Quarterly Surveillance Report 2000 No. 1 contents

STD Services and the Internet index page

STDServices.on.net web site report

E-mail received by STD Services

Sexual Health and the Internet
(Transcript from Australasian Sexual Health Conference, Darwin, June 2000)

• PowerPoint format

• HTML format

Links to other sexual health sites

Quarterly Surveillance Report 2000 No. 15:
Electronic mail received by STD Services, January 1999 - May 2000 

Use of e-mail by STD Services

The STD Services web site (stdservices.on.net), was described in a previous STD Services Quarterly Surveillance Report.¹ Each page of the web site includes a general e-mail address for STD Services, hence visitors to the site can send e-mail addressing sexual health concerns. Messages to the STD Services e-mail address are received by an administrative officer and forwarded to an appropriate staff member (Director, medical officer, trials nurse, etc.) for further action. Since January 1999, copies of all messages and replies have been retained. This article considers e-mail messages received by STD Services in the period January 1999 to May 2000.

Rationale for analysis of e-mail messages

The publication of a web site has provided numerous benefits for STD Services, its clients, referring health workers, South Australian students and members of the South Australian community affected by STDs. 1 Analysis of unsolicited e-mail sent by visitors to the site gives an insight into the benefits that STD Services can provide via its web site on local, national and international levels.

From e-mails of site visitors we gain an impression of the audience (type, location of person), information of interest to users and the purpose for seeking information on the web site. We can then deduce whether web site information is reaching our target audience, the conditions/issues of concern to site visitors and whether resources available to local visitors are adequately addressing these issues.

Questions raised (and not always easily answered) include:

• Who is the target audience of the STD Services web site?
• Is responding to e-mail an efficient use of STD Services resources? How does STD Services gain by providing this service?
• Could people e-mailing from other countries be more appropriately served by services closer to home?
• Should STD Services take responsibility for advising e-mail correspondents? Is it appropriate to offer diagnostic and management advice in situations where a medical consultation is not possible or the person refuses to seek face-to-face care?
• What are the medicolegal implications?

This article offers suggestions for management of e-mail correspondence from visitors to the STD Services web site.

Results

Some limitations apply when considering e-mail content and source. E-mail messages are an unstructured medium; senders do not provide a standard set of information. Information volunteered in some messages (for example, the sender is a client of Clinic 275) may not be specified in others. The country of origin of the message is not always apparent. (When the country of origin was not specified, the message was assumed to come from the USA.) Messages may deal with more than one subject and not all categories analysed were mutually exclusive or easily defined.

The characteristics of messages examined were:

• nature/subject of message
• condition under consideration (where specified)
• occupation of sender
• STD status of sender (for example, person with STD, person with undiagnosed condition, person with a history of STD risk activity)
• country of origin.

From January 1999 to May 2000, 201 e-mail messages were received from visitors to the STD Services web site. In two e-mails, (1%) the sender identified as a previous client of Clinic 275.

Table 1: Subject of message

Not all e-mail messages specified an STD, many referred to STDs in general, and some specified multiple conditions. Table 2 lists STDs named in e-mails, in order of frequency.

Table 2: Most common STD enquiries.

Details of correspondents

Occupational information was provided in 42 (21%) e-mail messages and information relating to STD status was stated in 96 (48%) messages. Eighty messages (40%) gave no details of the sender’s occupation or STD status. The majority were students (25), one identified as a medical practitioner and another as a nurse.

Table 3: STD status of e-mail correspondents

Notes:

1. described symptoms attributable to STD

2. confirmed diagnosis of STD, specified in the e-mail message

3. described a particular incident or behaviour, and requested assessment of likely STD transmission.

Country of origin

The majority of e-mails originated in the United States of America (146, 73%) whilst 28% were from Australia. South Australia was the place of origin for 6 (3%) messages. Two percent of e-mails came from each of the United Kingdom, Canada and Indonesia. Single messages originated from 17 different countries, such as Turkey, Bermuda and Japan.

Discussion

Managing requests for information

Requests for information from STD Services fall into two categories, general STD information and information relating to individuals.

