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What do young people in high-income countries want from STI testing services? A systematic review
  1. Joscelyn Gan1,
  2. Varsicka Kularadhan2,
  3. Eric P F Chow3,4,5,
  4. Christopher K Fairley3,4,
  5. Jane S Hocking5,
  6. Fabian Y S Kong6,
  7. Jason J Ong3,7
  1. 1 Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
  2. 2 School of Rural Health, Monash University, Bendigo, Victoria, Australia
  3. 3 Central Clinical School, Monash University, Carlton, Victoria, Australia
  4. 4 Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia
  5. 5 Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
  6. 6 Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Victoria, Australia
  7. 7 Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
  1. Correspondence to Miss Joscelyn Gan, University of Melbourne Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia; joscelyn.gan{at}gmail.com

Abstract

Background There are upward trends of STI rates among young people in most high-income countries. We reviewed the literature to provide a summary of information to support health services with the aim of increasing testing of STIs among young people living in high-income countries.

Methods We conducted a systematic review (Prospero: CRD42020179720) using PubMed, Embase, PsychINFO and CINAHL. The search was performed on 10 January 2020 for studies between January 2000 and 10 January 2020. Two reviewers independently screened articles, and any discrepancies were resolved by a third reviewer. Studies were included if they were performed in high-income countries and contained data on both young people (<26 years) and STI testing preferences. Data regarding the characteristics of STI testing services that young people preferred was extracted. We categorised these characteristics using the framework of a social-ecological model.

Results We identified 1440 studies, and 63 studies were included in the final review. We found 32 studies that addressed individual factors, 62 studies that addressed service factors and 17 studies that addressed societal factors. At an individual level, we identified eight attributes including the need for improved sexual health education. At a service level, 14 attributes were identified including preferences from different subgroups of young people (such as sexual and ethnic minorities) for the types of services. At a societal level, we identified two attributes including the need to address stigma associated with STIs.

Conclusion We provide an overview of the growing body of literature capturing the preferences of young people for STI testing services. To optimise the uptake of STI testing among young people, factors from all socioecological levels should be considered. In addition, understanding and accounting for distinct preferences from subgroups of young people could increase demand for STI testing services for those at greatest need.

  • health services research
  • delivery of health care
  • qualitative research
  • sexual and gender minorities
  • sexual health

https://doi.org/10.1136/sextrans-2021-055044

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    Background

    STIs remain a major global health problem; it is estimated that there are a million new curable STIs detected a day.1 In particular, young people are particularly vulnerable to acquiring STIs due to multiple biological, behavioural and environmental factors.2 3 These may include behaviours that increase their risk (condomless sex, number of partners, etc), avoidance of testing due to concerns regarding perceived lack of confidentiality and stigma associated with STIs, as well as inadequate knowledge about STIs.4–7 Equally important are structural factors that could limit access to STI testing and treatment.8–12

    High-income countries report a worrying rise in STI rates. For example, reports from the USA, Canada, Australia and Europe all show an increase in chlamydia and gonorrhoea cases among young people.2 13–17 In 2017, 73% of reported chlamydia cases in Australia were among young people aged 15–29 years.14 Similar findings were reported in Canada, which also noted an increase of gonorrhoea cases by 65% among people aged 20–25 years from 2013 to 2017.17

    Early detection and management of STIs is critical for the public control of STIs. In addition, at the individual level, early detection and management reduces the likelihood of the sequelae of STIs (pelvic inflammatory disease, infertility, chronic pelvic pain, etc) and onward transmission.18 However, one of the biggest challenges of controlling STIs is the asymptomatic nature of STIs. Without symptoms or warning cues, young people who carry STIs may not seek testing.19–21

    With multiple ways to improve access to STI testing, through sexual health clinics, general practice (GP), online STI testing services and home kits, there should be a testing service that suits the preferences of different demographics. As there are so many options available, it is important to understand which attributes of these services young people prefer, so that services can be better tailored towards the needs of this high-risk population.

