title: How online sexual health services could work; generating theory to support development.
abstract: BACKGROUND
  Online sexual health services are an emerging area of service delivery. Theory of change critically analyses programmes by specifying planned inputs and articulating the causal pathways that link these to anticipated outcomes. It acknowledges the changing and contested nature of these relationships.
  
  
  METHODS
  We developed two versions of a theory of change for an online sexual health service. The first articulated the theory presented in the original programme proposal and the second documented its development in the early stages of implementation through interviews with key programme stakeholders.
  
  
  RESULTS
  The programme proposal described an autonomous and empowered user completing a sexual health check using a more convenient, accessible and discreet online service and a shift from clinic based to online care. The stakeholder interviews confirmed this and described new and more complex patterns of service use as the online service creates opportunities for providers to contact users outside of the traditional clinic visit and users move between online and clinic based care. They described new types of user/provider relationships which we categorised as: those influenced by an online retail culture; those influenced by health promotion outreach and surveillance and those acknowledging the need for supported access.
  
  
  CONCLUSIONS
  This analysis of stakeholder views on the likely the impacts of online sexual health services suggests three areas for further thinking and research. 1. Co-development of clinic and online services to support complex patterns of service use. 2. Developing access to online services for those who could use them with support. 3. Understanding user experience of sexual health services as increasing user autonomy and choice in some situations; creating exclusion and a need for support in others and intrusiveness and a lack of control in still others. This work has influenced the evaluation of this programme which will focus on; mapping patterns of use to understand how users move between the online and clinic based services; barriers to use of online services among some populations and how to overcome these; understanding user perceptions of autonomy in relation to online services.
authors.affiliation: Kings Centre for Global Health, Kings College London, London, UK. paula.baraitser@kcl.ac.uk.|Department of Sexual Health and HIV, Kings College Hospital NHS Foundation Trust, London, UK. paula.baraitser@kcl.ac.uk.
authors.forename: Paula
authors.initials: P
authors.lastname: Baraitser
authors.affiliation: Kings Centre for Global Health, Kings College London, London, UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Syred
authors.affiliation: Lambeth and Southwark Public Health Directorate, London, UK.
authors.forename: Vicki
authors.initials: V
authors.lastname: Spencer-Hughes
authors.affiliation: SH:24, London, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Howroyd
authors.affiliation: Department of Public Health, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Caroline
authors.initials: C
authors.lastname: Free
authors.affiliation: Lambeth and Southwark Public Health Directorate, London, UK.
authors.forename: Gillian
authors.initials: G
authors.lastname: Holdsworth
mesh_terms: D036861:Delivery, Obstetric; D005260:Female; D006293:Health Promotion; D006801:Humans; D020407:Internet; D007407:Interviews as Topic; D017146:Models, Organizational; D011247:Pregnancy; D016730:Program Development; D034121:Reproductive Health Services; D012725:Sexual Behavior