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Enabling contraceptive use is critical for addressing high adolescent pregnancy rates in low- and middle-income countries (LMICs). Broader or ‘upstream’ determinants, such as poverty, education, and social norms, can affect the knowledge, attitudes, motivation, and ability to access and use contraception. Structural interventions aim to address these broader determinants, e.g., through poverty alleviation from livelihood training or cash transfers, increasing school participation, or changing social norms. We conducted an evidence synthesis using intervention component analysis, a case-based approach, following a systematic mapping of the evidence base. We identified 17 studies with 29 structural intervention arms, which reported adolescent contraceptive use outcomes compared to a control group or baseline. It was not possible to identify with certainty which interventions were ‘likely effective’ or ‘likely ineffective’ due to the high heterogeneity of the methods. We built on an existing framework of family planning use to propose three steps to designing interventions: (1) tailor interventions to adolescents’ life stages; (2) assess the baseline situation; and (3) select appropriate activities to match the gaps. These steps will aid developers and evaluators of structural adolescent contraceptive interventions to develop an evidence base that is of use across a wide range of settings and use scenarios.

Reducing adolescent childbearing is a global priority, and enabling contraceptive use is one means of achieving this. Upstream factors, e.g., gender inequalities, fertility norms, poverty, empowerment and schooling, can be major factors affecting contraceptive use. We conducted a systematic map to understand which structural adolescent contraception interventions targeting these upstream factors have been evaluated in LMICs. We searched eight academic databases plus relevant websites and a 2016 evidence gap map and screened references based on set inclusion criteria. We screened 6993 references and included 40 unique intervention evaluations, reported in 138 papers. Seventeen evaluations were reported only in grey literature. Poverty reduction/economic empowerment interventions were the most common structural intervention, followed by interventions to increase schooling (e.g., through legislation or cash transfers) and those aiming to change social norms. Half of the evaluations were RCTs. There was variation in the timing of endline outcome data collection and the outcome measures used. A range of structural interventions have been evaluated for their effect on adolescent contraceptive use/pregnancy. These interventions, and their evaluations, are heterogenous in numerous ways. Improved understandings of how structural interventions work, as well as addressing evaluation challenges, are needed to facilitate progress in enabling adolescent contraceptive use in LMICs.

Background Long-acting reversible contraception (LARC) is among the most effective contraceptive methods, but uptake remains low even in high-income settings. In 2009/2010, a target-based pay-for-performance (P4P) scheme in Britain was introduced for primary care physicians (PCPs) to offer advice about LARC methods to a specified proportion of women attending for contraceptive care to improve contraceptive choice. We examined the impact and equity of this scheme on LARC uptake and abortions. Methods and findings We examined records of 3,281,667 women aged 13 to 54 years registered with a primary care clinic in Britain (England, Wales, and Scotland) using Clinical Practice Research Datalink (CPRD) from 2004/2005 to 2013/2014. We used interrupted time series (ITS) analysis to examine trends in annual LARC and non-LARC hormonal contraception (NLHC) uptake and abortion rates, stratified by age and deprivation groups, before and after the P4P was introduced in 2009/2010. Between 2004/2005 and 2013/2014, crude LARC uptake rates increased by 32.0% from 29.6 per 1,000 women to 39.0 per 1,000 women, compared with 18.0% decrease in NLHC uptake. LARC uptake among women of all ages increased immediately after the P4P with step change of 5.36 per 1,000 women (all values are per 1,000 women unless stated, 95% CI 5.26–5.45, p < 0.001). Women aged 20 to 24 years had the largest step change (8.40, 8.34–8.47, p < 0.001) and sustained trend increase (3.14, 3.08–3.19, p < 0.001) compared with other age groups. NLHC uptake fell in all women with a step change of −22.8 (−24.5 to −21.2, p < 0.001), largely due to fall in combined hormonal contraception (CHC; −15.0, −15.5 to −14.5, p < 0.001). Abortion rates in all women fell immediately after the P4P with a step change of −2.28 (−2.98 to −1.57, p = 0.002) and sustained decrease in trend of −0.88 (−1.12 to −0.63, p < 0.001). The largest falls occurred in women aged 13 to 19 years (step change −5.04, −7.56 to −2.51, p = 0.011), women aged 20 to 24 years (step change −4.52, −7.48 to −1.57, p = 0.030), and women from the most deprived group (step change −4.40, −6.89 to −1.91, p = 0.018). We estimate that by 2013/2014, the P4P scheme resulted in an additional 4.53 LARC prescriptions per 1,000 women (relative increase of 13.4%) more than would have been expected without the scheme. There was a concurrent absolute reduction of −5.31 abortions per 1,000 women, or −38.3% relative reduction. Despite universal coverage of healthcare, some women might have obtained contraception elsewhere or had abortion procedure that was not recorded on CPRD. Other policies aiming to increase LARC use or reduce unplanned pregnancies around the same time could also explain the findings. Conclusions In this study, we found that LARC uptake increased and abortions fell in the period after the P4P scheme in British primary care, with additional impact for young women aged 20–24 years and those from deprived backgrounds., Richard Ma and colleagues study a scheme to improve uptake of long-acting reversible contraception in primary care in England, Scotland, and Wales., Author summary Why was this study done? Long-acting reversible contraception (LARC) is more effective and longer lasting than other methods such as condoms or contraceptive pills at controlling fertility. Primary care physicians (PCPs) in Britain were given financial incentives to give information on LARC methods to over 90% of women coming for contraceptive advice from 2009/2010. We wanted to find out whether this new scheme led to more LARC prescribing and fewer abortions, signifying fewer unplanned and unwanted pregnancies, particularly in younger women and those from poorer backgrounds. What did the researchers do and find? We studied health records of over 3 million women aged 13 to 54 years old, from over 600 primary care practices across Britain (England, Wales, and Scotland) from financial years 2004/2005 to 2013/2014. We compared yearly LARC prescriptions and abortions in the years before and after the LARC advice scheme was introduced in 2009/2010. We found 13% more LARC prescriptions and 38% fewer abortions than expected since the scheme was introduced, particularly in younger women aged 20–24 and those from poorer backgrounds. What do these findings mean? Financial incentives for PCPs to give LARC advice to women were associated with more LARC prescriptions and reductions in abortions. The greater impact in younger women and those from more disadvantaged backgrounds suggests potential to reduce health inequalities by improved awareness of options for effective fertility control.

