Recommendations for developing asynchronous online consultations for chlamydia treatment for underserved populations: A Behaviour Change Wheel analysis
1School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, United Kingdom
2Psychological Science and Health, University of Strathclyde, Glasgow, Scotland, United Kingdom
3Institute for Global Health, University College London, London, England, United Kingdom
4UK Health Security Agency (UKHSA), London, England, United Kingdom
5UCL Interaction Centre (UCLIC), University College London, London, England, United Kingdom
*Corresponding author: Claudia S. Estcourt claudia.estcourt@gcu.ac.ukABSTRACT
Introduction
People from underserved groups experience disproportionately poor sexual health and challenges accessing care. Asynchronous online consultations (a user completes a health questionnaire online, which is reviewed by a clinician) are being used within sexual healthcare to prescribe chlamydia treatment. Users require sufficient health and digital literacy to access online services and use them safely.
Methods
We used the PROGRESS-Plus framework to guide purposive recruitment of 35 participants from diverse underserved groups, from community settings and sexual health services in contrasting areas of the UK (15/10/21-18/03/22). We conducted qualitative semi-structured interviews and thematic analyses to derive key barriers and facilitators to using asynchronous online consultations. We used the Behaviour Change Wheel to specify recommendations to address them.
Results
Over half of participants were from the most deprived areas and 40% were from minoritised ethnic groups. Key barriers included: lack of familiarity with online healthcare; perceived need to see a healthcare professional in person; privacy concerns; concerns about difficulty interpreting the questions; discomfort answering personal questions online. Key facilitators included: familiarity with online consultations; perceived low sexually transmitted infection (STI) risk; perceived increase in convenience, control, and privacy; simple wording and design; and support whilst completing them. Recommendations included: increasing awareness and familiarity by promoting them offline and online, and providing demonstrations and instructions on how to use them; encouraging people to choose them by highlighting available support, equivalence to in-person consultations, and privacy and convenience; and reducing attrition by using simple wording and design, providing additional explanations, and offering audio and visual alternatives to text.
Conclusions
Incorporating these evidence-based, theoretically informed recommendations could widen access to underserved groups, and increase the usability and safety of asynchronous online consultations for chlamydia treatment. Recommendations are likely to benefit all users and could be of use across health more broadly.
Main Messages
- Some sexual health services provide chlamydia treatment through asynchronous online consultations, where patients complete an online health questionnaire which is reviewed by a clinician before issuing a prescription, without the need for direct interaction with a healthcare professional.
- Safe and effective use of asynchronous online consultations requires adequate digital and health literacy but there is limited evidence on how to design these consultations inclusively, posing a risk of excluding underserved groups and exacerbating health inequalities.
- Among people from underserved groups, we found key barriers to using asynchronous online consultations included: a lack of familiarity with online healthcare; perceived need to see a healthcare professional in person; privacy concerns; concern about difficulty interpreting the questions; discomfort answering personal questions online.
- Key facilitators included: familiarity with online consultations; perceived low STI risk; perceived increase in convenience, control, and privacy; simplicity in consultation wording and design; and support whilst completing them.
- Recommendations include: increasing awareness and familiarity by promoting asynchronous online consultations offline (e.g. in GP practices) and online (e.g., social media), and providing demonstrations/instructions on how to use them; encouraging uptake by highlighting options for support, equivalence to in-person consultations, and privacy and convenience; and reducing attrition by using simple wording and design, providing additional explanations, and offering audio/visual alternatives to text.
Article notes
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
This study/project is funded by the NIHR Programme Grants for Applied Research, NIHR200856.
