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The European Journal of Contraception & Reproductive
Health Care
ISSN: 1362-5187 (Print) 1473-0782 (Online) Journal homepage: https://www.tandfonline.com/loi/iejc20
Identifying young people exposed to or at risk
of sexual ill health: pilot implementation of an
evidence-informed toolkit (SEXIT) at Swedish youth
clinics
Sofia Hammarström, Per Nilsen, Malin Lindroth, Karin Stenqvist & Susanne
Bernhardsson
To cite this article: Sofia Hammarström, Per Nilsen, Malin Lindroth, Karin Stenqvist & Susanne Bernhardsson (2019) Identifying young people exposed to or at risk of sexual ill health: pilot implementation of an evidence-informed toolkit (SEXIT) at Swedish youth clinics, The European Journal of Contraception & Reproductive Health Care, 24:1, 45-53, DOI: 10.1080/13625187.2018.1564815
To link to this article: https://doi.org/10.1080/13625187.2018.1564815
© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
Published online: 07 Feb 2019.
Submit your article to this journal Article views: 602
ORIGINAL RESEARCH ARTICLE
Identifying young people exposed to or at risk of sexual ill health: pilot
implementation of an evidence-informed toolkit (SEXIT) at Swedish
youth clinics
Sofia Hammarstr€oma,b
, Per Nilsena, Malin Lindrothc,d , Karin Stenqvistb,e and Susanne Bernhardssonf,g
a
Department of Medical and Health Science, Division of Community Medicine, Link€oping University, Link€oping, Sweden;
b
N€arh€alsan Knowledge Center for Sexual Health, Gothenburg, Sweden;cDepartment of Nursing Sciences, School of Health and Welfare, J€onk€oping University, J€onk€oping, Sweden;dFaculty of Health and Society, Centre for Sexology and Sexuality Studies, Malm€o University, Malm€o, Sweden;eDepartment of Public Health and Community Medicine, Section for Epidemiology and Social Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;fN€arh€alsan Research and Development Primary Health Care, Gothenburg, Sweden;gDepartment of Health and Rehabilitation, Unit of Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
ABSTRACT
Objectives: We aimed to develop and pilot-implement an evidence-informed toolkit (SEXual health Identification Tool; SEXIT) for identifying young people exposed to or at risk of sexual ill health, at Swedish youth clinics, and to investigate SEXIT’s potential to identify young people in need of special care and monitoring.
Methods: The SEXIT toolkit was developed, validated and pilot-implemented at three Swedish youth clinics. Pre-implementation staff readiness was assessed and youth clinic visitors’ responses to SEXIT were analysed.
Results: All staff perceived a need for screening for sexual risk-taking and exposure. The response rate from 268 youth clinic visitors (aged 15–24 years) was 86%. Half of the visitors had one or no variable associated with sexual ill health, a third had two or three, and 15% reported between four and seven variables. The most common variables were alcohol use, three or more sexual partners in the past year and previous chlamydia. Visitors rated SEXIT as important and not uncomfortable or difficult to answer.
Conclusions: The SEXIT toolkit was found to be feasible and highly acceptable in a clinical setting. The use of SEXIT may facilitate important questions on sexual risk-taking and sexual ill health to be raised with youth clinic visitors.
ARTICLE HISTORY
Received 26 June 2018 Revised 3 November 2018 Accepted 13 December 2018 Published online 6 February 2019
KEYWORDS
Adolescents; implementa-tion; risk assessment; sexual behaviour; sexual violence; young adults; youth clinic
Introduction
Sexual ill health in terms of sexually transmitted infections (STIs), unintended pregnancy, transactional sex and sexual violence among young people is a global public health concern [1]. Different manifestations of sexual ill health tend to be interrelated and share many associated factors. To mention a few, STIs are associated with multiple sexual partners, early sexual debut, alcohol use and experience of transactional sex [2,3]. Experience of sexual violence is associated with unintended pregnancy and STIs through unprotected sex, and a greater likelihood of engaging in transactional sex [4–8]. Engaging in transactional sex is associated with a history of abuse, substance misuse, previ-ous STIs, multiple partners, state care and running away from home [9]. Previous STIs, unintended pregnancy and experience of sexual violence also increase the likelihood of repeated ill health [7,10,11]. Examples of groups identi-fied as disproportionally burdened are lesbian, gay, bisex-ual and transgender (LGBT) youth and young people in state care [12,13]. When in contact with the health care
system, systematic identification of individuals exposed to or at risk of sexual ill health is of major importance, not only for effective prevention and care but also for equit-able sexual health care.
