held on file about them. In the context of meeting initial objectives, the overall observation is that the IT system provides support to many aspects of administration and clinical care, improves the standard of record keeping, and increases the consultation time.^ieng

The patient's perspective of commercial clinical trials.

All drugs are tested on a large number of volunteers and patients prior to licensing by the Medical Controls Agency. Patients are often recruited while attending National Health Service (NHS) clinics. This paper reports a survey designed to ascertain patients' views of the desirability of such trials being undertaken in the NHS. Patients have a sophisticated understanding of who benefits from commercial clinical trials. Nonetheless, those taking part in trials did feel the process had some personal benefit. The patients overwhelmingly supported such clinical trials being undertaken in the NHS and felt that they were likely to raise the overall quality of care. The results can be used to influence the design of future patient information leaflets and the trial process.

Analysis of pill knowledge amongst oral contraceptive users in Scotland according to client characteristics.

OBJECTIVES: The primary objective of this study was to investigate the relationship between various client characteristics and knowledge of oral contraceptives amongst pill users. METHOD: This was a subanalysis of the data from the national audit of Scottish family planning clinics. RESULTS: There were significant differences in knowledge about many different criteria according to the characteristics of the client group. Low educational attainment, unemployment and more rural residence produced greater significant differences in contraception knowledge than social deprivation according to postcode (zipcode). Age and duration of use affected different criteria to varying degrees, but teenagers scored relatively poorly compared to the general population and knowledge did not significantly improve overall with duration of use. CONCLUSION: Client characteristics do affect levels of pill knowledge. Clinicians must reflect on how to communicate more effectively with all types of pill users. They should take the opportunity of clinic visits for repeat pill prescriptions to improve knowledge levels.

Depo Provera. Position paper on clinical use, effectiveness and side effects.

Depo Provera (medroxyprogesterone acetate, DMPA) when given as 150 mg by deep intramuscular injection every 12 calendar weeks (84 days+5 days), is a highly effective contraceptive with a very low failure rate comparable to modern copper IUDs and lower than many other methods. It should be available as a first line method to all who wish to make an informed choice about reversible methods of contraception. Pre-use counselling is essential to minimise the effect of menstrual change which occurs in most patients. However there is great patient variability. Use of DMPA is independent of intercourse and also independent of the user's memory (and thus of continuing motivation), other than remembering the 12 weekly appointments. For many women this is a great advantage. Oral contraceptive methods involve remembering to take a pill each day, in the case of the progestogen only pill within the same three hours each day. This places considerable strain on women who lead irregular lifestyles, who are very busy or travel frequently. Such women often describe a constant 'fear of forgetting', especially with the POP. The main potential disadvantage of DMPA in this country are likely to be menstrual disturbance and weight gain. The combined oral contraceptive pill gives the appearance of excellent cycle control because it removes the natural cycle altogether and replaces it with an artificial one. All progestogen-only methods, whether low or high dose, lead to menstrual disturbances, so in this respect DMPA is not unique. Although troublesome, the menstrual disturbances which occur in DMPA users very rarely require operative medical intervention, and can often be improved simply by short courses of oestrogen or shorter injection intervals. Again, women need to know what can be done so that they are aware that they should seek advice early, rather than miserably waiting.for their 12 week appointment. DMPA has no appreciable effects on blood pressure or thrombosis risk. In this it has an advantage over the combined oral contraceptive pill, and provides a simple, effective alternative for women who cannot use the pill for these reasons. Similarly, it has been suggested that women who suffer from focal migraine and are therefore advised against use of the combined oral contraceptive pill can still use progestogen-only contraceptives. Although the POP is medically safe in these circumstances, in young women it is less effective, and involves strict time keeping, which will be disadvantageous for some women. Side effects, long term use and schedules of administration are also discussed. The use of local protocols to allow nurse administration is to be supported both in general practice and the clinic situation. Perhaps the most important issue surrounding the use of DMPA is that of patient information. The method has had a particularly bad public image, which naturally makes potential users anxious and subject to misinformation from poorly informed or biased sources. Also, it is temporarily irreversible during its three months duration, so the duration of any problems or anxieties resulting from side effects may be longer than for other methods. It is of paramount importance that easily understood, accurate patient information leaflets are available, since biased and inaccurate information is readily available from women's magazines, perpetuating the myths surrounding the method.

