3. Trends in teenage pregnancy

3.1 Data used in profile

Data on teenage conceptions were obtained from the Office
of National Statistics (ONS). 6 A CD-ROM from ONS was the
main source of data used in the regional profiling of
teenage conceptions. This database contains conception
data for the two periods 1992-94 and 1995-97 for girls
aged under 18 and conceptions in 1992-97 for girls under
16 for each local authority ward in England and Wales. This
was supplemented by more recent abortion and conception
data up to 1999 published by ONS in Population Trends 7
and Health Statistics Quarterly. 8 The data were reviewed
alongside the research undertaken by the University of
Southampton on the factors accounting for the variation in
teenage conceptions across the South West region. 3
Information on the provision of services was obtained
from the local teenage pregnancy co-ordinators, the
Sexwise database of family planning clinics, British Pregnancy
Advisory Service, the Family Planning Association and
Marie Stopes. Deprivation data were obtained from the
DETR web site  at www.regeneration.detr.gov.uk and
mapped using a geographical mapping system. Data on
sexually transmitted diseases were obtained from the South
West Public Health Laboratory Service. Data on the educational
qualifications of care leavers were obtained from the
Internet at the Department of Health web site at
www.doh.gov.uk/public/stats1.htm .
 

3.2 National trends

In 1997 around 90,000 teenagers became pregnant in
England resulting in 56,000 live births.1 The majority of
these conceptions were to girls aged 18 or 19. However, the
scale of the problem in girls under 18 is still alarming with
nearly 7,700 conceptions in 1998 to girls under 16 and
2,200 to girls aged under 14 years. Around half of conceptions
in girls under 16 years of age and a third of conceptions
in girls 16-19 are aborted. It has also been noted that
a significant number of young women conceive more than
once in their teens with nearly a sixth of all teenagers who
underwent a termination in 1997 having a past history of a
live birth or termination. 1
Birth rates in the 16-19 year old age group have fallen
throughout most of Western Europe since the start of the
1970s. In the United Kingdom the teenage pregnancy birth
rate increased in the 1960s, peaked in 1971 and then fell
until the mid-1980s.9 Rates then rose until 1990 when the
trend reversed again and rates decreased slightly until 1995.
Recent data suggests that these rates are once again
starting to rise. The United Kingdom currently has the
highest rates of teenage pregnancies in Western Europe,
with rates in this country around seven times the rates
observed in the Netherlands. 1
It has been suggested that most of these fluctuations
seem to track other factors such as access to effective and
reliable forms of contraception, the availability of contraceptive
services, reports of possible adverse effects related to
contraception and the general climate surrounding the
sexual health of young people. 9 In general abortion rates in
teenagers throughout England and Wales have tracked
conception rates closely since abortions were decriminalised
in the late 1960s.
The rate of conceptions in the under 16 year olds has
been largely steady during the 1970s and 1980s, despite
evidence that the age of sexual initiation has fallen in young
people. 2 Indeed, current evidence suggests that a third of
girls are sexually active by the time they are aged 16. 1 A rise
in the rate has been noted in recent years, with the rate in
1997 noted to be 10% higher than the rate in 1993.6 The
latest data from ONS on underage conceptions indicates
that this trend has continued. 7 In the period 1996-8 the
total number of conceptions to girls under 16 in England
and Wales was 25,566, an increase of 2,453 from the
period 1993-5. The conception rates across these periods
also rose, from 8.3 to 9.1 per 1000 women aged 13-15.
Although the teenage conception rates in England and
Wales are still on the rise, the United States and most
countries in Western Europe have seen a dramatic fall in
their teenage conception rates in recent years. Recent
research in the United States has suggested that the recent
decline in conception, birth and abortion rates seen in the
States may been linked to the economic expansion in the
1990s leading to increased economic opportunities. 10
Indeed, it is suggested that economic opportunity may have
given teenagers a reason to value more highly work and
education. Other factors that are postulated to be linked to
this recent decline in the United States are indications that
increasing numbers of teenagers are abstaining from sexual
activity and those teenagers who are sexually active are
more likely to use contraception. 10