Sweden has a nationwide system of youth clinics, pro-viding an arena to address the different interrelated mech-anisms of sexual ill health. Youth clinics are highly accessible to adolescents and young adults between the ages of 13 and 24 years. They provide a wide range of services, from counselling on sexual and reproductive health to addressing psychosocial health concerns. Their services are free of charge and do not require parental involvement. Further, the clinics offer testing for STIs and provide subsidised condoms and other contraceptives [14].
Despite the potential of Swedish youth clinics to detect and intervene in matters of sexual ill health, they lack guidelines or recommendations to identify and monitor those who are particularly at risk [15]. Only 49% of young people report having received professional counselling on risks and protection during their most recent STI test [16].
CONTACTSofia Hammarstr€om sofia.hammarstrom@vgregion.se N€arh€alsan Knowledge Center for Sexual Health, Norra Hamngatan 36, Gothenburg
SE-411 06, Sweden
Supplemental data for this article can be accessedhere
ß 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License ( http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
2019, VOL. 24, NO. 1, 45–53
Young people seldom disclose experiences of sexual vio-lence or transactional sex to professionals of their own accord [17,18]. An assessment tool for identifying different factors associated with sexual ill health would potentially be valuable for identifying and intervening with the youth clinics’ most vulnerable visitors.
We have not been able to identify any such assessment tool for clinical use in the scientific literature. The aim of this study was therefore to develop and pilot-implement an evidence-informed toolkit for identifying young people exposed to or at risk of sexual ill health in terms of STIs, unintended pregnancy, experiences of transactional sex or sexual violence, at Swedish youth clinics. The aim was also to describe the outcomes of the assessment and investi-gate its potential to identify visitors in need of special care and monitoring.
Methods
Setting and participants
The pilot implementation of the toolkit was planned and conducted by an implementation team led by the project manager (SH). Implementation took place during March 2016 at youth clinics in the western part of Sweden, in the region of V€astra G€otaland. Three different youth clinics were selected based on their location, size and focus (one specialised in risk-taking and exposed youth, one was large and urban and the third was smaller and rural). Managers and all first-line health care staff (midwives, registered nurses, counsellors and psychologists) participated. Physicians were not included; visits to physicians are rare and are only booked following an assessment by other staff. Visitors to all health care staff were invited to partici-pate, regardless of whether the visit was booked, occurred during drop-in hours or as an emergency visit. Only visitors aged 15 or above and who understood Swedish were included.
Instrument development and validation
An instrument was developed to enable systematic assess-ment of sexual risk-taking and sexual ill health among youth clinic visitors. It was intentionally kept short to enable use during brief visits and adapted to be user-friendly from the perspectives of the youth clinics and young people. When possible, items from previously vali-dated questionnaires were used [19–21]. An expert panel assisted the development. The panel consisted of a special-ist in infectious diseases, a youth clinic development man-ager, an STI coordinator, and two midwives with competence in sexology.
Content validity was established in consensus discus-sions by the expert panel members. The first draft of the instrument was analysed to determine whether it was suffi-ciently comprehensive to cover the most important aspects of sexual ill health and risk-taking and ensure that it con-tained no irrelevant items.
Face validity of the instrument was tested in three focus groups of 15 adolescents and young adults of mixed gen-der divided by age: 15–17, 18–20 and 21–24 years. These groups completed an early version of the instrument and
commented on readability, comprehensiveness, perceived relevance of the items, completion time and reluctance to answer any of the questions. The test resulted in minor revisions of the introduction to the instrument and pro-vided useful information on the preferred way to complete the instrument.
The instrument was given the name SEXual health Identification Tool (SEXIT), analogously to the widely used risk assessment tools used for alcohol abuse (Alcohol Use Disorder Identification Test; AUDIT) and drug abuse (Drug Use Disorder Identification Test; DUDIT) [19,21]. Unlike AUDIT and DUDIT, SEXIT is primarily a conversational tool and does not provide an individual score. For publication of this paper, SEXIT was translated into English in a rigor-ous forward–backward translation process [22]. The instru-ment, together with associated training and guidance, forms the SEXIT toolkit. In this study, only the instrument is explored; experiences of SEXIT training and guidance are investigated in ongoing studies.
