Article Text

Original research
Exploring the wider societal impacts of sexual health issues and interventions to build a framework for research and policy: a qualitative study based on in-depth semi-structured interviews with experts in OECD member countries
  1. Lena Schnitzler1,2,
  2. Aggie T G Paulus2,3,
  3. Tracy E Roberts1,
  4. Silvia M A A Evers2,4,
  5. Louise J Jackson1
  1. 1Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
  2. 2Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht Universit, Maastricht, The Netherlands
  3. 3School of Health Professions Education (SHE), Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, The Netherlands
  4. 4Trimbos Institute, Centre for Economic Evaluations, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
  1. Correspondence to Dr Louise J Jackson; l.jackson.1{at}bham.ac.uk

Abstract

Objectives Sexual health is a complex public health challenge and can generate wide-ranging health, social and economic impacts both within and beyond the health sector (ie, intersectoral costs and benefits). Methods are needed to capture these intersectoral impacts in economic studies to optimally inform policy/decision-making. The objectives of this study were (1) to explore the different intersectoral costs and benefits associated with sexual health issues and interventions, (2) to categorise these into sectors and (3) to develop a preliminary framework to better understand these impacts and to guide future research and policy.

Design A qualitative study based on in-depth semi-structured online interviews.

Setting OECD (Organisation for Economic Co-operation and Development) member countries.

Participants Professionals with expertise in the field of sexual health including clinicians, medical practitioners, sexologists, researchers, professionals working for international governmental or non-governmental health (policy) organisations and professionals involved in implementation and/or evaluation of sexual health interventions/programmes.

Methods Sampling of participants was undertaken purposively. We conducted in-depth semi-structured online interviews to allow for a systemic coverage of key topics and for new ideas to emerge. We applied a Framework approach for thematic data analysis.

Results 28 experts were interviewed. Six themes emerged from the interviews: (1) Interconnections to other areas of health (ie, reproductive health, mental health), (2) Relationships and family, (3) Productivity and labour, (4) Education, (5) Criminal justice/sexual violence, (6) Housing, addiction and other sectors. The findings confirm that sexual health is complex and can generate wide-ranging impacts on other areas of health and other non-health sectors of society.

Conclusion These different sectors need to be considered when evaluating interventions and making policy decisions. The preliminary framework can help guide future research and policy/decision-making. Future research could explore additional sectors not covered in this study and expand the preliminary framework.

  • health economics
  • health policy
  • public health
  • HIV & AIDS
  • sexual medicine

Data availability statement

Data are available upon reasonable request. Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information. Where possible, additional material will be made available upon reasonable request to the corresponding author, in line with University guidelines.

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Strengths and limitations of this study

  • The use of semi-structured, open-ended interviews allowed for a systemic, rigorous and structural coverage of key topics while allowing for a degree of freedom and adaptability in seeking information from the interviewees, and for new ideas and themes to emerge.

  • The interviews generated a depth of information by including 28 experts from six different countries and covering a wide range of professional backgrounds.

  • There could be additional sectors affected by sexual health issues and interventions that are not covered in this study, suggesting the need for future research to explore such areas.

Introduction

Sexual health is a complex public health challenge and can generate wide-ranging health, social and economic impacts.1–4 Public health challenges relating to sexual health include sexually transmitted infections (STIs), HIV/AIDS, sexual violence, coercion and discrimination, sexual dysfunction and unintended pregnancies. With the recent COVID-19 pandemic the wider societal impacts of public health issues became more apparent.5 This has emphasised the need to look at public health issues and interventions from a wider societal perspective, taking into account the impacts on health and non-health sectors (ie, labour, education). The pandemic also made some of the most prominent health inequalities even more apparent, and how sexual health is part of these inequalities.6 For example, the pandemic caused disruptions in the provision of essential sexual health services (ie, access to pre-exposure prophylaxis (PrEP), STI/HIV testing),7 8 disproportionately affecting certain population groups (ie, people with lower average incomes, young people).9 10

