Disruptions of sexually transmitted and blood borne infections testing services during the COVID-19 pandemic: accounts of service providers in Ontario, Canada.

BACKGROUND: Since the onset of the COVID-19 pandemic in March 2020 in Canada, the availability of sexual health services including sexually transmitted and blood-borne infection (STBBI) testing has been negatively impacted in the province of Ontario due to their designation as "non-essential" health services. As a result, many individuals wanting to access sexual healthcare continued to have unmet sexual health needs throughout the pandemic. In response to this, sexual health service providers have adopted alternative models of testing, such as virtual interventions and self-sampling/testing. Our objective was to investigate service providers' experiences of disruptions to STBBI testing during the COVID-19 pandemic in Ontario, Canada, and their acceptability of alternative testing services. METHODS: Between October 2020-February 2021, we conducted semi-structured virtual focus groups (3) and in-depth interviews (11) with a diverse group of sexual health service providers (n = 18) including frontline workers, public health workers, sexual health nurses, physicians, and sexual health educators across Ontario. As part of a larger community-based research study, data collection and analysis were led by three Peer Researchers and a Community Advisory Board was consulted throughout the research process. Transcripts were transcribed verbatim and analysed with NVivo software following grounded theory. RESULTS: Service providers identified the reallocation of public health resources and staff toward COVID-19 management, and closures, reduced hours, and lower in-person capacities at sexual health clinics as the causes for a sharp decline in access to sexual health testing services. Virtual and self-sampling interventions for STBBI testing were adopted to increase service capacity while reducing risks of COVID-19 transmission. Participants suggested that alternative models of testing were more convenient, accessible, safe, comfortable, cost-effective, and less onerous compared to traditional clinic-based models, and that they helped fill the gaps in testing caused by the pandemic. CONCLUSIONS: Acceptability of virtual and self-sampling interventions for STBBI testing was high among service providers, and their lived experiences of implementing such services demonstrated their feasibility in the context of Ontario. There is a need to approach sexual health services as an essential part of healthcare and to sustain sexual health services that meet the needs of diverse individuals.

Cisnormativity as a structural barrier to STI testing for trans masculine, two-spirit, and non-binary people who are gay, bisexual, or have sex with men.

Trans masculine, two-spirit, and non-binary people who are gay, bisexual or otherwise have sex with men (TGBM) are under-tested for sexually transmitted infections (STI) and may face complex, intersectional barriers that prevent them from accessing STI testing. As part of a study on gay, bisexual and other men who have sex with men's (GBM) experiences of current STI testing systems in Ontario, Canada, this paper reports on the findings from TGBM participants' experiences with in-person STI testing in a range of venues (i.e. Family doctors, walk-in clinics, and community-based organizations) to explore testing barriers specific to TGBM. Using a community-based research approach, between June 2020 and December 2021 peer researchers who identified as GBM conducted focus groups and interviews with 38 cis and trans GBM, 13 of whom identified as TGBM. Data were analyzed following grounded theory. When questioned about past experiences with testing, TGBM participants reported several barriers to STI testing within current testing models in Ontario due to cisnormativity and heteronormativity. Cisnormativity is the assumption that everyone identifies as the gender they were assigned at birth, and those who do not are considered "abnormal", while heteronormativity is when it is assumed that everyone is heterosexual. From our research we identified three overarching themes concerning testing barriers among TGBM participants: (1) non-inclusive clinic environments, (2) lack of provider knowledge and competency, and (3) legal documentation. Inherent cis and heteronormativity in healthcare institutions appear to be factors shaping the historical under-testing for STI in the TGBM population. These findings suggest the relevance of implementing trans-specific clinical practices that reduce the stigma and barriers faced by TGBM in STI testing contexts, including: hosting all-gender testing hours, opening more LGBTQ+ clinics, offering training in transgender health to testing providers, and conducting a review of how gender markers on health documents can be more inclusive of trans, two-spirit, and non-binary communities.

Challenges in the development of digital public health interventions and mapped solutions: Findings from a scoping review.