SEXIT items
The final instrument comprises 16 items with fixed response options (Supplemental material). The first items provide background information about the visitor (age, gender and sexual orientation) that can affect the assess-ment of the remaining items [3,23,24]. One item concern-ing livconcern-ing arrangements was included based on sexual health risks among youth in the care of the state [12]. Three items concern alcohol and drug use: behaviours with a complex but well-established association with sexual risk-taking and ill health [3,8,12,25–27]. The inclusion was fur-ther motivated by convenience for the youth clinic staff, who are already advised to ask about alcohol and drug use. Two items, age at sexual debut and number of sexual partners, were included based on their association with sexual risk-taking, transactional sex, sexual violence and STIs [2,3,7,28–30]. One item concerning experience of first-date sex was included in order to prompt a clinical conver-sation about related risks, such as condom non-use, and unwanted sexual experiences. First-date sex reduces the possibility of knowing whether the partner has tested for STIs, and unprotected sex with a new or unknown partner has been associated with chlamydia [2] and other related factors: alcohol use [25], drug use, early sexual debut, mul-tiple sexual partners and sex against one’s will [21]. Two items, concerning chlamydia and unintended pregnancy, capture previous risk-taking and serve as possible markers of future risk-taking and ill health [10,11,27,31]. Since no item was found on unintended pregnancy regardless of gender, item 12 was constructed for this instrument. Four items concern experiences of transactional sex and sexual violence [4,9,32–35]. To initiate a discussion on sexually coercive behaviour, item 16 was formulated for this instru-ment [34]. The final item contains three statements about the experience of answering the instrument, answered on a five-point Likert-type scale [21]. There is no personal identifier on the instrument.
Staff training and locally adapted guidance
All staff at the three youth clinics (n¼ 18) attended a 6 h training session. Core components of training included the latest research on sexual risk-taking and sexually exposed youth and on management of visitors (e.g., follow-up ques-tions needed for a full patient history) and recommended actions when risk-taking or ill health is identified. Training was delivered by the project manager, an infectious disease specialist (KS), and a midwife specialising in risk-taking youth, through lectures, group assignments and role play.
To support the clinics in using the instrument, SEXIT guidance was developed and revised by the expert panel. The guidance includes which answers indicate risk or ill health, follow-up questions to ask, and recommendations for actions based on the SEXIT assessment. The guidance was developed together with the clinics to make sure that it suited their conditions (e.g., different local routines, health care partners and support groups).
Staff readiness assessment
As part of a pre-implementation assessment of needs, resources and fit of the innovation, the youth clinic staff’s readiness for change was assessed at the end of the train-ing session. The assessment included 10 items with Likert-type scale response options and was constructed by the project manager (SH). The items capture four implementa-tion outcomes defined by Proctor et al. [36]– acceptability, adoption, appropriateness and feasibility – which among other implementation outcomes indicate whether imple-mentation will be successful.
Assessment of youth clinic visitors’ sexual health
The 1 month data collection started four days after the training session. Posters in the waiting room notified visi-tors that the clinic was participating in a research project aimed at improving the clinic’s work in sexual health and that all visitors would be informed and asked to participate by a member of staff.
Participants completed the SEXIT instrument on their own in the consulting room. The staff then reviewed the answers with the visitor and posed follow-up questions. Based on SEXIT, the subsequent conversation and a full patient history, the health care professional made the assessment. This process could be either short (during drop-in hours) or part of a longer conversation about the visitor’s sexual health. Every SEXIT item has recommended actions in the guidance; some items have the same recom-mended actions but generally the more behaviours con-nected to risk of sexual ill health that an individual demonstrates, the more active actions are recommended. Time and resources at the clinics determined whether actions were taken immediately, or whether a new visit was planned for further follow-up. If necessary, another health care professional was booked for the follow-up, for example, a midwife to test for STIs or a counsellor to follow up reported experience of sexual coercion. The use of SEXIT does not rule out other existing routines: for example, providing an STI test to visitors asking for contraceptives.
Data analysis
Descriptive statistics with frequencies were used to exam-ine staff responses to the readexam-iness assessment. Items with responses on a scale of 3–5 were dichotomised.
Analysis of the youth clinic visitors’ assessment data was performed in two stages. First, means, frequencies and per-centages, grouped by gender, were analysed using descrip-tive statistics. The gender identity alternatives ‘Transgender’, ‘Other’ and ‘Do not wish to categorise myself’ were merged into ‘Transgender, non-binary and other’. Gender differences in the categorical variables were analysed using Pearson’s v2 test and Fisher’s exact test. ‘Transgender, non-binary and other’ participants were excluded from the gender analysis due to small numbers. Response rates are reported for every item.
