Opening the digital doorway to sexual healthcare: Recommendations from a Behaviour Change Wheel analysis of barriers and facilitators to seeking online sexual health information and support among underserved populations

Opening the digital doorway to sexual healthcare: Recommendations from a Behaviour Change Wheel analysis of barriers and facilitators to seeking online sexual health information and support among underserved populations | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Opening the digital doorway to sexual healthcare: Recommendations from a Behaviour Change Wheel analysis of barriers and facilitators to seeking online sexual health information and support among underserved populations View ORCID Profile Julie McLeod , View ORCID Profile Claudia S. Estcourt , View ORCID Profile Jennifer MacDonald , View ORCID Profile Jo Gibbs , View ORCID Profile Melvina Woode Owusu , View ORCID Profile Fiona Mapp , View ORCID Profile Nuria Gallego Marquez , View ORCID Profile Amelia McInnes-Dean , View ORCID Profile John Saunders , View ORCID Profile Ann Blandford , View ORCID Profile Paul Flowers doi: https://doi.org/10.1101/2024.07.11.24310216 Julie McLeod 1 School of Health and Life Sciences, Glasgow Caledonian University , Glasgow, Scotland, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Julie McLeod For correspondence: julie.mcleod{at}gcu.ac.uk Claudia S. Estcourt 1 School of Health and Life Sciences, Glasgow Caledonian University , Glasgow, Scotland, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Claudia S. Estcourt Jennifer MacDonald 1 School of Health and Life Sciences, Glasgow Caledonian University , Glasgow, Scotland, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jennifer MacDonald Jo Gibbs 2 Institute for Global Health, University College London , London, England, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jo Gibbs Melvina Woode Owusu 2 Institute for Global Health, University College London , London, England, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Melvina Woode Owusu Fiona Mapp 2 Institute for Global Health, University College London , London, England, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Fiona Mapp Nuria Gallego Marquez 2 Institute for Global Health, University College London , London, England, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Nuria Gallego Marquez Amelia McInnes-Dean 2 Institute for Global Health, University College London , London, England, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Amelia McInnes-Dean John Saunders 2 Institute for Global Health, University College London , London, England, UK 3 UK Health Security Agency (UKHSA) , London, England, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for John Saunders Ann Blandford 4 UCL Interaction Centre (UCLIC), University College London , London, England, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Ann Blandford Paul Flowers 5 Psychological Science and Health, University of Strathclyde , Glasgow, Scotland, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Paul Flowers Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Background The ability to access and navigate online sexual health information and support is increasingly needed in order to engage with wider sexual healthcare. However, people from underserved populations may struggle to pass though this “digital doorway”. Therefore, using a behavioural science approach, we first aimed to identify barriers and facilitators to: i) seeking online sexual health information and ii) seeking online sexual health support. Subsequently, we aimed to generate theory-informed recommendations to improve these access points. Methods The PROGRESS framework guided purposive recruitment (October 2021–April 2022) of 35 UK participants from diverse backgrounds, including 51% from the most deprived areas and 26% from minoritised ethnic groups. Semi-structured interviews and thematic analysis identified barriers and facilitators to seeking online sexual health information and support. A Behaviour Change Wheel (BCW) analysis then identified recommendations to better meet the needs of underserved populations. Results We found diverse barriers and facilitators. Barriers included low awareness of and familiarity with online information and support; perceptions that online information and support were unlikely to meet the needs of underserved populations; overwhelming volume of information sources; lack of personal relevancy; chatbots/automated responses; and response wait times. Facilitators included clarity about credibility and quality; inclusive content; and in-person assistance. Recommendations included: Education and Persuasion e.g., online and offline promotion and endorsement by healthcare professionals and peers; Training and Modelling e.g., accessible training to enhance searching skills and credibility appraisal; and Environmental Restructuring and Enablement e.g., modifications to ensure online information and support are simple and easy to use, including video/audio options for content. Conclusions Given that access to many sexual health services is now digital, our analyses produced recommendations pivotal to increasing access to wider sexual healthcare among underserved populations. Implementing these recommendations could reduce inequalities associated with accessing and using online sexual health service. Introduction Over the past decade, the online delivery of sexual healthcare has increased, accelerated by the COVID-19 pandemic ( 1 – 4 ). Such