Critique Of Aicken Et Al.'s Study On Smartphone-enabled Self-testing And Online STI Care

Define key terms hich are relevant to your essay – ensure the definitions are relevant to your essay content (e.g. if using quantitative research, ensure your definition relates to the type of studies and methodology you are discussing)

Critique the research paper using the framework issued by the module leader (see below) identifying strengths and limitations of the study in relation to believability and robustness:

The key points in the research paper

Sexually transmitted infections (STI) control is a public health priority across the globe. There are free and confidential services offered in the UK through sexual health clinics however, persons that are at the highest risk (that is, young people) report facing barriers to using these services. In this study, the authors explored the acceptability and usability of an STI testing toolkit among a youthful population aged 16-24 years.

Research in nursing is important as it legitimizes the profession even as it adds to the body of knowledge and nursing education. Critiquing research allows for the robustness of the study to be analyzed as this allows for any reader or researcher to validate the generalizability of the findings. This is important with regard to evidence based practice as EBP uses well designed studies to create a problem solving approach in health care. EBP improves patient outcomes and aims at decreasing patient outcome variations hence critiquing a research article ensures that the findings are applicable in any other similar scenario with the best patient outcomes as the final expectation. This paper will analyze the study conducted by Aicken et al (2016) and highlight on the strengths and weaknesses of it. The robustness of the study will be critiqued and a final conclusion given at the end of the paper.

Key terms used: sexually transmitted infections; validity of research; self testing.

The findings from the study by Aicken et al., (2016) suggest that online care pathways and remote self testing for STI has a high probability of acceptance as long as personal support, privacy, and accuracy concerns are addressed. In addition, based on the results from this study, the design of the intervention must also include concerns of the public health, clinical safety, and what is possible with regard to technology. In developing the intervention, the researchers need to keep in mind that young people prefer to keep their use of sexual healthcare a secret and this includes STI diagnosis too. With reference to sexual healthcare use evidence appearing on the Smartphones, cautions ought to be taken with regard to sender's name and text message wording. Further, web-apps that are not installed or downloadable to the user's phone can be used rather than using native apps. Also, the self testing Smartphone enabled service should come with NHS branding as this would instil a level of trustworthiness.  For enhanced speed and also privacy from friends and family, the self testing service can be linked to e-prescription services with local pharmacies as this would offer a better alternative to having the treatment delivered via postal services (this of course will depend on the nature of the STI and the treatment that is recommended).

Sexual health clinics have different innovations such as mute testing where clinical information and registration is provided on electronic or paper format (Fernando & Thompson, 2013, p. 341; Pittrof & McLellan, 2007, p.274) and which already meet privacy needs for young people seeking access to sexual health. However, the study by Aicken et al., (2016) shows that a remote access option to accessing sexual health care may overcome any further barriers and result in earlier STI detection. As long as persons are able to utilize the online care pathways in accessing prompt treatment, public health benefits would be harnessed from decline in transmission of STI and resulting complications that are linked to long term infection.

Believability of the research study

A major limitation to the study was that it did not address an important risk group: the gay men. Men who have sex with men were excluded in this study because the researchers did not want to compromise the privacy of individuals who were not open about their sexual orientation.

Another limitation was that the participants were all non-white. Although this was almost inevitable because of the location of the college where majority of the students are non-white, those that were approached declined to participate for reasons unknown. In addition, the required number of women to fill the 20-24 sampling quota (6-8 participants) did not happen (n=2) which leaves the results of the study open to interpretation and analysis.

Author Credentials

The paper has featured several authors with the main authors being:

Catherine R. H. Aicken: MSc., BSc (Hons)University College Research Department of Infection and Population Health, London.

Sebastian S. Fuller: PhD. St,. George's University Institute for Infection and Immunity, London

Lorna J. Sutcliffe: MSc. Registered Nurse at the Blizard Institute, Health Services Research (LSHTM), London and Barts School of Medicine and Dentistry, Centre for Immunology and Infectious Diseases, Queen Mary University of London

Others include: Claudia S. Estcourt, Pippa Oakeshott, Voula Gkatzidou, Kate Hone, Pam Sonnenberg, S. Tariq Sadiq, and Maryam Shahmanesh,

AMA referencing has been used in this paper with the authors using Active voice. The paper has an abstract that summarizes the key points found in the body. The in-text citations used are numerals in brackets for each reference.

The title of the paper is Young people’s perceptions of Smartphone enabled self-testing and online care for sexually transmitted infections: qualitative interview study. The title is clear and reflective of the entire study as discussed in the paper

The abstract gives a summary of the study done by the researchers; what the study entailed, the methodology used, the results of the study, and a conclusion. It also has 6 keywords which are in line with the subject matter of the paper.

