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.

The objective of this study was to evaluate a service improvement project offering HIV testing through either self-testing or self-sampling in an online sexual health service by measuring type of test chosen and the reason for this choice. We created a web-page offering choice of online self-sampling or self-testing with information on the advantages and disadvantages of both methods. Anyone aged over 18 years resident in England, Scotland or Wales could order either type of test. We describe the characteristics of users, the tests chosen and the reasons for the choice. A total of 1502 HIV testing orders were placed and 1466 (97.6%) testing kits were dispatched after exclusion of multiple orders by the same user. Sixty-seven per cent of users chose self-testing (n = 984) and the rest chose self-sampling (n = 482, 32.9%). The most frequent reasons for choosing self-testing were: immediate results (n = 264, 46.9%), ability to complete the test themselves (n = 168, 29.8%), less blood required (n = 67, 11.9%) and the privacy of testing at home (n = 55, 9.8%). Public sector provision of self-testing as an adjunct to clinic-based HIV testing services is likely to be highly acceptable to UK populations. However, a proportion will prefer self-sampling, and maintaining choice of testing modality is important.

ObjectiveTo describe the outcomes of user-led, choice of test within an online sexual health service.MethodsWe analysed routinely collected data from a free, online sexual health service in Essex, UK that enabled users to select their tests. The service website provided information on all sexually transmitted infections, recommended a testing package based on sexuality and ethnicity, and invited users to modify this if they chose. Data on orders were analysed for the 6 months before (May–October 2016) and after (October–April 2017) implementation.ResultsWe compared 7550 orders from 6253 users before and 9785 orders from 7772 users after implementation. There was no difference in the proportion of chlamydia (p=0.57) or gonorrhoea (p=0.79) tests that were positive between the two periods. HIV and syphilis positives were too few in our sample during both periods for analysis. During implementation, men who have sex with men (530 users) were offered genital, rectal and oral chlamydia and gonorrhoea testing plus HIV and syphilis testing. In 17.2% of orders, users removed tests. Black or ethnic minority users excluding those who reported as men who have sex with men (805 users) were offered chlamydia, gonorrhoea and HIV testing. In 77.9% of orders, users added a test. All other users were offered chlamydia and gonorrhoea tests only. In 65.2% of orders, users added tests. We observed a reduction in orders of 3083 blood tests (31%).ConclusionUsers engaged with the ‘choose to test’ intervention. Although a majority added tests, the intervention was cost saving by reducing the HIV and syphilis tests ordered.

invited by reception staff to leave the clinic until they were sent another text when they were due to be seen. Patients in possession of a Smartphone could refresh a link to check their place in the queue at any time. IR1s and patient feedback were assessed before and after implementation Results Average no of symptomatic patients seen over a weekend was 70 with an average wait time of 89 min. In the 4 month period prior to the software implementation there were 6 IR1 forms received from staff about patient aggression. In the 4 month period after its introduction there were none. Two months post its introduction the average number of patient complaints about waiting times received was 1 from an average of 4 prior to its use. Conclusion The introduction of the queuing software has been an inexpensive and effective method of reducing complaints about patient waiting times and improving patient satisfaction with the service.

ObjectivesTo evaluate the feasibility and acceptability of a pilot, free, online photodiagnosis service for genital herpes and warts with postal treatment delivered by a specialist digital sexual health service.SettingAn online sexual health service available free of charge in South East London, UK.ParticipantsRoutinely collected data from 237 users of the pilot service during the study period and qualitative interviews with a purposive sample of 15 users.InterventionA pilot, free, online photodiagnosis service for genital herpes and warts with postal treatment delivered by a specialist digital sexual health service.Primary and secondary outcome measuresProportion of users who successfully uploaded photographs and the proportion diagnosed, treated and referred to face-to-face clinical services. User experience of this service.ResultsThe service was accessed by 237 users during the study period with assessment possible for 86% of users based on the photographs provided. A diagnosis of genital herpes or warts was made for 40.5% and 89.6% were subsequently treated through the service. Eighteen per cent were diagnosed as normal/not needing treatment and 42% were signposted to clinic for further clinical assessment.Qualitative data showed that users felt able and willing to provide genital images for diagnosis. Those who were treated or reassured expressed high satisfaction with the service, valuing the convenience, discreetness and support provided. However, users, particularly those who required referral to other services requested more personal and detailed communication when a clinical diagnosis is given remotely.ConclusionsFindings suggest that online photodiagnosis was feasible and acceptable. However, effective and acceptable management of those who require referral needs careful remote communication.