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Objectives1.5 million people in the UK have mild to moderate learning disabilities. STIs and bloodborne viruses (BBVs) are over-represented in people experiencing broader health inequalities, which include those with mild learning disabilities. Self-managed care, including self-sampling for STIs/BBVs, is increasingly commonplace, requiring agency and health literacy. To inform the development of a partner notification trial, we explored barriers and facilitators to correct use of an STI/BBV self-sampling pack among people with mild learning disabilities.MethodsUsing purposive and convenience sampling we conducted four interviews and five gender-specific focus groups with 25 people (13 women, 12 men) with mild learning disabilities (July–August 2018) in Scotland. We balanced deductive and inductive thematic analyses of audio transcripts to explore issues associated with barriers and facilitators to correct use of the pack.ResultsAll participants found at least one element of the pack challenging or impossible, but welcomed the opportunity to undertake sexual health screening without attending a clinic and welcomed the inclusion of condoms. Reported barriers to correct use included perceived overly complex STI/BBV information and instructions, feeling overwhelmed and the manual dexterity required for blood sampling. Many women struggled interpreting anatomical diagrams depicting vulvovaginal self-swabbing. Facilitators included pre-existing STI/BBV knowledge, familiarity with self-management, good social support and knowing that the service afforded privacy.ConclusionIn the first study to explore the usability of self-sampling packs for STI/BBV in people with learning disabilities, participants found it challenging to use the pack. Limiting information to the minimum required to inform decision-making, ‘easy read’ formats, simple language, large font sizes and simpler diagrams could improve acceptability. However, some people will remain unable to engage with self-sampling at all. To avoid widening health inequalities, face-to-face options should continue to be provided for those unable or unwilling to engage with self-managed care.

PurposeThis paper describes the process of optimising a widely offered intervention - the self-sampling pack for sexually transmitted infections (STIs) and blood born viruses (BBVs). We drew upon the BCW approach, incorporating the theoretical domains framework (TDF) and the behaviour change technique taxonomy (BCTT) to systematically specify potential intervention components that may optimise the packs.MethodsA behaviour change wheel analysis built upon prior thematic analyses of qualitative data collected through focus groups and interviews with members of the public and people recruited from sexual health clinics in Glasgow and London (n=56). Salient barriers and facilitators to specific sequential behavioural domains associated with wider behavioural system of pack-use were subjected to further analyses, coding them in relation to the TDF, the BCW’s intervention functions, and finally specifying potential optimisation in relation to behaviour change techniques (BCTs).ResultsOur TDF analysis suggested that across the overall behavioural system of pack use the most important theoretical domains were ‘beliefs about consequences’ and ‘memory, attention and decision-making’. BCW analysis on the overall pack suggested useful intervention functions should focus on ‘environmental restructuring’, ‘persuasion’, ‘enablement’, ‘education’ and ‘modelling’. Ways of optimising the intervention were also specified in relation to potentially useful behaviour change techniques (BCTs).ConclusionsA detailed behavioural analysis building on earlier qualitative work using the TDF and the BCW provided a systematic approach to optimising an existing intervention. The approach enabled the specification of highly specific, evidence-based, and theoretically informed recommendations for intervention optimisation.What is already known on this subject?The use of self-sampling packs for sexually transmitted infections (STIs) and blood borne viruses (BBVs) has been widely implemented without in-depth assessment of user perspectives, adequate theorisation in relation to behaviour change, or optimisationIn a previous qualitative study we reported on our use of thematic analyses (inductive and deductive) to understand the behavioural system of using self-sampling packs. We identified multiple modifiable barriers, and several important facilitators to using these packs, and their content, correctlyOur thematic analyses showed that self-sampling packs offered a largely acceptable approach to STI and BBV testing and that with some modification it may be possible to increase both the range of people who can benefit from them and increase the return of samplesWhat does this study add?This study theorises key barriers and facilitators to each sequential step within the behavioural system of using the self-sampling pack. Across the whole behavioural system of pack use we identified ‘beliefs about consequences’ and ‘memory, attention and decision-making’ as being particularly important theoretical domainsTo optimise self-sampling packs for STIs, our use of the behaviour change wheel suggested that to modify the pack we should use intervention functions that detail environmental restructuring and assist the user using pack contents through persuasion and enablement with some education and modellingThe study provides an exemplar of how to use the behaviour change wheel within the process of intervention optimisation when building upon prior qualitative analyses. The results informed the redesign of the pack and the development of on-line support materials to be used within a large multi-site trial

A clinical prediction rule can be used to predict asymptomatic chlamydia/gonorrhea infections among women and heterosexual men using an Internet-based testing service in British Columbia, Canada (GetCheckedOnline.com). Supplemental digital content is available in the text., Background Clinical prediction rules (CPRs) can be used in sexually transmitted infection (STI) testing environments to prioritize individuals at the highest risk of infection and optimize resource allocation. We previously derived a CPR to predict asymptomatic chlamydia and/or gonorrhea (CT/NG) infection among women and heterosexual men at in-person STI clinics based on 5 predictors. Population differences between clinic-based and Internet-based testers may limit the tool's application across settings. The primary objective of this study was to assess the validity, sensitivity, and overall performance of this CPR within an Internet-based testing environment (GetCheckedOnline.com). Methods We analyzed GetCheckedOnline online risk assessment and laboratory data from October 2015 to June 2019. We compared the STI clinic population used for CPR derivation (data previously published) and the GetCheckedOnline validation population using χ2 tests. Calibration and discrimination were assessed using the Hosmer-Lemeshow goodness-of-fit test and the area under the receiver operating curve, respectively. Sensitivity and the fraction of total screening tests offered were quantified for CPR-predicted risk scores. Results Asymptomatic CT/NG infection prevalence in the GetCheckedOnline population (n = 5478) was higher than in the STI clinic population (n = 10,437; 2.4% vs. 1.8%, P = 0.007). When applied to GetCheckedOnline, the CPR had reasonable calibration (Hosmer-Lemeshow, P = 0.90) and discrimination (area under the receiver operating characteristic, 0.64). By screening only individuals with total risk scores ≥4, we would detect 97% of infections and reduce screening by 14%. Conclusions The application of an existing CPR to detect asymptomatic CT/NG infection is valid within an Internet-based STI testing environment. Clinical prediction rules applied online can reduce unnecessary STI testing and optimize resource allocation within publicly funded health systems.

Mass media and communication interventions can play a role in increasing HIV testing among gay, bisexual and other men who have sex with men (GBMSM). Despite the key role of social marketing principles and visual design within intervention development of this type, evidence is limited regarding interventions’ social marketing mix or visual design. As part of a systematic review, intervention content was assessed using social marketing theory and social semiotics. Data were extracted on the nature of the intervention, mode of delivery, use of imagery, content and tone and the eight key characteristics of social marketing. Data were synthesised narratively. Across the 19 included studies, reference to social marketing principles was often superficial. Common design features were identified across the interventions, regardless of effectiveness, including: the use of actors inferred to be GBMSM; use of ‘naked’ and sexually explicit imagery; and the use of text framed as statements or instructions. Our results suggest that effective interventions tended to use multiple modes of delivery, indicating high social marketing complexity. However, this is only part of intervention development, and social marketing principles are key to driving the development process. We identified consistent aspects of intervention design, but were unable to determine whether this is based on evidence of effectiveness or a lack of originality in intervention design. An openness to novel ideas in design and delivery is key to ensuring that evidence-informed interventions are effective for target populations.

Background Antimicrobial stewardship (AMS) describes activities concerned with safe-guarding antibiotics for the future, reducing drivers for the major global public health threat of antimicrobial resistance (AMR), whereby antibiotics are less effective in preventing and treating infections. Appropriate antibiotic prescribing is central to AMS. Whilst previous studies have explored the effectiveness of specific AMS interventions, largely from uni-professional perspectives, our literature search could not find any existing evidence evaluating the processes of implementing an integrated national AMS programme from multi-professional perspectives.Methods This study sought to explain mechanisms affecting the implementation of a national antimicrobial stewardship programme, from multi-professional perspectives. Data collection involved in-depth qualitative telephone interviews with 27 implementation lead clinicians from 14/15 Scottish Health Boards and 15 focus groups with doctors, nurses and clinical pharmacists (n=72) from five Health Boards, purposively selected for reported prescribing variation. Data was first thematically analysed, barriers and enablers were then categorised, and Normalisation Process Theory (NPT) was used as an interpretive lens to explain mechanisms affecting the implementation process. Analysis addressed the NPT questions ‘ which group of actors have which problems , in which domains, and what sort of problems impact on the normalisation of AMS into everyday hospital practice’ .Results Results indicated that major barriers relate to organisational context and resource availability. AMS had coherence for implementation leads and prescribing doctors; less so for consultants and nurses who may not access training. Conflicting priorities made obtaining buy-in from some consultants difficult; limited role perceptions meant few nurses or clinical pharmacists engaged with AMS. Collective individual and team action to implement AMS could be constrained by lack of medical continuity and hierarchical relationships. Reflexive monitoring based on audit results was limited by the capacity of AMS Leads to provide direct feedback to practitioners.Conclusions This study provides original evidence of barriers and enablers to the implementation of a national AMS programme, from multi-professional, multi-organisational perspectives. The use of a robust theoretical framework (NPT) added methodological rigour to the findings. Our results are of international significance to healthcare policy makers and practitioners seeking to strengthen the sustainable implementation of hospital AMS programmes in comparable contexts.

