Women's health: potential for better coordination of services

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.

An interview based approach to seeking user views in genitourinary medicine

OBJECTIVES

To assess user and potential user views on the appropriateness, nature and quality of genitourinary medicine (GUM) provision in Bristol, UK and to develop a model for ongoing user consultation by GUM providers and purchasers.

DESIGN

This qualitative study was based on semi-structured interviews with service users, potential users, community informants and NHS professionals.

PARTICIPANTS

76 current, past or potential users, 10 community informants and 11 NHS professionals were interviewed. African-Caribbean women and men, homeless men and women, lesbians and gay men, men and women living with HIV and women working in the sex industry were recruited to maximise the diversity of the sample.

RESULTS

The interviews demonstrated that participants commented positively on many aspects of the service available. The research also identified a number of areas where the service could be improved. Many users emphasised their initial difficulty in finding out about the department and the need for greater publicity and outreach. Users reported coming to the clinic with high levels of anxiety and negative preconceptions about the GUM service. Specific issues were identified for different groups of users. There was a strongly expressed need from a number of women and African-Caribbean men for completely single sex clinics.

CONCLUSIONS

The research identified a number of issues of importance to service users that had not been identified in the department's own questionnaire surveys. The results support the premise that qualitative interviews can be successfully employed to access a diverse sample of users, and can offer insights significantly beyond those available from structured patient questionnaires.

Evaluating a designated family planning clinic within a genitourinary medicine clinic

OBJECTIVE

To evaluate an integrated family planning clinic (FPC) established by genitourinary medicine (GUM) staff held within a GUM women-only clinic (WOC).

DESIGN

A retrospective case note review of women attending the FPC during the first year January-December 1992.

RESULTS

One hundred and thirteen women, aged 13-41 years, attended the FPC; 45 were new attenders, six had previously tested antibody positive for the human immunodeficiency virus (HIV), seven were intravenous drug users; 54% had a history of sexually transmitted disease (STD); 17.7% were using no contraception; 32.7% had previous termination of pregnancy (TOP) with 70 TOPs in total. Within three months of FPC attendance 89 (78.8%) women had genital STD screening performed; syphilis, HIV and hepatitis B serology, together with cervical cytology were performed in 77, 18, 13 and 62 women respectively. Infections identified were similar to those identified in the GUM clinic but the prevalence of Chlamydia trachomatis in diagnosed infections was commoner in FPC attenders and epidemiological treatment commoner in GUM attenders. No high grade cytology abnormalities were detected. No positive syphilis or new HIV positive results were identified; five women were found to be hepatitis B surface antibody positive. Contraception was changed in 60.8%. Most frequently supplied was the combined oral contraceptive pill (COCP). At the first FPC attendance six women required post coital contraception (PCC) and five were already pregnant, three suspected it, two were unaware. During the year three women conceived; two used COCP, but were non compliant; one used a diaphragm with unclear compliance. Seven of the eight pregnancies were terminated. Over the following year, 1992-93, contraception was supplied to 42 women; four required PCC; two intentional pregnancies occurred. Only one of the TOP women returned.

CONCLUSION

An integrated FPC provides co-ordinated sexual health care. Pregnancy, TOP and FPC re-attendance rates together with improvement strategies are discussed. Avoiding unwanted pregnancy remains a universal challenge.

Family planning in genitourinary medicine: an opportunistic service?

OBJECTIVE

To evaluate and serve the need for contraception in those not using conventional sources of family planning services.

SETTING

South London outpatient genitourinary medicine department at King's College Hospital.

DESIGN AND SUBJECTS

Prospective study of 200 women seen consecutively in the clinic by the same doctor (LM) during 1993. Women at risk of unwanted pregnancy were identified, and offered immediate contraceptive provision or referral.

RESULTS

15 women (7.5%) were using no contraception, despite being sexually active and not wishing to conceive; of these two presented with an unwanted pregnancy. A further 23 women (11.5%) were not using their chosen contraception effectively, and another 20 women were unclear about contraceptive methods and wanted advice. Young women were most at risk; 14% of those aged 25 years and under were using no contraception. Eight women wished to defer contraceptive advice; of these four defaulted from follow up. Eighteen women (9%) wanted immediate contraceptive supplies. Ten of 18 returned a follow up questionnaire; all these women were satisfied with the contraceptive advice service received.

CONCLUSIONS

Absent or ineffective contraception is common in women attending an inner city genitourinary medicine clinic. Immediate provision of contraceptive education, advice and supplies is welcomed by patients.

A women-only clinic for HIV, genitourinary medicine and substance misuse

OBJECTIVE

To evaluate a multidisciplinary women-only clinic (WOC) providing HIV testing, HIV follow-up, genitourinary screening and a substance misuse service. The clinic is designed to attract women who are at risk of acquiring sexually transmitted infections, including HIV, yet are not using existing medical services.

DESIGN

A questionnaire survey and review of the case notes of women attending the WOC during the first seven months (April to October 1991) and comparison with a mixed-sex, daytime genitourinary clinic (John Hunter Clinic), and a HIV out-patients clinic (Kobler Centre) all within St Stephen's Clinic.

RESULTS

One hundred and twenty-nine women attended the WOC over the seven month period and 113 completed a questionnaire. The main reasons for attendance included a preference to be seen by a female doctor and staff, the presence of female patients in the waiting area, and the greater convenience of an evening clinic. In the absence of the WOC over half the patients (56%) indicated that they would not have attended a genitourinary medicine (GUM) clinic. The WOC attracted significantly more new patients than in the JHC (31.5% vs 15% p < 0.001). One hundred and four women (81%) were screened for genitourinary infection. Compared with the JHC there were significantly more cases of genital warts (33.9% vs 16.1% p < 0.001) and candidosis (41.5% vs 22.3% p < 0.001). A greater number of HIV tests were also performed (19% vs 9% p < 0.01). Sixteen (12.4%) women were HIV positive. Their attendance record at both first appointment (88% vs 64% p < 0.05) and subsequent follow-up appointments (81% vs 43% p < 0.05) was significantly higher than a comparable group of women seen by the same doctor (FB) in the Kobler Centre. The women also saw the health adviser more frequently. Although the number of injecting drug users was small (eight), all women currently injecting drugs entered a detoxification programme.

CONCLUSION

The WOC has become an established and popular service at St Stephen's. Women not previously using medical services are attending. The multidisciplinary nature of the clinic encourages a wider use of medical and paramedical services. Attendance record for HIV positive women has improved significantly. Whether these factors will lead to improved standards of sexual health will require a longer period of audit. Seventy-nine per cent of women indicated they would use a family planning service if available. An integrated family planning clinic was introduced after the audit period.