Increasing access to services and screening frequency in particular have been found to be effective and acceptable methods of reducing the burden of sexually transmissible infections (STI) as outlined in the Australian National1 and New South Wales (NSW) STI2 strategies and the Australian National Syphilis Action Plan.3
Prior studies of health service accessibility for people from higher-risk populations show that client screening intentions are dependent on service characteristics and that of these, the length of time spent waiting at a service or for an appointment are cited as common barriers to access.4–7 Long waiting times to appointment have been shown to be associated with increased nonattendance rates for booked appointments.8
Fast-track or express services have been trialed in emergency departments and among low-risk clients of sexual health clinics, and various benefits have been found across numerous studies, for example, increased capacity, reduced wait times, and increased staff satisfaction and retention.9–17
Sydney Sexual Health Centre (SSHC) is a large, publicly funded sexual health clinic situated in the central business district of Sydney that offers free, confidential STI and HIV testing and treatment to identified priority populations,1,2 most of whom are men who have sex with men (MSM), sex workers, and young people. To facilitate STI screening among these populations, SSHC commenced a fast-track screening service for asymptomatic clients called Xpress. The evaluation and results of pre- and post-Xpress clinical services—including patient characteristics, waiting and consultation times, staff costs, and clinical capacity—are described elsewhere.18 In brief, that evaluation demonstrated an improvement in the patient journey by successfully reducing waiting times and increasing clinic capacity with more client throughput owing to increased staff hours while maintaining similar costs.18
This study reports the results of a client satisfaction survey conducted during the first 6 months of the Xpress pilot phase of operation and was used to help inform Xpress methodology decision making before Xpress was officially launched in December 2010. We aimed to identify why clients chose Xpress, client satisfaction and perceptions in relation to Xpress, perceived benefits associated with attending Xpress, perceptions of clinic flow and staff handling, and whether using the Xpress clinic altered intended STI testing frequency and to compare these domains across the priority populations of MSM, young people, and sex workers.
From March to September 2010, all clients were offered either Xpress or the routine care clinic upon calling for an appointment or arriving for a drop-in slot. Computer-assisted self-interview (CASI) software was developed by SSHC staff specifically for Xpress. The CASI collects the same information as the routine clinic paper pro forma with answers formatted electronically to the Xpress clinic nurse’s computer to look like the paper version. Exclusion criteria built into the CASI included symptoms, contacts of an STI and postexposure prophylaxis in the last 6 months. In addition, clients new to SSHC who identified as MSM, current injecting drug users, or those having had sex in a high HIV-prevalence country were excluded via the CASI from HIV testing at Xpress. Table 1 outlines the key features of Xpress versus routine clinics and the methodology used. Tests performed included pharyngeal culture for Gonorrhoea, self-collected rectal and vaginal swabs for Chlamydia and Gonorrhoea polymerase chain reaction, urine for Chlamydia polymerase chain reaction, and blood for HIV, syphilis, hepatitis B core antibody, and hepatitis A and C immunoglobulin G as clinically indicated based on clinical policy according to sexual history. Test results were available as per SSHC Clinical Business Rules policy 1 week after the Xpress visit, with most results being delivered over the phone.
All clients 16 years and older who attended Xpress clinic between March 17 and September 1, 2010, inclusive, were invited to participate in the study by the clinic nurse at the end of their Xpress clinic visit. Written consent was obtained.
A 38-item questionnaire based on the 2010 NSW Health Outpatient Care Survey19 was developed and piloted. To provide some comparable data with this biyearly NSW Health survey, questions were grouped into the same sections, that is, before visit, during visit, tests, health care professional, after visit, and overall impression. For the purposes of this study, we added items on the specific aspects of Xpress that we wanted client input for the CASI, not having a physical examination, time spent with the nurse, and self-collected swabs.
Study participants were asked to self-complete the questionnaire and return it to a sealed box upon leaving SSHC. Questionnaires were numbered and marked with the client’s record number to determine an accurate response rate. Demographic and behavioral data were extracted from the clinic database to compare responses between groups.
The study was designed to recruit 275 people, giving an estimate sampling error of 3%. The final estimated sampling error, assuming a 50% observed percentage, was 4.2%, giving a confidence interval (CI) of ±8.2%.
The subgroups of MSM, young people, and sex worker numbers were analyzed as percentages of the total number of participants, and individuals may have been included in more than 1 subgroup. Nonparametric tests of significance (χ2 or Fisher exact test) were used to compare preferences between groups. Data were analyzed using SPSS version 14.0.
Ethics approval was granted by the South Eastern Sydney Illawarra Area Health Service (Northern Sector) Human Research Ethics Committee (reference number 10/013).
Of the 243 clients who attended Xpress clinic in the study period, 145 (60%) returned completed questionnaires (respondents).
Of the total respondents, 105 (72%) were male and 75 (52%) were MSM. There were only small numbers who identified as sex workers (n = 12; 8%), and less than half were young people younger than 25 years (n = 60; 41%). Almost half were Australian born (n = 63; 43%), and most spoke English at home, reflecting the eligibility criteria for Xpress that users had to be able to read English.