E-mail and the world wide web are appropriate media for dissemination of general information, and STD Services can play an important role in community sexual health education by responding to requests. STD information can be researched by consulting reference material, such as diagnosis and management guidelines, basic STD facts and statistics. These represent the most common information requests received by STD Services (Table 1).

In many cases, the information requested is already available on the STD Services web site. The strategy for dealing with requests of this type is to refer the enquirer to specific sections of the web site. This reduces the need to individually supply existing information, and usually provides information additional to that requested. As an example, a request for herpes information is directed to stdservices.on.net/std/herpes. As this is the condition which generates the most requests for information, the herpes section of the STD Services web site contains a relatively large amount of information and suggestions for further research (books and web sites).

Information relating to individual cases requires consultation with a health worker. It is not appropriate to offer diagnosis or management advice or offer an assessment of STD risk because of inability to perform a physical examination, take a detailed history or perform investigations. To date, the approach of STD Services has been to respond to such enquiries with a standard message explaining the difficulty of assessment by e-mail and recommending that the person consult a doctor. This approach, while providing appropriate clinical advice and helping STD Services avoid medicolegal liability for misdiagnosis, may prove unsatisfying to the person concerned about STD.

An alternative approach might direct correspondents to a designated section of the STD Services web site which gives a range of possible diagnoses for given symptoms, reinforces the need to consult a doctor for diagnosis and provides an opportunity for further research of the conditions. The "Should I see a doctor?" section of the STD Services web site (stdservices.on.net/see_doctor) has been designed to offer such a service. The section includes a legal disclaimer as well as links to pages describing the STD check-up process.

An improved method for managing information requests may be to use automatically generated responses to direct the person to a specific area of the web site, thus sparing STD Services administrative resources. Different responses, triggered by particular words in the subject line of received e-mail messages, could direct the enquirer to a suitable area of information content. In most cases, this would obviate the need to manually reply to individual messages.

Demographics and target audience

As relatively few correspondents volunteered information relating to occupational or STD status (Table 3), it is difficult to comment on the readership of the STD Services web site. From the e-mail data, it seems few health professionals request information.

STD Services currently targets health workers preferentially with its printed publications (Diagnosis and Management Guidelines, Quarterly Surveillance Reports, Epidemiologic Reports). These publications are also published and updated on the web site. It may therefore be appropriate to further promote the STD Services web site to health professionals. In addition, STD Services needs to be mindful that most visitors to its web site are not necessarily familiar with specialist health-related literature, and the site should reflect the needs of this readership. Basic information about STDs should be easy to find and regularly updated.

Geographic considerations

The majority of e-mail received by STD Services comes from the USA. This implies that STD Services web site’s main use is dissemination of general STD information, rather than local information such as Clinic 275 opening hours and South Australian STD statistics. However, the publication of local information is a major function of STD Services, with printed publications relating to local STD information being distributed regularly. Wider promotion of the web site at a local level (eg. establishment of a local mailing list advising of new information on the site) may increase use of the site by South Australians.

As the majority of internet users are North American, the preponderance of e-mail correspondence from the USA is likely to continue. STD Services resources will continue to be expended on the management of e-mail sent from other countries, hence a philosophical rather than economic viewpoint is possibly indicated.

• If an STD is treated or prevented due to information obtained from STD Services, this is a worthwhile outcome, irrespective of the location of the person.
• International recognition of our service and web site comes at the price of receiving e-mails from people in other countries.

Future strategies

Future management of e-mail from visitors to the STD Services web site should focus on reducing unnecessary expenditure of resources whilst gathering information to analyse ongoing use of the site.

Strategies for achieving these objectives include:

• automated responses, based on key words in the message, directing the sender to suitable areas of the STD Services web site,
• replacement of the free-text e-mail message format with an on line form requesting a standard set of information from all correspondents,
• disclaimers and warnings about the limitations of STD Services resources and e-mail as a mode of STD diagnosis and management, enforced as a reading before an e-mail or a form can be sent from the web site.

Reference

1. Miller C, Copland J. STD Services web site. STD Services Quarterly Surveillance Report. No. 13, July-September 1999

Chris Miller
Clinic 275
May 2000

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