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Identification of young people at risk of sexual ill health: implementing a new tool in youth clinics
Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0002-9282-1142
2021 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Identifiering av unga som riskerar sexuell ohälsa : implementering av en ny metod på ungdomsmottagningar (Swedish)
Abstract [en]

Background: Young people are at increased risk of sexual ill health in terms of sexually transmitted infections, unintended pregnancy, and sexual violence. There is limited knowledge of evidence-based preventive practices for identification of young people at risk of sexual ill health when in contact with health care. 

Aims: The overall aim of this thesis was to generate new knowledge concerning how Swedish youth clinics can work systematically to identify young people at risk of sexual ill health or who have negative sexual experiences. Specific objectives were to develop a risk-assessment model for the identification of youth at risk of contracting chlamydia; to develop and pilot-implement an evidence-informed tool for identifying young people at risk of sexual ill health in terms of sexually transmitted infections, unintended pregnancies, and sexual violence at Swedish youth clinics; and to explore youth clinic visitors’ and staff’s experiences of using that tool. 

Methods: The thesis takes a mixed methods approach and includes four studies. First, data from a national sample of sexually active young people, aged 15–24 years (n=6544), were used to develop a risk-assessment model for chlamydia infection. Second, a risk-assessment tool (SEXual health Identification Tool; SEXIT) was developed and pilot-implemented at three youth clinics for 1 month. The tool includes three components: (1) staff training; (2) a questionnaire for youth clinic visitors; and (3) a written guide for staff to support the subsequent dialogue and risk assessment based on the questionnaire. Questionnaire data from visitors (n=268) and staff (n=18) were analysed. Third, youth clinic visitors’ experiences were explored in 20 interviews with visitors (15–24 years) from the participating youth clinics. Fourth, staff’s experiences of working with SEXIT were investigated in four focus group discussions (n=16). Quantitative and qualitative methods were used for data analyses. 

Results: The risk-assessment model demonstrated that the distribution of chlamydia is skewed; 38% of cases were estimated to occur among a tenth of the population. Women most at risk of chlamydia were best identified using the variables age, number of sexual partners in the past year, and experience of sex for reimbursement. The corresponding variables for men were age, number of sexual partners, and alcohol use. SEXIT was validated and pilot-implemented at three youth clinics (response rate 86%). Before implementation, all staff perceived a need for more systematic screening for sexual risk-taking and sexual ill health at youth clinics. Youth clinic visitors demonstrated between 0 and 7 parallel risk factors. Staff experienced that using SEXIT systematically increased the consistency and quality of the clinics’ work, and youth clinic visitors reported that the questions were important and not uncomfortable or difficult. The visitors explained that questions in a written format followed by a dialogue initiated by the youth clinic staff enabled disclosure of negative experiences. 

Conclusions: The risk-assessment model demonstrates that the number of partners during the past year is the most important risk factor for chlamydia regardless of gender. SEXIT is an acceptable, appropriate, and feasible tool from the perspective of youth clinic staff, youth clinic visitors, and from an implementation point of view. Using the tool systematically may help raise important questions on sexual risk-taking and sexual ill health with youth clinic visitors and identify visitors with multiple risk factors. Being asked the sensitive yet important questions in SEXIT, followed by a respectful and non-judgemental conversation led by the youth clinic staff, has the potential to open up a more in depth and broader dialogue about the visitors’ sexual health. The systematic procedure helps youths feel that they are taken seriously and instils a feeling of trust that enables disclosure of sensitive experiences. From the staff perspective, SEXIT facilitates identification of young people exposed to or at risk of sexual ill health by simplifying and ensuring consistency and quality in their work. 

Abstract [sv]

Bakgrund: Unga människor löper en ökad risk för sexuell ohälsa i form av sexuellt överförbara sjukdomar, oplanerade graviditeter och sexuellt våld. Sexuell ohälsa förblir dock ofta ouppmärksammad eftersom unga sällan berättar om dessa erfarenheter i kontakt med hälso- och sjukvården och vårdpersonal frågar inte regelbundet om riskutsatthet och negativa sexuella erfarenheter. Det finns tämligen begränsad kunskap om hur vården kan arbeta evidensbaserat för att identifiera unga personer som riskerar sexuell ohälsa så att ytterligare risktagande och ohälsa kan förebyggas. 

Syfte: Det övergripande syftet med avhandlingen var att utveckla kunskap om hur svenska ungdomsmottagningar kan arbeta mer systematiskt för att identifiera unga som riskerar sexuell ohälsa eller har negativa sexuella erfarenheter. Delstudiernas specifika syften var: 1) att utveckla en riskbedömningsmodell för identifiering av unga som riskerar klamydia; 2) att utveckla och pilot-implementera en vetenskapligt underbyggd metod för användning på ungdomsmottagningar i syfte att identifiera unga som riskerar sexuell ohälsa; 3) att undersöka ungdomsmottagningsbesökarnas erfarenheter av metoden; samt 4) att undersöka personalens erfarenheter av att arbeta med metoden. 

