Original research•

Client perspectives on creating supportive sexual health environments for people with persistent anxiety: a qualitative study

Abstract

Objectives We sought to explore sexual health service clients’ perspectives, preferences and suggestions for how to better address or alleviate anxiety among clients of sexual health services (eg, sexually transmitted infection testing) regarding both online and in-person sexual health services among those who experience persistent anxiety.

Methods We conducted qualitative interviews with 27 sexual health service clients with persistent experiences of anxiety in British Columbia, Canada. Participants were recruited from respondents to a COVID-19-related sexual health survey who consented to follow up. Interviews were conducted via Zoom, recorded and transcribed. Transcripts were coded and analysed using thematic analysis by searching for themes in order to summarise the experiences and needs of participants.

Results The median participant age was 34. 16 participants identified as women, 10 as men and 1 each as non-binary and gender fluid. Participants described anxiety related to sexual health service access and experiences due to sexual health-related stigma and privacy concerns; provider judgement and lack of communication or information regarding test results. They suggested that routinely integrating discussions with providers about mental health in sexually transmitted and bloodborne infection (STBBI) testing appointments may help clients feel safer and could connect them to support. They highlighted the need for personal and genuine interactions with providers (eg, making appointments feel less perfunctory, asking clients how they are feeling about why they are there) and sufficient time with providers (eg, not feeling rushed through the appointment, time to discuss resources, testing and advice).

Conclusions Disease-specialised health services may not adequately address the multifaceted and inter-related mental health needs of people accessing services. In STBBI testing service settings, more personalised appointments, additional communication with providers and easier access to results can help improve both the service experiences of people experiencing persistent anxiety and their connections to appropriate mental health support.

What is already known on this topic

  • Existing research suggests that sexual health testing settings may induce or exacerbate feelings of anxiety.

What this study adds

  • Little is known about sexual health clients’ mental health experiences or needs. This study describes experiences of anxiety among clients and identifies opportunities for improved sexual and mental health service integration.

How this study might affect research, practice or policy

  • Findings will help to inform provider approaches to addressing anxiety within a sexual health testing setting.

Introduction

Existing research suggests that sexual healthcare settings can unintentionally contribute to feelings of anxiety.1–4 Anxious feelings may stem from the possibility of a positive sexually transmitted and bloodborne infection (STBBI) result, the need for partner notification, anticipated provider judgement, embarrassment, stigma and privacy concerns.1–3 5 6 Previous research has demonstrated a high prevalence of general anxiety among STBBI testing clients (including in person and online),6 7 suggesting that acute experiences of anxiety may interact with more chronic experiences of anxiety.4 Further, in light of pervasive barriers to mental health services (eg, high costs, provider availability, long wait times, stigma and the logistics of accessing care7–9, low-barrier service settings such as sexual health services may offer opportunities to strengthen connections to care.

It is not uncommon for people to access mental healthcare (eg, seeking care for depression, anxiety, other mental health conditions) in other low barrier, more accessible locations like primary care and sexual health clinics.4 9 10 Indeed, previous research highlights the potential benefits of greater service integration and accessibility.10 11 It is important to understand how sexual health settings can better address the needs of people experiencing anxiety—both by helping to mitigate anxiety in the context of sexual health service access and by facilitating connections to mental health supports. Creating supportive sexual health environments for addressing anxiety during STBBI testing encounters may be beneficial to both the client and the broader healthcare system.5 10

However, little is known about how sexual health settings are experienced by people with chronic or persistent experiences of anxiety, nor about their perspectives on anxiety alleviation through improvements to service delivery and connections to mental health. Therefore, we conducted a study to explore sexual health service clients’ perspectives, preferences and suggestions for how to better address or alleviate feelings of anxiety regarding both online and in-person sexual health services among those who experience persistent anxiety. We conducted a qualitative descriptive study and used thematic analysis to analyse the data.12 13

Methods

Participants

We interviewed 27 participants from British Columbia (B.C.), Canada. They were recruited among respondents of an online COVID-19-related survey about sexual health, administered by the BC Centre for Disease Control to sexual health service clients in July–August 2020.14 A subset of participants consented to be contacted for interviews following the survey. Interviews took place October–December, 2020. In order to be eligible, prospective participants had to (1) be 16 years of age or older, (2) have accessed sexual health services in B.C. within the past 12 months and (3) have experienced anxiety (eg, nervousness, panic, inability to stop worrying) for 2 weeks or more within the past 12 months. Consent was obtained before proceeding with the interviews.