Background: "Digital public health" has emerged from an interest in integrating digital technologies into public health. However, significant challenges which limit the scale and extent of this digital integration in various public health domains have been described. We summarized the literature about these challenges and identified strategies to overcome them. Methods: We adopted Arksey and O'Malley's framework (2005) integrating adaptations by Levac et al. (2010). OVID Medline, Embase, Google Scholar, and 14 government and intergovernmental agency websites were searched using terms related to "digital" and "public health." We included conceptual and explicit descriptions of digital technologies in public health published in English between 2000 and June 2020. We excluded primary research articles about digital health interventions. Data were extracted using a codebook created using the European Public Health Association's conceptual framework for digital public health. Results and analysis: Overall, 163 publications were included from 6953 retrieved articles with the majority (64%, n = 105) published between 2015 and June 2020. Nontechnical challenges to digital integration in public health concerned ethics, policy and governance, health equity, resource gaps, and quality of evidence. Technical challenges included fragmented and unsustainable systems, lack of clear standards, unreliability of available data, infrastructure gaps, and workforce capacity gaps. Identified strategies included securing political commitment, intersectoral collaboration, economic investments, standardized ethical, legal, and regulatory frameworks, adaptive research and evaluation, health workforce capacity building, and transparent communication and public engagement. Conclusion: Developing and implementing digital public health interventions requires efforts that leverage identified strategies to overcome diverse challenges encountered in integrating digital technologies in public health.

Rumination, risk, and response: a qualitative analysis of sexual health anxiety among online sexual health chat service users.

BACKGROUND: Anxiety is common among sexual health service users. Accessible, anonymous online sexual health services may offer opportunities to connect users with mental health services, but little is known about anxiety in these settings. We sought to characterise expressions of anxiety among chat users and nurse responses to anxiety. METHODS: We conducted inductive thematic analysis of transcripts from an anonymous online sexual health chat service moderated by sexual health nurses. RESULTS: Among chat users, we identified: worry, anxiety, and emotional distress, particularly regarding HIV transmission risk, testing, and symptoms; exaggerated appraisal of HIV-transmission risk associated with sex-related shame and stigma; and patterns of anxiety that were unresolved by HIV education or testing interventions. Although nurses recognised and acknowledged anxiety, their responses to this anxiety varied; some provided anxiety management information, while others offered sexual health education and risk assessment. CONCLUSIONS: Targeted interventions addressing HIV-related stigma and anxiety among online sexual health service users are needed to facilitate connections to appropriate mental health supports.

Defining Digital Public Health and the Role of Digitization, Digitalization, and Digital Transformation: Scoping Review.

BACKGROUND: The recent proliferation and application of digital technologies in public health has spurred interest in digital public health. However, as yet, there appears to be a lack of conceptual clarity and consensus on its definition. OBJECTIVE: In this scoping review, we seek to assess formal and informal definitions of digital public health in the literature and to understand how these definitions have been conceptualized in relation to digitization, digitalization, and digital transformation. METHODS: We conducted a scoping literature search in Ovid MEDLINE, Embase, Google Scholar, and 14 government and intergovernmental agency websites encompassing 6 geographic regions. Among a total of 409 full articles identified, we reviewed 11 publications that either formally defined digital public health or informally described the integration of digital technologies into public health in relation to digitization, digitalization, and digital transformation, and we conducted a thematic analysis of the identified definitions. RESULTS: Two explicit definitions of digital public health were identified, each with divergent meanings. The first definition suggested digital public health was a reimagination of public health using new ways of working, blending established public health wisdom with new digital concepts and tools. The second definition highlighted digital public health as an asset to achieve existing public health goals. In relation to public health, digitization was used to refer to the technical process of converting analog records to digital data, digitalization referred to the integration of digital technologies into public health operations, and digital transformation was used to describe a cultural shift that pervasively integrates digital technologies and reorganizes services on the basis of the health needs of the public. CONCLUSIONS: The definition of digital public health remains contested in the literature. Public health researchers and practitioners need to clarify these conceptual definitions to harness opportunities to integrate digital technologies into public health in a way that maximizes their potential to improve public health outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/preprints.27686.

Caught between HIV exceptionalism and health service integration: Making visible the role of public health policy in the scale-up of novel sexual health services.

The role of contextual factors for program implementation is well-documented; however, their changing function throughout implementation phases is less established. We conducted an institutional ethnography to understand how structural conditions for scaling up initiatives are shaped by public health policy. We conducted 25 interviews with implementers of a comprehensive sexual health testing service in Canada, 21 meeting observations, and textual analyses of key policies and reports. Our analysis revealed a disjuncture between implementers' task of scaling up programming and the actualities of working within the discursive and material confines of policies premised on HIV exceptionalism and underfunded integrated health services.

Defining the Scope of Digital Public Health and Its Implications for Policy, Practice, and Research: Protocol for a Scoping Review.

