BackgroundRegular 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.ObjectiveThe 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.MethodsData 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.ResultsIntroduction 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.ConclusionsThis 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.
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.Co-development of clinic and online services to support complex patterns of service use.Developing access to online services for those who could use them with support.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.
Background The English National Health Service Cervical Screening Programme (NHSCSP) recommendation not to offer cervical screening to women aged 20-24 years is considered in the context of national rates of cervical intraepithelial neoplasia grade 3 (CIN3) and invasive cervical carcinoma, falling screening coverage in young women, detection of screen-detected invasive cancers and risks of excisional treatment of CIN.Methods Registrations of invasive and in situ cervical carcinoma were obtained from the Office for National Statistics, data on screening coverage and cytology results from the NHSCSP website and data on screendetected cancers from an audit at Guy's & St Thomas' NHS Foundation Trust (GSTFT).Results Before and after the introduction of organised screening in England, CIN3 was primarily detected in women aged 20-39 years. Increasing rates of CIN3 were recorded in women aged 20-24 years during the last decade (3000-4000 cases per year) despite falling screening coverage. IntroductionInvasive cervical cancer incidence and mortality have fallen by nearly 50% since screening was centrally organised in 1988, despite an escalating risk of disease seen across Europe in birth cohorts of women born since the 1940s. 1 Furthermore, birth cohort trends in mortality in England and Wales declined steeply after 1988 in all screening age groups, including women under 35 years whose mortality rates at the time were among the highest in the world. 2 That reversal in trend, which persisted in subsequent decades of life, suggests that an epidemic of cervical cancer was avoided by screening women when they were young: an epidemic likely to reflect the greater sexual freedom allowed by the availability of reliable contraception since the late 1960s. 2 In 2004, the National Health Service Cervical Screening Programme (NHSCSP) introduced new recommendations for screening intervals. 3 Women under 25 years would no longer be offered screening and the intervals would be standardised as 3-yearly for women aged 25-49 years and 5-yearly for those aged 50-64 years. A case-control study had shown that invasive cancer was rare in women under 25 years and that screening was Discussion and conclusions Delaying the age for screening eligibility carries a risk of CIN becoming more extensive, and therefore more difficult to excise, as well as a risk of progression. The NHSCSP should reconsider its decision and encourage young women to be screened, not excluding those aged 20-24 years. Facilities for taking the tests should be made more convenient. Women should be informed that low-grade CIN is potentially reversible and may safely be monitored. Cervical screening also provides an opportunity for education on healthy lifestyles and safer sex while treatment should be reserved for high-grade CIN.Keywords cervical screening, cervical intraepithelial neoplasia, cervical carcinoma incidence, CIN, microinvasive carcinoma, screen-detected cancer relatively ineffective in preventing fully invasive cancer (microinvasive cancers were ex...
Objectives To investigate why invasive cervical cancers developed in a high-risk urban population with an established screening programme and to place cancers in the context of high-grade cervical intraepithelial neoplasia (CIN) and cervical glandular intraepithelial neoplasia (CGIN) diagnosed during the same period of time. Results There were 133 invasive cancers, 53 CGIN, 1502 CIN3 and 1472 CIN2. Screen-detected cancers in asymptomatic women comprised 48.9% of cancers and were successively more likely to be in younger age groups (P = 0.03); all except one were stage IA or IB1. Screen-detected IA cancers were more likely (P < 0.001) to be in women screened within 0.5-5.0 years (80.5%) than screendetected fully invasive (58.3%) or symptomatic cancers (35.3%). Seventy-one (53.4%) women had been screened within 0.5-5.0 years; 11 had negative cytology within 0.5-3.5 years and two tests within 10 years. The other 60 had negative tests less frequently or had previous abnormal cytology, colposcopy or treatment. Potentially avoidable factors were often multiple, including false-negative cytology, high-grade cytology reported as low-grade and lapses in attendance either for routine or repeat screening, or for colposcopy or treatment.Conclusion While often potentially avoidable, cancers in previously screened women tended to be early stage, detected by cytology and rare when compared with high-grade CIN.
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