Client and staff perceptions of acceptability of MyCheck: a direct-to-pathology telehealth and e-testing service for comprehensive bloodborne virus and sexually transmissible infection screening

Introduction

Routine screening of sexually transmissible infections (STIs), including gonorrhoea and chlamydia, and bloodborne viruses (BBV; i.e. HIV and hepatitis C), are recommended for at-risk population groups, including men who have sex with men (MSM), trans and gender diverse people, sex workers, and people who inject drugs.¹ As many STIs are asymptomatic, regular testing allows for earlier detection of exposure and treatment for infections, thereby reducing transmission.² In Australia, testing guidelines recommend routine BBV/STI testing among MSM every 3 months.³ Among sex workers, this frequency may vary by jurisdiction, with some states legally mandating routine testing among this population group.³ Increasing access to BBV/STI testing is a target of the national strategies.^4–8

The coronavirus disease 2019 (COVID-19) pandemic has impacted the ways people engage in health care, including for BBV/STI testing.⁹ Amid public health-imposed lockdowns and clinic capacity constraints due to staff illness and redeployment, alternatives for engagement with health care became necessary, with many health services pivoting to telehealth and digital platforms for healthcare delivery.¹⁰ Healthcare responses to the COVID-19 pandemic have driven a push to implement telehealth and other digital models of care,¹¹ ensuring that people are able to seek health care in ways that are convenient and accessible to them. Digital health interventions have been shown to be effective, particularly for LGBTIQ+ populations.¹²

In response to the diverse BBV/STI testing needs for patients during COVID-19 restrictions, the MyCheck BBV/STI testing pathway pilot was implemented at Sydney Sexual Health Centre (SSHC), in New South Wales, Australia, between June 2021 and February 2022. During this time, greater metropolitan Sydney experienced a lockdown of 3.5 months. While healthcare services were exempt, capacity was significantly reduced during these imposed restrictions. Rather than clients attending SSHC in Sydney’s urban centre for routine testing as per standard care, existing SSHC clients were offered the option of a telehealth appointment, and an automated pathology referral that facilitated BBV/STI testing directly at a pathology centre (within a large network of providers in NSW) located across Greater Sydney.

Sekhon and colleagues’ Theoretical Framework of Acceptability (TFA) is the first framework to provide a comprehensive definition, utilising seven components of acceptability of a healthcare intervention.¹³ These components, comprising perceptions of acceptability, are: affective attitude (how a person feels about participating in the intervention); burden (any additional burdens associated with participating in the intervention); ethicality (whether the intervention is perceived as ethical); intervention coherence (understanding how the intervention works); opportunity cost (any additional time or other financial costs associated with participating in the intervention); perceived effectiveness (how well the intervention is perceived to work); and self-efficacy (the ability to participate in the intervention).¹³ The TFA was designed for use to assess acceptability from both the healthcare provider and patient perspectives.¹³ Utilising the TFA, this paper explores patient and healthcare provider perceptions of acceptability of the MyCheck BBV/STI testing pathway, a digital testing pathway implemented at SSHC (the state’s largest publicly funded sexual health service).

Materials and methods

SSHC clients routinely receive a BBV/STI reminder text every 3 months to encourage regular screening for STIs. Clients are then instructed to contact SSHC by phone and arrange an appointment with a nurse who asks scripted questions to assess BBV/STI risks and determine relevant testing protocols. Clients also actively call or physically walk-in to SSHC for appointments. During pilot implementation of MyCheck (June 2021–February 2022), eligible clients were offered the MyCheck digital testing pathway during the telephone triage process. Sexual Health Infolink provided the interface between the client, pathology provider and the clinic to welcome the client, submit pathology order, and process results. The MyCheck service provided barcodes (delivered via SMS by the pathology service) that transcribed into digital pathology forms when scanned at participating collection centres. Simultaneously, the Sexual Health Infolink database sent a welcome email to clients with instructions on how to do self-collection. Clients received this digital code within 4 h of phone referral; the barcode was valid for 2 weeks. Eligible clients included existing SSHC clients who regularly underwent BBV/STI testing as part of routine screening. Clients were ineligible for the MyCheck pathway if they were new to the service or required additional clinical care.

