T
his chapter contains information reproduced from Where do young men want to access STI screening? A stratified random probability sample survey of young men in Great Britain, Saunders JM, Mercer CH, Sutcliffe LJ, Hart GJ, Cassell JA, Estcourt CS, vol. 88, pp. 427–432, 2012,72with permission from BMJ Publishing Group Ltd; The SPORTSMART study: a pilot randomised controlled trial of sexually transmitted infection screening interventions targeting men in football club settings, Fuller SF, Mercer CH, Copas A, Saunders J, Sutcliffe LJ, Cassell JA, Hart G, Johnson AM, Roberts TE, Jackson LJ, Muniina P, Estcourt CS, vol. 91, pp. 106–10, 2015,113with permission from BMJ Publishing Group Ltd; and Exploring the costs and outcomes of sexually transmitted infection (STI) screening interventions targeting men in football club settings: preliminary cost-consequence analysis of the SPORTSMART pilot randomised controlled trial, Jackson LJ, Roberts TE, Fuller SF, Sutcliffe LJ, Saunders JM, Copas AJ, Mercer CH, Cassell JA, Estcourt C, vol. 91, pp. 100–105, 2015,114with permission from BMJ Publishing Group Ltd. Information was also reproduced from Merceret al.115© Merceret al.2015. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Abstract
Introduction:The optimal strategies for increasing men’s uptake of STI testing and the acceptability and public health impact of screening in different settings are poorly understood.
Objectives:(1) To explore the medical, sporting and social venues that young men find acceptable for accessing STI screening and determine the optimal models of screening therein; (2) to undertake a pilot RCT of two screening interventions in football settings; and (3) to explore the public health impact of screening in football settings.
Methods:(1) Stratified random probability survey of men aged 18–35 years; (2) qualitative study of men’s preferences for STI screening; (3) pilot cluster RCT of two STI screening interventions in football clubs with an integral health economic evaluation; and (4) anonymous questionnaire survey of men’s STI risk and prior health service use.
Results:Willingness to access self-sampling kits for STIs and HIV infection was high. Traditional health-care settings, such as general practice and GUM services, were preferred but sports venues were acceptable to half of men who played sport. Uptake of screening in the RCT was high irrespective of arm and costs of the interventions were similar. Men were at risk of STIs but previous testing was common.
Conclusions:Health-care settings were the most acceptable places for accessing STI and HIV self-testing kits. General practice offers considerable potential to screen large numbers of men. Screening men in
football settings could be valuable in areas with limited access to other STI services, but its impact requires further investigation.
Background
Over the last decade, there has been a sustained rise in the number of reported STIs in men and women90 and the number of reported chlamydial infections in men is similar to that in women.90However, men’s uptake of chlamydia screening within the English NCSP has been substantially lower than that reported for women.90Although the proportion of men being tested is rising, in 2013 the NCSP tested twice as many women as men.116
Over the last decade, highly sensitive and specific tests have been developed for the diagnosis of
chlamydia and other infections such asN. gonorrhoeaeand HIV, which can be performed on non-invasive, self-collected samples.23,117As a result, testing for STIs and HIV can now be conducted in a variety of non-health-care settings without the need for access to microscopy or interaction with HCPs. These technological advances have underpinned the development of the NCSP in England.
