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C. A. Edwards, M. L. Britton, L. Jenkins, D. J. Rickwood, K. E. Gillham, Including a client sexual health pathway in a national youth mental health early intervention service—project rationale and implementation strategy, Health Education Research, Volume 29, Issue 2, April 2014, Pages 354–359, https://doi.org/10.1093/her/cyt154
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Abstract
Young people have higher rates of sexually transmissible infections (STIs) than the general population. Research has shown that there is a clear link between emotional distress, depression, substance abuse and sexual risk taking behaviours in young people. ‘headspace’ is a youth mental health early intervention service operating in more than 55 locations around Australia. This setting is ideal for accessing troubled young people who are at risk of STIs and are unlikely to attend mainstream general practice services. In 2013, a partnership was formed between headspace National Office and Hunter New England Local Health District to develop a clear clinical pathway to ensure at-risk headspace clients received sexual health assessments, advice, appropriate treatment and referral as indicated. This article describes the implementation of the pathway at the national level and a control trial to measure its efficacy. Future work will involve providing sustainable sexual health training for headspace general practitioner and allied health professionals to supplement the roll-out of the pathway in headspace centres across Australia. Support will also be provided in adapting headspace environments to encourage service utilization by Aboriginal and Torres Strait Islander and gay, lesbian, bisexual, transsexual and intersex young people.
Rationale
Priority population
Sexually transmissible infections (STIs) can result in serious long-term health implications for people who contract them. The most common STI is chlamydia, which usually affects young people aged 15–29 years. Diagnoses in this age group account for ∼82% of chlamydia notifications in Australia [1]. It is often referred to as a ‘silent’ infection, as 50% of males and 70% of females afflicted will have no symptoms [2]. Chlamydia can result in chronic inflammation, pain and fertility issues in females and males, and the tubal scarring that can occur in females also increases the risk of ectopic pregnancies [3, 4].
The Australian National Centre in HIV Epidemiology and Clinical Research predicted that if 40% of men and women under the age of 25 years were screened annually and appropriately treated, the prevalence of chlamydia infection would decrease rapidly over 10 years in all age groups, with 50% of the reduction being achieved during the first 4 years [5]. In addition to this, if preventive advice was also routinely provided then a further reduction in the incidence of chlamydia could be expected [6]. General practice has been identified as an ideal setting to routinely offer testing to all sexually active people between 15 and 29 years [7]. However, at-risk young people are less likely to attend mainstream health services due to additional cultural, geographical, financial and physical barriers [8, 9]. As a result additional STI health promotion initiatives need to be developed for settings outside of general practice.
The Australian National STI Strategy recognizes young people as a priority population who would benefit from STI health promotion programmes, on the basis of infection rates and their behaviour which places them at an elevated risk [10].
Links between sexual health, substance use and mental illness
In addition, psychological research shows there is a clear correlation between emotional distress, depression, substance abuse and sexual risk taking behaviours in young people [11–15]. According to Lehrer et al. [13] adolescents with self-reported depressive symptoms were more likely to report higher levels of sexual risk taking behaviour such as inconsistent condom use and multiple sex partners. A bi-directional association has also been found, with young people who exhibited mild depressive symptoms at baseline and received an STI diagnosis more likely to report very high depressive symptoms at follow-up [16]. These results suggest that an STI diagnosis may further escalate depressive symptoms in at-risk young people. Overall, these findings suggest that a collaborative approach between mental health, drug and alcohol and sexual health services is required.
Setting
‘headspace’ is a national youth mental health early intervention service established and funded by the Commonwealth government in 2006, with centres currently operating in 55 different locations around Australia, and scaling up to 90 centres by mid-2015. Centres are intended to be a ‘one-stop shop’ where young people aged 12–25 years can access a variety of different services in four primary domains—general health, mental health and counselling, drug and alcohol, education and employment [17].
Hunter New England Local Health District (HNELHD) is one of eight LHDs in New South Wales (NSW), funded by the Federal Government to manage public hospital services within a defined local area. It provides services to around 850 000 people including 20% of the state’s Aboriginal population and spans 25 local council areas. HNE is the only district in NSW with a major metropolitan centre, a mix of several large regional centres, many smaller rural centres and remote communities within its borders.
Based on demographic data from headspace National Office and a working relationship with local headspace centres, HNELHD identified this service as ideal for accessing at-risk young people who are unlikely to attend mainstream general practice services, therefore, limiting their access to routine STI screening and sexual health advice.
The health professionals available at each headspace centre vary but usually include general practitioners (GPs), nurses, social workers, psychologists, drug and alcohol counsellors and adolescent and family counsellors. This setting provides a unique opportunity to engage with a large number of young people, with headspace centres across Australia seeing in excess of 100 000 young people since its inception in 2006. Furthermore, headspace deals specifically with young people who are experiencing issues with school, family, relationships, substance abuse, sexuality and mental or physical health. Client demographics and discussions with headspace staff indicate a much larger percentage of marginalized youth populations including young gay men and other young men who have sex with men (MSM), young Aboriginal and Torres Strait Islander people, young people with drug and alcohol issues and young people struggling with their mental health [18, 19].