ObjectivesUK Black African/Black Caribbean women remain disproportionately affected by HIV. Although oral pre-exposure prophylaxis (PrEP) could offer them an effective HIV prevention method, uptake remains limited. This study examined barriers and facilitators to PrEP awareness and candidacy perceptions for Black African/Black Caribbean women to help inform PrEP programmes and service development.MethodsUsing purposive sampling through community organisations, 32 in-depth, semi-structured interviews were conducted with Black African/Black Caribbean women living in London and Glasgow between June and August 2018. Participants (aged 19–63) included women of varied HIV statuses to explore perceptions of sexual risk and safer sex, sexual health knowledge and PrEP attitudes. A thematic analysis guided by the Social Ecological Model was used to explore how PrEP perceptions intersected with wider safer sex understandings and practices.ResultsFour key levels of influence shaping safer sex notions and PrEP candidacy perceptions emerged: personal, interpersonal, perceived environment and policy. PrEP-specific knowledge was low and some expressed distrust in PrEP. Many women were enthusiastic about PrEP for others but did not situate PrEP within their own safer sex understandings, sometimes due to difficulty assessing their own HIV risk. Many felt that PrEP could undermine intimacy in their relationships by disrupting the shared responsibility implicit within other HIV prevention methods. Women described extensive interpersonal networks that supported their sexual health knowledge and shaped their interactions with health services, though these networks were influenced by prevailing community stigmas.ConclusionsDifficulty situating PrEP within existing safer sex beliefs contributes to limited perceptions of personal PrEP candidacy. To increase PrEP uptake in UK Black African/Black Caribbean women, interventions will need to enable women to advance their knowledge of PrEP within the broader context of their sexual health and relationships. PrEP service models will need to include trusted ‘non-sexual health-specific’ community services such as general practice.

Increased public engagement is a feature of policy and communications focussed on the reduction of antimicrobial resistance. Explaining antimicrobial resistance for general publics has proven difficult and they continue to endorse apparently mistaken knowledge, including the conflation of antimicrobial resistance with the notion of the resistant body. We interviewed members of the general public in Melbourne, Australia, to explore explanatory models for antimicrobial resistance and shed light on the persistence of the resistant body assumption and related concepts. In the face of AMR's complexity and the portended antibiotic apocalypse, publics rely on a heavily inscribed understanding of the body defending itself against microbes. Publics also read antibiotic misuse and overuse messages as the responsibility of other patients and medical practitioners, and not themselves. Significantly, the scientific world view that has created expert knowledge about AMR hails publics in ways that discredits them and limits their capacity to take action. Increased engagement with publics will be required to ensure that collaborative and sustainable AMR approaches are fashioned for the future.

As antibiotics have become increasingly ineffective against bacteria, antibiotic stewardship has been introduced across a variety of settings world-wide. Members of the public have been entreated t...

Background The relationship between job insecurity, chronic health conditions (CHCs) and retirement among older workers are likely to differ between countries that have different labor markets and health and social safety nets. To date, there are no epidemiological studies that have prospectively assessed the role of job insecurity in retirement incidence, while accounting for CHC trajectories in two countries with different welfare systems. We investigated the strength of the association between baseline job insecurity and retirement incidence over an 11-year period while accounting for CHC trajectories, among workers 50–55 years of age at baseline in the UK and USA. Methods We performed Cox proportional hazards regression analysis, using 2006–2016 data from the Health and Retirement Study (US cohort, n = 570) and English Longitudinal Study on Aging (UK cohort n = 1052). Results Job insecurity was associated with retirement after adjusting for CHC trajectories (HR = 0.69, 95% CI = 0.50–0.95) in the UK cohort only. CHC trajectories were associated with retirement in both cohorts; however, this association was attenuated in the US cohort, but remained significant for the medium-increasing trajectory in the UK cohort (HR = 1.41, 95% CI = 1.01–1.97) after adjustment for all covariates. Full adjustment for relevant covariates attenuated the association between job insecurity and retirement indicating that CHCs, social and health factors are contributing mechanistic factors underpinning retirement incidence. Conclusions The observed differences in the two cohorts may be driven by macro-level factors operating latently, which may affect the work environment, health outcomes and retirement decisions uniquely in different settings.

Background Gay, bisexual and other men who have sex with men (GBMSM) are at a greater risk of mental health problems, such as anxiety and depression, than heterosexual adults. Numerous factors and stressors have been reported to impact men’s mental health, although it has been suggested that resilience could have a protective effect. The aim of this study is to explore mental health, minority stressors, and resilience among a large online cross-sectional survey of GBMSM in the Celtic nations. Methods Data for this cross-sectional study were collected from the Social Media, GBMSM and Sexual and Holistic Health (SMMASH2) self-report online survey. Participants (n = 3077) were recruited via gay sociosexual media in Scotland, Wales, Northern Ireland, and the Republic of Ireland. Binary logistic regression analyses were conducted to identify factors that increased the odds of moderate-to-severe anxiety and depression. Potentially relevant variables (p Results The prevalence of moderate-to-severe anxiety and depression was 19.9 and 14.4%, respectively. Having a disability (OR = 1.73) and having financial worries sometimes/all of the time (OR = 1.93) increased the odds of having moderate-to-severe depression and anxiety, respectively. No minority stressors were associated with depression, whereas experiencing any form of relationship abuse in the last 12 months significantly increased the odds of anxiety (OR = 1.50). Resilience, namely a sense of coherence, had a protective effect and significantly reduced the odds of moderate-to-severe depression (OR = 0.85) and anxiety (OR = 0.89). Conclusions Disability and financial worries were associated with increased depression and anxiety, respectively, while resilience had a protective effect for GBMSM in the SMMASH2 study. Future research is needed to better understand the role of resilience and the challenges and stresses of everyday life and intersecting health problems. Future research is also needed that incorporates the perspectives of those most affected by mental ill-health to co-develop effective solutions that respond to their contextual surroundings.

This paper employs an assemblage lens to generate analyses of general public narratives on antimicrobial resistance (AMR). Global efforts to reduce AMR include communications aiming to promote general public awareness, provide knowledge, encourage careful antibiotics use, and discourage demands for them. These efforts are somewhat compromised by the assumptions they make of individual lack of knowledge and motivation and the manner in which the AMR problem is framed in isolation from the biological, social and economic structures that produce it. Conceptualising AMR as an effect of antimicrobial assemblages of which publics are but one part, we analysed interviews with the general public on the lived experience of infections, antibiotic treatments and AMR. Far from science and policy discourse on AMR, these narratives showed antibiotics to be partly solutions to the social and biomedical challenges of infection, framed by self-defensive immunity and hygiene, the affective benefits of ‘immune boosting’, and the imperative to sustain the moral standing of the healthy citizen. Failing public awareness and action on AMR can be attributed to public health messages that overlook the social, affective and moral dimensions of infection care and separate AMR from its socio-economic drivers.

BackgroundUsing programme theory we report a process evaluation of Accelerated Partner Therapy (APT) - a novel contact tracing (partner notification) intervention for people with chlamydia as part of the LUSTRUM trial.MethodsFollowing the specification and visualisation of initial programme theory, questions of context dependency, fidelity, and functioning of putative intervention mechanisms were addressed using deductive thematic analysis of qualitative data collected through focus groups and individual interviews with purposively sampled health care professionals (n=34 from ten sites), index patients (n=15), and sex partners who received APT (n=17). Analyses were independent of trial results.ResultsAPT was anticipated to change key interactions and sexual health service organisation to accommodate safe and optimal remote care. APT training and resources transformed key interactions as anticipated. Overall intervention fidelity was good and APT was well-liked by those who delivered and received it. Putative intervention mechanisms worked mostly as expected although those concerned with local implementation sometimes worked counter to expectations. APT and its trial struggled to be implemented at scale across all sites. Considerable pressures drove services to constantly adapt to achieve efficiencies. APT was perceived as time consuming without visible impact on perceived patient numbers in clinic curtailing positive feedback loops driving normalisation.DiscussionUsing programme theory we show an evidence-based, theoretically informed, overview of how APT worked dynamically within the context of the trial and within UK sexual health services. We find a mixed picture of a well-liked, intuitive, coherent intervention struggling to gain purchase within an already pressured service.Trial registrationISRCTN15996256Study protocoldoi.org/10.1136/bmjopen-2019-034806Ethical approvalThis study received ethical approval from London—Chelsea Research Ethics Committee (18/LO/0773). Findings will be published with open access licences.FundingThis work presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (reference number RP-PG-0614-20009).

