Sampling and recruitment
One of the objectives of the research was to investigate the extent to which sexual health services are aware of the needs of ethnic minority MSM and how they respond to them. Treatment and prevention services were considered separately. To this end, we wanted to survey doctors, nurses, health advisors, counselors and psychologists working in NHS sexual health clinics in Britain. We only included clinics in the 15 British towns and cities with the largest ethnic minority populations according to the 2001 census (as described above) for two reasons. First, staff in these clinics were more likely to have had some experience of seeing and treating ethnic minority MSM in their clinics than staff in towns with smaller ethnic minority populations. Secondly, since we did not have sufficient resources to include every sexual health clinic in Britain, we focused on those most likely to provide services to ethnic minority MSM patients.
From the British Association of Sexual Health and HIV (BASHH) website http://www.bashh.org
we were able to identify all the National Health Service (NHS) sexual health clinics in the 15 target towns and cities in Britain (30 clinics in London, 19 outside London) (Additional file 1
). Using this sampling frame of NHS sexual health clinics, we identified a key contact in each clinic and provided them with information about the study by email and telephone. We emphasized that the research was being conducted in collaboration with BASHH. If requested to do so, we visited the clinic to discuss the research in person.
The sexual health clinics were asked to do two things: (i) to promote the project among their ethnic minority MSM clinic attendees (as described in the section "Ethnic minority, key migrant and white MSM - online survey"); (ii) for the clinical staff (doctors, nurses, health advisors, counselors, psychologists) to complete an online questionnaire concerning the needs of ethnic minority MSM using their clinic. Of the 49 clinics identified through the BASHH website, 40 (82%) initially agreed to participate in the research (London 22/30, 73%; outside London 18/19, 95%). The remaining clinics did not respond to our emails asking them to take part in the survey. Most of the London clinics that did not respond to our emails were in outer London.
The 40 clinics which were willing to take part in the research were located in 31 hospital trusts, each with its own Research and Development (R&D) department. In each clinic we identified one member of staff who agreed to be the designated Local Collaborator at his or her clinic for the purpose of receiving R&D approval for the research. We did not need to go to Local Research Ethics Committees since the research had received Multi-centre Research Ethics Committee (MREC) approval (ref: 06/MRE06/71). R&D approval was granted for 38 of the 40 clinics (95%) that had expressed their willingness to take part in the research. For two of the clinics who had said they were willing to take part in the research, R&D approval had not been granted by the time the online questionnaire for staff went live, so they had to be excluded. We required R&D approval not only for the clinical staff to participate in the research but also for the clinic to promote the online survey among their ethnic minority MSM attendees (as described in an earlier section).
Liaising with R&D departments, and completing the necessary paperwork, required at least one day of EM's time for each trust, ie at least 31 days in all. Completing formalities with the R&D offices was equivalent to more than six week's full-time work for the researcher. The average time between making initial contact with the R&D office in the hospital trust and their approving the clinic's participation in the study was six weeks (range 3 - 28 weeks).
Once R&D approval had been obtained, the Local Collaborator in each clinic was asked to identify and enumerate (but not name individually) the staff in their clinic who would be eligible for the questionnaire phase of the study. In November 2007 we sent an email to the key contact in each clinic and asked them to forward the email to all eligible clinical staff. The email briefly described the study and asked each staff member to complete a questionnaire concerning the sexual health needs of ethnic minority MSM. The questionnaire could be accessed online, with a direct link from the email to the questionnaire's homepage. After reading an information page, clinic staff were then asked to provide online consent before proceeding to the questionnaire.
We sent reminder emails in December 2007, in January 2008 and February 2008 to the key contact in each clinic, with a request that they forward a reminder to the staff in their clinic who were eligible to take part in the study. Recruitment stopped in March 2008.
Of the 38 clinics that agreed to take part in the survey and had R&D approval, staff from 36 clinics completed a questionnaire (London 19, outside London 17). Clinics from all but one of the target towns and cities took part in the staff survey.
So, of the 49 NHS sexual health clinics initially identified, staff from 36 clinics (73.5%) completed an online questionnaire (London 19/30, 63.5%; outside London 17/19, 89.5%). Overall 364 clinic staff completed an online questionnaire (London 152, outside London 199, unspecified 13) (table ).
NHS sexual health clinics in the 15 target towns and cities
The Local Collaborator in 30 of the 36 clinics provided information on the number of people in their clinic who were sent the email link to the clinic staff questionnaire. Using this information we estimated that 991 clinic staff were eligible for the survey in these 30 clinics (493 in London, 498 outside London). 311 people completed questionnaires in these clinics yielding a response rate of 31.4% (London 27.2%, outside London 35.5%) (table ).
The online questionnaire for sexual health clinic staff comprised both closed questions (with tick-box responses) and open questions where respondents could provide answers in their own words. The questionnaire was developed in close partnership with the BASHH Education Committee and was piloted among BASHH members.
The questionnaire sought information on:
• age, sex and ethnicity of the respondent
• training in relation to ethnicity, cultural awareness and sexuality
• experience of providing treatment and care for ethnic minority MSM
• main issues and problems facing ethnic minority MSM
The clinical director of each clinic was asked additional questions about services for MSM and men from ethnic minority backgrounds.
Since the questionnaire contained seven open questions we developed a coding scheme whereby answers to a specific question could be grouped under a number of headings. The coding scheme was initially developed by EM and then further scrutinized and finalized in a series of meetings with JE. We employed an experienced researcher to then code the answers to the open questions using the coding scheme.