A cohort study of the service-users of online contraception.

BACKGROUND: In January 2017, the first free service providing oral contraceptive pills (OCPs) ordered online and posted home became available in the London boroughs of Lambeth and Southwark - ethnically and socioeconomically diverse areas with high rates of unplanned pregnancy. There are concerns that online services can increase health inequalities; therefore, we aimed to describe service-users according to age, ethnicity and Index of Multiple Deprivation (IMD) quintile of area of residence and to examine the association of these with repeated use. METHODS: We analysed routinely collected data from January 2017 to April 2018 and described service-users using available sociodemographic factors and information on patterns of use. Logistic regression analysis examined factors associated with repeat ordering of OCPs. RESULTS: The service was accessed by 726 individuals; most aged between 20 and 29 years (72.5%); self-identified as being of white ethnic group (58.8%); and residents of the first and second most deprived IMD quintiles (79.2%). Compared with those of white ethnic group, those of black ethnic group were significantly less likely to make repeat orders (adjusted OR 0.53, 95% CI 0.31 to 0.89; p=0.001), as were those of Asian and mixed ethnic groups. CONCLUSIONS: These are the first empirical findings on free, online contraception and suggest that early adopters broadly reflect the population of the local area in terms of ethnic diversity and deprivation as measured by IMD. Ongoing service development should prioritise the identification and removal of barriers which may inhibit repeat use for black and minority ethnic groups

How online sexual health services could work; generating theory to support development.

BACKGROUND: Online sexual health services are an emerging area of service delivery. Theory of change critically analyses programmes by specifying planned inputs and articulating the causal pathways that link these to anticipated outcomes. It acknowledges the changing and contested nature of these relationships. METHODS: We developed two versions of a theory of change for an online sexual health service. The first articulated the theory presented in the original programme proposal and the second documented its development in the early stages of implementation through interviews with key programme stakeholders. RESULTS: The programme proposal described an autonomous and empowered user completing a sexual health check using a more convenient, accessible and discreet online service and a shift from clinic based to online care. The stakeholder interviews confirmed this and described new and more complex patterns of service use as the online service creates opportunities for providers to contact users outside of the traditional clinic visit and users move between online and clinic based care. They described new types of user/provider relationships which we categorised as: those influenced by an online retail culture; those influenced by health promotion outreach and surveillance and those acknowledging the need for supported access. CONCLUSIONS: This analysis of stakeholder views on the likely the impacts of online sexual health services suggests three areas for further thinking and research. 1. Co-development of clinic and online services to support complex patterns of service use. 2. Developing access to online services for those who could use them with support. 3. Understanding user experience of sexual health services as increasing user autonomy and choice in some situations; creating exclusion and a need for support in others and intrusiveness and a lack of control in still others. This work has influenced the evaluation of this programme which will focus on; mapping patterns of use to understand how users move between the online and clinic based services; barriers to use of online services among some populations and how to overcome these; understanding user perceptions of autonomy in relation to online services

Texting Sexual Health Pilot - Interview Guide

A semi-structured topic guide used to discover participants’ views, experiences, and recommendations for improvements to behavioral intervention on sexual health. Questions cover tone and frequency of text messages, views regarding the message content, any concerns about others viewing texts, what (if anything) they had learned from text messages, sexual behavior since enrolment (such as condom use and partner notification), and suggested improvements to the intervention

Can Internet-Based Sexual Health Services Increase Diagnoses of Sexually Transmitted Infections (STI)? Protocol for a Randomized Evaluation of an Internet-Based STI Testing and Results Service.

