Abstract
The study examined willingness to engage in patient-delivered partner screening (PDPS) and preferences for expedited partner services (EPS). Forty urban U.S. sexually transmitted infection (STI) clinic patients participated in individual mixed-methods interviews exploring EPS preferences and PDPS willingness. Most participants selected PDPS and PDPT together and uptake varied by patient–partner relationship closeness. For PDPS, several potentially important barriers and benefits were identified. Perceived benefits included improved sexual health for patients and their sexual partner(s) as well as convenience, privacy, and the potential to enhance trust between sexual partners. Perceived barriers included concerns about PDPS processes (e.g., time it would take to receive the result, risk of sample contamination), the accuracy of results, STI stigma and associated blame, lack of trust for a sexual partner, and the packaging/appearance of the screening kit. PDPS affords benefits and may overcome treatment barriers in some situations; however, it shares common PDPT barriers and has its own unique challenges. There are also concerns regarding how the offer of PDPS may interact with PDPT utilization.
Introduction
T
In some settings, PDPT may not be authorized and for some patients it may not be acceptable. An alternative to PDPT would be patient-delivered partner screening (PDPS). PDPS would provide the patient with a screening kit to be taken to a partner or partners. Typically, screening kits utilize a urine sample or swab for STI testing. PDPS may be accepted by some patients and partners who would not accept PDPT and may be allowed in jurisdictions where PDPT is not legal. Currently, EPT (PDPT) is only legal in 24 U.S. states. 9 As a result, PDPS may represent a useful addition to our EPS toolkit. PDPS is similar to efforts, to increase screening through other types of outreach, including offers in nonclinical environments, e.g., iwantthekit.org, but comes through a different channel with its own potential benefits and liabilities. 10 –14 Despite its potential, relatively little is known about whether patients would be willing to deliver and partners would be willing to receive PDPS and the factors that would influence such willingness. 11,12
This article reports on an effort to address this gap in our understanding of EPS by conducting a qualitative study among users of clinic services and examining partner-related STI service preferences (given an á la carte menu of services, including PDPT and PDPS, which would people select and why), willingness to engage in PDPS, and the perceived benefits and barriers to doing so.
Methods
Participants
Participants were English-speaking patients age 18–40 years attending an urban STI clinic in Indianapolis, Indiana, United States. Twenty men (mean age, 27.8; standard deviation (SD, 6.1) and 20 women (mean age, 27.4; SD 6.4) participated in the study. Twelve men and 11 women identified as black, 2 women identified as biracial, the remainder of the sample identified as white.
Procedure
Research assistants who were not clinic staff recruited patients from the clinic waiting room. Volunteers were screened for eligibility (age 18–40) and then taken to a private office to complete a 20- to 30-min individual interview. Interviews were digitally recorded and later transcribed for analysis. Participants were recruited until theoretical saturation was reached: that is, no new themes were emerging from the data. Participants received $20 for their time. The study was approved by the Institutional Review Board at Indiana University/Purdue University at Indianapolis.
Measures
A semistructured interview guide was designed for the study. In part one of the interview, participants completed a demographic questionnaire and responded to two counterbalanced hypothetical scenarios related to service choice. In the first scenario, participants were asked to imagine that a sex partner had tested positive for an STI. The partner could then take the following actions: bring a screening kit; bring prescription medication; bring both a screening kit and prescription medication; tell them to go to the doctor for testing and treatment; have the doctor call them; or do nothing. The interviewer described the screening kit as, “When I say ‘screening kit’, I'm talking about a container to collect urine (if the person is male) and a vaginal swab and a tube (if the person is female). The kit also has instructions on how to collect a sample, and what to do with it. The sample can be tested for STD, and your partner does not have to go to the clinic to get tested.” Prescription medication was described as, “When I say ‘prescription medication’, I'm talking about extra prescription medicine that a person could give to their partners to treat an STD.” Participants were asked which of the actions they prefer that their partner do. In the second scenario, participants were directed to imagine that they had tested positive for an STI. They could take the same actions listed above. Participants were then asked what actions they would take.