    In recent years, there has been a growing body of literature that examine the preferences of STI testing and management among young people; however, to our knowledge, there has not been a systematic review to synthesise the preference literature on this topic. This review aims to provide an overview of the attributes of STI testing services that facilitate or discourage young people to get tested for STIs, including HIV.

    Method

    Eligibility criteria and search strategy

    We conducted a systemic review (Prospero: CRD42020179720) of the existing literature on the attributes of STI testing services among young people (age less than 26 years old) living in high-income countries. We included articles published from January 2000 to 10 January 2020. The search was conducted using four databases: PubMed, Embase, PsychINFO and CINAHL. Additional studies were included from searches of the reference lists of the included articles. The search terms included: (1) terms related to STIs, (2) health services and (3) testing or patient preferences. Search terms were: (“sexually transmitted infection” OR “sexually transmitted disease” OR “STI” OR “STD”) AND (“health service” OR “sexual health service”) AND (“testing” OR “preference” OR “patient preference” OR “perspective” OR “acceptability” OR “experience” OR “satisfaction”). Further details of the search strategy can be found in online supplemental file 1.

    Supplemental material

    Inclusion and exclusion criteria

    Studies were included if they were conducted in a high-income country and had primary data on the preferences of young people for STI testing services. High-income countries were determined according to The World Bank Group classification as of January 2020.22 Studies that were published in languages other than English and published before January 2000 were excluded. No restrictions were placed on the type of study designs included to encapsulate the breadth of information available. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.23 The PRISMA checklist can be found in online supplemental file 2. A list of excluded studies can be found in online supplemental file 5.

    Analysis

    The data on attributes, preferences, demographics and study of origin were extracted independently by two reviewers (JG and VK). The two reviewers then carefully read through each study to identify codes for thematic analysis.24 This was also conducted independently. Three reviewers (JG, VK and JJO) discussed the identified codes, which included ‘individual experiences and perceptions’, ‘knowledge’, ‘testing methods’, ‘testing services’ and ‘societal factors’. Once the data were coded, themes were identified and developed, independently. Three reviewers (JG, VK and JJO) discussed and finalised the themes using an inductive approach and further classified them into ‘individual factors’, ‘service factors’ and ‘societal factors’. The results were then further analysed to observed for trends and patterns. The quality of studies was assessed using the PREFs checklist, a tool used to assess the quality of studies examining preferences.25

    Results

    The search yielded 1440 studies. After screening the titles and abstracts, 219 full texts were analysed, and 52 studies were included in this review. After reading through the studies, 11 additional studies were handpicked from the reference lists. Additional studies were selected from screening the reference lists of included studies to ensure we were capturing relevant studies that may not have been included from the initial search. These studies were included if they met the inclusion criteria. This process continued until no further attributes were found and the reviewers felt comfortable that the majority of studies and attributes had been included. In total, 63 studies were included in the final review (figure 1).

    Figure 1
    Figure 1

    PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

    The majority of studies were from the USA,9 10 26–39 UK,5–7 36 40–60 Canada,11 61–64 Australia8 20 65–70 and New Zealand.4 19 Many of these studies focus on young people as a broad risk group.4 6 7 12 19 21 29 31 32 36 38 41–43 45–47 49–53 55 56 59 61–69 71 72 Others studied the preferences of young people living in disadvantaged areas,11 40 44 48 57 58 73 or rural towns,8 20 sexual minorities,5 9 10 26–28 33 34 37 70 74 75 or ethnic minorities,5 28 30 33 35 40 44 54 58 first-time testers60 and low-risk young people.76

    An overview of attributes using a socioecological framework is shown in figure 2. At an individual level, we identified eight attributes including the need for improved sexual health education. At a service level, we identified 14 attributes including preferences from different subgroups of young people (such as sexual and ethnic minorities) for the types of services, availability of self-testing or self-collection and tester attitude. At a societal level, we identified two attributes including the need to address stigma associated with STIs. The methodologies used for each study is shown in table 1, and the study quality assessment is provided in online supplemental file 3.

