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The Real World of STD Prevention

Sender and Receiver Acceptability and Usability of an Online Partner Notification Tool for Sexually Transmitted Infection in the Netherlands

van Rooijen, Martijn S. MSc*; Gotz, Hannelore MD, PhD†‡; Vriens, Pjer; Heijman, Titia PhD*; Koekenbier, Rik MSc*; van Veen, Maaike PhD*; Voeten, Helene PhD†‡

Author Information
Sexually Transmitted Diseases: May 2018 - Volume 45 - Issue 5 - p 354-357
doi: 10.1097/OLQ.0000000000000738

Partner notification (PN) is the process whereby the sexual partner(s) of a patient diagnosed as having a sexually transmitted infection (STI) are identified and informed of their exposure to an STI.1 Many studies show a preference to notify partners face-to-face or by telephone rather than with technologies such as short message service (SMS) or e-mail.2–5 However, Internet-based PN might be an additional method to reach more partners.2

To assist PN at the STI clinics of Rotterdam and Amsterdam, the Netherlands, an online tool called Suggestatest.nl was developed explicitly for patients who were diagnosed as having an STI or HIV infection. Using this tool, index patients could send an anonymous or nonanonymous notification message by e-mail, SMS, or postal mail, or—with the username of their partner—to a gay social network account. A general evaluation of the use of Suggestatest.nl showed that this novel tool suits a small number of index clients, mainly by sending anonymous text messaging.6,7 Of those intending to use Suggestatest.nl, 23% notified a partner through Suggestatest.nl and 58% of the partners notified through Suggestatest.nl logged-in to read their notification online.

To date, Suggestatest.nl and CheckOUT (Portugal) are, to our knowledge, the only published health care provider–initiated Internet-based notification systems that are designed for patients with a verified STI only.8 Less is known about the acceptability of these tools for both the sender (index patient) and the receiver (notified partner). In addition, much of the published acceptability research relied on hypothetical scenarios of accessing options for PN.9

In this study, we evaluated the acceptability and usability of Suggestatest.nl in both index patients and notified partners who have used this PN tool.

MATERIALS AND METHODS

Study Setting

The STI outpatient clinics of Rotterdam and Amsterdam perform, respectively, approximately 12,500 and 40,000 STI consultations annually, free of charge and anonymous. In case an STI is diagnosed, the health care professional discusses the PN options and registers the patient's preference. These options consist of patient referral (supported with a contact card or—from March 2012 onward—with Suggestatest.nl), provider referral, or contract referral.

Suggestatest.NL

Patients with a confirmed STI diagnosis (chlamydia, lymphogranuloma venereum, gonorrhea, syphilis, HIV, and/or trichomoniasis) received a nurse-generated code when they preferred to use Suggestatest.nl for PN. To notify, the index patient had to log in to Suggestatest.nl using the nurse-generated code. For each partner, the patient had to select the method (SMS/e-mail/postal/gay dating site) and the mode (anonymous/nonanonymous) of sending the notification. All partners—irrespective of the previously mentioned selected method—received a standardized message with a unique partner code and had to log in to the Web site to read about the notified STI or HIV, possible treatment, and how to make an appointment at the STI clinic.

Theoretical framework from the technology acceptance model was used to develop the questionnaires for index patients and notified partners.10 The 2 factors that determine the technology acceptance model are “perceived usefulness” (referred to as acceptability) and “perceived ease of use” (referred to as usability).10 Questionnaires on acceptability and usability to notify/be notified through Suggestatest.nl of STI and HIV were offered online to all participants regardless of their diagnosis/received notification. After the index patient had sent a Suggestatest.nl notification, an invitation window popped up to complete an online questionnaire. Partners were recruited for an online questionnaire after reading their STI notification online. After completing the questionnaire, participants were asked to fill in their e-mail address to receive an additional online questionnaire after 2 weeks. The online questionnaires were collected from March 2012 to June 2013 (Supplementary Tables 1 and 2, https://links.lww.com/OLQ/A205). Because the online response of partners was low, partners visiting the STI clinics and notified through Suggestatest.nl (who had not yet filled in an online questionnaire) were recruited from July 2012 to June 2013 to fill in a paper-and-pencil questionnaire.

