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Griner S, Barnett T, Johnson K, Kinard A, Brosnan A, Neelamegam M. Direct-to-consumer STI screening information: mental health providers as a dissemination channel. HPHR. 2024. 84. https://doi.org/10.54111/0001/DDDD1
On college campuses, rates of sexually transmitted infections (STIs), including chlamydia and gonorrhea, are increasing. However, rates of screening are low among college women. Direct-to-consumer (DTC) screening may be an innovative solution to improve screening rates, but little research exists on how college women prefer to receive information about these novel methods. The purpose was to explore the preferred communication channels for knowledge about DTC STI screening among college women.
Guided by the Diffusion of Innovations (DOI), in-depth interviews were conducted with sexually active college women, ages 18-24 (n=24). Interviews were analyzed thematically by two coders (Kappa=.83). This study presents a salient, emergent theme within the communication channels construct – the role of mental health providers in providing information related to DTC STI screening.
A salient emergent theme of a preferred interpersonal communication channel for receiving STI screening information was mental health providers (MHPs) and the campus counseling center. Women described the counseling center and the MHPs on campus as an information and referral source for DTC STI screening. Interactions with the counseling center were viewed as more private and confidential than health clinics, and MHPs were viewed as trusted emotional support. Women viewed provision of DTC STI screening as a natural fit with the role of MHPs.
MHPs may be an underutilized resource to provide information about STI screening, particularly novel DTC methods, to college women. Incorporating MHPs into the system of sexual healthcare may increase adoption rates of innovative screening methods and reduce the negative impacts of STIs.
These results provide preliminary data that MHPs may be an underutilized resource to provide information about STI screening, particularly novel DTC screening. Future studies should evaluate the perspectives of MHPs regarding discussion of and recommendation for DTC STI screening to patients.
The 2022 Sexually Transmitted Infection (STI) Surveillance Data from the Centers for Disease Control and Prevention (CDC) reveals the high rates of bacterial STIs and reaffirms the need for STI prevention, screening, and treatment as a public health priority.1 Chlamydia and gonorrhea cases have remained high since 2014, with young adults under age 25 one of the groups disproportionately affected.1 There has been a reduction in STI screening rates since the pandemic,2 but the recent introduction of direct-to-consumer (DTC) screening services presents a novel and low- barrier method to address low screening rates. The FDA has granted marketing authorization of an at-home sample collection kit available without a prescription, but evidence-based messaging to consumers regarding this option has been limited. To increase access, it is vital to identify appropriate sources and strategies for communication regarding DTC screening.
Over one-half (57%) of young adult women in one study indicated that they wanted to receive information about DTC screening from a healthcare provider,3 but the current clinical workforce insufficiently prioritizes STI prevention, testing, and management.4 However, mental health professionals (MHPs) are often viewed as healthcare providers and likely a trusted source for health information. Like many healthcare providers, MHPs typically have advanced education and certifications (requirements vary by state). A recent report revealed that of participants aged 18 to 26, approximately 40% go to mental health therapy, and more than half (53%) have sought therapy in their lifetime.5 Given the desire to obtain information from a healthcare provider and the ages of those at highest risk for an STI, MHPs may contribute to providing trusted information about DTC screening to young adult women.
While DTC STI screening can reduce barriers related to accessing testing, little evidence exists regarding the best ways to disseminate information about DTC screening as an option. The Diffusion of Innovation theory (DOI) provides a theoretical framework for how a new product moves through the social system toward adoption or rejection by end users.6 DOI posits that dissemination channels can include formal or informal sources by which information is shared, and that the decision to adopt an innovation is influenced by social norms and communication patterns.6 Therefore, the purpose of this manuscript is to explore the salient, emergent theme of MHPs as a preferred dissemination channel for information about DTC screening and STI screening among college women. MHPs may help close the gap for STI screening disparities as a provider group with perceived low stigma or judgement, an established trusted relationship between client and provider, and likely ongoing discussion regarding various personal relationships. By involving this group of providers as STI screening “educators” for DTC methods, awareness of these methods may result in increased use and reduce disparities in screening based on access to care.
In-depth interviews were conducted on a large campus in the southeastern U.S. Inclusion criteria were: identified as a woman; age 18-24 years old; reported sexual activity in the past 12 months; and were currently enrolled at the university. Participants were recruited via purposive, criterion-based sampling using flyers and social media posts across campus and through a student organization web portal. Participants completed a 10-minute survey about STI screening behaviors7 and were asked to provide their contact information if they were interested in participating in an interview. Interested participants were contacted in order of survey completion. Interviews were audio recorded and transcribed, and participants were given a $25 gift card for their participation. This study was approved by the University’s Institutional Review Board.
The interview guide was based on the Diffusion of Innovations, focusing on communication channels for information about DTC screening. The transcripts were reviewed and a codebook was developed using a-priori theory-based constructs and emergent themes. Transcripts were entered and coded in MaxQDA using the developed codebook. This emergent theme, MHPs as a resource for DTC screening, did not consistently align with any of the a priori constructs identified in the larger study7 and was noted during the transcript review, prior to coding. Ten percent of the interviews were analyzed thematically by two coders. Interrater reliability was high (Kappa=.83).