    Figure 2
    Figure 2

    Overview of attributes and examples using a socioecological model.

    View this table:
    Table 1

    Summary of included studies

    Individual factors

    A summary of individual factors is described in table 2.

    View this table:
    Table 2

    Identified attributes of STI testing services – individual factors

    Knowledge, attitudes and perceptions

    Eight studies suggested that young people did not seek STI testing due to insufficient knowledge about STIs, its sequalae and misconceptions about STIs.4 6 11 21 26 42 44 65 Eleven studies observed that young people were not seeking testing due to beliefs that they were of low risk or that testing was not relevant to them.4 6 20 21 38 43 63 65 69–71 Two studies noted that young people with previous knowledge of STIs and testing were more likely to accept STI testing.19 21 However, one study suggested that knowledge alone was insufficient to encourage STI testing behaviours. This Australian study that investigated the knowledge and attitudes regarding sexual health among regional university students found that while the participants had sound knowledge on STIs, only 58.8% reported having discussed a sexual health topic with a healthcare professional (HCP) and only about one-third of sexually active participants had screened for chlamydia in the last 12 months.67

    Testing experience

    Nine studies noted that factors that provoked feelings of embarrassment among young people discouraged them to seek STI testing.4 12 20 35 43 55 65 69 75 Ten studies suggested that reducing embarrassment was an important factor to encourage more testing.20 29 42 48 55–57 59 62 70 Ways to reduce embarrassment included been seen quickly and appropriately, having options for home-based testing, making the patient feel comfortable, allowing patients to build familiarity with the health service and employing staff who were trained to provide quality treatment/advice.20 42 48 56 59 70 Reporting previous bad experiences with STI testing discouraged further testing.9 11 One study observed that less invasive testing options were preferable among young people seeking HIV testing.29

    Nine studies described the characteristics of the testers as having an important influence on young peoples’ experiences using a STI testing service.4 6 42 44 46 50 52 63 This included a preference for staff to collect the samples,46 had specialist knowledge44 50 and the gender of the tester.4 6 42 46 52 63

    Self-testing and self-collection

    Seventeen studies indicated that the availability of self-testing or self-collection was an appealing option for young people being tested for STIs.4 10 28 29 35 36 40 42 46 58 62 68 70 71 73 74 76 Self-testing and self-collection were viewed as an apealing option due to its convenience and ability to reduce embarrassment and maintain privacy.

    However, nine studies described limitations and hesitations towards self-collection or home testing options among young people.6 10 20 39 42–44 73 74 This included being worried about incorrectly performing the home-based test, with some even preferring to see a doctor to avoid this.74 Similarly, an randomised control trial (RCT) from America involving 186 transgender youth found similar concerns about home HIV tests, with particular worries about performing and interpreting the test correctly.39 Three studies raised concerns regarding testing kits or treatments being sent to their homes.10 20 44 This was due to fears of their parents finding out or initiating uncomfortable conversations. In regard to self-collected urine samples, there were issues with the need to return the sample to the clinic or a specified drop off location.6 42 43 73 Despite these challenges of self-testing and self-collection, several studies presented several solutions.10 20 28 40 These solutions included increasing awareness of newer HIV self-testing options, offering a variety of self-testing options, providing these self-testing kits for free and ensuring that their usage of these kits remains non-visible on their electronic devices.

    Service factors

    A summary of service factors is described in table 3.

    View this table:
    Table 3

    Identified attributes of STI testing services – service factors

    Provision of services

    Fifteen studies found that in-person services such as GP clinics, sexual health clinics and specialty clinics were acceptable locations for STI testing among young people.6 9 33 34 37 42 46 48 51 55 59 62 66 69 75 Reasons included familiarity with the services, rapport with staff, convenience of location, apparent discreteness and the security of test results and confidentiality.6 7 34 42 46 48 55 59 75 A summary of preferences among different subgroups of young people can be found in online supplemental file 4.

