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Anticipating the potential for positive uptake and adaptation in the implementation of a publicly funded… Chabot, Cathy; Gilbert, Mark; Haag, Devon; Ogilvie, Gina; Hawe, Penelope; Bungay, Vicky; Shoveller, Jean A Jan 30, 2018

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RESEARCH ARTICLE Open AccessAnticipating the potential for positiveuptake and adaptation in theimplementation of a publicly funded onlineSTBBI testing service: a qualitative analysisCathy Chabot1* , Mark Gilbert1,2, Devon Haag2, Gina Ogilvie1,2, Penelope Hawe3,4, Vicky Bungay5 andJean A. Shoveller1AbstractBackground: Online health services are a rapidly growing aspect of public health provision, including testing forsexually transmitted and other blood-borne infections (STBBI). Generally, healthcare providers, policymakers, andclients imbue online approaches with great positive potential (e.g., encouraging clients’ agency; providing cost-effective services to more clients). However, the promise of online health services may vary across contexts andbe perceived in negative or ambiguous ways (e.g., risks to ‘gold standard’ care provision; loss of provider controlover an intervention; uncertainty related to budget implications). This study examines attitudes and perceptionsregarding the development of a novel online STBBI testing service in Vancouver, Canada. We examine the perceptionsabout the intervention’s potential by interviewing practitioners and planners who were engaged in the developmentand initial implementation of this testing service.Methods: We conducted in-depth interviews with 37 healthcare providers, administrators, policymakers, andcommunity-based service providers engaged in the design and launch of the new online STBBI testing service.We also conducted observations during planning and implementation meetings for the new service. Thematicanalysis techniques were employed to identify codes and broader discursive themes across the interviewtranscripts and observation notes.Results: Some study participants expressed concern that the potential popularity of the new testing service mightincrease demand on existing sexual health services or become fiscally unsustainable. However, most participantsregarded the new service as having the potential to improve STBBI testing in several ways, including reducing waitingtimes, enhancing privacy and confidentiality, appealing to more tech-savvy sub-populations, optimizing the redistributionof demands on face-to-face service provision, and providing patient-centred technology to empower clients to seektesting.Conclusions: Participants perceived this online STBBI testing service to have the potential to improve sexual healthcare provision. But, they also anticipated actions-and-reactions, revealing a need to monitor ongoing implementationdynamics. They also identified the larger, potentially system-transforming dimension of the new technology, whichenables new system drivers (consumers) and reduces the amount of control health care providers have over onlineSTBBI testing compared to conventional in-person testing.Keywords: Internet-based intervention, Online STBBI testing, Qualitative research, Implementation context, Agency* Correspondence: cathy.chabot@ubc.ca1School of Population and Public Health, University of British Columbia, 2206East Mall, Vancouver, BC V6T 1Z3, CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Chabot et al. BMC Health Services Research  (2018) 18:57 DOI 10.1186/s12913-018-2871-xBackgroundInternet-based population health interventions are a newand growing area of public health service provision; yet, todate, there has been limited research regarding the imple-mentation context of internet-based health services. Pub-lished accounts have focused primarily on the adoption ofelectronic medical records [1–3]. This study takes place inVancouver, British Columbia (BC), Canada, where diagnosisrates of sexually transmitted infections (STI) are high andrising among some populations, including young peopleunder 25 and men who have sex with men (MSM). In BC,the rate of genital chlamydia increased to 288.4 per 100,000population in 2014, continuing the overall provincial trendof a steady increase since 1998. Similarly, diagnosis rates ofgonorrhea have increased among youth under 25 in thepast decade [4]. Diagnosis rates of other STI are highamong gay, bisexual, and other MSM in BC. For instance,in 2014, 84.9% of all new syphilis cases (466 of 549 newcases) occurred in MSM [4]. MSM also accounted for thegreatest number of new positive Human ImmunodeficiencyVirus (HIV) diagnoses (58%) in BC in 2014 [5].Despite these high rates of new infections, testing ser-vices for sexually transmitted and other blood-borne in-fections (STBBI) remain under-accessed by many groups,both in Canada and internationally [6–8]. As a result, pub-lic health services are developing new ways to promotetesting uptake, with the hope that it will enhance timelytreatment, lower rates of onward transmission, and reduceadverse health outcomes [9, 10]. Access to internet-basedtesting is provided in a variety of ways, ranging from pub-licly funded mail-in testing kits for chlamydia and HIV inthe United Kingdom [11], to commercial, fee-for-serviceSTBBI testing in some regions of Australia [12], theUnited States [13–15], and Canada [16, 17]. And, health-care providers (HCP), policymakers, and clients frequentlyregard online health services as having the potential to re-duce access barriers and service delivery costs, while con-tributing to patient self-care regimens [18–22].GetCheckedOnlineGetCheckedOnline (GCO) is a new internet-based STBBItesting service developed by the British Columbia Centrefor Disease Control (BCCDC) in Vancouver, Canada [23],and the first of its kind in Canada to offer comprehensiveonline testing for STBBI. GCO is a virtual extension of theprovincial STI clinic and is integrated with existing clinicaland public health services. As such, the aim of GCO is tocomplement – not replace – existing face-to-face clinicalservices, with the goal of increasing testing uptake and fa-cilitating earlier diagnosis and treatment, particularlyamong MSM and young people [17]. By providing aninternet-based option to asymptomatic persons to test,GCO also aims to result in “more focused use of clinicalnursing and physician resources for clients requiringclinical