Second, 11 dichotomised risk variables were constructed (items 5–9 and 11–16). For analytical purposes, the bles were compiled to an index and the number of varia-bles was calculated for every individual in order to present the total risk of sexual ill health for every respondent. Counting an individual SEXIT score is not part of the pro-cess when using SEXIT for a clinical assessment. Items 1–4 (age, gender, sexual orientation and living arrangements) were not included because they demonstrate groups with a statistical overrepresentation in risk assessments rather than individual risk exposure [3,12,13,23,24]. Alcohol use at least two to four times a month, cannabis use at least once in the past year and use of other illegal drugs at least once in the past year were considered to have a possible nega-tive impact on sexual health. Item 10 (having sex with someone at first encounter) was not included in the index because evidence is lacking for this behaviour being an established risk factor for STIs, unintended pregnancy or sexual violence. Having three or more sexual partners in the past year was considered to confer an elevated STI risk [2]. The items of chlamydia, unintended pregnancy, experi-ence of transactional sex and sex against one’s will, i.e., past or current sexual ill health, were also considered risk variables that increased the likelihood of repeated exposure in the future. The response option ‘Don’t know’ for the items on chlamydia and pregnancy was considered to demonstrate risk-taking and therefore merged with those answering yes to these items. The statistical analyses were performed using IBM SPSS, version 22.0 (IBM, Armonk, NY).
Ethical considerations
Youth clinic visitors received written and oral information about the study and were informed that participation was voluntary. All participants provided written consent and received contact details for help and support if needed after participation in the study. According to the Swedish Ethical Review Act, active consent is not required from parents of adolescents aged 15 years or older [37]. The study was approved by the regional ethics review board in Gothenburg (reference 935-15).
Results
Responses were received from 268 youth clinic visitors (response rate 85.6%). Figure 1 illustrates the inclusion
process. Respondents were 15–24 years of age, with a mean age of 20.3 years (standard deviation (SD) 2.42). Clinic visits were predominately booked in advance (73%), although 21% occurred during drop-in hours and 6% as emergency visits during regular hours. Most of the visits were made to midwives (63%), followed by counsellors (17%), nurses (10%) and psychologists (10%).
Staff readiness
All staff (n¼ 18) completed the assessment: nine midwives, two registered nurses, three counsellors, three psycholo-gists and one non-clinical unit manager. All perceived a need for more systematic screening for sexual risk-taking and sexual ill health at youth clinics and rated the
acceptability, feasibility, appropriateness and adoption of SEXIT as high. Some staff (4/17) feared that the introduc-tion of SEXIT would be time-consuming and/or difficult (Table 1).
Acceptability of SEXIT among youth clinic visitors
Among the youth clinic visitors invited to participate, 14% declined. The internal non-response rate varied between 0.0% and 0.8%, except for the item on unintended preg-nancy (1.9%). Participants rated the SEXIT questions as important and not uncomfortable or difficult. Attitudes towards SEXIT are presented inTable 2.
SEXIT assessment outcomes
Table 3 presents the responses by gender. Respondents who had never had sex (n¼ 11, 4.1%) ended the instru-ment halfway through but were assessed by the health care professional in the same manner as the other partici-pants. Age of sexual debut varied between 10 and 23 years of age (mean 15.9 years, SD 1.88). Number of sexual part-ners within the past 12 months ranged from 0 to 20, with an average of three partners (SD 3.34). Sexual ill health was reported by women, men and the ‘Transgender, non-binary and other’ group, respectively, as follows: previous
Youth clinic visitors screened for eligibility (n=345)
Ineligible due to insufficient Swedish (n=5)
Included in the study (n=268)
Declined participation
(n=45)
Invited to participate (n=313)
Eligible but not recruited due to time constraints, i.e. during drop-in hours (n=27) Eligible youth clinic visitors
(n=340)
Figure 1. Flow diagram of the inclusion process.
Table 2. Youth clinic visitors’ attitudes towards SEXIT.
Item
Proportion who agreed (%)a
What was it like for you to answer the instrument?
The questions were important 220/254 (87) The questions were uncomfortable 18/250 (7) The questions were difficult to answer 20/250 (8)
aDichotomised Likert scale ratings (1–5, completely disagree to
com-pletely agree).
Table 1. Responses to pre-implementation staff readiness assessment.