Sexual health is a broad concept and defined by the WHO as ‘a state of physical, emotional, mental and social well-being related to sexuality’. It acknowledges that sexual health involves a ‘positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence’. The WHO’s definition is expansive and reflects the complexity of sexual health, recognising and advocating for a more holistic approach to sexual health. For example, the effect of an STI can extend well beyond the acute infection, and people living with an STI are at an increased risk of acquiring other STIs or HIV.11 STIs can often be asymptomatic, which can result in missed or delayed treatment as well as increased risk of transmission.12 Beyond the physical health impact sexual health problems are often associated with shame, (self-)stigma and psychological distress, which can have an impact on an individual’s relationships and can result in difficulties in a marriage, partnership or with a sexual partner.13 In contrast, optimal sexual health, sexual functioning, sexual pleasure and intimacy can have a positive impact on relationships and an individual’s physical and mental well-being.14 On a societal level, adverse sexual health outcomes, like other public health consequences, can generate impacts both within and outside the health sector. Those impacts that occur outside the health sector could include costs due to lost work/labour productivity, school absence, housing insecurity and reduced physical, mental or social well-being.5 15 16 In this paper, we will use the term intersectoral costs and benefits to refer to costs and benefits beyond the health sector.17 18

Existing evidence suggests that very few economic studies in sexual health adopt a broader perspective in their analyses, and for those that claim to adopt such a perspective the types of costs considered tend to be narrow.18 Failing to capture relevant intersectoral costs and benefits in economic studies can potentially underestimate the true societal impact of a sexual health issue or intervention and can lead to sub-optimal policy decisions.17

The objectives of this study were (1) to explore the different intersectoral costs and benefits associated with sexual health issues and interventions, (2) to categorise these into sectors and (3) to develop a preliminary framework to better understand these intersectoral impacts and to guide future research and policy; using in-depth semi-structured interviews.

Methods

A qualitative study was conducted based on in-depth semi-structured interviews with experts in Organisation for Economic Co-operation and Development (OECD) member countries.

Sampling and recruitment of participants

Sampling of participants was undertaken purposively based on experts’ knowledge and expertise. We distributed email invitations to the study authors’ network as well as experts in the area. This was followed by snowball sampling. In this study, we use the term ‘experts’ to refer to professionals that are knowledgeable in a particular area, in this case in sexual health. Purposive sampling was used to ensure a spread of expertise across different areas and in relation to different roles. The purpose of this study was to develop a framework that could be used to inform evaluation and health policy in OECD member countries and hence we included participants from these countries to ensure comparability of healthcare systems. We included potential participants with diverse expertise, affiliations and experience in the field of sexual health including clinicians, medical practitioners, sexologists, researchers, professionals working for international governmental or non-governmental health (policy) organisations and professionals involved in the implementation and/or evaluation of sexual health interventions. We approached experts via email and invited them to participate in semi-structured, one-to-one online interviews in English with the lead researcher (LS). A participant information leaflet was attached to the email including more detailed information on the purpose and background of the study, voluntary participation in the study, confidentiality and anonymity, duration of the interview and dissemination of study findings. Interviews were conducted until data saturation was reached, meaning when no new insights emerged from additional interviews.19

Data collection and analysis

In-depth semi-structured online interviews were conducted to allow for a systemic coverage of key topics and to allow for new ideas and themes to emerge.20 Online interviews were chosen due to the circumstances relating to the COVID-19 pandemic. The videoconferencing platform Zoom was used to conduct the interviews. We used a topic guide to structure the interviews (see online supplemental appendix 1). The interviewer was a doctoral candidate, and the interviewees were all experts in sexual health. All interviews were audio-recorded, with the participant’s consent. Detailed field notes were taken during the interviews to provide further information for analysis. The interviewer (LS) used an interview protocol, containing a set of open-ended questions to discuss potentially relevant wider societal costs and benefits associated with sexual health services or interventions.

We applied the Framework approach as presented by Gale and colleagues for thematic data analysis. It is a widely used approach to manage the qualitative data derived and allows for systematic analysis, comparison and contrasting of data.21 All audio-recorded interviews were transcribed verbatim and entered into NVivo V.12 (a software for qualitative data analysis) by one author (LS) (step I). A sample of the transcripts was cross-checked for reliability by a second researcher (LJ). Both authors (LS and LJ) familiarised themselves with a set of the data and repeatedly coded several transcripts independently, identifying emerging themes and subthemes (step II and III). The authors then compared their themes and subthemes and discussed these with all coauthors, resulting in a coding framework (in form of a matrix) that all authors agreed on. Discrepancies were discussed, where needed (step IV). LS applied the established coding framework to the remaining transcripts (step V). A matrix was developed, charting all themes and subthemes, which was discussed with all authors (step VI and VII). LS reviewed, analysed and summarised a set of the coded themes and subthemes, which was again discussed with all authors. We followed the guidance outlined in the Standards for Reporting Qualitative Research (SRQR) for the reporting of the study context, methods and findings (online supplemental appendix 2).