Interviews were conducted with SSHC clients (October 2021–January 2022) who underwent the MyCheck digital testing pathway and SSHC staff (October–November 2021) involved in implementation of MyCheck. Purposive sampling was completed to ensure representation of clients who received negative results and those who had received a positive result via the MyCheck pathway. SSHC staff were eligible to participate in an interview if they were directly involved in either the implementation or operation of MyCheck, including nursing, managerial, and IT staff. Client participants were remunerated with an AU$50 e-voucher as compensation for their time; staff participants were not remunerated.

The semi-structured interview guides for both clients and staff included participant demographics and themes relevant to acceptability.¹³ Two postdoctoral researchers with experience in qualitative interviewing conducted the interviews. Client participants were informed of the qualitative sub-study by the sexual health nurse at SSHC during the initial introduction of the MyCheck pathway. Contact details of clients who provided preliminary verbal consent to participate in an interview were contacted directly by one of the two interviewers. A list of staff participants involved in the implementation of the MyCheck pathway was provided to the study team by SSHC. Potential participants were contacted directly by the interviewer. Participation in an interview was entirely voluntary, with no specific information of participation reported back to SSHC (for clients or personnel). All interviews were one-on-one (one interviewer and one participant) and conducted over the phone or via Zoom or Teams (with platform chosen by participant). Interviews were audio-recorded then transcribed by a professional transcriber; transcripts were proofed for accuracy. De-identified transcripts were uploaded to NVivo qualitative software (Ver. 12; QSR International); transcripts were iteratively coded, with preliminary findings discussed among the interviewers throughout data collection. A deductive coding framework was developed among the authors and informed by Sekhon’s acceptability framework. To ensure interpretation of data, two transcripts were separately coded by the first two authors then compared; discordant coding was discussed until agreement was reached. Remaining coding was completed by the first author. Participant recruitment was completed when data saturation was achieved; staff recruitment was limited to those directly and indirectly involved in implementation of MyCheck.

Ethics approval was obtained from South-Eastern Sydney Local Health District Human Research Ethics Committee (Ref: 2021/ETH01422).

Results

Eleven SSHC clients who underwent BBV/STI testing via the MyCheck pathway participated in semi-structured interviews. Client participants had a median age of 35 years (range, 20–42 years), identified as male (91%; one female; no transgender, non-binary, or undisclosed gender); nine received prescription PrEP (although one had not yet filled/used their script). Three clients had received a positive STI result following testing via the MyCheck pathway (two chlamydia, one gonorrhoea). All client participants reported routine BBV/STI testing; for men this was attributed to having sex with other men, the female participant engaged in sex work. Eight SSHC staff participated in semi-structured interviews. Staff roles included people directly involved in implementation of the MyCheck pathway (e.g. nurses) and those involved in operationalising the digital testing platform (including management, senior positions, and IT personnel).

Discussion

Clients who completed BBV/STI testing via the MyCheck digital pathway, and staff involved in implementation of the MyCheck digital pathway, broadly perceived the intervention to be acceptable. Both clients and staff described positive feelings about participation in / implementation of the digital testing pathway (‘affective attitude’). Among clients, the MyCheck intervention was regarded as reducing ‘burden’ of BBV/STI testing compared with standard care, with positive result clients regarding the digital testing pathway as reducing delay of engagement in sexual activities. Initial implementation of the MyCheck intervention initially increased workload ‘burden’ among staff, but this was overcome once integration became routine. Both clients and staff described interactions at pathology collection centres as influencing the intervention’s ‘ethicality’. Both participant groups largely described ‘intervention coherence’, although some issues arose when first utilising the new pathway. ‘Opportunity cost’ was viewed by clients as favourable owing to the reduced travel time through the ability to select a convenient collection site of their choosing. Self-efficacy was more prominent among clients familiar with self-swabbing; self-efficacy among staff was relayed throughout the other acceptability components.