In part two of the interview, we looked specifically at PDPS—the delivery or receipt of a screening kit. Participants were presented two counter-balanced hypothetical situations focused specifically on delivery or receipt of a screening kit and asked whether they would be willing to deliver/receive the kit, why, and what factors (i.e. perceived barriers and benefits) might influence their willingness to participate in PDPS. Additionally, preferences for packaging were explored. The interview guide covered the following: questions a patient or partner might have about PDPS (e.g., what it is, associated processes); what a person would need to know in order to engage in PDPS, circumstances under which PDPS would or would not be delivered or received; perceived benefits and barriers of PDPS; worries or fears associated with engaging in PDPS; things that would help overcome barriers, worriers, or fears; reasons for engaging or not engaging in PDPS; preferences/recommendation for PDPS packaging.
Analyses
Qualitative data were analyzed to determine acceptability of, preference for, and factors influencing willingness to engage in expedited services. Data were also analyzed to identify themes associated with the intention to deliver and receive a screening kit and perceived barriers and benefits to doing so. For analysis, broad thematic categories emerging from participant responses were first identified and coded. Subsequently, the coding scheme was revised and subcategories representing specific themes within the broader categories were created. In the final stage of analyses, the coding framework was applied to all of the data by annotating each interview with the codes that indexed the categories.
Results
Expedited STI service preferences
When asked which service they would prefer to deliver and receive and why, most of the participants chose delivering (n = 30) and receiving (n = 28) both the screening kit and prescription medication (Table 1). Preferences for this combined choice were primarily based on convenience and practicality. Having both the kit and the medication was viewed as the most expeditious option as it allowed for the person to, first, determine if they were indeed STI positive and, second, to have immediate treatment available. The combined option, which allowed a person to screen, first was important because many participants said that they would not want to take antibiotic medication if it were unnecessary. However, should they need it (i.e., positive test result), they wanted immediate access. Some participants preferred referral to medical care. Typically, these participants believed that a health care provider's office or clinic was the only legitimate setting for receiving health care services. None of the participants said that they would do nothing in this situation, meaning all participants would take some sort of action to deal with the STI. Knowing that a partner had introduced the STI into the relationship did not affect service choice preferences.
PDPS, patient-delivered partner screening; STI, sexually transmitted infection; STD, sexually transmitted disease.
Willingness to deliver screening kits
Ninety-two percent of participants (men = 19, women = 18) indicated that they would be willing to deliver an STI screening kit to their sexual partner(s) (results summarized in Tables 2 and 3). The primary reason was concern for the health of their partner. Secondary reasons included avoiding reinfection and reducing the likelihood of disease transmission. For some participants, willingness to deliver a kit was contingent on having information available for their partner. These participants wanted clear instructions on kit use, accessing results, and informational materials about STI.
STI, sexually transmitted infection; STD, sexually transmitted disease.
STD, Sexually transmitted disease; STI, Sexually transmitted infection
For many participants, the type and/or quality of their relationship was a major determinate of their intentions. Several participants said that they would be less likely to deliver a kit to a casual partner (i.e., someone you see on a regular basis but consider to be a casual sex partner) or one-night stand (i.e., someone with whom you have had sex but with whom you do not have an ongoing relationship—you do not see them sexually or otherwise often or at all). In some instances, this was purely dependent on the participant's ability to contact that partner. In other cases, it was associated with factors such as a lack of relational closeness, partner trust, or intimacy. Delivering a screening kit was also viewed as more difficult in situations involving extrarelational sex and when the deliverer assumed they were the source of the infection. We asked participants what they believed their partner would think of them in this situation, that is, if they were delivering the kit: 62% of respondents (men = 13, women = 18) indicated that their partners would believe they had “cheated.”
Among the participants (n = 3) who said they would not be willing to deliver a screening kit, the primary reason for refusal was the belief that screening should be performed in a health care setting.