healthcare includes online postal self-sampling (OPSS) for sexually transmitted infection (STI) and blood borne virus (BBV) testing (e.g., 5–8). More complex online clinical care pathways are also in development, such as the eSexual Health Clinic for accessing STI test results and treatment ( 9 ) and ePrEP for accessing HIV prevention medication, pre-exposure prophylaxis (PrEP) ( 10 ). For many people, the initial steps to accessing sexual healthcare, both online and traditional (i.e., in-person/phone), are seeking sexual health information and support online ( 11 – 13 ). Our definition of seeking online sexual health information is inclusive, referring to searching for, finding, understanding, and applying information from the internet (e.g., 14–16) typically found through search engines. Equally, regarding seeking online sexual health support, we refer to finding and using text-based interactions for answers to a range of sexual health queries. These include tools such as live chats and chatbots (synchronous communication with a trained professional (live chats) or with automatic responses (chatbots)) and email or short-messaging service (SMS) text exchange (asynchronous communication with a trained professional (e.g., 17–22). See Appendix A for a list of examples. Together, these two steps (seeking online sexual health information and support) form a digital doorway to wider sexual healthcare ( 23 – 27 ). Online sexual healthcare can overcome common barriers to accessing traditional sexual health services, offering privacy and convenience (e.g., 12,28,29). However, many may struggle to access and use online sexual healthcare due to inequalities patterned by socio-economic demographics, such as gender, sexual identity, ethnicity, and socio-economic status ( 3 , 30 – 40 ) (i.e., underserved populations ( 44 )). Further, for people to engage with and pass through the digital doorway to wider sexual healthcare, they require sufficient digital literacy (skills to perform tasks and solve problems in digital environments ( 41 )) and health literacy (capability to understand, evaluate, and use information and services to make choices about health ( 42 )). This complex intersection of socio-economic factors precluding access to healthcare for those who often bear a disproportionate burden of STIs (e.g., 43) illustrates how the provision of online sexual healthcare has the potential to widen inequalities amongst underserved populations. To prevent widening inequalities in access to online sexual healthcare, it is vital to understand the barriers and facilitators to the digital doorway among underserved populations, theorise the factors that underpin barriers and facilitators, and then identify appropriate theoretically informed recommendations for change ( 45 ). While some research exists in this area, the existing literature base is outdated ( 46 – 52 ) or uses exclusively quantitative methods ( 53 – 59 ). Thus, there is an absence of contemporary, in-depth research. Moreover, to our knowledge, there are no studies identifying evidence-based and theoretically informed recommendations for seeking online sexual health information and support among underserved populations. Therefore, using a behavioural science approach, we first aimed to identify barriers and facilitators to two key elements of the digital doorway: i) seeking online sexual health information and ii) seeking online sexual health support. Subsequently, we aimed to propose theory-informed recommendations to improve these two access points. We developed three research questions (RQs): RQ1) What are the barriers and facilitators to seeking online sexual health information among underserved populations? RQ2) What are the barriers and facilitators to seeking online sexual health support among underserved populations? RQ3) What evidence-based and theoretically informed recommendations can be made to enhance seeking online sexual health information and support among underserved populations? Methods Design A behaviourally focused cross-sectional qualitative approach, conducted as part of the SEQUENCE Digital Programme ( https://www.sequencedigital.org.uk/ ). Applying a behavioural lens High quality applied behavioural science requires a considered understanding of the specific behaviour(s) that are intended to be changed by an intervention ( 60 ). Within the broad behavioural system of ‘accessing and using online sexual healthcare’ we identified seven distinct yet interconnected behavioural domains (see Appendix B). Here, we focus on the first of these two domains that we consider to constitute the digital doorway: 1) seeking online sexual health information and 2) seeking online sexual health support. Participants Using a PROGRESS (Place of Residence, Race/Ethnicity, Occupation, Gender/Sex, Religion, Education, Socio-economic Status, Social Network) ( 61 , 62 ) informed purposive sampling framework (Appendix C), we recruited participants from underserved populations. See Table 1 for participant characteristics and demographics. Representatives from five regional National Health Service (NHS) Trusts/Boards (i.e., organisational areas), two non-governmental organisations (NGOs), and one community college across England and Scotland referred interested potential participants to the research team. One NGO served people with disabilities and learning difficulties, the other, people who identify as LGBTQI+ and Muslim. The community college served people with low educational attainment living in a deprived