Introduction
Health inequalities persist globally, disproportionately affecting underserved populations who face significant barriers to timely and appropriate healthcare. These disparities are particularly evident in sexual health, where access to prevention, testing, and treatment services remains uneven.1 2 Underserved groups/populations, defined as those with inadequate healthcare access and underrepresentation in research,3 include sex workers, people experiencing homelessness, those involved with the criminal justice system, individuals with substance dependence, trans and gender-diverse people, vulnerable migrants, victims of modern slavery, people with learning disabilities, severe mental illness, physical disabilities, and those with low digital and health literacy.4 These populations may experience disproportionately poor sexual health outcomes, including higher rates of STIs and delayed access to care and treatment.4
In some countries, sexual health services increasingly include a range of online services such as STI and blood-borne virus testing via online postal self-sampling,1 5 or by requesting testing online, followed by sample collection at a laboratory.6 More recently, online asynchronous consultations have been introduced to manage infections, such as chlamydia.7 This involves a patient diagnosed with chlamydia completing an online health questionnaire, which is then reviewed by a clinician who prescribes antibiotic treatment (if safe to do so) based on the information provided, without needing direct interaction with the patient.
While asynchronous consultations could reduce barriers to in-person healthcare, they could also exacerbate existing health inequalities or create new ones. Many underserved individuals, including those with low digital and health literacy may face structural barriers to accessing online services such as lack of connectivity and/or software access.8 Others could (also) struggle to navigate online health questionnaires effectively, limiting access to necessary care and/or their safe use. Safe prescribing requires adequate knowledge of the patient9 and while many regulatory bodies provide guidance on remote prescribing,9 there is little empirical evidence to inform the content and design of the asynchronous online consultations on which the prescribing decision is based. Further, being underserved or experiencing multiple disadvantage can have a cumulative impact, where intersectional identities contribute to compounded disparities in access and health outcomes. Recent literature underscores the interplay between socio-demographic factors and digital healthcare access, highlighting how online consultations may unintentionally exclude those most in need.10-12 The usability and accessibility of online questionnaires within asynchronous online consultations are modifiable but despite the growing adoption of asynchronous consultations, there is limited evidence on how to design them inclusively for underserved populations.13
To address this gap, our study aimed to: i) identify barriers and facilitators to accessing chlamydia treatment via asynchronous online consultations among underserved populations and ii) develop evidence-based recommendations to overcome these barriers. The work will inform the optimisation of an inclusive eSexual Health clinic14 for a future trial.15
Methods
Participants
We developed a target sampling frame (Appendix A) using the PROGRESS-Plus framework16 to purposively recruit people from a range of underserved populations, stratified by inequalities in health opportunities and outcomes (Table 1). In line with Braun and Clarke (2006),17 we did not seek to meet data saturation. Instead, prior to recruitment, a sample of 35 was identified as appropriate to meet the sample targets and sufficient Information Power.18 After 35 interviews, we reviewed the data and were satisfied that Information Power had been attained.
Recruitment
To reach a diverse range of participants, we collaborated with four NHS Trusts in England and one NHS Board in Scotland - large, state funded healthcare organisations, along with three non-governmental organisations (NGOs). These NGOs included one supporting people with learning disabilities, one serving lesbian, gay, bisexual, transgender, queer and intersex+ (LGBTQI+) people, and one focused on Muslim community members. Additionally, we partnered with one college (for national diplomas and qualifications) in a deprived area of Scotland, serving people with low educational attainment.
Representatives from each NHS Trust/Board, NGO and college identified potential participants who appeared to meet the inclusion criteria and with permission, referred them to the researcher (JMcL). JMcL conducted a 15-minute phone survey (Appendix A) to check eligibility, collect socio-economic demographic information, evaluate technology access and digital confidence, address queries and schedule the interviews. Participants were then provided with a consent form, participant information sheet, and interview visual aids (Figure 1) to read, either by email, WhatsApp, or hard copy.
Inclusion criteria were: aged 16 years and older; resident in the UK; access to the internet and a telephone; able to read and speak English well enough to participate; sexually active; and never used, or struggled to use, current postal STI self-sampling services.
Throughout recruitment, we monitored the sample closely by checking the demographics of potential participants against the existing sample and target sampling frame. As sample targets were met, we liaised with NHS, NGO and college contacts to focus recruitment of participants with characteristics not already included.
