The experience of providing young people attending general practice with an online risk assessment tool to assess their own sexual health risk

Implementing the Routine Use of Electronic Mental Health Screening for Youth in Primary Care: Systematic Review

BACKGROUND

Adolescents often present at primary care clinics with nonspecific physical symptoms when, in fact, they have at least 1 mental health or risk behavior (psychosocial) issue with which they would like help but do not disclose to their care provider. Despite global recommendations, over 50% of youths are not screened for mental health and risk behavior issues in primary care.

OBJECTIVE

This review aimed to examine the implementation, acceptability, feasibility, benefits, and barriers of e-screening tools for mental health and risk behaviors among youth in primary care settings.

METHODS

Electronic databases-MEDLINE, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews-were searched for studies on the routine screening of youth in primary care settings. Screening tools needed to be electronic and screen for at least 1 mental health or risk behavior issue. A total of 11 studies that were reported in 12 articles, of which all were from high-income countries, were reviewed.

RESULTS

e-Screening was largely proven to be feasible and acceptable to youth and their primary care providers. Preconsultation e-screening facilitated discussions about sensitive issues and increased disclosure by youth. However, barriers such as the lack of time, training, and discomfort in raising sensitive issues with youth continued to be reported.

CONCLUSIONS

To implement e-screening, clinicians need to change their behaviors, and e-screening processes must become normalized into their workflows. Co-designing and tailoring screening implementation frameworks to meet the needs of specific contexts may be required to ensure that clinicians overcome initial resistances and perceived barriers and adopt the required processes in their work.

Application of the COM-B model to barriers and facilitators to chlamydia testing in general practice for young people and primary care practitioners: a systematic review

Background

Chlamydia is a major public health concern, with high economic and social costs. In 2016, there were over 200,000 chlamydia diagnoses made in England. The highest prevalence rates are found among young people. Although annual testing for sexually active young people is recommended, many do not receive testing. General practice is one ideal setting for testing, yet attempts to increase testing in this setting have been disappointing. The Capability, Opportunity, and Motivation Model of Behaviour (COM-B model) may help improve understanding of the underpinnings of chlamydia testing. The aim of this systematic review was to (1) identify barriers and facilitators to chlamydia testing for young people and primary care practitioners in general practice and (2) map facilitators and barriers onto the COM-B model.

Methods

Qualitative, quantitative, and mixed methods studies published after 2000 were included. Seven databases were searched to identify peer-reviewed publications which examined barriers and facilitators to chlamydia testing in general practice. The quality of included studies was assessed using the Critical Appraisal Skills Programme. Data (i.e., participant quotations, theme descriptions, and survey results) regarding study design and key findings were extracted. The data was first analysed using thematic analysis, following this, the resultant factors were mapped onto the COM-B model components. All findings are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Four hundred eleven papers were identified; 39 met the inclusion criteria. Barriers and facilitators were identified at the patient (e.g., knowledge), provider (e.g., time constraints), and service level (e.g., practice nurses). Factors were categorised into the subcomponents of the model: physical capability (e.g., practice nurse involvement), psychological capability (e.g.: lack of knowledge), reflective motivation (e.g., beliefs regarding perceived risk), automatic motivation (e.g., embarrassment and shame), physical opportunity (e.g., time constraints), social opportunity (e.g., stigma).

Conclusions

This systematic review provides a synthesis of the literature which acknowledges factors across multiple levels and components. The COM-B model provided the framework for understanding the complexity of chlamydia testing behaviour. While we cannot at this juncture state which component represents the most salient influence on chlamydia testing, across all three levels, multiple barriers and facilitators were identified relating psychological capability and physical and social opportunity. Implementation should focus on (1) normalisation, (2) communication, (3) infection-specific information, and (4) mode of testing. In order to increase chlamydia testing in general practice, a multifaceted theory- and evidence-based approach is needed.

