A summary & update of SXT (www.sxt.org.uk)

Why was SXT formed?

The mission of SXT is to support access to sexual & reproductive health services.   The drivers to improve access are one person being diagnosed with HIV every 90 minutes in England & over half being diagnosed after they should have started treatment, half of all pregnancies being unplanned, syphilis infections the highest since the 1950’s, gonorrhoea becoming more difficult to treat, one third of women having an abortion had had one previously and 85,000 serious sexual assaults a year (http://bit.ly/W0CoNt).   

The importance of access is clear for time sensitive services, such as post exposure prophylaxis following sexual exposure [to reduce the risk of contracting HIV (PEP)], emergency contraception (EC) or sexual assault but it is also essential for patients who are symptomatic (e.g. first episode of anogenital herpes) and need prompt access to treatment and relief.  The detailed information within SXT reduces time wasting for patients and services because it reduces inappropriate referrals (e.g. the oral EC recommend depends upon the number of hours since unprotected sex).  In addition, SXT supports the ever-changing number of sexual & reproductive health services by allowing providers to edit and control their web presence as well as review activity and see why clients have selected their service.

What is SXT?

SXT (www.sxt.org.uk) is a free & anonymous platform for clients to find the right service in the right place at the right time as well as a powerful public health marketing tool for providers & commissioners.  The latest upgrade in August 2013 made it possible to upload providers from other databases, share the SXT service data with other web services and clients plus capture feedback.  There are currently over 2500 providers in SXT and this includes the British Association of Sexual Health and HIV clinics, all out of hours PEP providers (A&E services), UK sexual assault referral centres, HIV testing centres and GPs in England.  Fourteen percent of SXT users give feedback on the clinic locator service and 85% give a score of eight or more out of ten.

How SXT works for clients and providers?

The best way to see how SXT works for clients is to go onto the website and try it for yourself.  SXT has been designed to work on SMS, mobile and web.  All the information fits within a mobile phone text message and SXT strives to limit the digital divide to access information until there is near universal smart phone adoption.  Everything on the website & SMS responses can be edited or changed and the decision trees adapted.  If users have ideas or suggestions they can send it to feedback@sxt.org.uk so that the service can continually improve.   Providers can register or claim an uploaded service via the home page and it takes minutes to ensure that the service is up to date.

AdTags - converting an unmet to a met need

The first port of call for most people looking for information is Google.   Based on this reality, SXT ran a digital public health marketing campaigns last summer (see 05/08/13 blog post) using Google Adwords over six weeks across London.  During this time there were over 250,000 impressions, 864 clicks leading to 246 SXT clients who chose 163 specific providers [sexual health clinics, community services, GPs and pharmacies] for a one of four advertised services [Emergency contraception, STI testing, Contraception and Post Exposure Prophylaxis].

What was satisfying about the Google Adword approach was that it converted an unmet need in a Google search into a met need using SXT.  Assuming that every client who chose a provider in SXT actually visitied that venue then the return on investment was estimated to be £2.51 spent on Google Adwords for every provider chosen.  As impressive as this data is, SXT was keen to be there when an unmet need was identified in the real world and that is why it started to work with Connecthings (www.adtag.fr).   An AdTag is a 10 x 10 adhesive tag that can be seen from the photograph below.

The AdTag is stuck outside a clinic (for use when the clinic is closed), on a reception desk (for when a patient is turned away) or behind a toilet door for discreet use on a hospital ward or in a social venue.  The top left part of the AdTag advertises the service whilst the upper right area gives the website and SMS number for those clients who do not have a smart phone.  The QR (2D barcode) is for iPhone access whilst the Near Field Communication (NFC) section takes the Android user to the landing page when their phone is held over the AdTag.

The first weekend an AdTag was installed in a social venue frequented predominantly by men who have sex with men a user was directed to SXT and then used the risk checking function of the site to identify that he needed post exposure prophylaxis to prevent HIV exposure and finally chose a venue providing this service.  The AdTag connection to SXT made it possible to convert an unmet into a met real world need.  If HIV transmission was prevented in this person, by early access to this time sensitive service, then it would have saved the NHS over £300,000 in lifetime costs.

Use of AdTags and SXT is confidential; however, both services have powerful analtyical tools to understand usage.  For example, every AdTag is geographicallly located so that when a connection is made this can mapped.  When SXT is used to provide information and locate a local service it is also possible to map the chosen service if one is selected by the client.  The two distinct services can be linked by the date & time of usage and the referral details.

Over the last week there have been seven unique connections.  Four were at a pharmacy reception, one outside a clinic and two from AdTags placed in toilets; one on an antenatal ward and the other in a social venue.   SXT plans to continue with this analysis and is currently looking for sponsors to support and build upon this novel way to assist individuals with an unmet need.

