29 Jun 2023Part of our HSR UK Conference 2023 series
Over the past decade, more and more STI testing has taken place via online postal self-sampling (OPSS), which allows people to test without the need to attend a sexual health clinic. As COVID-19 led countries around the world to lock down, it was one of many digital solutions which played a crucial role in maintaining healthcare delivery while minimising the risk of virus transmission. Yet there is still a lot we don’t know about the impact of OPSS’s increasingly prominent role in sexual health.
Sexual health is hugely important for population health. Poor sexual health is known to affect some population groups in England more than others, namely:
- those living in more deprived areas;
- gay, bisexual and other men who have sex with men;
- those who identify as gender diverse; and
- those from Black ethnic minorities.
This is due to a number of factors, but these groups are known to face barriers to accessing traditional clinic-based testing services, such as awareness, language and social stigma. This is concerning given that many STIs are on the rise; in early June 2023, the UK Health Security Agency reported record levels of gonorrhoea and syphilis sex infections. However, funding for services has reduced, largely as a result of austerity measures over the past decade.
Online postal self-sampling (OPSS) is a relatively new way to deliver STI testing. OPSS provides individuals the opportunity to get tested for STIs (such as chlamydia, gonorrhoea and HIV) without always having to see a medical professional face-to-face. You order the testing kit online, take your own samples at home and post them back to a laboratory. Results are usually received by text message or through an online system, although in some cases – such as if you test positive – a healthcare professional may then call to discuss results.
Why do service users like this?
There are a number of reasons, including:
Convenience and accessibility: online self-sampling reduces the need for in-person visits to healthcare facilities, making it highly convenient for many individuals. It allows people to test for HIV and STIs from the comfort and privacy of their own homes. This can be particularly beneficial for individuals who may face barriers to accessing traditional clinic-based testing services, such as those living in remote areas, individuals with limited mobility, or those who aren’t able to take time off work.
Confidentiality and privacy: this can be a significant concern for individuals when it comes to STI and HIV testing. Online self-sampling offers a discreet and confidential testing experience for many individuals as it eliminates the need for face-to-face interactions, reducing the fear of being recognised or judged by others.
Results delivery: service users often appreciate having their results delivered electronically for many of the same reasons they appreciate OPSS as a whole, namely the convenience and privacy it offers. Some like being able to delete messages after reading them, to keep the contents confidential, while others value being able to look back and confirm their STI status.
However, there are also aspects of OPSS which many service users find challenging, such as having to self-sample blood from their fingers for HIV and syphilis testing. There are also service users who value the support they receive from staff in sexual clinics, and feel this is more appropriate for situations they deem high-risk.
How can we tell what impact OPSS is having?
There is little research to date to determine if OPSS services are improving access to sexual health care and benefiting those most in need. We also don’t know what affects the implementation and sustainability of OPSS services, despite them being widely available across the UK since the COVID-19 pandemic.
ASSIST (Assessing the impact of online self-sampling for STIs and HIV) is a 39-month study supported by ARC North Thames aiming to assess the impact of online postal self-sampling (OPSS) services for STIs and HIV on health inequalities, access to care, clinical and economic outcomes. It focuses on three geographical areas (London, Birmingham and Sheffield), which each implemented OPSS at different times, using different commissioning and delivery models.
The ASSIST team recently carried out a qualitative study of OPSS implementation. This involved interviews with 45 sexual health service staff, 15 stakeholders (such as commissioners), and analysis of 57 documents (such as commissioning specs), which shed light on the implementation and sustained use of OPSS services before, during and after COVID-19 lockdowns.
The research found that commissioning arrangements and broader service changes during the pandemic played a significant role in the implementation and sustained use of OPSS. For example, areas which were commissioned across larger populations could deliver OPSS more affordably at scale, whereas areas commissioning for smaller populations faced higher unit costs and more challenged sustaining OPSS.
Implementation was also impacted by the relationships between staff and stakeholders, both in the short and long term. Although all of the staff interviewed saw value in OPSS, those working in areas where OPSS was driven by commissioners were more likely to be critical of implementation compared to areas where it was service-led. This also affected staff engagement with the work of implementation.
The study also found that implementation of OPSS is an ongoing process that must adapt to changing contexts, even years after its initial launch. For example, COVID-19 required a reconfiguration of OPSS, with some services expanding the use and remit of OPSS while others experienced setbacks which needed to be mitigated. The mpox epidemic and austerity have had comparable, if lesser, effects. The implications of these findings are valuable for commissioners and providers seeking to establish or maintain OPSS services.
This blog is based on a presentation by an NIHR ARC North Thames researcher at the forthcoming HSR UK Conference 2023. “The implementation of online postal self-sampling (OPSS) for sexually transmitted infection (STI) Testing in England: staff and stakeholder perspectives” will be presented by Tommer Spence (UCL).
Click here to find out more about Tommer’s work with ARC North Thames.