Statistical Analysis and Data Collection

All questionnaire data were analyzed in IBM SPSS Statistics, version 21 (IBM Corporation, Armonk, NY). The acceptability and usability scores were constructed from the mean of the items included. Constructs were only calculated if none of the items for this construct had a missing value. For each construct, the reliability was calculated using the Spearman-Brown statistic (2 items) or the Cronbach coefficient α (≥3 items).11 Reliability values of at least 0.7 were assumed acceptable and all were 0.75 or greater than. Frequency of Internet use for arranging personal matters was categorized in less frequent (scores 1–3) and frequent (scores 4–5). Respondents and nonrespondents were compared using the χ2 test or Fisher exact test and the Mann-Whitney U test. Using the independent t test, the mean scores of notified partners who responded to the online and those who responded to the paper-and-pencil questionnaires were compared. The paired t test was used to compare scores on different items within the same group. P values of less than 0.05 were considered statistically significant.

Ethics

This study was waived by the Medical Ethical Committee of the Erasmus University of Rotterdam, because Suggestatest.nl was an extension of standard care.

RESULTS

Index Patients

During the study period, 112 (19.8%) of 565 Suggestatest.nl users completed the questionnaire (Supplementary Fig. 1, https://links.lww.com/OLQ/A205). Response was higher among men who have sex with men (MSM; 27.7%) compared with heterosexual men (13.1%) and women (17.0%; P = 0.002), and responders notified a higher median number of partners than did nonresponders (Supplementary Table 3, https://links.lww.com/OLQ/A205). Four responders were newly diagnosed as having HIV.

Most index patients reported that they were able to notify more partners than without the existence of Suggestatest.nl (Table 1). The acceptability and usability to use Suggestatest.nl to notify sexual partners of HIV were rated significantly less acceptable and usable (3.0 and 3.6, respectively) than notifying of another STI (4.4 and 4.7, respectively; P < 0.001; Table 1). Among MSM, the overall acceptability was higher (4.4) than among non-MSM (4.1; P = 0.007), whereas the overall usability was not different (4.5 vs. 4.4, respectively; P = 0.28).

TABLE 1
TABLE 1:
Acceptability and Usability Scores and PN-Related Answers of Index Patients Who Used SAT to Notify Sex Partners, the Netherlands, March 2012 to June 2013

Notified Partners

Of 2030 notified partners, 163 (8.0%) responded to the questionnaires (53 online and 110 offline at the STI clinic; Supplementary Fig. 1, https://links.lww.com/OLQ/A205). Notified partners who filled in the questionnaire were comparable with those who did not respond (Supplementary Table 1, https://links.lww.com/OLQ/A205). The acceptability and usability scores of online and offline responders were not significantly different. Of the 106 partners who were notified of HIV exposure, 3 responded to a questionnaire.

Most notified partners preferred to receive a nonanonymous notification via SMS (Table 2). Partners who were notified anonymously rated their notification less acceptable (2.7) than did partners who were notified by name (4.4; P < 0.001; Table 2). The acceptability and usability to be notified of HIV through Suggestatest.nl were rated significantly less acceptable and usable (3.3 and 3.2, respectively) than being notified of another STI (both 4.4; P < 0.001). The overall acceptability and usability scores of Suggestatest.nl (4.1) did not differ between MSM and non-MSM (P = 0.28 and P = 0.50).

TABLE 2
TABLE 2:
Acceptably and Usability Scores and PN-Related Answers of Partners Who Were Notified Through SAT, the Netherlands; March 1, 2012, to May 31, 2013

DISCUSSION

Statement of Principal Findings

The online PN tool Suggestatest.nl was rated acceptable and usable by both senders (index patients) and receivers (notified partners). Both groups were less positive about Suggestatest.nl to notify/get notified of HIV than of another STI. Partners notified anonymously perceived their mode of notification less acceptable compared with those notified by name.