Data collection

Team members used a semistructured interview guide (online supplemental file 1) to inquire about participants’ experiences of anxiety and other mental health concerns, accessing mental and sexual health supports, and desires and expectations regarding mental and sexual health service integration. Topics included in the interview guide were (A) Participant Motivation; (B) Mental Health Experiences & Access to Services; (C) COVID-19 Experiences; (D) Sexual Health Service Experiences and (E) Interpretations of Mental Health and Substance Use Tools Within Sexual Health Services. We used a semistructured interview guide to allow for natural conversation flow, follow-up questions and dialogue between interviewer and participant. Interviews lasted between 45 and 90 min. They were conducted via Zoom and were recorded, anonymised and transcribed for analysis. A follow-up survey was sent postinterview to collect demographic and mental health information.

Analysis

Interviews were conducted by SB, SW and patient partner RR. SB and SW are trained in qualitative methodologies and RR was trained by SW and SB to conduct interviews. Interviews were transcribed and accuracy checked by SB, SW and RR. All transcripts were double coded by SB, SW or RR. Team members met regularly to discuss the use of codes and to address any discrepancies. Descriptive coding using NVivo V.12, followed by pattern coding,11 was carried out by two researchers (SB and SW). We inductively searched for higher-level themes in order to summarise the experiences and meanings of participants9 while staying close to the data. Themes were defined and iteratively redefined by both analysts to achieve internal consistency.

Patient partner involvement

Team member RR was engaged in the study based on their lived experience working in and accessing sexual health services. They helped develop the interview guide, conducted interviews, supported accuracy-checking of transcripts and cocreated the codebook for analysis.

Results

Characteristics of sample

We conducted 27 interviews with STBBI testing clients (see table 1) from B.C. All participants self-reported that they had accessed online (n=22) and/or in-clinic (n=22) STBBI testing services within the past 12 months. Most participants accessed testing services routinely while some had only tested periodically or for a particular event.

Table 1
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Characteristics of participants in a qualitative study regarding anxiety among STBBI testing service clients (B.C., summer 2020)

Almost all participants (n=26) had previously accessed or were currently accessing mental health services (eg, counselling). Mental health experiences varied in duration and intensity. Participants described anxiety related to their sexual health in general, and anxiety when accessing STBBI testing services. Some participants described underlying mental health conditions (eg, generalised anxiety and depression) yet felt comfortable receiving STBBI tests while some reported anxiety specifically related to STBBI testing. Others experienced anxiety both directly related to STBBI testing and various underlying/chronic conditions.

The following sections detail the major themes identified: contributors to anxiety in STBBI testing settings; participant perspectives on integrating mental health supports in sexual health appointments and participant suggestions for ‘anxiety-supportive’ sexual health services.

Contributors to anxiety in sexual health settings

Regardless of whether they had a diagnosed mental health condition, many participants expressed anxiety related to STBBI testing. This was typically related to provider judgement, privacy, stigma, the possibility of having an STBBI and communication regarding test results.

Provider judgement

Many participants felt anxious about provider judgement when attending in-person appointments. Some experienced it directly while others anticipated the potential for judgement. Participants felt that accessing testing through online services, without having to speak with a provider allowed them to avoid potentially uncomfortable interactions. One participant said:

[…] I don’t need to speak to someone ‘cause they’re going to give me the same spiel every time. Sometimes there’ll be judgments because I’m in an open relationship and we’ve made that decision to do that. So I don’t have to explain all that. (Woman, mid twenties)

Another participant (man, late twenties) worried about the potential for providers to think less of him due to how frequently he sought testing.