area. We then telephoned each referred participant to verify eligibility according to our inclusion criteria, screen them against the target sampling frame, collect demographics and information on internet use (see Appendix D), and schedule an interview (phone, video, or face-to-face). Inclusion criteria were: 1) never ordered/used or struggled to order/use an STI self-sampling kit (to recruit participants of lower digital literacy); 2) aged 16+; 3) sexually active; 4) had phone and internet access to enable data collection; 5) lived in the UK; and 6) spoke English well enough to participate in an interview. View this table: View inline View popup Table 1. Participant self-reported socio-economic demographic characteristics. Materials We composed a questionnaire-based assessment of eligibility to take part in the study, demographics (based on the PROGRESS framework ( 61 , 62 )), and experience and skills using technology and the internet (Appendix D). In line with inclusive guidance ( 63 , 64 ), the questions asked regarding socio-economic demographics, such as gender identity and ethnicity, were open questions to capture how participants self-identified. We also developed an interview topic guide (Appendix E) and supporting visual aids (Appendix F). The topic guide was used to explore participants’ barriers (e.g., what makes it difficult, what are the drawbacks) and facilitators (e.g., what makes it easy, what are the benefits) to both seeking online sexual health information and support. Critically, barriers and facilitators could be either experiential (i.e., actually experienced) or hypothetical. The visual aids depicted the two behavioural domains of seeking online sexual health information and support. Respectively, these visual aids showed search engines with the typed words “sexually transmitted infection (STI) symptoms” for ‘seeking online sexual health information’ and examples of a sexual health live chat and SMS text exchange with a healthcare provider (HCP) for ‘seeking online sexual health support’. Participant and patient involvement and engagement For material development, we consulted public and patient involvement and engagement (PPIE) representatives (N=12) of diverse ages, genders, ethnicities, sexual orientations, religions, and experiences of disability, learning difficulties, and digital STI healthcare. The representatives offered intersectional perspectives and advice on our questionnaire-based assessment of participant demographics and internet use (n=5) and the interview topic guide and visual aids (n=7) to be used within data collection. Consent to share PPIE representatives’ demographic information was not obtained. Procedure One-to-one semi-structured interviews (duration range: 38-82 minutes, M =60 minutes) were conducted remotely (video call n=7, phone n=23) or face-to-face (n=5) (all by JMcL). Prior to the interview, we provided participants with an information sheet, consent form, and the visual aids by email or WhatsApp for remote interviews and hard copy for face-to-face interviews. At the beginning of the interview, we obtained verbal consent, recorded via an encrypted recorder for remote interviews and written consent for face-to-face interviews. At the end of the interview, all participants were offered a shopping voucher (value £30) and were provided with a list of sexual health resources (Appendix G) either by email, WhatsApp or hard copy. Analysis For RQs one and two, using NVivo (version 12), we conducted inductive thematic analysis ( 65 ) to identify barrier and facilitator themes for each of the behaviours (conducted by JMcL and checked by PF). To do this, we described data using a brief summary barrier or facilitator statement (e.g., “ I suppose, when my son was younger, I worried that he might see…. […] search history and stuff like that, might have put me off ” was described as ‘Concern about family seeing search history’). We then grouped similar summary statements for each behaviour to identify themes (e.g., ‘Concern about family seeing search history’, ‘Having a shared device – lack of privacy’ and ‘Concern about people you know, particularly partners, finding out you may have an STI’ were grouped together and labelled as the theme, ‘Concerns about privacy’). For RQ three, using the BCW approach ( 45 ), barrier and facilitator themes were mapped onto appropriate components of the COM-B Model ( 66 ) (by JMcL and checked by PF). The COM-B model posits that behaviour is determined by ‘ Capability ’ (physical and psychological attributes of a person), ‘ Opportunity’ (physical and social attributes of a person’s environment), and/or ‘ Motivation’ (a person’s reflective and automatic mental processes). The COM-B components were then matched to relevant Intervention Functions (nine broad categories of potential interventions to change the capability, opportunity and/or motivation to engage in a behaviour) ( 45 , 67 ) (by PF, audited by JMcL and JMacD). Subsequently, we drew on our collective expertise to operationalise the Intervention Functions into recommendations (conducted by PF and JM, audited by JMacD). The recommendations were reviewed by an interdisciplinary team including sexual health clinicians, public health researchers, and human computer interaction specialists. All BCW analyses were conducted by health psychology researchers who have completed the behaviour change technique taxonomy (version 1) training ( https://www.bct-taxonomy.com/ ). Throughout all stages of analysis, discrepancies were resolved