PIP: This study presents a review of current clinical evidence on the usefulness of Depo Provera (medroxyprogesterone acetate, DMPA), a long-term method of reversible contraception. It is taken as an intramuscular long-acting agent (150 mg every 12 calendar weeks). The user failure rate approaches the method failure rate, which varies considerably with age. In terms of metabolic effects, it did not show changes in cholesterol or triglycerides and had no significant effect on hemostasis, which impairs the oral glucose tolerance test (OGTT) glucose response and increases insulin response. There were no significant adverse effects on long term growth and development in DMPA exposed children and no delays in return to fertility. For cancers, controlled surveillance of DMPA users found no overall increased risk of ovarian, liver or cervical cancer and even found a prolonged protective effect in reducing the risk of endometrial cancer. However, increased risk of breast cancer in recent users was observed; this could be due to enhanced detection of breast tumors of women using DMPA. The main DMPA disadvantages are menstrual disturbance and weight gain after 1 year. Bone mineral density (BMD) is found to be significantly lower. DMPA patients' sociodemographic characteristics and behavior placed then at higher risk for adverse pregnancy outcome in low infant birth weight and also possibly in polysyndactyl and chromosomal defects. Thus, for injectable progestogen, the data is again less conclusive. Risks may be similar to POP (progestogen-only contraceptive pill), but did not reach significance in the meta-analysis.

Nationwide audit of pill knowledge amongst family planning users in Scotland.

OBJECTIVES: The primary objective of this study was to estimate knowledge about oral contraceptives amongst oral contraceptive users within family planning clinics in Scotland and to ascertain if this was due to clinicians not attempting to convey certain information or to a lack of understanding of teaching. METHOD: This was a criterion-based audit using three separate questionnaires to estimate the agreement of senior staff with criteria set by a multi-disciplinary expert panel, actual routine clinical practice and user knowledge. RESULTS: Senior clinical staff within family planning clinics in Scotland agreed with 12 out of 15 criteria set by a multidisciplinary panel in over 85% of cases. For six out of 15 criteria, there was a discrepancy of more than 30% in what clinicians did in practice compared to what senior staff thought they ought to do. For a further two criteria, there was a deficiency of over 30% between the number of clients who understood the criteria and the number of clients the clinicians thought they had taught. Most importantly, these latter criteria included the rules for safe and effective pill taking. CONCLUSION: An improvement in user knowledge is required to achieve effective and reliable use of oral contraceptives. Methods of doing this, such as staff and client prompts, should be further explored.

Outcomes in action: how relevant to clinical practice are health outcome measures such as the rate of unintended pregnancies in young teenagers?

Scientific evidence shows that correct contraceptive use will prevent unintended pregnancy and the provision of contraceptives is recognized as a cost-effective intervention. This could encourage health authorities to keep investing more resources in family planning until the target rate of unintended pregnancies is reached, but if this was the only approach taken, the target rate never would be reached. Clinicians and their public health colleagues need to examine their practice in the light of all available evidence. Once desirable changes of practice are identified, local relevant health outcome measures need to be used to assess the effectiveness of the chosen approaches. Blunt factors, such as the unintended pregnancy rate in a city or region, will not suffice to inform individuals whether they are contributing to the overall picture.

Oral contraceptives and thrombosis.

PIP: Recent studies have identified an increased risk of venous thromboembolism associated with use of third-generation oral contraceptives (OCs). Use of these newer formulations has been estimated to cause an excess of 10 deaths/year in the UK. The possibility has been raised, however, that prescribing bias and confounding by duration of OC use and other personal risk factors accounts for the difference in the risk of venous thromboembolism between second- and third-generation OCs. Other studies have identified an increased risk of myocardial infarction and stroke in OC users, including users of low-dose formulations, but this risk is almost exclusively limited to older women who smoke or have other cardiovascular risk factors. The interpretation of all such studies on OC side effects should take into account that the absolute risk of an adverse thrombotic event while taking OCs is small. This risk appears to be affected far more by factors such as smoking, age, hypertension, and familial disorders than the type of progestagen contained in the OC.^ieng