Introduction Loneliness is prevalent and associated with negative health outcomes in young people. Our understanding of how it can be best addressed is limited. This systematic review aims to assess the acceptability and effectiveness of interventions to reduce and prevent loneliness and social isolation in young people. Methods Six bibliographic databases were searched; references of included studies were screened for relevant literature. A pre-defined framework was used for data extraction. Quality appraisal was performed using the Mixed Method Appraisal Tool. Data were synthesised narratively. Results 9,358 unique references were identified; 28 publications from 16 interventions met the inclusion criteria. The majority of interventions were high intensity, individual or small group interventions, often targeted at specific ‘at risk’ populations. While 14 interventions were associated with a statistically significant reduction in loneliness or social isolation, the heterogeneous measures of loneliness, small sample sizes, short periods of follow-up and high attrition rates limit evidence on effectiveness. Interventions implemented in more general populations of young people appeared more acceptable than those in specific ‘at risk’ populations. Conclusion High intensity interventions are unlikely to be feasible at a population level. Further work is required to develop and evaluate theoretically-informed loneliness interventions for young people that reach wider audiences.

IntroductionYoung people aged 16 to 24 have the highest prevalence of genital chlamydia and gonorrhoea compared with other age groups and re-infection rates following treatment are high. Long-term adverse health effects include subfertility and ectopic pregnancy, particularly among those with repeated infections. We developed the safetxt intervention delivered by text message to reduce sexually transmitted infection (STI) by increasing partner notification, condom use and (STI) testing among young people in the UK.Methods and analysisA single-blind randomised trial to reliably establish the effect of the safetxt intervention on chlamydia and gonorrhoea infection at 1 year. We will recruit 6250 people aged 16 to 24 years who have recently been diagnosed with chlamydia, gonorrhoea or non-specific urethritis from health services in the UK. Participants will be allocated to receive the safetxt intervention (text messages designed to promote safer sexual health behaviours) or to receive the control text messages (monthly messages asking participants about changes in contact details) by an automated remote online randomisation system. The primary outcome will be the cumulative incidence of chlamydia and gonorrhoea infection at 1 year assessed by nucleic acid amplification tests. Secondary outcomes include partner notification, correct treatment of infection, condom use and STI testing prior to sex with new partners.Ethics and disseminationEthics approval was obtained from NHS Health Research Authority - London – Riverside Research Ethics Committee (REC reference: 15/LO/1665) and the London School of Hygiene & Tropical Medicine. We will submit the results of the trial for publication in peer-reviewed journals.Trial registration numberInternational Standard Randomised Controlled Trials Number:ISRCTN64390461. Registered on 17thMarch 2016.WHO trial registration data setavailable at:http://apps.who.int/trialsearch/Trial2.aspx?TrialID=ISRCTN64390461.Trial protocol version12, 19thJuly 2018.