Metoder: Avhandlingen använder både kvantitativa och kvalitativa metoder i en mixad-metod-ansats. Studie I bygger på data från ett nationellt urval av unga, 15–24 år (n=6544), för att utveckla en riskbedömningsmodell för klamydia. I studie II utvecklades en metod (SEXual health Identification Tool; SEXIT) som pilot-implementerades på tre ungdomsmottagningar i Västra Götaland under en månad. SEXIT består av tre delar: utbildning för personal, ett formulär för besökare och en guide för att stödja personal i det efterföljande samtalet och riskbedömningen. Enkätsvar från både besökare (n=268) och personal (n=18) samlades in. I studie III intervjuades 20 unga personer (15–24 år) som besökt en ungdomsmottagning då SEXIT användes. I studie IV hölls fyra fokusgruppsdiskussioner med personal (n=16) från de deltagande ungdomsmottagningarna.

Resultat: Riskbedömningsmodellen för klamydia visade att klamydia är ojämnt fördelad bland unga. En tiondel av de unga beräknades stå för 38% av klamydiafallen under en treårsperiod. För kvinnor var de viktigaste riskfaktorerna ålder, antal sexpartners det senaste året och erfarenhet av att ta emot ersättning för sex. Motsvarande för män var antal sexpartners det senaste året samt alkoholkonsumtion. Samtlig personal menade att det fanns ett behov av ett mer systematiskt arbete med att identifiera unga som riskerar sexuell ohälsa på ungdomsmottagningar. Besökarna som besvarade SEXIT uppvisade stor variation i riskutsatthet och angav 0 till 7 parallella riskfaktorer. Personalen bedömde att systematisk användning av SEXIT med alla besökare ökade både kvalitén och jämlikheten i den vård som erbjöds, samt att metoden underlättade bedömningen av riskutsatthet. Besökarna svarade att frågorna i SEXIT var viktiga och varken svåra eller obehagliga att besvara. Vidare ansåg besökarna att formatet med skriftliga frågor med fasta svarsalternativ som besvaras enskilt och följs upp i ett samtal med personalen, möjliggjorde att berätta om negativa erfarenheter som annars kan vara svåra för dem att ta upp i vårdmötet. 

Slutsatser: Gruppen unga som löper ökad risk att få klamydia kan identifieras med en riskbedömningsmodell där antalet partners under det senaste året är den enskilt viktigaste riskfaktorn oavsett kön. SEXIT är en välfungerande och uppskattad metod både ur vårdpersonalens och besökarnas perspektiv. Systematisk användning av SEXIT säkerställer att alla besökare får möjlighet att samtala kring sexuellt risktagande och sexuell ohälsa, samt hjälper personalen att uppmärksamma besökare som rapporterar flera parallella riskfaktorer och är i större behov av råd och stöd. Att ställa de potentiellt känsliga men viktiga frågorna i SEXIT, följt av ett respektfullt och icke-dömande samtal som leds av vårdgivaren, har potential att öppna upp för en fördjupad och utökad dialog om besökarens sexuella hälsa. Rutinen att SEXIT erbjuds alla men också är frivilligt att besvara, fick besökarna att känna att ungdomsmottagningen var angelägna om ämnen som också var viktiga för besökarna, men att de samtidigt respekterade besökarnas integritet. Rutinen bidrog till att skapa en känsla av tillit som underlättade att berätta om svåra erfarenheter. Ungdomsmottagningens personal upplever att SEXIT säkerställer kvalitet och kontinuitet i deras arbete och underlättar identifiering av unga som riskerar eller har erfarenhet av sexuell ohälsa. Implementeringen av SEXIT fungerade väl, men försvårades av att det ännu inte är införlivat i befintliga kliniska rutiner såsom journalföring och svårigheter att hinna med SEXIT under drop-in mottagning. Det fanns en viss ambivalens hos kuratorer och psykologer kring att använda SEXIT med samtliga besökare eftersom de är vana vid att individanpassa sina metoder.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2021. , p. 101
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1784
Keywords [en]
Adolescents, Chlamydia, Implementation, Risk assessment, Sexually transmitted infections, Sexual violence, Unplanned pregnancy, Youth clinic.
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:liu:diva-178042DOI: 10.3384/diss.diva-178042ISBN: 9789179296384 (print)OAI: oai:DiVA.org:liu-178042DiVA, id: diva2:1581343
Public defence
2021-09-06, Belladonna, Building 511 and online (Zoom)., Campus US, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Note

Funding agencies: Financial support was received from the Healthcare Committee, Region Västra Götaland; the Medical Research Council of Southeast Sweden; the Research and Development Centre of Gothenburg and Södra Bohuslän; and Knowledge Centre for Sexual Health, Region Västra Götaland.

