England’s National Strategy for Sexual Health and HIV had a requirement to improve sexual health service access that led to delivery innovations for target populations such as sex workers (outreach services) and intravenous drug users (IDUs) (provision of blood-borne virus testing in substance misuse services). General health assessment guidance from the National Treatment Agency for Substance Misuse includes sexually transmitted infection (STI) risk assessment (either directly or by referral) but excludes assessment of pregnancy risk.
The evidence base however suggests that a range of sexual health risks and morbidities are experienced not only by female injecting drug users (IDUs) but by substance-misusing women (SMW) as a whole (substance misuse in this context incorporating studies of female populations using variously crack cocaine, opioids and ‘illicit substances’). Studies indicate high risk of STIs, and of unintended pregnancy; and elevated sexual health risks including sexual assault, intimate partner violence and exchange of sex. Infrequent cervical screening and inconsistent condom and contraceptive use further suggest services have not been successfully provided.
Funded by the National Institute for Health Research 'Research for Patient Benefit' programme this study had two key aims, and corresponding stages.
In stage one, the study sought to identify sexual health risks and morbidities, and sexual health service use among substance-misusing women. Women aged 18+, residing in Hastings and Rother and who had used illicit or illegal substances in the previous month were invited to participate. Women were recruited at Hastings NHS Substance Misuse Service and Crime Reduction Initiative, and from Seaview Health and Wellbeing Centre in St. Leonard's on Sea. A combination of survey data and in-depth interview data were collected concerning:
In stage two, the study sought to specify a model for optimal sexual healthcare delivery to substance misusing women. Using stage one findings and relevant policy documents a model was informally developed. This was then ‘tested’ on two panels of stakeholders to problem-solve difficult elements of the model, and to identify and resolve likely issues of feasibility and implementation.
Current and ex-service users collaborated on the study from its design through to dissemination - culminating in the production of a lay report made accessible to attendees at the recruitment sites, and in the co-presenting of an oral paper to the Society for Study of Addiction conference in November 2010.
The study completed in June 2011. Locally, the findings have been presented to the Sussex drug practitioners' conference in 2011, to the Brighton Women’s Oasis conference in 2011 and to HIV and genitourinary medicine staff in Brighton. The latter groups have incorporated the recommendations of the study into new joint working practices and Hastings & Rother Primary Care Trust wrote the designed model into their sexual health commissioning plan.
Stage One interview findings were presented as an oral paper at the World Congress on Sexual Health in June 2011. A paper arising from the qualitative interviews has now been published in the Journal of Family Planning and Reproductive Health Care, while two further papers (concerning survey data and the modelling process) are being prepared for journal submission. Stage one data also indicated a particular need to investigate fertility management for this population – consequently a funding application to address this topic has been developed and is currently under review.
A range of practical, social and emotional barriers to sexual health service access exist for this population, presenting a context from within which use of services may come at considerable personal cost to SMW. Interventions addressing anticipated stigma and emotional, hygiene and fiscal concerns are warranted for this population.
Dr Harish Patel
Dr Anthony Glasper
Edelman, N, Patel, H, Glasper, A., Bogen-Johnston L (2014), Sexual health risks and health-seeking behaviours among substance-misusing women, Journal of Advanced Nursing, DOI: 10.1111/jan.12442
Commissioning Framework document (PDF)
Understanding barriers to sexual health service access among substance-misusing women on the South East coast of England
Seaview health and wellbeing project
The Hastings NHS Substance Misuse Service
The Crime Reduction Initiative.