Privacy, stigma and testing anxiety

Privacy related to testing concerned several participants. Some felt that clinic spaces did not afford adequate anonymity from others in and around the clinic. A desire for privacy when accessing sexual health services in particular stemmed from the stigmatised nature of sexual health, sexual practices, sexuality and STBBI testing. One participant explained:

[I]t’s just like I really don’t want to have one [an STBBI]. You know, I think part of just growing up in a world with all those stigmas about it is you’re just taught that it’s the worst thing in the world to get, and it’s like, you know, cancer, but embarrassing. (Man, early twenties)

Similarly, another person identified shame around partner notification when diagnosed with an STBBI. They said: ‘it implies that you’re slutty or that you aren’t safe, um…yeah, it’s a very shameful thing to have to do’ (Woman, late twenties).

Communication regarding STBBI test results

Many of the services participants accessed only followed up with clients if results were positive. This lack of communication from providers troubled several people who felt anxious waiting for results. One participant (man, early twenties), described the ‘no news is good news’ approach to test results as ‘frustrating’, and wished providers would call to deliver results either way. Participants using an online testing service appreciated having access to all results within the service portal. The desire for concrete information was important to participants. Being able to look up their test results through e-health systems offered people something to return to in moments of anxiety. One participant explained:

In those moments I can’t just talk myself out of it or do something to distract myself. I have to go back, look at the written thing that said ‘negative,’ and that’s the only thing that kind of tends to calm it [anxiety] down. (Woman, mid twenties)

Participant perspectives on integrating mental health supports in sexual health appointments

Participants expressed a range of perspectives when asked how and whether mental health supports should be integrated into STBBI testing services. Most participants were supportive of integration, provided that it was optional and sensitive to clients’ needs. They suggested that doing so may enhance the testing experience and help strengthen connections to mental health supports for those who were otherwise disconnected. They desired more connections to mental health services as well as more emotionally supportive interactions with providers.

Participants indicated that routinely asking about mental health in sexual health settings to strengthen pathways to mental health supports could enable a more tailored approach and help to normalise mental health discussions. Several participants emphasised that, given the stigmatised nature of mental health, care must be given to how and when this conversation is raised. They emphasised the importance of transparency from providers about why they are inquiring about mental health so that clients do not feel caught off guard:

I might just be like: ‘Well, why are you asking this, what are you picking up on?’ Whereas if it’s more front-loaded with a: ‘As part of this we’d like to do general screenings for sorts of mental health supports to see if there’s other things that could support you if we noticed you might benefit from them.’ I’d be more open to that idea[.] (Woman, mid twenties)

Conversely, some participants were sceptical of integrating sexual and mental health services. They indicated that the stigmatised nature of sexual health and mental health may cause clients to feel reluctant to discuss the latter. One participant explained that clients may already feel intimidated by the process of accessing STBBI testing services; to add a discussion of mental health may be overwhelming:

I think at a sexual health clinic when you know you’re going to be focused on the swabs and the blood tests and stuff it’s almost like enough to be kind of managing, and then the one-on-one questions about anxiety might just be, I don’t know, like you’d already be anxious because of what was about to happen, and it would just feel a little too personal when you’re already doing something personal. (Woman, late thirties)

For others, the two fields of practice were perceived as too unrelated. For these participants, discussions of mental health would be out of place or even intrusive in sexual health settings. One person likened receiving sexual and mental health services together to ‘getting your Christmas ham at the car dealership’ (woman, mid-thirties), highlighting their disparate nature.

Participant suggestions for ‘anxiety-supportive’ sexual health services

Participants offered a number of suggestions for supporting people with anxiety through their testing experiences (table 2). Suggestions highlighted opportunities to improve communication with providers, access to information and access to support. These are summarised in a tabular format.

Table 2
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Participant recommendations for reducing anxiety among sexual health service clients