Breaking the silence: the role of a slide-out feedback form to capture user experience

The challenge to capture feedback

Accurate information about service provision is important for patients to decide which provider to attend.  SXT (www.sxt.org.uk) was formed in 2012 and over 3000 clients have been successfully directed to a local provider offering the service they require.  However, despite adding a hyperlink to a webform for feedback less than a dozen individuals elected to leave their thoughts.  Feedback is a challenge to capture across all web-based services (e.g. TripAdvisor 2%, I want great care 25%*).  We therefore tested if the introduction of a slide-out feedback form, appearing three seconds after the client viewed a single provider page, would engage users and determine if they found the SXT service useful.  

Developing a new approach

Over the summer months in 2013 the website was re-designed (v3.0) and made responsive so that it adapts to any device – computer, phone & tablet.  During this development a slide-out feedback form was added asking the question ‘Did you find this service useful?  This form gives the option to score from 10 (very useful) to 1 (not useful) using radio buttons and a comment box is available for any text.  The new site went live on the 5^th August 2013 and the database records details of the date, time, postcode, service requested, local providers displayed, the provider selected, feedback score and comment.  The design and development of the website was done by Matthew Ford, Laura Paplauskaite & Michael Wallace (www.bitzesty.com)

What was the result?

Over six months a total of 683 clients looked for information or a service and 451 (66%) chose a specific provider and the slide-out feedback form was displayed.  A total of 67 (15%) clients left a score and these are shown on the table below.  The provider types chosen by clients giving feedback were 15 genitourinary medicine clinics, five sexual reproductive health clinics, five third sector clinics, four general practices, two sexual assault referral centres and one pharmacy. Only three clients wrote text with their feedback. The majority of clients found the service useful with 85% giving a response of eight or more out of ten.

Device used	Did you find this service useful? [Score 1 – 10]					Total
	1	7	8	9	10
Phone & Tablet	0	1	5	3	26	35
Computer	5	4	6	3	14	32
Total	5	5	11	6	40	67

What's next?

The slide-out feedback form has enabled SXT to engage clients and the responses to date support its utility to identify local services.  Further work will include placement of slide-out feedback form(s) on other pages of the website to determine the utility of the information services provided.

* Personal communication Dr Neil Bacon (Founder of I want great care www.iwgc.org)

All good things have a price

What is the role of the condom IF a sexual network does not have a sexually transmitted infection (STI)?  In heterosexual couples it is to reduce the risk of unwanted pregnancy; however, with a typical failure rate of 15 per 100 per year these couples would be better off finding something more effective (http://bit.ly/1cG5AxR).  

Unfortunately, unless a couple is exclusively monogamous, it is a good idea to continue to use a condom just in case an STI is brought into the relationship.  Once an infection enters a sexual network, its transmission depends on how infectious the organism is, the number & frequency of sexual acts, any concurrency (two plus partners at the same time) and the duration of the infection. 

Since many infections do not have symptoms it is important that everyone who starts a new relationship is tested for the four infections recommended by the British Association of Sexual Health and HIV (BASHH) which are HIV, Syphilis, Chlamydia & Gonorrhoea.  

Unfortunately all good things have a price and even non-penetrative acts such as oral sex can transmit infections.  The risk of catching an infection depends upon the sexual act. SXT has developed a simple risk estimator http://bit.ly/17k5Td0 to help its clients know the facts. 

Finally, SXT has developed a way to support individuals to let their partners know about infections (http://bit.ly/14dj4KQ).  The new share function can be anonymous if the user wishes; although, SXT recommends that the clinic name and the patient number is added to the message to help the health advisors support the treatment of the whole network.  “What goes around comes around” and SXT is keen to support all providers of sexual health services to break the chain of transmission.

Digital public health marketing

Where do you go when you need to look something up?  

Rarely do people carry around health leaflets, flyers, business cards just in case they may one day use this information.  Similarly, few remember the adverts on buses and trains when they realize that a specific service is required.   Google is the most common answer you hear to this question and this is where public health marketing needs to be to make a difference.

SXT Health CIC (www.sxt.org.uk) was set up with a grant from UnLtd (www.unltd.org.uk) Guy's & St Thomas' Charity (www.gsttcharity.org.uk) to increase access to information and services and over two years it has proven itself to be a flexible digital platform to support health education and a range of providers.   SXT is free to use and the providers control their web profile, times, services and have access to a powerful analytics page. This year, SXT has run a number of digital public health marketing campaigns using Google Adwords in London to sign post clients to services on both sides of the Thames.

The latest round of Ads have focused on four areas and keywords used have been informed by the experience of working in sexual health, discussion with colleagues in Guy's & St Thomas' (GSTT) Sexual Health Department and Brook as well as advice from the Google Adwords software.  The latest Ads have been running since 24th June and the adverts have been displayed on 235,022 occasions to Londoners during this time with 864 clicking on an advert [344 Emergency contraception, 296 STI testing, 123 Post Exposure Prophylaxis (PEP) & 101 on Contraception].  The average cost per click has been £0.47 and this SXT June 4:1 campaign has cost so far £409.43.