diagnosis and treatment, and increased capacityfor drop-in visits” at BCCDC STI clinics [24]. Its develop-ment is aligned with the BC Ministry of Health, which ad-vocates increasing implementation of patient-centred careservices, such as self-management of healthcare, patientand HCP shared decision-making, increasing patients’ ac-cess to information, and advancing health promotingbehaviours [25].GCO is provided free of charge to all users and is cur-rently available in Vancouver and select communities intwo other BC health regions. Users create a secure onlineaccount before initiating an assessment of their risk of ex-posure to STBBI. Users complete an online informed con-sent process to indicate that they understand what STIthey are being tested for, how they will receive their testresults, and how to access more information [26]. Usersare then instructed to print a laboratory requisition thatincludes orders for chlamydia, gonorrhea, syphilis, HIV,and (for some clients) Hepatitis C tests. Clients take theirprinted requisition to a participating laboratory, whereblood and urine samples (and in some cases, self-collectedoral and rectal swabs) are collected and then transferredto the provincial Public Health Lab for analysis. All userstest under an alphanumeric code in place of first and lastnames. Specimen analysis is typically completed withinseven to 12 days, whereupon clients are prompted viaemail to sign into their GCO account to view their test re-sults. Clients are able to view their negative test results on-line. If they test positive or have an inconclusive result, thewebsite prompts them to contact the provincial STI clinicat BCCDC by phone; at the same time, BCCDC nurseswill attempt to contact any client with a positive result. Atthis point, all clients with inconclusive or positive lab re-sults are treated as all other BCCDC clients with a similarresult, where results are discussed by phone and the indi-vidual is referred to a BCCDC clinic for further testing ortreatment, as warranted [14]. Clients living in select com-munities in the two other health regions where GCO isavailable are referred to public health clinics, walk-inclinics, or pharmacies that have partnered with the healthauthority to provide treatment to GCO clients. Overall,GCO reduces the interaction with the traditional healthcare system by removing the need for an in-person pre-test visit at a clinic to obtain a requisition for testing, anda post-test visit for the majority of clients who have anegative result. Clients are still required to present to a la-boratory for specimen collection.GCO was first piloted in September 2014 and modifica-tions were made based on feedback from users andBCCDC staff, as well as early evaluation of the intervention.The risk assessment questions were revised in Autumn2015 to be more appropriate for clients of all gender iden-tities and to allow for the prospective collection of variablesneeded to validate clinical prediction rules for gonorrhea,Chabot et al. BMC Health Services Research  (2018) 18:57 Page 2 of 11chlamydia, and HIV testing. In January 2016, self-collectedthroat and rectal swab testing for chlamydia and gonorrheawas added based on feedback from clinician consultationsand to reflect clinical practice guidelines [27]. GCO devel-opers continue to adapt the intervention, based on ongoingmonitoring and evaluation across contexts. BCCDC’sOnline Sexual Health Services (OSHS) coordinator hasoverseen the development and delivery of GCO acrosshealth authority regions, which implicates contextual fea-tures of geography (e.g., rural; urban), epidemiology (e.g.,STI ‘hot spots’ and areas with below average STI rates), andvarying perspectives on the potential value of GCO. Theprovincial Ministry of Health and regional health author-ities are generally supportive of GCO and have identifiedlocal champions [25] who help shape GCO’s adaptationand gradual expansion.The implementation context of GCOIn order to understand the implementation context intowhich GCO was being introduced, one must understandhow STBBI testing and treatment services are provided inBC. Context is “a constellation of active interacting vari-ables” that are unique to the implementation of a particu-lar intervention [28]. In British Columbia, STBBI testingand treatment services are a complex system comprised ofindividual agents (e.g., healthcare providers, administra-tors and policymakers, support staff, and clients) that havethe freedom to act in ways that are not always predictable,and whose actions are interconnected so that one agent’sactions may alter the context for other agents [29]. For in-stance, it is important to consider factors such as innova-tions in STBBI testing technologies (e.g., urine-basedNAAT testing, rather than urethral swabs, are the currentstandard of care) and treatment policies (e.g., routine im-plementation of partner delivered therapy), as well aschanges in settings (e.g., staffing changes at clinics andlocal health regions) where testing and treatment occur[28]. In BC, sexual health services are provided free ofcharge through regional or provincial health authorities(e.g., public health clinics and primary care programs), aswell as by other clinics run by publicly-funded fee-for-service physicians and non-government organizationsstaffed by salaried nurses and physicians. STBBI testingand treatment options include screening (e.g., routine pre-natal and/or gynecological care); testing, counseling, andpartner notification (e.g., through physician-delivered pri-mary care and public health programs); and more special-ized sexual health services offered in particular settings(e.g., STBBI clinics; youth clinics; community health cen-tres). Testing procedures vary depending on where theyare accessed. Typically, face-to-face testing involves an ini-tial consultation with a HCP to gather a client’s sexual his-tory, conduct a physical exam, provide education andcounseling, and collect specimens (blood, urine, swabs)[7]. Clinicians usually do sample collection on-site, butsome may send clients to external specimen collectionsites for blood and/or urine tests. Test results are normallyavailable within seven to 10 days and the process of givingresults varies across settings. HCP may tell clients to makea follow-up appointment to get their test results or onlyphone clients if they need to follow-up in person