When comparing nonrespondents versus respondents, there was a borderline significant difference in sex with more females being in the nonsurveyed group (41% vs. 28%, P = 0.052) and more non–Australian-born clients in the nonsurveyed group (74% vs. 57%, P = 0.013). There were no other differences between respondents and nonrespondents including MSM, HIV status, condom use, sex overseas, paid sex work, injecting drug user, past STI or HIV testing, and number of sexual partners.
How Did Clients Hear About Xpress Clinic?
Most clients who provided information as to how they found out about Xpress (n = 139) were told about the clinic when they called or arrived at SSHC (n = 89 [64%]; 95% CI, 55%–71%). Male clients were more likely to have found out about Xpress in this way compared with female clients (74% vs. 39%, P = 0.002). Other respondents had been recommended Xpress by friends/family (n = 23 [17%]; 95% CI, 11%–23%), other unstated reason (n = 18 [13%]; 95% CI, 8%–19%), offered during a previous SSHC visit (n = 5 [4%]; 95% CI, 1%–7%), or recommended by their general practitioner (n = 4 [3%]; 95% CI, 0.9%–6%). Six times more young people found out about Xpress from family and friends compared with those older than 25 years (33% vs. 5%, P ≤ 0.001).
Why Did Clients Choose Xpress Services Versus the Routine Service?
When asked why they chose Xpress, 47% (n = 69/138; 95% CI, 41%–58%) stated that it was because they were offered it as a new service of SSHC. However, 30% (n = 42/138; 95% CI, 23%–38%) chose Xpress because they did not want to wait long, whereas the remaining 12% (n = 16/138; 95% CI, 7%–17%) did not want a long consultation.
When asked if they would have come to SSHC anyway if Xpress was not an option, MSM were more likely than non-MSM to say that they would come for screening anyway (77% MSM vs. 59% non-MSM, P = 0.034). Youth younger than 25 years were less likely than those 25 years and older to have come for screening anyway (53% vs. 79%, P = 0.012).
How Satisfied Were Clients With All Aspects of Xpress Clinic?
Eighty-nine percent (n = 127/143; 95% CI, 82%–93%) of respondents stated that their Xpress appointment, the time of which was provided over the telephone or given upon arrival, started on time. Ninety-two percent (n = 133/145; 95% CI, 86%–95%) rated highly the courtesy of reception staff (good, 23%; very good, 31%; excellent, 37%).
Client satisfaction with new processes introduced for Xpress was high (Table 2). Sex workers were less likely to be satisfied with not receiving a physical examination (n = 3; 25%) than non–sex workers (n = 6; 5%) (P = 0.033). Completeness of care was rated excellent or very good by 62% (n = 85/138; 95% CI, 53%–59%) and 29% (n = 40/138; 95% CI, 21%–36%) of respondents, respectively, with quality of explanation and overall Xpress clinic care also rating very highly.
There was high satisfaction across all other areas of Xpress (Table 3). For example, most would use Xpress again (83% definitely [n = 119/143; 95% CI, 76%–88%], and 86% would definitely recommend Xpress to others [n = 122/142; 95% CI, 79%–90%]). However, a small number (7% [n = 10/144]; 95% CI, 3%–12%) stated that they had questions about their care or treatment they felt they could not discuss.
Do Clients Perceive That Xpress Clinic Would Affect Their STI Screening Frequency?
Overall, 73% (n = 101/138; 95% CI, 65%–80%) of respondents stated that they would come for a sexual health checkup more often because Xpress was available, and none stated that they would come less often, whereas 23% (n = 32/138; 95% CI, 16%–30%) stated that their attendance frequency would remain the same. Within our priority populations, there was no difference in perceived changes to screening frequency between MSM and non-MSM, young people and those older than 25 years, or sex workers and non–sex workers.
In addition, when asked if the offer of same-day HIV or syphilis point-of-care testing (POCT) at Xpress would affect their screening frequency, 58% (n = 82/142; 95% CI, 49%–65%) of respondents stated that they would come more often if this was the case compared with only 2% (n = 3/142; 95% CI, 0.5%–5%) who stated that they would come less often and 31% (n = 44/142; 95% CI, 23%–38%) who thought that their screening frequency would remain the same. Nine percent (n = 13/142; 95 CI, 5%–14%) were not sure. Within our priority populations, MSM were more likely than non-MSM to come more often if POCT for HIV and syphilis was available (74% vs. 41%, P = <0.001); however, this factor would not make a difference to attending for screening among young people or sex workers.
Overall, the satisfaction and perceptions of clinic flow and staff handling associated with attending Xpress, as well as completeness of care received, were high and would result in recommendations to others. Most respondents reported high satisfaction with all aspects of the Xpress clinic that they were asked about and high intentions to retest using this model of care. In addition, they felt involved in their care and able to discuss their situation with the health professional. Although a small percentage did have questions they felt they could not discuss likely due to the limited time available in an Xpress consultation, this is likely to be an ongoing problem for fast-track services. Despite the small number of people in this instance who felt this way, it is a situation worth monitoring to maintain a high client satisfaction benchmark and not detract from either the real or perceived needs of clients in what is a personally stressful situation.