BACKGROUND: Ensuring rapid access to high quality sexual health services is a key public health objective, both in the United Kingdom and internationally. Internet-based testing services for sexually transmitted infections (STIs) are considered to be a promising way to achieve this goal. This study will evaluate a nascent online STI testing and results service in South East London, delivered alongside standard face-to-face STI testing services. OBJECTIVE: The aim of this study is to establish whether an online testing and results services can (1) increase diagnoses of STIs and (2) increase uptake of STI testing, when delivered alongside standard face-to-face STI testing services. METHODS: This is a single-blind randomized controlled trial. We will recruit 3000 participants who meet the following eligibility criteria: 16-30 years of age, resident in the London boroughs of Lambeth and Southwark, having at least one sexual partner in the last 12 months, having access to the Internet and willing to take an STI test. People unable to provide informed consent and unable to read and understand English (the websites will be in English) will be excluded. Baseline data will be collected at enrolment. This includes participant contact details, demographic data (date of birth, gender, ethnicity, and sexual orientation), and sexual health behaviors (last STI test, service used at last STI test and number of sexual partners in the last 12 months). Once enrolled, participants will be randomly allocated either (1) to an online STI testing and results service (Sexual Health 24) offering postal self-administered STI kits for chlamydia, gonorrhoea, syphilis, and HIV; results via text message (short message service, SMS), except positive results for HIV, which will be delivered by phone; and direct referrals to local clinics for treatment or (2) to a conventional sexual health information website with signposting to local clinic-based sexual health services. Participants will be free to use any other interventions or services during the trial period. At 6 weeks from randomization we will collect self-reported follow-up data on service use, STI tests and results, treatment prescribed, and acceptability of STI testing services. We will also collect objective data from participating STI testing services on uptake of STI testing, STI diagnoses and treatment. We hypothesise that uptake of STI testing and STI diagnoses will be higher in the intervention arm. Our hypothesis is based on the assumption that the intervention is less time-consuming, more convenient, more private, and incur less stigma and embarrassment than face-to-face STI testing pathways. The primary outcome measure is diagnosis of any STI at 6 weeks from randomization and our co-primary outcome is completion of any STI test at 6 weeks from randomization. We define completion of a test, as samples returned, processed, and results delivered to the intervention and/or clinic settings. We will use risk ratios to calculate the effect of the intervention on our primary outcomes with 95% confidence intervals. All analyses will be based on the intention-to-treat (ITT) principle. RESULTS: This study is funded by Guy's and St Thomas' Charity and it has received ethical approval from NRES Committee London-Camberwell St Giles (Ref 14/LO/1477). Research and Development approval has been obtained from Kings College Hospital NHS Foundation Trust and Guy's and St Thomas' NHS Foundation Trust. Results are expected in June 2016. CONCLUSIONS: This study will provide evidence on the effectiveness of an online STI testing and results service in South East London. Our findings may also be generalizable to similar populations in the United Kingdom. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 13354298; http://www.isrctn.com/ISRCTN13354298 (Archived by WebCite at http://www.webcitation.org/6d9xT2bPj)

Comparing the characteristics of users of an online service for STI self-sampling with clinic service users: a cross-sectional analysis.

OBJECTIVES: Online services for self-sampling at home could improve access to STI testing; however, little is known about those using this new modality of care. This study describes the characteristics of users of online services and compares them with users of clinic services. METHODS: We conducted a cross-sectional analysis of routinely collected data on STI testing activity from online and clinic sexual health services in Lambeth and Southwark between 1January 2016 and 31March 2016. Activity was included for chlamydia, gonorrhoea, HIV and syphilis testing for residents of the boroughs aged 16 years and older. Logistic regression models were used to explore potential associations between type of service use with age group, gender, ethnic group, sexual orientation, positivity and Index of Multiple Deprivation (IMD) quintiles. We used the same methods to explore potential associations between return of complete samples for testing with age group, gender, ethnic group, sexual orientation and IMD quintiles among online users. RESULTS: 6456 STI tests were carried out by residents in the boroughs. Of these, 3582 (55.5%) were performed using clinic services and 2874 (44.5%) using the online service. In multivariate analysis, online users were more likely than clinic users to be aged between 20 and 30 years, female, white British, homosexual or bisexual, test negative for chlamydia or gonorrhoea and live in less deprived areas. Of the individuals that ordered a kit from the online service, 72.5% returned sufficient samples. In multivariate analysis, returners were more likely than non-returners to be aged >20 years and white British. CONCLUSION: Nearly half (44.5%) of all basic STI testing was done online, although the characteristics of users of clinic and online services differed and positivity rates for those using the online service for testing were lower. Clinics remain an important point of access for some groups

Does internet-accessed STI (e-STI) testing increase testing uptake for chlamydia and other STIs among a young population who have never tested? Secondary analyses of data from a randomised controlled trial.

