Objectives: Traditionally, genitourinary medicine (GUM) and contraceptive services have been provided separately. Providing these services on one site, as a one-stop shop, has been suggested as a way of improving access to care. There is little evidence about the acceptability of such an approach. We aimed to assess acceptability of different one-stop shop models (a young people's, an all ages (mainstream) and a general practice service) of sexual health provision among different community groups.
Methods: Between April and December 2005, 19 semi-structured interviews and 14 focus groups were conducted with young heterosexual men (n = 48), men who have sex with men (MSM; n = 46) and minority ethnic men and women (n = 28) across England.
Results: Knowledge of one-stop shops was limited. The concept was acceptable to participants (except MSM), although there was variation as to the preferred model. Young men and African individuals described distrust of general practice confidentiality, preferring young people's or mainstream models, respectively. South Asians associated stigma with GUM, preferring instead a general practice one-stop shop. Regardless of model, respondents expressed preference for one provider/one session to provide GUM and contraceptive care.
Conclusion: In terms of acceptability there can be no blue print one-stop shop model. Local assessments should determine whether a one-stop shop would have public health benefit and if so how best one should be set up to maximise access. To accommodate client preference for one provider/session for their sexual health needs it may be that the development of “integrated training” for providers across clinical specialities is a more realistic way forward.
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Sexual health is a major public health priority in the UK.1 In 2006, genitourinary medicine (GUM) clinics provided almost a million sexual health screens (up 9% from 2005) and made over 621 000 sexually transmitted infection (STI) diagnoses (up 2.4%).2 In 2006 the total number of abortions was 193 700 compared with 186 400 in 2005, a rise of 3.9%. Poor knowledge and improving access to STI and appropriate contraception remain key issues.3 Traditionally in the UK, sexual health care has been provided by separate, standalone, specialist clinics. However, there is increasing emphasis on STI testing outside of GUM settings and a diversity of services now contribute to STI management. Community contraceptive services, general practice and young people’s clinics are increasingly involved in the National Chlamydia Screening Programme in England,2 though many primary care trusts still lack formal strategies for addressing rising STI rates.4 Some GUM clinics also provide contraception, although provision is often basic—for example, emergency contraception.
Varying degrees of collaboration and integration between services have evolved to improve access to a full range of sexual health services.5 6 A one-stop shop is one example and in its broadest sense refers to the provision of sexual health services (usually, but not always limited to GUM and contraceptive clinics) on a single site. There is no standardised “one-stop shop” across the UK and services in different locations have evolved differently. Although all one-stop shops aim to provide “integrated” care on one site, the way in which this is delivered often varies. There is no consensus on whether one provider should manage care (both STI and contraceptive related needs) or whether different specialist services should be housed on the same site with clear pathways between them.
In 2002/3, the Department of Health (DH) identified three different operational one-stop shop models for evaluation: a young people’s service, a service for all ages (defined as a mainstream service) and one set within a general practice. The evaluation of these models aimed to assess effectiveness, acceptability, accessibility and efficiency in comparison to more traditional models of service provision. The evaluation team selected two “control” services (recognised as standalone GUM and community contraceptive services) for comparison with each one-stop shop model. The control services were located in areas with similar geographic, sociodemographic and service (for example, opening times) characteristics to the one-stop shop sites. The evaluation covered staff/stakeholder, community and service user perspectives. Full evaluation findings are presented elsewhere.7 This paper presents one component of the evaluation—the acceptability of the different one-stop shop models among certain population groups.
Participants and recruitment
Between April and December 2005 we conducted 14 focus groups and 19 semi-structured interviews with specific population groups across nine evaluation areas in England. These included small seaside towns, Greater London boroughs and other city areas with high residential occupancy and higher than average deprivation scores. The initial sampling framework included young heterosexual men (16–21 years), men who have sex with men (MSM) and black and minority ethnic (BME) men and women, including black Africans, black Caribbeans and South Asians (Bangladeshi, Pakistani and Indian). These groups were selected either because of high rates of STIs and/or because they are less likely to access services for sexual health needs and may not therefore have been represented in other parts of the evaluation (for example, service user survey and interviews).2 8–11 We were unable to recruit adults of black Caribbean ethnicity. This was due to problems occurring in the local area that hindered recruitment within the study timeframe. However, the perspectives of black Caribbean adolescents (16–18 years) were obtained through two of the young heterosexual men focus groups. Table 1 shows sample composition. Written consent was obtained for all participants.