abouttheir test results (i.e., a positive or inconclusive test result)and possible treatment [30]. It is into these multiple differ-ent contexts that GCO is being implemented.Theoretical frameworkIn this paper, we employ potentiality theory [31] fromthe field of anthropology to examine how the develop-ment of GCO was regarded by key agents involved insexual health services (HCP, administrators, policy-makers, and community-based sexual health serviceproviders) to prospectively impact STI testing serviceprovision for both providers and clients. Taussig andcolleagues describe potentiality as “a hopeful idiomthrough which to imagine the benefits of new medicalinterventions”, while also often concurrently reflectingbiomedicine’s “increasing anxiety about the negativepotentials of life”, such as injury, disease, aging, ordeath at both the individual and population levels ([31],p. S4). Online health services are a rapidly growingcomponent of public health provision, including testingfor STBBI. In general, HCP, policymakers, and clientsimbue online approaches with great positive potential(e.g., encouraging clients’ agency; providing testing tomore clients in a cost-effective manner) [9]. However,the promise (i.e., the imagined benefits) of online healthservices may vary across contexts. Potentiality theory isespecially useful for understanding context-based issuesaffecting implementation as it provides a useful framingto help unpack perceptions of GCO – be they positive,negative or ambiguous (e.g., enhanced appeal to youngpeople; risks to ‘gold standard’ care provision; loss ofprovider control over an intervention; uncertainty re-garding budget implications). Asking stakeholdersabout the anticipated effects of implementing this newintervention offers a way to examine potential gaps “be-tween what is and what might, could, or even shouldbe” ([31], p. S5). GCO’s hypothetical future can be ar-ticulated in positive, negative, or ambiguous ways, de-pending on how it is perceived. Understanding theways in which the promise of GCO is perceived is auseful feature of context that provides another windowinto the ways in which context affects its continued im-plementation and adaptation.Our aim in this paper is to examine how study partici-pants’ attitudes and expectations about GCO reflect thecontext in which this intervention is being implemented,and provide insights into adaptations to the STBBI systemChabot et al. BMC Health Services Research  (2018) 18:57 Page 3 of 11that key stakeholders value. We also examine how inter-viewees anticipate GCO might affect the agency of STBBItesting clients. To the best of our knowledge, this is thefirst research to be published on the implementation con-text of an internet-based STBBI testing intervention.These data may provide important considerations not onlyfor those involved in the implementation of GCO, but alsoothers seeking to implement similar online STBBI testingservices in other jurisdictions.MethodsData collectionData for this paper are drawn from a four-year ethno-graphic study of the development and early implementationstages of GCO. We completed semi-structured, one-to-oneinterviews with 37 key agents (HCP, administrators, policy-makers, and community-based sexual health service pro-viders) involved in GCO’s development. Another studyexplored the opinions and expectations MSM had of GCOduring its development [14], and an analysis of users’ expe-riences with the pilot test of GCO in Vancouver indicatedthat 13% of clients who created GCO accounts were underage 25, suggesting that the program may need to beadapted or promoted in different ways to increase uptakeamongst youth [32]. Interviews were conducted during thepre-implementation phase of GCO in Vancouver in 2013,prior to its launch in September 2014. Participants wereasked about their knowledge, perceptions, and experienceswith online sexual health services. Their perceptions ofGCO and its potential to function as a complementary ser-vice to existing face-to-face STBBI testing were examined,as was GCO’s perceived fit with existing clinical practices.A number of interview questions focused on aspects of theimplementation context of GCO (e.g., which client popula-tions might benefit the most or least from GCO; perceivedcomplementarity of GCO with current practices at STBBIclinics and labs; cost considerations for changes to theSTBBI system). (See Table 1 for Interview Guide questions.)We also conducted observations at 71 OSHS planningand implementation meetings to better understand GCO’simplementation context. Participants were recruited usingpurposive sampling and through participant observationactivities. We selected participants who were directly in-volved in GCO’s development or implementation, as wellas health and community service providers who do sexualhealth promotion.Each participant was asked to provide written informedconsent prior to being interviewed or included in partici-pant observations. All study participants were asked to se-lect a pseudonym (used to identify participants’ quotationsin this paper). Thirty-four participants were interviewed inprivate rooms at their workplaces; the three remaining in-terviews were conducted by telephone due to distance orscheduling challenges. Each participant answered a five-item socio-demographic questionnaire before the semi-structured interview began. Interviews ranged in lengthTable 1 Interview GuideTopics QuestionsKnowledge of online sexual health services Please tell me what you know about:a) the provision of online health care within and outside of Canada.b) online sexual health services within and outside of the country.c) the BCCDC’s Online Sexual Health Services.Perceived factors affecting the implementation ofGCOHow feasible do you think the new GetCheckedOnline service will be with existing health humanresource capacity in your health jurisdiction, clinic, or lab?What client populations do you think will benefit the most from the introduction of GCO?The least? Why?Would you recommend GCO to people who access your organization’s services? Why/why not?Tell me about any funding implications you think there might be for the new GetCheckedOnlineservice.Perceived complementarity of GCO with currentpractices at STI/HIV testing clinics or labsHow well do you think the new GetCheckedOnline service might fit within your existing rolesand responsibilities in the health