    Two American studies found that young black men who have sex with men (YBMSM) preferred to be tested for STIs in a clinical setting.33 75 One study that surveyed 108 young black men living in San Francisco noted that 86.5% preferred to seek care at a STI testing venues like GP surgeries or specialty clinics compared with alternative testing sites such as work, schools and pharmacies.33 However, this study did not explore the reasons for this preference. A focus group study compromising of YBMSM living in Alabama observed that participants preferred attending clinical testing sites due to an increased sense of privacy, availability of immediate treatment and opportunities to develop a trusting relationship with their healthcare provider.75

    Five studies observed online STI and/or HIV testing services that used home-based or smartphone-enabled tests were viewed favourably among young people.20 40 43 60 62 Reasons for this were multiple, examples included being easy to use, time saving, less embarrassing, increased control over when to be tested, protection of privacy and anonymity.20 40 43 62

    Three studies noted that pharmacies were not acceptable locations for STI testing among young people.7 46 72 One of these studies was a UK study assessing where young people wanted chlamydia screening services to be located. It was found that over 90% of respondents rejected the idea of pharmacy testing.46 Similarly, an American study that investigated the acceptability of pharmacy testing among young females seeking emergency contraception found that while this method was feasible, the low uptake of the service indicated low acceptability.72 Two of these studies suggested that this may be explained by the high visibility in a public setting.7 46

    Several studies emphasised that young people desired having multiple types of services available.10 34 49 75 For example, an American study that looked at the experiences of STI testing among YMSM noted that participants used various service providers, including primary care physicians, specialty clinics and emergency rooms.34

    Privacy and confidentiality

    Twenty-six studies highlighted that young people valued the maintenance of privacy, confidentiality and data security as important features of STI testing.4 6–10 20 28 31 38 40 41 44 47 48 51 52 54–57 61 62 65 70 75 This might be an HCP who provides assurance of confidentiality, ensuring private waiting rooms and anonymous services that do not mandate identification documents to access the service.8 10 39 74 Six studies that specifically examined the acceptability of online services noted that confidential, privacy and data security were highly desirable features of that service.10 20 40 44 57 62

    Cost and speed

    Eleven studies noted that free or inexpensive STI testing was an important enabler for young people.4 7 20 28 41 44 56 61 67 68 72 A previously mentioned New Zealand study found that many participants preferred free testing and would only consider paying if they were involved in a high-risk activity or developed symptoms.4

    Ten studies noted that young people were less likely to engage in STI or HIV testing if a cost was involved.8–10 28 34 38 39 46 65 75 Five of these studies highlighted that a reason may be due to a lack of health insurance.9 34 38 65 75

    Twelve studies found that fast time to results and speed of testing were highly favourable factors among young people.4 10 27–30 36 39 40 44 53 62 Two discrete choice experiments performed in the UK, which assessed preferences among STI service attendees, found participants favoured same-day results over the standard waiting time of 7 days.36 53 Ten studies noted that rapid testing and the fast processing of tests were highly favourable among young people, primarily because of faster linkage to treatments and shorter appointments.4 10 27–30 39 40 44 62

    Tester reputation and attitudes

    One study noted that the reputation of a service may also play a factor in the decision of young people attending a sexual health service. An American study, which looked at the preferences of YBMSM and transgender youth noted that the participants were more reluctant to attend a service that was unfamiliar to them or had a poor reputation.9

    Twelve studies observed that the attitudes of the testers were also influenced young people’s willingness to seek STI testing.6 8 9 11 31 34 42 44 54 56 61 75 Eight studies demonstrated that young people appreciated testers with non-judgemental attitudes.6 8 11 34 42 54 56 61 This also seemed to reduce feelings of shame and embarrassment during the consultation. Other favourable tester characteristics included friendliness, respect, compassionate and culturally competent.8 31 54 56 75 Participants that felt mistreated, judged or threatened by a service were less likely to return.9 11 44

