This audit explores teenagers’ contact with a sexual health service (SHS) in England during the COVID-19 pandemic. The 6-month April–September 2020 data are compared with the 2019 equivalent. The audit also examines adherence to the safeguarding remit within the service for the age group for the 6 months following the first lockdown in March 2020.
The global COVID-19 pandemic has prompted a dramatic reduction in people’s healthcare seeking behaviour.1 This includes SHSs. In England, healthcare service delivery underwent significant change during the 3 months of the first lockdown. It became necessary to assess and treat via teleconsultation where possible to reduce viral spread of COVID-19. Since the first lockdown, the SHS can offer in-person appointments; however, teleconsultation remains while COVID-19 risk persists.
SHSs are also vital services for assessing safeguarding risk for both children and adults. SHSs have been identified as having an important role in identifying violence and abuse, both of which have increased during other epidemics and now COVID-19.2 Thomson-Glover et al
3 observed a dramatic reduction in contact for young people aged 17 years and under in the first month of lockdown in two SHSs and flagged up concern regarding possible unseen abuse and exploitation.
Telephone consultation has long been available to patients in the local SHS, although attending a drop-in or appointment clinic was the norm. The pathway during the pandemic is that the young person makes online or phone contact with the service, they are called back by a health advisor who assesses for safeguarding issues and then a consultation with a nurse or doctor. There is a low threshold for offering an in-person appointment for any young person aged 17 years or younger. The local service has a specific safeguarding assessment for those under the age of 16 years and a rapid safeguarding screening tool for those aged 16 and 17 years, which may prompt a more detailed assessment.
While it is likely that teenager’s sexual activity was reduced in the early stages of the pandemic due to restrictions in social activities, there is evidence that child maltreatment has increased during the pandemic.4 Making contact via phone or online rather than in person may render the service more accessible for young people; alternatively, restricted space and time for the young person to do this may be a barrier to access. This study in a local SHS begins to explore the impact of COVID-19 restrictions on the sexual health-seeking behaviour of teenagers, the impact of initial telephone consultations on their access to the service and how to ensure that young people who contact the service receive appropriate safeguarding support.
The study’s first aim was to examine how the COVID-19 restrictions on movement impacted on teenager’s contact with a local SHS. It also explored adherence to protocol by clinicians in assessing young people for safeguarding concerns where teleconsultation was the initial mode of contact.
The review compares attendance and safeguarding data for teenagers attending the host service from April to September 2019 with that of the same period in 2020, which covered the time from 1 week after first lockdown. Four broad aspects were reviewed: numbers of young people attending, their age, reason for attendance and safeguarding risk assessments completed.
Twenty-four young people aged 13 years and younger attended the service from April to September 2019, by comparison with no contacts by this age group in the same period of 2020. For the 15 years and under age group, there were 232 attendances in this time period in 2019 and 112 in 2020. There were also nine consultations instigated by the school health service in the 2020 data for this age group, increasing the contacts to 121. Although month by month data were unobtainable for 16 and 17 year olds attending the service during these two periods, overall attendance for this age group in April–September 2019 was 416 and 285 in April–September 2020. This is a reduction in direct contact with the service of 100% for those aged 13 years and younger, 52% for those aged 14 and 15 years and 31% for those aged 16 and 17 years for the compared months.
Safeguarding assessments during the COVID-19 pandemic for each age group have been examined in two quarters: April–June, and July–September 2020. In April–June 2020, there were 41 contacts with the service for those aged 15 years and younger, and none for 13 years and under. Thirty-eight full safeguarding assessments were carried out via telephone consultation. One of the young people not assessed at this contact was carried out by a nurse in a specialist child sexual exploitation unit prior to contact with the SHS, and the others had an assessment in the previous 3 months with the service, which is in line with local protocol. In the subsequent 3 months, as some social activities and school began to take place again, contacts for those 15 years and younger with the service rose to 71. Again, there were no contacts for those aged 13 years and under. A safeguarding assessment was carried out for all contacts in this quarter.
For those aged 16 and 17 years old, there were 285 contacts with the service across April–September 2020. Of these, some did not have a consultation after making a telephone appointment. Most no longer required a consultation, and eight young people were uncontactable after their initial email or telephone booking contact. Two hundred and seventy-two consultations took place for 16 and 17 years old. Two hundred and sixty (96%) safeguarding assessments were documented.
Overall numbers of young people making contact with the service in the first 3 months of lockdown were low across the age groups. Contacts increased dramatically for 16–17 year olds in the second 3 months. Safeguarding assessments were carried out in 97% of those 15 years and younger (100% if including recent or referring agency assessment) and 96% for those aged 16–17 years. While small in number in 2019, there were no contacts for those 13 years or younger with the SHS in the 6 months after lockdown in 2020. Please see table 1 for a summary of contacts with the SHS and safeguarding assessment for the three age groups across the comparative months 2019–2020.
It is clear that there has been an overall reduction in consultations during the COVID-19 pandemic. For those 13 years and younger, while previously seen in small numbers, there were no consultations from initial lockdown and the subsequent 3 months. Fourteen and 15 years olds’ access to the service halved and 16 and 17 year old’s contact with SHS dipped by a third. This adds to growing evidence that in addition to reduced sexual activity, isolation, lack of confidentiality, reduced face-to-face servicesmay be a barrier for some young people accessing sexual health services.3 These barriers are more limiting for those 15 years or younger. Restricted safe and confidential space in the home to seek support and advice is likely to have impacted teenager’s ability to access SHSs.5 Yet safeguarding risk remains, with some areas such as online grooming, bullying and sexting,6 domestic violence and abuse,2 increasing during the pandemic. For the young people that did have a consultation with the SHS, there was vigilance regarding safeguarding assessment and liaison with partner agencies. There was proactive liaison with partner agencies such as school nurses and social care for those 15 years and younger who were uncontactable. This illustrates the strength of the local multiagency safeguarding network.
These data are from a single SHS and do not represent other geographical areas. This study has not been able to ascertain whether teenagers were accessing partner agencies in lieu of SHS clinic attendance, that is, other SHS, pharmacies, abortion services, sexual assault referral centres and condom card scheme outlets. Liaising with such agencies would give a broader picture of whether consultations were fewer overall or displaced to other agencies. We have hypothesised regarding potential barriers to access reflected in the audit numbers. It would be helpful to gather qualitative data from young people on their experience of accessing SHS during the pandemic to add to the statistical picture.
Conclusion and recommendations
There was a reduction in number of consultations by teenagers with the SHS during the 6 months of variable lockdown measures in 2020 in comparison with the same period in 2019. Broadly, telephone consultation appears to be an acceptable mode for accessing SHS for teens aged 14–17 years. Continuation of this pathway beyond the pandemic for older teens would be a recommendation from this small study. Overall, those who did have a consultation received appropriate safeguarding screening. However, it is likely that some safeguarding issues remain undisclosed which, in normal circumstances, young people would have brought to or have been identified by contact with SHS. Nevertheless, formalised multiagency safeguarding networks and telephone consultations with a low threshold for promoting an in-person consultation facilitated access to SHS, and a robust safeguarding pathway, during the constraints of the COVID-19 pandemic.