JMIR Publications

ABSTRACT

Background:

Online postal self-sampling (OPSS) allows service users to screen for sexually transmitted infections (STIs) by ordering a self-sampling kit online, taking their own samples, returning them to a laboratory for testing and receiving their results remotely. OPSS availability and use has increased both in the UK and globally over the past decade but has been adopted in different regions of England at different times, with different models of delivery. It is not known why certain models were decided on, or how implementation strategies have influenced outcomes, including the sustainability of OPSS in sexual health service delivery.

Objective:

This study set out to evaluate the implementation of OPSS in three case study areas (CSAs) of England, with a focus on the sustainability of implementation and the relationship between implementation strategies and outcomes.

Methods:

Qualitative data collection methods were employed: interviews with staff and stakeholders involved in the implementation and delivery of OPSS; analysis of local implementation and national policy documents; and observations in sexual health clinics. Analysis of interviews and observations was undertaken using qualitative implementation science frameworks, including Normalisation Process Theory, with documentary sources used primarily to map processes over time and triangulate against interview and observational evidence.

Results:

Across the three CSAs, 60 staff and stakeholders were interviewed,12 observations were conducted and data from 86 documents collated. OPSS was part of, or occurred parallel to, major system changes in all areas. Its implementation was not a one-off outcome but an ongoing process in response to changes in context. Financial pressures and organisational relationships determined the implementation strategies available to decision-makers, how these strategies were enacted and, in turn, led to different outcomes at different time points. The COVID-19 pandemic had profound but divergent effects on OPSS implementation in each area.

Conclusions:

In this multisite case study, OPSS implementation was part of systems change to address a wider problem of insufficient funding to deliver sexual health care. OPSS implementation decisions were made before sufficient evidence to effectively guide implementation was available. The resultant unintended consequences need acknowledgement to enable future commissioners and providers to optimise sexual health service provision.