BACKGROUND: There has been rapid development and application of digital technologies in public health domains, which are considered to have the potential to transform public health. However, this growing interest in digital technologies in public health has not been accompanied by a clarity of scope to guide policy, practice, and research in this rapidly emergent field. OBJECTIVE: This scoping review seeks to determine the scope of digital health as described by public health researchers and practitioners and to consolidate a conceptual framework of digital public health. METHODS: The review follows Arksey and O'Malley's framework for conducting scoping reviews with improvements as suggested by Levac et al. The search strategy will be applied to Embase, Medline, and Google Scholar. A grey literature search will be conducted on intergovernmental agency websites and country-specific websites. Titles and abstracts will be reviewed by independent reviewers, while full-text reviews will be conducted by 2 reviewers to determine eligibility based on prespecified inclusion and exclusion criteria. The data will be coded in an iterative approach using the best-fit framework analysis methodology. RESULTS: This research project received funding from the British Columbia Centre for Disease Control Foundation for Population and Public Health on January 1, 2020. The initial search was conducted on June 1, 2020 and returned 6953 articles in total. After deduplication, 4523 abstracts were reviewed, and 227 articles have been included in the review. Ethical approval is not required for this review as it uses publicly available data. CONCLUSIONS: We anticipate that the findings of the scoping review will contribute relevant evidence to health policy makers and public health practitioners involved in planning, funding, and delivering health services that leverage digital technologies. Results of the review will be strategically disseminated through publications in scientific journals, conferences, and engagement with relevant stakeholders. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/27686.

On the imperative of thinking through the ethical, health equity, and social justice possibilities and limits of digital technologies in public health.

The COVID-19 pandemic has demonstrated both the positive and negative use, usefulness, and impact of digital technologies in public health. Digitalization can help advance and sustain the core functions of public health, including health promotion and prevention, epidemiological surveillance, and response to emergent health issues. Digital technologies are thus-in some areas of public discourse-presented as being both necessary and inevitable requirements to address routine and emergency public health issues. However, the circumstances, ways, and extent to which they apply remain a subject of critical reflection and empirical investigation. In this commentary, we argue that we must think through the use of digital technologies in public health and that their usefulness must be assessed in relation to their short- and long-term ethical, health equity, and social justice implications. Neither a sense of digital technological optimism and determinism nor the demands of addressing pressing public health issues should override critical assessment before development and implementation. The urgency of addressing public health emergencies such as the ongoing COVID-19 pandemic requires prompt and effective action, including action facilitated by digital technologies. Nevertheless, a sense of urgency cannot be an excuse or a substitute for a critical assessment of the tools employed.

RéSUMé: La pandémie de COVID-19 a montré les aspects positifs et négatifs de l'utilisation, de l'utilité et de l'impact des technologies numériques en santé publique. La numérisation peut contribuer à promouvoir et à soutenir les fonctions de base de la santé publique, dont la promotion de la santé, la prévention, la surveillance épidémiologique et la riposte aux nouvelles crises sanitaires. Les technologies numériques sont donc­dans certaines parties du discours public­présentées comme étant à la fois nécessaires et inévitables pour résoudre les problèmes de santé publique ordinaires ou urgents. Par contre, les circonstances, les moyens et la mesure dans laquelle elles s'appliquent font encore l'objet d'une réflexion critique et d'une investigation empirique. Dans ce commentaire, nous faisons valoir qu'il faut bien réfléchir à l'utilisation des technologies numériques en santé publique, et que leur utilité doit être analysée par rapport à leurs conséquences à court et à long terme sur l'éthique, l'équité en santé et la justice sociale. Ni les sentiments d'optimisme et de déterminisme à l'égard des technologies numériques, ni la nécessité de résoudre les problèmes de santé publique pressants ne devraient prendre le dessus sur l'analyse critique avant leur développement et leur mise en œuvre. L'urgence de résoudre des crises sanitaires comme la pandémie actuelle de COVID-19 nécessite une action rapide et efficace, et cette action peut être facilitée par les technologies numériques. Néanmoins, le sentiment d'urgence ne doit pas être une excuse et ne peut pas remplacer une analyse critique des outils employés.

Pay to skip the line: The political economy of digital testing services for HIV and other sexually transmitted infections.