Item Proportion who agreeda Implementation outcomeb
1. It is possible to prevent STIs and unwanted pregnancies through early detection of sex-ual risk-taking and exposure among people who visit the youth clinic (Completely agree, partially agree)
18/18
2. It is possible to prevent (reduce the risk) that people are exposed to (some types of) sexual violence through early detection of sexual risk-taking and exposure among peo-ple who visit the youth clinic (Compeo-pletely agree, partially agree)
18/18
3. In your opinion, is there a need for more systematic screening for sexual risk-taking and exposure at the youth clinic in comparison with today? (Yes)
18/18 4. A questionnaire can be a tool for early detection of people at risk of sexual ill health
caused by sexual risk-taking and exposure (Completely agree, partially agree)
18/18 Appropriateness 5. A questionnaire measuring sexual risk-taking and exposure can be a useful tool for me
working at the youth clinic, in consultation with visitors who are at risk of sexual ill health caused by sexual risk-taking and exposure (Completely agree, partially agree)
18/18 Appropriateness Feasibility
6. If a questionnaire is confirmed to be an effective tool for early detection of people at risk of sexual ill health caused by sexual risk-taking and exposure, I am willing to use the questionnaire as part of the consultation (Completely agree, partially agree)
18/18 Adoption
7. Do you believe that the use of SEXIT will affect the number of sexually risk-taking youth that are identified at your clinic? (We will identify more)
18/18 Appropriateness Feasibility 8. How do you feel about starting to work with SEXIT? (Completely agree, partially agree) Acceptability
(a) It feels important 17/18
(b) It feels fun 13/17
(c) It feels time-consuming 4/17
(d) It feels difficult 4/17
9.How confident do you feel about your ability to make correct decisions about follow-up questions and actions when sexual risk-taking is identified through SEXIT? (Very confi-dent or partially conficonfi-dent)
16/18 Feasibility
10.In total, how prepared do you feel about the forthcoming pilot implementation of SEXIT? (Very well prepared, well prepared or prepared)
18/18 Feasibility
a
Dichotomised Likert scale ratings.
bTaxonomy defined by Proctor et al. [36].
Table 3. Sample characteristics and analysis of gender differences.
Missing values Women Men Transgendera
Determinant n (%) n (%) n (%) n (%) p Value
Total number of participants (n¼ 268) 225 (84) 33 (12.3) 10 (3.7)
Age, years (n¼ 268) 0 (0.0) .065 15–17 43 (19) 2 (6) 0 (0) 18–24 182 (81) 31 (94) 10 (100) Sexual orientation (n¼ 268) 1 (0.4) Heterosexual 183 (82) 30 (91) 1 (10) Homosexual 2 (1) 1 (3) 1 (10) Bisexual 27 (12) 2 (6) 3 (30)
None of the categories 12 (5) 0 (0) 5 (50)
Living arrangements (n¼ 268) 0 (0.0)
Alone 44 (20) 4 (12) 1 (10)
With parents 120 (53) 20 (61) 1 (10)
In foster family/care home/institution 1 (0) 0 (0) 0 (0)
With friends 19 (8) 3 (9) 7 (70) With partner 33 (15) 5 (15) 1 (10) Other arrangement 8 (4) 1 (3) 0 (0) Alcohol use (n¼ 268) 0 (0.0) .997 Never 28 (12) 3 (9) 3 (30) 1 time/month 88 (39) 14 (42) 4 (40) 2–4 times/month 80 (36) 10 (30) 3 (30) 2 times/week 29 (13) 6 (18) 0 (0) Cannabis use (n¼ 268) 0 (0.0) .240 Never 161 (72) 16 (48) 5 (50)
Yes, more than a year ago 28 (12) 9 (27) 3 (30)
Yes, during the past 12 months 24 (11) 7 (21) 2 (20)
Yes, during the past 30 days 12 (5) 1 (3) 0 (0)
Use of other illegal drugs (cocaine, heroin, amphet-amine, ecstasy, unprescribed medicines, etc.) (n¼ 268)
1 (0.4) .361
Never 206 (92) 28 (88) 9 (90)
Yes, more than a year ago 7 (3) 1 (3) 1 (10)
Yes, during the past 12 months 12 (5) 3 (9) 0 (0)
Sexual initiation<15 years of age (n ¼ 257) 0 (0.0) .757
No 173 (80) 25 (78) 8 (80)
Yes 42 (20) 7 (22) 2 (20)
Sexual encounter the first time we met (n¼ 257) 2 (0.8)
Never 141 (66) 14 (44) 6 (60)
Yes, once 24 (11) 8 (25) 1 (10)
Yes, twice 21 (10) 2 (6) 0 (0)
Yes, three times 12 (6) 2 (6) 1 (10)
Yes, more than three times 15 (7) 6 (19) 2 (20)