Trial registration

PROSPERO CRD42016041786

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0821-y) contains supplementary material, which is available to authorized users.

Interventions to Improve Sexually Transmitted Disease Screening in Clinic-Based Settings

BACKGROUND

The asymptomatic nature and suboptimal screening rates of sexually transmitted diseases (STD) call for implementation of successful interventions to improve screening in community-based clinic settings with attention to cost and resources.

METHODS

We used MEDLINE to systematically review comparative analyses of interventions to improve STD (chlamydia, gonorrhea, or syphilis) screening or rescreening in clinic-based settings that were published between January 2000 and January 2014. Absolute differences in the percent of the target population screened between comparison groups or relative percent increase in the number of tests or patients tested were used to score the interventions as highly effective (>20% increase) or moderately effective (5%-19% increase) in improving screening. Published cost of the interventions was described where available and, when not available, was estimated.

RESULTS

Of the 4566 citations reviewed, 38 articles describing 42 interventions met the inclusion criteria. Of the 42 interventions, 16 (38.1%) were categorized as highly effective and 14 (33.3%) as moderately effective. Effective low-cost interventions (<$1000) included the strategic placement of specimen collection materials or automatic collection of STD specimens as part of a routine visit (7 highly effective and 1 moderately effective) and the use of electronic health records (EHRs; 3 highly effective and 4 moderately effective). Patient reminders for screening or rescreening (via text, telephone, and postcards) were highly effective (3) or moderately effective (2) and low or moderate cost (<$1001-10,000). Interventions with dedicated clinic staff to improve STD screening were highly effective (2) or moderately effective in improving STD screening (1) but high-cost ($10,001-$100,000).

CONCLUSIONS

Successful interventions include changing clinic flow to routinely collect specimens for testing, using EHR screening reminders, and reminding patients to get screened or rescreened. These strategies can be tailored to different clinic settings to improve screening at a low cost.

A meta-analysis of the effect of new-media interventions on sexual-health behaviours

BACKGROUND AND OBJECTIVES

Direct access to individuals in non-intrusive ways, as well as the technical abilities of new-media to provide tailored information in relatively inexpensive ways, creates a unique opportunity for the delivery of health-related information. The aim of the present research was to examine the effect that new-media-based sexual-health interventions have on sexual-health behaviours in non-clinical populations and to determine the factors that moderate the effect of technology-based sexual-health interventions on sexual--health behaviours.

DATA SOURCES

A systematic literature search of the following databases was conducted: MEDLINE, psycINFO, Global health, and EMBASE, using terms that captured three subject areas-'Sexual-health', 'New Technology' and 'Intervention'.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trial, or a quasi-experiment; delivered exclusively via new-media; included sexual risk behaviour change as an outcome measure and delivered to non-clinical groups.

RESULTS

Twelve studies tested the effect of new-media interventions on condom use, whereas nine tested the effect on sexually transmitted disease testing. Results indicated that new-media interventions led to significant increases in both outcomes; however, these effects were not homogeneous. Moderation analyses revealed that interactivity of the intervention, target population and study design influenced the efficacy of interventions on both sexual-health outcomes, whereas intervention duration influenced sexually transmitted infection testing.

CONCLUSIONS AND IMPLICATIONS

Interventions aiming to improve condom use are more successful when an interactive component is used. Further research needs to be conducted to reach specific at-risk populations.

Use of digital media technology for primary prevention of STIs/HIV in youth

STUDY OBJECTIVE

The relevant literature was reviewed to identify issues in research evaluating digital media technology (DMT) interventions for the primary prevention of STIs/HIV in adolescents and young adults.

METHOD

A literature search with relevant key terms was conducted in PubMed, for articles with studies that included: (a) participants between 11-29 years; (b) use of one or more of the following forms of DMT: interactive digital video or CD-ROM, computer, text messaging, or Internet; (c) evaluation of an STI/HIV primary prevention intervention; and (d) use of a cognitive, psychosocial, behavioral, or biological outcome.