The value of digital healthcare has been lauded in Canada at local, provincial, and national levels. Digital medicine is purported to enhance patient access to care while promising cost savings. Using institutional ethnography, we examined the potential for publicly funded digital testing for HIV and other sexually transmitted infections (STI) in Ontario, Canada. Our analyses draw from 23 stakeholder interviews with healthcare professionals conducted between 2019 and 2020, and textual analyses of government documents and private, for-profit digital healthcare websites. We uncovered a "two-tiered" system whereby private digital STI testing services enable people with economic resources to "pay to skip the line" queuing at public clinics and proceed directly to provide samples for diagnostics at local private medical labs. In Ontario, private lab corporations compete for fee-for-service contracts with government, which in turn organises opportunities for market growth when more patient samples are collected vis-à-vis digital testing. However, we also found that some infectious disease specimens (e.g., HIV) are re-routed for analysis at government public health laboratories, who may be unable to manage the increase in testing volume associated with digital STI testing due to state budget constraints. Our findings on public-private laboratory funding disparities thus discredit the claims that digital healthcare necessarily generates cost savings, or that it enhances patients' access to care. We conclude that divergent state funding relations together with the creeping privatisation of healthcare within this "universal" system coordinate the conditions through which private corporations capitalise from digital STI testing, compounding patient access inequities. We also stress that our findings bring forth large scale implications given the context of the global COVID-19 pandemic, the rapid diffusion of digital healthcare, together with significant novel coronavirus testing activities initiated by private industry.

Validation of a Clinical Prediction Rule to Predict Asymptomatic Chlamydia and Gonorrhea Infections Among Internet-Based Testers.

BACKGROUND: Clinical prediction rules (CPRs) can be used in sexually transmitted infection (STI) testing environments to prioritize individuals at the highest risk of infection and optimize resource allocation. We previously derived a CPR to predict asymptomatic chlamydia and/or gonorrhea (CT/NG) infection among women and heterosexual men at in-person STI clinics based on 5 predictors. Population differences between clinic-based and Internet-based testers may limit the tool's application across settings. The primary objective of this study was to assess the validity, sensitivity, and overall performance of this CPR within an Internet-based testing environment (GetCheckedOnline.com). METHODS: We analyzed GetCheckedOnline online risk assessment and laboratory data from October 2015 to June 2019. We compared the STI clinic population used for CPR derivation (data previously published) and the GetCheckedOnline validation population using χ2 tests. Calibration and discrimination were assessed using the Hosmer-Lemeshow goodness-of-fit test and the area under the receiver operating curve, respectively. Sensitivity and the fraction of total screening tests offered were quantified for CPR-predicted risk scores. RESULTS: Asymptomatic CT/NG infection prevalence in the GetCheckedOnline population (n = 5478) was higher than in the STI clinic population (n = 10,437; 2.4% vs. 1.8%, P = 0.007). When applied to GetCheckedOnline, the CPR had reasonable calibration (Hosmer-Lemeshow, P = 0.90) and discrimination (area under the receiver operating characteristic, 0.64). By screening only individuals with total risk scores ≥4, we would detect 97% of infections and reduce screening by 14%. CONCLUSIONS: The application of an existing CPR to detect asymptomatic CT/NG infection is valid within an Internet-based STI testing environment. Clinical prediction rules applied online can reduce unnecessary STI testing and optimize resource allocation within publicly funded health systems.

"Mini Dial-A-Nurses" and "Good Brands": What Are the Desirable Features of Online HIV/STI Risk Calculators?

A wide variety of risk calculators estimate individuals' risk for HIV/sexually transmitted infections (STI) online. These tools can help target HIV/STI screening and optimize clinical decision-making. Yet, little evidence exists on suitable features for these tools to be acceptable to end-users. We investigated the desirable characteristics of risk calculators among STI clinic clients and testing service providers. Participants interacted with online HIV/STI risk calculators featuring varied target audiences, completion lengths, and message outputs. Thematic analysis of focus groups identified six qualities that would make risk calculators more appealing for online client use: providing personalized risk assessments based on users' specific sexual behaviors and HIV/STI-related concerns; incorporating nuanced risk assessment and tailored educational information; supplying quantifiable risk estimates; using non-stigmatizing and inclusive framing; including explanations and next steps; and developing effective and appropriate branding. Incorporating these features in the design of online HIV/STI risk calculators may improve their acceptability among end-users.

A recurring rollercoaster ride: a qualitative study of the emotional experiences of parents of children with juvenile idiopathic arthritis.