Consent form

All participants that agreed to take part in the interviews signed and returned their written consent to the lead researcher (LS) via email prior to the start of the interview.

Patient and public involvement

None.

Results

Interviews

A total of 28 experts (16 women and 12 men) were interviewed between November 2020 and June 2021. The duration of the interviews ranged between 30 and 60 minutes each.

Participant characteristics

All participants had expertise in the field of sexual health including the provision of clinical sexual health services, or the design, implementation or evaluation of (clinical and non-clinical) sexual health interventions. At the time of the interviews, participants worked in Australia, Canada, The Netherlands, Switzerland, the UK or the USA (table 1). Among those were clinicians or clinical academics (n=8), non-clinical academics or researchers (n=15), programme managers (n=3) and technical advisors (n=2). Many experts were affiliated with a university or research institute (n=16). Others worked at governmental (n=3), non-governmental (n=4) or international policy organisations (n=4). Some participants had training in sexology (n=2), medical anthropology (n=2) or health economics (n=3).

Table 1

Interview sample, roles and affiliations

Themes

The participants in the interviews highlighted the holistic nature of sexual health, which meant that there were a wide range of impacts on other areas of health and different sectors of society. As shown in figure 1, six themes emerged from the interviews: (1) Interconnections to other areas of health, (2) Relationships and family, (3) Productivity and labour, (4) Education, (5) Criminal justice/sexual violence, (6) Housing, addiction and other sectors.

Theme 1: interconnections to other areas of health

When considering the societal impacts of STIs, the holistic nature of sexual health and interconnections to other areas of health became evident. Although not strictly an ‘intersectoral’ impact, we include this as a theme, as participants felt that it was important to highlight these connections to other areas of health, as they may otherwise be overlooked. The inextricable link between sexual and reproductive health as well as the relationship to mental health was expressed by almost all clinicians repeatedly.

Long-term consequences

When first asked about potential societal impacts of any sexual health aspect, almost all experts instantly described the impact of STIs as being potentially serious, with long-term consequences for the physical and mental health of an affected individual. These long-term consequences included pelvic inflammatory disease (PID), chronic pelvic pain, infertility and adverse pregnancy outcomes.

Chlamydia is most likely to be asymptomatic in women and yet can have one of the worst sequelae in terms of say tubal infertility, ectopic pregnancy and that sort of thing. That obviously has a huge impact on women and also pelvic inflammatory disease from chlamydia and gonorrhoea can be really devastating, even as an illness when treatment can be offered. (I.2, University/Research Institute, UK)

You still have people that get ectopic pregnancy or infertility, and this is directly related to chlamydia. I think these are also important things to look at and also PID [pelvic inflammatory disease]. (I.25, Governmental Organisation, The Netherlands)

About syphilis we know that it can have adverse effects on pregnancy outcomes, and we know that there is significant foetal and natal death every year because of not detecting syphilis. It would be greater than that when it comes to loss or miscarriage. (I.27, Non-governmental Organisation, UK)

The inextricable link between sexual and reproductive health

The majority of experts highlighted the inextricable link between sexual and reproductive health. They expressed the importance of providing more holistic care, which means ensuring that essential services around sexual, reproductive and potentially other areas of health are addressed.

When you look at sexual health provision for women that’s very much bundled in with reproductive health. […] I’ve seen this a lot in STI clinics, women who come in for screening but also get a LARC [long-acting reversible contraception] while they are there. Women who talk to you about contraception while they've come in for let’s say a pap [smear test]. Even though contraception isn't what we do in sexual health the two things overlap quite a lot. (I.2, University/Research Institute, UK)

What we try to ensure within our clinics is that we get those essential service areas around contraception, abortion care, issues around HIV, the wider STIs covered, we know that a lot of STIs are not always included. (I.27, Non-governmental Organisation, UK)

Mental health problems relating to sexual health

Alongside those physical, sexual and reproductive health concerns, experts highlighted the serious impacts STIs can have on an individual’s mental health and psychological well-being. In particular, syphilis, herpes simplex virus (HSV) and HIV were listed among those causing serious psychological consequences.

