What can be learnt from a qualitative evaluation of implementing a rapid sexual health testing, diagnosis and treatment service?

Abstract

ObjectivesTo investigate experiences of implementing a new rapid sexual health testing, diagnosis and treatment service.DesignA theory-based qualitative evaluation with a focused ethnographic approach using non-participant observations and interviews with patient and clinic staff. Normalisation process theory was used to structure interview questions and thematic analysis.SettingA sexual health centre in Bristol, UK.Participants26 patients and 21 staff involved in the rapid sexually transmitted infection (STI) service were interviewed. Purposive sampling was aimed for a range of views and experiences and sociodemographics and STI results for patients, job grades and roles for staff. 40 hours of observations were conducted.ResultsImplementation of the new service required co-ordinated changes in practice across multiple staff teams. Patients also needed to make changes to how they accessed the service. Multiple small ‘pilots’ of process changes were necessary to find workable options. For example, the service was introduced in phases beginning with male patients. This responsive operating mode created challenges for delivering comprehensive training and communication in advance to all staff. However, staff worked together to adjust and improve the new service, and morale was buoyed through observing positive impacts on patient care. Patients valued faster results and avoiding unnecessary treatment. Patients reported that they were willing to drop-off self-samples and return for a follow-up appointment, enabling infection-specific treatment in accordance with test results, thus improving antimicrobial stewardship.ConclusionsThe new service was acceptable to staff and patients. Implementation of service changes to improve access and delivery of care in the context of stretched resources can pose challenges for staff at all levels. Early evaluation of pilots of process changes played an important role in the success of the service by rapidly feeding back issues for adjustment. Visibility to staff of positive impacts on patient care is important in maintaining morale.

The impact of rapid near-patient STI testing on service delivery outcomes: a controlled interrupted time series study

“…These improvements, while maintaining activity at a lower overall cost, suggests that the introduction of clinic-based rapid testing had the intended impact, and this is in line with previous NPT modelling studies [10,11]. The qualitative evaluation of this rapid STI service also reported that patients valued faster results and avoiding unnecessary treatment, and that the better targeting of infection-specific treatment improved antimicrobial stewardship [29].…”

“…In light of the target trial framework for natural experiments[30], our study was limited by being non-randomised, having only one control site, relying on the construction of certain outcomes from multiple variables, and the impact of the Covid-19 pandemic on the follow up period for females. The unit costs were based on data provided by Unity SHS and estimates from literature, and commissioners will need to assess their applicability to their locality.…”

“…In contrast, rates for females appeared to respond to the intervention almost immediately and stabilise at a much lower level within about six months (Figure S5A). The differing implementation timeframes may reflect several barriers to implementation with the initial rollout for males, including providing training to a large group staff with varying timetables exacerbated by understaffing and budget cuts; variable application of eligibility criteria for the new service; and iterative revision of the new system and pathway [29].…”

“…This is broadly consistent with findings from Whitlock et al [28] who reported an average time-to-notification of 0.27 days for a new rapid NAAT testing service compared to 8.95 days for an off-site testing service for symptomatic patients. The temporary increase in median time-to-notification for males after the intervention may result from the implementation challenges outlined above [29] in addition to a clinician-reported backlog in the early stages of transitioning to the new system. Once again, for males the transition appeared to take place over the full post-intervention period, while the equivalent period for females appeared faster with the lowest post-intervention sensitivity estimates occurring 21 weeks after the new system was implemented (supplement Figures S4B and S5B).…”

“…It also reduced the queueing time for walk-in clinics. Conversely, case-mix in the walk-in clinics became more demanding, with patients more likely to be symptomatic and/or complex [29], which may explain the lack of observed improvement in staff capacity during clinics. The lack of evidence for a capacity decrease through the implementation period despite a more demanding patient group and the growing numbers of asymptomatic patients being tested both suggest increased capacity of the SHS overall.…”