jurisdiction, clinic, or lab where you work?How do you think GCO might affect the quality of care clinicians and lab techniciansprovide to clients seeking STI/HIV testing and treatment?Perceived fit with extra-mural connections How might GCO dovetail with (or clash with) clinical practice guidelines or accreditationrequirements for clinics and labs in your health jurisdiction?Do you anticipate that GCO may identify a need to adapt or develop additional clinical practiceguidelines or institutional regulations for STI/HIV testing services?New training opportunities and other changemanagement processesWhat training opportunities do you think are needed in order to implement GCO in your healthjurisdiction?How do you think this change to service provision can best be managed in your jurisdiction foryou, your staff/co-workers, and clients?Chabot et al. BMC Health Services Research  (2018) 18:57 Page 4 of 11from 40 min to over 2 hours, with the average duration be-ing 75 min. The lead author, who has extensive trainingand experience conducting qualitative health research,conducted each interview (and in a few instances wasassisted by another research staff member). Interviewswere audio-recorded and transcribed verbatim. Partici-pants had the opportunity to review their transcripts forany errors or revisions. Fieldnotes were prepared describ-ing meeting observations, interview dynamics, and prelim-inary analyses [33]. The University of British Columbia’sBehavioural Research Ethics Board approved this study(certificate # H11–00547).Data analysisThematic analysis techniques from grounded theory [34]were employed to identify codes and broader discursivethemes across the data. Research staff met regularly withthe lead investigator to develop coding consensus and dis-cuss newly emergent themes. The qualitative analysis soft-ware NVivo 10 was used to manage the data codingprocess [35]. Initial codes to organize the data intodiscrete categories were developed deductively through acombination of general themes informed by the literatureand inductively through an in vivo reading of the data[33]. Sample initial codes included: human resource pol-icies; privacy policies and legislation; and intramural andextramural influences on GCO’s development (all groupedunder a broader theme of implementation context). Wealso developed codes to capture participants’ perceptionsregarding the potentiality and promise of GCO (e.g., re-ceptivity to GCO, feedback on the development of GCO,and anticipated effects on service provision post-implementation). As coding of the transcripts and field-notes progressed, we referred back to relevant policy andprogram documents we had analyzed at an earlier stage ofour study. These documents provided additional macro-level context to the interview and observation data (e.g.,participants’ references and interpretations of policies andbest practice guidelines) and informed the later stages ofour analysis and writing. During the final stage of coding(which is referred to as theoretical coding in groundedtheory), we identified potentiality as the theoretical con-struct that explained study participants’ varied perceptionsregarding their expectations about GCO [34]. As thedrafting of this manuscript progressed, we frequently dis-cussed our interpretations of the data to ensure consensuswas reached.ResultsThe 37 interview participants ranged in age from 25 to64 years. Fourteen participants were employed as HCP(nurses or physicians) who provide STBBI testing andtreatment, while the remainder worked in healthcare ad-ministration (n = 7), policymaking (n = 4), community-based sexual health services (e.g., education, advocacy)(n = 6), or on the development of the BCCDC's OSHSprogram (n = 6).As we began the initial phase of analysis, our reading ofthe discursive references in the data regarding the potentialfor GCO to improve STBBI service provision focusedmostly on explicit statements about GCO’s “potential”; dis-cussions about GCO’s possible impact on client agency andchanges to service provision; and other contextual-basedreferences (e.g., possible funding implications; impacts on“gold standard” service provision) to the intervention’s pos-sible positive, negative, or ambiguous effects [31]. As theanalysis continued, we were able to identify two broad the-matic categories which summarize interviewees’ perspec-tives on GCO’s potential. First, improving access to STBBItesting; and second, impacts on STBBI service deliverypost-implementation.Improving access to STBBI testingIn all of the interviews, participants said they believeGCO has the potential to improve the accessibility ofSTBBI testing in a number of ways, including (a) redu-cing waiting times; (b) providing enhanced privacy andconfidentiality; and (c) directly appealing to more tech-savvy population subgroups. People who do not test be-cause of long waiting times at clinics and young menwho are uncomfortable seeking clinical care wereregarded as ideal potential users of this low-barrier ser-vice. One public health administrator said:It’s gonna stop people from having to sit in a waitingroom with other people potentially that they don’twant to be around. … Even if it’s people they don’tknow, people don’t like people to know about theirsexual infections or that kind of thing. (‘Aidan’,administrator)Most participants suggested that GCO’s developersprioritized client confidentiality and were followingrigorous policy standards to ensure clients’ data werekept secure, which they perceived to be very importantto most potential GCO users. A few administrators andclinicians expressed concern that a security breach couldpossibly jeopardize GCO users’ privacy, but counteredthat potentiality by noting the system’s features werebuilt with privacy as an implementation and functionalpriority, and that GCO complied with the provincialgovernment’s privacy legislation and operational frame-work. One salaried physician who specializes in sexualhealth service provision stated:[T]hey’re being very cautious to protect the clientsfrom [a privacy breach]. ‘Cause I think they just get[client code] numbers and such, like. So, I think, youChabot et al. BMC Health Services Research  (2018) 18:57 Page 5 of 11know, I think the way they’re presenting it is donevery well. Less privacy issues than just going to theclinic. (‘Elizabeth’, physician)An emphasis on client confidentiality and privacy