Procedure
JMcL conducted interviews 15/10/21-18/03/22, either remotely via phone call (n=23) or video call using Microsoft Teams/Zoom (n=7), or face-to-face (n=5). Consent was obtained at the beginning of each interview, verbally on an encrypted audio recorder for remote interviews, and written for face-to-face interviews. Interviews were semi-structured (Appendix A: interview topic guide) ranging from 38-82 minutes duration (median=60), focussing on participant-led data collection by prompting participants to elaborate on their responses. Throughout, participants were referred to visual aids (Figure 1) and regular sense checks were conducted to ensure the participants had a clear understanding of the asynchronous online consultation. At the end of the interviews, all participants were offered a shopping voucher worth £30 and provided with sexual health support resources (Appendix A).
All interviews were audio recorded using encrypted digital devices; recordings were transcribed verbatim for analysis. Transcripts were fully anonymised for reporting, presentation, and publication purposes.
Analysis
JMcL conducted a two staged analysis under the supervision of PF. In Stage one, using NVivo (version 12), we conducted inductive thematic analysis17 to derive participant-led barrier and facilitator themes. We initially described data with brief summary barrier and facilitator statements which we then grouped with similar summary statements to identify subsequent themes and subthemes. We resolved any disagreements on the naming and grouping of statements, themes, and subthemes through discussion.
In Stage two, we used the Behaviour Change Wheel19 to develop recommendations to overcome the barriers and enhance the facilitators. First, we coded barrier and facilitator themes to the Theoretical Domains Framework.20 We then matched these domains with corresponding intervention functions and further operationalised them with specific behaviour change techniques (BCTs) using the BCT Taxonomy version 121 to provide evidence-based and theoretically informed recommendations. Clinicians CSE, JG, JS, PS reviewed the recommendations for clinical relevance.
Patient and public involvement
For material development, we consulted 12 public and patient involvement and engagement (PPIE) representatives of diverse ages, genders, ethnicities, sexual orientations, religions, and experiences of disability, learning difficulties, and digital STI healthcare. Five representatives offered intersectional perspectives and advice on our questionnaire-based assessment of participant demographics and internet use, and seven advised on the interview topic guide and visual aids to be used within data collection.
Ethical considerations
Ethical approval for this study was granted by the East of England - Cambridge South Research Ethics Committee (REC) (reference 21/EE/0148) and Glasgow Caledonian University REC (reference HLS/NCH/20/045).
Results
Participants
The 35 participants (Table 1) (age range 18-70 years, mean=34) came from various underserved populations; for example, 18 (51%) lived in the most deprived areas of the UK (defined by the Index of Multiple Deprivation)22 and one (3%) was experiencing homelessness; 18 (51%) had no higher (post-college) education; 15 (40%) were of a ethnic minority group,23 eight (23%) reported English was not their first language; 17 (49%) had a mental health or physical illness or condition lasting 12 months or more; and 10 (29%) had a learning difficulty.
Participants used the internet extensively (mainly for social media) and self-rated their online skills as high. However, amongst the examples of internet activities reported, very few included using the internet for more sophisticated tasks, such as online banking, and few had experience of online healthcare (Appendix A).
Six main barrier and facilitator themes were identified from the inductive analysis (Stage 1): awareness and familiarity; perceived needs; convenience and resources; privacy and disclosures, answering questions correctly; and answering personal questions online. These are shown in Table 2 along with indicative quotations from participants. The BCW analysis (Stage 2) built on the barrier and facilitator themes to provide systematic recommendations to enhance the use of online consultations are shown in Table 3. Please see Appendix B for the full BCW analysis.
DISCUSSION
To our knowledge, this is the first study to describe, evidence based and theoretically informed recommendations for developing online asynchronous consultations, which also focus on the needs of people from underserved groups. Key barriers to using asynchronous online consultations included: a lack of familiarity with online healthcare; perceived need to see a healthcare professional in person; privacy concerns; concerns about difficulty interpreting the questions; and discomfort answering personal questions online. Key facilitators included: familiarity with (any) online consultations; perceived low risk of having an STI; perceived increase in convenience, control, and privacy; simple wording and design; and support whilst completing them. Recommendations include; increasing awareness and familiarity by promoting them offline and online, and providing demonstrations/instructions on how to use them; encouraging people to choose them by highlighting available support, equivalence to in-person consultations, and privacy and convenience; and reducing attrition by using simple wording and design, providing additional explanations, and offering audio/visual alternatives to text.