Syphilis, I mean goodness, it causes horrible psychological illness and it’s a systemic illness, it has a huge impact. (I.2, University/Research Institute, UK)

HSV which is herpes simplex virus is a very common infection and depends on the individuals most of them have minor symptoms some have more severe symptoms. That can be very psychologically damaging. (I.1, Hospital, UK)

I argue there is a mental health cost to living with an HIV infection. (I.23, Government Researcher, UK)

Theme 2: relationships and family

Most participants highlighted the need to think beyond health aspects, and family, friendships and relationships were seen as an important part of this.

Beyond the health sector you want to look at what is my relationship with my family and peers, do I have access to safe shelter, do I have food, do I have a job. (I.28, Non-governmental Organisation, UK)

Several interviews revealed that the use of PrEP was expected to have additional non-health benefits, in particular, for people’s relationships with partners and peers. Similarly partner notification interventions were perceived to have a positive impact on interpersonal relationships for various STIs including HIV, genital warts, amongst others.

What we see with PrEP when people are not afraid of HIV, we think that people enjoy sex more. Or positive sexual relations, pleasure, connections with people. It impacts your relationship, how you stand in your sexual network. (I.5, Non-governmental Organisation, The Netherlands)

They feel that PrEP is giving people a lot more confidence of having new relationships, it makes them be more confident in their sex life, knowing that they can’t pass the virus on. (I.23, Government Researcher, UK)

Theme 3: productivity and labour

A link was drawn between sexual health and productivity by many experts. They indicated that STIs that are left untreated can continue to affect an individual’s health and can have a ‘knock-on effect’ on an individual’s productivity and participation in the labour market. One concern was also that untreated STIs will continue to spread and infect more and more people and create an even bigger impact on society’s productivity and ability to work.

I think the impact on the labour market and the impact on the health sector are very similar in that every single STI has horrible consequences down the line if it isn’t treated. […] If it’s not treated then you’re going to get more people that are incredibly unwell. And yes, that’s going to have a huge impact. (I.2, University/Research Institute, UK)

It will be in terms of work productivity so they would not be able to work or there are some mental health issues that then kind of snowballs into the need for disability pensions, but this would be a very small minority of my patients. (I.3, University/Research Institute, Australia)

The loss of income and productivity was often linked to chronic conditions, illustrating the relationship between health and work. For example, many clinicians explained that the development of PID can have an impact on women’s productivity as well as economic consequences.

In terms of the labour market, so treating every single STI has huge health impacts down the line. If you’'ve got women who then develop PID a couple years down the line they will be out work for a while, they are going to be hospitalised for a while, etc. […] The provision of healthcare you need when you don’t treat an STI is huge. […] and that’s going to have an impact on their productivity as well. (I.2, University/Research Institute, UK)

One expert highlighted the possibility of people living with well-managed HIV to work effectively.

Similarly, if HIV is well managed then you’ve got people coming in once or twice a year getting their blood sample done, getting their medications checked, it’s all very easy and they probably aren’t taking a huge amount of time off work. However, if HIV progresses to AIDS people are incredibly ill and probably have to be off work for quite some time. (I.2, University/Research Institute, UK)

Theme 4: education

Other wider societal impacts raised by experts included those in the education sector. For example, one described the impact of teenage pregnancy on future educational and professional attainment.

The same applies to all the broader levels of for instance teenage pregnancy, teenage mothers. […] But also there, of course, they miss out on further education. They miss out on getting a good job or being economically independent. All that ripple effect is happening and this all needs to be taken into consideration. (I.12, University/Research Institute, The Netherlands)

Experts also explained the relationship between sexual health and education in terms of the costs and benefits of comprehensive sexuality education and sexual health education in schools.

For example, in our implementation research on comprehensive sexuality education, we are working to build linkages between education provision and linkages to health and social services and studying how these linkages function. (I.7, International Policy Organisation, Switzerland)

The benefits of providing sexual health education as outlined by experts included the prevention of STIs, unplanned pregnancies, sexual coercion, sexual abuse and/or unwanted sexual experiences.

And of course there is the more direct benefit [of school-based sexual health interventions], the more prepared young people are the less likely they are to be at risk of sexual health issues and that includes HIV and STIs but also unplanned pregnancies and sexual coercion or abuse or unwanted sexual experience. (I.20, University/Research Institute, The Netherlands)

The implications are huge. […] If we do these [school-based sexual health] programmes better and we get to prevent STIs or unwanted pregnancies even more, the cost in the STI testing clinics should in the best scenario go down. (I.12, University/Research Institute, The Netherlands)

The need for sexual health education programmes to be more comprehensive and integrate, among other aspects, sexuality education was expressed.