AimTo describe prevalence and trends in contraceptive method use in Britain through a comparison of the second and third National Surveys of Sexual Attitudes and Lifestyles (Natsal-2 and Natsal-3).MethodsCross-sectional probability sample surveys. General population sample of women aged 16–44 years, resident in Britain, with ever-experience of vaginal sex and, for analysis by sociodemographic characteristics, vaginal sex in the last year. Main outcome measure was current contraceptive method use (‘usual these days’), categorised by effectiveness.ResultsPrevalence of current contraceptive use among women who had ever had vaginal sex declined between Natsal-2 and Natsal-3, 83.5% (95% CI 82.4 to 84.5) and 76.4% (95% CI 75.0 to 77.7), respectively. The condom and oral contraceptive pill remain the most commonly used methods. One in five women reported use of a most effective method. While no difference was found between surveys in use of most effective methods, a decline in sterilisation use was compensated by an increase in long-acting reversible contraceptive (LARC) use. Increased LARC use was particularly evident among under-25s compared with women aged 40–44 years (OR 11.35, 95% CI 3.23 to 39.87) and a decline was observed among those with two or more children relative to those with none (OR 0.21, 95% CI 0.13 to 0.35).ConclusionsStrategies to improve access to LARC methods have been particularly successful in increasing uptake among young people in the first decade of the 21st century. Whether this trajectory is maintained given changing sociodemographic characteristics and more recent financial cuts to sexual health service provision will warrant investigation.

Background Adolescents who self-harm are often unsure how or where to get help. We developed a Web-based personalized decision aid (DA) designed to support young people in decision making about seeking help for their self-harm. Objective The aim of this study was to evaluate the feasibility and acceptability of the DA intervention and the randomized controlled trial (RCT) in a school setting. Methods We conducted a two-group, single blind, randomized controlled feasibility trial in a school setting. Participants aged 12 to 18 years who reported self-harm in the past 12 months were randomized to either a Web-based DA or to general information about mood and feelings. Feasibility of recruitment, randomization, and follow-up rates were assessed, as was acceptability of the intervention and study procedures. Descriptive data were collected on outcome measures examining decision making and help-seeking behavior. Qualitative interviews were conducted with young people, parents or carers, and staff and subjected to thematic analysis to explore their views of the DA and study processes. Results Parental consent was a significant barrier to young people participating in the trial, with only 17.87% (208/1164) of parents or guardians who were contacted for consent responding to study invitations. Where parental consent was obtained, we were able to recruit 81.7% (170/208) of young people into the study. Of those young people screened, 13.5% (23/170) had self-harmed in the past year. Ten participants were randomized to receiving the DA, and 13 were randomized to the control group. Four-week follow-up assessments were completed with all participants. The DA had good acceptability, but qualitative interviews suggested that a DA that addressed broader mental health problems such as depression, anxiety, and self-harm may be more beneficial. Conclusions A broad-based mental health DA addressing a wide range of psychosocial problems may be useful for young people. The requirement for parental consent is a key barrier to intervention research on self-harm in the school setting. Adaptations to the research design and the intervention are needed before generalizable research about DAs can be successfully conducted in a school setting. Trial Registration International Standard Randomized Controlled Trial registry: ISRCTN11230559; http://www.isrctn.com/ISRCTN11230559 (Archived by WebCite at http://www.webcitation.org/6wqErsYWG)

Objective To test the procedures proposed for a main trial of a safer sex intervention for young people delivered by mobile phone text message (‘safetxt’). Design and setting Pilot randomised controlled trial. Participants were recruited through sexual health services in the UK. An independent online randomisation system allocated participants to receive the safetxt intervention or to receive the control text messages (monthly messages about participation in the study). Texting software delivered the messages in accordance with a predetermined schedule. Participants Residents of England aged 16–24 who had received either a positive chlamydia test result or reported unsafe sex in the last year (defined as more than 1 partner and at least 1 occasion of sex without a condom). Intervention The safetxt intervention is designed to reduce sexually transmitted infection in young people by supporting them in using condoms, telling a partner about an infection and testing before unprotected sex with a new partner. Safetxt was developed drawing on: behavioural science; face-to-face interventions; the factors known to influence safer sex behaviours and the views of young people. Outcomes The coprimary outcomes of the pilot trial were the recruitment rate and completeness of follow-up. Results We recruited 200 participants within our target of 3 months and we achieved 81% (162/200) follow-up response for the proposed primary outcome of the main trial, cumulative incidence of chlamydia at 12 months. Conclusions Recruitment, randomisation, intervention delivery and follow-up were successful and a randomised controlled trial of the safetxt intervention is feasible. Trial registration number ISRCTN02304709; Results.