RESULTS

Twenty-nine studies were identified and included in the review. Based on the review of these studies, 7 main issues were discussed and recommendations for improving future research were offered. The 7 main issues were: (a) need for a balance between universal application and specific sub-group focus, (b) lack of a developmental framework, (c) challenge of applying DMT in resource limited contexts, (d) rapidly changing nature of DMT, (e) lack of biological outcomes, (f) lack of comparison/control groups to assess the impact of DMT, and (g) limited temporal follow-up.

CONCLUSIONS

There is increasing literature evaluating the effectiveness of DMT for preventing STIs/HIV among adolescents and young adults. A careful consideration of 7 main issues identified in the literature can improve the design and evaluation of these interventions and enhance our understanding of their effectiveness.

Chlamydia screening in young people as an outcome of a HEADSS; Home, Education, Activities, Drug and alcohol use, Sexuality and Suicide youth psychosocial assessment tool

AIMS AND OBJECTIVES

To identify the percentage of young people presenting to a primary healthcare service targeting homeless youth, in Melbourne, Australia, who, based on youth-specific Home, Education, Activities, Drug and alcohol use, Sexuality and Suicide (HEADSS) psychosocial assessment tool, were screened for the sexually transmitted infection Chlamydia and tested positive.

BACKGROUND

Homeless young people are at high risk of poor health outcomes including sexual health. Chlamydia prevalence is highest in 16-24 years. Youth psychosocial assessment tools such as the HEADSS can engage young people and provide comprehensive health assessment that identifies health risks.

DESIGN

A retrospective audit.

METHODS

One hundred consecutive client files of youth who presented to a primary healthcare service for the first time were selected. Client data were collected at the health services' inner city drop-in clinic and clinical refuge outreach (CRO). HEADSS assessments were made on new presentations to identify those at risk of Chlamydia. These young people were then offered screening for Chlamydia using a first-pass urine sample.

RESULTS

One hundred HEADSS assessments were audited, of which 15 were incomplete. Of the 85 completed HEADSS assessments, 43 were tested and 11 had Chlamydia-positive results.

CONCLUSION

Comprehensive youth assessment tools, such as the HEADSS, can provide a valuable resource in identifying sexual health risks such as Chlamydia. In turn, skilled nursing staff can provide opportunistic screening. Early identification and treatment for Chlamydia can reduce the spread and sequela of this highly infectious STI.

RELEVANCE TO CLINICAL PRACTICE

Youth health nurses can enhance their nursing practice in working with young people at risk of homelessness and improve their health outcomes by employing youth-specific assessments.

Pilot study of a brief intervention based on the theory of planned behaviour and self-identity to increase chlamydia testing among young people living in deprived areas

OBJECTIVES

This study sought to estimate the effects of a novel intervention, compared with usual chlamydia testing promotion, on chlamydia test uptake and intentions among young people living in deprived areas. The intervention was based on the theory of planned behaviour, augmented with self-identity, and targeted the significant predictors of chlamydia testing intentions identified in the previous research.

METHODS

Cluster randomization was used to allocate college tutor groups (intervention n = 10; control n = 11) to the intervention or control group. The sample comprised 253 participants (intervention n = 145, control n = 108). The primary outcome was test offer uptake at the end of the session. Other outcomes measured at immediate follow-up were intention, attitude, subjective norm, perceived behavioural control, and self-identity.

RESULTS

Generalized estimating equations, controlling for cluster effects and sexual activity, found a small but non-significant effect of condition on test offer uptake, OR = 1.65 (95% CI 0.70, 3.88) p = .25, with 57.5% of intervention participants accepting the offer of a test compared with 40.2% of control participants. Using the same analysis procedure, small-to-medium intervention effects were found on other outcome variables, including a significant effect on attitudes towards chlamydia testing, OR = 1.37 (95% CI 1.00, 1.87), p = .05.