3.3 Regional trends
3.3.1 Conceptions

In the South West region there are eight health authorities,
45 local authorities and 1,237 census wards (see Figure 1 ).
There are around 85,000 teenage girls aged between 15
and 17 in the region. The latest data from ONS suggests
that the South West region has a favourable teenage
conception profile compared to other regions across the
country and to the overall national picture. 7 The South West
region ranked third out of the nine regions in terms of the
lowest rates of conceptions for teenage girls in 1998. A
conception is recorded for around one in every 25 girls aged
15-17 in the South West region, which is less than the
national figure of one conception in every 21 girls in this
age group. In 1998 the total number of conceptions in this
age group accounted for around 8% of the total in England
and Wales.
Table 1 displays the numbers and rates of conceptions
for girls aged 15-17 in each of the health authorities in the
South West region for the periods 1992-4 and 1995-7 and
for the year 1998. Data relating to under 18 conceptions
reveal an increase in the numbers and rates of conceptions
across England and Wales, which is reflected in the South
West data presented in the table. Indeed, there is an
increase in the number of conceptions and in the conception
rate across the three periods for all the health authorities
and for the region as a whole. It is interesting to note
that the proportion of the national total of teenage conceptions
occurring in the South West was stable across these
three periods at just under 8%.
There is a similar trend seen in the national data relating
to under 16 conceptions, with a rise in the conception rate
from 8.3 conceptions per 1000 girls aged 13-15 in 1993-5
to 9.1 for the period 1996-8.7 In the South West region
conception rates in this age group have also increased
across the two periods from 6.5 to 7.4 per 1000 women
aged 13-15. A total of 1,897 conceptions occurred to girls
aged under 16 during the period 1996-8, which accounted
for around 7% of the national total.
Table 1 illustrates that the burden of the problem is not
evenly distributed around the region, with marked variation
in the numbers of conceptions between different health
authorities. In the 1992-4 period the number of total
conceptions in each health authority ranged from 686 in
North and East Devon to 1,617 in Avon, a difference of 931
conceptions. In the 1995-7 period this difference between
the same two health authorities with the lowest and highest
numbers of conceptions had increased to 986 conceptions.
This variation between health authorities is also seen in the
data relating to conceptions in girls under 16. North and
East Devon and Cornwall have the lowest number of
conceptions with Avon and Wiltshire having the highest
numbers. (Data not shown.)
There is also considerable variation in the conception
rates between health authorities, with a similar pattern
observed across the two age groups and over time. All the
health authorities in the South West region report conception
rates considerably lower than the national rate in both
age groups and for all the periods reported. North and East
Devon Health Authority consistently has the lowest conception
rates in the region, whilst its neighbour South and West
Devon consistently reports the highest rates. It should also
be noted that although Avon Health Authority has the
greatest number of conceptions in the region, its rate is well
below the national rate and only around the third highest in
the region. Indeed, the research undertaken by the University
of Southampton found that after accounting for key
demographic and socio-economic factors, Avon Health
Authority had the lowest teenage conception rate in the
region. 3

3.3.2 Terminations

In 1995-97 the rate of terminations in the South West was
slightly higher at 42% of conceptions than the national
average of 39.8%. Avon Health Authority carried out the
highest number of terminations (701); this was 40% of their
conceptions. In Dorset, with the second highest number of
terminations, teenagers had the highest percentage of
conceptions terminated at 49.4%. By contrast, South and
West Devon, which is the health authority with the highest
conception rate, has the second lowest percentage of
terminations (39.4%). (For details see Table A, Appendix 1 .)
Whilst at local authority level there is a threefold
variation in conceptions (18.6/1000 in North Dorset, and
59.6/1000 in Swindon) there is only a twofold increase in
terminations (9/1000 in West Dorset, to 24.5/1000 to 25/
1000 in Bournemouth). Of more interest, perhaps, is the
percentage of teenage conceptions which are terminated. In
general, the higher the rate of conceptions the lower
proportion are terminated. Thus, in Swindon, with the
highest rate in the South West only 32% of conceptions are
terminated, while East Dorset, one of the lowest, has 69%
terminations. (For details see Table C, Appendix 1 .)
Research undertaken at the University of Southampton
has speculated that one of the reasons that Dorset has
consistently high proportions of conceptions leading to
termination may be the presence of a BPAS centre in
Bournemouth. 3 However, there are now a total of five BPAS
centres situated across the South West region, which are
located in four of the health authorities. There is considerable
variation between these four areas in the proportion of
teenage conceptions which result in abortion and there is
no obvious difference in this proportion between those
areas with a BPAS centre and those without.
More recent data have indicated a falling trend in the
number and rate of abortions in all age groups in England
and Wales. 8 Provisional figures for abortions performed in
1999 indicate that 173,696 abortions were performed in
England and Wales, a fall of 4,175 (2.3%) compared to
1998. These data also indicate that abortion rates have also
fallen in all age groups in 1999 with a reduction of 3% for
women under 20. However, in the South West the proportion
of teenage conceptions leading to a termination has
remained stable over time, the abortion rate per 1000 15-
17 year olds has increased steadily and the number of
abortions in this age group increased by 1,649 between
1993-5 and 1996-8.
Table 2 displays the provisional figures on terminations
performed during 1999 by health authority, purchaser, age
group and gestation. The table reveals considerable
variation between health authorities in the percentage of
terminations paid for in each area by the NHS. Nationally
74% of terminations were paid for by the NHS. Within the
South West region this varied from over 96% in South and
West Devon to only 60% in Wiltshire. There is no obvious
pattern between abortion figures and this variation in the
number of terminations purchased by the NHS in the South
West. National research has shown considerable variation
between health authorities across the country in their access
to NHS abortions, with some authorities paying for only
around half and others paying for more than 90%. 9 This
research also found there to be little correlation between
areas with a low NHS payment proportion and those with
low rates of abortion.
Nationally 89% of terminations were performed before
13 weeks of gestation. Across the region this figure varied
only slightly from 85% in Avon to 93% in Cornwall and the
Isles of Scilly, with the overall regional proportion the same
as that observed nationally.

