Baraitser, Paula

Free, Caroline J

McCulloch, Hannah

Shather, Zainab

LSHTM Research Online

  157Baraitser P, et al. BMJ Sex Reprod Health 2021;47:157–158. doi:10.1136/bmjsrh-2020-200887Supporting blood pressure measurement prior to online prescription of the combined oral contraceptivePaula Baraitser   ,1 Hannah McCulloch   ,1 Zainab Shather,1 Caroline J Free21SH:24 CIC, London, UK2Department of Population Health, London School of Hygiene and Tropical Medicine, London, UKCorrespondence toDr Paula Baraitser, SH:24 CIC, London, UK;  paula_ baraitser@ mac. comReceived 24 September 2020Revised 12 January 2021Accepted 14 January 2021Published Online First 9 February 2021To cite: Baraitser P, McCulloch H, Shather Z, et al. BMJ Sex Reprod Health 2021;47:157–158.Editorial© Author(s) (or their employer(s)) 2021. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.Online sexual health tests and contraception may improve access to sexual health care.1 2 Online services offer the benefits of increased convenience and control but also require additional responsibilities and resources (time, skills, information) from users3 with associated health risks and benefits. In this editorial we think through strategies to support these new user responsibilities and minimise health risks, using the example of self- reported blood pressure (BP) prior to a prescription of the combined oral contracep-tive (COC).International guidelines specify that a BP check is required prior to a prescription of the COC.4 Ethinylestradiol stimulates an increase in hepatic protein production including angiotensinogen with slightly reduced renal blood flow and small BP increases that are clinically significant in 2% of users. BP is therefore monitored before first prescription of the pill and then annu-ally, and the COC is contraindicated if BP is consistently above 140/90 mmHg.4In face- to- face services, BP is collected and recorded by clinicians prior to prescribing, usually as a single measurement with repeat readings taken if the first reading is high.5 BP is highly variable and errors taking BP are common.6 Large variations in BP measured in office settings in clinical trials and primary care suggest limitations to the accuracy of measurements taken in this way.7 8The UK Faculty of Sexual and Reproduc-tive Healthcare (FSRH) recommends that remote and online prescribing is suitable for COCs based on a recent, self- reported BP measurement.9 BP measurement may be obtained from general practitioners, pharmacies or using home BP machines. Ownership of BP machines in the UK is increasingly common among populations with hypertension, mostly older people and pregnant women, and self- measurement of BP is both feasible and more accurate than measurements taken during clinic visits.8 Many pharmacies offer BP checks without charge, and primary care consultation rates among young women are high, for example, 42 033/10 000 person- years among women aged 16–24 years,10 giving multiple opportu-nities for BP measurement.Research with users of online contra-ceptive services report that most (90.51%, 296/327) obtain BP readings in a clinically appropriate way, for example, a reading taken with a BP home monitor or at a clin-ical location by someone with appropriate technical skill, within 12 months prior to ordering. Ninety- three percent of users felt confident about reporting their BP to online services.11Clinicians may inform users that their BP is normal, but may not provide the numer-ical reading. In a large, online contraceptive service ( www. sh24. org. uk) women were asked to report a numerical BP reading, where possible, as well as where and when it was taken. Those who could not report a numerical reading were asked to report whether they were told whether it was normal. Of 2224 COC orders created between 22 June 2020 and 9 August 2020, 1171 (53%) women provided a numerical BP measurement and 1053 (47%) could not provide a value. Of those who could not provide a numerical value, 95% were able to give details of where and when their BP had last been measured, and 71% were able to report that it was normal (SH:24, routinely collected data, 2020).Reporting a normal BP measurement is a gateway to accessing the COC. In situations where users feel under pressure because, for example, they are running out of pills then there may be incentives to provide inaccurate Baraitser P, et al. BMJ Sex Reprod Health 2021;47:157–158. doi:10.1136/bmjsrh-2020-200887158Editorialreadings. The study cited found that self- reported BP was a poor predictor of researcher- measured BP but that self- reported body mass index (BMI) was a good predictor of researcher- measured BMI.11 One possible interpretation of this finding is that people are used to reporting height and weight but need a little more help to measure and interpret their BP. We cannot think of a reason why they would knowingly report one type of measurement inaccu-rately but not the other.Services providing online prescriptions for sexual health products are required to adapt strategies used in clinics, acknowledge the responsibilities taken on by users, and generate an enabling environment to facilitate self