Available from: 2021-07-21 Created: 2021-07-21 Last updated: 2023-12-28Bibliographically approved
List of papers
1. Identification and risk assessment of Swedish youth at risk of chlamydia
Open this publication in new window or tab >>Identification and risk assessment of Swedish youth at risk of chlamydia
2015 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 43, no 4, p. 399-407Article in journal (Refereed) Published
Abstract [en]

Aims: The aim of the study was to identify youth at high risk of chlamydia including variables related to sexual health and negative experiences of sexuality. Methods: In late 2009, a questionnaire on sexuality was answered by Swedish youth. The study sample was self-selected from different Internet communities. Data from 6544 sexually active participants, aged 15?24 years, were analyzed in a multivariable logistic regression model. Discriminative power was measured by the area under the receiver operating characteristic curve. Results: In the univariate analysis, self-reported chlamydia was associated with most risk behavior variables, experience of coerced sex, and reimbursement for sex, with slight gender variation. The factors that best predicted self-reported chlamydia among females were number of partners, age, and having been reimbursed for sex. Among males, the number of partners and alcohol consumption were the strongest predictors. Increasing number of partners up to 10 during the past 12 months was the most important predictor for both genders. A skewed distribution of chlamydia was demonstrated, in that 37.6% of cases in females and 38.6% in males were estimated to occur among a tenth of the population. Conclusions: Testing, prevention, and care for chlamydia should be directed toward those most at risk, as they account for a large proportion of the total number of chlamydia cases. The special needs of the high-risk group need to be acknowledged and chlamydia regarded as a possible marker for risk behavior and negative sexuality experiences.

Place, publisher, year, edition, pages
SAGE Publications Ltd STM, 2015
Keywords
Youth, adolescents, chlamydia infection, risk assessment, sexual risk behavior, number of sexual partners, alcohol consumption, reimbursed for sex, Sweden
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-178039 (URN)10.1177/1403494815572722 (DOI)
Conference
2021/07/20
Available from: 2021-07-21 Created: 2021-07-21 Last updated: 2023-12-28Bibliographically approved
2. Identifying young people exposed to or at risk of sexual ill health: pilot implementation of an evidence-informed toolkit (SEXIT) at Swedish youth clinics
Open this publication in new window or tab >>Identifying young people exposed to or at risk of sexual ill health: pilot implementation of an evidence-informed toolkit (SEXIT) at Swedish youth clinics
Show others...
2019 (English)In: European journal of contraception & reproductive health care, ISSN 1362-5187, E-ISSN 1473-0782, Vol. 24, no 1, p. 45-53Article in journal (Refereed) Published
Abstract [en]

Objectives: We aimed to develop and pilot-implement an evidence-informed toolkit (SEXual health Identification Tool; SEXIT) for identifying young people exposed to or at risk of sexual ill health, at Swedish youth clinics, and to investigate SEXITs potential to identify young people in need of special care and monitoring. Methods: The SEXIT toolkit was developed, validated and pilot-implemented at three Swedish youth clinics. Pre-implementation staff readiness was assessed and youth clinic visitors responses to SEXIT were analysed. Results: All staff perceived a need for screening for sexual risk-taking and exposure. The response rate from 268 youth clinic visitors (aged 15-24 years) was 86%. Half of the visitors had one or no variable associated with sexual ill health, a third had two or three, and 15% reported between four and seven variables. The most common variables were alcohol use, three or more sexual partners in the past year and previous chlamydia. Visitors rated SEXIT as important and not uncomfortable or difficult to answer. Conclusions: The SEXIT toolkit was found to be feasible and highly acceptable in a clinical setting. The use of SEXIT may facilitate important questions on sexual risk-taking and sexual ill health to be raised with youth clinic visitors.

Place, publisher, year, edition, pages
TAYLOR & FRANCIS LTD, 2019
Keywords
Adolescents; implementation; risk assessment; sexual behaviour; sexual violence; young adults; youth clinic
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-156216 (URN)10.1080/13625187.2018.1564815 (DOI)000461893000010 ()30730215 (PubMedID)
Note

Funding Agencies|Public Health Agency of Sweden [03393-2015]; Healthcare Board, Region Vastra Gotaland, Sweden [VGFOUREG-573441]; Medical Research Council of Southeast Sweden [FORSS-664621]