3.4 Local authority trends

A recent report by the TPU which examined local authority
level data from ONS alongside profile reports produced by
local teenage pregnancy co-ordinators identified a number
of interesting points. 4 Firstly, this analysis of the data
revealed a four-fold variation between local authorities.
Secondly, pockets of extremely high levels of conceptions
were found close to areas with no conceptions recorded for
several years. Thirdly, this analysis found that 60% of
teenage pregnancies between 1992 and 1997 occurred in
only 20% of the total electoral wards, although these are
spread over 230 of the 350 local authorities. In addition,
15% of wards had no teenage pregnancies over this period
and a further quarter had two or less pregnancies a year.
Finally, all local authorities in England were found to have
rates higher than Western European levels, with a number
of rural and seaside areas showing increasing trends in
rates.
There is also considerable variation in conception
numbers and rates between local authority areas in the
South West region (see Figures 2, 3 and 4 ). The total
number of conceptions in local authority areas for the
period 1992-4 ranged from 34 in West Somerset to 808 in
Bristol, representing a 24-fold variation (data not shown). In
the period 1995-7 the total number of conceptions was
greater in most local authorities and ranged from 53 in
West Somerset to 882 in Bristol (Figure 2). In Bristol, the
high rates of teenage conceptions coupled with the large
inner city population mean that the numbers in this local
authority are far higher than other local authorities across
the South West region.
Conception rates in girls aged 15-17 across both
periods varied markedly between local authorities within the
region (Figures 3 and 4). These rates were on the whole
higher in the latter period and during this period ranged
from 18.6 in North Dorset to 59.6 in Swindon. Areas with
high rates of conceptions are often in close geographical
proximity to areas with low rates. This is particularly marked
in the Avon area, where the numbers and rates of teenage
pregnancy are not spread evenly across the four local
authorities. The teenage conception rate in Bath and North
East Somerset for the 1995-7 period was about half of the
rate in Bristol.
In general the local authority areas with the highest
numbers and rates of teenage conceptions were those with
the highest population densities. The local authorities with
the lowest number of conceptions were similar across the
two periods and included the more rural areas in Somerset,
Dorset, Devon, and Gloucestershire. Penwith and the Isles of
Scilly, which have seen a doubling in teenage conception
numbers and rates in recent years, are a notable exception
to this trend. Recent data indicate that this trend has
continued in Penwith and its rates are now well above the
national average and the third highest rates in the region,
behind Gloucester and Swindon.
The proportion of conceptions which lead to terminations
in the under 18 age group is variable across the region
(see Figures 5 and 6 ). Areas with high conception rates also
tend to have a lower percentage of these pregnancies
terminated. There is also a suggestion that a lower proportion
of teenage conceptions is terminated in local authorities
in Cornwall in comparison to other counties. This trend
is most obvious for the earlier data relating to 1992-4 (data
not shown). Although recent figures do indicate that Cornwall
has the lowest proportion of teenage conceptions leading to
abortion in the South West, the overall numbers and rates of
abortions have climbed steadily across Cornwall in recent
years despite increasing numbers of teenage conceptions and
in contrast to the national trend.
Many of the larger towns and cities including Plymouth,
Bristol, Exeter and Swindon across the region stand out as
having lower percentages of conceptions leading to termination
than rural areas, even though these areas have better access
to services offering abortions. However, Taunton and the
Bournemouth area, which are both large urban areas with
high population densities, have relatively high proportions
of teenage conceptions leading to abortion. One possible
explanation for the general pattern seen across the region
may be the link between large urban areas and social
deprivation. Indeed, considerable research has found that
the proportion of pregnancies terminated is generally lower
in deprived areas. 2 This link between deprivation and
termination may also explain the pattern seen across
Cornwall, which has considerable rural deprivation issues.