In the first 11 months since the new rural headspace in HNELHD opened its doors in January 2013, more than 400 new clients sought assistance from the centre and 25% of these identified as Aboriginal or Torres Strait Islander. The regional HNE headspace saw 800 new clients during this period and 14% were Aboriginal or Torres Strait Islander. In both centres, ∼12% of new clients self identified as gay, lesbian, bisexual or questioning their sexuality and one of the four most common reasons given for attending the headspace centre was drug and alcohol problems (see Table I).
Main reasons for cominga . | Established headspace . | % . | Newly opened headspace . | % . |
---|---|---|---|---|
No. of new clients . | No. of new clients . | |||
Problems with how I feel | 476 | 66.57 | 270 | 62.51 |
Problems with relationships | 85 | 11.89 | 64 | 14.81 |
None of the above | 82 | 11.47 | 48 | 11.11 |
Problems at school or work | 46 | 6.43 | 30 | 6.94 |
Problems with alcohol or other drugs | 22 | 3.08 | 17 | 3.94 |
Problems with my physical health | 4 | 0.56 | 3 | 0.69 |
Grand total | 715 | 100.00 | 432 | 100.00 |
Main reasons for cominga . | Established headspace . | % . | Newly opened headspace . | % . |
---|---|---|---|---|
No. of new clients . | No. of new clients . | |||
Problems with how I feel | 476 | 66.57 | 270 | 62.51 |
Problems with relationships | 85 | 11.89 | 64 | 14.81 |
None of the above | 82 | 11.47 | 48 | 11.11 |
Problems at school or work | 46 | 6.43 | 30 | 6.94 |
Problems with alcohol or other drugs | 22 | 3.08 | 17 | 3.94 |
Problems with my physical health | 4 | 0.56 | 3 | 0.69 |
Grand total | 715 | 100.00 | 432 | 100.00 |
aEighty-six clients did not answer this question at the established headspace in Maitland.
Main reasons for cominga . | Established headspace . | % . | Newly opened headspace . | % . |
---|---|---|---|---|
No. of new clients . | No. of new clients . | |||
Problems with how I feel | 476 | 66.57 | 270 | 62.51 |
Problems with relationships | 85 | 11.89 | 64 | 14.81 |
None of the above | 82 | 11.47 | 48 | 11.11 |
Problems at school or work | 46 | 6.43 | 30 | 6.94 |
Problems with alcohol or other drugs | 22 | 3.08 | 17 | 3.94 |
Problems with my physical health | 4 | 0.56 | 3 | 0.69 |
Grand total | 715 | 100.00 | 432 | 100.00 |
Main reasons for cominga . | Established headspace . | % . | Newly opened headspace . | % . |
---|---|---|---|---|
No. of new clients . | No. of new clients . | |||
Problems with how I feel | 476 | 66.57 | 270 | 62.51 |
Problems with relationships | 85 | 11.89 | 64 | 14.81 |
None of the above | 82 | 11.47 | 48 | 11.11 |
Problems at school or work | 46 | 6.43 | 30 | 6.94 |
Problems with alcohol or other drugs | 22 | 3.08 | 17 | 3.94 |
Problems with my physical health | 4 | 0.56 | 3 | 0.69 |
Grand total | 715 | 100.00 | 432 | 100.00 |
aEighty-six clients did not answer this question at the established headspace in Maitland.
The presence of on-site GPs and practice nurses facilitates the use of interventions to increase testing for chlamydia and other STIs as well as blood borne viruses (BBVs) such as hepatitis C. Allied health professionals are able to play crucial roles in identifying young people at risk and referring them to the headspace GP or nurse for testing and education. Most on-site health professionals provide their services to headspace on a part-time basis, working in other health services the rest of the time. Therefore, building their sexual health capacity will not only improve the sexual health of headspace clients but also affect the broader youth population accessing other health services.
Although some headspace centres across the nation already have specific initiatives in place to address the sexual health needs of their clients, it is a more recently acknowledged national priority to develop pathways to ensure headspace clients receive sexual health assessments, advice, appropriate treatment and referral. In 2013, a partnership was formed between headspace National Office and HNELHD Sexual Health Promotion Service to initiate a multi-strategic sexual health intervention and investigate its efficacy. The intervention was designed to introduce a clear sexual health pathway for at-risk headspace clients, and support the pathway with sustainable education and training for headspace GP and allied health staff.
Implementation strategy
Study design
A quasi-experimental matched pair trial is currently being conducted with two experimental and two control headspace centres in NSW. Measurable outcomes for the project include GP and allied health professional knowledge and skills, number of referrals of at-risk youth to the GP or nurse, amount of sexual health advice given to patients and percentage of eligible young people tested for STIs. Knowledge and skills will be measured by GP and allied health professional surveys. Number of referrals will be recorded on the headspace database and amount of sexual health advice provided will be recorded on patient consultation forms. The number of tests ordered will be collected through pathology data. Data collected prior to intervention implementation (baseline) will be compared with data collected at the completion of the 12-month intervention (follow-up).