wasregarded by some study participants as a factor thatcould encourage online testing as a ‘safer’ mode of test-ing (i.e., less risk of a confidentiality breach) than in-person testing.Most participants said GCO would appeal to two prior-ity groups: MSM and young people. GCO and the tech-savvy, proactive reputation of these groups were perceivedas synergistic in terms of the intervention’s potential toenhance testing services. One administrator said:This is going to be fantastic for MSM and youth!There’s not any question in my mind, because theseare wider populations who are very comfortable beingproactive and informed in their own care. (‘Marilyn’,administrator)This comment reflects a common presumption that allyoung people and MSM are technologically savvy, haveeasy internet access, and are self-motivated to seek test-ing. This view was tempered slightly by some interviewparticipants, who acknowledged that low-income indi-viduals may not have affordable and reliable internet ac-cess, and some youth may not have private internetaccess. Most interviewees suggested that BC’s STBBItesting system will continue to need a diversity of ap-proaches (GCO, clinics, outreach) in order to meet theoverall population’s testing needs.Impacts on STBBI service provision post-implementationParticipants had conflicting perspectives on the value ofGCO as it pertains to HCP productivity, conserving fi-nite human resources, and budgetary constraints. Someparticipants stated that GCO may improve the product-ivity of the public STBBI system by shifting some clientsto internet-based testing and away from more humanresource-intensive face-to-face testing (including the ser-vices that they provide). These participants emphasizedthat they and the larger public health system can adaptto changing public demands when necessary, includingduring periods of fiscal constraint. In response to a ques-tion about the prospect of a funding shortfall should de-mand for STBBI testing increase as a result of theintroduction of GCO, one administrator said:I think it’s great that we hear [public health] labsfreaking out about these costs because you knowwhat? This is the true cost of providing the care thatwe should have been providing all along. Yeah, it’s aproblem, but the people who need to figure it out willfigure it out. Our job is to provide care … accordingto the clinical guidelines. Are we being successful byrationing care and being afraid of success andmotoring on with these same terrible uncontrolledepidemics? That’s the failure. (‘Phinn’, administrator)Many study participants suggested GCO would be acost-effective alternative for people who test routinely anddo not need to see a clinician every time. Some partici-pants also suggested that GCO could reduce in-clinic test-ing demand by the so-called ‘worried well’ – people whoare anxious about contracting an illness, despite often be-ing perceived to be at low risk. These participants sug-gested GCO could provide the worried well with thereassurance they seek in a more cost-effective manner, ra-ther than ‘wasting’ clinicians’ valuable time with face-to-face testing. One administrator said:It allows people to get into testing but it also allowsmany of the worried well … the chance to get thatreassurance that they want without necessarilyimpacting on a very limited resource in the system.(‘Marilyn’, administrator)These participants predicted that by encouraging routinetesters and the ‘worried well’ to use GCO, it would redu-cing wait times for people seeking in-person testing atSTBBI clinics.GCO developers also hoped that this interventionwould appeal to MSM who test routinely. However,prior to its implementation, some HCP expressed con-cerns about this goal because GCO did not providethroat and rectal swab tests for chlamydia and gonor-rhea. One clinician manager stated:I think that there’s lots of people out there that wesee, particularly in our gay male population, whodon’t want to particularly talk to a nurse. They knowthe routine. … So they don’t really want to interfacewith us, right? They do it because they have to. …The only thing I worry about aroundGetCheckedOnline is that there are no swabs, thereare no throat or rectal swabs, and so I know it saysthat all over the [web]site … but people will assumethey have been really checked when they haven’t beenchecked, right? (‘Arthur’, clinician manager)GCO developers always planned to eventually introduceswab tests but this was not immediately feasible duringthe pilot phase because the laboratory collection centreswere not structured to support client self-collection ofswabs.Chabot et al. BMC Health Services Research  (2018) 18:57 Page 6 of 11While most study participants acknowledged GCO’s po-tential to redirect some clients from in-clinic to onlinetesting, some predicted that GCO might not decrease thedemand for in-person testing services. One nurse said:I think that it’s another tool that we can use toencourage people into normalized testing. I don’t seeit as replacing a clinic visit, but enhancing or maybeintroducing people to testing and maybe one day theyfeel comfortable coming in and seeing somebody for afull exam or a more thorough exam. (‘Chloe’, nurse)Some participants also asserted that GCO would not beable to match clinicians’ expert knowledge. These partici-pants believed that face-to-face STBBI testing is the ‘goldstandard’ and suggested it may be the preferred form oftesting for some clients. One administrator stated:[GCO is] meant to supplement and guide people intothe system [and] make it more efficient. … And peoplealso go where they know the quality is, so if it turns outthat they’re not getting quality services online and theythink they’ll get their needs met better by going to theclinic, they’ll go to the clinic. (‘Phillip’, administrator)Some clinicians expressed concern that demand forGCO might lead to a corresponding decrease in demandfor in-clinic testing, resulting in job cuts at sexual healthclinics or reduced fee-for-service visits at physicians’ gen-eral practice offices. However, most clinicians emphasizedthat online testing was not introduced into the system as ameans to serve all populations or replace face-to-face test-ing. Rather, it was intended to complement existing clinic-based services, which were perceived to be already heavilyutilized, as one OSHS developer stated:[GCO] has pros and cons compared to