We previously proposed a framework for developing the content and flow of medical questions in online asynchronous consultations25 but this did not explicitly address the needs of underserved groups. Although one study provides recommendations for implementation of asynchronous telemedicine platforms into primary care,13 few studies have focussed on the digital health needs of underserved groups and none have specifically explored issues relating to asynchronous online consultations leading to prescription of treatment, nor focussed specifically on sexual health care. Some countries have national accessibility guidelines26 and broad principles relating to digital exclusion but these lack the granularity needed. Our findings address this gap.
A systematic review of asynchronous telemedicine consultations in general practice concluded that they could increase access to timely care, although equity was poorly reported in the included studies.10 A systematic review of characteristics of “eConsultation” users in primary care reported that socio-demographically disadvantaged users used eConsultations less than other groups.12 Other studies report that HCPs perceive that online consultations could differentially disadvantage people who experience digital exclusion.11 13 27 However, it is unclear whether any of the systems used were developed with content/design tailored to those with lower digital and or health literacy, which could mitigate some access issues.
Similar to the findings of this study, Leighton et al’s analysis of the implementation of online asynchronous telemedicine platforms into primary care, found that patients (and staff) were concerned about privacy and confidentiality.13 Recommendations from a behaviour change wheel analysis of barriers and facilitators to seeking online sexual health information and support among underserved populations, derived from the same interviews as in this study, also found that online and offline promotion and endorsement by healthcare professionals and peers would reduce barriers to uptake.28
A study of users of HIV Pre-Exposure Prophylaxis (PrEP) in Scotland (participants were all men who have sex with men) suggested that some people would find it easier to provide accurate details about current medication when doing so online, as they would not feel time-pressured and could check medication details at home.29 Overall, these findings highlight the timeliness and importance of the current study for ensuring that inequalities, both digital and longstanding, are not widened by the shift to delivering healthcare online.
By working closely with NGOs and clinical services, and using targeted recruitment, we included the perspectives of people from groups who are seldom heard and often underserved, including people with learning disabilities. However, we missed target recruitment for gender diverse people, limiting insights for this group. We did not seek to sample or analyse data in relation to intersectionality but recognise that intersectional demographics and experiences can put people at even greater risk of poor sexual health and result in additional barriers to accessing care.30 Our methods extended beyond thematic analysis to the use of wider, robust behavioural science tools (the BCW) for systematic development of recommendations built both on the evidence we collected and on previous theory and cumulative knowledge (Appendix B).
Few participants had used online health care, so it was hard for some to conceptualise the eSexual Health Clinic. While we attempted to mitigate this by using screenshots (Fig 1) and careful explanations, some participants did not have a precise understanding of all the features of the eSexual Health Clinic which limited the specificity of their barriers and facilitators. Further, although digital and health literacy tools were available,31 we developed our own survey (Appendix A) to avoid inadvertently excluding people from the research due to difficulties completing the assessment tool. This may have complicated the recruitment of participants of lower digital and health literacy, as indicated by the number of participants who self-reported as having ‘high’ skills using the internet when their reported online activity suggested less complex usage.
Recommendations from this study could be used in conjunction with appropriate broader national guidance by service planners and providers to develop novel, and improve existing, asynchronous online consultations for maximum inclusivity. Many of the recommendations, such as those to increase awareness and help users complete the consultations could be straightforward to implement and beneficial for all users. Techniques from Human–Computer Interaction (HCI) should also be used in conjunction with our recommendations to ensure that the digital component of the intervention is efficient, effective and provides a positive user experience.32 Key stakeholders should thoroughly consider local factors in implementation to ensure recommendations are meaningful and appropriate in each setting, and to ensure asynchronous online consultations are integrated into existing systems and work flows.13
We have used the findings from this study to optimise our eSexual Health Clinic14 for maximal inclusivity and reach, ahead of a forthcoming randomised controlled trial.15 We will include an integral health inequalities evaluation as well as a distributional cost effectiveness analysis to evaluate the extent to which our design has influenced known differences in uptake and use of online sexual health systems, according to sociodemographic and other characteristics. Trials such as this, with a clear equity focus, are needed to fill the evidence gaps10 and ensure digital health meets its potential to narrow, rather than widen, health inequalities.