ObjectiveGay and bisexual men who have sex with men (GBMSM) bear a disproportionate burden of sexually transmitted infections (STIs). Most STIS are asymptomatic and people infected won’t know to seek care unless they are told about their exposure. Contact tracing, is the process of identifying and contacting sex partners of people with STIs for testing and treatment. Contact tracing is sometimes particularly challenging amongst GBMSM because of the kinds of sexual relationships which GBMSM enjoy. These include one-off partners who are particularly important for transmission dynamics as they contribute disproportionately to onwards transmission. The effectiveness of contact tracing interventions within sexual health are patterned by sexual-partner type. Contact tracing and management for ‘one-off’ partners is an on-going public health challenge. Low motivation amongst index patients, high resource burden on health care professionals and problems with contactability are key barriers to contact tracing. Using insights from complex adaptive systems thinking and behavioural science, we sought to develop an intervention which addressed both the upstream and down-stream determinants of contact tracing and change the system in which many inter-dependent contact tracing behaviours are embedded.SettingUK community-recruited GBMSM, stakeholders, sexual hcp, dating app providersMethodUsing the MRC complex intervention framework and insights from the INDEX study, a three-phase intervention development process was adopted to specify intervention content. Phase one consisted of an inter-professional and community-member stakeholder event (n=45) where small mixed groups engaged in exploratory systems-mapping and the identification of ‘hot spots’ for future intervention. Phase two used a series of focus groups with GBMSM (n=28) and interviews with representatives from key dating app providers (DAPs) (n=3) to further develop intervention ideas using the theoretical domains framework, the behaviour change wheel and the behaviour change technique taxonomy. In Phase 3 we again worked with key stakeholders expert health care professionals (HCPs) (n=5) and key workers from community-based organisations (CBOs) (n=6) to hone the intervention ideas and develop programme theory using the APEASE criteria.ResultsThe co-produced intervention levers change simultaneously across the system within which contact tracing is embedded. Multiple change-agents (i.e., GBMSM, CBOs, HCPs) work together, sharing an overall vision to improve sexual health through contact tracing. Each make relatively modest changes that over time, synergistically combine to produce a range of multiple positively-reinforcing feedback loops to engender sustainable change around contact tracing. Agreed intervention elements included: a co-ordinated, co-produced mass and social media intervention to tip cultural norms and beliefs of GBMSM towards enabling more contact tracing and to challenge enduring STI- and sex-related stigmas; complementary CBO-co-ordinated, peer-led work to also focus on reducing STI stigma and enabling more contact tracing between one-off partners; priming GBMSM at the point of STI diagnosis to prepare for contact tracing interactions and reduce HCP and sexual health-service burden; changes to SHS environments and HCP-led interactions to systematically endorse contact tracing; changing national audits and monitoring systems to directly address one-off partner targets; delivering bespoke training to HCPs and CBO staff on one-off partners and the social and cultural context of GBMSM; DAPs active involvement in mass and social media promoting appropriate contact tracing messaging.ConclusionOur combination of multiple data sources, theoretical perspectives and diverse stakeholders have enabled us to develop an expansive, complex intervention that is firmly based in the priorities of those it will affect, and which has a solid theoretical foundation. Future work will assess if and how it will be possible to evaluate it. The resulting intervention is profoundly different than other ways of enhancing contact tracing, as it simultaneously addresses multiple, multi-levelled, upstream and social determinants of contact tracing.

Background Accelerated partner therapy (APT) is a partner notification (PN) method whereby healthcare professionals assess sex partners by telephone, then send or give the index patient antibiotics and self-sampling kits for their sex partner(s). APT was implemented within a cluster cross-over randomised control trial in 17 sexual health clinics in Britain (2018–2019, ISRCTN Reference 15996256). We conducted an integral process evaluation to help explain experiences of using APT. Methods Focus groups and telephone interviews with 34 healthcare professionals who delivered APT, and telephone interviews with 15 index patients and 17 sex partners who chose APT. Topic guides focussed on how APT was implemented and overall APT experiences. Data were analysed deductively using a bespoke framework derived from initial conceptualisations of APT, and key trial findings. Results Low uptake of APT was largely because index patients felt it was only suitable for certain types of sex partner. APT was considered best suited to established relationships and not appropriate for relationships with lower emotional connection. However, APT was not always offered by healthcare professionals and many sex partners attended clinic with index patients when they attended for treatment. Nevertheless, those who chose APT felt it worked better than existing options and helped partners overcome barriers to face-to-face care. Most sex partners received APT packs directly from the index patient within a day of consultation; some prioritised taking treatment over self-sampling. Some sex partners reported difficulties in blood sampling (finger-prick) resulting in fewer HIV and syphilis samples being returned than chlamydia and gonorrhoea (urine/vulvo-vaginal swab). Some sex partners did not value testing for infections other than chlamydia/gonorrhoea. Conclusions APT benefits established sexual partnerships with greater emotional connection, by providing treatment rapidly and overcoming barriers to face-to-face care. Targeting of APT combined with interventions to increase sex partner return of self-samples are needed.

Background Widely accessible, acceptable, equitable, HIV pre-exposure prophylaxis (PrEP) services are central to HIV transmission elimination. Multi-stakeholder collaboration, activism and government support enabled Scotland to implement a publicly-funded national PrEP programme delivered through sexual health services from 2017. Although innovations in PrEP implementation occur, they are rarely analysed or consolidated. We address this gap in Scotland by: 1) examining diverse perspectives on barriers and facilitators to the key steps of PrEP implementation (i.e., awareness, access, uptake, initiation, adherence and retention in care) and 2) using implementation science theories to systematically specify transferable ways to improve these steps. Method Semi-structured interviews and focus groups (2018–2019) with geographically and demographically diverse sexual health clinic patients seeking/using/declining or stopping PrEP (n=39), sexual healthcare professionals (n= 54), community-based organisation (CBO) service users (n=9) and staff (n=15). Thematic analysis identifying barriers and facilitators to implementing PrEP was complemented by analyses using the Behaviour Change Wheel to specify detailed recommendations for enhancing PrEP implementation. Results Barriers and Facilitators to the key steps ranged from: macrosocial (political will, competitive dynamics in the service ecology, structural racism); mesosocial (effective monitoring systems and reporting); to microsocial (staff skills and self-efficacy, low HIV literacy). Enhancing implementation across the key steps included: incentivising organisations to share expertise (funding mechanisms, equitable partnership work); targeted culturally sensitive, normalising and awareness-raising interventions; co-production of nationally co-ordinated training and patient resources (e.g. for managing side-effects, adherence support, improving cultural competencies); guidance for correct use of event-based PrEP; supporting PrEP provision in diverse settings to reach underserved communities. Conclusion Systematic analysis of what had and had not worked, and why has enabled development of wide-ranging but specific recommendations for policy-makers, clinicians, CBOs and individuals to optimise PrEP awareness, access, uptake, initiation, adherence and retention in care. These recommendations could be used to improve all PrEP services.

HIV testing is central to biomedical HIV prevention, but testing among men who have sex with men remains suboptimal. We evaluated effectiveness of mass media and communication interventions to increase HIV testing and explored patterns between study type, internal validity and intervention effectiveness for the first time. Five databases were searched for articles published between 2009 and 2016 using standard MeSH terms. Eligible studies were quality appraised using standard checklists for risk of bias. Data were extracted and synthesised narratively. Nineteen studies met inclusion criteria; 11 were cross-sectional/non-comparative studies, four were pre/post or interrupted time series, three were randomised controlled trials (RCTs) and one was a case study. Risk of bias was high. Five cross-sectional (two graded as high internal validity, one medium and two low) and one RCT (medium validity) reported increased HIV testing. Further work is required to develop and evaluate interventions to increase frequency and maintenance of HIV testing. Electronic supplementary material The online version of this article (10.1007/s10461-019-02507-7) contains supplementary material, which is available to authorized users.

Summary Background To reduce the risk of transmission of meticillin-resistant Staphylococcus aureus (MRSA), international guidelines recommend admission screening to identify hospital patients at risk of colonization. However, routine monitoring indicates that optimum screening compliance levels are not always achieved. In order to enhance compliance, we must better understand those factors which influence staff screening behaviours. Aim To identify factors which influence staff compliance with hospital MRSA screening policies. Methods A sequential two-stage mixed-methods design applied constructs from normalization process theory and the theoretical domains framework to guide data collection and analysis. Initial qualitative findings informed subsequent development of a national cross-sectional survey of nursing staff (N = 450). Multiple regression modelling identified which barriers and enablers best predict staff compliance. Findings Three factors were significant in predicting optimum (>90%) compliance with MRSA screening: having MRSA screening routinized within the admission process; category of clinical area; feedback of MRSA screening compliance within the clinical area. Integration of data-sets indicated that organizational systems which ‘make doing the right thing easy’ influence compliance, as does local ward culture. Embedded values and beliefs regarding the relative (de)prioritization of MRSA screening are important. Conclusion To our knowledge, this is the first study to provide original evidence of barriers and enablers to MRSA screening, applying both sociological and psychological theory. As antimicrobial resistance is a global health concern, these findings have international relevance for screening programmes. Future policy recommendations or behaviour change interventions, based on the insights presented here, could have significant impact upon improving screening compliance.