It’s not only about knowledge but it’s also about sexual norms, attitude, skills on how to communicate, how to negotiate, that’s very important but still it’s a challenge. (I.26, Non-governmental Organisation, The Netherlands)

For me it is very important, complementary to add interventions for example comprehensive sexuality education because it can boost here. Even where it exists the young people might understand what sexuality means and what sexual life and sexual health means but in real life they can still face some issues. (I.6, International Policy Organisation, Switzerland)

Theme 5: criminal justice/sexual violence

Sexual health was also linked to criminal justice, mainly discussing the wider societal impacts of sexual violence, abuse or assault. Victims of sexual abuse were seen as not only having to bear the direct physical and emotional burden of being violated but also serious mental health consequences.

For sexual abuse, this is also a double sword, there is this immediate impact of being violated which of course has a mental health impact but behind that there always sits a trauma that is about the rumination, the reliving, but also the thought of what did I do wrong. And society somehow reinforces that. (I.20, University/Research Institute, The Netherlands)

The prevention of sexually violent behaviour(s) can help to avoid significant wider societal impacts, according to experts.

If we can prevent that violent behaviour then we can also prevent societal costs you know in the mental health part, and broader, people might have depression or other mental health problems, and they don’t work anymore or have less participation in labour because of their mental health problems. (I.24, Governmental Organisation, The Netherlands)

The important role of sexual health services in identifying and signposting cases of sexual violence and abuse was emphasised by some experts.

In terms of victims of crime, you definitely get a lot of that coming through sexual health services. The role of sexual services usually is to funnel them through the system in terms of trying to get justice. Often a lot of support services are available including psychosexual counselling and that sort of stuff. From STI clinics you can kind of funnel them into the type of services that they might need. (I.2, University/Research Institute, UK)

Especially for sexual health interventions there’s a lot of testing and referrals. For example, in a situation where you’re experiencing partner violence you may be constantly exposed to whatever sexual health outcome, so we need to direct that to services. (I.16, Researcher, USA)

One expert drew further links between sexual health and the criminal justice system, explaining that those incarcerated are vulnerable to STI outbreaks and are at an increased risk to acquire STIs.

I think also when you think about the criminal justice system healthcare provision for people that are incarcerated is also really important. STI outbreaks in prisons happen a lot and you know a lot of people go in to prison risking STIs or with STIs and those are often very vulnerable populations. (I.2, University/Research Institute, UK)

Theme 6: housing, addiction and other sectors

The interviews revealed that sexual health can often relate to other issues including housing insecurity, drug use or other issues. Although such issues and sectors were less frequently mentioned, important links were highlighted.

I was interviewing clients to find out how these (HIV care) services are really influencing people’s engagement and experience going through the care continuum. And these things keep popping up you know saying ‘I am housing insecure’ or ‘I also use injection drugs’ or ‘there is so much stigma’ or ‘I need social support’. (I.16, Researcher, USA)

The clinic that I used to work we had health advisors so people with complex sexual health needs got support from the health advisors who would then talk to them about all sorts of things you know housing, chemsex, relationships all that sort of stuff. (I.2, University/Research Institute, UK)

Discussion

Principal findings

This study is the first to comprehensively explore the intersectoral costs and benefits of sexual health issues and interventions and systematically categorise these into sectors to develop a preliminary framework for understanding and considering these intersectoral impacts, and guiding future research and policy. The study findings confirm that sexual health is complex and can generate wide-ranging impacts relating to (1) other areas of health including reproductive and mental health; (2) relationships and family, (3) labour and productivity, (4) education, (5) criminal justice in particular relating to sexual violence and (6) housing, addiction and other sectors.

Furthermore, the participants all felt that sexual health is holistic in nature and there were important impacts on other sectors outside health. This study reveals that there is a need to also consider the wider impacts sexual health issues and interventions can have on an individual’s family, friendships and relationships. Experts explained that if STIs are left untreated or unmanaged they can continue to spread and can have a ‘knock-on effect’ on an individual and society’s productivity and participation in the labour market, potentially causing economic consequences. The education sector and, in particular, the provision of sexual health education was perceived to play a key role in the promotion of good sexual health and well-being, the prevention of STIs and the prevention of unplanned teenage pregnancy. Sexual violence, abuse and assault and the risk of developing mental health problems because of such traumatic experience was also discussed, drawing a link to the criminal justice sector.