Uptake of these recommendations could increase access to, and successful completion of, asynchronous online consultations for all populations, including those who are underserved. This, in turn, could reduce inequalities in health outcomes. Although developed in the context of a clinical consultation for treatment of an STI, we believe that the recommendations are broadly generalisable across the population and for use with other health conditions.
By directly focussing on people from underserved groups, the findings from this study could improve existing online asynchronous consultation systes and inform the development of new ones for maximum inclusivity. The findings could be easily applied across online health care for different health conditions, particularly when designing with a focus on the needs of underserved groups. It is likely that all users, not just the underserved, would benefit from the simplicity, clarity, and usability features suggested by the participants. However, as remote service access is not always appropriate, nor accessible due to non-modifiable factors, they must be provided alongside accessible, non-digital, alternatives.
Supporting information
Data Availability
Due to the sensitive nature of the questions asked in this study, participants were assured that transcripts would remain private and confidential and would not be shared beyond the use of anonymised illustrative quotes in publications about the research. In line with our ethical approvals form Glasgow Caledonian University (GCU) Nursing and Community Health Research Ethics Committee (HLS/NCH/20/045) and the East of England - Cambridge South Research Ethics Committee (21/EE/0148), participants were not asked and did not consent to sharing their full transcripts. The transcripts will be stored long-term, for a minimum of 10 years (from 2021) on a secure GCU network drive. Data access requests may be made to the corresponding author, Claudia Estcourt (claudia.estcourt@gcu.ac.uk), the SEQUENCE digital team (cnwl.sequencedigital@nhs.net) or the Glasgow Caledonian University Research Ethics Committee (hlsethics@gcu.ac.uk) and the East of England - Cambridge South Research Ethics Committee (cambridgesouth.rec@hra.nhs.uk).
Acknowledgements
We would like to thank the participants who took part in the study. We are also grateful to the following sexual health services and organisations for invaluable assistance with the study: Castle Circus Health Centre (Torbay & South Devon NHS Foundation Trust), Devon Sexual Health – Exeter & Barnstaple (Northern Devon NHS Foundation Trust), Mortimer Market Centre, Archway, Barnet and Buryfields Clinics (Central and North West London NHS Foundation Trust), Sandyford Clinic (Greater Glasgow & Clyde), and Sexual Health Sheffield (Sheffield Hospitals NHS Foundation Trust) for advertising the study to support with recruitment. We are very grateful to our sponsor, Central and North West London NHS Foundation Trust, and the staff of the Noclor NHS Research team for their support and assistance. We would also like to thank the representatives of Hidayah LGBT, get2gether, and Scottish Wider Access Programme (SWAP) college courses for publicising the study to help with recruitment.
Finally, we would like to thank the members of our Community Advisory Panel whose valuable input supported the development of an inclusive participant recruitment strategy and accessible, culturally appropriate data collection materials (consent forms, interview materials, demographic questionnaires, topic guides, case scenarios and clinical pathway diagrams).
This study/project is funded by the NIHR Programme Grants for Applied Research, NIHR200856. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
SEQUENCE Digital team: Claudia Estcourt (PI), Vanessa Apea, Ann Blandford, Andrew Copas, Paul Flowers, Jo Gibbs, Lynne Haahr, Karen Lloyd, Jennifer MacDonald, Danita Mooney, Nuria Gallego Marquez, Fiona Mapp, Amelia McInnes-Dean, Julie McLeod, Mark Monahan, Jonathan O’Sullivan, Tracy Roberts, Jonathan Ross, John Saunders, Pam Sonnenberg, Merle Symonds, Roos Van Greevenbroek, Andrew Winter, Melvina Woode Owusu.
Appendix Group
Appendix A
Target sampling frame, Socio-economic demographics and screening survey, Interview topic guide, Sexual health support resources, Participant self-reported skills and experience using the internet
Appendix B
BCW analysis