IntroductionNosocomial transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been a significant cause of mortality in National Health Service (NHS) hospitals during the coronavirus disease 2019 (COVID-19) pandemic. The aim of this study is to evaluate the impact of rapid whole genome sequencing of SARS-CoV-2, supported by a novel probabilistic reporting methodology, to inform infection prevention and control (IPC) practice within NHS hospital settings.Methods and analysisCOG-UK HOCI (COG-UK Consortium Hospital-Onset COVID-19 Infections study) is a multicentre, prospective, interventional, superiority study. Eligible patients must be admitted to hospital with first confirmed SARS-CoV-2 PCR positive test result >48h from time of admission, where COVID-19 diagnosis was not suspected upon admission. The projected sample size for 14 participating sites covering all study phases over winter-spring 2020/2021 in the United Kingdom is 2,380 patients. The intervention is the return of a sequence report, within 48 hours in one phase (rapid local lab) and within 5-10 days in a second phase (mimicking central lab use), comparing the viral genome from an eligible study participant with others within and outside the hospital site. The primary outcomes are the incidence of Public Health England (PHE)/IPC-defined SARS-CoV-2 hospital-acquired infection during the baseline and two interventional phases, and proportion of hospital-onset cases with genomic evidence of transmission linkage following implementation of the intervention where such linkage was not suspected by initial IPC investigation. Secondary outcomes include incidence of hospital outbreaks, with and without sequencing data; actual and desirable changes to IPC actions; periods of healthcare worker (HCW) absence. A process evaluation using qualitative interviews with HCWs will be conducted alongside the study and analysis, underpinned by iterative programme theory of the sequence report. Health economic analysis will be conducted to determine cost-benefit of the intervention, and whether this leads to economic advantages within the NHS setting.Ethics and disseminationThe protocol has been approved by the National Research Ethics Service Committee (Cambridge South 20/EE/0118). This manuscript is based on version 5.0 of the protocol. The study findings will be disseminated through peer-reviewed publications.Study Registration numberISRCTN50212645Strengths and limitations of this studyThe COG-UK HOCI study harnesses the infrastructure of the UK’s existing national COVID-19 genome sequencing platform to evaluate the specific benefit of sequencing to hospital infection control.The evaluation is thought to be the first interventional study globally to assess effectiveness of genomic sequencing for infection control in an unbiased patient selection in secondary care settings.A range of institutional settings will participate, from specialist NHS-embedded or academic centres experienced in using pathogen genomics to district general hospitals.The findings are likely to have wider applicability in future decisions to utilise genome sequencing for infection control of other pathogens (such as influenza, respiratory syncytial virus, norovirus, clostridium difficile and antimicrobial resistant pathogens) in secondary care settings.The study has been awarded UK NIHR Urgent Public Health status, ensuring prioritised access to NIHR Clinical Research Network (CRN) research staff to recruit patients.The study does not have a randomised controlled design due to the logistics of managing this against diverse standard practice.

Objectives:\ud \ud Increasing appropriate HIV testing among men who have sex with men (MSM) is crucial to HIV prevention. Mass media interventions are effective in promoting testing, but to date, there has been little examination of their active content.\ud \ud Design:\ud \ud We conducted a qualitative analysis of intervention materials (n = 69) derived from a systematic review of mass media interventions designed to improve testing with MSM.\ud \ud Methods:\ud \ud Visual data were analysed for their affective and ideological content using a novel method drawing on concepts from semiotics (i.e., broadly speaking, the analysis of signs).\ud \ud Results:\ud \ud Whilst affect was not explicitly theorized or examined in any of the studies, there are clearly identifiable affective elements implicitly at play in these interventions. Four thematic categories of affect/ideology were identified including (1) sexual desire and the ‘pornographication’ of the gay/bisexual male subject; (2) narratives of romance and love; (3) fear, threat, and regret; and (4) ‘flattened’ affect.\ud \ud Conclusions:\ud \ud This is the first study to examine and detail the affective and ideological aspects of intervention content in this field. Using analytic techniques such as those reported here, in addition to approaches that focus on the manner in which intervention content address more proximal determinants of behaviour, can provide a rich and potentially more useful evidence base to assist with future interventions.

ObjectivesTo develop a classification of sexual partner types for use in partner notification (PN) for STIs.MethodsA four-step process: (1) an iterative synthesis of five sources of evidence: scoping review of social and health sciences literature on partner types; analysis of relationship types in dating apps; systematic review of PN intervention content; and review of PN guidelines; qualitative interviews with public, patients and health professionals to generate an initial comprehensive classification; (2) multidisciplinary clinical expert consultation to revise the classification; (3) piloting of the revised classification in sexual health clinics during a randomised controlled trial of PN; (4) application of the Theoretical Domains Framework (TDF) to identify index patients’ willingness to engage in PN for each partner type.ResultsFive main partner types emerged from the evidence synthesis and consultation: ‘established partner’, ‘new partner’, ‘occasional partner’, ‘one-off partner’ and ‘sex worker’. The types differed across several dimensions, including likely perceptions of sexual exclusivity, likelihood of sex reoccurring between index patient and sex partner. Sexual health professionals found the classification easy to operationalise. During the trial, they assigned all 3288 partners described by 2223 index patients to a category. The TDF analysis suggested that the partner types might be associated with different risks of STI reinfection, onward transmission and index patients’ engagement with PN.ConclusionsWe developed an evidence-informed, useable classification of five sexual partner types to underpin PN practice and other STI prevention interventions. Analysis of biomedical, psychological and social factors that distinguish different partner types shows how each could warrant a tailored PN approach. This classification could facilitate the use of partner-centred outcomes. Additional studies are needed to determine the utility of the classification to improve measurement of the impact of PN strategies and help focus resources.

Good sexual health requires navigating intimate relationships within diverse power dynamics and sexual cultures, coupled with the complexities of increasing biomedicalisation of sexual health. Understanding this is important for the implementation of biomedical HIV prevention. We propose a socially nuanced conceptual framework for sexual health literacy developed through a consensus building workshop with experts in the field. We use rigorous qualitative data analysis to illustrate the functionality of the framework by reference to two complementary studies. The first collected data from five focus groups (FGs) in 2012 (n = 22), with gay, bisexual and other men who have sex with men aged 18–75 years and 20 in-depth interviews in 2013 with men aged 19–60 years. The second included 12 FGs in 2014/15 with 55 patients/service providers involved in the use/implementation of HIV self-testing or HIV prevention/care. Sexual health literacy goes well beyond individual health literacy and is enabled through complex community practices and multi-sectoral services. It is affected by emerging (and older) technologies and demands tailored approaches for specific groups and needs. The framework serves as a starting point for how sexual health literacy should be understood in the evaluation of sustainable and equitable implementation of biomedical sexual healthcare and prevention internationally.

PurposeThis paper illustrates initial steps of an intervention optimisation process. Self-sampling packs for sexually transmitted infections (STIs) and blood borne viruses (BBVs) are widely offered within the UK, yet have problems with reach and sample return rates. They have arisen without any formal intervention development.MethodsEleven focus groups and seven interviews were conducted with convenience samples of patients recruited from sexual health clinics and members of the public in late 2017 (n=57). To enable intervention optimisation firstly we formulated initial programme theory situating the intervention. Secondly, we conducted an inductive appraisal of the behavioural system of using the pack to understand meaningful constituent behavioural domains. Subsequently we conducted a thematic analysis of barriers and facilitators to enacting each sequential behavioural domain in preparation for future behaviour change wheel analysis.ResultsOverall, we found that self-sampling packs were acceptable. Our participants understood their overall logic and value as a pragmatic intervention that simultaneously reduced barriers to, and facilitated, individuals being tested for STIs. However, at the level of each behavioural domain (e.g., reading leaflets, returning samples), problems with the pack were identified as well as a series of potential optimisations which might widen the reach of self-sampling and increase the return of viable samples.ConclusionsThis paper provides an example of a pragmatic approach to optimising an intervention already widely offered across the UK. The paper demonstrates the added value health psychological approaches make; systematically considering the context of the intervention, in addition to illuminating granular areas for improvement.What is already known on this subject?The use of self-sampling packs for sexually transmitted infections (STIs) and blood borne viruses (BBVs) has been widely implemented without in-depth assessment of user engagement or theorisationSome evidence suggests that the uptake of self-sampling packs, and the concomitant return of samples to enable diagnosis, are socially patternedDespite increasing and widespread use of self-sampling packs across the UK, relatively little is currently known about their acceptability, or how they could be improvedWhat does this study add?This study provides an illustrative example of using a preliminary programme theory to situate the problem to be addressed by intervention optimisationThe thematic analyses show that self-sampling packs offer a largely acceptable means to enabling STI and BBV testing and diagnosis; they remove many barriers to testing. However, several modifiable barriers to use endure, potentially reducing sample return and amplifying health inequalitiesThis study presents a range of barriers and facilitators to the various behavioural domains included within the use of self-sampling packs. It summarises the findings ready for subsequent behaviour change wheel analyses