clinicalpractice but it fills a niche that needs to be filled,right? Some people need to test more frequently andit’s really around convenience or accessibility: peoplewho can’t get into a clinic, or people who won’t comeinto a clinic and [GCO] is how they’ll get tested. So Idefinitely see that it’s sort of filling a void and beingreally complementary to clinical services. (‘Mike’,OSHS developer)Many interviewees also described online STBBI testingas an inevitable next frontier in the ever-expanding con-text of service provision. As one administrator commen-ted, GCO reflects a broader trend towards patient-centred healthcare:Either we make it available or people will just order itthemselves. Like, this idea that we can control peoplethe way we used to is ridiculous. I mean, they’ll orderchlamydia kits from the UK. They’ll order gonorrheakits from Mexico. It’s just gonna happen. So, myperspective is okay, let’s ensure some quality,opportunities for engagement, let’s monitor progress.… And that’s the perspective we need to take.(‘Marilyn’, administrator)‘Marilyn’ supported GCO, in part, because she believedit would provide better quality of care than direct-to-consumer STBBI tests from outside of Canada. More-over, she and a number of other study participantsdescribed GCO as having the potential to enhance theagency of people seeking testing by providing it online.However, GCO’s potential as a patient-centred form ofhealthcare created some uncertainty for some HCP whoare accustomed to provider-controlled interventions. Aspreviously noted, these clinicians regard provider-controlled interventions as providing the ‘gold standard’of care. These clinicians asserted that the more detailedand nuanced nature of face-to-face, pre- and post-testcounseling offers the highest standard of STBBI-relatedcare and provides the added value of opening up discus-sions about other health issues, including referrals toother relevant services. Nonetheless, even though GCOwas often not considered comparable to face-to-facetesting, some regarded it as having the potential to em-power users. As one GCO planner said:[GCO] is a very self-directed approach, right? ... And Ithink there’s a sensibility out there, especially withyoung folks and what the internet can empower youto do. And you see this in the medical field. Peoplethink that they’re doctors because they, you know,googled something.... And so there’s that sometimesfalse belief that they know more than the doctor. ButI think the good part of that, with [GCO], is that itputs their healthcare in their control and the feelingthat comes with that is very powerful. You know, ‘Ineed to manage myself and I need to be in control ofmy own health. This is a tool that allows me to dothat.’ I think that’s the crux of it. … It representsempowerment, I think, for health. (‘Rufus’, OSHSdeveloper)This perception that GCO has the potential to empower cli-ents to take more proactive care of their sexual health givesthe intervention significant symbolic value, which could beemployed by its champions during its planned expansion toincrease acceptance by HCP and uptake by users.DiscussionGCO is an intervention embedded in the social andstructural processes of the public health system [36], andChabot et al. BMC Health Services Research  (2018) 18:57 Page 7 of 11it is shaped by a varied range of attitudes and policies re-garding healthcare provision standards. While many par-ticipants perceived this intervention would increaseclients’ agency, it was also viewed with caution, particu-larly by a few HCP who were concerned by the prospectof a patient-centred (but not provider-controlled) inter-vention. These participants described GCO as a way fornew clients to be introduced to STBBI testing and sug-gested that many users may ultimately seek out face-to-face testing, which they regarded as the gold standard ofcare. In contrast, GCO developers, policymakers, andadministrators were more inclined to describe this inter-vention as a complement to existing in-person testing.This latter group emphasized GCO’s potential to in-crease patients’ agency and to empower BC’s STBBI test-ing system to expand its capacity.The various agents in the public health system whoparticipated in this study perceived that the implementa-tion context into which GCO is being introduced is notstatic and they recognized that this intervention is a newway of ‘doing business’. This breakaway from the statusquo created some uncertainty and can be regarded asembodying a set of potentialities which conflict with thestandard conventions of provider-controlled STBBI test-ing and may eventually require adaptation by variousagents in the system (e.g. shifting power dynamics at theservice provision level; possible redistribution of testingresources). Other features of GCO were strongly alignedwith a collective vision of ‘progress’, including publichealth policy’s shift to patient-centred care, increased pa-tient access to services, and, ultimately, improved healthoutcomes. Some study participants noted that the STBBItesting system – as well as the broader health care sys-tem – is capable of adapting to these possible changes.Many study participants noted that GCO may also needto adapt as it expands to other regions of the provinceand seeks to meet the needs of local jurisdictions (e.g.,adaptations to treatment provision). Hence, the symbolicvalue of the potential and promise of GCO could emergeas a powerful influence on its acceptance and eventualuptake by both healthcare providers and users acrossvarious contexts, regardless of the (real) multiple andmultiplied effects, which could vary from place to place.Study participants agreed that the status quo forSTBBI testing and treatment in BC is not ideal. STI inci-dence rates are rising and people often do not receivetesting and treatment in a timely manner. Participantswanted GCO to succeed, even if they were uncertain ofthe extent to which it might trigger adaptations to test-ing and treatment provision. The potential changesGCO might generate “creates a world on which realitiestravel in spite of unknown feasibility” ([37], p. S34), eli-citing a range of reactions from participants. GCO’s de-velopers are well aware that some might be fearful of thechanges this new intervention brings (e.g., some HCPprefer provider-controlled STBBI service provision),while others might expect more than can be