Strengths and Weaknesses of the Study

Although most articles on acceptability of electronic PN relied on hypothetical scenarios, we measured acceptability and usability in a real setting, in both patients and partners who used Suggestatest.nl.9 Moreover, we measured the opinion of both MSM and heterosexuals who used Suggestatest.nl. Patients who chose to use Suggestatest.nl may be more enthusiastic about Suggestatest.nl than STI patients in general. However, their partners who did not have any choice in the method of how they received a notification were also generally positive about Suggestatest.nl.

For our study, we recruited notified partners when they visited the Web site to read their notification or during the resulting consultation at the STI clinic. Unfortunately, the overall participation rate of notified partners was low (8%). This might have resulted in overestimated acceptability and usability scores, making it difficult to generalize the measured opinion to the general STI clinic population. Because of missing notification codes of 43 notified clients, no information of the received notification was known.

The questions concerning the acceptability and usability of using Suggestatest.nl to notify of HIV exposure were mainly answered by patients and partners who notified or were notified of an STI other than HIV. As a consequence, the lower acceptability and usability to notify of HIV through Suggestatest.nl were mainly hypothetical. Theoretically, the usability to notify partners of STI or HIV exposure through Suggestatest.nl should be comparable because it uses the same system with identical actions. However, the construct of usability was rated lower for HIV than for other STI, indicating that it probably did not measure usability only.

Comparison With Other Studies

A study among Peruvian MSM and transgender women diagnosed as having STI showed that the introduction of a hypothetical Internet-based PN system resulted in a dramatic increase in anticipated notification of secondary partners.12 In our study, almost 80% of the index patients reported that they had notified more partners than they would have done without the existence of Suggestatest.nl.

A study among Spanish MSM of their anticipated notification behavior showed that face-to-face or a telephone call was the preferred method to notify of STI or HIV for both stable and casual partners.13 An identifiable SMS was the next most popular method to notify stable and casual partners of STI or HIV. The preference for sending an identifiable SMS contradicts our findings: most patients notified their partners anonymously.6,7 A similar effect was seen in a UK study: the preference of respondents for a PN method was dependent on whether they see themselves as index patients or contacts.14 Another possibility is that patients in our study who were willing to send an identifiable SMS or e-mail have used their own mobile or e-mail, and only those with interest in sending an anonymous notification have used Suggestatest.nl.

In a review of the acceptability of electronic PN, a pattern emerged across studies showing that anonymity was less acceptable than the electronic delivery method itself.9 In our study, the same effect was seen: notified partners were less positive about the fact that their Suggestatest.nl notification was anonymous but were still content about Suggestatest.nl.

Implications for Clinicians and Policymakers

It seems that, according to the opinion of our patients, STI clinics should offer an online PN tool like Suggestatest.nl. As stated by Hottes and Gilbert,15 a Web-based PN service like inSPOT should be supplementary to traditional PN tools. After developing a PN Web site, the costs of facilitating online PN are relatively low and it can easily be offered as an addition to already existing traditional tools. On the basis of our findings, we would recommend to incorporate the possibility to notify anonymously.

Patients could be asked to immediately start filling in the contact information of their partners in Suggestatest.nl when they are at the STI clinic for a treatment consultation. Possibly, patients are then more motivated to notify their partners than later at home, and public health nurses could assist with this process. However, it is also important to offer Suggestatest.nl use at a later stage, because at the STI clinic, most participants reported that they were unable to fill in contact details of all partners.

Unanswered Questions and Future Research

We recognize that there is a possible trade-off between reaching more partners by the implementation of a low threshold online PN tool and the quality of the sent notification: because many partners do not read their online notification (42%; e.g., because they think that it is an unsolicited message/spam), the sent notification might not have resulted in health care seeking.6 Future research should focus on the most suitable ways of directing online notified partners into care. After the inclusion period of this study, the tool was renamed to “Partnerwaarschuwing.nl” (Partnernotification.nl in English) because some notified partners reported that they were confused about the name Suggestatest.nl.

Our study mainly focuses on patients who chose to use Suggestatest.nl and their partners in which participation was low. For generalizability, more research that measures the opinion of all notified STI-clinic clients regarding online PN is necessary.

REFERENCES

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