Objectives1.5 million people in the UK have mild to moderate learning disabilities. Sexually transmitted infections (STIs) and blood borne viruses (BBVs) are over-represented in people experiencing broader health inequalities, which include those with mild learning disabilities. Self-managed care, including self-sampling for STIs/BBVs, is increasingly commonplace, requiring agency and health literacy. To inform the development of a partner notification trial, we explored barriers and facilitators to correct use of an STI/BBV self-sampling pack amongst people with mild learning disabilities.MethodsUsing purposive and convenience sampling we conducted four interviews and five gender-specific focus groups with 25 people (13 female, 12 male), with mild learning disabilities (July-August 2018) in Scotland. We balanced deductive and inductive thematic analyses of audio-transcripts to explore issues associated with barriers and facilitators to correct use of the pack.ResultsAll participants found at least one element of the pack challenging or impossible but welcomed the opportunity to undertake sexual health screening without attending a clinic and welcomed the inclusion of condoms. Reported barriers to correct use included perceived overly complex STI/BBV information and instructions, feeling overwhelmed, and the manual dexterity required for blood sampling. Many women struggled interpreting anatomical diagrams depicting vulvo-vaginal self-swabbing. Facilitators included pre-existing STI/BBV knowledge, familiarity with self-management, good social support, and knowing that the service afforded privacy.ConclusionIn the first study to explore the usability of self-sampling packs for STI/BBV in people with learning disabilities, participants found it challenging to use the pack. Limiting information to the minimum required to inform decision-making, “easy read” formats, simple language, large font sizes and simpler diagrams could improve acceptability. However, some people will remain unable to engage with self-sampling at all. To avoid widening health inequalities, face-to-face options should continue to be provided for those unable or unwilling to engage with self-managed care.Key messagesPeople with mild learning disabilities found the existing self-sampling pack overly complex; many would not use it and did not feel able to engage with self-managed care at all.Minimum “need to know” information, very simple diagrams, and “easy read” formats specific to the needs of people with mild learning disabilities, could improve acceptability.Adoption of self-sampling and other elements of self-managed care without provision of alternative care models could widen health inequalities.Face-to-face options need to be provided but identifying those with limited health literacy will be challenging.

ObjectivesDevelopment of a vaccine against COVID-19 will be key to controlling the pandemic. We need to understand the barriers and facilitators to receiving a future COVID-19 vaccine so that we can provide recommendations for the design of interventions aimed at maximising public acceptance.DesignCross-sectional UK survey with older adults and patients with chronic respiratory disease.MethodsDuring the UK’s early April 2020 ‘lockdown’ period, 527 participants (311 older adults, mean age = 70.4 years; 216 chronic respiratory participants, mean age = 43.8 years) completed an online questionnaire assessing willingness to receive a COVID-19 vaccine, perceptions of COVID-19, and intention to receive influenza and pneumococcal vaccinations. A free text response (n=502) examined barriers and facilitators to uptake. The Behaviour Change Wheel informed the analysis of these responses, which were coded to the Theoretical Domains Framework (TDF). Behaviour change techniques (BCTs) were identified.ResultsEighty-six percent of respondents want to receive a COVID-19 vaccine. This was positively correlated with the perception that COVID-19 will persist over time, and negatively associated with perceiving the media to have over-exaggerated the risk. The majority of barriers and facilitators were mapped onto the ‘beliefs about consequences’ TDF domain, with themes relating to personal health, health consequences to others, concerns of vaccine safety, and severity of COVID-19.ConclusionsWillingness to receive a COVID-19 vaccination is currently high among high-risk individuals. Mass media interventions aimed at maximising vaccine uptake should utilise the BCTs of information about health, emotional, social and environmental consequences, and salience of consequences.Statement of ContributionWhat is already known on this subject?Uptake of a vaccine for COVID-19 will be vital for controlling the pandemic, but the success of this strategy relies on public acceptance of the vaccine.Uptake of vaccinations and public confidence in vaccines has been falling in recent years.Evidence suggests that 74% of the French population want to receive a COVID-19 vaccination.What does this study add?This study found that 86% of our sample of high-risk participants in the UK are willing to receive a future vaccine for COVID-19.This study showed that perceived barriers and facilitators to uptake of the COVID-19 vaccination concentrated on the ‘beliefs about consequences’ TDF domain.This study suggests that the content of mass media interventions to improve vaccine uptake should focus on the BCTs of information about health, emotional, social and environmental consequences, and salience of consequences. These techniques should be pitched in relation to both self and, most importantly, to others.

ObjectivesTo develop a classification of sexual partner types for use in partner notification (PN) and other interventions to prevent sexually transmitted infections (STI).MethodsA four-step process: 1) an iterative synthesis of five sources of evidence: scoping review of social and health sciences literature on partner types; analysis of relationship types in dating apps; systematic review of PN intervention content; review of PN guidelines; qualitative interviews with public, patients and health professionals, to generate an initial comprehensive classification; 2) multidisciplinary clinical expert consultation to revise the classification; 3) piloting of the revised classification in sexual health clinics during a randomised controlled trial of PN; 4) application of the Theoretical Domains Framework (TDF) to identify index patients’ willingness to engage in PN for each partner type.ResultsFive main partner types emerged from the evidence synthesis and consultation: ‘Established partner’, ‘New partner’, ‘Occasional partner’, ‘One-off partner’ and ‘Sex worker’. The types differed across several dimensions, including likely perceptions of sexual exclusivity, likelihood of sex reoccurring between index patient and sex partner. Sexual health professionals found the classification easy to operationalise. During the trial, they assigned all 3288 partners described by 2223 index patients to a category. The TDF analysis suggested that the partner types might be associated with different risks of STI reinfection, onward transmission and index patients’ engagement with PN.DiscussionWe developed an evidence-informed, useable classification of five sexual partner types to underpin PN practice and other STI prevention interventions. Analysis of biomedical, psychological and social factors that distinguish different partner types shows how each could warrant a tailored PN approach. This classification could facilitate the use of partner-centred outcomes. Additional studies are needed to determine the utility of the classification to improve measurement of the impact of PN strategies and help focus resources.Key messagesCurrent classifications of sexual partners limit understanding of STI transmission dynamics and hinder targeting and tailoring of partner notification interventions.The limits and constraints of current classifications, together with recent socio-sexual changes, mean that a new classification is needed.We developed a comprehensive, evidence-based classification of sexual partner types for use in partner notification that characterised and distinguished between partner and partnership types.The five partner categories were readily adopted and easily operationalised in UK sexual health services.

Attitudes towards sexual health and relationships are learned from a young age, and there is an ongoing need for innovative and comprehensive approaches to sex education that keep pace with rapidly changing contexts of people’s lives. We used thematic analysis of data from two qualitative studies in Scotland to explore learning contexts from a multi-generational perspective, as well as the influence of different socio-cultural factors on provision, access to and experience of sex education. The importance, but inadequacy, of school as a source of learning, was a persistent theme over time. Participants’ strategies to address perceived gaps in knowledge included experience, conversations, vicarious and online learning. Gender and age differences emerged, with younger participants more likely to go online for information, and prevailing gender norms shaping attitudes and behaviours across both study groups. Participants who identified as gay, lesbian or bisexual described feeling particularly unprepared for sex and relationships due to the narrow, heteronormative content received. Although schools continue to be a common source of information, it appears that they fail to equip young people for their post-school sexual life-course. We recommend the mandatory provision of comprehensive, positive, inclusive and skills-based learning to improve people’s chances of forming and building healthy, positive relationships across the lifespan.

Background Previous research has indicated that effort reward-imbalance (ERI) is independently associated with retirement and cross-sectional multimorbidity. In addition, aging populations and pension reform across western societies has led to older adults who are at increased risk of aging related disease onset and progression, participating in the labour force for longer. The objective of this study was to examine the association between multimorbid chronic health trajectories and retirement in older workers experiencing high and low effort-reward imbalance. Methods This study used longitudinal data from the Health and Retirement Study (2006–2016) and the English Longitudinal Study of Ageing (2004–2014) for adults aged 50–55 years. Group-based trajectory modelling was used to construct multimorbidity trajectories (0–6 of diabetes, hypertension, heart disease, stroke, lung disease and cancer) over a 10-year period separately for participants reporting low and high ERI at baseline. Logistic regression analysis fully ad-justed for relevant variables examined the association between the multimorbidity trajectories and cross-sectional retirement at the final wave. Results Mean ERI scores were higher in UK workers (low ERI = 0.75, high ERI = 1.38), compared to U.S. workers (low ERI = 0.67, high ERI = 1.32). Four trajectory classes were identified for U.S. workers with low ERI (no conditions, no-increasing, low-increasing, and high-stable). Compared to the no conditions trajectory, the high stable trajectory was associated with retirement (HR=4.50, 95%CI=2.08–9.62). Four trajectory classes (no-increasing, low-increasing, medium-stable, and high increasing) were identified for U.S. participants with high ERI. The medium-stable (HR=3.14, 95%CI = 1.19–8.29) and high-increasing (HR=4.52, 95%CI = 1.32–15.46) trajectories were associated with retirement. UK participants with high and low ERI were each classified into 3 trajectory classes respectively (no conditions, low-increasing, high-increasing), however no significant associations with retirement were observed. Conclusion Our findings demonstrate country differences in mean ERI scores and trajectories of multimorbidities and their association with retirement. Trajectories with high intercepts indicating multimorbidity (i.e. 2+ chronic conditions at baseline) were associated with retirement in U.S. older adults only, regardless of ERI. These results imply that baseline multimorbidity status may play a more important role than ERI on retirement in those approaching the retirement age, however further research is required. Socio-economic inequalities and social policies may provide partial explanations for these findings. Public health and workplace interventions may be warranted for workers with multimorbidities.

