Jonathan Syred

Would You Tell Everyone This? Facebook Conversations as Health Promotion Interventions

Background Health promotion interventions on social networking sites can communicate individually tailored content to a large audience. User-generated content helps to maximize engagement, but health promotion websites have had variable success in supporting user engagement. Objective The aim of our study was to examine which elements of moderator and participant behavior stimulated and maintained interaction with a sexual health promotion site on Facebook. Methods We examined the pattern and content of posts on a Facebook page. Google analytics was used to describe the number of people using the page and viewing patterns. A qualitative, thematic approach was used to analyze content. Results During the study period (January 18, 2010, to June 27, 2010), 576 users interacted 888 times with the site through 508 posts and 380 comments with 93% of content generated by users. The user-generated conversation continued while new participants were driven to the site by advertising, but interaction with the site ceased rapidly after the advertising stopped. Conversations covered key issues on chlamydia and chlamydia testing. Users endorsed testing, celebrated their negative results, and modified and questioned key messages. There was variation in user approach to the site from sharing of personal experience and requesting help to joking about sexually transmitted infection. The moderator voice was reactive, unengaged, tolerant, simplistic, and was professional in tone. There was no change in the moderator approach throughout the period studied. Conclusions Our findings suggest this health promotion site provided a space for single user posts but not a self-sustaining conversation. Possible explanations for this include little new content from the moderator, a definition of content too narrow to hold the interest of participants, and limited responsiveness to user needs. Implications for health promotion practice include the need to consider a life cycle approach to online community development for health promotion and the need for a developing moderator strategy to reflect this. This strategy should reflect two facets of moderation for online health promotion interventions: (1) unengaged and professional oversight to provide a safe space for discussion and to maintain information quality, and (2) a more engaged and interactive presence designed to maintain interest that generates new material for discussion and is responsive to user requests.

Internet-accessed sexually transmitted infection (e-STI) testing and results service: A randomised, single-blind, controlled trial.

Background Internet-accessed sexually transmitted infection testing (e-STI testing) is increasingly available as an alternative to testing in clinics. Typically this testing modality enables users to order a test kit from a virtual service (via a website or app), collect their own samples, return test samples to a laboratory, and be notified of their results by short message service (SMS) or telephone. e-STI testing is assumed to increase access to testing in comparison with face-to-face services, but the evidence is unclear. We conducted a randomised controlled trial to assess the effectiveness of an e-STI testing and results service (chlamydia, gonorrhoea, HIV, and syphilis) on STI testing uptake and STI cases diagnosed. Methods and findings The study took place in the London boroughs of Lambeth and Southwark. Between 24 November 2014 and 31 August 2015, we recruited 2,072 participants, aged 16–30 years, who were resident in these boroughs, had at least 1 sexual partner in the last 12 months, stated willingness to take an STI test, and had access to the internet. Those unable to provide consent and unable to read English were excluded. Participants were randomly allocated to receive 1 text message with the web link of an e-STI testing and results service (intervention group) or to receive 1 text message with the web link of a bespoke website listing the locations, contact details, and websites of 7 local sexual health clinics (control group). Participants were free to use any other services or interventions during the study period. The primary outcomes were self-reported STI testing at 6 weeks, verified by patient record checks, and self-reported STI diagnosis at 6 weeks, verified by patient record checks. Secondary outcomes were the proportion of participants prescribed treatment for an STI, time from randomisation to completion of an STI test, and time from randomisation to treatment of an STI. Participants were sent a £10 cash incentive on submission of self-reported data. We completed all follow-up, including patient record checks, by 17 June 2016. Uptake of STI testing was increased in the intervention group at 6 weeks (50.0% versus 26.6%, relative risk [RR] 1.87, 95% CI 1.63 to 2.15, P < 0.001). The proportion of participants diagnosed was 2.8% in the intervention group versus 1.4% in the control group (RR 2.10, 95% CI 0.94 to 4.70, P = 0.079). No evidence of heterogeneity was observed for any of the pre-specified subgroup analyses. The proportion of participants treated was 1.1% in the intervention group versus 0.7% in the control group (RR 1.72, 95% CI 0.71 to 4.16, P = 0.231). Time to test, was shorter in the intervention group compared to the control group (28.8 days versus 36.5 days, P < 0.001, test for difference in restricted mean survival time [RMST]), but no differences were observed for time to treatment (83.2 days versus 83.5 days, P = 0.51, test for difference in RMST). We were unable to recruit the planned 3,000 participants and therefore lacked power for the analyses of STI diagnoses and STI cases treated. Conclusions The e-STI testing service increased uptake of STI testing for all groups including high-risk groups. The intervention required people to attend clinic for treatment and did not reduce time to treatment. Service innovations to improve treatment rates for those diagnosed online are required and could include e-treatment and postal treatment services. e-STI testing services require long-term monitoring and evaluation. Trial registration ISRCTN Registry ISRCTN13354298.

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)

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

BackgroundOnline 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.MethodsWe 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.ResultsThe 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.ConclusionsThis 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.