CONCLUSIONS

The results provide encouraging initial evidence that this theory-based intervention, targeting the key determinants of chlamydia testing, may help to improve chlamydia testing uptake in a high-risk group. They support the conduct of a larger trial to evaluate the effectiveness of the intervention.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Young people living in areas of increased socio-economic deprivation have been identified as a high-risk group for chlamydia. Previous research within an extended model of the theory of planned behaviour (TPB) found that attitude, subjective norm, perceived behavioural control, and self-identity all significantly predicted chlamydia testing intentions in this high-risk group. What does this study add? Development and testing of a novel, TPB-based intervention targeting predictors of chlamydia testing intentions. The intervention led to significantly more positive attitudes towards chlamydia testing. Preliminary indication that a TPB-based intervention may help to improve chlamydia testing in a high-risk group.

Efficacy of interventions to increase the uptake of chlamydia screening in primary care: a systematic review

Background

As most genital chlamydia infections are asymptomatic, screening is the main way to detect and cases for treatment. We undertook a systematic review of studies assessing the efficacy of interventions for increasing the uptake of chlamydia screening in primary care.

Methods

We reviewed studies which compared chlamydia screening in the presence and the absence of an intervention. The primary endpoints were screening rate or total tests.

Results

We identified 16 intervention strategies; 11 were randomised controlled trials and five observational studies, 10 targeted females only, five both males and females, and one males only. Of the 15 interventions among females, six were associated with significant increases in screening rates at the 0.05 level including a multifaceted quality improvement program that involved provision of a urine jar to patients at registration (44% in intervention clinics vs. 16% in the control clinic); linking screening to routine Pap smears (6.9% vs. 4.5%), computer alerts for doctors (12.2% vs. 10.6%); education workshops for clinic staff; internet-based continuing medical education (15.5% vs. 12.4%); and free sexual health consultations (16.8% vs. 13.2%). Of the six interventions targeting males, two found significant increases including the multifaceted quality improvement program in which urine jars were provided to patients at registration (45% vs. 15%); and the offering by doctors of a test to all presenting young male clients, prior to consultation (29 vs. 4%).

Conclusions

Interventions that promoted the universal offer of a chlamydia test in young people had the greatest impact on increasing screening in primary care.

Interactive computer-based interventions for sexual health promotion

BACKGROUND

Sexual health promotion is a major public health challenge; there is huge potential for health promotion via technology such as the Internet.

OBJECTIVES

To determine effects of interactive computer-based interventions (ICBI) for sexual health promotion, considering cognitive, behavioural, biological and economic outcomes.

SEARCH STRATEGY

We searched more than thirty databases for randomised controlled trials (RCTs) on ICBI and sexual health, including CENTRAL, DARE, MEDLINE, EMBASE, CINAHL, British Nursing Index, and PsycINFO. We also searched reference lists of published studies and contacted authors. All databases were searched from start date to November 2007, with no language restriction.

SELECTION CRITERIA

RCTs of interactive computer-based interventions for sexual health promotion, involving participants of any age, gender, sexual orientation, ethnicity or nationality. 'Interactive' was defined as packages that require contributions from users to produce tailored material and feedback that is personally relevant.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts, applied eligibility and quality criteria and extracted data. Results of RCTs were pooled using a random-effects model with standardised mean differences (SMDs) for continuous outcomes and odds ratios (ORs) for binary outcomes. We assessed heterogeneity using the I(2) statistic. Separate meta-analyses were conducted by type of comparator: 1) minimal intervention such as usual practice or leaflet, 2) face-to-face intervention or 3) a different design of ICBI; and by type of outcome (cognitive, behavioural, biological outcomes).