Background Employment and occupation can greatly influence one’s life course, identity, resilience, health and health inequalities. At the same time, the working environment is rapidly changing, with flexible and agile working conditions and extended working lives, often resulting in ‘non-traditional’ career trajectories. We aimed to explore and identify common occupational history patterns and assess the associations between these patterns and self-rated health. Methods We analysed baseline UK Biobank data to construct participants occupational histories using employment start/end dates to identify patterns of employment status during working life, with each year being categorised into different employment or employment gap states. We used sequence analysis, followed by optimal matching and cluster analysis methods to classify respondents’ occupational history patterns. We produced Sequence Index Plots (SIPs) by gender and age groups. Theoretically derived occupational history patterns based on the SIPs were compared to the data-driven ones, to determine final patterns. Logistic regression models were run using occupational histories as explanatory variables for the health outcome of self-rated health (dichotomised: ‘excellent/good’ versus ‘fair/poor’). Results There was good agreement between the SIPs and cluster analysis; resulting in 3–5 different occupational history patterns per age/gender group, including continuous employment, employed then retired and employed with breaks for education and caring responsibilities as examples. Women aged 40–49 had better overall self-rated health if continuously employed compared with those with a pattern that included employed/in education/caring responsibilities (OR=0.80; CI:0.69, 0.93), or those off work at some point due to ill health (OR: 0.68; CI: 0.59, 0.79). Men aged 40–49 reported worse self-rated health if employed and retired (OR=0.64; CI:0.53, 0.78)) or were off work at some point due to ill health (OR=0.42; CI: 0.31, 0.57). Women aged 50–59 and 60–69 tended to have better self-rated health if retired, even if their employment histories involved multiple gaps due to caring responsibilities or short-term employment. This was not the case for men; being continuously employed or continuously employed and then retired was generally associated with better self-rated health compared to groups with non-continuous employment. Conclusion Continuous employment appeared to be associated with better self-rated health in men but not always for women. Our study is limited by the retrospective nature of the data and the limited representativeness of the study population. The modern working environment is rapidly changing, increasingly giving rise to ‘non-traditional’ career trajectories which might result in future adverse health impacts.

Globally, gay, bisexual and other men who have sex with men (GBMSM) experience an increased burden of poor sexual, mental and physical health. Syndemics theory provides a framework to understand comorbidities and health among marginalised populations. Syndemics theory attempts to account for the social, environmental, and other structural contexts that are driving and/or sustaining simultaneous multiple negative health outcomes, but has been widely critiqued. In this paper, we conceptualise a new framework to counter syndemics by assessing the key theoretical mechanisms by which pathogenic social context variables relate to ill-health. Subsequently, we examine how salutogenic, assets-based approaches to health improvement could function among GBMSM across diverse national contexts. Comparative quantitative secondary analysis of data on syndemics and community assets are presented from two international, online, cross-sectional surveys of GBMSM (SMMASH2 in Scotland, Wales, Northern Ireland and the Republic of Ireland and Sex Now in Canada). Negative sexual, mental and physical health outcomes were clustered as hypothesised, providing evidence of the syndemic. We found that syndemic ill-health was associated with social isolation and the experience of stigma and discrimination, but this varied across national contexts. Moreover, while some of our measures of community assets appeared to have a protective effect on syndemic ill-health, others did not. These results present an important step forward in our understanding of syndemic ill-health and provide new insights into how to intervene to reduce it. They point to a theoretical mechanism through which salutogenic approaches to health improvement could function and provide new strategies for working with communities to understand the proposed processes of change that are required. To move forward, we suggest conceptualising syndemics within a complex adaptive systems model, which enables consideration of the development, sustainment and resilience to syndemics both within individuals and at the population-level., Highlights • Gay and other men who have sex with men experience syndemics in varied contexts. • Some salutogenic community assets have a protective effect on syndemic ill-health. • Conceptualising syndemics within a complex adaptive systems model is required.

ObjectiveTo synthesize the existing evidence base of systematic reviews of interventions to improve healthcare worker (HCW) hand hygiene compliance (HHC).MethodsPRISMA guidelines were followed, and 10 information sources were searched in September 2017, with no limits to language or date of publication, and papers were screened against inclusion criteria for relevance. Data were extracted and risk of bias was assessed.ResultsOverall, 19 systematic reviews (n=20 articles) were included. Only 1 article had a low risk of bias. Moreover, 15 systematic reviews showed positive effects of interventions on HCW HHC, whereas 3 reviews evaluating monitoring technology did not. Findings regarding whether multimodal rather than single interventions are preferable were inconclusive. Targeting social influence, attitude, self-efficacy, and intention were associated with greater effectiveness. No clear link emerged between how educational interventions were delivered and effectiveness.ConclusionsThis is the first systematic review of systematic reviews of interventions to improve HCW HHC. The evidence is sufficient to recommend the implementation of interventions to improve HCW HHC (except for monitoring technology), but it is insufficient to make specific recommendations regarding the content or how the content should be delivered. Future research should rigorously apply behavior change theory, and recommendations should be clearly described with respect to intervention content and how it is delivered. Such recommendations should be tested for longer terms using stronger study designs with clearly defined outcomes.

Frank’s (2018) article provides an excellent summary of transdisciplinary research concerned with collective sex environments, synthesizing highly diverse studies spanning five decades. The contributing papers utilize a broad range of methods and reflect many key sexual health risks across several diverse and distinct populations. For many readers, such as ourselves, with a particular interest in a single population, Frank’s synthesis provides a much needed and entirely fascinating wider perspective. This overarching vantage point can teach us about similarities and differences across populations, while simultaneously illuminating the populations and research we know so well through a different lens. As such, the paper provides an essential contribution to the literature. However, rather than champion the paper’s many strengths, within this Commentary we wish to grapple with what could be seen as its potential shortcomings. Our aim here is not be critical for the sake of it, but to somewhat playfully push debates further about many issues addressed within the paper. In this way, we wish to initiate more dialogue concerning collective sex, concomitant risks, and imaginative ways to ameliorate such risks.

Evidence-based guidance for national infection prevention and control (IPC) programmes is needed to support national and global capacity building to reduce health-care-associated infection and antimicrobial resistance. In this systematic review we investigate evidence on the effectiveness of IPC interventions implemented at national or subnational levels to inform the development of WHO guidelines on the core components of national IPC programmes. We searched CENTRAL, CINAHL, Embase, MEDLINE, and WHO IRIS databases for publications between Jan 1, 2000, and April 19, 2017. 29 studies that met the eligibility criteria (ie, economic evaluations, cluster-randomised trials, non-randomised trials, controlled before-and-after studies, and interrupted time-series studies exploring the effective of these interventions) were categorised according to intervention type: multimodal, care bundles, policies, and surveillance, monitoring, and feedback. Evidence of effectiveness was found in all categories but the best quality evidence was on multimodal interventions and surveillance, monitoring, and feedback. We call for improvements in study design, reporting of research, and quality of evidence particularly from low-income countries, to strengthen the uptake and international relevance of IPC interventions.

Background:\ud \ud Antimicrobial resistance (AMR) is a growing public health problem across the world. As the negative consequences of AMR become apparent at local, national and international levels, more attention is being focussed on the variety of mechanisms by which AMR is potentiated. We explore how interactions between pet owners and veterinarians represent a key arena in which AMR-related behaviours can be shaped.\ud Methods:\ud \ud In depth semi-structured interviews were carried out with pet owners (n = 23) and vets (n = 16) across the UK in 2017. A thematic analysis approach was taken, with inductively gathered data analysed deductively using a behavioural framework to identified key behaviours emerging from participant accounts which were amenable to change.\ud Results:\ud \ud Interactions between vets and pet owners were characterised by misunderstandings and misconceptions around antibiotics by pet owners, and a lack of clarity about the positions and intentions of the other party. Vets and pet owners had differing perceptions of where pressure to prescribe antibiotics inappropriately originated. Vets perceived it was mostly pet owners who pushed for inappropriate antibiotics, whereas pet owners reported they felt it was vets that overprescribed. Low levels of understanding of AMR in general were apparent amongst pet owners and understandings with regard to AMR in pets specifically were almost non-existent in the sample.\ud Conclusions:\ud \ud Improved use of antibiotics could be assisted by educating the pet owning public and by guideline development for companion animal vets, concurrent development of mandatory legislation, increased consultation time to facilitate better communication, development of vet training on antimicrobial therapy and stewardship led interactions with pet owners, and increased levels of knowledge of pet-related AMR amongst pet owners.