through discussion between JMcL, PF and, latterly, JMacD. Ethics Ethical approval for this study was granted by the East of England - Cambridge South Research Ethics Committee (REC) (reference 21/EE/0148) and Glasgow Caledonian University REC (reference HLS/NCH/20/045). Results Participants Participants (N=35) (see Table 1 ) ranged in age from 18-70 ( M =34 years) and were diverse, representing several underserved populations: 51% (n=18) lived in the most deprived areas of the UK; 51% (n=18) had no higher (i.e., university) education; 40% (n=14) were of a minoritised ethnic group, of which, five were from an ethnic group other than White; 23% (n=8) did not speak English as their first language; 49% (n=17) had a mental or physical illness or condition lasting 12 months or more; and 29% (n=10) had a learning difficulty. The majority of participants reported owning a digital device (e.g., mobile phone or laptop) to access the internet (n=30, 86%) and using the internet every day (n=29, 83%) for a wide range of activities, most frequently, social media (n=22, 63%), work including research (n=17, 48%), streaming TV shows or videos (n=10, 29%), searching the internet for information (n=9, 26%), and checking news (n=5, 14%) and emails (n=5, 14%). Over half of the participants described themselves as having ‘high’ level skills using the internet (i.e., digital literacy) (n=20, 57%), 12 reported ‘medium’ (34%) and 2 reported ‘low’ (6%). Over a third (n=12, 34.3%) had never searched for any sexual health information online, none had ever used a live chat or email or text exchange service for getting sexual health support, and few had used other online sexual health services such as booking an appointment (n=4, 11.4%) or ordering medication through a private (non-state-funded) clinic (n=1, 2.9%). Moreover, the majority had never ordered a postal STI self-sampling kit (n=24, 68.6%) and a few reported having tried and struggled to order (n=3, 9%), or use (n=7, 20%), a self-sampling kit for STIs and blood borne viruses. See Appendix H for an overview of participant data regarding experience and self-rated skills of using the internet. RQ1) What are the barriers and facilitators to seeking sexual health information online among underserved populations? Table 2 details the nine barrier and eleven facilitator themes to seeking online sexual health information, with indicative data extracts, and their corresponding COM-B components. View this table: View inline View popup Table 2. Barrier and facilitator themes and related COM-B components for seeking online sexual health information among underserved populations. Barrier themes relating to ‘Capability’ were ‘ Lack of awareness’; ‘Lack of familiarity’; ‘Lack of knowledge of where to search’; and ‘ Communication and understanding difficulties’. This cluster of barriers related to a lack of important knowledge about the existence of sexual health information and how to access and understand it. The barrier theme relating to ‘Opportunity’ focussed on features of the digital environment: ‘ Volume of information sources’ and ‘Lack of inclusivity and personal relevance’. This barrier provides a sense of how some people find seeking online sexual health information overwhelming whilst navigating search engine results and finding relevant information. Barrier themes relating to ‘Motivation’ were negative perceptions of online sexual health information: ‘ Concerns about privacy’; ‘Concerns about credibility’; ‘Concerns about adequacy/inferiority (compared to in-person/phone)’. This cluster related to concerns about the internet as a source of sexual health information. Facilitator themes related to ‘Capability’ centred around knowledge: ‘ Knowledge of how and for what to search’ and ‘ Ability to determine credibility’. Facilitator themes related to ‘Opportunity’ focussed on features of the digital environment, promotion, and help: ‘ Credible information being easy to find’; ‘Video and audio options (alternative to text)’; ‘Simplicity of information and layout’; ‘Inclusivity and personal relevancy’; ‘Advertisements to raise awareness’; and ‘In-person assistance’. Further, in- person assistance speaks to the need for help to seek online sexual health information, for example from a key worker or family member, among those of lower digital literacy or with learning difficulties. Facilitator themes relating to ‘Motivation’ were positive perceptions on online sexual health information: ‘ Belief that information is credible’; ‘Beliefs about equal/increased privacy (compared to in-person/phone)’; and ‘ Belief that online information is a good starting point’ . RQ2) What are the barriers and facilitators to seeking online sexual health support among underserved populations ? Table 3 details eight barrier and eight facilitator themes to seeking online sexual health support (via a synchronous live chat or asynchronous email or SMS text exchange), with illustrative extracts, and corresponding COM-B components. View this table: View inline View popup Table 3. Barrier and facilitator themes and corresponding COM-B components for seeking online sexual health support among underserved populations. Barrier themes relating to ‘Capability’ were : ‘Lack of awareness’ and ‘ Lack of familiarity’ with online text-based support. These themes revealed a lack of awareness of the existence of online sexual health support services and experience using digital technology and the internet for sexual health support. Barrier themes relating to ‘Motivation’ were negative perceptions about digital sexual health support: ‘ Concerns about confidentiality and anonymity’; ‘Concerns about the impersonal nature of online support’; ‘Concerns about understanding and communication’; ‘Concerns about online support meeting their needs’; ‘Concerns about chatbots and automated responses’; and ‘Concerns about response wait times’. This cluster of themes highlighted the span of participants’ concerns about seeking online support. Participants consistently reported that they would not use online support for sexual health that had any wait times (i.e., was not instantaneous) to receive a response, or if they would be speaking to a ‘chatbot’ with pre-set or automated responses instead of a person, particularly a trained professional. No barriers corresponded to Opportunity . One facilitator theme related to ‘Capability’ was identified regarding knowledge: ‘ Familiarity with online text-based support services’. Facilitator themes corresponding to ‘Opportunity’ related to advertisements, help, and features of the digital environment: ‘ Immediate responses’; ‘Clear quality and trustworthiness’; ‘Personal feel’; ‘Advertisements to increase awareness’; and’ In-person assistance’. Immediacy of the response was a feature that people felt they needed to engage with online support. Advertisements were also important in relation to ways in which awareness and skills with online support could be enhanced. Further, ‘ in-person assistance’ illustrates the needs of participants of lower digital literacy and/or those with a learning difficulty for help engaging and accessing online support. Facilitator themes relating to ‘Motivation’ were positive perceptions on online sexual health support: ‘ Beliefs about equal/increased privacy (compared to in-person/phone)’ and ‘Beliefs about online support meeting their needs’ . RQ3) What evidence-based and theoretically informed recommendations can be made to enhance seeking online sexual health information and support among underserved populations? The BCW analysis identified potentially useful Intervention Functions to assist underserved populations in seeking online sexual health information and support: Education, Persuasion, Training, Modelling, Enablement, and Environmental Restructuring (see Appendix I for definitions). From these Intervention Functions, we proposed a range of more specific recommendations outlined below. Table 4 and Table 5 provide an overview of the BCW analysis of barriers and facilitators and proposed recommendations for online sexual health information and support, respectively. View this table: View inline View popup Table 4. Intervention content from Behaviour Change Wheel to address barriers and facilitators to seeking sexual health information online. View this table: View inline View popup Table 5. Intervention content from Behaviour Change Wheel to address barriers and facilitators to seeking online sexual health support. Education and Persuasion It may be critical to educate people from underserved populations that online sexual health information and support services exist, for example, through advertising online (e.g., via social media) and offline (e.g., via HCPs and NGOs), and persuade them to use these via endorsement by a range of credible professionals and peers. This education could be delivered via face-to-face interactions with service staff (e.g., HCPs and key workers), posters or leaflets, or posts on professional social media accounts (e.g., from HCPs or influencers) detailing where to search (i.e., search engines/NHS website), what to search for (i.e., key terms), and how to identify credible sources (i.e., key logos). It may also be important to inform people about the benefits and limits of online sexual health information and support and when in-person care should be sought i.e., that online information and support are appropriate for simple issues, such as symptom checking, finding clinics, booking appointments, and signposting, and not appropriate for complex healthcare, such as diagnosis. Further, education regarding the privacy and confidentiality of online sexual health information and support may be important, as well as promoting them as simple and easy to use, personal, synchronous with immediate responses, and not reliant on automated responses). It is critical that Education and Persuasion are delivered alongside Environmental Restructuring and Enablement to ensure online sexual health information and support are private/confidential and simple to use. Training and Modelling Training opportunities for necessary skill acquisition could be part of all services that offer online information and support. Specifically, this could involve step-by-step instructions on using search engines, identifying and typing key terms, determining source credibility, and understanding and applying information. Training could be delivered in the form of videos, posters or leaflets, or professional or peer-led tutorials. To ensure accessibility in relation to digital provision, audiovisual training options should be offered alongside text-based and training should be provided both in-person as well as online. It might also be critical to provide modelling of peers successfully using online sexual health information and support, such as showing videos or images of peers from underserved populations searching for sexual health information such as STI symptoms or using a sexual health live chat to discuss safe sex. Further, online sexual health information and