Benefits
A significant perceived benefit of PDPS was knowing one's STI status. Participants believed that partners would be more likely to seek treatment if they knew they were STI positive than if they were uncertain (although possibly infected) about their status. Other significant perceived benefits included convenience, privacy, and minimizing the likelihood of reinfection. Some participants viewed delivering a kit as an opportunity to discuss the STI with their partner directly rather than having their partner informed of their STI exposure by a third-party such as a physician or disease intervention specialist. This was seen as beneficial because it allowed for a conversation about who introduced the STI into the relationship.
Barriers
Primary barriers to delivery were worries about the accuracy of results, the time it would take to receive results, and the appearance of the kit (i.e., looking unprofessional). STI stigma, relationship context (e.g., one-night stand), and issues of infidelity were also salient themes. Most participants said that knowing they were responsible for STI transmission would make delivering a kit more difficult; however, this did not appear to diminish willingness to do so. Many participants feared that they would be blamed for transmitting the STI and would have to admit to extrarelational sex. Even in the context of nonmonogamous partnerships, participants were concerned about blame. Several men and women indicated that they would be afraid of their partner's reaction, with the fear of physical violence specifically mentioned by two women.
Willingness to receive screening kits
Seventy percent of participants (men = 17, women = 18) were willing to receive an STI screening kit from a sexual partner. Willingness to receive a kit was largely driven by the desire to maintain sexual health. For some participants the willingness to receive a kit was contingent on the provision of specific information and/or the perceived legitimacy of the kit. These participants indicated that they would want information about where the kit was obtained, the accuracy of test results, instructions for proper use and handling, the types of STI being tested and the associated symptoms. The kit needed to appear both professional and tamper-proof.
For several participants, willingness to receive was influenced by the nature and quality of the relationship with the partner delivering the kit. Those individuals were less likely to accept a kit from a partner who was not perceived to be “close.” For some participants, this appeared to be associated with a lack of trust for partners who are not well known or with whom the quality of the relationship is poor. For others, this related to a lack of trust for a sexual partner who is perceived as responsible for transmitting an STI. Participants were asked what they would think about their sex partner in this situation (receiving a kit). Forty-six percent of men (n = 11) and women (n = 12) said that they would think their partner had been unfaithful and would assume their partner was responsible for transmitting the STI. The other 54% reported that they would feel positively about that partner, primarily because their partner was honest about the situation.
Most participants who said they would refuse the kit did so because they preferred to see their own health care provider for testing. Many of these participants said they would want to be screened for all STI, including HIV, “just in case” they had contracted “something else.” A pervasive belief among some participants who were unwilling to receive a kit was that screening should only be performed in a health care setting. These participants expressed uncertainty that they could trust the results to be accurate and the fear of sample contamination was a prevalent theme.
Benefits
Similar to delivery, the most significant perceived benefit of receiving PDPS, was learning one's STI status. All participants indicated hthat they would be more likely to seek care if they knew they were STI positive versus being uncertain about their status. Secondarily, avoiding unnecessary visits to a health care provider in the instance of a negative STI test result was viewed as a major benefit. Other common perceived benefits included convenience and privacy. Some participants felt screening kits could be beneficial to relationships in that it may facilitate open and honest discussions about sexual health and sexual behavior.
Barriers
Barriers to receiving a kit were primarily related to concerns about the accuracy of results and the time it would take to receive results: results needed to be accurate and rapid. Both men and women considered cost a potential barrier. Men, more often than women, cited appearance as a potential barrier to receiving a screening kit. These participants said that they would be unlikely to accept a kit if it appeared unprofessional or easy to tamper with. Participants were less likely to accept screening kits from partners who were not well known, with whom the relationship quality was poor, or who were believed to have introduced the STI into the relationship. Two male participants also expressed concerns about the potential for their sample to be used for other types of testing (i.e., unauthorized drug testing).
Screening kit packaging
Participants were asked to make suggestions for packaging a screening kit. The consensus was that packaging should be discreet, small in size, look official, and contain easy to read instructions/directions for use and handling. Participants strongly believed that labeling, in particular, should be inconspicuous to protect the privacy of both the deliverer and receiver. Many participants expressed a fear of tampering and suggested that the package and its contents needed to appear tamper-proof. Worries about contamination were also common.
