TEENAGERS who live in a small town or the country are increasingly at risk from having unprotected sex. According to a 15-year review of teenage pregnancies published by the Scottish Office, areas such as Cumnock and Doon Valley, Wigtown and Lochaber have even higher rates than Glasgow, Motherwell and the former district of Monklands.
One rural community which is facing up to the problem imaginatively is Angus. In 1997, there were 76.6 pregnancies for every 1,000 16 to 19-year-olds in comparison with the national average of only 70.4. Among 13-15s, a rate per 1,000 of 10.3 compared with a national average of 8.7.
One difficulty in bringing contraceptive services to young people in an area like Angus is the scattered nature of its population: a large central clinic will not do. Another problem is the lack of anonymity - and the perceived judgmental attitude of adults - in local mainstream health services. A disastrous experiment in Forfar where a teen clinic was sited in the local secondary school showed wariness also of peer judgment.
So the project Angus Under 21 Health has introduced a network of seven small clinics in local health centres held at discreet times. The most recent has just opened in Carnoustie. The centres are staffed by school nurses and health visitors with a special interest in working with teenagers.
Arlene Nelson, a school nurse based in Forfar, describes herself as a "definite resource" in her community. She runs a teen clinic, and if necessary offers appointments at other times, and helps schools plan and deliver health and sex education programmes.
She says that a vital element is an understanding of the effects of alcohol, a major factor contributing to high-risk sexual behaviour.
Health workers advise young people on a range of issues but what concerns teenagers most is their sexual health. Hayley Whitaker, aged 17, says:
"Young people are having sex and they are starting to do so at a much younger age than their parents did. It's like smoking, it's happening."
Services like Angus Under 21 are essential, she says. "It would be patronising to tell young people, wait till you are older before you have sex. A lot say, they are older, it's right for me. It has to be said, though, if you are going to do it, do it right."
The clinics are backed by health promotion activities in which teenagers themselves play a major part. Hayley played the role of Ashley in The Sex Files, a series of programmes broadcast by Radio Tay FM in co-operation with Angus Under 21 and Tayside health promotion department.
The series gave the teen clinics and their health workers valuable publicity. "We are not saying all teenagers are having sex - they are not. But if they are, here are the services they should use," Hayley says.
Kerry Taylor, leader of Angus Under 21's youth involvement programme, has encouraged young people to draw up their own charter on the standards of health service they expect. Confidentiality, non-judgmental attitudes and being treated with respect are high on their agenda.
Through her work Ms Taylor finds out what teenagers think of the Under 21 services and she passes her conclusions to the education and health services. Christine Watkins, Angus's 5-18 adviser, says the dialogue has influenced in-service programmes for teachers. "It has encouraged us to get them thinking more about young people's needs," she says.
In planning the clinic in Carnoustie, Ms Taylor talked to third-year social education classes and conducted a pupil survey. The majority wanted a weekly drop-in clinic after school in a nearby health centre. So that is what they now have.
Pregnancy figures for the 16-19 age-group remained the same between 1996 and 1997, while there was one fewer pregnancy among 13-15s. But Angus Under 21 Health can measure some success in terms of rising numbers and in the nature of consultations. There have been fewer first-time visits for emergency contraception.
The area's teenagers, Kerry Taylor says, are becoming more responsible and that is a step in the right direction.