Summary Background In 2000, a 10-year Teenage Pregnancy Strategy was launched in England to reduce conceptions in women younger than 18 years and social exclusion in young parents. We used routinely collected data and data from Britain's National Surveys of Sexual Attitudes and Lifestyles (Natsal) to examine progress towards these goals. Methods In this observational study, we used random-effects meta-regression to analyse the change in conception rates from 1994–98 to 2009–13 by top-tier local authorities in England, in relation to Teenage Pregnancy Strategy-related expenditure per head, socioeconomic deprivation, and region. Data from similar probability sample surveys: Natsal-1 (1990–91), Natsal-2 (1999–2001), and Natsal-3 (2010–12) were used to assess the prevalence of risk factors and their association with conception in women younger than 18 years in women aged 18–24 years; and the prevalence of participation in education, work, and training in young mothers. Findings Conception rates in women younger than 18 years declined steadily from their peak in 1996–98 and more rapidly from 2007 onwards. More deprived areas and those receiving greater Teenage Pregnancy Strategy-related investment had higher rates of conception in 1994–98 and had greater declines to 2009–13. Regression analyses assessing the association between Teenage Pregnancy Strategy funding and decline in conception rates in women younger than 18 years showed an estimated reduction in the conception rate of 11·4 conceptions (95% CI 9·6–13·2; p

Ensuring that sexually active adolescents are using contraception consistently and correctly is an effective means of reducing unplanned pregnancy. Use of highly effective long-acting reversible methods, such as subdermal implants, is low. We need to challenge the perception that the pill and condoms, the most commonly used contraceptive methods, are always the most suitable methods for young people. Changes in adolescent sexual behaviour, including increased number of sexual partners, is consistent with a rise in sexually transmitted infections. No contraceptive methods, with the exception of male or female sterilisation, are contra-indicated solely on the grounds of age. Young people need to be counselled about both the benefits and risks associated with each method so that they can make an informed choice. Most of the clinical evidence on contraceptive use comes from studies of 'older' women, with little research identified that specifically addressed implications for adolescent contraceptive use.

Objectives: Young black women are disproportionately affected by sexually transmitted infections (STI) in the UK, but effective interventions to address this are lacking. The Young Brent Project explored the nature and context of sexual risk-taking in young people to inform the translation of an effective clinic-based STI reduction intervention (Project SAFE) from the USA to the UK. Methods: One-to-one in-depth interviews (n = 37) and group discussions (n = 10) were conducted among men and women aged 15–27 years from different ethnic backgrounds recruited from youth and genitourinary medicine clinic settings in Brent, London. The interviews explored the context within which STI-related risks were assessed, experienced and avoided, the skills needed to recognise risk and the barriers to behaviour change. Results: Concurrent sexual partnerships, mismatched perceptions and expectations, and barriers to condom use contributed to STI risk exposure and difficulties in implementing risk-reduction strategies. Women attempted to achieve monogamy, but experienced complex and fluid sexual relationships. Low risk awareness, flawed partner risk assessments, negative perceptions of condoms and lack of control hindered condom use. Whereas men made conscious decisions, women experienced persuasion, deceit and difficulty in requesting condom use, particularly with older partners. Conclusions: Knowledge of STI and condom use skills is not enough to equip young people with the means to reduce STI risk. Interventions with young women need to place greater emphasis on: entering and maintaining healthy relationships; awareness of risks attached to different forms of concurrency and how concurrency arises; skills to redress power imbalances and building self-esteem.

Objective To describe contraceptive service use and identify demographic and sexual behavioural characteristics associated with use (and non-use) of different services. Methods Probability survey sample of men and women aged 16–44 years, resident in Britain. Participants comprised 3369 men and 4375 women reporting vaginal intercourse in the last year (excluding those reporting exclusive use of sterilisation or medical investigations for infertility). Main outcome measures were use of contraceptive services, grouped as: general practice, community contraceptive clinics, retail services and nonuse of services. Results General practice was the most commonly reported source of contraceptive supplies for women (59.2%), while retail services were most frequently reported by men (42.7%). 16.3% of women and 7.3% of men reported using more than one type of service. 20.7% of women and 45.1% of men had used no service in the last year, and amongst 16–17-year-olds the proportions reporting non-use of services was 13.8% and 31.2%, respectively. Use of community contraceptive clinics was associated with being younger, childless, single and reporting more heterosexual partners in the last year. Conclusions There was relatively little 9shopping around9 between different services, suggesting that choice of contraceptive providers ensures a range of needs is met for most people. While general practice is the most commonly used source of supplies, community contraceptive clinics are seeing those potentially at higher sexual health risk, particularly the young and those with multiple partners. Ways of improving young people9s access to services for contraceptive supplies need to be addressed.

