Written by Sarah Pearson
Public Health Nurses (PHNs) play a vital role in the community; protecting and educating young people. Their job is varied but includes sexual health education through school clinics where young people (focus group 13-18 year olds) can talk safely to a Registered Nurse (RN) in a confidential, accessible, appropriate and approachable environment (Hayter, 2005). New Zealand teenagers have high rates of Sexually Transmitted Infections and unwanted pregnancies (Sexually transmitted infections in New Zealand,2012; Statistics New Zealand, 2003). If the role of the PHN was expanded to spend more time in schools, sexual health education and monitoring could potentially improve the health outcomes of New Zealand youth. Effective contraception use and education have been proven to make differences to the Sexually transmitted infections and unwanted pregnancy rates of teenagers (Sidebottom, Harrison, Amidon & Finnegan, 2008). If PHNs were to expand their role even further and prescribe contraception, then teenagers could have an all-in-one service, potentially improving their compliance with the service.
New Zealand teenagers (13-18 year olds) have high rates of Sexually Transmitted Infections (STIs) and unwanted pregnancies (Sexually transmitted infections in New Zealand, 2012). In 2011, New Zealand laboratory data was collected and 70% of Chlamydia cases were in people between the ages of fifteen and twenty four years. In the same report, 60% of gonorrhoea cases were from the fifteen to twenty four age group (Sexually transmitted infections in New Zealand, 2012). This can be attributed to changes in the body, particularly hormones, which give teenagers a physical sexual inclination without the brain development to make informed decisions on their own. This lack of effective decision making can result in risky sexual behaviour such as not using any protection and having multiple sexual partners (Takakura, Wake & Kobayashi, 2007).Unwanted pregnancy rates for New Zealand were third ranked after England and the United States of America in the early 2000s and Statistics New Zealand [SNZ](2003). American teenagers have exceptionally high rates of unwanted pregnancy which can be related to their abstinence-only education in schools which avoids providing vital information on contraception (Harper, Henderson, Schalet, Becker, Stratton, & Raine, 2010). Sexual health education in New Zealand is often done in a classroom environment with a school teacher as the educator. Fortunately, New Zealand schools do give information on contraception. As sexual health is a personal, sensitive and often embarrassing subject, a confidential, one-on-one service needs to be available to young people along-side classroom education so that they can feel safe and ask questions.
I chose this issue because I believe that the health of our teenagers will affect the health of our future. Teenage pregnancy and STIs can affect those teenagers’ lives through employment and education difficulty, which then affects their children, and the cycle continues (Hayter, 2005). Although this is not a new health issue, it is an issue that needs to be reviewed and Public Health Nurses (PHNs) are in the front line of recommended people to address it (Sidebottom et al., 2008). PHNs have a large range of knowledge and experience and already work with teenagers in many schools to deliver health care. There is evidence that supports the effectiveness of one-on-one interactions with teenagers and more consistent access to a PHN will provide teenagers with that type of interaction (Waterworth, 2010). PHNs already educate on condom use, hormonal contraception and will answer any questions that a young client may have.
An excellent tool used to holistically assess teenagers is the HEEADSSS assessment: home, education, eating, activities, drugs, sexuality, suicide/depression and safety (Waterworth, 2010). It is used to assess how an adolescent is feeling in their life, not just sexually, and it gives an opportunity for the nurse to find out why a young person might be having sex or wanting to have sex. After assessing a teenager, the PHN can give the client condoms, but they will have to make an appointment with another organisation to get a prescription for hormonal contraception. If a PHN could prescribe the contraception then the teenager would only need one appointment and is more likely to keep that appointment (Sidebottom et al., 2008).
This topic led me to search the literature to decide whether teenagers are indeed likely to respond well to PHNs being in schools more often and whether more education will change risky sexual behaviours. I used the CINAHL database and this search question to find appropriate articles: “Would the sexual health of New Zealand teenagers benefit from a public health nurse being at school to hold health clinics more often, and prescribe contraceptives?” I used limiters to refine my search and came up with 506 results. Through reading the titles of the articles and the abstracts of some, I was able to find thirteen relevant and useful articles.
Three themes occurred throughout the literature: contraception use and education makes a positive difference to teenage sexual health, PHNs are the right people for the job and health clinics held in a school environment are ideal for teenage clients. All of these themes support the notion that if PHNs were in schools more often and could prescribe contraception, rates of unwanted pregnancies and STIs could be lowered.