Antimicrobial resistance (AMR) imperils health for people across the world. This enormous challenge is being met with the rationalisation of prescription, dispensing and consumption of antimicrobials in clinical settings and in the everyday lives of members of the general population. Individuals need to be reached outside clinical settings to prepare them for the necessary changes to the pharmaceutical management of infections; efforts that depend on media and communications and, therefore, how the AMR message is mediated, received and applied. In 2016, the UK Review on Antimicrobial Resistance called on governments to support intense, worldwide media activity to promote public awareness and to further efforts to rationalise the use of antimicrobial pharmaceuticals. In this article, we consider this communications challenge in light of contemporary currents of thought on media publics, including: the tendency of health communications to cast experts and lay individuals in opposition; the blaming of individuals who appear to ‘resist’ expert advice; the challenges presented by negative stories of AMR and their circulation in public life, and; the problems of public trust tied to the construction and mediation of expert knowledge on the effective management of AMR.

Background There has been an increased focus on antimicrobial stewardship (AMS) within the animal health domain ( World Health Organization, 2015 ; O’Neill, 2016 ). Evidence of the effectiveness of interventions designed to enhance AMS is essential to support the development of this practice. This scoping review summarises for the first time the extent, range, and nature of global research activity on approaches for improving AMS in farmers and veterinarians involved in livestock farm animal management, health & well-being. Methods In November 2017 AGRICOLA, CAB Abstracts, EMBASE, MEDLINE, VetsRev and the Web of Science were searched. Studies were selected by two reviewers with 30 % of excluded and all included studies being independently reviewed by another reviewer. Inclusion criteria were primary studies or literature reviews focusing on antimicrobial use (AMU) in farming or veterinary practices for food-producing animals. Outcomes were changes in, or factors influencing farmers’ or veterinarians’ AMS. Exclusion criteria were studies on wild or companion animals or reports of the level of, rather influencing factors for AMS, or knowledge/awareness related to antimicrobial resistance (AMR). Study characteristics and relevant outcomes were extracted, identified facilitators and barriers grouped into categories, and a narrative synthesis was conducted. The PRISMA checklist extension for scoping reviews was used to guide the reporting of the review. Results 52 studies were included in the review; seven were intervention studies and 45 were studies of facilitators and barriers of AMU or antimicrobial prescribing (AMP). Studies were predominantly from high-income countries with only seven studies from low- or middle-income countries. Evidence for effective interventions was limited in terms of number of studies and robustness of evidence. There was some effect for an educational intervention in European cattle farmers and the Yellow Card scheme for Danish pig farmers. Significant facilitators to veterinarians’ prudent AMP, in the cattle and pig livestock sector, included education, veterinarians’ positive attitudes towards AMU reduction, and diagnostic. For farmers, significant facilitators to reduction of AMU were most frequently related to farming management practices. Conclusion This review describes a scarcity of robust study designs and recommendations can be confidently made for better designed studies. Furthermore, greater consideration needs to be given to the outcome measures used in such studies. Nevertheless, the review summarises the evidence on the effectiveness of interventions and significant facilitators to farmers’ and veterinarians’ AMS, which can provide best currently available evidence to guide improvements in different livestock sectors.

Background Emergency personnel face unpredictable and challenging incidents and their resilience and ability to cope influences their well-being. Personality traits, such as neuroticism, are postulated to be robust predictors of health and health behaviours. Despite evidence in the general population that neuroticism can positively impact health and health behaviours; to date neuroticism in emergency personnel has primarily been associated with adverse health outcomes. Aims To assess whether neuroticism has a negative or positive impact on subjective and objective health and health behaviours in emergency personnel. Methods This study used cross-sectional UK Biobank baseline data of emergency personnel (police, firemen and paramedics). Logistic regression models examined the strength of the associations of neuroticism tertiles with subjective (self-reported overall health and chronic conditions) and objective health (abdominal obesity) and self-reported smoking, sleeping, alcohol use and exercise levels. Results High neuroticism was positively associated with poorer subjective health outcomes in all emergency personnel (n = 2483). The association between neuroticism and chronic disease/s was significant for police in the second (odds ratio [OR] = 1.93, 95% confidence interval [CI] = 1.15–1.94) and third (OR = 1.62, 95% CI = 1.21–2.16) neuroticism tertiles. Neuroticism in firemen was associated with reduced abdominal obesity (OR = 0.49, 95% CI = 0.25–0.96) and increased exercise (OR = 2.14, 95% CI = 1.07–4.25). Conclusions We observed positive and negative associations between neuroticism and health outcomes and behaviours. While differences were observed across the emergency personnel groups, more research is needed to better understand how personality traits may impact health in workers with physically and mentally intense jobs.

IntroductionHepatitis C virus (HCV) is the second largest contributor to liver disease in the UK, with injecting drug use as the main risk factor among the estimated 200 000 people currently infected. Despite effective prevention interventions, chronic HCV prevalence remains around 40% among people who inject drugs (PWID). New direct-acting antiviral (DAA) HCV therapies combine high cure rates (>90%) and short treatment duration (8 to 12 weeks). Theoretical mathematical modelling evidence suggests HCV treatment scale-up can prevent transmission and substantially reduce HCV prevalence/incidence among PWID. Our primary aim is to generate empirical evidence on the effectiveness of HCV ‘Treatment as Prevention’ (TasP) in PWID.Methods and analysisWe plan to establish a natural experiment with Tayside, Scotland, as a single intervention site where HCV care pathways are being expanded (including specialist drug treatment clinics, needle and syringe programmes (NSPs), pharmacies and prison) and HCV treatment for PWID is being rapidly scaled-up. Other sites in Scotland and England will act as potential controls. Over 2 years from 2017/2018, at least 500 PWID will be treated in Tayside, which simulation studies project will reduce chronic HCV prevalence among PWID by 62% (from 26% to 10%) and HCV incidence will fall by approximately 2/3 (from 4.2 per 100 person-years (p100py) to 1.4 p100py). Treatment response and re-infection rates will be monitored. We will conduct focus groups and interviews with service providers and patients that accept and decline treatment to identify barriers and facilitators in implementing TasP. We will conduct longitudinal interviews with up to 40 PWID to assess whether successful HCV treatment alters their perspectives on and engagement with drug treatment and recovery. Trained peer researchers will be involved in data collection and dissemination. The primary outcome – chronic HCV prevalence in PWID – is measured using information from the Needle Exchange Surveillance Initiative survey in Scotland and the Unlinked Anonymous Monitoring Programme in England, conducted at least four times before and three times during and after the intervention. We will adapt Bayesian synthetic control methods (specifically the Causal Impact Method) to generate the cumulative impact of the intervention on chronic HCV prevalence and incidence. We will use a dynamic HCV transmission and economic model to evaluate the cost-effectiveness of the HCV TasP intervention, and to estimate the contribution of the scale-up in HCV treatment to observe changes in HCV prevalence. Through the qualitative data we will systematically explore key mechanisms of TasP real world implementation from provider and patient perspectives to develop a manual for scaling up HCV treatment in other settings. We will compare qualitative accounts of drug treatment and recovery with a ‘virtual cohort’ of PWID linking information on HCV treatment with Scottish Drug treatment databases to test whether DAA treatment improves drug treatment outcomes.Ethics and disseminationExtending HCV community care pathways is covered by ethics (ERADICATE C,ISRCTN27564683, Super DOT C Trial clinicaltrials.gov:NCT02706223). Ethical approval for extra data collection from patients including health utilities and qualitative interviews has been granted (REC ref: 18/ES/0128) and ISCRCTN registration has been completed (ISRCTN72038467). Our findings will have direct National Health Service and patient relevance; informing prioritisation given to early HCV treatment for PWID. We will present findings to practitioners and policymakers, and support design of an evaluation of HCV TasP in England.

PURPOSE: Mass media HIV testing interventions are effective in increasing testing, but there has been no examination of their theory or behaviour change technique (BCT) content. Within a heterogeneous body of studies with weak evaluative designs and differing outcomes, we attempted to gain useful knowledge to shape future interventions.METHODS: Within a systematic review, following repeated requests to the authors of included studies for intervention materials, the Theory Coding Scheme, the Theoretical Domains Framework (TDF), and Behaviour Change Technique Taxonomy (BCTT) were used to extract data relating to active intervention content.RESULTS: Of 19 studies, five reported an explicit theoretical basis to their intervention. TDF analysis highlighted the key domains employed within the majority of interventions: 'knowledge', 'social roles and identities', and 'beliefs about consequences'. BCT analysis showed three BCT groupings commonly reported within interventions: 'Comparison of outcomes', 'Natural consequences', and 'Shaping knowledge'. Three individual BCTs formed the backbone of most interventions and can be considered 'standard' content: 'Instructions on how to perform behaviour'; 'Credible source'; and 'Information about health consequences'.CONCLUSIONS: This is the first study to examine and detail active intervention content in this field. It suggests future interventions should improve knowledge about testing, and use well-branded and trusted sources that endorse testing. Future interventions should also provide clear information about the health benefits of testing. Our analysis also suggests that to improve levels of effectiveness characterizing the current field, it may be useful to elicit commitment, and action plans, relating to how to implement testing intentions.STATEMENT OF CONTRIBUTION: What is already known on this subject? Interventions are urgently needed to increase HIV testing among men who have sex with men (MSM) and enable increased access to effective treatment for HIV infection. There is some evidence of the effectiveness of mass media interventions in increasing HIV testing among MSM. Nothing is known about the active components of existing mass media interventions targeting HIV testing. What does this study add? It describes the available literature concerning evaluated mass media interventions to increase HIV testing. It shows few interventions report any explicit theoretical basis although many interventions share common components, including coherently connected causal mechanisms and behaviour change techniques to moderate them. As a minimum, future interventions should improve knowledge about testing; use well-branded and trusted sources that endorse testing; and provide clear information about the health benefits of testing. Our analysis also tentatively suggests it may be useful to elicit commitment and planning of how to implement testing intentions.