These adverts have been paid from the marketing budget of the sexual health department at GSTT to prove the concept for digital public health marketing and determine a return on investment.  SXT is charging a 10% fee per advert clicked during this proof of principle trial [Total cost £500].  Of the 246 SXT users of the site during this campaign, two thirds (163) chose a specific clinic and 32 of these clients (20%) selected a GSTT clinic [Burrell Street or Lloyd clinic].   The median (range) distance between the SXT client and the GSTT clinic they chose was 2.2km (0.58 - 12.71km).  The other 131 providers chosen were sexual health clinics, community services, GPs and pharmacies.

SXT is keen to support commissioners to pool their financial risk and expand public health marketing strategy across other digital platforms such as Facebook & Twitter as well as run banner adverts on Gaydar, Grindr, Manhunt etc. to optimize the access of men of sex with men to HIV testing and PEP.  In addition, SXT is partnering with Connecthings (www.connecthings.com) to facilitate the creation of SXT clients by the use of NFC tags and QR codes in venues to support access to information on sexual health, drugs and find high quality services across the capital. 

The clinic was closed or busy! (The turn away tragedy)

We have a problem with matching capacity with demand for sexual & reproductive health care services.  If a clinic becomes popular then it can be difficult to be seen.  Some clinics use an appointment system for their consultations, others only walk-in whilst a large majority use a combination of the two.  

A walk-in service is crucial to meet the needs of service users who need urgent care and these patients include those requiring post exposure prophylaxis following sexual exposure to HIV or emergency contraception.  The earlier these services are delivered the better and the walk-in service is the only way to provide this.  Similarly the walk-in service is really important for those patients who are symptomatic (for example the first episode of anogenital herpes) or they have complications that affect the Fallopian tube or testicles.  If you make the whole service walk-in then it is possible that clients will arrive when the clinic opens and all the time slots over the day can be used up within the first hour.  The impact of this for those who are in work or school is that they can turn up later in the day only to find that the service is now closed for the day.

The use of an appointment system is attractive to clinics because they can spread out the work load across the service and it supports users who are unable to attend at the time when the clinic opens.  However, some of the problems with an appointment system are that it can be oversubscribed and the waiting time to access the service can become weeks, there are unused slots from non-attendance or the service is put under significant pressure because the appointments have been made but there are not enough staff because of sickness, compassionate leave etc. 

Getting the balance right is challenge to all services but this does not always have to be the case.  In many areas there are range of providers that are not been fully realized such as general practitioners with a special interest, pharmacies and online providers.  In big cities where there are more than one provider of sexual & reproductive health services it is possible that one is busy and the other one quiet that this imbalance can only be resolved by real-time information about where is the next service open that can serve this individual.

In SXT there are a number of verified clinics who have been partners since its inception in 2012.  The range of providers include condom providers to university teaching hospitals and this includes GPs & pharmacy services within its database.  The third iteration of SXT (launch 6th August 2013) will have all the sexual health providers in the UK, all the UK emergency departments for out of hours post exposure prophylaxis and a range of free emergency contraception providers in London.  The mission of SXT is to improve access to sexual & reproductive health services and these changes will be a significant step towards this goal. 

Confidentiality

Despite the progress that have been made in sexual health services there is still significant

stigma associated with these type of services.  Like mental health, the providers of

sexually transmitted infection (STI) testing & contraception services have to support clients

who may come to a consultation with mixed emotions including fear, embarrassment,

shame, anger, sadness.......(the list is extensive).


Even the provision of emergency contraception or asking somebody to provide samples

for STI testing can carry these emotions and staff who serve these clients are aware of

these sensitivities.  The public health impact of stigma means that people are reluctant to

test for infections and they risk of carrying an infection to any new partner.  Also women

who don't access contraception services are more likely to experience an unwanted pregnancy.


When sexual health clients are asked about what they value the most in sexual health

services they report confidentiality, speed of service and rapid results (http://1.usa.gov/

14PX080).  Confidentiality is really important for young people and the young persons

charity Brook has clear guidance in every clinic about this important issue (http://bit.ly/

15C0LBU).


SXT recognizes the full privacy concerns of its clients and it has been designed to keep

everything anonymous.  No personal information is requested at any point during the SXT

service and when a mobile phone number is used it is deleted once the SXT service has

been provided.


The new features that go live next week in SXT are also influenced by these privacy

concerns.  Consequently if a client wishes to share a piece of information about an

infection / contraception or the clinic location it is possible to do this within the SXT site

without having to add their email address or mobile number.  The text box in the share

function allows a personal message to be included within the shared page and the SXT

client can decide how much personal information they would like to include.


Some clients may choose to use the share function to tell a partner about an infection

when they do this it is recommended that they use their clinic reference number

(pseudonym) to help clinics identify that partners have been effectively treated.  Other

clients may not be happy to add any details and they can keep their notification

anonymous.  Just in case this communication channel is used incorrectly, SXT has

created a feature that will allow a recipient of a shared message to report abuse and block

further messages from SXT.


Finally, SXT provides analytic pages to all the verified clinics that shows the location

of clients, the services they were looking for, the clinics that were displayed during that

search in if their clinic was chosen.  In order to maintain the IP address privacy of the

person using the locate me function on their computer or mobile, SXT has decided to

report this location with a random offset so that our client cannot be identified by their

geographical location.