3.5 Ward level trends

There is even greater variation between electoral wards
across the region than between local or health authorities.
These data are difficult to interpret due to confidentiality
issues leading to suppression of small numbers at this level.
The data should also be treated with caution because the
numbers are small and subject to fluctuation. Ward level
conception rates would provide a clearer picture of the
situation, but robust ward level population data are not
available. Nonetheless, ward level data of conception
numbers do provide valuable information from which some
conclusions may be drawn. The broad picture that emerges
from looking at the numbers on conceptions at ward level is
well illustrated when this data are laid out in the dot density
maps for the region.
The maps displaying ward level conception data
highlight the widespread problem of teenage pregnancy
across the region (see Figures 7 and 8 ). Indeed, despite the
clustering of conceptions around urban areas, the maps
illustrate that teenage pregnancy is not just an inner city
problem. Conceptions are spread throughout the region,
with many occurring in rural wards. This is illustrated by
looking at the situation in Cornwall, a county of small towns
and villages, which has low overall conception rates, but
pockets with high numbers of conceptions at the sub-health
authority level. Although these pockets are mainly focused
around the areas with the highest population densities,
there are also high numbers of conceptions seen across the
more rural areas of Cornwall.
Bristol is the largest urban conurbation in the South
West region, with a sizeable population and substantial
pockets of inner city deprivation. There is considerable
variation between the wards in Bristol with regard to the
teenage conceptions. Areas with high levels are generally
found in the areas of high deprivation. For example,
numbers of conceptions to girls under 18 during the 1995-
97 period ranged from four in the relatively affluent wards
of Henleaze, Cotham and Westbury-on-Trym to over 60 in
the deprived wards of Lawrence Hill, Kingsweston and
Whitchurch Park, representing a fifteen-fold difference.
A specific focus on the inner city ward of Lawrence Hill
in Bristol enables the complex relationship between teenage
pregnancy and deprivation to be explored in more depth.
Although a number of young pregnant women and young
mothers from inner city areas around Bristol are re-housed
in Lawrence Hill, it also has the highest numbers of conceptions
within the city and has consistently high rates of both
terminations and conceptions. 11 It is a predominantly white
working class area, which is economically deprived, with a
high prevalence of alcohol and drug problems. It has also
been noted that many young pregnant girls move into the
area to be housed in high rise council flats. However,
community services in the area are perceived as poor and
many also believe the area to be unsafe and are fearful of
being attacked. These issues suggest that the relationship
between teenage pregnancy and deprivation is both
complex and multi-factorial and that social exclusion is an
important factor within this relationship.
A review of ward level conception data reveals that the
majority of electoral wards across the region have 0,1 or 2
under 16 conceptions (see Table 3 ). The burden of conceptions
to girls under 16 falls to only around a third of all
wards, with two thirds of the wards in the region having 0,
1 or 2 conceptions only. A similar but less marked pattern is
seen for conceptions to girls under 18. This general pattern
is similar to the national picture, where between 1992 and
1997 60% of the teenage pregnancies occurred in only
20% of the total electoral wards.4 In the South West, 60%
of the total number of teenage conceptions in girls under
18 occurred in around 18% of the electoral wards in 1995-
7, highlighting the fact that teenage pregnancy is a fairly
localised problem in the region, with the burden of the
problem falling to a handful of areas.