delivered,particularly early in the program. From the outset, GCOhas been promoted as ‘another tool in the toolbox’,which also served as a way to manage expectations whileconcomitantly demonstrating GCO’s potential feasibilityand success within the larger sexual healthcare system.For example, GCO initially lacked the capacity to pro-vide throat and rectal swab tests for gonorrhea and chla-mydia – a feature HCP regarded as critical for MSMclients. It was feasible for GCO to incorporate throatand rectal swab tests based on this feedback from clini-cians – and these tests were added to the overall ‘tool-box’ available in either online or clinic settings [27].GCO is the first comprehensive internet-based servicein Canada to offer testing for STBBIs, and one of a lim-ited number in the world. To date, most research relatedto internet-based testing services has been focused ondemonstrating acceptability, uptake, and testing out-comes among populations targeted during the immedi-ate pre- and post-implementation period, withoutbroader consideration of impacts on providers andhealth systems [38–42]. Qualitative research to under-stand how these services are perceived and their poten-tial to overcome testing barriers has largely beenhypothetical (i.e., before a program is in development)and focused on potential end-users or clients of the ser-vice. To our knowledge, only one other published studyhas considered the views of healthcare workers regard-ing internet-based testing [43]. In this UK study examin-ing internet-based chlamydia screening for heterosexualmen in general, interviews with physicians and publichealth nurses demonstrated broad support for a plannednationwide program. Similar to our study, HCPs in theUK-based study regarded the planned screening programas having the potential to appeal to young men becauseit would be convenient, easy to access, and more privateand anonymous than clinic-based testing [43]. In ourstudy, we asked key stakeholders to go beyond describ-ing GCO’s potential to appeal; we also engaged withthem in discussions about possible adaptations of GCOpost-implementation, including the development ofstrategies to adapt GCO within the existing STBBI sys-tem (e.g., with minimal disruption or added burden toclinic staff work loads) as well as the identification ofkey adaptations to GCO (e.g., introducing swab tests toGCO) that synergize with the existing system. Partici-pants also identified how the larger system itself couldreact (e.g., increases in costs and wait times as testingextends to more people). They also identified whatwould be considered a ‘game-changer’ to the system.GCO not only empowers consumers; providers haverelinquished their previous level of control. This changeChabot et al. BMC Health Services Research  (2018) 18:57 Page 8 of 11to the drivers of the system requires a new “perspective”(in ‘Marilyn’s’ words). It’s a change to the system’s para-digm and mindset, and hence it is widely considered tobe transformative [44].Recommendations for future researchConventional health intervention research has focusedprimarily on examining the effects of an intervention,often overlooking the context in which interventionsoccur [36, 45, 46]. This is particularly true for internet-based health interventions, where research has focusedprimarily on acceptance of technology and proof-of-concept or feasibility studies, with few evaluations takinginto consideration the agentic practices of various agents(e.g., client empowerment; HCP-controlled serviceprovision) within implementation contexts [10, 47–50].We demonstrate that HCP, policymakers, and commu-nity stakeholders’ attitudes and expectations about GCOprior to its implementation can provide valuable insightsinto how it should be implemented, influencing the po-tentiality and promise of this service. We recommendthat evaluators of internet-based health interventions de-liberately seek to understand contextual factors influen-cing implementation, as one component of an overallprogram of research to assess the effectiveness of theseinterventions. We have adopted this approach for GCO,where research and evaluation has been embedded at allphases of development and implementation [27].Since the pre-implementation interviews were con-ducted, the roll-out of GCO has progressed in a deliber-ate and controlled manner, with OSHS developersmaking changes to the intervention when challengeshave arisen or from research findings [27, 32]. GCO isnow in the implementation and scale-up phase, follow-ing demonstration of proof-of-concept and feasibility,leading to adoption by two other health regions in BC in2016. This points to the need for longer-term research,monitoring, and follow-up of GCO program aims (e.g.,rates of testing), as well as key features of the implemen-tation context (e.g., geographic considerations; jurisdic-tion issues; cost-effectiveness in reaching new groups,total cost of the innovation, and funding implications forthe system; community-based sexual health serviceprovision) and local user experiences in order to informsubsequent adaptations. Future research examining whatactivities GCO may displace in the public health practicesystem and any subsequent effects would also be benefi-cial [51], as it could help inform improvement of GCOand its expansion into other settings. Our results also il-lustrate the importance of considering clients’ agencywhen developing this intervention and have informedour current study examining the experiences of GCOusers. Early results of this latter research have beenpublished [32], and further research will be published inthe near future.Strengths and limitationsFindings from this qualitative study provide insights intosome of the anticipated benefits and challenges of imple-menting a publicly funded internet-based STBBI testingservice in BC. In addition to university-based re-searchers, our research team included physician and op-erations leads involved with GCO at the BCCDC whowere known to many of the individuals interviewed inthis study. Only the university-based team membersconducted data collection and analysis and had access tothe full transcripts. To minimize social desirability biasduring the informed consent process, participantsemployed at the BCCDC were assured that their deci-sion of whether or not to participate in the study wouldin no way affect their employment, and that BCCDC re-search