Identification of young people at risk of sexual ill health : implementing a new tool in youth clinics

Abstract: Background: Young people are at increased risk of sexual ill health in terms of sexually transmitted infections, unintended pregnancy, and sexual violence. There is limited knowledge of evidence-based preventive practices for identification of young people at risk of sexual ill health when in contact with health care. Aims: The overall aim of this thesis was to generate new knowledge concerning how Swedish youth clinics can work systematically to identify young people at risk of sexual ill health or who have negative sexual experiences. Specific objectives were to develop a risk-assessment model for the identification of youth at risk of contracting chlamydia; to develop and pilot-implement an evidence-informed tool for identifying young people at risk of sexual ill health in terms of sexually transmitted infections, unintended pregnancies, and sexual violence at Swedish youth clinics; and to explore youth clinic visitors’ and staff’s experiences of using that tool. Methods: The thesis takes a mixed methods approach and includes four studies. First, data from a national sample of sexually active young people, aged 15–24 years (n=6544), were used to develop a risk-assessment model for chlamydia infection. Second, a risk-assessment tool (SEXual health Identification Tool; SEXIT) was developed and pilot-implemented at three youth clinics for 1 month. The tool includes three components: (1) staff training; (2) a questionnaire for youth clinic visitors; and (3) a written guide for staff to support the subsequent dialogue and risk assessment based on the questionnaire. Questionnaire data from visitors (n=268) and staff (n=18) were analysed. Third, youth clinic visitors’ experiences were explored in 20 interviews with visitors (15–24 years) from the participating youth clinics. Fourth, staff’s experiences of working with SEXIT were investigated in four focus group discussions (n=16). Quantitative and qualitative methods were used for data analyses. Results: The risk-assessment model demonstrated that the distribution of chlamydia is skewed; 38% of cases were estimated to occur among a tenth of the population. Women most at risk of chlamydia were best identified using the variables age, number of sexual partners in the past year, and experience of sex for reimbursement. The corresponding variables for men were age, number of sexual partners, and alcohol use. SEXIT was validated and pilot-implemented at three youth clinics (response rate 86%). Before implementation, all staff perceived a need for more systematic screening for sexual risk-taking and sexual ill health at youth clinics. Youth clinic visitors demonstrated between 0 and 7 parallel risk factors. Staff experienced that using SEXIT systematically increased the consistency and quality of the clinics’ work, and youth clinic visitors reported that the questions were important and not uncomfortable or difficult. The visitors explained that questions in a written format followed by a dialogue initiated by the youth clinic staff enabled disclosure of negative experiences. Conclusions: The risk-assessment model demonstrates that the number of partners during the past year is the most important risk factor for chlamydia regardless of gender. SEXIT is an acceptable, appropriate, and feasible tool from the perspective of youth clinic staff, youth clinic visitors, and from an implementation point of view. Using the tool systematically may help raise important questions on sexual risk-taking and sexual ill health with youth clinic visitors and identify visitors with multiple risk factors. Being asked the sensitive yet important questions in SEXIT, followed by a respectful and non-judgemental conversation led by the youth clinic staff, has the potential to open up a more in depth and broader dialogue about the visitors’ sexual health. The systematic procedure helps youths feel that they are taken seriously and instils a feeling of trust that enables disclosure of sensitive experiences. From the staff perspective, SEXIT facilitates identification of young people exposed to or at risk of sexual ill health by simplifying and ensuring consistency and quality in their work.