3.6 Associated factors
3.6.1 Education

There are a number of factors associated with early sexual
initiation in teenagers, the use of contraception and the risk
of pregnancy. The Social Exclusion Unit report on teenage
pregnancy documented those factors associated with an
increased risk of pregnancy amongst teenagers. 1 In general,
the risk of teenage pregnancy is greatest for children who
have grown up with poverty and general disadvantage. As
the report states ëteenage pregnancy is often a cause and a
consequence of social exclusion'. In particular, education has
been found to be closely correlated with teenage pregnancy
and a good general education is a factor that is very strongly
associated with deferring pregnancy. 2
The Department of Health has recently published local
level education data on looked after children, 12 a group
found to be at increased risk of pregnancy during their
teenage years. 2 The variation in educational qualifications of
care leavers across the South West raises a number of
interesting issues. In England 70% of young people left care
without having gained any GCSE or GNVQ qualifications. In
the South West although only 64% left care with no
qualifications, within the region this ranged from 30% in
Bath and North East Somerset to 84% in Plymouth. There
appears to be no consistent pattern in the distribution of
qualifications across the region and the data are difficult to
interpret, as the numbers are small in some areas. However,
it appears that the Unitary Authorities of Plymouth and
Bristol, which have the highest number of care leavers, also
have the poorest educational record for this particular group
and the areas of Bath and North East Somerset, Poole and
Torbay which have the lowest number of care leavers have
the best educational records.

3.6.2 Deprivation

A considerable body of research has observed a high
correlation between deprivation and teenage pregnancy
rates. 1 A detailed analysis of the variation in teenage
conception rates across the South West region was undertaken
by Clements et al at the University of Southampton in
1999. 3 This research also confirmed that conception rates
are generally higher in areas with high levels of deprivation
and that conceptions in these areas are more likely to end in
a maternity. However, Clements et al note that most
research fails to explore the more complex behavioural
explanations that lie behind this variation. 13 They argue that
ìdifferences in teenage pregnancy rates could reflect
different levels of sexual activity, use of contraceptives,
availability of services and sex education, different attitudes
towards sexual behaviour, being pregnant, young mothers
and termination, different aspirations for the future and
different levels of resistance of women to pressures regarding
sexual conduct.
The Department of the Environment, Transport and the
Regions has developed new indices of deprivation. 14 The
constituents are:
• Income (including child poverty as a subset)
• Employment
• Health deprivation and disability
• Education, skills and training
• Housing
• Geographical access to services
which are combined to provide an index of multiple
deprivation.
An index of child poverty is also provided. The index is
becoming widely used across agencies and is generally
thought to provide a robust and sensitive tool for highlighting
deprivation. In particular, it should be noted that unlike
the Jarman Index that includes information on the elderly, all
the domains used in composing the index are fairly relevant
to teenage pregnancy.
Mapping of the ward level deprivation indices across the
South West identifies a number of interesting patterns in
deprivation (see Figure 8 ). Firstly, it should be noted that
although there is considerable variation there appears to be
a similar pattern between the general picture seen across
the deprivation indices and the overall picture of teenage
conceptions across the region. Secondly, it appears that
although the large cities and towns in the region are
highlighted in most of the domains as having deprivation
problems there are also marked pockets of deprivation in
many rural areas, especially in Cornwall and parts of Devon
and Gloucestershire.
The domains of health, employment, income and access
to services show fairly similar trends, with the west of the
region faring poorly overall. The multiple deprivation rank
and the child poverty index show similar trends across the
region and mapping these domains reveals a generally more
favourable picture in the east of the region than the west.
This trend is most marked for the domains of employment
and income.
A detailed interpretation of the patterns of deprivation
seen throughout the South West region is beyond the scope
of this report. However, it is interesting to look in more
depth at those areas with notable levels of deprivation
alongside the local levels of teenage pregnancy. In particular,
Devon and Cornwall stand out in terms of their patterns of
deprivation and teenage pregnancy profile. These are both
areas with economies largely dependent on agriculture and
tourism and both have pockets of considerable affluence
alongside pockets of extreme social deprivation.
In South and West Devon, many of the towns are fast
growing urban areas with large amounts of new housing
being developed for young families resulting in high
proportions of young people in these areas. 15 Plymouth has
historically relied for much of its prosperity on the defence
industry and has suffered greatly from its decline. Some of
the Plymouth inner city areas are amongst the most
deprived in England and Wales and it is now a Health,
Education and Employment Action Zone.
Cornwall has also been designated a Health Action Zone
on account of its high levels of deprivation and inequalities.
It has marked problems of rural isolation, which may result
in problems of access for young people seeking advice and
care around sexual health issues. 16 Within Cornwall and
South and West Devon, wards with high levels of teenage
conceptions are largely seen in the areas with the highest
population densities. It is likely that a number of factors
including the high levels of deprivation, socio-economic
inequalities and the burgeoning youth population in these
areas are important. It is interesting to speculate how rapid
urban growth, which is common to these areas, parts of
Bristol and to areas around Swindon, which also have high
rates of teenage conceptions, is associated with teenage
pregnancy.
In North and East Devon the economic difficulties in the
agricultural industry have had a considerable negative effect
on employment patterns within the district leading to high
levels of deprivation throughout this area. Problems of
access to services are also likely to be important. However,
apart from problems around Exeter, the levels of teenage
pregnancy in North and East Devon are noticeably less
marked than in South and West Devon and Cornwall. This
may be related to the fact that the population in this area
has proportionately less young people and more elderly
people than England and Wales as a whole. 17