No. of sexual partners during the past 12 months (n¼ 257) 1 (0.4) .137 0 2 (1) 3 (9) 1 (10) 1–2 128 (60) 12 (38) 4 (40) 3–4 45 (21) 5 (16) 1 (10) 5–10 36 (17) 9 (28) 3 (30) >10 3 (1) 3 (9) 1 (10)
Ever had chlamydia infection (n¼ 257) 1 (0.4) .834
Never 151 (71) 22 (69) 9 (90)
Yes, more than a year ago 23 (11) 2 (6) 1 (10)
Yes, during the past 12 months 17 (8) 5 (16) 0 (0)
Don’t know 23 (11) 3 (9) 0 (0)
Ever had unintended pregnancy, own or part-ner (n¼ 257)
5 (1.9) .077
Never 192 (91) 25 (81) 8 (80)
Yes 16 (8) 4 (13) 0 (0)
Don’t know 3 (1) 2 (6) 2 (20)
Ever been reimbursed/paid for sex (n¼ 257) 1 (0.4) 1.000
No 209 (98) 32 (100) 10 (100)
Yes 5 (2) 0 (0) 0 (0)
Ever reimbursed/paid someone else for sex (n¼ 257) 1 (0.4) .130
No 214 (100) 31 (97) 10 (100)
Yes 0 (0) 1 (3) 0 (0)
Experienced sex against one’s will (masturbation or oral/vaginal/anal sex) (n¼ 257)
2 (0.8) .005
No 170 (80) 32 (100) 4 (40)
Yes, more than a year ago 31 (15) 0 (0) 4 (40)
Yes, during the past 12 months 12 (6) 0 (0) 2 (20)
Been sexually coercive (including suspicion that the sex was against the partner’s will, through pressure or persuasion) (n¼ 257)
1 (0.4) .505
No 210 (98) 31 (97) 9 (90)
Yes 4 (2) 1 (3) 1 (10)
chlamydia infection (19%, 22%, 10%), experience of unin-tended pregnancy (8%, 13%, 0%), transactional sex (2%, 0%, 0%) and sex against one’s will (21%, 0%, 60%). Low fre-quency of some experiences, such as transactional sex, and relatively few men in the sample limited the gender analy-ses. The only significant gender difference found was that women reported more experience of sex against their will compared with men.
The five most common variables associated with sexual ill health, irrespective of gender, were alcohol use (48%), three or more sexual partners in the past year (41%), previ-ous chlamydia (29%), early sexual initiation (20%) and sex against one’s will (19%).Table 4 shows the most common variables by gender.
The youth clinic visitors demonstrated between zero and seven risk variables out of a possible 11 associated with sexual ill health (Figure 2). Half of the visitors (49%) had no or one variable. About one-third (36%) had two or three variables and the remaining 15% had between four and seven variables. Among the young people with four or more variables, 40% came during drop-in hours or as emer-gency visits.
Discussion
Findings and interpretation
A new evidence-informed toolkit, SEXIT, was implemented at Swedish youth clinics, for the identification of young people exposed to, or at risk of, sexual ill health in terms of STIs, unintended pregnancy, transactional sex or sexual violence. The youth clinic staff were found to be highly motivated in the pre-implementation readiness assessment, suggesting that SEXIT as an innovation is acceptable, appropriate for its purpose and feasible in the youth clinic setting, and that adoption of SEXIT (intention to try)
among staff was high. These comprise four indicators of successful implementation [36]. The instrument had high acceptance among the youth clinic visitors, indicated by the fact that only 14% declined participation and those who participated rated the SEXIT questions as important and not uncomfortable or difficult. The youth clinic popula-tion demonstrated considerable variapopula-tion in levels of sexual risk-taking and negative experiences of sexuality. Overall, the SEXIT tool facilitated identification of youth clinic visi-tors who demonstrated multiple variables indicating risk of sexual ill health. As such it succeeded in identifying individ-uals in most need of special care and monitoring.
The study findings, although not representative of all Swedish youth clinic visitors, increase our knowledge about sexual risk-taking and sexual ill health among youth clinic visitors. Half of the visitors demonstrated no or one risk variable and about one-third demonstrated two or three risk variables. The vast majority in the low- to medium-risk group have needs that can be addressed by regular youth clinic activities, such as STI preventive counselling and test-ing, contraceptive counselling and motivational interview-ing for alcohol and drug use.
