SXT - Why it was created, what we do, and how it has been achieved.

Why?

SXT Health CIC is a social enterprise with a mission to improve access to sexual & reproductive health services.  It was formed to meet the needs of clients, providers and commissioners and its goal is to optimise the relationship between capacity and demand.  

What?

www.sxt.org.uk is a mobile enabled website which guides clients to the right service in the right place at the right time.  Providers simply control their details within the database and www.sxt.org.uk translates this for clients so that they can act upon accurate information.  Commissioners are provided with a real-time gap analysis to support their development of the service.

The providers on www.sxt.org.uk have come from two main sources:

1. Providers signing up to www.sxt.org.uk and adding their services (n>300) [SXT verified]

2. Uploaded from other online databases (n>2000) - these services can be claimed by the provider

The provider has the ability to edit all the information about their service to ensure that they are accurately represented on www.sxt.org.uk.  As soon as changes are made they are live for clients to see.  All the information provided to clients is sourced from NHS Choices, the Family Planning Association and other reputable sources.

www.sxt.org.uk is as good as the data it holds and providers are encouraged to claim a service or register for free today to support the SXT mission

When?

The key events on the timelines have been:

• The idea was conceived and the community interest company was formed 2009
• The website & SMS engine started in January 2011
• A client facing mobile friendly version of www.sxt.org.uk was released August 2013
• The slide out feedback form was introduced at this time too (8.5% of clients who chose a single service give feedback and 81% give a score that is eight or more out of ten)
• A login for commissioners was developed in October 2014
• Providers were given access to a mobile friendly version of www.sxt.org.uk in February 2015

How?

To date SXT has been funded by the generous grants from:

• UnLtd / 4iP in July 2009
• Guy’s & St Thomas’ Charity in August 2010 & 2013

In November 2014 Big Issue Invest awarded SXT a corporate social venturing loan to build up the service.

The business model of SXT is to deliver digital public health marketing packages to raise awareness and improve access to services.

All money raised by the community interest company will be used to pay for its services and any surplus reinvested into the SXT mission.

If you are a provider and would like to support SXT’s mission please visit www.sxt.org.uk or watch this 1 minute video on how to join.

Return on investment - SXT is looking for partners to run highly effective prevention campaigns

Return on investment (ROI) is key for all the stakeholders in health care delivery.

Most ROI calculations are taken from the perspective of costs to the NHS

It has been estimated that for every pound spent on contraception £11 is saved by the NHS.

A range of ROIs has recently been published by the King's Fund and Local Government in their publication 'Making the case for public interventions'

SXT has just run a campaign to help clients find access to post exposure prophylaxis (PEP) which if taken after sexual exposure to HIV can reduce transmission of the potentially fatal virus.

It has been estimated that PEP needs to be given to 217 high risk exposures to prevent one person contracting HIV whilst the lifetime cost of HIV to the NHS has been estimated to be £320,000.

In the recent Google Adword campaign run in London, Brighton & Manchester 43 clients used SXT to find PEP.  Using very strict criteria to estimate the cost of this campaign it has been estimated that for every pound spent on this campaign £2 would be saved by the NHS.

This figure includes the costs of attending the clinic and medications whilst the cost of targeted Google Adword advertising represents less than 1% of the total cost to prevent one infection.

SXT is now looking for partners to pay for prevention programs that have the following features:

1.Demonstrate a clear return on investment

2.Utilize the power of digital public health marketing tools

3.Support providers to engage with SXT and clearly map their services so that clients can find the right service in the right place at the right time

4.Optimize the delivery of time sensitive services that have a significant public health value

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.