    Delivery of results

    Nine studies discussed young people’s preferences regarding test result delivery or which results they wanted to receive.36 45 47 50 51 53 66 68 73 Three studies performed in the UK observed that young people preferred to receive all results, regardless as to whether they were positive or negative.45 50 53 Six studies found that there was a preference for results to be delivered by calls to mobile over text, email or mail.45 47 50 51 66 73 However, three studies noted that there was a preference to receive STI/HIV results through in-person consultations.33 45 64 The reasons for this were not explored further.

    Societal factors

    A summary of societal factors is described in table 4.

    View this table:
    Table 4

    Identified attributes of STI testing services – societal factors

    Stigma associated with STI testing and fear of being found out

    Eleven studies found that one of the major barriers to young people seeking STI testing was the associated stigma and embarrassment associated with it.4 5 7 8 10–12 41 43 44 66 In particular, 10 studies noted young people were concerned that seeking STI testing would reveal their sexual activity.6–8 10 41–44 65 75 Of these, six studies suggested that young people were worried that their parents would find out about their sexual activity if they got tested for STIs.6 8 10 42 44 65

    Discussion

    To our knowledge, this is the first systematic review that summarises the preferences for STI testing services among young people living in high-income countries. Other reviews have either focused on interventions rather than preferences or have taken place in a low-income to middle-income setting.77–82 Our review contributes to the literature by using a socioecological framework to provide an overview of the attributes of STI testing services examined by studies and the preferences among young people for these attributes. Though many different preferences for STI testing services among young people were identified, an ideal STI testing service would be most attractive to young people if it addresses attributes across all three socioecological levels. This study provides a list of attributes that should be considered when designing a STI testing service for young people. A summary of these can be found in table 5.

    View this table:
    Table 5

    Summary of attributes to consider when designing an STI testing service for young people

    To improve access and utilisation of STI testing services across the young people population and decrease STI incidence, testings services should take into consideration the attributes explored in this paper and the preferences of subpopulations they wish to target. From the literature, it is clear that there are subpopulations within the young people population that seem to carry a higher burden of STIs. These subpopulations include sexual minorities, transgender and those with lower access to healthcare services.83–87 Designing a service with the preferences of these groups could have a more meaningful impact on the rising rates of STIs. More research is needed to understand the preferences of these high-risk populations living in high-income countries. Out of 63 studies analysed, less than 50% of these examined the preferences of high-risk young people to some degree. Eleven studies explored the preferences of sexual minorities,5 9 10 26–28 33 34 37 70 74 75 nine studies explored the preferences of ethnic minorities,5 28 30 33 35 40 44 54 58 seven studies explored the preferences of young people experiencing socioeconomic disadvantage11 40 44 48 57 58 73 and two assess the preferences of young people in a rural or regional context.8 20 For young people and health services to benefit from these suggestions, an intersectional response that considers attributes across all socioecological levels is needed.

    Service level attributes may be more easily modified to support and increase STI testing for young people. For example, ensuring a pleasant testing experience by optimising waiting times, staffing centres who are competently trained with non-judgemental attitudes and providing options for self-collection of specimens are important to encourage more testing.20 29 42 48 56 57 59 62 70 Preferable service-level attributes common among the studies include ensuring high levels of confidentiality and privacy, the employment of friendly and non-judgemental staff, fast processing of tests and reduced time to results, and at a minimal cost.4 6–10 20 28 30 31 36 38 40 41 44 47 48 51–57 61 62 65 67 68 70 72 75 Several studies highlighted the differences of preferences among subpopulations of young people.9 33 34 37 39 75 For instance, a focus group of sexual and ethnic minorities from Alabama, Chicago and San Francisco reported a preference to see their private doctor or visit a clinic for STI testing rather than use home-based testing.75 In contrast, low-risk, asymptomatic, heterosexual young people in the Netherlands were comfortable in using a home collection kit.76 Similarly, young people who required retesting for chlamydia in Australia found that home-based testing was highly favourable.70 Most studies included found that young people prefer to use in-person or online services that were free and maintained confidentiality compared with pharmacies and other alternative testing means. Feeling comfortable and respected were also important factors for young people during the testing process. Where possible, the fast processing of results should also be used to reduce anxiety associated with testing and improve access to better health outcomes. Together, our review suggests that deriving local preferences is important and that a diversity of services may be required to address the different needs of young people.

