Sex, Lives and Red Tape

Lessons from a C-Card Scheme Evaluation Paper

The Institute for Women’s Health is based at UCL. My research is part of the ‘Sexual Health and Reproduction’ group.

Today I hosted a journal club discussion for my Sexual Health and Reproduction group colleagues.  As I’m about to embark upon my literature review, I decided to pick a paper which was relevant to my research area (young people and contraception). A quick browse through recent publications… and I came across this paper:

Karina Kinsella, Ruth Cross and Jane South (2014) An evaluation of the condom distribution scheme (C-Card) with young people in northeast England. Perspectives in Public Health 2014 134: 25.

The questions I posed of my colleagues were similar to those i used for Public Health Twitter Journal Club, namely; is there a clear aim? Are the methods appropriate? Do you believe the results? Do the results warrant a change in policy or practice ? Below is a summary of the points which were raised.

What is a C-Card scheme?

A C-Card scheme is a free, confidential service which provides free condoms, advice and information to young people. The scheme aims to make condoms more accessible to young people and to provide them with support and information about sexual health and how to use condoms correctly. Typically, users are required to register with the service and undertake a short learning intervention (e.g. demonstration of how to use a condom, discuss STIs and contraception options) – thereafter the user is able to use the C-Card to obtain free condoms, from a range of local outlets.

Since 2010, C-Card schemes have been available to ‘young people’ (ranges of included ages vary) across the UK. However there is no national guidance regarding C-Card scheme implementation or evaluation, and to date no studies have compared scheme variations. A quick search on Embase and Medline suggests that Kinsella et al (2014) is the first published evaluation on C-Card schemes.

Summary of journal club discussion:

  • The study did not present a clear research question, and the aims of the study were unclear. For example, it was not clear who the population were (all people under 19 years?), nor what geographical area was covered (how was North East England defined?), nor what time period the intervention and evaluation took place over. Without a clear description of the baseline population, the results risk being ‘floating numerators’ and are difficult to interpret.
  • Following some discussion, the group felt the paper didn’t achieve it’s stated aims; these were to improve access to condoms (there was no baseline reported) and to provide young people with information to support safe sex decision making. Instead, the group agreed that the paper succeeded in establishing the opinion of the local C-Card scheme.
  • The methods employed left much to be desired. Although a convenience sample of focus group participants was somewhat justified, it is unclear how the two outlets for focus group recruitment were selected – nor why they were not selected randomly. The questionnaire response rate appears low (n=55) however, without knowing more about the denominator population this is difficult to judge. Furthermore, the authors noted that a mixed methods approach was adopted – however no mention of data integration was noted in the paper.
  • Based on the above points, it is difficult to have confidence that the results obtained are representative of the population of young people in this region. It is also disappointing to note a number of contradictions made by the authors (e.g. the authors concluded that the scheme appealed equally to males and females, yet their results indicated greater uptake by males).

Overall, I felt that the paper was quite a disappointing read. Possibly the evaluation of the scheme had not been integrated into the initial set-up and planning (which is frequently the case in public health service work). And in-spite of the low number of participants, the reporting of the details of the study is somewhat sloppy, which (for me) makes it difficult to be confident in the authors conclusions…

Academic versus service research

I’m feeling quite negative about this paper, but am I being fair? Afterall, this paper is an evaluation of a sexual health promotion initiative in a service environment – is it fair to use the standards one would expect from a robust academic research paper to appraise? Here are some points which were raised and reflections following the journal club:

  • Service research can often ‘skip’ out on gaining approval from an ethics committee. Although this can be advantageous in speeding up the research process, some may argue that this process is a means of demonstrating your professional ability to conduct ethical research and to assure against possible harms for participants.
  • Evaluations should be proportional and realistic. A local service evaluation is unlikely to  to demonstrate an impact upon population health, compared to a cluster randomised-controlled-trial which has been set-up in the knowledge of the sample size needed to disprove the null hypothesis. Therefore the aims of studies should be proportional also, and SMART.

Thank you to Professor Judith Stephenson and Dr Hannat Akintomide for contributing to the Journal Club discussions.

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