Our survey was based on the 2010 NSW Health Outpatient Care Survey19 and included most of the domains pertinent to client experience at SSHC. For comparison purposes, SSHC-specific data were isolated from the State survey and analyzed for our own clients’ responses.19 Although the number of SSHC respondents in the State survey was small (n = 75) and direct comparisons were difficult due to some differences in measurements—for example, age ranges, MSM, or sex worker status—client satisfaction across both surveys within the same domains was similar.19 For example, there was high satisfaction among SSHC clients with regard to courtesy of staff, explanations of tests and results, confidence in the health care professional, and level of care received.19 We did not separately evaluate the routine nurse clinic to compare the 2 models, and this is a limitation of this study. There is a possibility that nonresponders did not complete the survey due to dissatisfaction with Xpress, and we have no way of measuring this potential bias. Overall, women attending Xpress were less likely to participate in the survey. We speculate that many of these women may have been travelers who had less of a vested interest in the service. That there were more non–Australian-born clients in the nonsurveyed group may reflect this traveler population.
Clients’ reasons for choosing Xpress showed that many either did not want to wait too long or have a long consultation. Clients were informed on arrival that Xpress was expected to have a shorter waiting time than the routine clinic, and this is a possible source of bias in relation to this finding. However, this limitation in our study does not detract from the literature regarding waiting for a consultation or appointment as barriers to access4–7 and reduced waiting times as a source of increased client satisfaction.10,11,16 Of the SSHC clients who completed the 2010 NSW Health Outpatient Care Survey at SSHC, 30% stated that they waited too long in the waiting room before being seen, which we consider a marker for decreased satisfaction among SSHC clients. The Xpress clinic has demonstrated the ability to reduce wait times,18 and most appointments commencing on time as reported by clients in this study both add to the body of evidence that these aspects of service provision are necessary to reduce barriers to access.
Our results show that most clients felt that they would come for STI screening more often because Xpress is available, although this perception will not be tested until Xpress attendance rates are reviewed in the future. Significantly more MSM would be likely to attend, with POCT for HIV and syphilis being provided; however, should these tests be introduced, the wait time for the POCT result may involve a longer client visit and increased clinician time and will need to be considered. Men who have sex with men were more likely to say that they would come for screening regardless of Xpress being present, which probably reflects the strategies already in place to educate this group about regular screening.
In contrast, young people in our study reported that they would be less likely to attend SSHC without Xpress. This shows that we may be attracting a new group of service users who potentially would not be screened elsewhere. That 6 times more young people found out about Xpress from family or friends compared with those older than 25 years reinforces the importance of peer suggestion as a strategy to encourage youth attendance and STI screening.
Although MSM were more likely than non-MSM to say that they would come for screening anyway, Xpress criteria exclude MSM new to SSHC from HIV testing on their first visit. We hypothesize that if we removed this barrier, we may attract increased numbers of MSM to the service and potentially those who may not test regularly.
Previous studies show that removal of the physical examination has been a successful method for fast-track services in terms of clinic efficiency and some patient outcomes,10,12–15 and some sex workers are reported as disliking the physical examination.20,21 Given that some sex workers in this study reported dissatisfaction with the lack of a physical examination, we will monitor uptake of Xpress among our English-speaking sex workers to determine if more work needs to be done regarding acceptability of this model in this population.
Client satisfaction with self-collected specimens was high, which reflects positive outcomes documented in the literature showing self-collected specimens to be an acceptable method for screening among women, sex workers, and MSM.21–31 Sydney Sexual Health Centre is currently planning a feasibility and acceptability study of an Xpress service for our culturally and linguistically diverse sex worker clients wherein we will explore the preferences of self-collected specimens and lack of physical examination within this population.
Xpress was not promoted externally during this pilot phase; therefore, clients heard about it either from reception staff on arrival or via word of mouth. This resulted in low use of Xpress throughout the study period,18 and the small number of respondents is a limitation of the study. However, it provided an opportunity for the methodologies within the model to be tested and improved as errors became apparent. After an official launch and local media uptake, Xpress promotion continues via posters, business cards, and advertisements in sex worker, young people, and MSM media and via www.sshc.org.au
We believe that this study, along with Knight et al,18 is the first evaluation of a comprehensive fast-track sexual health service in Australia. More research is required to ascertain if our higher-risk group clients are screening more frequently as a result of Xpress. In addition, we would be interested to know if our young clients who find out about Xpress from family or friends are local or traveling youth, given that our area has a high prevalence of backpackers who reside in the Sydney eastern beaches areas.
Client satisfaction with our Xpress model was high, and if more frequent screening is demonstrated, this model could be used in a range of sexual health clinic settings.
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