3.6.3 Sexually transmitted infections

National surveys have described trends in teenage sexual
activity, however it is difficult to estimate the levels of sexual
activity in teenagers at a local level. Some local teenage
pregnancy co-ordinators in the South West have used
sexually transmitted infections in teenagers as a proxy for
sexual activity in this age group. Data on sexually transmitted
infections is readily available from the Public Health
Laboratory Service. A regional report from the Communicable
Disease Surveillance Centre South West indicates that
there is a rising incidence of sexually transmitted infections
in the region with alarmingly high rates in the younger age
groups. 18
This report notes that attendances at sexual health
clinics in the UK have doubled over the last decade across all
age groups. The report also observes that there has been an
increase in virtually all sexually transmitted infections
reported in the UK. In the South West region a rising trend
in the number of cases of Chlamydia trachomatis and
gonorrhoea has been noticed in recent years. These two
infections are the most common sexually transmitted
infections in the UK and within the South West region the
rates of these infections were found to be highest in girls
aged 15-19 and 20-24.
If the sexually transmitted disease infection is considered
a proxy for sexual activity it does suggest that levels of
sexual activity in teenagers in the South West is on the
increase, which is consistent with national data. 9 However,
data from NHS contraceptive services suggests that sexually
active teenagers today are more likely to attend family
planning clinics than previously. 19 Rates of girls under 16
attending for the first time at family planning clinics have
increased from 0.8 per 100 resident population in 1975 to
7.6 in 1997-8. A similar, but less dramatic increase is noted
in the 16-19 age group across this period.

3.7 Provision of services aimed at tacklingteenage pregnancy

Differential provision of family planning services is found
across the country. 13 Variations in access to and supply of
young people's services occur in urban and rural areas.
Evidence suggests that areas with close access to specialised
young people's family planning clinics tend to have lower
levels of teenage conceptions than areas further away. 3
Most family planning services in the South West region
are situated in areas with high population densities (see
Figure 10 ). In general, there is a clustering of services around
the main cities and towns in the region. There appears to be
no obvious pattern between family planning clinics and local
authority teenage conception rates. Some rural areas with
relatively low teenage conception rates such as North
Devon, Cotswolds and North Dorset have few family
planning clinics compared to other local authorities. Areas
such as Swindon, Gloucester and parts of Cornwall also
appear to have relatively few family planning clinics compared
to other local authority areas but have much higher
conception rates.
Historic investment choices concerning the provision of
family planning services in the South West have resulted in
little equity in current entitlement. The situation of services
in larger communities throughout the region has resulted in
many individuals across the rural areas in the South West
having to travel great distances to access appropriate
services. 15 There is often poor provision of outreach or
satellite clinics and young people often rely predominantly
on their local GP surgery for treatment and care which may
not be sensitive or appropriate to young peoples needs.
Overall access to services in rural areas is generally lower
than access in urban areas. 14 Public transport in rural areas
for young people who may not have a car is often slow and
unreliable. It has also been noted that indirect costs such as
time off work or school may also be prohibiting factors
contributing to the inequities of access for those living in
rural areas. 20 The siting of most services in larger urban
communities may also fail to address the needs of young
people. Frequently these services tend to focus on the needs
of young people already engaged with primary care and
little on the needs of the vulnerable or excluded.