    Of the included studies, only six (9.5%) took a multilevel approach to assess young people’s preferences.4 6 7 44 55 65 These studies agreed that to effectively increase testing and demand for STI testing among young people, all socioecological levels should be considered in the response of testing services. Of six studies, two studies suggested that increasing awareness of STIs and having different testing options were particularly important.6 10 One paper recommended that the key to increase testing among young people would include a holistic approach with an emphasis on social and cultural factors.4 However, as these are only a few studies with different populations and settings, it is difficult to conclusively determine if one socioecological level was more influential than the other.

    The strength of this review includes its broad collection of preferences from multiple studies. This enabled us to identify preferences for STI testing attributes that were common among young people and those that were unique to particular risk groups among young people. This study has several limitations. First, as this study was part of a larger study to identify the preferences of high-risk groups, the search strategy was not tailored specifically to young people. However, we addressed this by screening the references lists for additional studies to include in our analysis. In addition, we stopped looking for new studies when we did not find any new attributes and was satisfied that data saturation was achieved. However, we may have still missed studies that specifically assessed high-risk young people. Second, we excluded articles not written in English that may limit the generalisability of our findings to English-speaking contexts. Most papers included in this study did not explore in detail the potential for different preferences among subpopulations of young people. We recommend that future research carefully explore the heterogeneous values and preferences among subpopulations of young people. Furthermore, as most studies were from either the USA, UK, Canada, Australia or New Zealand, it is important to confirm these findings in other settings.

    Conclusion

    Assessing the preferable attributes of young people living in high-income countries regarding STI testing services is an important area of research; hence, this review is therefore timely and necessary for synthesising these data. Addressing attributes across all socioecological levels through an intersectoral response could improve the uptake of STI testing among young people and reduce the overall incidence and burden in high-income countries. This would also involve addressing the current barriers to accessing testing that impact demand. More research regarding subpopulations of young people at higher risk for STIs is warranted to further target resource allocation efficiently and equitably.

    Key messages

    • With rising incidence of STIs among young people in high-income countries, testing services and governments need to look at ways to reduce the burden of disease.

    • We systematically reviewed studies that reported the preferences of young people for STI testing services and summarised the findings using a socioecological framework.

    • To effectively decrease the incidence of STIs among young people, services need to consider attributes across all socioecological levels to inform an intersectoral response.

    • Further research is needed to determine the preferences from subpopulations of young people to support them seeking STI testing.

    Ethics statements

    Patient consent for publication

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    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • JG and VK are joint first authors.

    • Handling editor Laith J Abu-Raddad

    • Twitter @EricPFChow, @kitfairley, @DrJasonJOng

    • Contributors All authors have contributed significantly to, seen and approved the final submitted version of the manuscript. JJO conceived the study idea and design. JG and VK are equal cofirst authors and led the study, including independently screening articles and performed the data extraction and analysis. JG supported the article screening, data extraction and analysis. All authors contributed to various drafts of the manuscript. All authors read, provided feedback and approved the final manuscript. The study was submitted by JG.

    • Funding JJO and EPFC are supported by the Australian National Health and Medical Research Council Emerging Leadership Investigator Grant (GNT1193955 and GNT1172873, respectively).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.