Interviews and analysis
Semi-structured interviews were selected for the BME groups as some people from these communities find it difficult to talk about sexual health issues within groups.12 However, nine HIV positive black African women expressed preference for a group discussion. An ethnically matched male interviewer conducted the South Asian interviews as previous experience found that men in particular from these communities sometimes find it difficult to talk to a female researcher about sexual matters.12 South Asian female participants were offered a (non-matched) female interviewer. Interview questions focused on awareness of sexual health services in the local area, including the one-stop shop (if present) and preferred service for sexual health care. Participants were given basic descriptions of the three one-stop shop models and discussions focused on reasons for their preferences. The focus was on one-stop shops defined as integrating GUM and contraceptive services, rather than as a model encompassing the broad range of sexual health services (for example, termination of pregnancy, sexual dysfunction, gynaecology and so forth). All sessions were recorded and transcribed verbatim. The transcripts were analysed using a thematic approach. Given the objective of assessing acceptability and preference, themes related to these factors were identified. All data were organised using the general principles of framework analysis.13 This involved organising data into a “case (that is, focus group/interview) by theme” framework using Excel as a data management tool. The same substantive areas were mapped for each group to allow similarities and differences to be identified. The analysis presented here focuses on preferred model and acceptability of one-stop shops for young heterosexual men, MSM and African and South Asian men and women.
Young men (box 1)
Few young men had heard of or used a one-stop shop; however, the concept was acceptable. In some localities there were perceived to be no locally available services for young people to access and often travel into city or town centres from suburb or rural areas was problematic. Available services were described as having restricted opening times. The most important attributes of a one-stop shop were therefore easy access, convenience and close proximity. It was also an important attribute that both STI and contraceptive care be provided within one session and by one provider. There was concern, however, particularly among those living in small communities, of being recognised by family going into a designated one-stop shop service. Among 16–18 year olds, a young person’s one-stop shop was perceived as less intimidating and more convenient to access than mainstream and general practice models. In contrast 19–21 year olds preferred mainstream one-stop shops, describing reluctance to wait with others considerably younger than themselves and anxiety of being recognised in a young person’s service. Young MSM echoed this anxiety. Although perceived poor confidentiality was a factor that prevented many young men from using general practice for sexual health care, in one area young men expressed preference for a one-stop shop located at their local doctor’s surgery. Their preference however was for a nurse to provide the service. Ideal characteristics of a one-stop shop included well advertised, confidential, community setting (as opposed to hospital), broad opening times, discreet reception, separate sex waiting areas and provision of other youth support services.
Box 1 Young mens’ perceptions of one-stop shops
Convenience is most important factor
“It’s basically local and one place where you can go and get your things done simple, quick and easy. Local, that’s what you need more than anything.” (young heterosexual men’s focus group 7, 19–21 years, youth group)
“I think having it done all in one day and session is good because if you have to see different doctors it’s frustrating because you get shunted about the place and you just get really annoyed.” (young heterosexual men’s focus group 2, 16–18 years, youth group).
Preference for young person’s one-stop shop
M1: “If it’s a separate place with people the same age going there and it’s purely for that, then they’ll probably feel more comfortable going there knowing everyone is in the same boat.”
M2: “If they’re older you feel more intimidated.”
M3: “One that’s geared mostly towards young people because then you think your problems can be taken more seriously.”
M4: “Yeah, they know what they’re doing for your specific age.”
(young heterosexual men’s focus group 3, 16–18 years, youth group).
Anonymity of mainstream one-stop shops
“I think you’ve got less chance of meeting somebody you might know [at a mainstream one-stop shop]. If you go to a young person’s one… you might see someone you know there.„ (Young MSM 16–18 years, youth group).
