Integrating sexual health services: an ethnographically-informed study of attendee experience

Abstract

Across the UK the integration of historically divergent specialities of genitourinary medicine (GUM) and well-woman/family planning (WW/FP) has emerged as a modern approach to sexual and reproductive health care provision. Integration’s most visible form is the ‘one-stop shop’ (OSS), where a full range of services are brought together under one roof and wherein care is provided by comprehensively trained practitioners. To date, there exists only limited insights into stakeholder experiences of integrated clinics. Conducting ethnographically-informed research at one such purpose-built OSS over a 9 month period (2013-2014), I sought to redress this gap in knowledge. Accompanying 29 attendees along their journey through the clinic, my research offers a detailed examination of the extent to which experience is shaped by integration. Drawing upon literature at the confluence of medical sociology, social geography, and anthropology, including Gesler’s (1992) ‘geographic metaphor’ of the ‘therapeutic landscape’, the thesis puts forward two key arguments. First, I suggest that participants often reconstructed the clinic as aligned to their presenting need, for example, a ‘GUM clinic’, or a ‘family planning’ service. This finding, teased out over the course of the thesis, destabilises assumptions present in previous studies that integration be inevitably deterministic in shaping attendees’ experiences. Second, the thesis contributes to a gaps in literature relating to Gesler’s (1992) ‘therapeutic landscapes’ in three key ways. The first contribution is to show how affective landscapes matter, are significant, in the formation of experience in a novel setting – a transient, ‘walk-in’ clinic. The findings, further, point to the elevated import of the physical and symbolic landscapes in the case of the OSS - a place where there is little opportunity to cultivate therapeutic social relationships. Finally, the thesis speaks to the ways in which the affective landscapes of the clinic work to challenge, confirm or reshape attendees’ preconceptions and expectations of sexual health services. Together, these findings contribute to pre-existing accounts of the experience of integrated services by asking us to consider the influence of forces other than the integrated status of service delivery on attendee experiences of such sites. I argue that place should not be conceived as immutable but, rather, is subject to individual interpretations that are, themselves, the product of both situated and external contexts.