Research Problem/ Significance

Research Problem: High prevalence of STI among youth in the UK and more specifically in a Further Education colleges in London

Purpose of the study: offer information on the development of the proposed e-health intervention (Craig, Dieppe, & Macintyre, 2008, p. 1; Catwell & Sheikh, 2009,) whose objective is to be an adjunct as opposed to being a replacement to the existing services.

Sexually transmitted infections (STI) prevalence in England is a major issue to public health with the young population being at risk of infection (Sonnenberg, Clifton, & Beddows, 2013, p.1795; Public Health England, 2015). STI services aim at identifying, diagnosing and treating persons who exhibit the asymptomatic infections, with the aim of preventing transmission and minimizing medical complications that are associated with long term and repetitive infection. However, attending an STI clinic is perceived by some people as a form of stigmatisation (Normansell, Drennan, & Oakeshott, 2015, p322; PHE, 2015) which impacts on the experiences and expectations of attending the clinic in a negative way.

An STI self testing method that is Smartphone enabled and which is linked to online clinical pathways of management offers a complex and unique intervention. Although there are currently some STI form of care that is available online (Woodhall, Sile, & Talebi et al., 2012, p.23, Richardson, Maple, & Perry, 2010, p.187; Huang, Gaydos, & Barnes et al, 2013, p. 108), the proposed intervention goes beyond these pathways.

Robustness of the study

Home self-testing acceptability qualitative research (Rompalo, Hsieh, & Hoganet al., 2013, p. 541) and use of the internet with regard to STI testing (Friedman & Bloodgood, 2013, p. 96; Hottes, Farrell, Bondyra et al., 2012, p. 42; Shoveller, Knight, Davis et al., 2102, p. 14) propose that there is reservation among potential users with regard to test reliability, safety, confidentiality, and privacy. Most of these studies were done in Canada and US (that is different contexts of health service) and transferability of the findings to the proposed intervention is not possible. Therefore, it was necessary for the researchers to conduct a formative study that would offer information on the development of the proposed e-health intervention (Craig, Dieppe, & Macintyre, 2008, p. 1; Catwell & Sheikh, 2009,) whose objective is to be an adjunct as opposed to being a replacement to the existing services.

The study by Aicken et al., (2016) explored the acceptability and perceptions of remote self testing of STI and the related online treatment care pathways (at the time of the study it was a hypothetical intervention), among youth from a locality in Inner London that had high prevalence rates of STIs (PHE, 2013) and large African ethnic and Black Caribbean populations.  The population under study is reflective of the fact that the urban youth populations may be new technologies' early adopters and are thus considered as potential consumers of the service once it is launched in the future

This study was undertaken during the early stages of the intervention's development and was part of and formative research program which offered information on the development of the self testing STI online care pathway. Additional formative research put into consideration design of the user interface (Gkatzidou, Hone, & Sutcliffe et al., 2015, p. 72) and clinical safety and quality (Gibbs, Sutcliffe, & Sadiq et al., 2014, p. 69) which along with this study resulted to a recent study of proof-of-concept of an online Chlamydia care pathway with evaluations using mixed-method. Survey research offered evidence that was indicative with regard to user population, and device development for self-testing (Aicken, Estcourt, & Johnson et al., 2016) is ongoing.

There was no sufficient literature provided in this paper. The authors pointed out that they were unaware of any other research that explored the remote self-testing acceptability related to online STI care seeing that the intervention that the researchers proposed was unique. However, the proposed intervention includes some elements that have been evaluated albeit to a limited extent in other studies. One such study was a qualitative research that involved young women in the US which was conducted between 2007 and 2008, and which reported reservations with regard to STI testing using ht internet and included unavailable personal support, data security and online privacy (Friedman et al, 2013), which are less prominent in reported findings of similar studies done among young Canadians (Shoveller et al., 2015).

This study by Aicken et al., (2016) showed similar findings with regard to desire to get support from healthcare professionals after positive diagnosis is made. Most participants discussed privacy from family and peers as being important in relation to preference for self testing rather than going to a sexual health clinic and preference for messaging that is discrete. However, online security, confidentiality/privacy elicited fewer concerns. This was probably a reflection of the study sample's ownership of Smartphones and the confidence they have in the NHS that they described.

Study Population

The participants for this study were recruited from a Further Education college in Inner London. FE colleges in the UK offer education that is post-compulsory for persons aged 16 years and above, often vocational and are different from universities which offer academic qualifications of degree level. FE colleges tend to have an over-representation of persons from socio-economic groups that are lower. The students that were eligible for the study were those aged between 16-24 years and who had self-reported as having been involved in sexual activity at least once.

According to Bryman, (2008, p.6) research methodology may be perceived as the strategy which  silhouettes in a comprehensive manner, our choice and utilization of particular methods and relating  them to expected outcomes however, the choice of research methodology is based on the research problem features and the research (Noor, 2008, p. 1602) .

The most suitable research methodology is Qualitative research methodology when it comes to investigating a new study field or when aiming to theorize and ascertain pertinent issues (Creswell, 2007, p. 23; Corbin &Strauss, 2007, p.14).  

