Guidance

Flowcharts in section 3: accessible text description

Published 12 May 2021

Applies to England

Questions to ask about sexual and reproductive health to identify inequalities

1.1a Is your population using services at the level you would expect?

Is your STI testing rate (excluding chlamydia under 25) lower or higher than your Chartered Institute of Public Finance and Accountancy (CIPFA) neighbours? What has been the trend in this data?

Use: Sexual and reproductive health (SRH) profiles.

If higher or similar detection rate and/or increasing trend, then continue with current delivery and review annually.

If lower rate and/or decreasing trend, then continue to explore.

Explore

1. STI positivity (%) – how does this compare to the positivity in England or CIPFA neighbours?

If positivity is not low, this suggests that the right people are being tested. If positivity is low, explore the reasons that may explain this.

Use: SRH profiles.

2. If low positivity – does the service have partner notification figures in line with British Association for Sexual Health and HIV (BASHH) standards?

Using local sexual health provider data – explore whether the service is testing key population groups in proportion to the local population make-up? For example:

• young people
• ethnic minority groups
• men who have sex with men (MSM)

Explore based on areas of deprivation – are those in more deprived areas accessing testing?

Use: Local data from sexual health service.

Further action

Based on what you know about your local population and area:

• identify opportunities to increase testing in underserved areas or populations
• explore if further action is needed to increase partner notification and testing

1.1b Is your population using services at the level you would expect? Are you testing the right people?

This needs to be interpreted in conjunction with the testing rate flowchart at 1.1a.

Is your all new STI diagnosis rate higher than England and/or your CIPFA neighbours? What has been the trend in this data?

Use: SRH profiles.

If lower diagnosis rate and/or decreasing trend – but only if testing rates or positivity are not low, then continue with current delivery and review annually.

If higher diagnosis rate and/or increasing trend, then continue to Explore.

Explore

1. Look at patterns within your local authority. Look at numbers and rates by:

• age
• gender
• sexual orientation
• ethnicity
• deprivation (Index of Multiple Deprivation [IMD] quintile)

Use: Summary Profile of local authority Sexual Health (SPLASH) use map.

2. Explore whether:

• testing results turnaround times
• treatment initiation time
• partner notification standards
• re-testing standards

are delivered to BASHH standards.

Use: Local data from sexual health service or National Chlamydia Screening Programme (NCSP) audit.

Further action

If higher STI rates exist in particular population groups or geographies, consider if targeted local interventions are required.

1.2 Chlamydia is the most common STI – what are your local patterns?

Is your chlamydia detection rate (in under 25s) lower than the rate in England or your CIPFA nearest neighbours? And what is the trend?

Use: SRH profiles.

Is there within local authority variation of the chlamydia detection rate by Middle layer Super Output Areas (MSOA)?

Use: SPLASH.

If higher or similar detection rate and/or increasing trend, then continue with current delivery and review annually.

If lower rate and/or decreasing trend and/or variation at MSOA level, then continue to Explore.

Explore

1. What is the local authority (LA) population coverage and positivity (%)?

It’s important to ensure a sufficient proportion of the population is being screened for example, if proportion testing positive is 9% you need to screen 26% of the population to achieve the detection rate of 2,300 per 100,000.

What is the positivity (%) by testing service type?

Positivity between 5% and 12% ensures the programme is accessible to all, whilst being effective at identifying and treating infections. Review testing service types with positivity below 5% and consider whether screening activity is best focused elsewhere.

Number tested, and positivity can be reviewed by age and gender; and number tested by ethnicity.

Use: HIV/STI Data Exchange: CTAD Reports.

2. Evidence suggests an association between socioeconomic disadvantage and risk of chlamydia infection.

How does your area compare to other local authorities within the same IMD decile for:

• proportion of 15 to 24 year olds screened
• chlamydia detection rate

Review the variation in detection rate within your area and consider whether it is focused on areas of higher deprivation.

Use: SRH profiles and SPLASH use map.

3. Is local delivery in line with NCSP standards for: testing results turnaround times; treatment initiation times; partner notification standards; re-testing standards?

Effective delivery against standards ensures young people are notified and treated quickly, and partners can seek STI testing and treatment in a timely manner. Together with re-testing, these measures will help reduce onward transmission and harm from untreated chlamydia.

Use: Local data from sexual health service or NCSP audit.

Further action

Review local delivery using the Chlamydia Care Pathway and identify key local actions – for further details and support contact: ncspteam@phe.gov.uk

1.3 High rates of gonorrhoea and syphilis in a population reflect high levels of risky sexual behaviour – what does your data tell you?

Is your syphilis and/or gonorrhoea rate higher than England and/or your CIPFA neighbours?

What has been the trend in this data?

Use: SRH profiles.

If lower or similar rate and/or decreasing trend AND sustained or increased STI testing rate and higher or similar positivity, then continue with current delivery and review annually

If higher rate and/or increasing trend, then continue to Explore

Explore

1. Who is affected in your area? Review numbers of diagnoses by:

• age
• gender
• sexual orientation
• ethnicity

Use: HIV/STI Data Exchange: Selected diagnoses reports.

