Impact case study database

Kelly and Lohan’s research has led to: the re-organisation of community sexual healthcare provision, the training of nearly 250 healthcare professionals and consequent improved health outcomes for the general population; the implementation in prisons of a new sexual healthcare service, associated health promotion strategy and educational service and consequent improved health outcomes for prisoners; and the generation of global agenda setting by the World Health Organisation on how to best engage males in sexual healthcare.

Community

**Re-organisation of sexual healthcare provision. Kelly and Lohan’s research on seven GP practices demonstrated how a new community-based model of sexual healthcare could be implemented. This led to major financial investment from the NI Health & Social Care Board for the roll out of the model to an additional 42 practices, now covering 49 of 54 GPs in a Trust that serves 20% of the NI population. An essential feature of this widespread roll-out is the upskilling of health professionals to facilitate the effective delivery of this new service. Queen’s University led the training in the evidence-based community/primary sexual healthcare model to key professionals.

“The joint appointment in QUB and SEHSCT of Dr Kelly as Consultant Nurse and lecturer has strengthened the Queen’s team in providing quality training programmes for GPs, practice nurses and prison healthcare in effective sexual health promotion within patient consultations. To date, almost 200 medical and nursing staff from 48 GP practices, along with 30 prison nursing staff have completed training”. ( S1, Director of Nursing SEHSCT)

“I am now more confident in discussing sexual health with patients”. (Nurse, S2)

Improved health outcomes. The roll out of the community model of care to 49 GP practices increased capacity to test and treat from 288 per annum patient consultations for the whole Trust in 2012 (pre-implementation) to 817 per annum consultations in 2018 (post-implementation), as measured by the Health & Social Care Board for NI ( S3). Improving access to testing increases earlier detection of asymptomatic STIs, resulting in earlier treatment and preventing onward transmission and long-term sequelae. The largest impact in the early detection and treatment of STIs in NI is in relation to chlamydia. Initally as sexual healthcare expanded in GP practices, Trust data showed an increased chlamydia detection rate across GP Practices with minimal decrease in the hospital-based detection rate, reflecting a new and additional burden of previously undetected infection within the community (see Figure 1). Since 2017, diagnoses in GP Practices (n= 198) have overtaken the specialist sexual health service (n= 126), now making chlamydia testing a routine part of primary care. Crucially, this increases the capacity of specialist services to see more complex symptomatic patients.

Figure 1 Chlamydia diagnoses in Specialist Hospital Care (SHC)

and Primary Care (PC) 2013-2018 [S3]

Impact on health policy. This new community-based model has proved to be cost-effective with improved medical outcomes, and expansion of the model to cover all of NI is being considered. As stated by the Chief Medical Officer of NI:

“Independent evaluation of this new model of care by the Public Health Agency demonstrated a clinically robust and cost effective service delivery model, leading to my recommendation that this model be considered for extension to the whole of Northern Ireland, as stated in the Addendum to the Progress and Priorities: Addendum to the Sexual Health Promotion Strategy and Action Plan”. ( S4 published Strategy & S5, Testimonial, CMO)

Prisons

Re-organisation of sexual healthcare provision. Kelly and Lohan’s research demonstrated how a contextually appropriate version of their new community-based model could be applied in all prisons throughout NI (serving circa 2000 prisoners). This new prison-based, continuous nurse-led service is now applied in all prisons replacing since 2018 the previous inferior minimal and ad hoc system. As stated by the Chief Medical Officer:

“Prior to Kelly’s conception of this service in a Burdett Trust research grant, prisons had an ad hoc consultant led in reach service for mostly symptomatic patients, with no nurse involvement or health promotion focus”.

( S5, Chief Medical Officer, NI)

Effective health promotion strategy. Both the Director of Public Health NI and Assistant Director of Prisons, NI have acknowledged that Kelly and Lohan’s research has led to an award-winning health promotion strategy co-produced with prisoners and implemented in all prisons in NI (Trust and Chartered Institute of Public Relations Awards, 2018). ( S6 & 7) The two key elements of the health promotion strategy are featured prominently: the Dick loves Doot posters are displayed around the prisons and the video https://goo.gl/iZf4qJ is played in waiting areas of prison sites (and youTube hits exceeded 22,500 in 2020). In addition, their research led to the roll-out since 2019 of ‘ If I were a Dad’, the first relationship and sexuality education programme in the national youth offender institutions of Scotland and NI. ( S7)

**Improved health outcomes. The new model and associated health promotion led to an increased detection rate and earlier treatment of chlamydia and gonorrhoea as well as syphilis, HIV and hepatitis in all prisons ( S2). A case note audit of 171 patients seen in the NI prison service during the first six-month period (1 July to 31 December 2018), demonstrated 90% of Chlamydia (CT) positive patients received treatment within 14 days, 94% received an HIV test and partner notification was documented as completed in 90% of CT positive patients. This meant the NI prison health service was for the first time meeting robust clinical performance indicators set by the British Association of Sexual Health & HIV (BASHH). ( S2)

According to the Assistant Director of Prisons in NI, “everything the Queen’s team has achieved has begun with a better understanding of the prison residents, tapping into their motivations and their own possible solutions to turning around their lives”. The Assistant Director emphasises how, on this “innovative basis”, the Queen’s team “has developed services that actually have serious traction with the young men and have led to improving their health and education”. ( S7) He further emphasises that “the feedback from prisoners themselves speaks volumes of the importance of this work on their lives”. He highlights an example of young men’s feedback on the If I were a Dad programme:

“I really hate this programme. It wraps all my issues up into one ball and shows me them. I hate it but I love it and need to do it”. (Participant, NI Young Offender Institution, included in testimonial of A/Director of Prison Service, S7 )

International Policy Impact

The WHO is co-ordinating a global agenda for future programming on engaging boys and men in sexual and reproductive health to address the sustainable development goals, based on the underpinning ‘Evidence-and-Gap Maps’ and systematic reviews of evidence of Professor Lohan and the QUB-WHO team ( S8 & 9). According to the Director of Sexual and Reproductive Health and Research, including the Human Reproduction Programme, at WHO:

“Drawing from our collaboration with Professor Lohan and her team, WHO and HRP will be able to offer global leadership and guidance on masculinities and sexual and reproductive health and rights (SRHR) through: 1) a published research agenda on addressing masculinities and engaging men and boys in the context of SRHR; and 2) guiding principles for programmers, policy makers and researchers working on this issue. In the context of the 2030 Agenda for Sustainable Development, this work contributes to the attainment of SDG 3 on healthy lives and wellbeing (i.e. target 3.7 on ensuring universal access to SRH care services) and SDG 5 on gender equality (i.e. targets 5.2 on elimination of violence against women, 5.3 on ending harmful practices and 5.7 on universal access to SRH and reproductive rights)”. ( S10, Director of SRH, WHO)