Discussion

This study explored sexual health service clients’ suggestions, perspectives and preferences for how to better address or alleviate anxiety concerns within STBBI testing service settings. Participants reported different levels of anxiety, a range of perspectives regarding the integration of mental health and STBBI testing services and provided suggestions for mitigating anxiety in these settings. Results highlight an important opportunity to integrate more ‘anxiety-supportive’ resources and methods in sexual health settings. Consistent with previous research, this suggests that improved resource and referral options are needed to better support sexual health service clients experiencing anxiety.15 For instance, a study about a sexual health information chat service described strategies and opportunities used by nurses to respond to persistent sexual health-related anxiety among clients (eg, providing anxiety management information, offering sexual health education and risk assessment).1 Effective identification of and response to anxiety in STBBI testing service settings can help to ensure that clients are connected with appropriate resources and supports. Furthermore, providing reputable sources of STBBI information to clients can help them avoid excessive online information-seeking, which can be detrimental to one’s mental health.1 4 Other research has also shown how low barrier (free, anonymous, inclusive of sexual/gender minorities, self-referred) sexual health settings may be particularly well placed to attend to such needs, given that mental health concerns often intersect and co-occur with sexual health concerns.4–6 13 14 It is also known from previous research that primary care and sexual health clinics can be advantageous sites of mental healthcare due to their accessibility, cost-effectiveness for both clients and the healthcare system and increased mental and physical health outcomes.15 16 Research has further demonstrated high levels of client desire for integrated or bundled mental health services alongside STBBI testing.10 Findings from the current study provide insight into clients’ perspectives about how connections to mental health may be facilitated within a sexual health setting. Previous research has focused on sexual health provider perspectives about the integration of mental and sexual health services.12 14 Providers felt that integrating mental health workers within sexual health settings could help direct people to better resources and ensure clients receive timely care from trained mental health professionals. Our current study allowed us to hear clients’ own perspectives on a different kind of mental health integration, focusing on anxiety reduction in sexual health settings. Practical implications for sexual health providers include: Ensuring STBBI test results are easily accessible online for clients to refer to at their convenience; providing reputable sources of educational STBBI information to clients, creating greater communication opportunities with providers to ensure clients feel heard and supported, and the creation of a live pop up chat service in online testing interventions for added support with a professional. These practical implications are in line with previous research showing a need for anxiety-supportive sexual health environments, and a need for further education of sexual health clients.1 For instance, one study showed that clients preferred one-on-one results notification to Short Message Service (SMS) notification because they had more time with a provider and cited anxiety about test results as a reason to refuse SMS notification of results.16

Findings from this study also contribute to the sparse literature about how clients with existing anxiety navigate health systems, and how best to improve mental and sexual health pathways for this population. Our findings are relevant to providers seeking to create environments that minimise barriers to sexual healthcare for people experiencing anxiety. More research is needed about the merits of integrating mental health and sexual health services, and about ways to implement such an integration. We also identified several limitations related to participant sampling and recruitment. First, in order to be eligible, prospective participants had to have experienced anxiety for 2 weeks or more within the preceding 12 months. However, recruitment occurred during the second wave of the COVID-19 pandemic. Given the profound mental health effects of the pandemic, some self-reported anxiety may have been situational rather than ongoing. Second, participants were recruited among respondents of a sexual health survey. The majority of respondents to this survey had experience accessing online sexual health services. This could have resulted in a sample with a high degree of digital health literacy, and disproportionately favourable views about, and comfort with, online testing service access. In addition, because we were specifically interested in experiences of anxiety within sexual health service settings, all participants had accessed sexual health services. Future studies should explore the needs of those whose experiences of anxiety have prevented them from accessing services. Existing research indicates that experiences accessing sexual health services may be shaped by intersecting experiences of stigma and discrimination (eg, related to gender, age).3 17 However, the homogeneity of the sample (eg, with regard to ethnic identity, gender), impeded our ability to explore these intersections. Future studies may build on existing research3 17 by exploring the unique experiences of anxiety in the context of sexual health services based on age, gender or other aspects of identity.

Conclusion

Disease-specialised health services may not adequately address the multifaceted and inter-related mental health needs of people accessing services. In STBBI testing service settings, more personalised appointments, additional communication with providers and easier access to results can help improve both the service experiences of people experiencing anxiety and their connections to appropriate mental health support. Providers should consider ways to alleviate anxiety in sexual health settings, as outlined by the participants in this study. There is a need to review best practices to allow more time in appointments to help those experiencing anxiety feel comfortable with the providers and to ask any questions they have. Furthermore, ensuring that results are available promptly online in all cases (not just in the case of online testing services) would improve the experiences of all clients, including those with anxiety and sexual health anxiety specifically. Developing nurse text chat or phone lines could also be an outlet for those with anxiety to receive comforting and accurate information to alleviate their anxiety.

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