This paper presents data on the sexual health perspectives of young British Bangladeshis and their mothers. It discusses the implications of these data for the development of appropriate sexual health education. Between April and September 2006, 36 young people and 25 mothers of Bangladeshi young people were interviewed through seven focus group discussions. Groups were gender and age specific (16-18 years, 19-20 years and mothers). Recruitment took place in community-based organisations in an inner city London borough. Mothers expressed concern about pre-marital sex but felt unable to control out-of-home activity. Feelings of isolation, lack of control and communication difficulties were key issues for them. Young people had varied perspectives on pre-marital sex. Some experienced emotional conflict between what was expected of them in terms of their faith and their engagement in intimate relationships. Both the young people and mothers highlighted the need for sex and relationship education to take account of cultural perspectives and the involvement of parents and the wider community. However, parents and community representatives require information and communication support to enable this involvement. Sex and relationships education content needs to be inclusive, have both secular and faith perspectives and engage where relevant with local communities.

Objective To measure agreement between the client9s and the clinician9s responses to questions regarding client history as answered on a questionnaire based on the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) for combined hormonal contraception (CHC). Methods Clients aged 18 years and over, attending a central London community contraceptive clinic requesting a repeat supply of CHC, completed a history questionnaire and an evaluation form. Clinicians then completed their copy of the same questionnaire during the consultation. Percentage agreement and the Kappa statistic were used to assess the level of client—clinician agreement. Results Data from 328 client—clinician pairs were analysed. Agreement was above 93% for all identified risk factors. There was complete agreement for thrombosis, diabetes, stroke, cancer and liver problems. Least agreement was noted in the recording of migraine and abnormal bleeding. For all risk factors except smoking, the proportion of clients reporting a risk factor was more than the proportion of clinicians reporting a risk factor. No clinically important information relevant to a particular client9s use of CHC was missed and none of them would have been wrongly prescribed the CHC based just on their self-completed questionnaires. Most women (97%) were happy with this method of history taking. Conclusions A self-completed history questionnaire is acceptable to women and can potentially replace traditional routine medical history taking for continuing CHC. Women completed the questionnaire with a high degree of reliability. There was complete client—clinician agreement on UKMEC Category 4 criteria. Overall, clients reported more risk factors than clinicians, which increases the safety of the questionnaire.

INTRODUCTION: Self-harm is common in adolescents, and it is the strongest predictor of suicide. Young people who self-harm are often unsure of how and where to get help. Decision aids (DAs) have been shown to help with decisional conflict where there is uncertainty around different options. We have developed an online DA to support young people in help-seeking for self-harm. A feasibility trial will examine the acceptability of the online intervention and the ability to recruit and follow-up participants within a school setting. METHODS AND ANALYSIS: In this parallel arm, single-blind feasibility trial, 60 participants aged 12-18 years who have self-harmed in the past 12 months, will be randomised to either (1) a group receiving the online DA or (2) a control group receiving general information about feelings and emotions. Both groups will complete measures assessing decision-making and help-seeking behaviour. The school counsellor will be notified of any participants who have been randomised to ensure safeguarding for the young person. Participants in both groups will be followed up at 4 weeks, and the measures will be repeated. Qualitative interviews will be conducted with a subset of participants to explore their views and experiences of the DA and of participation in the study. ETHICS AND DISSEMINATION: Ethical approval was granted by King's College London (KCL) College Research Ethics Committee. Results of this study will help to clarify if we can recruit and administer an online decisional support intervention within a school setting for young people who self-harm. The study will inform the design and implementation of a larger randomised controlled trial to test the effectiveness of the DA. Dissemination of the study findings will target publication in peer-reviewed journals of general and special interest. The funder will be sent a report outlining the major findings of the study. TRIAL REGISTRATION NUMBER: ISRCTN11230559.

