Going online: the future of sexual health services

In many countries, local authorities play a crucial role in the delivery and dissemination of information surrounding sexual health services, yet many are met with insufficient funding. As a result, they are seeking new ways to diversify care and improve access – could going online be the answer?

The delivery of sexual health care is a complex and multifaceted system that requires collaboration between local government and many actors including pharmacies, general practitioners, specialised sexual health services, schools, and charity organisations. Voluntary and third sector organisations fill many service gaps in sexual health delivery. Many of these organisations provide advice, and access to at-home STI testing kits, contraception, and abortion services.

Sexual health services go beyond purely providing contraception, abortion, and STI testing. Delivering these services assists in preventing unwanted pregnancy and potential long-term health conditions such as HIV, genitourinary cancers, and pelvic inflammatory diseases. Furthermore, evidence suggests that cutting funding and increasing budget pressures on preventative interventions (including sexual and reproductive health services) creates a false economy in which the effects of reduced services are felt in more serious and burdensome ways in the future, both for individuals and public services.

For example, sexual health clinics can also be a gateway to identifying and signposting other services, as risky sexual behaviour can go hand in hand with addiction, abuse, and mental health challenges. Earlier interventions are considered to be significantly more cost-effective and more beneficial overall. Plus, local councils are uniquely positioned to respond directly to the needs of their constituents and make services available that support historically hard-toreach populations, such as people of colour, immigrants and refugees, and the LGBTQIA+ community.

Despite the financial challenges, steps are being taken to try and ensure sexual health care is more accessible, in the hope that diversifying care will enable more people to access these essential baseline services. As digital services expand, investing in clear online signposting, user-friendly platforms, and provision of high-quality, easy-to-understand information is an increasingly essential next step for all.

To help relieve funding pressures, integrated services that combine the likes of family planning and genitourinary medicine are crucial. They also create opportunities for preventative intervention, swifter diagnoses and treatment pathways, and holistic sexual health and wellbeing care. Another option is partnering with third sector organisations and start-up companies who can offer innovative ways to reach populations and strengthen sexual health services.

Inspiring examples

Health tech start-up, LVNDR, in the UK, developed an LGBTQ+ inclusive sexual health online service that aims to facilitate greater access to tailored sexual healthcare. Working with Sexual Health London, the service has committed to researching the benefits of remote interventional tools and medication adherence reporting. Similarly, the digital platform Numan aims to provide accessible, stigma-free health advice, including on sensitive issues such as sexual wellbeing. These services, which have a comprehensive and ongoing understanding of service users, can provide excellent collaborative avenues for local authorities that are hoping to expand and develop current public sexual health services.

In Canada, the British Columbia Centre for Disease Control launched GetCheckedOnline as the first comprehensive online testing platform for STIs. During the first five years of the service, 16,500 accounts were created and feedback data demonstrated high rates of user approval

In Victoria, the capital of British Columbia, community health centres have been included in the province’s primary care strategy in order to enhance coverage. This approach includes partnering with Island Sexual Health, a not-forprofit with the aim of recruiting more health professionals, including nurses, counsellors, and community health workers. Greater recruitment aims to help integrate sexual healthcare into primary care offerings and create a more holistic, patient-centred approach.

Already, the move to digitalised services in sexual health has been heralded as having the potential to revolutionise health care delivery. Local authorities are well-placed to invest in these services. Innovative care delivery can be more cost-effective, especially in online settings, and analysis has highlighted that reducing spending is not necessarily detrimental or indicative of lower-quality services. Online services can require less staffing to deliver, but initial investment is required. All future investment in digital services should be directed towards providing high-quality, easy-to-understand information, presented through clear online signposting and user-friendly platforms.

However, to ensure that sexual health service delivery is comprehensive, it is vital that some focus remains on in-person care. Cost-effective and widely acceptable telehealth services are becoming more popular, in the form of online testing, telephone appointments, and digital information dissemination. However, traditionally hard-to-reach populations, including drug users, the LGBTQIA+ community and refugee and immigrant populations, may be better served by face-to-face or in-clinic appointments. Therefore, in-person appointments should continue to be made available.

Alcohol was prohibited in Iceland from 1915 until March 1st 1989. That day is now referred to as Beer Day – because beer very quickly became the most popular type of alcoholic beverage as the country’s alcohol sales and drinking habits soared.