General practice one-stop shop should be provided by nurse
“No I don’t think it should be your GP. I reckon at the doctor they should have a little separate bit where you see a separate person, a nurse.” (young heterosexual men’s focus group 7, 19–21 years, youth group).
MSM (box 2)
The idea of a one-stop shop was unacceptable to almost all MSM. Most expressed preference for GUM services. Only a few men thought that one-stop shops would help to “normalise” sexual health. The men described not wanting to attend a clinic that also provided contraception services as they did not want to wait with families, women and children. Contraception was not relevant to them and their perception of community based clinics was poor—in particular the confidentiality of receptionists working in these settings. There were anxieties that one-stop shops would lose the confidentiality of GUM services and concerns that the reason for a man’s visit would be obvious. Some described the risk of being identified as HIV positive. Fear of potential homophobia from groups of young people attending the same site for services was also raised. Other perceived disadvantages of one-stop shops included the loss of intimacy, acceptance of MSM issues and specialist staff knowledge.
Box 2 MSMs' perceptions of one-stop shops
Reason for one-stop shop visit obvious for men
“With it mixed for women I don’t think it’s so difficult because you could be there for any sort of contraception but I can’t go along and pretend I’m having a coil fitted. They know that I’m at the clinic because I’m either having a test or I’ve got a dose.” (MSM, focus group 4, lesbian, gay, bisexual forum).
Family planning a “happy time” versus STI testing an “anxious time”
“Depending if you’re very emotional or you think you’ve got something wrong with you, to be thrown into an environment where there is a lot of distraction and people are happy, happy and that moment you’re not…I don’t think you’re in party mode when you’re expecting the test and you’re expecting bad news.” (MSM, focus group 3, community group).
GP reluctance to do sexual health
“There are a whole lot of issues around confidentiality. There are laws covering my records at GUM services that are not covered by my GP. When I was trying to get a MSM GUM service set up I actually spoke to my GP. My practice has two GPs and I was talking to them both about it. My GP said she would be very uncomfortable about doing it because of issues around—she didn’t have the skills to do it but also she felt uncomfortable about having to write it on the records. The other GP said she will be happy to go to a GUM service and do a session for men—if she was paid of course—but would feel uncomfortable about doing it in the surgery. So, I think we’re going to struggle to get GPs to do it and I think we’re going to struggle to get gay men to go. Gay men might not even have not told their GP their own sexuality, let alone go in and say, excuse me, can you give me some doxycycline.” (MSM, focus group 4, lesbian, gay, bisexual forum).
“One of my friends, he’s actually HIV positive and his GP told him that he didn’t want to see him because he was gay.”
(MSM, focus group 2, community organisation).
GUM staff acceptance of MSM issues
“What you want is that there isn’t going to be this judgemental person. When they say to you, how many sexual partners have you had and you say 332 that they aren’t going to slump and look at you in absolute horror. So you need a service [like GUM] that is aware of what gay men’s issues really are and can just take that in their stride.” (MSM, focus group 6, community group).
Black African and South Asian men and women (box 3)
Though none of the African participants had previously used a one-stop shop, they found the concept acceptable, including those who were HIV positive. Preference was for a mainstream one-stop shop over one set within general practice due to a perceived lack of confidentiality in general practice. There was anxiety about general practitioners (GP) disclosing information that was felt could affect immigration and work status. Although African men thought one-stop shops were a good idea, they felt they were more suited to women as the reason for a visit could be concealed—women could be perceived to be there for contraception rather than STI related needs. Having one service provider was preferable, but not essential.
In contrast to African respondents, the majority of South Asian individuals preferred the idea of a one-stop shop located in general practice. It was perceived as more convenient and, importantly, unlike attending mainstream one-stop shops, the reason for the visit would not be obvious or stigmatising. General practice was particularly important for Bangladeshi individuals who felt unable to travel to town centres to use specialist services. Familiarity of the service was also important. This preference was not universal. Indian respondents in particular expressed reservation about accessing a local family GP for fear that they may disclose confidential information to family members. For similar reasons, other South Asian respondents thought that older individuals would be reluctant to disclose intimate information to their GP. One of the main service access barriers for South Asian and African respondents was the cultural taboo around discussion of sexual matters, leading to reluctance, lack of awareness and confidence to access any services at all.