The research by Aicken et al., (2016) was appropriate as it used in-depth interviews where participants aged between 16-24 years and who had self reported as being sexually experienced were recruited in the 2012 study. The participants were from urban Further Education colleges within areas of high prevalence of STI. The study undertook a thematic analysis.  

The participants included 16 males and 9 females. 21participants were self defined as Black, one was Asian/Muslim, and three were from a mixed ethnicity. 22 participants reported as having experience in sexual activity, 2 persons reported having been diagnosed with an STI in the past, and all participants owned Smartphones.

The sample used was valid as it represented the population under study.

The data collection method was valid as the participants signed a written consent to be interviewed. In addition, the researchers got approval from the Ethics committee at the University College London to conduct the interviews. The researchers also included in their paper transcriptions from participants so as to show and enable understanding.

Participants in semi-structured interviews are required to answer in an in-depth manner, open ended questions that are preset. They are used in interviewing individuals and groups and are carried out only once (Corbin &Strauss, 2008, p.18) the length of the interviews is usually half an hour or more. Data recording is done via audio or video recording with the researcher at times opting to write down key points though this is the exception rather than the norm. The research by Aicken et al., 2016 used semi structured interviews which were audio recorded. The recording of the interviews and transcription of the same validate the data collection method used

The study undertook a thematic analysis where the major themes and recurring messages were used to modify the interview questions to make the tool more relevant and accurate. The participants were enthusiastic about the new services that the researchers proposed and hinted that they would use the device and spread the word to their peers including availing themselves for further testing of the service. Using sexual healthcare was seen as being much easy and faster with the online self testing for STI clinical care which allowed for STI testing concealment form family and friends and avoided consultations that were embarrassing. However, even with these expected advantages on privacy, other privacy concerns arose with regard to communication technology: more so the inherent risk of STI diagnosis and results being retrievable or visible on the Smartphone. Other concerns arose with regard to the accuracy of the proposed test, novelty of the technology, and self operation. Some participants expressed anxiety of the possible diagnosis and treatment without getting into any contact with a healthcare professional. The study concluded that the remote online care self testing was appealing to the young people as it addressed barriers that conventional STI services were associated with. This may be beneficial to the public health through early diagnoses and treatment. The findings from the research underpin online care pathways currently in developmental stages.

The proposal of a novel treatment and self-testing online STI approach was acceptable to the participants who had been selected from a high prevalence area. In making a decision between using the existing services for STI testing and the self-testing, the participants tried to balance three major factors: privacy, convenience, and speed. Privacy was seen as being maintained through the use of remote self-testing through reducing the risk of family members and peers discovering the participants' utilization of sexual healthcare, through avoidance of visiting a sexual health clinic, and through potential embarrassing encounters of face to face healthcare consultations. When these privacy concerns are addressed, and facilitation of testing access is done, the participants stated that they would test more often or would test at least once, if the option of remote testing availed to them.

There were other new privacy concerns that the participants were made aware of and these included use of sexual healthcare evidence, STI diagnosis evidence on their Smartphones, treatment provision via post, and online data security. The participants gave descriptions on the several different ways that they would manage the risks and also how the design of the intervention could ensure that the suggested risk management could be incorporated into the final product while yet other participants considered online data breech as inevitable.

There was contrast in the enthusiasm for the new technology among the participants with some doubting the rapid accuracy of the self operated test and yet expressed no doubts of the conventional testing methods. The discomfort of some of the participants with regard to the sexual health consultations differed with the needs they anticipated and receiving positive results, or with specific concerns: seeking individualized support from healthcare personnel. Self testing credibility increased including data security, and online care, when it was associated with NHS services or healthcare professionals. However, because the study was undertaken before the STI self testing device was made available and operating in the online care pathways, the researchers had to rely on the participants' understanding and engagement with a novel albeit hypothetical intervention.

Most participants stated that providing treatment to their partners was an option they would find difficult to engage with, probably because of the personal nature of the topic under study and its abstract nature (the participants were required to imagine a context where they were engaged in sexual relations which resulted in infection occurring and also receiving positive results after using the self-testing device).

Conclusion

The implications from this study for policies, clinical practice, education, and research are very significant. The study reinforces the need for the provision of interventions that are conducted by professionals in the field of healthcare and more so nurses, who can reach the high risk areas. The study offered insight on young people's concerns with reference to STI and their need for privacy while at the same time the desire to get support from a healthcare professional (in this case a nurse).

The use of the self testing device can be utilized by nurses in enhancing their education as well as an intervention tool with their patients. The device can also be instrumental in training provision to clinical nurses on prevention, and also on elimination of stigmatization attitudes toward STI patients by nurses and other healthcare workers (Cianelli et al., 2011, p.3; Norr et al., 2012, p.73). When nurses are trained in using the self testing device, they can improve their understanding an attitude while utilizing an efficient and non threatening tool.

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