Positive effects of contraception use and education
Affective education on a topic provides a person with the knowledge, and therefore the power, to make an informed decision. Teenagers have a natural sexual curiosity that can be dangerous if they are not educated and informed on how to be safe with it. Contraception is a safety net designed to prevent unwanted pregnancies and STIs, but if it is not used properly then it can fail. Harper et al., (2010), Kahn et al., (1999) and Sidebottom et al. (2008) support the fact that contraception education is an effective tool. Harper et al. (2010) compares the use of abstinence education and contraception education in America. American schools have high use of abstinence education and also have the highest rates of teenage pregnancies; this reveals that a lack of contraception education has a negative effect (SNZ, 2003). On the opposite end of the scale, Japanese teenagers had the lowest rates of teenage pregnancies and their sexual health education begins in Primary School (SNZ, 2003; Takakura et al., 2007). As PHNs have a large amount of knowledge and resources on sexual health, they can arm teenagers with the correct information and produce educated, powerful New Zealanders. If PHNs could also prescribe contraception, teenagers would only need one appointment. When a teenager has to make another appointment to receive a prescription for contraception, they are less likely to go that appointment and can have un-safe sex in that time (Sidebottom et al., 2008). In regards to diabetes mellitus, some nurses have the authority to adjust and prescribe insulin (Stenner, Carey, & Courtenay, 2010). This works well for both diabetes clients and nursing staff. PHNs could have the same positive results with contraception prescribing.
Public Health Nurses: the right person for the job
Nurses are trained and knowledgeable in anatomy and physiology, but not all nurses are appropriate for the role of sexual health education. Nurses working in most environments will not have the time or resources to discuss sexual health with teenage clients. An example of this is nurses working in a gynaecology ward; they are knowledgeable but do not have the time or the appropriate, private space available to teach young people about their sexual health (Jolley, 2001). PHNs, on the other hand, are far more flexible and can transport themselves and their resources to an appropriate space. Hayter (2005) and Jolley (2001), Waterworth (2010) and Westwood and Mullen (2006) all support PHNs being a main educator and supportive health advisor for young people. PHNs are in the community, experienced, well trained and can use holistic assessment to provide the right advice and contraception for teenagers (Waterworth, 2010).
Schools:the right place for the job
Secondary schools and high schools are the perfect place to access thirteen to eighteen year olds on a regular basis. Hayter (2005) explored the use of clinics run by nurses in youth clubs situated in the United Kingdom. Although New Zealand does not have youth clubs, schools are the closest thing to a place where teenagers are able to socialise in a safe environment. In Hayter’s report, a down-fall of the youth clubs was the issue of confidentiality due to lack of suitable rooms for young people to talk to a nurse (2005). In schools this issue is less likely to occur. The key aspects that were important to the service of the clinic were confidentiality, accessibility, appropriateness and the approachability and attitudes of the staff (Hayter, 2005). As schools can usually offer a safe room, all of these key aspects can be met by a PHN based in a school. Hayter and Harrison (2008), Westwood and Mullan (2006), Waterworth (2010) and Teenagers prefer to use school-based sexual health clinics (2008) all have evidence to support the notion of PHNs spending more time in schools. The accessible nature of a school service is often brought up as a positive; a teenager can access the clinics during their school day and not interrupt extra-curricular activities. It also offers the teenager some privacy from their parents. If a PHN receives any information from a teenager that suggests that they are at risk or are a risk to themselves or others, then confidentiality is no longer relevant. Otherwise, the teenager’s consultation is completely private which is important to that age group (Waterworth, 2010).
From reviewing the literature, I have come to the understanding that New Zealand teenagers have a good service in place but that it could be improved. From reading about other countries, I have realised that we are on the right track in our sexual health education, but our rates of unwanted pregnancies and STIs do not reflect this. I believe that PHNs could make a difference to those rates through a service that provides more time and education for New Zealand teenagers in their schools. It appears obvious from the literature that contraception is an important tool in the battle against STIs and unwanted pregnancy. I also believe that nurses, given the right training, are fully capable and appropriate professionals to prescribe contraception. If this is put in place I believe that young people are more likely to obtain contraception and therefore more likely to use it. The literature also mentions that the nature in which sexual education is given makes a difference as to how it is received. Through reading, and experience, I observed that teenagers need a safe, confidential and non-judgemental person to communicate with them. PHNs have the experience and empathy to do this. New Zealand teenagers need time, guidance and effective education to change their sexual health behaviours, thus changing their futures by preventing unwanted pregnancy and STIs.
In conclusion, the expanded use of PHNs could greatly affect thirteen to eighteen year olds sexual health in New Zealand. Although PHNs already play a vital role in the community for young people, if their job could be expanded to include more school clinics and the ability to prescribe contraceptives, the rates of STIs and unwanted pregnancies could be reduced. Evidence has proven that contraception education and proper use work well to provide safer sexual habits in teenagers (Harper et al., 2010; Kahn et al., 1999). PHNs can provide a consistent service within schools that is confidential, accessible and appropriate (Hayter, 2005). If this is established and combined with the nurses’ ability to prescribe contraception, the youth of New Zealand will have a one-stop sexual health service. This will empower teenagers with the knowledge and effective tools to be safe sexually, thus lowering the rates of STIs and unwanted pregnancies.
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