Title: IMPROVING CARE FOR PEOPLE WITH SEXUALLY TRANSMITTED INFECTIONS (STIs) IN A DIGITAL NHS.
Funder: Department of Health and Social Care

Abstract: Background: Multiple factors challenge the control of Sexually Transmitted Infections (STIs), including rises in key STIs, increasing antimicrobial resistance, and large-scale disinvestment in sexual health services with growing unmet need. Online sexual healthcare offers considerable potential for health gains and aligns with NHS digital- and self-managed strategies, but evidence for effectiveness is lacking, particularly related to clinical outcomes, impact on health inequalities, patient experience, and economic parameters. We previously developed an innovative eSexual Health Clinic (eSHC), accessible on mobile phones, and demonstrated safety and feasibility in exploratory studies. It contains a unique-to-the-NHS online automated clinical consultation and electronic prescribing algorithm for comprehensive management of people with chlamydia and their partners via the Online Chlamydia Care Pathway (OCP). It could provide considerable health gains for people with STIs and could be applied across the NHS for many other health conditions, but it now needs full scale evaluation. Overarching aim: To improve health outcomes for people with STIs and their partners, by developing and evaluating inclusive, comprehensive, evidence-based clinical care pathways fit for a digital NHS. This will be achieved through five inter-linking work packages (WPs): WP1 determines patterns of uptake of current online versus physical sexual health services and identifies modifiable factors to increase engagement and reduce health inequalities, using quantitative analysis of existing surveillance, research and service datasets, qualitative interviews with thematic analysis, secondary behavioural analysis, and mixed methods studies (Year 1). WP2 optimises key components of the OCP, focussing on the partner elements, and conducts randomised pilot studies, together with a preliminary cost-consequence analysis, using behaviour change wheel analysis and Human Computer Interaction methods, preliminary cost analyses, and external and internal pilot studies (Years 1-3). WP3 determines the effectiveness of the OCP compared with routine care in a pragmatic individually-randomised RCT, with an integral process evaluation to explore how content and context intersect to shape outcomes, for people with chlamydia and their partners (Years 4-5). WP4 evaluates the equity and efficiency of the OCP through undertaking an economic analysis based on the outcomes of the trial, exploratory distributional cost-effectiveness analysis and exploring the potential impact on health inequalities (Years 4-5). WP5 ensures the research remains responsive to a rapidly changing environment and enables timely translation of findings into health policy and practice, using co-production, using World caf&eacute; methods with analysis using Theoretical Domains Framework and Normalisation Process Theory (Years 1-5). Impact: This programme will improve clinical outcomes, service efficiency and public health practice. The proposed intervention aims to reduce STI transmission, reinfection and complications with individual and population-level impacts. It will provide new insights and outputs to advance the development, uptake and delivery of online clinical care within a digital NHS. PPI: Our Research Voice Advisory Group encouraged us to do this research; one member is a co-applicant. Patients and public and community groups are involved in design, planning, delivery and dissemination. Dissemination: Our multi-format, multi-perspective dissemination strategy, underpinned by three interactive stakeholder workshops to co-produce pathways will enable timely dissemination of programme findings and translation into practice.

Lay abstract: Aim: Within a digital NHS, sexual healthcare systems need ways of helping people get into the right care pathway for their needs. For some, ideal pathways to appropriate care are online, for others face-to-face, or a combination of both. Currently people are getting less or no choice in available care pathways. This could make things worse and cost more. Some people with the poorest sexual health already find it hard to engage with existing services; we need to make sure nobody is left behind as NHS care shifts online. We aim to improve health outcomes for people with sexually transmitted infections (STIs) and their sex partners by creating clinical care pathways fit for a digital NHS, and measuring how well they work in getting people the care they need. We believe we re tackling the problems important to people in the groups most affected by STIs, by securing safe and equitable care for all. Background: STIs are rising. They have a huge impact on people s lives and are very costly for the NHS. Sexual health funding has been cut; online STI testing (self-sampling) is replacing face-to-face care. This could help many people, but others might find it difficult to use, particularly people at greater risk of STIs. We need to understand what hinders/helps people at high risk and how we can best engage them with a range of options for testing, treating and preventing STIs, within inclusive, good-value-for-money services. We ll take advantage of our new technology, the eSexual Health Clinic, the first NHS service to offer an online automated consultation and ePrescribing in a web-app. It was very successful in treating people with chlamydia in early studies. But it isn t the finished product yet, hasn t been tested out large-scale and we don t know if it suits the people at highest risk of STIs. Design and methods: We ll talk to service users and staff, and use routinely collected data to learn about the pros/ cons of online and other pathways for testing/treatment/prevention. We ll use this information to further develop some of these pathways within the eSexual Health Clinic. We ll make them as inclusive as possible and measure their effectiveness, value for money, and who does and doesn t use them in a clinical trial. We ll look at services for partners of people with STIs too. PPI: Our Research Voice Advisory Group encouraged us to do this research, particularly to take the eSexual Health Clinic forward. They re involved in design, planning and delivery; one member is on the research team. Dissemination: We ll use our website, Twitter, and scientific conferences to take our work to different audiences, and publish in scientific journals. Our researchers have national roles which help get our findings into NHS practice.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.2 HEALTH AND WELFARE ECONOMICS;7.3 MANAGEMENT AND DECISION MAKING
Health categories: INFECTION