support service providers could explore partnerships with NGOs for delivery of training. Environmental restructuring and Enablement Restructuring the online environment and enabling people from underserved populations to seek online sexual health information and support is essential. Particularly, it may be vital to ensure that online sexual health information and support services are clearly labelled as delivered by credible, trusted sources (i.e., NHS, registered charities) and are designed to be simple to use, avoiding medical jargon and explaining terms when they must be used. Further, enablement could involve providing a glossary of sexual health terms for examples of correct spelling and video and/or audio options for information. Online sexual information and support content could also be demonstrably tailored to a range of communities (e.g., gender, sexuality, and religious minorities, and people who use recreational drugs). Further, in-person assistance could enable people of lower digital literacy and with learning difficulties to access and use sexual health information and support. Finally, online sexual health information and support service providers could ensure that any text-based interactions are synchronous (in real-time) and delivered by a trained professional, stating the name and training/qualifications of the professional involved. Discussion This study is the first to detail barriers and facilitators to seeking online sexual health information and support amongst underserved populations and propose specific recommendations to enable underserved populations to find and use online sexual health information and support. These findings can be applied existing and novel online sexual health information and support services to improve access to this digital doorway to wider sexual health services. Barriers and facilitators to passing through the digital doorway Key barriers to people from underserved populations seeking online sexual health information and support were a lack of awareness of their availability and familiarity with using them; privacy concerns; and the perception of as inadequate to meet varied and complex sexual health needs and inferior to traditional information and support services (e.g., in-person appointment or phone call with a HCP). For seeking online sexual health information, specifically, barriers were navigating the overwhelming volume of information and different sources of and the perceived lack of inclusivity and relevance of information, particularly on government websites. For seeking online sexual health support, specifically, barriers were chatbots and automated responses; asynchronous communication; and wait times for responses. An important consideration here is that none of the participants had ever used an online sexual health support service, despite their availability (e.g., 17–22), thus these barriers were exclusively hypothetical. Important facilitators to seeking online sexual health information and support were the perceived benefit of increased privacy compared to traditional services; the provision of video and/or audio options as alternatives to text; the presentation of information and support in a simple way – such as step by step and without jargon; and in-person assistance, for example, from key workers, family members, NGO staff, or GPs. For seeking online sexual health information, specifically, facilitators were inclusivity and personal relevancy of sexual health information, particularly for people from LGBTQI+ populations, religious backgrounds, and recreational drug users. For seeking online sexual health support, specifically, facilitators were synchronous communication; the perception of online support as acceptable for simple tasks such as appointment booking, general sexual health advice, and signposting to services; and delivery by qualified personnel. Some of these findings are novel to this study. Importantly, low awareness of online sexual health information and support was common, even among participants who reported using the internet ‘all the time’. Additionally, the perceived inferiority and inadequacy of online sexual health information compared to traditional sources of sexual health information and unanimous rejection of chatbots and automated responses for sexual health support, due to the perceived complexity of sexual health, were critical. However, beliefs about the inferiority of online services may change, as generative artificial intelligence becomes more commonplace and trusted ( 80 ). Further, many of our barrier and facilitators findings are consistent with previous literature, offering a novel perspective from a diverse sample of underserved populations. Privacy benefits and concerns ( 38 , 57 , 71 – 74 ) and the value of video and audio options and simplicity (e.g., 29,38,75) have been previously reported amongst a range of populations. Further, the overwhelming volume of sources and information, need for inclusivity and personal relevancy of information, and preferences for online support to be delivered synchronously have been reported previously among sexual minority women ( 76 ) and African American youth ( 75 ), and young people ( 38 , 77 , 78 ). Moreover, concerns about the adequacy of online information and support has been reported previously ( 73 , 74 , 79 ) and the acceptability of online support for simple tasks is in line with research regarding HCPs’ views of chatbots for sexual health ( 73 ). Overall, the consistency of these findings