At the time the project was initiated, there were 13 geographically separate headspace centres in NSW. HNELHD had two headspace centres in their district which were both allocated to the experimental condition. One of the headspace centres was well established (operating for 5 years) and the other had just opened its doors. Two control headspace centres were selected from outside the HNELHD and were matched to the intervention headspace centres based on years in operation, number and type of staff and client demographics. A comparison of the impact of the intervention on a new centre versus a well-established centre will also be examined. Ethics approval was granted by the HNE Human Research Ethics Committee.
Intervention
Several broad strategies were included in the intervention using four of the action areas of the Ottawa Charter [2, 7, 20] and addressing the barriers identified in the scientific literature as preventing at-risk young people from accessing main stream sexual health or general practices [8, 9]. The strategies are as follows:
(1) Incorporate sexual health into the four headspace domains of care at the National headspace policy level.
Step A: headspace National Office has included sexual health questions as part of their minimum data set that is collected from every young person when they complete initial registration using hand held computer tablets. At this stage these questions are being trialled for young people 16 years and over with a view to adding them to all surveys if they trial positively. This is the first step in the client’s sexual health pathway (see Fig. 1) and enables the young people to self-identify as sexually active and to describe their sexual preference. This initial data acts as a filter for those young people who are not yet sexually active and negates the need to ask further sexual health questions at the psychological assessment stage, and also flags gay sexually active males for discussion regarding safer sex and HIV testing.
Step B: headspace National Office has included sexual health questions in the face to face client psychological assessment. This data identifies whether the client has been sexually active in the last 12 months and also whether the client has been tested for STIs in the last 12 months. The psychological assessment follows the Royal Australian College of General Practitioners (RACGP) guidelines in recommending to the intake officer that if the client has had sex in the last 12 months and not been tested they should refer them to the GP for STI testing [7]. The assessment also asks the client about safe sex practices. This data can flag the client for further sexual health advice and counselling either by the GP or an allied health professional. In the drug and alcohol section of the assessment, if the client answers ‘yes’ to ever having injected drugs the document recommends the client be referred to the GP for appropriate STI and BBV tests as per the NSW Sexually Transmitted Infections Program Unit (STIPU) guidelines [21].
Step C: headspace GP and/or nurse provides sexual health testing, treatment, contact tracing, advice, education and further referral when necessary. Further referral may be to a sexual health, HIV or hepatitis C clinic, or other external specialist when complex STIs or BBVs have been diagnosed by the headspace GP.
headspace allied health professionals provide sexual health advice and education, and refer to the GP for testing if client risk is not detected at the psychological assessment stage.
(2) Improve the knowledge, skills and capacity of headspace GPs, nurses and allied health professionals to identify young people at risk of STIs, and provide testing, treatment, safe sex advice, education and referral.
A series of face to face sexual health workshops will be rolled out in HNELHD for all headspace GPs and nurses in collaboration with the Australasian Society for HIV Medicine. At the completion of the 12-month trial, headspace National Office will follow these workshops with national webinars designed to increase the sexual health knowledge and skills of headspace GPs, nurses and allied health professionals across Australia.
All headspace GPs across Australia will be provided with a sexual health resources kit, which will include best practice guidelines and resources to assist them in meeting young people’s sexual health needs.
(3) Support the design of culturally appropriate environments to encourage service utilization by Aboriginal and Torres Strait Islander and gay, lesbian, bisexual, transgender and intersex (GLBTI) young people.
Aboriginal and Torres Strait Islander and GLBTI cultural appropriateness audits and follow-up training programmes will be provided to intervention headspace centres. Components of these training programmes will be included in the headspace National Office webinars at the completion of the 12-month trial, and audit resources and funding for physical environment changes will be made available to all headspace centres where necessary.
(4) Support headspace physical environments that encourage good sexual health.
Intervention headspace centres will be assisted in sourcing free condoms for clients 16 years and over and displaying sexual health pamphlets and posters in their waiting areas. Resources will be distributed nationally at the completion of the trial.
This project aims to integrate a structured client sexual health pathway within a multidisciplinary early intervention mental health service. Overall, the integration of sexual health into headspace services will allow at-risk young people to have greater access to opportunistic sexual health knowledge, testing and treatment. In addition to this, the capacity building approach used to up-skill staff will ensure the sustainability of the sexual health pathway beyond this project. Outcomes of the 12-month control trial will be available in early 2014.
Funding
This project was funded by a Hepatitis C Education and Prevention Initiative (HCEP) grant from NSW Health.
Conflict of interest statement
None declared.
References
- patient referral
- substance abuse
- australia
- bisexuality
- child
- depressive disorders
- early intervention (education)
- health personnel
- homosexuality
- female homosexuality
- mental health
- new england
- physicians, family
- infections
- intersex persons
- risk-taking behavior
- clients
- psychological distress
- clinical pathways
- partnerships
- rationale