The alcohol consumption rates increased so much that during the 1990s, Icelandic teenagers drank more heavily than most other European teens. By 1998, 42% of 15 and 16-yearolds reported having been drunk in the last month, 17% smoked marijuana regularly, and 23% of them smoked cigarettes daily. In stepped a core team of researchers and psychologists who were instrumental in reversing the problem.

Following a successful internship in the early 70s, psychology professor, Harvey Milkman, was drafted by the US National Institute on Drug Abuse to find the answer to questions surrounding why people start and continue to use drugs and how they stop. He developed his trademark idea of behavioural addiction and this led to a breakthrough idea – why not orchestrate a social movement around natural highs?

In 1992, ‘Project Self-Discovery’ was born, which offered teenagers naturalhigh alternatives to drugs and crime. Participants were offered lessons in music, dance, hip hop, art and martial arts as well as life-skills training, which focused on improving their thoughts about themselves and their lives, and the way they interacted with other people. The young people were told it was a three-month programme, but some stayed for five years – highlighting the success.

Soon his idea caught the attention of others, including researchers Gudberg Jónsson and Inga Dora Sigfusdottir, and her brother, psychologist Jon Sigfusson. They had ambitions to take the project even further and formed what would become Youth in Iceland by launching national surveys to identify problems and attitudes associated with alcohol and drug consumption.

In 1999, with the support of the Mayor of Reykjavik, the team launched a nationwide plan to intervene and change the Icelandic teen population’s relationship with these substances. However, this involved some pretty stringent changes:

Laws

The legal age for tobacco and alcohol purchases changed to 18 and 20 respectively. In addition, all tobacco and alcohol advertising products was banned nationwide and it became illegal for children aged between 13 and 16 to be outside after 10pm in the winter and midnight in the summer. All but the advertising (and only to a certain degree) are still in effect today.

Parents

Every school in Iceland had to establish parent organisations and create a school council with parental representatives. In addition, a national organisation called Home and School was formed which focused on four major areas involving parents and their children:

• Spending more time together overall, as opposed to occasional ‘quality’ time.

• Talking to their children about their lives.

• Knowing who their children’s friends are.

• Keeping their children inside at night.

Funding

Government funding increased for sports, music, art, dance, and other such clubs, to give children alternative ways to feel part of a group and to make them feel good. Low-income families were given the chance to participate as well. For example, in Reykjavik, where onethird of Iceland lives, qualifying families were given the equivalent of approximately $300 a year, in order to help fund their children’s participation in organised activities.

Surveys

School surveys have continued annually since the inception of Youth in Iceland and almost every child in Iceland completes one. This means up-to-date, reliable data is always available.

Results

Iceland now tops the European table for the cleanest-living teens. Back in 2016, the rates of 15 and 16-year-olds who had been drunk in the previous month fell from 42% in 1998 to 5%. Similarly, cannabis use also fell from 17% to 7% and rates of smoking cigarettes every day also decreased from 23% to 3%. More positively, the time 15- and 16-year-olds spent with their parents on weekdays doubled from 1998 levels (23% to 46%) and participation in organised sports at least four times a week increased from 24% to 42%.

The legacy today…

Following the success in Iceland, the ‘Youth in Europe’ programme was launched which provided interventions at a municipal level instead of national. This version also saw great success, resulting in another expansion to become ‘Planet Youth’ with participants from countries all over the world.

Regardless of location, the method remains the same – local officials help devise a questionnaire with the same core questions as those used in Iceland plus any locally tailored extras. After the questionnaires are returned, an initial report with the results, plus information on how they compare with other participating regions is produced. The team has analysed 99,000 questionnaires from places as far afield as the Faroe Islands, Malta and Romania, South Korea, Nairobi and GuineaBissau.

Broadly, the results show that the same protective and risk factors identified in Iceland apply everywhere. Although there are some differences – for example, one location found organised sport to actually increase the risk of substance use. Further investigation revealed that this was due to the clubs being run by young ex-military men who promoted muscle-building drug use, drinking and smoking. Once the issue was identified, the local problem could be addressed by the council.

Despite this success story, it is worth pointing out, that no other country has made changes on the scale seen in Iceland. The success here relied on the relationship between the people and the state to create an effective programme that reduced the rates of teenagers smoking and drinking to excess – and, in the process, arguably brought families closer together and helped children to become healthier. Could this really work everywhere else? Not without multi-level government intervention, that’s for sure – but, that doesn’t mean there aren’t some lessons and benefits to be gained by all.