OBJECTIVES: To assess the effectiveness of an internet-accessed STI (e-STI) testing and results service on testing uptake among young adults (16-30 years) who have never tested for STIs in London, England. METHODS: We conducted secondary analyses on data from a randomised controlled trial. In the trial, participants were randomly allocated to receive a text message with the web link of an e-STI testing and results service (intervention group) or a text message with the link of a website listing the locations, contact details and websites of seven local sexual health clinics (control group). We analysed a subsample of 528 trial participants who reported never testing for STIs at baseline. Outcomes were self-reported STI testing at 6 weeks, verified by patient record checks, and time from randomisation to completion of an STI test. RESULTS: Uptake of STI testing among 'never testers' almost doubled. At 6 weeks, 45.3% of the intervention completed at least one test (chlamydia, gonorrhoea, syphilis and HIV), compared with 24.1% of the control (relative risk [RR] 1.88, 95% CI 1.47 to 2.40, p<0.001). For chlamydia and gonorrhoea testing combined, uptake was 44.3% in the intervention versus 24.1% in controls (RR 1.84, 95% CI 1.44 to 2.36, p<0.001). The intervention reduced time to any STI test (restricted mean survival time: 29.0 days vs 36.3 days, p<0.001) at a time horizon of 42 days. CONCLUSIONS : e-STI testing increased uptake of STI testing and reduced time to test among a young population of 'never testers' recruited in community settings. Although encouraging, questions remain on how best to manage the additional demand generated by e-STI testing in a challenging funding environment. Larger studies are required to assess the effects later in the cascade of care, including STI diagnoses and cases treated

Supporting blood pressure measurement prior to online prescription of the combined oral contraceptive.

Editorial - No Abstract available

Web-Based Activity Within a Sexual Health Economy: Observational Study.

BACKGROUND: Regular testing for sexually transmitted infections (STIs) is important to maintain sexual health. Self-sampling kits ordered online and delivered in the post may increase access, convenience, and cost-effectiveness. Sexual health economies may target limited resources more effectively by signposting users toward Web-based or face-to-face services according to clinical need. OBJECTIVE: The aim of this paper was to investigate the impact of two interventions on testing activity across a whole sexual health economy: (1) the introduction of open access Web-based STI testing services and (2) a clinic policy of triage and signpost online where users without symptoms who attended clinics for STI testing were supported to access the Web-based service instead. METHODS: Data on attendances at all specialist public sexual health providers in an inner-London area were collated into a single database. Each record included information on user demographics, service type accessed, and clinical activity provided, including test results. Clinical activity was categorized as a simple STI test (could be done in a clinic or online), a complex visit (requiring face-to-face consultation), or other. RESULTS: Introduction of Web-based services increased total testing activity across the whole sexual health economy by 18.47% (from 36,373 to 43,091 in the same 6-month period-2014-2015 and 2015-2016), suggesting unmet need for testing in the area. Triage and signposting shifted activity out of the clinic onto the Web-based service, with simple STI testing in the clinic decreasing from 16.90% (920/5443) to 12.25% (511/4172) of total activity, P<.001, and complex activity in the clinic increasing from 69.15% (3764/5443) to 74.86% (3123/4172) of total activity, P<.001. This intervention created a new population of online users with different demographic and clinical profiles from those who use Web-based services spontaneously. Some triage and signposted users (29.62%, 375/1266) did not complete the Web-based testing process, suggesting the potential for missed diagnoses. CONCLUSIONS: This evaluation shows that users can effectively be transitioned from face-to-face to Web-based services and that this introduces a new population to Web-based service use and changes the focus of clinic-based activity. Further development is underway to optimize the triage and signposting process to support test completion

Contraception in Person-Contraception Online (CiP-CO) cohort study.