MAIN RESULTS

We identified 15 RCTs of ICBI conducted in various settings and populations (3917 participants). Comparing ICBI to 'minimal interventions' such as usual practice, meta-analyses showed statistically significant effects as follows: moderate effect on sexual health knowledge (SMD 0.72, 95% CI 0.27 to 1.18); small effect on safer sex self-efficacy (SMD 0.17, 95% CI 0.05 to 0.29); small effect on safer-sex intentions (SMD 0.16, 95% CI 0.02 to 0.30); and also an effect on sexual behaviour (OR 1.75, 95% CI 1.18 to 2.59). Data were insufficient for meta-analysis of biological outcomes and analysis of cost-effectiveness.In comparison with face-to-face sexual health interventions, meta-analysis was only possible for sexual health knowledge, showing that ICBI were more effective (SMD 0.36, 95% CI 0.13 to 0.58). Two further trials reported no difference in knowledge between ICBI and face-to-face intervention, but data were not available for pooling. There were insufficient data to analyse other types of outcome.No studies measured potential harms (apart from reporting any deterioration in measured outcomes).

AUTHORS' CONCLUSIONS

ICBI are effective tools for learning about sexual health, and they also show positive effects on self-efficacy, intention and sexual behaviour. More research is needed to establish whether ICBI can impact on biological outcomes, to understand how interventions might work, and whether they are cost-effective.

The positive role of social networks and social networking technology in the condom-using behaviors of homeless young people

OBJECTIVE

To examine the impact of condom-using peers in the social networks of homeless young people, differences in behaviors were assessed based on the social location of ties (home-based vs. street-based) and how those ties are maintained (face-to-face vs. via social networking technology).

METHODS

"Ego-centric" social network data were collected from 103 currently sexually active homeless young people aged 16-26 years in Los Angeles, California. Associations between condom use and the condom-using behaviors of social network influences were assessed using standard logistic regression.

RESULTS

About 52% of respondents had a street-based peer who was a condom user. Having such a peer was associated with a 70% reduction in the odds of having unprotected sex at last intercourse. About 22% of respondents had a condom-using, home-based peer with whom they communicated only via social networking technology. Having such a peer was associated with a 90% reduction in risky sexual behavior and a 3.5 times increase in safer sex behavior.

CONCLUSION

The study revealed several implications for new human immunodeficiency virus-prevention interventions that mobilize these networks and social networking technologies.

A pilot qualitative analysis of the psychosocial factors which drive young people to decline chlamydia testing in the UK: implications for health promotion and screening

The main objectives of this study are to investigate the psychosocial issues for young people who decline chlamydia testing as part of the national chlamydia screening programme in the UK and to consider the implications for future opportunistic screening. Transcripts of qualitative semi-structured interviews were analysed using interpretative phenomenological analysis to identify themes. The study involved 14 young people aged 16–24 years who declined chlamydia tests in non-health-care settings as part of the chlamydia screening programme. The study was conducted in educational settings where chlamydia screening is available. Four interlinked themes were identified: stigmatization of young people with chlamydia and who take a test, the feeling of embarrassment, their perception of risk and their beliefs of what the test involves. These beliefs and feelings were pervasive and negatively affected their personal decisions of having a test. In conclusion, understanding psychosocial cultural phenomena in the context of screening programmes for sexually transmitted infections (STIs) in young people are important for their success. Chlamydia and STIs remain stigmatized; testing is poorly understood and embarrassing for young people, which impacts the poor uptake for opportunistic screening. Strategies are needed to normalize and de-stigmatize chlamydia and the chlamydia test.

Incentive payments to general practitioners aimed at increasing opportunistic testing of young women for chlamydia: a pilot cluster randomised controlled trial

BACKGROUND

Financial incentives have been used for many years internationally to improve quality of care in general practice. The aim of this pilot study was to determine if offering general practitioners (GP) a small incentive payment per test would increase chlamydia testing in women aged 16 to 24 years, attending general practice.