with research with other populations indicates that addressing the barriers and enhancing the facilitators from this current study will improve online sexual health information and support for many beyond this sample. Recommendations for the digital doorway to wider sexual healthcare We identified a range of theory informed Intervention Functions to improve access to the digital doorway to wider sexual healthcare, including Education, Persuasion, Training, Modelling, Environmental Restructuring, and Enablement. First, advertising and promotion of services that provide online sexual health information and support and HCP’s endorsing online services and supporting patients to use them is vital. Together, these findings resonate with wider research on telehealth per se ( 81 ), highlighting the importance of marketing and communication activities to increase awareness of online services to enable equitable access. Additionally, interventions could include online services offering audio-visual forms of communication, such as text-to-speech or cartoon animations. Moreover, our recommendations include the provision of inclusive and personally relevant information and support, such as information about sexual health relevant to those of diverse sexual and/or gender identities, religious backgrounds, and drug use. This is in line with previous research showing that tailoring of information can positively influence acceptability of interventions and address barriers to care ( 82 – 84 ). Further, interventions could include training HCP’s on how to use and promote online sexual health services effectively, in line with previous research regarding reducing digital inequalities ( 81 ). The latter is essential for effective professional endorsement of high-quality online services for sexual health information and support ( 85 ). Such endorsements should stress the services’ credibility, useability, and details of its functionality (e.g., trained professional will interact in real time). Interventions could also include embedding optional training for service users regarding how to use online services. While the BCW analysis identified the above recommendations, it is important to consider that intervention development guidance highlights the centrality of the involvement of relevant stakeholders to co-produce culturally appropriate intervention content ( 86 ), whilst considering affordability, practicability, efficacy, acceptability, side-effects, and equity ( 45 ). Such stakeholder engagement must consider and address the operationalisation of our proposed recommendations to ensure final intervention content aligns with local circumstances and wider legislative socio-cultural contexts. Furthermore, the involvement of stakeholders in shaping future interventions can help secure their effective delivery, given their investment of time and resource. Implications Changes to the ways online sexual health information and support are provided are required to facilitate more people to pass through the digital doorway to wider sexual healthcare. Given that some of these findings are already well documented in the literature, it is concerning that sufficient changes have not yet been made. Our evidence-based and theoretically informed recommendations (i.e., Tables 5 and 6) should assist these changes to take place. As such, our detailed specification of recommendations is a valuable contribution to the field of sexual health with the potential to catalyse change in the delivery of sexual health information and support online. Strengths and limitations First, the PPIE activities with diverse representatives ensured the development of inclusive study materials that were fit for purpose. Second, as the study was conducted in the UK, some of the findings may be specific to the UK health setting. However, most of the findings presented here are likely to be generalisable to the wider population and to other countries and settings. Third, in addition to a rigorous thematic analysis, we conducted a BCW analysis to provide theory informed and evidence-based recommendations for improvements to seeking online sexual health information and support. As the BCW draws on the cumulative learning from multiple theories of behaviour change ( 66 ), it enabled us to specify potentially useful intervention content beyond that suggested by our participants. Furthermore, our sample included people from a range of underserved populations whose needs are typically unmet by existing services and whose perspectives are often overlooked, such as people from minoritised sexual, ethnic, and religious groups, and those living in the most deprived areas. However, despite our best efforts, we were unable to meet our target recruitment for participants who are from minoritised gender and ethnic groups, particularly those of Black African and Black Caribbean ethnicity who experience a disproportionate burden of STIs ( 35 , 43 ) and have been historically underserved. Such populations have been involved in previous research into online sexual health information and support ( 48 , 75 , 87 – 89 ), however, all of these studies were conducted in the United States. Future research should prioritise recruiting people from minoritised gender and ethnic groups in the UK. Conclusion This study identified key barriers and facilitators to seeking online sexual health information and support among a diverse sample of underserved populations. Our BCW analyses then suggested an array of potentially useful changes that could