BackgroundYounger people bear the heaviest burden of sexually transmitted infections (STIs). Partner notification, condom use and STI testing can reduce infection but many young people lack the knowledge, skills and confidence needed to carry out these behaviours. Text messages can provide effective behavioural support. The acceptability and feasibility of a randomised controlled trial of safer sex support delivered by text message are not known.ObjectivesTo assess the acceptability and feasibility of a randomised controlled trial of a safer sex intervention delivered by text message for young people aged 16–24 years.Design(1) Intervention development; (2) follow-up procedure development; (3) a pilot, parallel-arm randomised controlled trial with allocation via remote automated randomisation (ratio of 1 : 1) (participants were unmasked, whereas researchers analysing samples and data were masked); and (4) qualitative interviews.SettingParticipants were recruited from sexual health services in the UK.ParticipantsYoung people aged 16–24 years diagnosed with chlamydia or reporting unprotected sex with more than one partner in the last year.InterventionsA theory- and evidence-based safer sex intervention designed, with young people’s input, to reduce the incidence of STIs by increasing the correct treatment of STIs, partner notification, condom use and STI testing before unprotected sex with a new partner. The intervention was delivered via automated mobile phone messaging over 12 months. The comparator was a monthly text message checking contact details.Main outcome measures(1) Development of the intervention based on theory, evidence and expert and user views; (2) follow-up procedures; (3) pilot trial primary outcomes: full recruitment within 3 months and follow-up rate for the proposed primary outcomes for the main trial; and (4) participants’ views and experiences regarding the acceptability of the intervention.ResultsIn total, 200 participants were randomised in the pilot trial, of whom 99 were allocated to the intervention and 101 were allocated to the control. We fully recruited early and achieved an 81% follow-up rate for our proposed primary outcome of the cumulative incidence of chlamydia at 12 months. There was no differential follow-up between groups. In total, 97% of messages sent were successfully delivered to participants’ mobile phones. Recipients reported that the tone, language, content and frequency of messages were appropriate. Messages reportedly increased knowledge of and confidence in how to use condoms and negotiate condom use and reduced stigma about STIs, enabling participants to tell a partner about a STI.ConclusionsOur research shows that the intervention is acceptable and feasible to deliver. Our pilot trial demonstrated that a main trial is feasible. It remains unclear which behaviour change techniques and elements of the intervention or follow-up procedures are associated with effectiveness. A further limitation is that in the trial one person entering data and the participants were unmasked. A randomised controlled trial to establish the effects of the intervention on STIs at 12 months is needed.Trial registrationCurrent Controlled Trials ISRCTN02304709.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 57. See the NIHR Journals Library website for further project information.

Objective: Self-harm is common in adolescence, but most young people who self-harm do not seek professional help. The aim of this literature review was to determine (a) the sources of support adolescents who self-harm access if they seek help, and (b) the barriers and facilitators to help-seeking for adolescents who self-harm. Method: Using a pre-defined search strategy we searched databases for terms related to self-harm, adolescents and help-seeking. Studies were included in the review if participants were aged 11–19 years. Results: Twenty articles met criteria for inclusion. Between a third and one half of adolescents who self-harm do not seek help for this behaviour. Of those who seek help, results showed adolescents primarily turned to friends and family for support. The Internet may be more commonly used as a tool for self-disclosure rather than asking for help. Barriers to help-seeking included fear of negative reactions from others including stigmatisation, fear of confidentiality being breached and fear of being seen as ‘attention-seeking’. Few facilitators of help-seeking were identified. Conclusions: Of the small proportion of adolescents who seek help for their self-harm, informal sources are the most likely support systems accessed. Interpersonal barriers and a lack of knowledge about where to go for help may impede help-seeking. Future research should address the lack of knowledge regarding the facilitators of help-seeking behaviour in order to improve the ability of services to engage with this vulnerable group of young people.

This paper describes an independent evaluation of a peer-led STD/HIV prevention intervention conducted by Gay Men Fighting AIDS (GMFA) in a public sex environment (PSE). A variety of quantitative and qualitative research methods were employed to collect data on the intervention process as well as its outcomes. The main aim of the intervention was the distribution of condoms and safer sex literature to PSE users. During a five-month period, over 100,000 condoms and 2,200 safer sex information packs were distributed by GMFA volunteers to the PSE users. Condom provision was identified as the most needed health promotion activity in PSEs in a survey of gay and bisexual men (n = 688) conducted by the evaluators. Data collected showed that condoms provided by GMFA, as well as from other sources, were being used in the PSE. The peer-led focus of the intervention was acceptable to the PSE users. In addition, high levels of commitment and input from the volunteers contributed considerable added value to the intervention. The evaluation found that GMFA was successful in reaching the target population and addressing their needs and demands.

BACKGROUND: The purpose of this study was to examine variation in positivity within the English National Chlamydia Screening Programme during 2007/2008. METHODS: Data were analyzed using multivariable logistic regression. The outcome measure was positivity. Funnel plots were used to explore variation in positivity according to screening volume. RESULTS: Three hundred and thirty-four thousand nine hundred and two screening tests were done, 29% of which were in men. Overall positivity was 7.6% in men and 9.3% in women. For men, positivity increased rapidly to plateau from ages 19 to 24. For women, rates peaked at 18 years-those aged 21 being at the same risk of chlamydial infection as 16-year-olds. For men and women, positivity was generally higher for those of black or mixed ethnicity compared with whites, whereas Asians were at lower risk. Similarly, risk of infection for men and women varied by screening venue. Multivariable analysis showed that, for men and women positivity varied significantly with age, ethnicity, screening venue attended, whether the young people had had a new sexual partner in the past 3 months, and whether the patient had had 2 or more sexual partners in the past year. Positivity did not vary significantly with implementation phase. CONCLUSIONS: This is the largest description of testing for Chlamydia trachomatis in healthcare and nonhealthcare settings outside Genitourinary Medicine clinics in England and allowed a detailed analysis of positivity by age and ethnic group. Considerable heterogeneity exists and local health service commissioners need to ensure that the implementation of chlamydial screening reflects these differences.