The mean age of participants (n=24) was 19.5 years (SD=1.1) and all participants identified as cisgender women and were undergraduate students. Most participants were white (75%), non-Hispanic (83%), and half of the participants were sexual minorities, self-identifying as bisexual, lesbian, pansexual, or bi-curious. Demographic information about the participants are in Table 1.
Table 1. Interview Participant Demographics, n=24.
| Mean (SD) |
Age in Years | 19.5 (1.06) |
| N (%) |
Gender Identity |
|
Woman | 24 (100.0%) |
Race |
|
White | 18 (75.0%) |
Black | 2 (8.3%) |
Asian or Pacific Islander | 2 (8.3%) |
Bi or Multiracial | 1 (4.2%) |
Another Race^ | 1 (4.2%) |
Ethnicity |
|
Hispanic or Latina | 4 (16.6%) |
Not Hispanic or Latina | 20 (83.3%) |
Sexual Orientation |
|
Heterosexual | 12 (50.0%) |
Bisexual* | 8 (33.3%) |
Pansexual* | 2 (8.4%) |
Lesbian* | 1 (4.2%) |
Bi-curious* | 1 (4.2%) |
^Other race: Caribbean Creole; *Included as sexual minority
Many participants described the counseling center and MHPs on their university’s campus as a source of information about STIs generally, but also specifically around DTC screening. Participants viewed the counseling center and mental health services as private and confidential, which was valued given the perceived sensitivity of discussing STIs and STI screening (Table 2; Participant 20). Additionally, participants described MHPs as one of the first sources to approach when seeking care (Participant 12), including for issues outside of mental healthcare.
Table 2. Themes and Examples Quotes from Participants.
Theme | Quote | ||||||||
Mental Health Resources are Often Private and Confidential | “Counseling would be a nice place to go because I really think the idea of the confidentiality is comforting. Even if it’s just a silly little question, nobody is going to be asking about it. Nobody is going to be like, “Why was so and so here?” The idea of it being confidential, I think that’s really comforting. I think counseling is a really nice on-campus option. Especially for people who aren’t comfortable with talking to their parents about something like that.” Participant 20 | ||||||||
“I feel like through counseling would work out. When I feel like someone is needing help, you go like to a counselor or a therapist. So that’s why I keep thinking like, “If you need help, go to therapy or go to a counselor.” Participant 12 | |||||||||
Mental Health Providers May Provide Emotional Support and Build Trust
| “The counseling center needs it [DTC kits] especially, because more people will go there because they’re more accepting. If you go there they’re more likely to accept you than if you go to your normal doctor who takes care of you. They’ll be like “Why do you need to get tested for STDs? Why do you need to get tested for depression.” Which, we go to someone who deals with people who have those issues, they’re trained differently, they know how to help you differently.” Participant 17 | ||||||||
“Possibly in counseling and stuff. Maybe some of the counselors can have access to them, or provide a way to get it to you. I think that’s why, having a set group of people, like counselors on campus, should have access to this… It’s a different type of doctor, and it’s someone that they know, they trust. And sometimes there’s more trust, more relationship built, between you and the therapist versus you and your primary care doctor. I definitely would be comfortable talking to someone who I know is confidential, who has my best interests, to give me the best information, and they won’t lead me astray.” Participant 7 | |||||||||
“I feel like it’d be good to have at the health center and the counseling services. Obviously they wouldn’t have the box kit ready at the health counseling services, but just saying if they notice anything about any of their patients, then maybe they can be like, “All right, I know that you mentioned being sexually promiscuous. Maybe you want to try this, just an alternative option if you’re not comfortable going in with a doctor,” or something like that.” Participant 13
|
Participants viewed the counseling center as more accepting and less judgmental than primary care providers on campus, as MHPs were viewed as providing emotional support and comfort with difficult conversations. Because of this, women felt more comfortable discussing health concerns such as STIs with their therapist or counselor than their primary care provider. One participant described counselors and MHPs as “trained differently” than other medical professionals such as physicians (Participant 17), referring to their communication skills and ability to approach and discuss topics perceived as sensitive.
Participants identified counselors as a source of information as well as emotional support and viewed discussing DTC screening and STI screening as a natural fit with the services counselors already provide. Participants described the trusting relationship between students and their MHP and the difference between that relationship compared to relationships with their primary care physician (Participant 7). Participants discussed logistics of offering DTC screening and stated that MHPs and the counseling center may not need to have the kit or other resources available but could refer students to the proper sources for care and screening (Participant 13).
The participants in this sample expressed unprompted acceptance and described their perceptions of MHP’s role in providing information about DTC screening. Support for this role included trust, as MHPs are viewed as confidential providers, and relationship building given the long-term nature of mental healthcare treatment. MHPs are frequently visited by young adults, and participants expressed the role of emotional support and knowledge an MHP could provide for them about STI information and utilizing DTC screening.