Screening for Child Sexual Exploitation in Online Sexual Health Services: An Exploratory Study of Expert Views

Background Sexual health services routinely screen for child sexual exploitation (CSE). Although sexual health services are increasingly provided online, there has been no research on the translation of the safeguarding function to online services. We studied expert practitioner views on safeguarding in this context. Objective The aim was to document expert practitioner views on safeguarding in the context of an online sexual health service. Methods We conducted semistructured interviews with lead professionals purposively sampled from local, regional, or national organizations with a direct influence over CSE protocols, child protection policies, and sexual health services. Interviews were analyzed by three researchers using a matrix-based analytic method. Results Our respondents described two different approaches to safeguarding. The “information-providing” approach considers that young people experiencing CSE will ask for help when they are ready from someone they trust. The primary function of the service is to provide information, provoke reflection, generate trust, and respond reliably to disclosure. The approach values online services as an anonymous space to test out disclosure without commitment. The “information-gathering” approach considers that young people may withhold information about exploitation. Therefore, services should seek out information to assess risk and initiate disclosure. This approach values face-to-face opportunities for individualized questioning and immediate referral. Conclusions The information-providing approach is associated with confidential telephone support lines and the information-gathering approach with clinical services. The approach adopted online will depend on ethos and the range of services provided. Effective transition from online to clinic services after disclosure is an essential element of this process and further research is needed to understand and support this transition.

Exploration of gender differences of Chlamydia trachomatis infection amongst young people reveals limitations of using sexual histories to assess risk in high-prevalence areas:

Summary In England, chlamydia positivity in young men occurs at a slightly older age group (20–24 years) than positivity among young women (16–20 years) but total rates of infection among the population aged under 25 years are similar. Where there is variation, explanations often focus on individual sexual risk behaviours. We aimed to explore the extent to which variations in chlamydia positivity could be explained by reasons for attendance and sexual behaviour at a sexual health clinic in a high-prevalence area of England. Data routinely collected during clinic appointments were extracted retrospectively from the medical records of 952 clinic users (634 women) aged 16 to 24. We tested for associations with chlamydia positivity using the Chi square statistic and multiple logistic regression for men and women separately; 19.5% of men tested positive (95% CI: 15.1–23.8) compared to 11.5% of women (95% CI: 9.0–14.0). Reporting a partner with symptoms or a sexually transmitted infection diagnosis was significantly associated with a positive diagnosis (Men OR: 3.14, 95% CI: 1.5–6.25; Women OR: 3.78, 95% CI: 1.83–7.83). All other reasons for attendance and all sexual behaviour variables were not significantly associated with a positive diagnosis. Differences in chlamydia positivity between men and women attending this service cannot be explained by individual sexual behaviours found to be associated with higher risk of infection in national studies. Our findings question the utility of individual behavioural data routinely collected during clinic appointments for predicting risk of sexually transmitted infections in high-prevalence areas.

P121 Choose to test

Introduction Choice is an increasingly important element of health care. We introduced choice of test into an online sexual health service. Methods Users were offered testing based on their risk profile (table 1) with an option to request additional tests. Routinely collected anonymised data were collected on choice of test.Abstract P121 Table 1 Results from Choose to test <24 24+ BME MSM Genital GC/CT* Yes Yes Yes Yes Oral GC/CT* No No No Yes Anal GC/CT* No No No Yes Syphilis No No No Yes HIV No No Yes Yes Results 2550 users ordered tests (30/10/16 – 19/12/16). 56% were <24, 10% were from black or ethnic minority (BME) groups and 17% were men who have sex with men (MSM). 1853 (72.6%) returned a test, 6.7% were positive for any STI. Of the non-BME/non-MSM users offered chlamydia/gonorrhoea testing, 66% chose to add HIV + syphillis testing. Of the BME/non-MSM users offered chlamydia/gonorrhoea + HIV testing, 71% chose to add syphilis testing. Of the MSM users offered chlamydia/gonorrhoea (genital, oral, anal) + HIV + syphilis testing, 85% chose this option. 6% chose to omit the HIV/syphilis test. User choice resulted in 611 fewer HIV tests, 596 fewer syphilis tests and 27 fewer chlamydia/gonorrhoea tests. Discussion Online service users actively exercise choice in STI test selection. The majority of users choose to test for chlamydia, gonorrhoea, HIV and syphilis regardless of what they are offered. User choice of test reduces the total number of tests offered online.

P102 Integration of clinic services with online sexually transmitted infection (STI) testing (sh:24) in camberwell, se london: impact of active referral of asymptomatic testing online in 2016

Introduction An online service was implemented in an area with high burden of sexually transmitted infections and poor sexual health outcomes. The aim was to improve access and availability of sexual health, fully integrated within NHS services. This study looks at the impact of a change in management, whereby asymptomatic patients seeking STI testing in the GUM clinic were directed to the online service. Methods We compared clinic attendance in 2016 before (quarter 2, Q2) and after (quarter 3, Q3) the change in clinical practice. Individual level clinic attendance data were collated and summarised as simple STI test performed (chlamydia, gonorrhoea, HIV, syphilis) or complex service required. We also compared service use by age, ethnicity and sexual orientation. Changes in pattern of clinic attendance between the quarters were analysed using a Chi2 test. Results Abstract P102 Table 1 Changing pattern of GUM clinic use. Q2 (Before) Q3 (After) Total visits (valid code) 6,949 5,397 Simple STI test 4,044 (58%) 2,823 (52%) Complex service 4,785 (69%) 4,083 (76%) Complex service & simple STI test 2,845 2,170 There were significantly fewer simple STI tests (Chi-squared, p<0.001) and more visits requiring complex services (p<0.001) in Q3 versus Q2. Discussion Following establishment of efficient online STI testing, the clinic changed its triage practice: asymptomatic patients seeking STI testing were directed to use the online service. The change appears to facilitate a higher proportion of more complex visits although the absolute number of visits has decreased.