Comparison to other literature

There is a growing body of evidence that advocates for a more holistic approach to sexual health.22 Studies have shown important links to mental health, that is, finding a need to support people’s mental health and sexual health needs holistically,23–25 as well as housing, employment status and alcohol use.26 27 More and more evidence calls for an integrated approach to address the complexity of sexual health by providing holistic services that include health practitioners, mental health professionals, social workers, youth services, employment services and others.28 29 This study contributes to this emerging literature by providing a comprehensive analysis of the broader impacts relating to sexual health and providing an initial framework.

Implications for policy

This study presents a preliminary framework of relevant intersectoral impacts of sexual health issues and interventions by policy sector, which researchers and policy/decision-makers can use to ensure evaluations are holistically capturing costs and benefits. The findings of this research are in line with the Action Framework by the WHO, which suggests the need for a ‘multisectoral framework’.30 This study highlights the need to take such a multisectoral (intersectoral, societal) approach when evaluating interventions and programmes in sexual health to provide policy/decision-makers in the field of sexual health with optimal and comprehensive estimates of the costs and benefits of sexual health interventions.

Implications for research

The findings of this study have important implications for the design of health economic studies. There is acknowledgement that capturing wider societal implications is (methodologically) challenging.17 Methods to capture intersectoral costs and benefits are needed, and this study’s preliminary framework of intersectoral costs can help guide future research in sexual health and other public health issues. Future research is recommended to explore other potentially relevant links between sexual health and additional sectors not covered in this study, and to expand the preliminary framework.

Strengths and limitations

One of the key strengths of this study is the use of semi-structured, open-ended interviews that allowed for a systemic, rigorous and structural coverage of key topics while, at the same time, allowing for a degree of freedom and adaptability in seeking information from the interviewees. Another strength is the depth of information generated by including 28 experts from six different countries and covering a wide range of different professions. As the interviews were conducted with participants based in OECD member countries, it would be important to explore the views and experiences of those based in other settings.

The use of online interviews allowed for more flexibility with regard to the recruitment of participants and therefore ensured a larger sample of participants over a short period of time. Participants did not have to travel to take part in the interviews, which was considered time saving. The online interviews also allowed participants to join the interviews from a setting most convenient and comfortable to them.31 We acknowledge that the facilitation of online interviews can be challenging, for example, due to internet issues, power cuts, etc, particularly in some low-income and middle-income countries. Further, as the interviewees were all experts in sexual health it could be important to conduct interviews with other stakeholders outside of this area. There could be additional sectors affected by sexual health issues and interventions that are not covered in this study, and further research is warranted in this area.

Conclusion

Sexual health issues and interventions can generate costs and benefits across different sectors of society. These need to be considered when evaluating interventions relating to sexual health to ensure well-informed, optimal (policy) decisions are made. This preliminary framework developed by this study can help guide future research and policy.

Data availability statement

Data are available upon reasonable request. Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information. Where possible, additional material will be made available upon reasonable request to the corresponding author, in line with University guidelines.

Ethics statements

Patient consent for publication

Ethics approval

Ethical approval was granted by the University of Birmingham (ERN_19-1371) and Maastricht University (FHML-REC/2020/017/02). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors would like to thank all experts who participated in the interviews.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors This work was part of the first author’s (LS) PhD work and LS is responsible for the overall content as the guarantor. All authors (AP, LJ, LS, SE, TR) made substantial contributions to the planning, conduct, analysis and reporting of the study. LS developed the study protocol and ethical approval request, with involvement from all other authors (AP, LJ, SE, TR). LS developed the interview guide, together with all other authors (AP, LJ, SE, TR). LS conducted and transcribed the online interviews. LS and LJ independently coded the transcripts, and all authors (AP, LJ, LS, SE, TR) contributed to the analysis and interpretation of the data. LS wrote the first draft of the manuscript and all other authors (AP, LJ, SE, TR) provided constructive feedback, and contributed to the final version of the manuscript.

  • Funding The first author (LS) is supported by a PhD Studentship, which is funded jointly by the University of Birmingham and Maastricht University (award/grant number: N/A). None of the other authors received any specific funding for the study. The funders had no role in the study design or analysis, nor in the preparation of the manuscript.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.