Integrated sexual health services: the views of medical professionals

From 'holding pen' to 'a space to breathe': affective landscapes in a newly-integrated sexual health clinic

This paper examines the role of affective landscapes in the formation of attendees' experiences at a re-provisioned, integrated sexual and reproductive healthcare facility. The 'One-Stop Shop' (OSS) is an example of the organisational shift towards integrated services occurring across the UK, bringing together in one clinic the historically discreet services of genitourinary medicine, HIV medicine and Family Planning. An ethnographically-informed study of new spaces of care and changed organisation, this paper focuses on the experiences of 29 attendees as they made their way along the clinic's care pathways. Drawing on concepts of affect and atmosphere to augment the analytic lens of 'therapeutic landscapes', this paper demonstrates how various spaces of the clinic influenced attendees' experiences. A cramped, featureless 'holding pen', the foyer served to exacerbate pre-existing anxieties while creating new fears. The main waiting room, an organisational sorting space, both soothed and aggravated attendees' concerns. Serving as an architectural feature to connect the old Victorian hospital with the new clinical extension, the atrium was experienced as a space to breathe, with an affective atmosphere that challenged the assumed unpleasantness of sexual health clinics. This paper demonstrates how affective landscapes of the clinic shape attendee experiences in a novel setting.

Integration of STI and HIV prevention, care, and treatment into family planning services: a review of the literature

The last comprehensive literature review to examine the effectiveness of family planning (FP) services in delivering STI and HIV prevention and care was published in 2000. This review updates that report by examining evidence of the impact of integrating any component of STI or HIV prevention, care, and treatment into a family planning setting in developing countries. Forty-four reports were identified from a comprehensive search of published databases and "grey literature". The weight of evidence demonstrates that integrated services can have a positive impact on client satisfaction, improve access to component services, and reduce clinic-based HIV-related stigma, and that they are cost-effective. Evidence of FP services reaching men and adolescents and of their impact on health outcomes is inconclusive. Several studies found that providers frequently miss opportunities to integrate care and that the capacity to maintain the quality of care is also influenced by many programmatic challenges. The range of experiences indicates that managers need to determine appropriate health-care service-delivery models based on a consideration of epidemiological, structural, and health-systems factors.

Meeting the sexual and reproductive health needs of people living with HIV: challenges for health care providers

A trained health service workforce is critical to ensuring good quality service delivery to people with HIV. There is only limited documented information on the challenges and constraints facing health care providers in meeting the sexual and reproductive health needs of HIV positive women and men. This paper reviews information on providers' attitudes, motivation and level of preparedness in addressing the sexual and reproductive health needs of people living with HIV in the context of the human resources crisis and emerging treatment and prevention strategies. There is a need for significant investment in improving the health infrastructure and providers' ability to take universal precautions against infection in health care settings. Additionally, there is need for comprehensive and appropriate training for health care providers to build their capacity to meet the requirements and expectations of different sub-populations of HIV positive people. This includes not only physicians but also nurses and midwives, who are the primary caregivers for most of the population in many resource-poor settings. Supportive and knowledgeable providers are crucial for helping HIV positive people seek and adhere to treatment, prevent sexually transmitted infections, unintended pregnancies and vertical transmission of HIV and support positive living free from stigma and discrimination. Providers, some of whom may themselves be HIV positive, can make an important difference, especially if they are supported in their working conditions, are knowledgeable about HIV and sexual and reproductive health and have the skills to provide good quality care.

One stop shop versus collaborative integration: what is the best way of delivering sexual health services?

OBJECTIVES

To examine various models of integrated and/or one stop shop (OSS) sexual health services (including general practice, mainstream specialist services, and designated young people's services) and explore their relative strengths and weaknesses.

METHODS

Literature review and interviews with key informants involved in developing the National Strategy for Sexual Health and HIV (n = 11).

RESULTS

The paper focuses on five broad perspectives (logistics, public health, users, staff, and cost). Contraceptive and genitourinary medicine issues are closely related. However, there is no agreement about what is meant by having "integrated" services, about which services should be integrated, or where integration should happen. There are concerns that OSSs will result in over-centralisation, to the disadvantage of stand alone and satellite services. OSS models are potentially more user focused, but the stigma that surrounds sexual health services may create an access barrier. From staff perspectives, the advantages are greater career opportunities and increased responsibility, while the disadvantages are concern that OSSs will result in loss of expertise and professional status. Cost effectiveness data are contradictory.

CONCLUSION

Although there is a policy commitment to look at how integrated services can be better developed, more evidence is required on the impact and appropriateness of this approach.

Surveys on sexual health: recent developments and future directions

The increasingly widespread adoption of the term sexual health reflects a move away from the medicalisation of this specialty. The focus has shifted from clinical practice to lifestyle and behaviour; from clinician to client, and from treatment to prevention. This article discusses these themes, identifying their implications for sexual health research. Recent times have seen, for example, a growing number of studies combining biological and behavioural measures conducted by interdisciplinary teams able to combine biomedical measurements of morbidity with insights into the subjective interpretations of symptoms and consequences. Considerable progress has been made, too, in mounting community based studies, and much has been achieved in gaining compliance and refining sampling methods. Integrated sexual health services, encompassing more than contraceptive or prophylactic service provision, have provided the impetus to investigation of the costs and benefits of coordinated family planning and genitourinary medicine services. Despite its broader focus, there remain opportunities for sexual health research to expand its remit. Studies to date may have focused too narrowly on pathological, to the neglect of health enhancing, consequences of sexual behaviour.