BACKGROUND: Online contraception services increasingly provide information, clinical assessment and home-delivered oral contraceptives (OCs). Evidence is lacking on the effects of online contraceptive service use on short-term contraceptive continuation. METHODS: Cohort study comparing contraceptive continuation between new users of a free-to-access online OC service in South East London with those from other, face-to-face services in the same area. Online questionnaires collected data on participants' sociodemographic characteristics, motivations for OC access, service ratings, OC knowledge and contraceptive use. Contraceptive use in the 4-month study period was measured using health service records. Unadjusted and multivariable logistic regression models compared outcomes between the online service group and those using other services. RESULTS: Online service-users (n=138) were more likely to experience short-term continuation of OCs compared with participants using other services (n=98) after adjusting for sociodemographic and other characteristics (adjusted OR 2.94, 95% CI 1.52 to 5.70). Online service-users rated their service more highly (mean 25.22, SD 3.77) than the other services group (mean 22.70, SD 4.35; p<0.001), valuing convenience and speed of access. Among progestogen-only pill users, knowledge scores were higher for the online group (mean 4.83, SD 1.90) than the other services group (mean 3.87, SD 1.73; p=0.007). Among combined oral contraceptive users, knowledge scores were similar between groups. CONCLUSIONS: Free-to-access, online contraception has the potential to improve short-term continuation of OCs. Further research using a larger study population and analysis of longer-term outcomes are required to understand the impact of online services on unintended pregnancy

Young People's Views and Experiences of a Mobile Phone Texting Intervention to Promote Safer Sex Behavior.

BACKGROUND: The risk of poor sexual health, including unplanned pregnancy and sexually transmitted infections (STIs), is greatest amongst young people. Innovative and acceptable interventions to improve sexual health are required. Mobile phone text messaging (short message service, SMS) interventions have the potential to reach large numbers of people at relatively low cost, but greater understanding is needed on how these interventions should be developed and how they work. OBJECTIVES: The aim of this paper is to explore young people's views of and experiences with a mobile phone text messaging intervention to promote safer sex behavior. METHODS: We undertook qualitative interviews with young people aged 16 to 24 years as part of a pilot trial of a sexual health intervention delivered by text message in the United Kingdom. Study participants received sexual health promotion text messages based on behavior-change techniques. The message content, tailored by gender and STI status, included support for correct STI treatment and promotion of safer sex behaviors. Young people were eligible if they had received a positive chlamydia test or had more than one partner and at least one episode of unprotected sex in the last year. Telephone interviews were conducted 2 to 3 weeks after initiation of the intervention. A semi-structured topic guide was followed to explore participant experiences and a thematic analysis was conducted. RESULTS: We conducted 16 telephone interviews with participants who had received the text intervention and an additional four interviews with those in the control group (13 women and 7 men). Intervention participants found text messages easy to understand and appearing to come from a friendly and trustworthy source. They considered the frequency and timing of messages to be appropriate, and delivery via mobile phones convenient. Receipt of support by text message allowed recipients to assimilate information at their own pace, and prompted reflection on and sharing of messages with friends, family members, and partners, thus providing opportunities for education and discussion. For some recipients, the messages had increased their knowledge of how to correctly use condoms. Some described how the messages had increased their confidence and reduced stigma, enabling them to disclose infection to a partner and/or to do so sooner and more calmly. Discussing the messages with a partner reportedly enabled some women to negotiate condom use. CONCLUSION: From the perspective of the recipients, the tone, frequency, and content of the text messaging-based sexual health intervention was acceptable and appropriate. Their accounts indicated that the intervention increased knowledge, confidence, and safer sex behaviors. A large-scale randomized controlled trial (RCT) is needed to assess effectiveness