Discussion
PDPS was largely viewed favorably as an efficient, noninvasive means of STI screening. The most common reason to deliver or receive PDPS was to learn one's STI status. All of our participants' believed that knowing that one was STI positive, versus being uncertain of one's status, would facilitate care seeking and treatment. Relationship context was another primary theme that influenced willingness to deliver and receive an STI screening kit. Previous research has found that perceived relationship quality (i.e., “close”) may be central to participants' willingness to deliver and receive PDPT and these findings extended to PDPS in our study. 10,17,18 As such, PDPS may be more effective at preventing infection and reinfection within established relationships than in more fragile, tenuously connected sexual networks.
STI stigma has received little attention in the literature on expedited partner services; however, stigma associated with STI has been identified as a salient barrier to the delivery of prescription medication intended to treat chlamydia. 10,17 –20 Earlier research found that STI stigma was a barrier to accepting PDPS in a nonclinical venue but only among women. 16 Our data suggest that STI stigma, particularly associated with blame for nonmonogamy resulting in STI transmission, was a barrier to PDPS delivery. Overall, many participants believed that more blame would be associated with delivering PDPS compared to receiving because assuming the role of deliverer was viewed as either an admission of introducing the STI into the relationship or of nonmonogamy. Counseling patients and providing partner education materials to mitigate stigmatized responses may be an important aspect of EPS offers. Moreover, the context of such offers may affect stigma and should be considered.
We acknowledge that our data come from hypothetical scenarios rather than actual offers; however, our findings indicate that the concept of PDPS in the context of a public health clinic encounter was acceptable to most people. This, and related findings surrounding barriers, facilitators, and packaging, should serve as a preliminary basis for efforts incorporating actual offers.
From the perspective of patient and partner uptake, our data suggest that the decision to incorporate PDPS within a kit of expedited partner services offerings may be complex. There were some participants who would only engage in PDPT following PDPS. Therefore, for this segment of the population offering PDPS with PDPT may lead to increased uptake. However, previous studies have indicated that PDPT is well-accepted and a question that remains unanswered is: what effect will an offer of PDPS (or both PDPS and PDPT together) have on acceptance and implementation of PDPT among those who would, if only offered PDPT, accept and use it? Our data suggest that such offers may actually reduce initial PDPT uptake, and as such, could slow treatment. Our data are based on a limited sample and a methodology that did not include a forced choice of treatment versus screening, so there is much that remains to be learned in this regard, including how sequential as opposed to concurrent offers, by providers and index patients, would affect uptake and implementation. On the other hand, there are some structural reasons why PDPS may be of benefit in certain practice environments: in particular, in some jurisdictions it may be authorized, whereas PDPT may not. These questions merit further research as we examine ways to incorporate “home testing” within expedited partner services efforts.
When provided an á la carte menu of expedited partner services, users of clinical services selected both PDPT and PDPS together, whether selecting as a deliverer (the index patient) or a receiver (the partner). When asked whether they would participate in PDPS if that were the only service offered, they were quite willing to do so. The magnitude of these results varied by the nature of the patient–partner relationship, with greater willingness in the context of “close” relationships. Several important beliefs, barriers, and facilitators were identified, including convenience, stigma, and timeliness and accuracy of results. A segment of the population appears unwilling to participate in any EPS care and we have concerns regarding the impact of offering PDPS on those who would otherwise adopt PDPT. Despite these reservations, PDPS appears to be a service that would strengthen our STI treatment toolkit; however, considerable research remains to be done in order to better understand when to offer PDPS and how best to integrate PDPS within the larger framework of EPS.
Footnotes
Acknowledgements
Supported in part by contract #200-2008-M-18977 from the United States Centers for Disease Control and Prevention (CDC). The information and opinions expressed herein do not necessarily reflect those of the CDC.
Author Disclosure Statement
No competing financial interests exist.