Purpose: To describe young people's knowledge and use of contraceptive services over initial stages of England's Teenage Pregnancy Strategy, and to investigate factors associated with use of different services.Methods: A random location sample of young people aged 13-21 years (n = 8879) was interviewed in 12 waves over 2000-2004. Individual data were analysed to investigate factors associated with knowledge and use of contraceptive services and to observe trends over time. Area-level data were analyzed to explore differences in key variables.Results: In all, 77% of young women and 65% of young men surveyed knew a service they could use to obtain information about sex. Amongst those who had had vaginal sexual intercourse, the most common source of contraceptive supplies was general practice for young women (54%) and commercial venues for young men (54%). Young women's use of school-based services to obtain supplies increased significantly from 15.4% in Year I to 24.4% in Year 4, p

Summary Background The aim of this study was to quantify the change in the number of conceptions and abortions among women younger than 18 years in England in relation to the government's national teenage pregnancy strategy. Methods We undertook geographic analysis of data for 148 top-tier local authority areas. The main outcomes were changes in under-18 conceptions, abortions, and births between the 5-year period before implementation of the strategy (1994–98) and the period immediately after implementation (1999–2003). Findings The number of teenage conceptions peaked in 1998, then declined after the implementation in 1999 of the teenage pregnancy strategy. Under-18 conception rates fell by an average of 2·0% (95% CI 1·8 to 2·2) per year between 1998 and 2003, below the rate needed to achieve the target of 50% reduction by 2010. The net change between 1994–98 and 1999–2003 was a fall in conceptions of 3·2% (2·6 to 3·9) or 1·4 per 1000 women aged 15–17 years, a rise in abortions of 7·5% (6·5 to 8·6) or 1·4 per 1000, and a fall in births of 10·6% (9·9 to 11·3) or 2·8 per 1000. The change in the number of conceptions was greater in deprived and more rural areas, and in those with lower educational attainment. The change was greater in areas where services and access to them were poorer, but greater where more strategy-related resources had been targeted. Interpretation The decline in under-18 conception and birth rates since 1998 and evidence that the declines have been greatest in areas receiving higher amounts of strategy-related funding provides limited evidence of the effect of England's national teenage pregnancy strategy. The full effect of local prevention will be clear only with longer observation, and substantial further progress is needed to remedy England's historically poor international position in teenage conceptions.

High rates of sexually transmitted infections (STIs) and unplanned pregnancy amongst young people in England emphasize the need to explore innovative ways of delivering sexual health information. The National Teenage Pregnancy Strategy and the National Strategy for Sexual Health and HIV advocate better sexual health education. The latter states: "Information on sexual health is often uncoordinated or poorly targeted. It is not consistently accessible and doesnt make enough use of new media and technology". The Internet is a practical accessible tool for increasing sexual health awareness. Sexual health sites can be particularly valuable information sources for young people who have trouble accessing sexual health services and can be used to publicise services by providing information that tackles access barriers (e.g. confidentiality for all ages free emergency contraception how to get there and so on). Access content site quality and level of maintenance are four components we feel should be considered prior to the development of sexual health sites. We present these as a starting point to encourage further debate on the use and evaluation of the Internet in sexual health promotion and to build on Susan Quilliams review of self-help websites in this issue of the journal. (excerpt)

Information on age- and gender-specific prevalence of herpes simplex virus (HSV) types 1 and 2 infections is crucial to guide genital herpes control strategies. Such data are not available from the newly independent Eastern European countries. We present of study of the age- and gender-specific prevalence of HSV-1 and HSV-2 in low risk populations in Estonia. Serum samples from 1016 children, 794 first trimester antenatal women, and 1036 blood donors (462M, 574F) were tested for HSV IgG antibodies by type-specific HSV-1 and HSV-2 assays. High seroprevalence rates of HSV-1 among children, pregnant women and (non-paid) blood donors were found. HSV-2 infection was not detected among boys. Gender differences in HSV-2 seroprevalence rates among people of reproductive age were observed: higher rates were recorded among pregnant women (23%) and female blood donors (21%), compared to 11% among male blood donors. HSV-1 seroprevalence was high in adults. HSV-2 seroprevalence was higher among females than males and increased substantially with age. HSV-2 prevalence in these non-high risk populations was relatively high, and may indicate a risk for an impending sexually- and STI- driven HIV epidemic.