Background Sex-partner type influences sexually transmitted infection (STI) risk. Evaluating partner notification (PN) outcomes by sex-partner type could facilitate effective targeting of resources for PN for STIs. To inform development of PN outcomes for bacterial STIs, we reviewed PN guidelines and randomised control trials (RCTs) for sex-partner type characterisation and its impact on PN outcomes. Methods We searched online/via experts for PN guidelines worldwide and systematically reviewed RCTs of PN for bacterial STIs in PubMed to December 2018. We extracted data on PN recommendations and outcomes by sex-partner type. Results We found PN guidelines from United Kingdom (UK), United States of America (USA), Canada, Australasia, Australia, and New Zealand (NZ). They recommend collecting sex-partner data using terms such as: ‘regular’/‘main’/‘primary’/‘casual’/‘past’/‘anonymous’, without providing definitions. Australasian, NZ, Australian, and USA guidelines recommend prioritising PN based on factors that can enhance STI risk (e.g. having multiple partners), and emphasise PN of ‘regular’ partners to prevent index case re-infection. Only Australian guidelines outline auditable PN outcomes accounting for sex-partner type: index-reported number of treated ‘current regular partners’ or ‘all past partners (includes current casual partners)’. Ten of 28 RCTs reported study participants’ baseline data on sex-partner type (e.g. ‘steady’/‘regular’/‘main’/‘long-term’/‘casual’/‘one-time’), without defining them. Three RCTs reported PN outcomes by sex-partner type. Two RCTs reported higher chlamydia/gonorrhoea/trichomonas treatment rates for ‘main’ than ‘casual’ partners using expedited-partner-therapy (EPT) vs. patient-referral. Another RCT reported no difference in chlamydia re-infection rates in EPT vs. self-referral among women with a single ‘steady’ partner than women in overall trial. Conclusion Current PN guidelines do not define sex-partner type nor address public health benefits of notifying different sex-partners. Sex-partner type definitions should be developed and integrated in clinical practice. RCTs should examine the effect of sex-partner types on PN outcomes. PN guidelines should account for sex-partner type based on evidence from RCTs. Disclosure No significant relationships.

Background Behavioural surveillance enables monitoring of disease epidemics, assessment of health promotion, development of health policy and service planning. However, the emergence of multiple effective biobehavioral risk management strategies to prevent HIV transmission (including PrEP, treatment-as-prevention (TasP), negotiated safety (NS), serosorting, condom use), demands new surveillance tools able to reflect this complexity. Here, we critically discuss our new surveillance tool, developed to measure MSM’s biobehavioural HIV risk-taking. Methods Items were developed with surveillance experts in Scotland and Australia, piloted within Scotland, then delivered within the Scottish Gay Men’s Bar Survey (n=972 MSM), across the commercial gay scenes of Scotland’s two largest cities in 2017. Participants were asked about sex with regular and casual partners separately, condom use and condomless anal intercourse (CAI), their HIV status, PrEP use and their partners’ HIV and undetectable viral load (UVL) status. Results Overall, 5.6% of participants were HIV+. For our HIV-/untested participants, 67.7% were categorised as ‘lower risk’ since, in the last year, they reported; (i) PrEP use (4.5%) (ii) no CAI (37.1%) (iii) Negotiated safety; CAI with 1 regular HIV- partner (16%) (iv) TasP; CAI with 1 regular HIV+ UVL partner (0.4%) (v) Serosorting; CAI with casual and/or multiple regular HIV- partners (4.1%) (vi) Both serosorting and TasP CAI with multiple regular and casual partners (5.4%) The remaining 32.3% were categorised as ‘higher risk’; HIV-/untested men not on PrEP who reported CAI with HIV status-unknown partners, or HIV+ partners with unknown/detectable viral load. Of these, 67.6% report 2+ CAI partners, making them potentially eligible for PrEP in Scotland. Conclusion No CAI, NS and PrEP were the key biobehavioural risk strategies used. Two-thirds of our higher risk men could, but are yet to, benefit from PrEP. Although offering new insights, we invite critical engagement with these risk criteria which present different, yet related challenges for researchers and MSM alike. Disclosure No significant relationships.

Background Globally, gay, bisexual and other men who have sex with men (GBMSM) experience an increased burden of poor sexual, mental and physical health. Syndemics theory provides a framework to understand these interrelated health problems and how to intervene. Methods Comparative quantitative secondary analysis of syndemic-related data are presented from two international, online, cross-sectional surveys: SMMASH2 in Scotland, Wales, Northern Ireland and the Republic of Ireland (N=3220); and Sex Now in Canada (N=7872). Results In both studies negative sexual, mental and physical health outcomes were clustered, providing evidence of the syndemic (SMMASH2 O/E Ratio=1.32, 95% CI 1.25–1.40; Sex Now O/E Ratio=1.59, 95% CI 1.45–1.73). There were differences between the studies in the variables that were associated with experience of the syndemic. In Sex Now we found experience of the syndemic was associated with worries about sexuality-related stigma (AOR 1.87, 95% CI 1.23–1.54) and experience of discrimination (AOR=1.83, 95% CI 1.60–2.10). Equally, some community assets appeared to have a protective effect on the experience of syndemics. In Sex Now, aspirations were significant; e.g., being unlikely to achieve quality of life significantly associated with increased odds of experiencing the syndemic (AOR=1.89, 95% CI 1.63–2.19), while measures of community engagement were not significant. In SMMASH2, sense of coherence – a measure of resilience – was significant (AOR=0.98, 95% CI 0.96–0.99), indicating that higher sense of coherence was associated with decreased odds of experiencing the syndemic. Conclusion These results present an important step forward in our understanding of syndemics. They provide new insights into how to intervene to reduce the interrelated burden of poor sexual, mental and physical health among GBMSM and point to a theoretical mechanism through which assets-based approaches to health improvement could function. Disclosure No significant relationships.

Background Scotland was the first country to introduce free criterion-based PrEP for all citizens. So far, uptake has been almost exclusively among MSM. Herein, we examine PrEP awareness and acceptability among MSM in Scotland from a national level behavioural surveillance project. Methods Time and location sampling was used to survey n=972 MSM across the commercial gay scenes of Scotland’s two largest cities. Results 5.4% of participants were HIV+. 94.6% were HIV-/untested, of whom, 4.5% were on PrEP. Most of the remaining men had heard of PrEP (81.7%). Multivariate logistic regression suggested that gay men (OR=2.76), men aged 26–35 (OR=2.38) and 36–45 (OR=2.31), men who used the gay scene ≥=twice a month (OR=2.19), reported an HIV test in the last year (OR=1.96) or an STI other than HIV diagnosed in the last year (OR=3.47) were significantly (p Conclusion PrEP awareness among MSM in Scotland is high, but disparities in awareness remain along traditional indicators of inequality. Findings suggest substantial interest in PrEP, particularly among those most likely to benefit although other issues may be more indicative of use than pure behavioural risk. As the biobehavioural HIV risk management strategies now available to MSM require high levels of health literacy, health promotion strategies must focus on enabling men to negotiate these complexities. Disclosure No significant relationships.

Background Accelerated Partner Therapy (APT) is a method of partner notification (PN) which includes remote assessment, self-sampling and treatment of the sex partner(s) of a person diagnosed with STIs. Using the Behaviour Change Wheel approach, we sought to understand, and then systematically moderate, the psychological and behavioural challenges involved in delivering and receiving APT as part of LUSTRUM, a UK-based chlamydia PN trial. Methods We conducted 11 focus groups with patients (n=30) and the public (n=26), and five focus groups with healthcare professionals (n=30) involved in PN. Initial thematic analysis explored the barriers and facilitators to each essential and sequential step in APT, from the perspective of each role in this interpersonal, relay intervention. Further analysis specified a series of theoretically based, and evidence-informed approaches that can be used to methodically reduce the various barriers to uptake and implementation of APT Results Active, intervention components that can enhance staff delivery, index patient and sex partner uptake of APT included providing: clearer information for all about the overall sequential steps involved in APT (highlighting shared roles and responsibilities); a stronger focus upon what healthcare professionals, index patients and their sex partners should do in relation to each step of APT, including written checklists for staff and index patients; essential messages supporting PN and self-management of sex partners engaging in APT; pertinent information about why to engage in APT (in relation to considering key consequences). Conclusion This is the first study to provide evidence-based and theoretically informed approaches to enhance contemporary PN. These findings informed the development of an intervention manual, training resources for staff and online video materials. