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Josephine G Paterson
Self-screening for sexually transmitted infections Potter Y (2014) Self-screening for sexually transmitted infections. Nursing Standard. 28, 41, 37-43. Date of submission: January 18 2014; date of acceptance: March 12 2014.
Abstract There is an increasing trend towards self-collection of samples for sexually transmitted infection screening in lieu of genital examination and clinician-obtained urethral and cervical swabs. This article examines the advantages and disadvantages of this trend, and the effect on nursing practice particularly within integrated sexual health (ISH) services, which provide genito-urinary medicine (GUM) and contraceptive services. This article might also be of interest to nurses working within separate GUM and contraceptive services, especially those that are preparing to become ISH services.
Author Yvonne Potter Staff nurse, North Lincolnshire Sexual Health, The Ironstone Centre, Scunthorpe. At the time of writing, staff nurse, Centre for Sexual Health, Diana Princess of Wales Hospital, Grimsby. Correspondence to: [email protected]
Keywords Contraception and sexual health, genito-urinary medicine, integrated sexual health services, sexually transmitted infections
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
SINCE 2001, when genito-urinary medicine (GUM) services became the focus of government attention with the publication of Better Prevention, Better Services, Better Sexual Health: The National Strategy for Sexual Health and HIV (Department of Health (DH) 2001), there have been fundamental changes within these services in the UK. This, and subsequent policies, standards and reports, focused on young people between the age of 16 and 24, for whom the highest (and, until recently, increasing) rates of sexually transmitted infections (STIs) have been reported (Health Protection Agency (HPA) 2013). In particular, the Medical Foundation for HIV and Sexual Health (MEDFASH) (2005) standards aimed to tackle this public health problem by founding accessible and effective GUM services that are capable of meeting the needs of this client group. Consequently, GUM services have been expected to offer appointments to all new clients within 48 hours (DH 2008). Moreover, with the aim of reducing teenage conceptions, The National Strategy for Sexual Health and HIV (DH 2001) also introduced the concept of combining contraception and GUM services (French et al 2010), creating an integrated, one-stop shop that offers specialist screening and treatment for STIs, along with the availability of all forms of contraception, from condoms to long-acting reversible products (Rogstad et al 2002). To meet the increasing demand for integrated sexual health (ISH) services, nurse-led clinics have become commonplace. These clinics are managed by qualified nurses with extended roles, such as non-medical prescribers who examine and treat both asymptomatic and symptomatic men and women, as well as offering advice about and supply of contraceptives, including
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Art & science sexual health the insertion and removal of contraceptive implants and intrauterine devices (Rogstad et al 2002, Royal College of Nursing (RCN) 2009). Nevertheless, with demand continuing to exceed service provision, it is becoming increasingly common for asymptomatic patients to be offered a fast-track service that dispenses with the need for examination, and screening is undertaken using blood samples and self-collection of urine and low vaginal swabs (LVS) (Shamos et al 2008, Brown et al 2010). This article reviews the nursing literature to ascertain best practice in the collection of samples for STI screening, including a discussion of currently available laboratory testing methods; identifies the rationale for offering self-collection of samples (SCS); and determines the advantages and disadvantages of SCS for STI.
Literature review Electronic nursing literature databases, including the British Nursing Index, CINAHL Plus, Google Scholar, MEDLINE and Proquest Nursing and Allied Health Source, were searched to identify current research and expert opinion articles. The key words listed in Box 1 were used as single words, phrases or as Boolean search terms. From this extensive search, research and expert opinion articles that had been published within the past ten years in English language journals and written by authors from Western countries with comparable healthcare and laboratory infrastructures were identified. To ensure that no articles were missed, the electronic search was supplemented by manually searching the reference lists of articles obtained through the search to identify any additional articles. Relevant DH policies and current national guidance from the British Association for Sexual Health and HIV (BASHH), the Faculty of Sexual and Reproductive Healthcare (FSRH), MEDFASH and the RCN were also included.
BOX 1
Current screening options Changes in how patients are screened for STIs have been governed largely by advances in microbiological laboratory technology, including improvements in test sensitivities (Carder et al 2010). Historically, samples for microbiology testing were obtained by clinicians using urethral, endocervical and high vaginal swabs transported in appropriate media (Wilson 1995). At the laboratory, these samples were cultured and the resulting bacterial growth subjected to sensitivity tests to select and identify bacterial species (Bignell et al 2012). Although culture and sensitivity testing remains the most common laboratory test and is still essential for determining antibiotic sensitivities (Bignell et al 2012), this has recently been superseded by nucleic acid amplification tests (NAATs) for Chlamydia screening and, more recently, for gonorrhoea screening (Carder et al 2010, Bignell et al 2012). Since first-pass urine (FPU) specimens from women may contain amplification inhibitors, they do not provide the most reliable NAAT results, particularly when screening for gonorrhoea (Cook et al 2005, Fang et al 2008, Falk et al 1010), unlike in men, where NAAT responsiveness to FPU samples meets the BASHH national standard for gonorrhoea and Chlamydia (Carder et al 2010, Bignell et al 2012). From their research studies, Fang et al (2008) and Falk et al (2010) concluded that self-taken LVS can be equally effective or even better than professionally-taken cervical samples. Consequently, it is acceptable to offer asymptomatic women the option to take their own LVS. In asymptomatic men, FPU samples are adequate for routine Chlamydia and gonorrhoea screening (Carder et al 2010, Bignell et al 2012). SCS are sufficient in men and women with the proviso that, if the sample is positive for gonorrhoea, a urethral swab in men or an endocervical swab in women must be taken by a clinician to confirm the appropriate treatment regimen, which depends on the antibiotic sensitivity of the culture (Cook et al 2005, Bignell et al 2012). Figure 1 illustrates the basic range of genital screening and testing options available to patients in the UK (Lazaro 2013).
Key words used to search electronic nursing literature databases ‘chlamydia’ AND ‘screening’ ‘fast-track clinic’ ‘first catch urine’ ‘first-pass urine’ ‘first void urine’ ‘genital examination’ ‘missed diagnosis’ ‘non-invasive testing’ ‘one-stop shop’ ‘patient evaluation’ ‘patient preference’
‘self-collected’ ‘self-sampling’ ‘self-swab’ ‘self-testing’ ‘sexual’ AND ‘infection’ ‘sexual infections’ ‘sexually transmitted infections’ ‘speculum examination’ ‘stigma’ ‘vaginal examination’ ‘vaginal swabs’
Advantages of self-collection of samples Increased clinic capacity
With the constant demand for ISH services (HPA 2013), the efficacy of self-taken LVS from women and FPU from men creates the opportunity for a fast-track service and means that more clients can be accommodated in each clinic. Several large studies support this notion (Shamos et al 2008, Brown et al 2010, Martin et al 2013). Instead of performing a full genital examination on every client, these
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FIGURE 1 Basic genital screening and testing options (a) for men, (b) for women without genital symptoms and (c) for women with genital symptoms (a)
SYMPTOMATIC Plus (if indicated) clinician-taken skin swab for genital herpes (PCR)
SYMPTOMATIC Plus (if indicated) clinician-taken skin culture for balanitis
SYMPTOMATIC Plus (if indicated) clinician-taken urethral culture for gonorrhoea
ASYMPTOMATIC Self-taken FPU for Chlamydia and gonorrhoea (NAAT). Blood sample for HIV and syphilis testing (b)
Self-taken LVS for Chlamydia and gonorrhoea
OR
Clinician-taken endocervical swab for Chlamydia and gonorrhoea (NAAT)
(c) Clinician-taken endocervical swab for gonorrhoea culture Clinician-taken endocervical swab for Chlamydia and gonorrhoea (NAAT)
Plus (if indicated) clinician-taken HVS for microscopy for bacterial vaginosis and culture for Trichomonas vaginalis and yeasts (thrush)
Plus (if indicated) clinician-taken swab for genital herpes (PCR) and/or labial culture for yeasts (thrush)
FPU = first-pass urine; HIV = human immunodeficiency virus; HVS = high vaginal swab; LVS = low vaginal swab; NAAT = nucleic acid amplification tests; PCR = polymerase chain reaction
studies suggest that clinical staff of every grade can work alone with asymptomatic clients, who will only need the use of a toilet or private room to supply their own samples. Dispensing with the need for chaperones doubles the potential availability of clinical staff, which further increases clinic capacity and decreases waiting times (Christophers
et al 2008, Brown et al 2010). Allocation of staff in this way is deemed best practice in DH (2008) guidance, which recommends that asymptomatic screening clinics be staffed by healthcare assistants. Box 2 provides an overview of the advantages and disadvantages of incorporating SCS into the range of screening options available at ISH services.
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Art & science sexual health Reduced waiting times
With fewer examination rooms occupied by asymptomatic clients and clinic throughput increased, waiting times decrease (Brown et al 2010, Martin et al 2013). Shorter waiting times reduce the possibility that clients may leave the clinic before being treated because they are unable to wait any longer as a result of personal, academic or work commitments (Llewellyn et al 2012). Faster services meet the expectations and needs of young people in particular. For example, although Llewellyn et al (2012) and Martin et al (2013) sought the views of clinic attendees of all ages in their studies, it is evident from their findings, and Bender and Fulbright’s (2013) content analysis, that minimal clinic waiting times are desirable to adolescents. This ‘get in, get seen, get out’ mentality (French and Mercer 2009) may be related to the social stigma associated with attending ISH clinics (Llewellyn et al 2012, Bender and Fulbright 2013). Although modern ISH clinics incorporate private waiting areas, Llewellyn et al (2012) and Bender and Fulbright (2013) indicated that waiting in a clinic can unwittingly expose attendees to the likelihood that they may be recognised against their will by their peers. Llewellyn et al (2012) and Bender and Fulbright (2013) also concurred with Balfe et al (2010), who suggested that embarrassment and shame resulting from such encounters can deter people from re-attending ISH services. Thus, along with the assurance of confidentiality (Bender and Fulbright 2013), the availability of discreet, fast ISH services is of importance to clients, and particularly young people (Llewellyn et al 2012).
Faster diagnosis and treatment
Reduced waiting and screening times not only enhance clinic accessibility and capacity (Shamos et al 2008, Brown et al 2010), but also hasten diagnosis and treatment, which with proficient
BOX 2 Advantages and disadvantages of self-collection of samples Advantages Increases clinic capacity. Decreases waiting times. Leads to faster diagnosis and treatment. Involves less invasive sampling, which encourages attendance. Greater opportunity for nurse-led practice and advanced skills development. Disadvantages Staff become deskilled. Potential for nurse redundancy. Potential for missed diagnosis and misdiagnosis. Potential trivialisation of the integrated sexual health service by clients. Deters service use by clients other than adolescents.
health advice, can curtail the spread of STIs. Although refuted by Sanmani et al (2008), support for this conclusion was first shown by Mercer et al (2007), who found in their cross-sectional survey that a ‘greater availability of walk-in slots’ reduced delay to treatment compared with appointment-based sessions. More recently, Mercer et al (2012) compared two surveys taken five years apart, and reported that, although clients continue to engage in sex before treatment, shorter waiting times and increased client awareness could lead to a reduction in this activity and, therefore, a reduction in the potential for onward transmission of infection.
Less invasive sampling
The less invasive nature of FPU or LVS self-sampling could encourage people to attend ISH services. In the past, both sexes have been deterred from attending ISH, especially if they are asymptomatic, because of the expectation of embarrassment caused by clinician examination (Stewart et al 2008, Bender and Fulbright 2013). Men have been particularly daunted by peer hearsay detailing the torturous use of the ‘umbrella’ in sampling (Bradbeer et al 2006) or, more genuinely, the discomfort associated with urethral swab sampling (Apoola et al 2011). Although less painful, meatal self-swabbing in men may yield greater test sensitivity than urine samples (Chernesky et al 2013). The potential for causing trauma and distress through urethral and meatal sampling methods, particularly in asymptomatic men, has highlighted the merits of highly-sensitive, non-invasive FPU testing. For women, self-taken LVS have been welcomed as an effective alternative to clinician-taken endocervical swabs that, similar to urethral swabbing in men, have been associated with patient discomfort resulting from speculum examinations (Yanikkerem et al 2009). Although some women may dislike the process of self-swabbing (Mills et al 2006), the advantage of this technique for obtaining samples is that it negates religious or cultural objections associated with genital examinations, especially if the attending clinician is of the opposite sex (Yanikkerem et al 2009).
Staff deployment, dual-training and skills development
There are other advantages of introducing fast-track clinics and the diversion of asymptomatic clients to community screening facilities, such as pharmacies and outreach services in schools and colleges (Christophers et al 2008). Senior staff can be redirected towards meeting additional or more complex needs, for example contraceptive services (Shamos et al 2008, Brown et al 2010). Although in England and Wales, teenage conceptions in 2012
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were at their lowest level since 1969 (Office for National Statistics 2014), ‘the evidence is clear that teenage parenthood results in poor health, under-achievement and low earnings for both the mother and her baby’ (Frances 2010). One model designed to expedite success in the reduction of teenage pregnancies is the introduction of one-stop shops (French et al 2010), in which the full range of contraceptives (Christophers et al 2008) and sexual health services are available. In meeting this need, and in line with the recommendations from the MEDFASH report to the Independent Advisory Group on Sexual Health and HIV (Christophers et al 2008), nursing staff have become dual-trained; they can attend to clients with both sexual health and contraceptive needs during the same visit (Mehigan et al 2010). As a result, under Patient Group Directions, which permit ‘specified registered healthcare professionals to supply and/or administer a medicine directly to a patient with an identified clinical condition without him/her necessarily seeing a prescriber’ (National Prescribing Centre 2009), nurses have become authorised to supply a range of contraceptive pills, patches, injections, vaginal rings, diaphragms and caps (Christophers et al 2008). Moreover, some senior nursing staff have undertaken more advanced training in inserting and removing contraceptive implants and intrauterine devices (Christophers et al 2008, Mehigan et al 2010). Such opportunities assist staff in meeting their professional development requirements and can enhance career prospects (French et al 2006, RCN 2009, Mehigan et al 2010, FSRH 2013).
specialties such as paediatrics (Bray et al 2010). As a result, it is arguable that dual-trained staff are becoming inferior ‘jacks of all trades’, possessing little or no quality specialism within either GUM or contraceptive services (Robinson 2009), and consequently failing client expectations (Llewellyn et al 2012). Appointments can be lengthy when both contraceptive and sexual health needs are addressed on the same occasion (French et al 2006, 2010, FSRH 2013). This can be challenging not only for the healthcare professional involved, but the service as a whole because it reduces clinic capacity, while failing to generate proper remuneration through existing payment by results tariffs (French et al 2010).
Problems with self-diagnosis
Tipping the balance too far in favour of contraception services to the detriment of GUM provision not only affects ISH staff but also, and more fundamentally, clients. The onus is placed on clients to determine their symptomatic status, a responsibility fraught with inconsistencies and ignorance (Markos 2007, Shamos et al 2008). Although self-triaging and self-diagnosis empowers clients and accelerates clinic throughput, research evidence has shown repeatedly that lay knowledge of STIs can result in missed diagnosis or misdiagnosis (Shamos et al 2008, Brown et al 2010, Jutel 2010). Effective history-taking by trained healthcare professionals, and the provision of appropriate education to improve client recognition of the symptoms of common STIs, appear to be the best defence against inappropriate self-triage and self-diagnosis (Goyder et al 2009).
Implications of omitting specialist examination
Disadvantages of self-collection of samples Although simplified screening can increase Staff deskilling and redundancy
By limiting genital examinations to those clients with symptoms, healthcare professionals are potentially becoming deskilled (French et al 2006). This can especially affect those nurses who, because of their junior position, may have been limited to examining asymptomatic patients and who are of insufficient seniority to provide contraceptive advice and services (RCN 2009). In this straitened economic climate, it remains to be seen whether junior registered nurses, who have little opportunity for promotion and role development, will face redundancy as they are replaced by cheaper unqualified staff, such as healthcare assistants redeployed from chaperoning duties to running asymptomatic clinics (Wetherall 2012). Senior practitioners are not unaffected by this change and are also at risk of becoming deskilled as a consequence of the reduced opportunity to examine clients, as has been noted in other
uptake, elimination of professional examination of patients might conflict with established public health objectives (DH 2001). Without proper physical examination and identification of genital conditions, infections such as anogenital warts and vaginitis may be missed, leading to inappropriate treatment or uninhibited onward transmission between partners (Shamos et al 2008, Brown et al 2010, Xu et al 2013). Without routine surveillance of the cervix, vagina and vulva, potentially harmful cervical warts or occult early stages of uncommon serious disease, for example lichen sclerosus or cervical cancer, can be overlooked. Although the significance of asymptomatic urethritis is debated (Shahmanesh and Radcliffe 2007, Moi et al 2009) and yet to be determined (Heseltine et al 2012), the preclusion of urethral swabbing and microscopy in asymptomatic men can fail to identify Mycoplasma genitalium, a lesser known STI. Although the prevalence of
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Art & science sexual health mycoplasma genitalium is apparently low, failure to identify this infection allows preventable onward transmission (Moi et al 2009). Markos (2007) stated that failure to examine men and undertake urethral swabbing and microscopy ‘is clinically questionable and could lead to medico-legal consequences’. Medical practitioners interviewed by Stewart et al (2008) found this issue was equally applicable to women.
Trivialisation of and deterrence from service use To allay the shame and embarrassment experienced by individuals attending ISH services, some clients might invite friends and family to accompany them to clinics (Balfe et al 2010). The consequences of this are two-fold. First, catalysed by the ease with which STI screening can be accessed and undergone, attempts by clients to normalise screening to the extent that they attend
in groups ‘for a giggle’ can trivialise the potential seriousness of STIs (Balfe et al 2010). Second, although increased attendance figures may meet government objectives (DH 2001), other patients may be put off from attending a busy clinic that caters primarily for adolescents (Robinson 2009, Llewellyn et al 2012). French et al (2006) and Sauer et al (2013) indicated that patients who attend solely for contraception services were less likely to access one-stop shops because of the stigma associated with STIs and their prejudice against those they imagined attend such services.
Needs of clinic attendees This article has discussed clients’ preference for less invasive screening tests for STIs. Nevertheless, this does not mean that attendees wish to dispense with examinations altogether. Howard et al (2011)
References Apoola A, Herrero-Diaz M, FitzHugh E, Rajakumar R, Fakis A, Oakden J (2011) A randomised controlled trial to assess pain with urethral swabs. Sexually Transmitted Infections. 87, 2, 110-113. Balfe M, Brugha R, O’Donovan D, O’Connell E, Vaughan D (2010) Triggers of self-conscious emotions in the sexually transmitted infection testing process. BMC Research Notes. Doi: 10.1186/1756-0500-3-229. Bender SS, Fulbright YK (2013) Content analysis: a review of perceived barriers to sexual and reproductive health services by young people. European Journal of Contraception and Reproductive Health Care. 18, 3, 159-167. Bignell C, Ison C, FitzGerald M (2012) United Kingdom National Guideline for Gonorrhoea Testing 2012. British Association for Sexual Health and HIV, Macclesfield. Bradbeer C, Soni S, Ekbote A, Martin T (2006) You’re not going to give me the umbrella, are you? British Medical Journal. 333, 7582, 1287-1288.
non-invasive testing for sexually transmitted infections an efficient and acceptable alternative for patients? A randomised controlled trial. Sexually Transmitted Infections. 86, 7, 525-531. Carder C, Mercey D, Benn P (2010) Chlamydia Trachomatis UK Testing Guidelines. British Association for Sexual Health and HIV, Macclesfield. Chernesky MA, Jang D, Portillo E et al (2013) Self-collected swabs of the urinary meatus diagnose more Chlamydia trachomatis and Neisseria gonorrhoeae infections than first catch urine from men. Sexually Transmitted Infections. 89, 2, 102-104. Christophers H, Mann S, Lowbury R (2008) Progress and Priorities – Working Together for High Quality Sexual Health. Review of the National Strategy for Sexual Health and HIV. Medical Foundation for AIDS and Sexual Health, London. Cook RL, Hutchison SL, Østergaard L, Braithwaite RS, Ness RB (2005) Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Annals of Internal Medicine. 142, 11, 914-925.
Bray L, Sanders C, Flynn A (2010) Paediatric catheterisation: exploring and understanding children’s nurses’ perceptions and practice in an acute setting. Journal of Clinical Nursing. 19, 21-22, 3235-3243.
Department of Health (2001) Better Prevention, Better Services, Better Sexual Health: The National Strategy for Sexual Health and HIV. DH, London.
Brown L, Patel S, Ives NJ, McDermott C, Ross JD (2010) Is
Department of Health (2008) Genitourinary Medicine 48-Hour
Access: Getting to Target and Staying There. DH, London. Faculty of Sexual and Reproductive Healthcare (2013) Service Standards for Sexual and Reproductive Healthcare. Clinical Standards Committee of the Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists, London. Falk L, Coble BI, Mjörnberg PA, Fredlund H (2010) Sampling for Chlamydia trachomatis infection – a comparison of vaginal, first-catch urine, combined vaginal and first-catch urine and endocervical sampling. International Journal of STD and AIDS. 21, 4, 283-287. Fang J, Husman C, DeSilva L, Chang R, Peralta L (2008) Evaluation of self-collected vaginal swab, first void urine, and endocervical swab specimens for the detection of Chlamydia trachomatis and Neisseria gonorrhoea in adolescent females. Journal of Paediatric and Adolescent Gynaecology. 21, 6, 355-360. Frances G (2010) Teenage Pregnancy Independent Advisory Group Final Report. Teenage Pregnancy: Past Successes – Future Challenges. Teenage Pregnancy Independent Advisory Group, London. French RS, Mercer CH (2009) Commentary. Sexually Transmitted Infections. 85, 6, 467-468.
French RS, Mercer CH, Robinson AJ, Gerressu M, Rogstad KE (2010) Addressing sexual health needs: a comparison of a one-stop shop with separate genitourinary medicine and family planning services. Journal of Family Planning and Reproductive Health Care. 36, 4, 202-209. French RS, Coope CM, Graham A, Gerressu M, Salisbury C, Stephenson JM (2006) One stop shop versus collaborative integration: what is the best way of delivering sexual health services? Sexually Transmitted Infections. 82, 3, 202-206. Goyder C, McPherson A, Glasziou P (2009) Diagnosis in general practice. Self-diagnosis. British Medical Journal. 339, b4418. Health Protection Agency (2013) Sexually transmitted infections and chlamydia screening in England, 2012. Health Protection Report. 7, 23, 8-21. Heseltine K, Foley E, Alborough B, Patel R (2012) Patient views on examinations as part of asymptomatic screening in sexual health clinics. International Journal of STD and AIDS. 23, 5, 305-307. Howard EJ, Xu F, Taylor SN et al (2011) Screening methods for Chlamydia trachomatis and Neisseria gonorrhoeae infections in sexually transmitted infection clinics: what do patients prefer? Sexually Transmitted Infections. 87, 2, 149-151.
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acknowledged that some clients prefer swabs to be taken by clinicians because they believe that the test results will be more reliable. Even those clients who opt for SCS may request genital examination for peace of mind (Stewart et al 2008, Heseltine et al 2012). Therefore, it is important to advise patients of all types of screening available to promote informed choice (MEDFASH 2005, Heseltine et al 2012) and offer these in the clinic (Martin et al 2013).
Conclusion Fast-track screening incorporating SCS appears to be an inevitable consequence of the present situation in sexual health, and is becoming more common in ISH services. SCS are less invasive and are of equivalent sensitivity to clinician-obtained swabs and can increase clinic capacity, resulting in more patients being tested and treated for STIs Jutel A (2010) Self-Diagnosis: A Discursive Systematic Review of the Medical Literature. tinyurl.com/ oc6tpao (Last accessed: May 21 2014). Lazaro N (2013) Sexually Transmitted Infections in Primary Care. Second Edition. Royal College of General Practitioners and British Association for Sexual Health and HIV, London. Llewellyn C, Pollard A, Miners A et al (2012) Understanding patient choices for attending sexually transmitted infection testing services: a qualitative study. Sexually Transmitted Infections. 88, 7, 504-509. Markos AR (2007) The incidence of sexually related conditions in asymptomatic versus symptomatic patients. International Journal of STD and AIDS. 18, 9, 610-612. Martin L, Knight V, Ryder N, Lu H, Read PJ, McNulty A (2013) Client feedback and satisfaction with an express sexually transmissible infection screening service at an inner-city sexual health centre. Sexually Transmitted Diseases. 40, 1, 70-74. Medical Foundation for HIV and Sexual Health (2005) Recommended Standards for Sexual Health Services. Medical Foundation for HIV and Sexual Health, London. Mehigan S, Moore W, Hayes L (2010) Nurse training in sexual
rapidly, thereby reducing onward transmission. Simultaneously, contraception provision can be broadened in an effort to maintain the decrease in teenage pregnancies. Although this wider provision can enhance staff expertise in contraception services, the introduction of fast-track screening heralds a downgrade in GUM services, which can deskill staff, rendering them incapable of accurately assessing and diagnosing clients who require examination. Potentially inadequate lay diagnosis could lead to missed diagnosis or misdiagnosis of STIs, the consequences of which are uninhibited onward transmission and an increase in STI rates. Championing best practice, nurses would do well to delineate every option for screening when triaging clients, using effective clinical decision making and negotiation skills so that clients can make an informed choice about whether or not to accept examination NS
and reproductive health. Journal of Family Planning and Reproductive Health Care. 36, 1, 5-6. Mercer CH, Aicken CR, Estcourt CS et al (2012) Building the bypass – implications of improved access to sexual healthcare: evidence from surveys of patients attending contrasting genitourinary medicine clinics across England in 2004/2005 and 2009. Sexually Transmitted Infections. 88, 1, 9-15. Mercer CH, Sutcliffe L, Johnson AM et al (2007) How much do delayed healthcare seeking, delayed care provision, and diversion from primary care contribute to the transmission of STIs? Sexually Transmitted Infections. 83, 5, 400-405. Mills N, Daker-White G, Graham A, Campbell R (2006) Population screening for Chlamydia trachomatis infection in the UK: a qualitative study of the experiences of those screened. Family Practice. 23, 5, 550-557. Moi H, Reinton N, Moghaddam A (2009) Mycoplasma genitalium is associated with symptomatic and asymptomatic non-gonococcal urethritis in men. Sexually Transmitted Infections. 85, 1, 15-18. National Prescribing Centre (2009) Patient Group Directions: A Practical Guide and Framework of Competencies for all Professionals using Patient Group Directions. National Prescribing Centre, Liverpool.
Office for National Statistics (2014) Statistical Bulletin: Conceptions in England and Wales, 2012. ONS, Newport. Robinson G (2009) Integrated sexual health: a better way of working? Journal of Family Planning and Reproductive Health Care. 35, 4, 249-250. Rogstad KE, Ahmed-Jushuf IH, Robinson AJ (2002) Standards for comprehensive sexual health services for young people under 25 years. International Journal of STD and AIDS. 13, 6, 420-424. Royal College of Nursing (2009) Sexual Health Competences: An Integrated Career and Competency Framework for Sexual and Reproductive Health Nursing Across the UK. RCN, London. Sanmani L, Foley E, Samraj S, Rowen D, Yadegarfar G, Patel R (2008) Patient-initiated delay at a genitourinary medicine clinic: are there public health consequences? Sexually Transmitted Infections. 84, 7, 560-562. Sauer U, Singh A, Rubenstein P, Pittrof R (2013) Do women requesting only contraception find attendance at an integrated sexual health clinic more stigmatizing than attendance at a family planning-only clinic? International Journal of Women’s Health. 5, 57-64.
Shahmanesh M, Radcliffe KW (2007) Is the urethral smear necessary in asymptomatic men attending a genitourinary medicine clinic? Sexually Transmitted Infections. 83, 2, 79-81. Shamos SJ, Mettenbrink CJ, Subiadur JA, Mitchell BL, Rietmeijer CA (2008) Evaluation of a testing-only “express” visit option to enhance efficiency in a busy STI clinic. Sexually Transmitted Diseases. 35, 4, 336-340. Stewart RA, Thistlethwaite J, Evans R (2008) Pelvic examination of asymptomatic women: attitudes and clinical practice. Australian Family Physician. 37, 6, 493-496. Wetherall C (2012) Editorial: call yourself a nurse? Time to get precious. Journal of Clinical Nursing. 21, 19-20, 2809-2811. Wilson JD (1995) Female Genital Infections. Martin Dunitz Ltd, London. Xu F, Stoner BP, Taylor SN et al (2013) “Testing only” visits: an assessment of missed diagnoses in clients attending sexually transmitted disease clinics. Sexually Transmitted Diseases. 40, 1, 64-69. Yanikkerem E, Özdemir M, Bingol H, Tatar A, Karadeniz G (2009) Women’s attitudes and expectations regarding gynaecological examination. Midwifery. 25, 5, 500-508.
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If you would like to contribute to the Art & science section, email [email protected]
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Self-screening for sexually transmitted infections Potter Y (2014) Self-screening for sexually transmitted infections. Nursing Standard. 28, 41, 37-43. Date of submission: January 18 2014; date of acceptance: March 12 2014.
Abstract There is an increasing trend towards self-collection of samples for sexually transmitted infection screening in lieu of genital examination and clinician-obtained urethral and cervical swabs. This article examines the advantages and disadvantages of this trend, and the effect on nursing practice particularly within integrated sexual health (ISH) services, which provide genito-urinary medicine (GUM) and contraceptive services. This article might also be of interest to nurses working within separate GUM and contraceptive services, especially those that are preparing to become ISH services.
Author Yvonne Potter Staff nurse, North Lincolnshire Sexual Health, The Ironstone Centre, Scunthorpe. At the time of writing, staff nurse, Centre for Sexual Health, Diana Princess of Wales Hospital, Grimsby. Correspondence to: [email protected]
Keywords Contraception and sexual health, genito-urinary medicine, integrated sexual health services, sexually transmitted infections
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
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SINCE 2001, when genito-urinary medicine (GUM) services became the focus of government attention with the publication of Better Prevention, Better Services, Better Sexual Health: The National Strategy for Sexual Health and HIV (Department of Health (DH) 2001), there have been fundamental changes within these services in the UK. This, and subsequent policies, standards and reports, focused on young people between the age of 16 and 24, for whom the highest (and, until recently, increasing) rates of sexually transmitted infections (STIs) have been reported (Health Protection Agency (HPA) 2013). In particular, the Medical Foundation for HIV and Sexual Health (MEDFASH) (2005) standards aimed to tackle this public health problem by founding accessible and effective GUM services that are capable of meeting the needs of this client group. Consequently, GUM services have been expected to offer appointments to all new clients within 48 hours (DH 2008). Moreover, with the aim of reducing teenage conceptions, The National Strategy for Sexual Health and HIV (DH 2001) also introduced the concept of combining contraception and GUM services (French et al 2010), creating an integrated, one-stop shop that offers specialist screening and treatment for STIs, along with the availability of all forms of contraception, from condoms to long-acting reversible products (Rogstad et al 2002). To meet the increasing demand for integrated sexual health (ISH) services, nurse-led clinics have become commonplace. These clinics are managed by qualified nurses with extended roles, such as non-medical prescribers who examine and treat both asymptomatic and symptomatic men and women, as well as offering advice about and supply of contraceptives, including
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Art & science sexual health the insertion and removal of contraceptive implants and intrauterine devices (Rogstad et al 2002, Royal College of Nursing (RCN) 2009). Nevertheless, with demand continuing to exceed service provision, it is becoming increasingly common for asymptomatic patients to be offered a fast-track service that dispenses with the need for examination, and screening is undertaken using blood samples and self-collection of urine and low vaginal swabs (LVS) (Shamos et al 2008, Brown et al 2010). This article reviews the nursing literature to ascertain best practice in the collection of samples for STI screening, including a discussion of currently available laboratory testing methods; identifies the rationale for offering self-collection of samples (SCS); and determines the advantages and disadvantages of SCS for STI.
Literature review Electronic nursing literature databases, including the British Nursing Index, CINAHL Plus, Google Scholar, MEDLINE and Proquest Nursing and Allied Health Source, were searched to identify current research and expert opinion articles. The key words listed in Box 1 were used as single words, phrases or as Boolean search terms. From this extensive search, research and expert opinion articles that had been published within the past ten years in English language journals and written by authors from Western countries with comparable healthcare and laboratory infrastructures were identified. To ensure that no articles were missed, the electronic search was supplemented by manually searching the reference lists of articles obtained through the search to identify any additional articles. Relevant DH policies and current national guidance from the British Association for Sexual Health and HIV (BASHH), the Faculty of Sexual and Reproductive Healthcare (FSRH), MEDFASH and the RCN were also included.
BOX 1
Current screening options Changes in how patients are screened for STIs have been governed largely by advances in microbiological laboratory technology, including improvements in test sensitivities (Carder et al 2010). Historically, samples for microbiology testing were obtained by clinicians using urethral, endocervical and high vaginal swabs transported in appropriate media (Wilson 1995). At the laboratory, these samples were cultured and the resulting bacterial growth subjected to sensitivity tests to select and identify bacterial species (Bignell et al 2012). Although culture and sensitivity testing remains the most common laboratory test and is still essential for determining antibiotic sensitivities (Bignell et al 2012), this has recently been superseded by nucleic acid amplification tests (NAATs) for Chlamydia screening and, more recently, for gonorrhoea screening (Carder et al 2010, Bignell et al 2012). Since first-pass urine (FPU) specimens from women may contain amplification inhibitors, they do not provide the most reliable NAAT results, particularly when screening for gonorrhoea (Cook et al 2005, Fang et al 2008, Falk et al 1010), unlike in men, where NAAT responsiveness to FPU samples meets the BASHH national standard for gonorrhoea and Chlamydia (Carder et al 2010, Bignell et al 2012). From their research studies, Fang et al (2008) and Falk et al (2010) concluded that self-taken LVS can be equally effective or even better than professionally-taken cervical samples. Consequently, it is acceptable to offer asymptomatic women the option to take their own LVS. In asymptomatic men, FPU samples are adequate for routine Chlamydia and gonorrhoea screening (Carder et al 2010, Bignell et al 2012). SCS are sufficient in men and women with the proviso that, if the sample is positive for gonorrhoea, a urethral swab in men or an endocervical swab in women must be taken by a clinician to confirm the appropriate treatment regimen, which depends on the antibiotic sensitivity of the culture (Cook et al 2005, Bignell et al 2012). Figure 1 illustrates the basic range of genital screening and testing options available to patients in the UK (Lazaro 2013).
Key words used to search electronic nursing literature databases ‘chlamydia’ AND ‘screening’ ‘fast-track clinic’ ‘first catch urine’ ‘first-pass urine’ ‘first void urine’ ‘genital examination’ ‘missed diagnosis’ ‘non-invasive testing’ ‘one-stop shop’ ‘patient evaluation’ ‘patient preference’
‘self-collected’ ‘self-sampling’ ‘self-swab’ ‘self-testing’ ‘sexual’ AND ‘infection’ ‘sexual infections’ ‘sexually transmitted infections’ ‘speculum examination’ ‘stigma’ ‘vaginal examination’ ‘vaginal swabs’
Advantages of self-collection of samples Increased clinic capacity
With the constant demand for ISH services (HPA 2013), the efficacy of self-taken LVS from women and FPU from men creates the opportunity for a fast-track service and means that more clients can be accommodated in each clinic. Several large studies support this notion (Shamos et al 2008, Brown et al 2010, Martin et al 2013). Instead of performing a full genital examination on every client, these
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FIGURE 1 Basic genital screening and testing options (a) for men, (b) for women without genital symptoms and (c) for women with genital symptoms (a)
SYMPTOMATIC Plus (if indicated) clinician-taken skin swab for genital herpes (PCR)
SYMPTOMATIC Plus (if indicated) clinician-taken skin culture for balanitis
SYMPTOMATIC Plus (if indicated) clinician-taken urethral culture for gonorrhoea
ASYMPTOMATIC Self-taken FPU for Chlamydia and gonorrhoea (NAAT). Blood sample for HIV and syphilis testing (b)
Self-taken LVS for Chlamydia and gonorrhoea
OR
Clinician-taken endocervical swab for Chlamydia and gonorrhoea (NAAT)
(c) Clinician-taken endocervical swab for gonorrhoea culture Clinician-taken endocervical swab for Chlamydia and gonorrhoea (NAAT)
Plus (if indicated) clinician-taken HVS for microscopy for bacterial vaginosis and culture for Trichomonas vaginalis and yeasts (thrush)
Plus (if indicated) clinician-taken swab for genital herpes (PCR) and/or labial culture for yeasts (thrush)
FPU = first-pass urine; HIV = human immunodeficiency virus; HVS = high vaginal swab; LVS = low vaginal swab; NAAT = nucleic acid amplification tests; PCR = polymerase chain reaction
studies suggest that clinical staff of every grade can work alone with asymptomatic clients, who will only need the use of a toilet or private room to supply their own samples. Dispensing with the need for chaperones doubles the potential availability of clinical staff, which further increases clinic capacity and decreases waiting times (Christophers
et al 2008, Brown et al 2010). Allocation of staff in this way is deemed best practice in DH (2008) guidance, which recommends that asymptomatic screening clinics be staffed by healthcare assistants. Box 2 provides an overview of the advantages and disadvantages of incorporating SCS into the range of screening options available at ISH services.
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Art & science sexual health Reduced waiting times
With fewer examination rooms occupied by asymptomatic clients and clinic throughput increased, waiting times decrease (Brown et al 2010, Martin et al 2013). Shorter waiting times reduce the possibility that clients may leave the clinic before being treated because they are unable to wait any longer as a result of personal, academic or work commitments (Llewellyn et al 2012). Faster services meet the expectations and needs of young people in particular. For example, although Llewellyn et al (2012) and Martin et al (2013) sought the views of clinic attendees of all ages in their studies, it is evident from their findings, and Bender and Fulbright’s (2013) content analysis, that minimal clinic waiting times are desirable to adolescents. This ‘get in, get seen, get out’ mentality (French and Mercer 2009) may be related to the social stigma associated with attending ISH clinics (Llewellyn et al 2012, Bender and Fulbright 2013). Although modern ISH clinics incorporate private waiting areas, Llewellyn et al (2012) and Bender and Fulbright (2013) indicated that waiting in a clinic can unwittingly expose attendees to the likelihood that they may be recognised against their will by their peers. Llewellyn et al (2012) and Bender and Fulbright (2013) also concurred with Balfe et al (2010), who suggested that embarrassment and shame resulting from such encounters can deter people from re-attending ISH services. Thus, along with the assurance of confidentiality (Bender and Fulbright 2013), the availability of discreet, fast ISH services is of importance to clients, and particularly young people (Llewellyn et al 2012).
Faster diagnosis and treatment
Reduced waiting and screening times not only enhance clinic accessibility and capacity (Shamos et al 2008, Brown et al 2010), but also hasten diagnosis and treatment, which with proficient
BOX 2 Advantages and disadvantages of self-collection of samples Advantages Increases clinic capacity. Decreases waiting times. Leads to faster diagnosis and treatment. Involves less invasive sampling, which encourages attendance. Greater opportunity for nurse-led practice and advanced skills development. Disadvantages Staff become deskilled. Potential for nurse redundancy. Potential for missed diagnosis and misdiagnosis. Potential trivialisation of the integrated sexual health service by clients. Deters service use by clients other than adolescents.
health advice, can curtail the spread of STIs. Although refuted by Sanmani et al (2008), support for this conclusion was first shown by Mercer et al (2007), who found in their cross-sectional survey that a ‘greater availability of walk-in slots’ reduced delay to treatment compared with appointment-based sessions. More recently, Mercer et al (2012) compared two surveys taken five years apart, and reported that, although clients continue to engage in sex before treatment, shorter waiting times and increased client awareness could lead to a reduction in this activity and, therefore, a reduction in the potential for onward transmission of infection.
Less invasive sampling
The less invasive nature of FPU or LVS self-sampling could encourage people to attend ISH services. In the past, both sexes have been deterred from attending ISH, especially if they are asymptomatic, because of the expectation of embarrassment caused by clinician examination (Stewart et al 2008, Bender and Fulbright 2013). Men have been particularly daunted by peer hearsay detailing the torturous use of the ‘umbrella’ in sampling (Bradbeer et al 2006) or, more genuinely, the discomfort associated with urethral swab sampling (Apoola et al 2011). Although less painful, meatal self-swabbing in men may yield greater test sensitivity than urine samples (Chernesky et al 2013). The potential for causing trauma and distress through urethral and meatal sampling methods, particularly in asymptomatic men, has highlighted the merits of highly-sensitive, non-invasive FPU testing. For women, self-taken LVS have been welcomed as an effective alternative to clinician-taken endocervical swabs that, similar to urethral swabbing in men, have been associated with patient discomfort resulting from speculum examinations (Yanikkerem et al 2009). Although some women may dislike the process of self-swabbing (Mills et al 2006), the advantage of this technique for obtaining samples is that it negates religious or cultural objections associated with genital examinations, especially if the attending clinician is of the opposite sex (Yanikkerem et al 2009).
Staff deployment, dual-training and skills development
There are other advantages of introducing fast-track clinics and the diversion of asymptomatic clients to community screening facilities, such as pharmacies and outreach services in schools and colleges (Christophers et al 2008). Senior staff can be redirected towards meeting additional or more complex needs, for example contraceptive services (Shamos et al 2008, Brown et al 2010). Although in England and Wales, teenage conceptions in 2012
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were at their lowest level since 1969 (Office for National Statistics 2014), ‘the evidence is clear that teenage parenthood results in poor health, under-achievement and low earnings for both the mother and her baby’ (Frances 2010). One model designed to expedite success in the reduction of teenage pregnancies is the introduction of one-stop shops (French et al 2010), in which the full range of contraceptives (Christophers et al 2008) and sexual health services are available. In meeting this need, and in line with the recommendations from the MEDFASH report to the Independent Advisory Group on Sexual Health and HIV (Christophers et al 2008), nursing staff have become dual-trained; they can attend to clients with both sexual health and contraceptive needs during the same visit (Mehigan et al 2010). As a result, under Patient Group Directions, which permit ‘specified registered healthcare professionals to supply and/or administer a medicine directly to a patient with an identified clinical condition without him/her necessarily seeing a prescriber’ (National Prescribing Centre 2009), nurses have become authorised to supply a range of contraceptive pills, patches, injections, vaginal rings, diaphragms and caps (Christophers et al 2008). Moreover, some senior nursing staff have undertaken more advanced training in inserting and removing contraceptive implants and intrauterine devices (Christophers et al 2008, Mehigan et al 2010). Such opportunities assist staff in meeting their professional development requirements and can enhance career prospects (French et al 2006, RCN 2009, Mehigan et al 2010, FSRH 2013).
specialties such as paediatrics (Bray et al 2010). As a result, it is arguable that dual-trained staff are becoming inferior ‘jacks of all trades’, possessing little or no quality specialism within either GUM or contraceptive services (Robinson 2009), and consequently failing client expectations (Llewellyn et al 2012). Appointments can be lengthy when both contraceptive and sexual health needs are addressed on the same occasion (French et al 2006, 2010, FSRH 2013). This can be challenging not only for the healthcare professional involved, but the service as a whole because it reduces clinic capacity, while failing to generate proper remuneration through existing payment by results tariffs (French et al 2010).
Problems with self-diagnosis
Tipping the balance too far in favour of contraception services to the detriment of GUM provision not only affects ISH staff but also, and more fundamentally, clients. The onus is placed on clients to determine their symptomatic status, a responsibility fraught with inconsistencies and ignorance (Markos 2007, Shamos et al 2008). Although self-triaging and self-diagnosis empowers clients and accelerates clinic throughput, research evidence has shown repeatedly that lay knowledge of STIs can result in missed diagnosis or misdiagnosis (Shamos et al 2008, Brown et al 2010, Jutel 2010). Effective history-taking by trained healthcare professionals, and the provision of appropriate education to improve client recognition of the symptoms of common STIs, appear to be the best defence against inappropriate self-triage and self-diagnosis (Goyder et al 2009).
Implications of omitting specialist examination
Disadvantages of self-collection of samples Although simplified screening can increase Staff deskilling and redundancy
By limiting genital examinations to those clients with symptoms, healthcare professionals are potentially becoming deskilled (French et al 2006). This can especially affect those nurses who, because of their junior position, may have been limited to examining asymptomatic patients and who are of insufficient seniority to provide contraceptive advice and services (RCN 2009). In this straitened economic climate, it remains to be seen whether junior registered nurses, who have little opportunity for promotion and role development, will face redundancy as they are replaced by cheaper unqualified staff, such as healthcare assistants redeployed from chaperoning duties to running asymptomatic clinics (Wetherall 2012). Senior practitioners are not unaffected by this change and are also at risk of becoming deskilled as a consequence of the reduced opportunity to examine clients, as has been noted in other
uptake, elimination of professional examination of patients might conflict with established public health objectives (DH 2001). Without proper physical examination and identification of genital conditions, infections such as anogenital warts and vaginitis may be missed, leading to inappropriate treatment or uninhibited onward transmission between partners (Shamos et al 2008, Brown et al 2010, Xu et al 2013). Without routine surveillance of the cervix, vagina and vulva, potentially harmful cervical warts or occult early stages of uncommon serious disease, for example lichen sclerosus or cervical cancer, can be overlooked. Although the significance of asymptomatic urethritis is debated (Shahmanesh and Radcliffe 2007, Moi et al 2009) and yet to be determined (Heseltine et al 2012), the preclusion of urethral swabbing and microscopy in asymptomatic men can fail to identify Mycoplasma genitalium, a lesser known STI. Although the prevalence of
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Art & science sexual health mycoplasma genitalium is apparently low, failure to identify this infection allows preventable onward transmission (Moi et al 2009). Markos (2007) stated that failure to examine men and undertake urethral swabbing and microscopy ‘is clinically questionable and could lead to medico-legal consequences’. Medical practitioners interviewed by Stewart et al (2008) found this issue was equally applicable to women.
Trivialisation of and deterrence from service use To allay the shame and embarrassment experienced by individuals attending ISH services, some clients might invite friends and family to accompany them to clinics (Balfe et al 2010). The consequences of this are two-fold. First, catalysed by the ease with which STI screening can be accessed and undergone, attempts by clients to normalise screening to the extent that they attend
in groups ‘for a giggle’ can trivialise the potential seriousness of STIs (Balfe et al 2010). Second, although increased attendance figures may meet government objectives (DH 2001), other patients may be put off from attending a busy clinic that caters primarily for adolescents (Robinson 2009, Llewellyn et al 2012). French et al (2006) and Sauer et al (2013) indicated that patients who attend solely for contraception services were less likely to access one-stop shops because of the stigma associated with STIs and their prejudice against those they imagined attend such services.
Needs of clinic attendees This article has discussed clients’ preference for less invasive screening tests for STIs. Nevertheless, this does not mean that attendees wish to dispense with examinations altogether. Howard et al (2011)
References Apoola A, Herrero-Diaz M, FitzHugh E, Rajakumar R, Fakis A, Oakden J (2011) A randomised controlled trial to assess pain with urethral swabs. Sexually Transmitted Infections. 87, 2, 110-113. Balfe M, Brugha R, O’Donovan D, O’Connell E, Vaughan D (2010) Triggers of self-conscious emotions in the sexually transmitted infection testing process. BMC Research Notes. Doi: 10.1186/1756-0500-3-229. Bender SS, Fulbright YK (2013) Content analysis: a review of perceived barriers to sexual and reproductive health services by young people. European Journal of Contraception and Reproductive Health Care. 18, 3, 159-167. Bignell C, Ison C, FitzGerald M (2012) United Kingdom National Guideline for Gonorrhoea Testing 2012. British Association for Sexual Health and HIV, Macclesfield. Bradbeer C, Soni S, Ekbote A, Martin T (2006) You’re not going to give me the umbrella, are you? British Medical Journal. 333, 7582, 1287-1288.
non-invasive testing for sexually transmitted infections an efficient and acceptable alternative for patients? A randomised controlled trial. Sexually Transmitted Infections. 86, 7, 525-531. Carder C, Mercey D, Benn P (2010) Chlamydia Trachomatis UK Testing Guidelines. British Association for Sexual Health and HIV, Macclesfield. Chernesky MA, Jang D, Portillo E et al (2013) Self-collected swabs of the urinary meatus diagnose more Chlamydia trachomatis and Neisseria gonorrhoeae infections than first catch urine from men. Sexually Transmitted Infections. 89, 2, 102-104. Christophers H, Mann S, Lowbury R (2008) Progress and Priorities – Working Together for High Quality Sexual Health. Review of the National Strategy for Sexual Health and HIV. Medical Foundation for AIDS and Sexual Health, London. Cook RL, Hutchison SL, Østergaard L, Braithwaite RS, Ness RB (2005) Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Annals of Internal Medicine. 142, 11, 914-925.
Bray L, Sanders C, Flynn A (2010) Paediatric catheterisation: exploring and understanding children’s nurses’ perceptions and practice in an acute setting. Journal of Clinical Nursing. 19, 21-22, 3235-3243.
Department of Health (2001) Better Prevention, Better Services, Better Sexual Health: The National Strategy for Sexual Health and HIV. DH, London.
Brown L, Patel S, Ives NJ, McDermott C, Ross JD (2010) Is
Department of Health (2008) Genitourinary Medicine 48-Hour
Access: Getting to Target and Staying There. DH, London. Faculty of Sexual and Reproductive Healthcare (2013) Service Standards for Sexual and Reproductive Healthcare. Clinical Standards Committee of the Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists, London. Falk L, Coble BI, Mjörnberg PA, Fredlund H (2010) Sampling for Chlamydia trachomatis infection – a comparison of vaginal, first-catch urine, combined vaginal and first-catch urine and endocervical sampling. International Journal of STD and AIDS. 21, 4, 283-287. Fang J, Husman C, DeSilva L, Chang R, Peralta L (2008) Evaluation of self-collected vaginal swab, first void urine, and endocervical swab specimens for the detection of Chlamydia trachomatis and Neisseria gonorrhoea in adolescent females. Journal of Paediatric and Adolescent Gynaecology. 21, 6, 355-360. Frances G (2010) Teenage Pregnancy Independent Advisory Group Final Report. Teenage Pregnancy: Past Successes – Future Challenges. Teenage Pregnancy Independent Advisory Group, London. French RS, Mercer CH (2009) Commentary. Sexually Transmitted Infections. 85, 6, 467-468.
French RS, Mercer CH, Robinson AJ, Gerressu M, Rogstad KE (2010) Addressing sexual health needs: a comparison of a one-stop shop with separate genitourinary medicine and family planning services. Journal of Family Planning and Reproductive Health Care. 36, 4, 202-209. French RS, Coope CM, Graham A, Gerressu M, Salisbury C, Stephenson JM (2006) One stop shop versus collaborative integration: what is the best way of delivering sexual health services? Sexually Transmitted Infections. 82, 3, 202-206. Goyder C, McPherson A, Glasziou P (2009) Diagnosis in general practice. Self-diagnosis. British Medical Journal. 339, b4418. Health Protection Agency (2013) Sexually transmitted infections and chlamydia screening in England, 2012. Health Protection Report. 7, 23, 8-21. Heseltine K, Foley E, Alborough B, Patel R (2012) Patient views on examinations as part of asymptomatic screening in sexual health clinics. International Journal of STD and AIDS. 23, 5, 305-307. Howard EJ, Xu F, Taylor SN et al (2011) Screening methods for Chlamydia trachomatis and Neisseria gonorrhoeae infections in sexually transmitted infection clinics: what do patients prefer? Sexually Transmitted Infections. 87, 2, 149-151.
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acknowledged that some clients prefer swabs to be taken by clinicians because they believe that the test results will be more reliable. Even those clients who opt for SCS may request genital examination for peace of mind (Stewart et al 2008, Heseltine et al 2012). Therefore, it is important to advise patients of all types of screening available to promote informed choice (MEDFASH 2005, Heseltine et al 2012) and offer these in the clinic (Martin et al 2013).
Conclusion Fast-track screening incorporating SCS appears to be an inevitable consequence of the present situation in sexual health, and is becoming more common in ISH services. SCS are less invasive and are of equivalent sensitivity to clinician-obtained swabs and can increase clinic capacity, resulting in more patients being tested and treated for STIs Jutel A (2010) Self-Diagnosis: A Discursive Systematic Review of the Medical Literature. tinyurl.com/ oc6tpao (Last accessed: May 21 2014). Lazaro N (2013) Sexually Transmitted Infections in Primary Care. Second Edition. Royal College of General Practitioners and British Association for Sexual Health and HIV, London. Llewellyn C, Pollard A, Miners A et al (2012) Understanding patient choices for attending sexually transmitted infection testing services: a qualitative study. Sexually Transmitted Infections. 88, 7, 504-509. Markos AR (2007) The incidence of sexually related conditions in asymptomatic versus symptomatic patients. International Journal of STD and AIDS. 18, 9, 610-612. Martin L, Knight V, Ryder N, Lu H, Read PJ, McNulty A (2013) Client feedback and satisfaction with an express sexually transmissible infection screening service at an inner-city sexual health centre. Sexually Transmitted Diseases. 40, 1, 70-74. Medical Foundation for HIV and Sexual Health (2005) Recommended Standards for Sexual Health Services. Medical Foundation for HIV and Sexual Health, London. Mehigan S, Moore W, Hayes L (2010) Nurse training in sexual
rapidly, thereby reducing onward transmission. Simultaneously, contraception provision can be broadened in an effort to maintain the decrease in teenage pregnancies. Although this wider provision can enhance staff expertise in contraception services, the introduction of fast-track screening heralds a downgrade in GUM services, which can deskill staff, rendering them incapable of accurately assessing and diagnosing clients who require examination. Potentially inadequate lay diagnosis could lead to missed diagnosis or misdiagnosis of STIs, the consequences of which are uninhibited onward transmission and an increase in STI rates. Championing best practice, nurses would do well to delineate every option for screening when triaging clients, using effective clinical decision making and negotiation skills so that clients can make an informed choice about whether or not to accept examination NS
and reproductive health. Journal of Family Planning and Reproductive Health Care. 36, 1, 5-6. Mercer CH, Aicken CR, Estcourt CS et al (2012) Building the bypass – implications of improved access to sexual healthcare: evidence from surveys of patients attending contrasting genitourinary medicine clinics across England in 2004/2005 and 2009. Sexually Transmitted Infections. 88, 1, 9-15. Mercer CH, Sutcliffe L, Johnson AM et al (2007) How much do delayed healthcare seeking, delayed care provision, and diversion from primary care contribute to the transmission of STIs? Sexually Transmitted Infections. 83, 5, 400-405. Mills N, Daker-White G, Graham A, Campbell R (2006) Population screening for Chlamydia trachomatis infection in the UK: a qualitative study of the experiences of those screened. Family Practice. 23, 5, 550-557. Moi H, Reinton N, Moghaddam A (2009) Mycoplasma genitalium is associated with symptomatic and asymptomatic non-gonococcal urethritis in men. Sexually Transmitted Infections. 85, 1, 15-18. National Prescribing Centre (2009) Patient Group Directions: A Practical Guide and Framework of Competencies for all Professionals using Patient Group Directions. National Prescribing Centre, Liverpool.
Office for National Statistics (2014) Statistical Bulletin: Conceptions in England and Wales, 2012. ONS, Newport. Robinson G (2009) Integrated sexual health: a better way of working? Journal of Family Planning and Reproductive Health Care. 35, 4, 249-250. Rogstad KE, Ahmed-Jushuf IH, Robinson AJ (2002) Standards for comprehensive sexual health services for young people under 25 years. International Journal of STD and AIDS. 13, 6, 420-424. Royal College of Nursing (2009) Sexual Health Competences: An Integrated Career and Competency Framework for Sexual and Reproductive Health Nursing Across the UK. RCN, London. Sanmani L, Foley E, Samraj S, Rowen D, Yadegarfar G, Patel R (2008) Patient-initiated delay at a genitourinary medicine clinic: are there public health consequences? Sexually Transmitted Infections. 84, 7, 560-562. Sauer U, Singh A, Rubenstein P, Pittrof R (2013) Do women requesting only contraception find attendance at an integrated sexual health clinic more stigmatizing than attendance at a family planning-only clinic? International Journal of Women’s Health. 5, 57-64.
Shahmanesh M, Radcliffe KW (2007) Is the urethral smear necessary in asymptomatic men attending a genitourinary medicine clinic? Sexually Transmitted Infections. 83, 2, 79-81. Shamos SJ, Mettenbrink CJ, Subiadur JA, Mitchell BL, Rietmeijer CA (2008) Evaluation of a testing-only “express” visit option to enhance efficiency in a busy STI clinic. Sexually Transmitted Diseases. 35, 4, 336-340. Stewart RA, Thistlethwaite J, Evans R (2008) Pelvic examination of asymptomatic women: attitudes and clinical practice. Australian Family Physician. 37, 6, 493-496. Wetherall C (2012) Editorial: call yourself a nurse? Time to get precious. Journal of Clinical Nursing. 21, 19-20, 2809-2811. Wilson JD (1995) Female Genital Infections. Martin Dunitz Ltd, London. Xu F, Stoner BP, Taylor SN et al (2013) “Testing only” visits: an assessment of missed diagnoses in clients attending sexually transmitted disease clinics. Sexually Transmitted Diseases. 40, 1, 64-69. Yanikkerem E, Özdemir M, Bingol H, Tatar A, Karadeniz G (2009) Women’s attitudes and expectations regarding gynaecological examination. Midwifery. 25, 5, 500-508.
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