More than half of the NCSP tests carried out on women are carried out in‘core services’(general practice, CASH services and pharmacies).118In contrast, around one-quarter of tests on men are carried out in‘core services’, with testing more commonly occurring in‘outreach’and non-health-care settings.118Positivity rates of men tested by the NCSP in non-health-care settings are generally lower than those from men tested in core services.119This suggests that screening men in non-health-care settings may have a limited impact on public health, as it is not only the coverage of screening that is important but also ensuring that populations with the highest prevalence of infection are tested.67The difference in approach to screening for men as opposed to women has probably developed as a result of widely held perceptions that young men are infrequent attenders at general practice whereas women are believed to attend more frequently and have multiple opportunities for screening as part of‘routine’visits for related health needs such as contraception. Data do not support this view16and the vast majority of men have attended their GP within the last year.59 In spite of this, there appears to be a mismatch between GP’s perceptions of men’s low attendance rates and reality.102
Evidence suggests that, although women of reproductive age bear the majority of adverse health consequences of chlamydial infection,120the inclusion of men in screening efforts can be effective in reducing the population burden of infection.23,121However, this may be less cost-effective than other strategies such as improving the effectiveness of partner notification.117,122,123It is also possible that the inequity in screening uptake may inadvertently fuel the perception that chlamydia is a woman’s infection, which could lead to a situation in which‘men have been effectively silenced on these issues . . . if both responsibility and accountability are defined as exclusively female, men have neither the social means nor the personal motivation to take a more active interest’(p. 932).124Mindful of these factors, it is generally accepted that efforts should be made to engage more men with STI screening and the Department of Health has commissioned research to look specifically at this issue.125
Men’s lower uptake of screening could be explained by differences in men’s and women’s health-seeking behaviours, underpinned by different beliefs about health and illness.116,126,127However, growing evidence suggests that men are beginning to appreciate the rationale for STI screening and have clear preferences for how and where they would like to access it.72,128–133To date there has been limited success in
implementing effective male STI screening in primary care in England, suggesting that offering men screening in other settings remains important.
Sports settings offer the potential for STI screening activities for men who engage in sport and STI screening in some sports settings has been undertaken in the UK and overseas in a variety of ways and with varying degrees of success. The aim of such initiatives has been to encourage more men to test for STIs and to engage in
general health care.134–136In a recent English survey, 40% of men (aged>16 years) reported participating in sport at least once a week.137Football is the most popular team sport in England, with over 16% of those aged 14–25 years playing at least once a week.137Many teams operate within a national league structure, which could facilitate widespread implementation of new interventions. Although this suggests that football venues could provide feasible settings in which to provide large numbers of men with access to STI and HIV testing, the acceptability of this approach is poorly understood.
The optimal approach to offering screening in other settings is also unknown. Involving people who are not medically trained to impart information about sexual health, testing and treatment offers potential and seems to be well accepted by targeted populations.138–140Two broad types of‘promoter’have been used: peers and opinion leaders. A peer is‘a person of the same standing or rank as the person(s) in question; a person or thing of the same effectiveness or ability as the one(s) in question; an equal’(p. 795),141 although this definition is rarely strictly adhered to in studies. A popular opinion leader is a more complex concept to define but involves‘the degree to which an individual is able to influence other individuals’ attitudes or overt behaviour informally in a desired way with relative frequency’(p. 27).142Although several theories potentially help to explain the use of popular opinion leaders to encourage men to screen for STIs and HIV,143 no one theory explains all of the processes involved and often no underlying theory is stated in published studies of peer-led and popular opinion leader-led interventions. These approaches have not been evaluated as a means of promoting sexual health in sports settings in the UK.
To investigate these issues we conducted three research studies with the following overarching aims and specific objectives.
Aims
l To explore the medical, sporting and social venues that young men find acceptable and feasible for accessing STI screening and to determine the models of screening that young men consider acceptable and feasible in those contexts (phase 1).
l To undertake a pilot RCT of two screening interventions in sports settings (phase 2).
Specific objectives
l To determine young men’s usage of medical, sporting and leisure venues.
l To determine which venues young men would find acceptable and feasible for accessing STI screening.
l To develop through qualitative research and consumer and stakeholder consultation two feasible and replicable interventions for delivering STI screening in football club venues.
l To determine the acceptability to young men and feasibility of football trainer-led STI and HIV screening.
l To undertake a pilot RCT of football captain-led STI screening in two contrasting football clubs in different geographical areas.
l To determine the uptake of STI screening by young men in football club settings.
l To obtain cost data for the football captain-led STI screening strategies to use in a preliminary economic evaluation.