BACKGROUND: Despite the wealth of clinical research carried out in children with juvenile idiopathic arthritis (JIA), little is known about the emotional experiences of their parents. This article describes the predominant emotional experiences reported by parents of children with JIA in two Canadian cities. METHODS: Research participants included 15 experienced parents and 8 novice parents (<6 months since children's JIA diagnosis). Their children were 2 to 16 years old with various JIA categories. A qualitative dataset including audio recordings and verbatim transcripts of three focus groups, and written reports of 59 reciprocal interviews (parents interviewing each other) were examined by a multidisciplinary research team following a four-step qualitative analytical process. RESULTS: Parents of children with JIA experienced recurrent mixed negative and positive emotions that varied over time. Between disease onset and diagnosis, mounting anxiety, fear and confusion were the predominant emotions. Shortly after diagnosis there were shock, disbelief, and fear, with a sense of having being blindsided by the disease. At times of disease quiescence there was hope and gratitude, but also fatigue and frustration with ongoing treatment and fear of flares. During periods of increasing or ongoing symptoms there was admiration and sympathy for the courageous way children coped with JIA, as well as sorrow and frustration for ongoing pain and limitations. There were at times, frustration and indignation with peers and teachers unable to understand the child's fluctuations in physical activity and schoolwork. Throughout the disease, parents felt an underlying anxiety and powerlessness. CONCLUSIONS: Parents of children with JIA described complex emotional journeys akin to the recurring ups and downs of rollercoaster rides, instead of ordered emotional phases ending in resolution. This has implications for healthcare providers who need to be aware of the complexity of these emotional journeys to support parents more effectively, thereby helping improve patient outcomes.

What matters most for patients, parents, and clinicians in the course of juvenile idiopathic arthritis? A qualitative study.

OBJECTIVE: To assess which clinical features are most important for patients, parents, and clinicians in the course of juvenile idiopathic arthritis (JIA). METHODS: Forty-nine people participated in 6 audience-specific focus group discussions and 112 reciprocal interviews in 3 Canadian cities. Participants included youth with JIA, experienced English- and French-speaking parents, novice parents (<6 mos since diagnosis), pediatric rheumatologists, and allied health professionals. Participants discussed the importance of 34 JIA clinical features extracted from medical literature. Transcripts and interview reports underwent qualitative analysis to establish relative priorities for each group. RESULTS: Most study participants considered medication requirements, medication side effects, pain, participant-defined quality of life, and active joints as high priority clinical features of JIA. Active joint count was the only American College of Rheumatology core variable accorded high or medium priority by all groups. Rheumatologists and allied health professionals considered physician global assessment as high priority, but it had very low priority for patients and parents. The parent global assessment was considered high priority by clinicians, medium to high by parents, and low by patients. Child Health Assessment Questionnaire scores were considered low priority by patients and parents, and moderate or high by clinicians. The number of joints with limited motion was given low to very low priority by all groups. Parents gave high priority to arthritis flares. CONCLUSION: If our findings are confirmed, medication requirements, medication side effects, pain, participant-defined quality of life, and active joint counts should figure prominently in describing the course of JIA.

Development of a support tool for complex decision-making in the provision of rural maternity care.

CONTEXT: Decisions in the organization of safe and effective rural maternity care are complex, difficult, value laden and fraught with uncertainty, and must often be based on imperfect information. Decision analysis offers tools for addressing these complexities in order to help decision-makers determine the best use of resources and to appreciate the downstream effects of their decisions. OBJECTIVE: To develop a maternity care decision-making tool for the British Columbia Northern Health Authority (NH) for use in low birth volume settings. DESIGN: Based on interviews with community members, providers, recipients and decision-makers, and employing a formal decision analysis approach, we sought to clarify the influences affecting rural maternity care and develop a process to generate a set of value-focused objectives for use in designing and evaluating rural maternity care alternatives. SETTING: Four low-volume communities with variable resources (with and without on-site births, with or without caesarean section capability) were chosen. PARTICIPANTS: Physicians (20), nurses (18), midwives and maternity support service providers (4), local business leaders, economic development officials and elected officials (12), First Nations (women [pregnant and non-pregnant], chiefs and band members) (40), social workers (3), pregnant women (2) and NH decision-makers/administrators (17). RESULTS: We developed a Decision Support Manual to assist with assessing community needs and values, context for decision-making, capacity of the health authority or healthcare providers, identification of key objectives for decision-making, developing alternatives for care, and a process for making trade-offs and balancing multiple objectives. The manual was deemed an effective tool for the purpose by the client, NH. CONCLUSIONS: Beyond assisting the decision-making process itself, the methodology provides a transparent communication tool to assist in making difficult decisions. While the manual was specifically intended to deal with rural maternity issues, the NH decision-makers feel the method can be easily adapted to assist decision-making in other contexts in medicine where there are conflicting objectives, values and opinions. Decisions on the location of new facilities or infrastructure, or enhancing or altering services such as surgical or palliative care, would be examples of complex decisions that might benefit from this methodology.