be made to reduce barriers and enhance facilitators to passing through this digital doorway and subsequently increase access to wider in-person and online sexual healthcare. Overall, our recommendations focus on adding to existing services in ways that enable used of them and educate, persuade, and offer accessible training to those from underserved populations. Recommendations include educate about the existence of online services that provide sexual health information and support; persuade people about their credibility; provide training, such as step-by-step instructions on how to seek information online and use online support and appraise the credibility of online information and support services; model peers successfully seeking information and using support services online; and enable use of them by ensuring they are inclusive and simple to use, including provision of providing a glossary of terms to assist with spelling for searches and communication and step-by-step instructions on how to seek information online and use online support. Ultimately, while online sexual health provision has the potential to extend access to healthcare for some, addressing the needs of underserved population outlined here is crucial to facilitate access to through the digital doorway to sexual healthcare and prevent the widening of health inequalities. Data Availability Data produced in the present study are available upon reasonable request to the first author. Author contributions Funding acquisition: CSE, JG, MWO, AB, PF; Conceptualisation: JMcL, PF, JMacD; Project administration: MWO; Supervision: PF, CSE; Methodology: JMacD, PF; Resources: JMcL, JMacD, FM; Investigation: JMcL; Formal analysis: JMcL, PF; Visualisation: JMcL, PF; Writing – original draft: JMcL, PF; Writing – review & editing: JMcL, PF; CSE, JMacD, JG, MWO, FM, NGM, AMD, JS, AB. Acknowledgements We would like to thank the participants who took part in the study. We are also grateful to the following sexual health services and organisations for invaluable assistance with the study. We would like to thank Castle Circus Health Centre (Torbay & South Devon NHS Foundation Trust), Devon Sexual Health – Exeter & Barnstaple (Northern Devon NHS Foundation Trust), Mortimer Market Centre, Archway, Barnet and Buryfields Clinics (Central and North West London NHS Foundation Trust), Sandyford Clinic (Greater Glasgow & Clyde), and Sexual Health Sheffield (Sheffield Hospitals NHS Foundation Trust), for advertising the study to support with recruitment. We would also like to thank Hidayah LGBT and get2gether, for publicising the study to help with recruitment. Appendices Appendix A: A list of examples of online sexual health information and support services View this table: View inline View popup Download powerpoint Appendix B: An overview of seven interrelated elements of care within the behavioural system of accessing and using online sexual healthcare Download figure Open in new tab Note. Numbers and thick arrows represent a pathway for accessing and using online sexual healthcare, typically beginning with seeking online sexual health information and support online, which can lead to a sequential online STI and BBV self-sampling service pathway. Thick yellow arrows indicate a non-sequential order, where the elements of care can occur in any order, e.g., seeking online sexual health information can occur before, simultaneous to, or after seeking online sexual health support. Thin yellow arrows indicate that seeking online sexual health information or support can occur at any point in the STI self-sampling and treatment pathway. Thick blue arrows indicate a sequential order, where a later element of care cannot precede an earlier domain, e.g., getting STI test result online must occur after getting a postal STI/BBV self-sampling kit online. Appendix C: Target sampling frame developed prior to data collection View this table: View inline View popup Download powerpoint Appendix D: Socio-economic demographics and screening survey View this table: View inline View popup Download powerpoint Appendix E: Interview topic guide View this table: View inline View popup Appendix F: Interview slides provided to every participant prior to the interview Download figure Open in new tab Download figure Open in new tab Appendix G: Sexual health resources information provided to each participant post interview Sources of support We want to make sure that you have a list of services that offer different types of support and information in case something came up in the interview that was difficult or uncomfortable for you. Sexual health services and organisations View this table: View inline View popup Download powerpoint Wider health services and organisations View this table: View inline View popup Appendix H: Participant self-reported experience and skills using the internet View this table: View inline View popup Appendix I: Intervention Functions and their definitions, adapted from Michie et al. ( 45 ) View this table: View inline View popup Download powerpoint Footnotes Data availability. Data and analyses can be made available on request to the corresponding author. Funding: This research is part of the SEQUENCE Digital programme funded by the National Institute for Health Research ( https://www.sequencedigital.org.uk/about ) Competing interests: The authors declare that they have no conflicts of interest. References 1. ↵ Tucker JD , Hocking J , Oladele D , Estcourt C . 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