In the United Kingdom, services for contraceptive consultation and family planning were first opened in the 1960s. Early and relevant information to adolescents is of importance. The aim of this paper was to examine young people's attitudes towards and experiences of consultations with health care providers about contraception, taking account of the context of their contraceptive use. Young people aged 16-21 years were recruited to the study from health services (young people's contraceptive and sexual health clinics and a termination of pregnancy clinic), secondary schools and community projects (a youth club, a young mothers' support group, a community education project and a young women offenders unit). As part of the needs' assessment, in-depth interviews and focus groups were conducted. Thirty-two young male and females were interviewed. Knowledge about contraception, sexually transmitted infections and the risk of pregnancy was often high. Many respondents noted that in a five to ten minute consultation there was not the time to discuss personal factors that may affect contraceptive decision making and effective use of methods. Many described a feeling of being rushed through the service and did not feel they had the opportunity to ask questions. What young people said they wanted from consultations with health care workers and their experiences of the consultation process often conflicted. They wanted the time and opportunity to discuss their options. Often the young men, who were accessing services, described how initially they had gone in to collect condoms, but once they knew the clinic and staff would consider making an appointment. It is concluded that young people want to be given choices and information regarding contraception that fit their lifestyles. Improving the structures of contraceptive and sexual health services for young people will help to remove some of the barriers that prevent some young people from accessing them. However, it is just as important that barriers in the service delivery are tackled to ensure young people receive effective contraceptive advice.

Objective: To evaluate the feasibility and effectiveness of a standardized HIV partner notification programme within genitourinary medicine clinics in England. Design: A prospective survey of HIV partner notification activity over a 12-month period. Setting: Nineteen genitourinary medicine clinics in England. Patients and participants: A total of 501 eligible HIV-positive patients (either newly diagnosed or with whom partner notification had not been undertaken previously) seen during the study period. Main outcome measures: The numbers of partners named by patients, and the number of contacts notified, counselled and HIV-tested. Results: Information on overall partner notification activity was obtained by reviewing available medical records of 471 patients; 353 (75%) had discussed partner notification with a health-care worker during the study period and 197 (42%) had undertaken partner notification. Detailed information on outcomes was obtained for only 70 patients who named 158 contacts as being at risk of acquiring HIV. Although 71 (45%) contacts were eventually notified, only 28 were subsequently seen in participating clinics. Almost all contacts (n = 27) requested HIV counselling and testing, and five were diagnosed HIV-positive. Patient referral was the most popular notification method chosen. Conclusions: This study illustrates some of the practical difficulties that limit HIV partner notification within genitourinary medicine clinics. These include health-care workers' misgivings about undertaking partner notification, insufficient locating information to identify contacts, and migration of newly diagnosed patients, which prevents continuity and completion of notification. Nevertheless, HIV partner notification uncovered previously undiagnosed HIV infections. Further work needs to be undertaken in staff training and policy implementation if higher rates of partner notification and outcome measurements are to be achieved.

Loss to follow-up in randomised controlled trials reduces statistical power and increases the potential for bias. Almost half of all trials fail to achieve their follow-up target. Statistical methods have been described for handling losses to follow-up and systematic reviews have identified interventions that increase follow-up. However, there is little guidance on how to develop practical follow-up procedures. This paper describes the development of follow-up procedures in a pilot randomised controlled trial of a sexual health intervention that required participants to provide and return questionnaires and chlamydia test samples in the post. We identified effective methods to increase follow-up from systematic reviews. We developed and tested prototype procedures to identify barriers to follow-up completion. We asked trial participants about their views on our follow-up procedures and revised the methods accordingly.We identified 17 strategies to increase follow-up and employed all but five. We found that some postal test kits do not fit through letterboxes and that that the test instructions were complicated. After identifying the appropriate sized test kit and simplifying the instructions, we obtained user opinions. Users wanted kits to be sent in coloured envelopes (so that they could identify them easily), with simple instructions and questionnaires and wanted to be notified before we sent the kits. We achieved 92 % (183/200) overall follow-up for the postal questionnaire at 1 month and 82 % (163/200) at 12 months. We achieved 86 % (171/200) overall follow-up for the postal chlamydia test at 3 months and 80 % (160/200) at 12 months.By using established methods to increase follow-up, testing prototype procedures and seeking user opinions, we achieved higher follow-up than previous sexual health trials. However, it is not possible to determine if the increase in response was due to our follow-up procedures.Current Controlled Trials ISRCTN02304709 Date of registration: 27 March 2013.