care. This process reminds us of the limitations of current clin-ical practice and the challenges of online provision. On this basis we suggest some possible innovations and hope to stimulate informed debate on this issue.Possible innovations in face- to- face care: ► Build self- monitoring skills by engaging users in the process of measurement, explaining the meaning and significance of BP checks and providing testing stations in waiting areas. ► Consider the role of home BP monitoring for COC prescriptions in clinics and referral for ambulatory moni-toring in those with high BP diagnosed in clinic.Possible innovations in online services: ► Provide accessible information on how to obtain and interpret a BP reading and the consequences of taking the COC with high BP. ► Create and promote opportunities for interaction with clinicians for support with BP measurement or reporting. ► Accept a report of a normal BP measurement (without numerical values) with a credible explanation of where and when it was taken for a 3- month supply of the COC. This could be supported with system reminders and information to prompt users to obtain a numerical measurement before their next order. ► Advise women using online services to measure their BP using a home monitor where they have access to one and to consider purchasing one if not. ► Offer proactive follow- up where there is evidence of poor understanding of BP, for example, reporting of a clinically impossible reading.We would like to engage the contraceptive service provision community in a discussion of these issues and would welcome responses to the thinking set out here and further research into this issue.Funding Some of the work that underpins this editorial is independent research funded by the National Institute for Health Research (NIHR) (Research for Patient Benefit Programme, PB- PG-0815-20009). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the Department for Health and Social Care.Competing interests PB is clinical director of the not- for- profit digital sexual health service provider SH:24. HMC is employed as a research associate at SH:24 on a different research project. This work is part of a process of research on innovation at SH:24 where all innovation is the subject of research to ensure that learning is shared widely. SH:24 is a ‘not- for- profit’ organisation that provides health services to the National Health Service, and sharing learning through innovation and research is one of the principles of the organisation.Provenance and peer review Not commissioned; externally peer reviewed.Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.ORCID iDsPaula Baraitser http:// orcid. org/ 0000- 0002- 3354- 6494Hannah McCulloch http:// orcid. org/ 0000- 0001- 5006- 967XREFERENCES 1 Wilson W, Morris T, Syred J, et al. e- STI testing and results service: a single blind randomised controlled trial. Plos Medicine 2017;14:e1002479. 2 Rezel- Potts E, Free C, Syred J, et al. Expanding choice through online contraception: a theory of change to inform service development and evaluation. BMJ Sex Reprod Health 2020;46:108–15. 3 Narasimhan M, Allotey P, Hardon A. Self care interventions to advance health and wellbeing: a conceptual framework to inform normative guidance. BMJ 2019;365:l688. 4 World Health Organization (WHO). Medical eligibility criteria for contraceptive use, 2015. Available: https://www. who. int/ publications/ i/ item/ 9789241549158 [Accessed 12 Jan 2021]. 5 National Institute for Health and Care Excellence (NICE). Hypertension in adults: diagnosis and management. (NICE guideline NG136), 2019. Available: https://www. nice. org. uk/ guidance/ ng136/ resources [Accessed 12 Jan 2021]. 6 Benediktsson R, Padfield PL. Maximizing the benefit of treatment in mild hypertension: three simple steps to improve diagnostic accuracy. QJM 2004;97:15–20. 7 Sebo P, Pechère- Bertschi A, Herrmann FR, et al. Blood pressure measurements are unreliable to diagnose hypertension in primary care. J Hypertens 2014;32:509–17. 8 McManus RJ, Mant J, Franssen M, et al. Efficacy of self- monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial. Lancet 2018;391:949–59. 9 Faculty of Sexual and Reproductive Healthcare (FSRH), British Association for Sexual Health and HIV (BASHH). FSRH/BASHH standards for online and remote providers of sexual and reproductive health services, 2019. Available: https://www. fsrh. org/ standards- and- guidance/ documents/ fsrhbashh- standards- for- online- and- remote- providers- of- sexual/ [Accessed 25 Aug 2020]. 10 Hobbs FDR, Bankhead C, Mukhtar T, et al. Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007–14. Lancet 2016;387:2323–30. 11 Baraitser P, McCulloch H, Morelli A. A mixed methods evaluation of online provision of oral contraceptives to measure: validity of self- reported biometric data; essential information transfer and user experience of self measurement and submission of biometric data. End of project report submitted to the National Institute for Health Research, 2020.

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

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

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