team members would not be informed of theirreal identities. In addition, BCCDC-based members ofthe research team engaged HCP, policy makers, andcommunity stakeholders in all stages of the developmentof GCO (including inviting them to participate in thisstudy). Ensuring the ongoing involvement of stake-holders was integral to the design and early implementa-tion of this intervention and contributed to thefeasibility and efficacy of GCO.Our study also has some limitations. Interviews werecompleted with HCP, administrators, and communitystakeholders primarily in Vancouver, and they were con-ducted prior to the implementation of GCO. Interviewswere conducted with HCP who were familiar with, or in-volved in, the development of GCO model; therefore,our study may not reflect the perceptions of providerswho were unfamiliar with this service [52] and may bebiased toward a positive view of the intervention’s antici-pated benefits. Our research team initially planned toconduct follow-up interviews with key agents post-implementation. However, lengthy delays in the develop-ment and implementation of GCO (e.g., restructuring ofthe provincially-funded technical support service thatprovides service to the BCCDC) beyond the fundingperiod for this study made follow-up interviews unfeas-ible. Given that our study examined how the develop-ment of GCO was regarded by key agents involved insexual health service provision in Vancouver, BritishColumbia, the relevance of our study findings to otherinternet-based testing programs or health interventionsmay be limited.ConclusionThe majority of participants emphasized the anticipatedbenefits of GCO over its potential challenges and risks.Key stakeholders believed GCO has the potential toChabot et al. BMC Health Services Research  (2018) 18:57 Page 9 of 11reduce waiting times, to enhance privacy and confidenti-ality for clients hesitant to access in-person testing, toappeal to tech-savvy population subgroups, and tooptimize and/or redistribute finite resources to providetesting to more people, more often. Overwhelmingly,study participants perceived that the introduction ofGCO might trigger adaptations within its implementa-tion contexts, such as the redistribution of testing re-sources and changing power dynamics at the serviceprovision interface. Study participants also noted thatimplementation contexts are not in a static state;changes within other parts of the STBBI testing system,or indeed the broader health care system (e.g., re-allocation or reduction of resources), may trigger theneed for adaptation within GCO. This dialectical view ofadaptation used by GCO’s developers as they continueto engage various agents is key to realizing the potentialand promise of GCO across BC and to determining rele-vance for other jurisdictions.AbbreviationsBC: British Columbia; BCCDC: British Columbia Centre for Disease Control;GCO: GetCheckedOnline; HCP: Healthcare provider; HIV: Humanimmunodeficiency virus; MSM: Men who have sex with men; OSHS: Onlinesexual health services; STBBI: Sexually transmitted and other blood-borne in-fections; STI: Sexually transmitted infection(s)AcknowledgementsThe authors thank all of the interviewees who participated in this study. Weacknowledge the contributions of Anna Carson, Lola Falasinnu, Wendy Davis,and Rod Knight with data collection. Anna Carson and Jonathan Contreras-Whitney assisted with coding of the data and preparation of the draftmanuscript. An early draft of this paper was presented at the 2014 BritishSociological Association Annual Meeting; the authors thank audience membersfor their insightful feedback.FundingThe research activities described in this manuscript were funded by theCanadian Institutes of Health Research (MOP-111222).Availability of data and materialsWe are unable to make our qualitative dataset fully or partially publicallyavailable due to confidentiality issues and as outlined within our Universityof British Columbia Behavioral Research Ethics Board approval (certificate #H11–00547). The interview transcripts and fieldnotes used for our analysisinclude sensitive topics with professionals working in the field of publichealth and may include potentially identifiable information about studyparticipants. These data cannot be aggregated and de-identified in ways thatfully ensure the anonymity of our participants. All relevant data are presentedwithin this paper and are fully sufficient to replicate the study findings.Authors’ contributionsJS and MG conceived and designed the study, with PH, GO, VB, and CCcontributing to the study design. CC conducted the majority of datacollection and coding. CC, MG, DH, GO, PH, VB, and JS all contributed to thedevelopment and revisions of the codebook. JS and MG supervised datacollection, analysis, and writing up. CC, MG, DH, GO, PH, VB, and JS allcontributed to the drafting and revising of this manuscript, and approvedthe final version to be published.Ethics approval and consent to participateThis study was approved by the University of British Columbia’s BehaviouralResearch Ethics Board (certificate # H11–00547). All participants providedwritten informed consent prior to being interviewed or included inparticipant observations, and were asked to select a pseudonym. Interviewswere conducted either in person or by telephone. Participants were askedto complete a five-item socio-demographic questionnaire prior to thesemi-structured interview. Interviews were audio-recorded and transcribedverbatim and participants were given the opportunity to review theirtranscripts for any errors or revisions.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1School of Population and Public Health, University of British Columbia, 2206East Mall, Vancouver, BC V6T 1Z3, Canada. 2Clinical Prevention Services,British Columbia Centre for Disease Control, 655 West 12th Avenue,Vancouver, BC V5Z 4R4, Canada. 3Menzies Centre for Health Policy and TheAustralian Prevention Partnership Centre, Charles Perkins Centre (D17), TheUniversity of Sydney, Sydney, NSW 2006, Australia. 4O’Brien Institute forPublic Health, Cumming School of Medicine, University of Calgary, 3280Hospital Drive NW, Calgary, AB T2N 4Z6, Canada. 5School of Nursing,University of British Columbia, 111-2176 Health Sciences, Vancouver, BC V6T1Z3, Canada.Received: 23 September 2016 Accepted: 22 January 2018References1. 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