Available from: 2019-04-09 Created: 2019-04-09 Last updated: 2023-12-28
3. Ask me, listen to me, treat me well and I shall tell: a qualitative study of Swedish youths’ experiences of systematic assessment of sexual health and risk-taking (SEXIT)
Open this publication in new window or tab >>Ask me, listen to me, treat me well and I shall tell: a qualitative study of Swedish youths’ experiences of systematic assessment of sexual health and risk-taking (SEXIT)
Show others...
2022 (English)In: Sexual and Reproductive Health Matters, E-ISSN 2641-0397, Vol. 30, no 1, article id 2146032Article in journal (Refereed) Published
Abstract [en]

Sexual ill health among young people, in terms of sexually transmitted infections (STIs), unintended pregnancy, transactional sex and sexual violence, is a global public health concern. To that end, the SEXual health Identification Tool (SEXIT) was developed. The purpose of this study was to explore the visitors’ experiences of a youth clinic visit when SEXIT was used. A purposively selected sample of 20 participants (16–24 years of age) was recruited from three Swedish youth clinics using SEXIT. Participants were interviewed individually in March and April 2016, and data were analysed using inductive qualitative content analysis. The analysis resulted in four main categories describing the participants’ experiences of using SEXIT: “Issues of concern” includes descriptions of the items in SEXIT as important; “Enabling disclosure” describes how SEXIT serves as an invitation to talk and facilitates disclosure of negative experiences; “Road to change” captures experiences of the conversation with the healthcare professional; and “Managing power imbalance” describes experiences regarding the response and attitudes of the healthcare professional as well as the participants’ fears of being judged. The categories are connected by the overarching theme “Ask me, listen to me, treat me well and I shall tell”. This study contributes knowledge on young people’s experiences of a tool-supported dialogue on sexual health and risk-taking initiated by the healthcare professional. Structured questions in a written format, as a basis for dialogue, are appreciated and experienced as a functioning way of addressing sexual ill health and risk-taking at Swedish youth clinics.

Place, publisher, year, edition, pages
Taylor & Francis, 2022
Keywords
adolescents, risk assessment, sexual behaviour, sexually transmitted infections, sexualviolence, qualitative research, young adults, youth clinic, unintended pregnancy
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-190422 (URN)10.1080/26410397.2022.2146032 (DOI)000893738600001 ()36476113 (PubMedID)
Available from: 2022-12-08 Created: 2022-12-08 Last updated: 2023-12-28Bibliographically approved
4. Staff’s experiences of a pilot implementation of the SEXual health Identification Tool for assessing sexual ill health among visitors to Swedish youth clinics: A focus group study
Open this publication in new window or tab >>Staff’s experiences of a pilot implementation of the SEXual health Identification Tool for assessing sexual ill health among visitors to Swedish youth clinics: A focus group study
Show others...
2021 (English)In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 29, article id 100643Article in journal (Refereed) Published
Abstract [en]

Background

Young people are disproportionally burdened by sexual ill health. The SEXual health Identification Tool (SEXIT) was developed for use at youth clinics, to facilitate identification of visitors exposed to or at risk of sexual ill health. The aim of this study was to explore experiences of using SEXIT among youth clinic staff who participated in a pilot implementation, with a focus on usefulness, implementation determinants, and feasibility of implementing SEXIT at Swedish youth clinics.

Methods

Four focus group discussions were conducted with youth clinic staff from three clinics. The clinics had used SEXIT systematically in consultations with all visitors for one month. Data were analysed using qualitative analysis designed for focus groups.

Results

Most participants experienced that the SEXIT routines were well functioning and that using SEXIT gave a comprehensive picture of the visitor and resulted in more concrete answers, which facilitated the risk assessment. The medical staff experienced that they identified more youth at risk with SEXIT, while the psychosocial staff were less convinced. Existing challenges related to the routines at the clinics and heavy workload during drop-in hours.

Conclusions

Staff experience SEXIT as useful for identifying young people exposed to or at risk of sexual ill health. Systematic use ensures consistency and quality in assessing the visitors, which may facilitate implementation. The use of SEXIT is challenged by heavy workload, conflicting routines, and the experience that some visitors identified through SEXIT decline further care. Implementation of SEXIT in Swedish youth clinics is considered feasible.

Place, publisher, year, edition, pages
Elsevier, 2021
Keywords
Adolescent, Implementation science, Risk assessment, Sexually transmitted infections, Sexual violence, Qualitative research
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-178041 (URN)10.1016/j.srhc.2021.100643 (DOI)000696626800007 ()
Note

Funding agencies: This work was supported by the Healthcare Committee, Region Västra Götaland, Sweden [grant number VGFOUREG-573441, 643461, 843361]; the Medical Research Council of Southeast Sweden [grant number FORSS-664621, 851251]; and a doctoral grant from the Research and Development Centre of Gothenburg and Södra Bohuslän.

Available from: 2021-07-21 Created: 2021-07-21 Last updated: 2023-12-28Bibliographically approved

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