1. Are your local:

• testing results turnaround times
• treatment initiation times
• partner notification standards
• re-testing standards

delivered to BASHH standards?

Use: Local data from sexual health service – for example, performance reports.

Further action

If higher rates exist in particular population groups, identify targeted local interventions. Review interventions to promote condom use locally.

Work towards ensuring all actions in the Syphilis Action Plan are being delivered.

1.4 How effectively is HIV being addressed in your local population?

Is your HIV diagnosed prevalence rate above 2 per 1,000 15 to 59 year olds?

Or

Is your late diagnosis figure higher than:

• the England average
• your CIPFA neighbours average
• 50%

Use: SRH profiles.

If no to all, then continue with current delivery and review annually.

If yes to any, then continue to Explore.

Explore

1. Review HIV prevalence by MSOA to identify within area variation.

Use: SPLASH.

2. Review data on those receiving HIV-related care by:

• ethnicity
• probable route of infection

Use: SPLASH.

3. Review late diagnosis data for:

• MSM
• women
• men

Use: SRH profiles.

4. Review HIV testing coverage data for:

• MSM
• women
• men

Use: SPLASH.

5. Review repeat testing in MSM data.

Use: Local data from sexual health service.

Note: Point of care testing may be commissioned in your area – this is not included in the above data. If this is the case, review local data.

Further action

Based on the review of prevalence and HIV testing identify if there are actions that can be taken in relation to HIV testing within commissioned services.

Use the information from the data review to inform your prevention strategy.

Work with local partners to ensure all aspects of the NICE HIV testing guidelines are being implemented in your area.

Consider late diagnosis reviews to identify missed opportunities and inform work to improve future practice.

2.1 England has higher teenage pregnancy rates than similar western European countries, what are your local patterns?

Is the LA (or district for UTLAs) under 18 conception rate higher than England and/or your CIPFA neighbours? What has been the trend in this data? Is there within area variation at ward level?

Use: SRH profiles and SPLASH.

If lower or similar rate and/or decreasing trend and/or little variation between wards, then continue with current delivery and review annually.

If higher rate or increasing trend or within area variation, then continue to Explore.

Explore

1. Identify the wards that have high rates of under 18 conceptions benchmarked against your local authority average and the England average.

Use TP maps*: SPLASH.

*Also available through the Sexual Health, Reproductive Health and HIV Knowledge Hub.

2. Are these wards the same over time?

ONS: Under 18 conceptions ward level data available to LAs via health.data@ons.gov.uk

3. How does the LA compare with England and/or your CIPFA neighbours on risk indicators for teenage pregnancy: children in care, children in low income families, average attainment 8 score, 16 to 17 year olds not in education, employment or training.

Use: Child and Maternal Health profiles.

Further action

Review the Teenage Pregnancy Prevention Framework and complete the self-assessment checklist to identify local gaps and action required.

2.2 Is there good access to contraception?

Is the total prescribed LARC excluding injections rate low compared to England average and/or your CIPFA neighbours? What has been the trend in this data?

Use: SRH profiles.

If higher rate and/or increasing trend, then continue with current delivery and review annually.

If lower rate and/or decreasing trend, then continue to Explore.

Explore

1. If rates are low overall – is this due to low rates in:

• SRH services
• GP practices
• both

Use: SRH profiles.

2. Using local data from commissioned services – are there any key population groups not using long acting reversible contraception (LARC)? Consider:

• age groups
• ethnicity
• geography

Use: Local data from commissioned services.

Further action

• review service provision, including active promotion and encouragement of LARC
• explore availability of LARC in abortion and maternity services and for non-contraceptive purposes
• consider opportunities for joint commissioning arrangements with the Clinical Commissioning Group (CCG)
• provision of LARC is one indicator of access to contraception – other elements to consider locally are access to emergency contraception, postnatal contraception (particularly for vulnerable groups) and online contraception provision

2.3 Are abortions easily accessible for those that choose them?

Abortions data – look at:

• total abortion rate
• under 25s repeat abortions
• under 25s abortions after a birth
• over 25s abortion rate

Are these rates higher than England and/or your CIPFA neighbours? What has been the trend in this data?

Use: SRH profiles.

If lower rates and decreasing trend for all 4 indicators, then continue with current delivery and review annually.

If higher rate and/or increasing trend, then continue to Explore.

Explore

1. If numbers are high, this suggests there may be a problem with timely access to contraception. If numbers are low, this suggests there may be a problem with timely access to abortion services.

Use: DHSC abortion statistics*.

*May need to review CCG data rather than LA data where these are not co-terminus due to data suppression to avoid disclosure by differencing.

2. Look at published abortion statistics for a more detailed age breakdown (including under 18s) in your local area. CCGs will have local data on abortion service provision – review if available.

Use: Local data from abortion provider.

Further action

• explore if barriers exist in local access to contraception and abortion services
• explore whether contraception is available from termination services and if pathways are in place to services that provide contraception