An internet-based testing pathway, GetCheckedOnline, based in Vancouver, Canada, found that men who opted for the digital testing pathway, compared with in-person presentation at a sexual health clinic, were more likely to be accustomed to routine testing, and selected the online pathway due to clinic wait times and distance to clinic.¹⁴ Similarly, clients within our study reported positive affective attitude of the MyCheck intervention due to its convenience and location choice (of pathology centre), and reduced burden associated with travel and wait times. Indeed, internet-based self-testing services have been found to be acceptable among users, largely due to the convenience and anonymity this type of service provides.¹⁵

Multimodal testing pathways have been viewed as a means to ‘enhance’ engagement with sexual health services and HIV/STI testing (p. 280).¹⁶ As noted by our participants, fostering client agency is a key component of effective engagement with sexual health care.¹⁷ Responses from staff participants suggest that STI digital testing pathways work best when provided as another testing option or offered as an alternative testing strategy rather than the only testing model, allowing for clients to self-select the option most suitable to them. Our findings, situated with the literature, demonstrate the eligibility criteria for MyCheck participation/referral are consistent with those clients who would likely feel most comfortable attending a pathology provider for routine testing.

One of the benefits of the MyCheck pathway is the reduction of barriers to testing, particularly for people who are Medicare-ineligible and/or those located in areas where publicly funded sexual health clinics are not easily accessible. There are a few private fee-based online/digital testing services available to people within Australia (and internationally); however, the out-of-pocket costs may be prohibitive for some patients.^18,19 Despite efforts to revise the pathology requisition form to clearly denote cost burden of testing to be redirected to SSHC, several Medicare-ineligible clients experienced barriers to accessing BBV/STI testing when presenting at pathology centres. Publicly funded services seeking to scale up similar digital testing pathways should ensure clear communication with pathology providers to reduce disruption to service uptake among people who are ineligible for Medicare.

Patients accessing BBV/STI testing, for whatever reason, have the right to safe and judgment free health care. However, interactions with pathology providers impeded on the intervention’s ethicality, as some participants relayed feeling unsafe or vulnerable to stigmatisation. Inadvertent harms experienced during engagement with health care is regarded as a ‘global challenge’ (p. 1).²⁰ De-stigmatising health care is crucial for patient engagement and retention.²¹ As was demonstrated by staff participants, the importance of pathology providers who can provide competent, gender-safe care for trans and gender diverse people is an important component of ethicality of any healthcare engagement, including BBV/STI testing.²² Stigma reduction strategies in healthcare settings would enhance positive health outcomes for people from marginalised population groups.²³ Negative interactions during BBV/STI testing can inhibit future sexual healthcare engagement.²⁴ As such, sensitivity training of pathology providers regarding sensitivities associated with people accessing BBV/STI testing and specimen collection may improve patient safety when presenting at pathology collection centres. As many general practitioners refer to pathology services for BBV/STI testing, improving patient experience in the pathology setting would likely have broad impact for people accessing BBV/STI testing across NSW and nationally.

This study has several limitations. It was our intention to interview pathology personnel across some of the collection centres where participants had attended for specimen collection. Due to the extensive COVID-19 outbreak at time of data collection, coupled with interstate travel requirements of a negative polymerase chain reaction result, pathology personnel across the greater Sydney metropolitan area were heavily burdened with the increase in COVID-19 testing. As such, their participation in an interview was not possible. However, both clients and SSHC staff were able to reflect on personal and patient experiences of pathology attendance, which may have reflected greater nuance within patient experiences than perspectives of pathology workers who may have only encountered one or two patients via the MyCheck pathway.

Our research has demonstrated that digital testing platforms are broadly perceived as an acceptable healthcare intervention for BBV/STI testing among people routinely engaged in sexual health care. Effective interventions to enhance patient reach and enable greater access to digital testing pathways, including for those who are ineligible for Medicare or may have aversions to sexual healthcare engagement, are needed. The current design of MyCheck restricts enrolment to existing clientele. While this can facilitate clinical capacity planning and effective patient management including mitigating loss to follow up, the expansion of MyCheck is inherently dependent on having an existing clinical setting. Further research is needed to determine whether this model would be suitable for people who may be less familiar with routine BBV/STI testing (including self-collection), living in remote/regional areas, lacking access to stable internet/telecommunication connectivity, or those who have never tested for BBV/STIs in the past.

Conclusion

People who are accustomed to routine BBV/STI testing are likely more suitable candidates for digital testing pathways where specimen collection occurs at a pathology centre. Clients who may feel more vulnerable when presenting in the public health space, may be better suited to one-on-one care in a sexual health-specific setting, particularly where appropriate language around unique health needs are known and used by care providers. While digital testing platforms offer greater convenience and patient autonomy for accessing routine BBV/STI testing, the ability for patients to choose is paramount to ensuring safe and appropriate care for all clients.