Box 3 Black African and South Asian men and women’s perceptions of one-stop shops
Mainstream one-stop shops could improve awareness of services
“If you’re going to family planning and say you may not even know about sexual health, but if you went there, the one place, and you realise oh, there’s one [service] here—I could find out more information. Then it sells itself that way. People get to know.” (African female, age 29, interview 4).
Mainstream one-stop shops more relevant/appropriate for women
“It’s not unusual for women to have issues with family planning and if they were both together in one place it would be a normal thing for any person to understand that oh, this woman has issues with maybe family planning rather than sexual health.” (African male, age 40, interview 5).
Perceptions of confidentiality of general practice
“If they have an immigration authority plus a health issue they will think twice going to a GP knowing that the GP’s connected to the Department of Health and the Minister of Health sits on the same desk as the Minister of Home Affairs and they would not be willing, maybe, to believe that what I say or how much I disclose to my GP would not land in the corridors of power.” (African male, age 32, interview 1).
“Our community is quite small and we might all go to the same GP. It’s just too close to home. I can’t generalise but I think there is a fear of being known or spotted or it may be reported back to your family.” (Indian female, age 25, interview 6).
Convenience of general practice for sexual health
“I mean whatever the problem is, you can go to your GP, so people wouldn’t have a clue what you’re going for. So it leaves a question mark and he or she would feel more comfortable.” (Bangladeshi male, age 35, interview 14).
Cultural barriers to sexual health/one-stop shops
“People from South Asian ethnic backgrounds are generally not very open about sex, it is not talked about and they believe in sex after marriage, and family planning is something that would be passed down by their mothers. For them to attend a GUM clinic would be simply problematic, and I think there would be stigma attached to that. I’m not sure how comfortable they would be talking about it.” (Pakistani female, age 22, interview 3)
“Someone who has been quite promiscuous in their youth and they are now older, they might comply with the stereotype of their generation not being very promiscuous and therefore not attend the clinic and therefore suffer in silence.” (Pakistani male, age 20, interview 2).
Participants had limited knowledge of one-stop shops in general and of the one-stop shop sites participating in the evaluation. The concept was acceptable though there was variation as to the preferred model of care. The focus on community samples is a strength of this work as much data collection on sexual health service needs tends to focus on service users. We also aimed to obtain the perspectives of individuals/groups that may have been under represented in other parts of the evaluation (service user survey and interviews). Although represented in the user survey and interviews, recruitment of black Caribbean adults was unsuccessful in this component. Ample time is needed to foster community trust in the research and to explore alternative recruitment strategies.14 15 The majority of Indian and Pakistani respondents were in their early to mid twenties and many were recruited from college/university settings. Their experiences may therefore differ from older generations and individuals not in further education. The majority of African women were HIV positive and though their views and experiences concurred with other African respondents their perspectives may be influenced by their HIV status. We need to be mindful that broad categories, such as black African and South Asian, mask the heterogeneity of attitudes that may exist between and within specific ethnicities and that socio-economic factors may also influence attitudes and behaviours.