METHODS

General practice clinics (n = 12) across Victoria, Australia, were cluster randomized to receive either a $AUD5 payment per chlamydia test or no payment for testing 16 to 24 year old women for chlamydia. Data were collected on the number of chlamydia tests and patient consultations undertaken by each GP over two time periods: 12 month pre-trial and 6 month trial period. The impact of the intervention was assessed using a mixed effects logistic regression model, accommodating for clustering at GP level.

RESULTS

Testing increased from 6.2% (95% CI: 4.2, 8.4) to 8.8% (95% CI: 4.8, 13.0) (p = 0.1) in the control group and from 11.5% (95% CI: 4.6, 18.5) to 13.4% (95% CI: 9.5, 17.5) (p = 0.4) in the intervention group. Overall, the intervention did not result in a significant increase in chlamydia testing in general practice. The odds ratio for an increase in testing in the intervention group compared to the control group was 0.9 (95% CI: 0.6, 1.2). Major barriers to increased chlamydia testing reported by GPs included a lack of time, difficulty in remembering to offer testing and a lack of patient awareness around testing.

CONCLUSIONS

A small financial incentive alone did not increase chlamydia testing among young women attending general practice. It is possible small incentive payments in conjunction with reminder and feedback systems may be effective, as may higher financial incentive payments. Further research is required to determine if financial incentives can increase testing in Australian general practice, the type and level of financial scheme required and whether incentives needs to be part of a multi-faceted package.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12608000499381.

Interventions for young people in Australia to reduce HIV and sexually transmissible infections: a systematic review

Background: Like young people in other developed countries, sexually active young Australians can have an increased risk of acquiring sexually transmissible infections (STIs). This paper reviews intervention programs that aim to reduce the incidence and transmission of HIV and STIs among young people in Australia. Methods: Articles were identified from seven databases. Intervention studies conducted in Australia that included young people aged 12–25 years were reviewed. A two-dimensional matrix consisting of ‘setting’ and ‘intervention type’ was developed to categorise each study. Results: Forty-two studies met the inclusion criteria, and the majority were uncontrolled intervention studies. Of these, 23/42 studies measured participation in chlamydia ± other STI testing and found that the highest participation rates took place in non-clinical and non-general practice health care settings. Four studies facilitated access to testing indirectly, through the internet or other media. Ten studies involved the provision of education and measured its impact on factors such as knowledge, attitudes and/or behaviour. Three studies involved novel immunisation strategies for either hepatitis B or human papillomavirus vaccines. Two studies evaluated the impact of enhanced STI surveillance programs on prevalence rates. Conclusions: Proactive STI testing in non-clinical and some health settings appears feasible and achieves higher testing rates than in general practice; however, more evaluation of testing strategies in general practice settings is required. New technologies such as the internet and SMS are useful adjuncts for influencing behaviours such as condom use and STI testing. Media campaigns that promote STI testing can have a positive impact on testing rates.

The Internet as an adjunct for pediatric primary care

PURPOSE OF REVIEW

This review highlights recent publications on the use of the Internet as it relates to pediatric primary care, including its application to the pediatrician, teen, pediatric patient, and patients' parents. A brief overview of early work is introduced.

RECENT FINDINGS

The Internet has become a tool to expand the reach of preventive interventions, including school-based online pediatric health education. Although research continues to describe barriers to the adoption of online resources, recent reports highlight newer applications, including user-generated content (i.e. social networking sites), and the impact on teens and their health. There are concerns and benefits of Web 2.0 and the teen population, with adolescents at risk online yet also learning about their health online. Internet referrals, prescriptions for information, and online assessment methods have had varied success to date. There have been some studies of e-learning and online continuing medical education having an impact on clinical decision making, but there is a need for more research on the electronic medical record as it relates to the practicing pediatrician and the Internet at the point of care.

SUMMARY

The Internet is more than an information repository and continues to affect the lives and health of the pediatric population, parents, and providers. The growth of and changes to the Internet over time bring online innovations that have yet to be studied.