Visitors demonstrating between four and seven parallel risk-taking behaviours and/or experiences of coercive or transactional sex, however, need to be addressed more carefully. Repeated and multiple sexual risk-taking behav-iours can be symptoms of more severe psychological dis-tress and are not merely due to a lack of safer-sex knowledge. Exposure to sexual, mental and/or physical vio-lence and other underlying mechanisms need to be explored and addressed in order to improve sexual health [32,38,39]. Following a potentially traumatising event a stepped procedure is suggested: initial risk-screening for trauma or trauma-related symptoms; early psychological interventions, including psycho-education and individual coping skills; and, lastly, treatment, i.e., psychological ther-apy [40–43]. Health care staff should pay extra attention when assessing and treating young people who, apart from being sexually exposed or taking risks, are also of very young age, identify as LGBT and/or live in a foster family or institution, because they represent particularly vulnerable and disproportionally burdened groups [12,23,24]. When the youth clinic’s services and expertise are insufficient, collaboration with other health care special-ties, social services and local resources is warranted.
Among the young people with between four and seven variables indicating sexual ill health, many made non-booked visits, underscoring the need to direct resources to easily accessible visits and not refrain from screening for sexual risk-taking and ill health because of time constraints.
Table 4. Reported variables associated with sexual ill health, by gender and frequency.
Women (n¼ 225) Men (n¼ 33) Transgendera(n¼ 10)
Alcohol use2 times/month (48%) 3 sexual partners (53%) Sex against will (60%) 3 sexual partners (39%) Alcohol use2 times/month (48%) 3 sexual partners (50%)
Chlamydia (30%) Chlamydia (31%) Alcohol use 2 times/month (30%) Sex against will (21%) Cannabis use (24%) Early sexual initiation (20%) Early sexual initiation (20%) Early sexual initiation (22%) Unintended pregnancy (20%) Cannabis use (16%) Unintended pregnancy (19%) Cannabis use (20%) Unintended pregnancy (9%) Other illegal drug use (9%) Chlamydia (10%)
Other illegal drug use (5%) Been sexually coercive (3%) Been sexually coercive (10%) Been sexually coercive (2%) Given reimbursement for sex (3%) Other illegal drug use (0%) Received reimbursement for sex (2%) Sex against will (0%) Given reimbursement for sex (0%) Given reimbursement for sex (0%) Received reimbursement for sex (0%) Received reimbursement for sex (0%)
aTransgender, non-binary and other.
25% 24% 20% 16% 6% 6% 2% 1% 0% 5% 10% 15% 20% 25% 30% 0 1 2 3 4 5 6 7 Percen ta ge o f yo u th cl in ic vi si to rs
Number of variables associated with sexual ill health (0–11)
Figure 2. SEXIT index: variables associated with sexual ill health. 50 S. HAMMARSTR€OM ET AL.
In the absence of routine asking of questions on sensitive subjects, such as experiences of violence or transactional sex, these questions are rarely asked. Young people seldom disclose these experiences to professionals of their own accord [17,18]. The systematic use of SEXIT could help identify the most vulnerable youth clinic visitors, while sim-ultaneously ensuring equitable health care where all visi-tors have the same opportunity to discuss sexual risk-taking and disclose negative experiences.
Strengths and weaknesses
To our knowledge, this is the first published instrument developed to facilitate identification of young people exposed to, or at risk of, sexual ill health, including STIs, unintended pregnancy, transactional sex and sexual vio-lence, when meeting health care professionals.
Collaboration with different stakeholders during the development process, including participating youth clinics, is one of the study’s main strengths, resulting in a feasible clinical tool and not merely an instrument for research. A high response rate (86%), a low non-response rate for indi-vidual items (0.0–1.9%) and youth clinic visitors’ viewing the questions as important and not uncomfortable or diffi-cult suggest that SEXIT can play an important role in the future sexual health care of young people.
Close collaboration with stakeholders during planning and conduct of the pilot implementation helped ensure stakeholder buy-in and foster a supportive organisational climate. The implementation largely followed the critical steps proposed by Meyers et al. [44] in their quality imple-mentation framework. Key steps in this framework include process evaluation, obtaining stakeholder buy-in, providing staff training and ongoing implementation support, all of which was done in the SEXIT implementation.
The methods used to validate the instrument were lim-ited to content and face validity evaluations. The instru-ment was developed for use in clinical settings as a basis for risk assessment, including a discussion based on the youths’ responses to the instrument. The fact that it is not a stand-alone diagnostic tool limited the relevance of some established methods for validating instruments. For example, test–retest reliability was inappropriate because different answers after repeated visits could be expected as caregiver–patient trust developed. Testing construct validity would have required a full set of questions concerning every theme in the instrument, and the instrument then would have lost its advantage of being brief and feasible for systematic use.