Confidentiality, stigma and anxiety of being recognised at a designated one-stop shop were key concerns for participants. In addition, men felt that, unlike women, the reason for their visit would be obvious in a one-stop shop clinic open to all people. Yet the majority of respondents across groups expressed preference for one provider/one session to address their STI and contraceptive related needs. Service user interviews in another component of the one-stop shop evaluation showed that individuals attending an “all ages” mainstream one-stop shop site that ran separate clinics were not aware they were attending a one-stop shop as they had booked into either a GUM or family planning clinic (set up as separate clinics with different waiting areas but on the same site) but had then received integrated care.7 They did not conceptualise clinics in the same way as providers. This set-up (as opposed to one standalone integrated clinic for all) may be appealing to men who do not see contraception and family planning as relevant to them and who also have concerns that the reason for their visit would be more obvious than women’s. Clear care pathways between specialties would be necessary to facilitate prompt referral of patients needing specialist care. Conceived in this way the one-stop shop also accommodates the client preference for convenience and one provider/one session (integrated care). However this requires dually trained service providers across clinical specialties. There is little consensus as to how integrated training needs may be met across specialties and there remain barriers (structural and cultural) to training development.16
A one-stop shop situated within a general practice setting was acceptable to most South Asian participants and some young heterosexual men. In another component of the evaluation, a population survey showed that general practice is also used by a majority of respondents for sexual health related needs.7 Other studies have shown that many Africans use their GP for sexual health care.17 In contrast, we found barriers that prevent some individuals from doing so. Similarly, some young men’s concerns about confidentiality in general practice is consistent with other studies.18–20 These (mis)conceptions need to be addressed if general practice is to be seen by potential users as an option for sexual health care, particularly as it may be the only locally accessible service for some people. Effort needs to focus at an individual and service/practice level, on addressing both perceptions and provision of confidentiality.
From an acceptability perspective there is no blue print model for a one-stop shop. There is a continued need for community based or outreach services for marginalised, vulnerable, young or minority ethnic individuals who may have difficulty accessing or travelling to centralised services. However, when considering outreach and local provision we need to weigh up the opportunity costs of providing a large one-stop shop with high throughput versus a small service for a limited patient population. Services, therefore, need to be defined and developed based on locally identified need. It may be that further developments in “integrated” training for health providers across settings is a more realistic way to provide integrated services than the development of centralised one-stop shops. Training and resource issues in terms of services adopting a more integrated approach are discussed further elsewhere.7 The development of sexual health services within general practice warrants further investigation.
The perspectives in this paper focus on integration in terms of STIs and contraception only. There is, however, a need to ensure people have access to a broad range of sexual health services (for example, termination of pregnancy, sexual dysfunction and so forth). Ongoing partnership working and implementation of clear care pathways between primary and acute NHS organisations as well as with services from other statutory, independent and voluntary sectors delivering a range of sexual health care is key. A well-established example of a “social model of health” approach to integrated sexual health care that operates across sectors can be found in Scotland.21 The development of formalised “sexual health networks” (linked services, providers and commissioners across sectors) is also under way in some parts of England.5 The applicability of these approaches in different locations warrants further investigation.
Different one-stop shop models of sexual health service provision are acceptable to different population groups; there can be no blue print model.
A common preference is having one provider deliver integrated (both sexually transmitted infection and contraceptive) care.
To accommodate client preference for integrated care, further development of a shared basic “integrated training” for providers of genitourinary medicine and contraceptive services is needed.
The members of the one-stop shop project team are the University of Bristol: Jo Coast, Anna Graham, Debra Gray, Susan Hamilton, Sandra Hollinghurst and Chris Salisbury. University College London: Caroline Coope, Rebecca French, Makeda Gerressu, Catherine Griffiths, Catherine Mercer, Kevin Miles, Angela Robinson and Judith Stephenson. Royal Hallamshire Hospital, Sheffield: Karen Rogstad. We would like to thank the members of the advisory group: Paula Baraitser, Jan Barlow, Gill Bell, Jackie Cassell, Roslyn Kane, Hansa Patel-Kanwal, Alan McOwan, Ian Simms and Connie Smith, and also Ahmed Kazmi for assistance with fieldwork. Finally, thank you to all participating sites and respondents for all their help and support.
Funding: The National Evaluation of One-Stop Shops (OSS) in Sexual Health is funded by the Department of Health. The views expressed in this paper are those of the authors and not necessarily those of the Department of Health.
Competing interests: None.
Ethics approval: Ethics approval was obtained.
Contributors: RSF conceived the study. All authors contributed to study design. CG carried out the fieldwork and analysis for the community component, with assistance from MG. CG led the writing of the paper. All authors contributed to the preparation of the paper.
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