The American College Health Association’s (ACHA) Best Practices for Sexual Health Guide recognizes the importance of MHPs’ roles in supporting sexual health, including discussion of topics such as STIs.8 Additionally, there appears to be a syndemic relationship between STI diagnoses and mental health issues, providing an opportunity for primary care and mental health care to be integrated,9 particularly on college campuses. The intersection of STI screening and mental health warrants further exploration, especially as campuses strive to meet their students’ increasing mental health needs—which includes topics such as sexual dysfunction, healthy communication, dealing with a difficult diagnosis, or managing intimate relationships.8 MHPs may also fill a gap regarding sexual health disparities through open conversation regarding personal relationships and may lead to conversations about STIs with individuals who are comfortable seeking care from an MHP, but not a primary care provider. As healthcare trends toward telemedicine, implementation of novel STI screening methods by alternative healthcare providers, such as MHPs, may reduce the burden of STIs among individuals with access to care issues. However, one of the gaps that remains is considering receptiveness to MHP discussion of these topics among individuals who are multiply marginalized, and fully understanding if there are differences in access to MHPs by these identities. There may also be groups of women who do not seek mental health counseling at all, or refuse counseling – these women may have additional complex perceptions of the role of MHPs, particularly in relation to STI care.
College women viewed receiving STI screening recommendations from MHPs as aligned with the type of care they currently provide. Additionally, incorporating trauma-informed approaches are recommended in all sexual health promotion efforts, which may align with MHP’s training and expertise.8 One strategy to prevent STIs is behavioral counseling interventions, which often include techniques and approaches familiar to counselors, such as motivational interviewing and cognitive behavioral therapy.10 While behavioral counseling is effective at reducing STI infections and increasing condom use,10 it remains unclear how these strategies could be incorporated into mental healthcare to increase awareness and uptake of DTC screening. Notably, MHPs are already in high demand with substantial patient volume, and the addition of unbillable tasks could be viewed negatively. However, topics such as gender identity, sexual orientation, sexual behaviors, and personal relationships are very likely incorporated into counseling sessions at current. Recent work also proposed that while MHPs are well placed to promote STI prevention via education and discussion, referring individuals to physicians for screening may be the most effective approach.4 Therefore, exploring potential workflow and linkages across these two provider groups may provide insight into the feasibility of incorporating MHPs into the continuum of STI prevention, screening, and treatment, without too much additional burden.
It is important to consider these findings in the context of the limitations of the study. MHPs as a source of STI information was a consistent, emergent theme that arose during the interviews, but participants were not asked directly about the role MHPs may have. While this indicates the salience of this theme, the data and information about MHP’s role may not be as comprehensive as other sources, which were explicitly discussed. This study included participants recruited from only one university with a large, well-resourced counseling center, which may have influenced these results. Additionally, the sample was primarily white and half heterosexual, which limited perspectives, resulting in a lack of information about disparities and access to care issues experienced by other populations. Further study should explore the potential for MHP inclusion outside of university settings and specifically among populations that experience disparities in sexual health access and therefore, mental healthcare access. Finally, this analysis does not include the perspectives of MHPs about their perceived role but rather focuses on the young adults’ perceptions. Future work should utilize larger-scale, mixed-methods studies for more representative data.
These results provide preliminary data that MHPs may be an underutilized resource to provide information about STI screening, particularly novel DTC screening. Future studies should evaluate the perspectives of MHPs regarding discussion of and recommendation for DTC STI screening to patients. In the future this work could expand to explore the specific needs of sexual and gender minority individuals and their perceptions about the role of an MHP in discussing sexual health, and the potential associated stigma. Prioritizing salient communication channels and information sources preferred by young adults to develop communication and educational campaigns may promote awareness of DTC screening. Incorporating MHPs into the continuum of sexual healthcare also may increase adoption rates of DTC screening methods and improve rates of STI screening among this priority population.
The authors received support for this work from Indiana University-Bloomington Rural Center for AIDS/STD Prevention, through the Doug Kirby Adolescent Sexual Health Grant; and the University of South Florida College of Public Health Student Research Scholarship.
The author(s) have no relevant financial disclosures or conflicts of interest.
Stacey B. Griner, PhD, MPH, CPH, is an Assistant Professor in the School of Public Health at the University of North Texas Health Science Center.
Tracey E. Barnett, PhD, is an Associate Professor and Founding Chair in the Department of Quantitative & Qualitative Health Sciences at the UT School of Public Health San Antonio.
Kaeli C. Johnson, MS, is a PhD student and graduate research assistant in the School of Public
Health at the University of North Texas Health Science Center.
Ashlyn Kinard, DO, is a graduate of the Texas College of Osteopathic Medicine at the University of North Texas Health Science Center
Amanda Brosnan, MPAS, MPH, PA-C, is an Assistant Professor in the Department of Physician Assistant Studies at the University of North Texas Health Science Center.
Malinee Neelamegam, PhD, MPH, CPH, is an Assistant Professor in the School of Public Health at the University of North Texas Health Science Center.
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