Based on the broad variation of questions and the many circumstances not accounted for in a very brief instrument like SEXIT, we have chosen not to use a summative score or propose definite cut-off values (like AUDIT or DUDIT) in the clinical tool. A score or cut-off value would be mislead-ing and would oversimplify complex circumstances. Despite using best available evidence, the cross-sectional designs employed in the cited research provide weak evidence of causal relationships between risk factors and sexual ill health. We might have overlooked items that should have been included, or included items that will prove to be irrelevant in the future. Revisions of the instrument are expected based on the results from this and future studies.
Answers were self-reported and may be subject to recall and reporting bias. From this study, we cannot tell to what degree participants answered SEXIT truthfully, and there might be some underestimation in the assessment out-comes. Ongoing qualitative studies are expected to gener-ate more knowledge on how visitors perceived answering SEXIT.
Non-response was highest for the item of unintended pregnancy (1.9%). Refraining from responding to individual items is information in itself; it could be a sign of risk-tak-ing or ill health related to that specific question, but there might also be other explanations. Answering the instru-ment is voluntary and posing follow-up questions after a deliberate non-response would be unethical.
The findings of this study are possibly generalisable to other high-income countries with a similar system of youth clinics and a similar liberal view on sexuality among young people.
Similarities and differences in relation to other studies
In the pre-implementation assessment of readiness for change, the staff answered positively in all measures, expressing belief in both their capability and intention to try SEXIT, two variables found to best predict individual behaviours of health care professionals [45]. Some staff reported concerns that the introduction of SEXIT would be time-consuming or difficult, which may be considered a natural hesitation regarding a forthcoming practice change. Such concerns are commonly identified barriers for imple-mentation of new practices in health care [46].
Low attrition rates and youth clinic visitors rating the questions in SEXIT as important and not difficult or uncom-fortable to answer suggest that the use of SEXIT in youth clinics was appropriate and feasible. This finding is sup-ported by previous research that young people have a positive attitude towards health care professionals asking questions about sexual risk-taking and about negative experiences of sexuality [47–49].
Rates of specific exposures are comparable to those found in previous research in young people in Sweden: chlamydia [2,16], unintended pregnancy [16,32], sexual vio-lence [2,16,32,50] and reimbursement for sex [2,16,38]. The finding of clustering of sexual risk-taking behaviours, vio-lence exposure and outcomes such as rates of STIs and unintended pregnancy is in agreement with the results of both national and international studies [2–4,32], some of which have proposed that extended screening be per-formed by sexual health services [2,4,27]. To our know-ledge, the clinical screening endeavours described in the scientific literature only focus on specific forms of ill health, which limits possible comparisons: child sex trafficking [9], violence victimisation [47,51], chlamydia [52] and alcohol use [53]. The questions and procedures in the mentioned studies are, however, similar to those of the present study, further supporting the feasibility of this approach to better identify youth with sexual health needs, when they come into contact with health care professionals.
Open questions and future research
Qualitative studies that provide a deeper understanding of the implications of SEXIT for youth clinic visitors and staff are essential to better understand barriers and facilitators for implementation and will be conducted to inform future revisions and developments of the SEXIT toolkit. Future studies should also focus on the process after identifica-tion, i.e., what type of care the identified youth clinic visi-tors receive, and the impact it has on their health and wellbeing. For use in other settings or countries, adapta-tions of SEXIT might be necessary. We encourage use of SEXIT by other researchers, to further validate it in other contexts.
Conclusions and clinical relevance
The SEXIT toolkit was successfully implemented in three youth clinics during 1 month and was found to be feasible and highly acceptable for use in a clinical setting. Systematic use of SEXIT may help important questions on sexual risk-taking and sexual ill health to be raised with youth clinic visitors.
Acknowledgements
Participating youth clinics and the Department of Communicable Disease Control of V€astra G€otaland assisted in developing and pilot-implementing SEXIT. The authors thank Emma Svanholm, Jennie Elisson, Susann Frostholm, and Peter Nolskog for their substantive contributions to the study, and Margit Neher and Carin Sj€ostr€om Greenwood for their help with the English translation of SEXIT.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This work was supported by the Public Health Agency of Sweden (grant 03393-2015); the Healthcare Board, Region V€astra G€otaland, Sweden (grant VGFOUREG-573441); and the Medical Research Council of Southeast Sweden (grant FORSS-664621).
ORCID
Sofia Hammarstr€om http://orcid.org/0000-0002-9282-1142
Malin Lindroth http://orcid.org/0000-0002-5637-5106
Karin Stenqvist http://orcid.org/0000-0003-4773-512X
Susanne Bernhardsson http://orcid.org/0000-0001-8212-7678
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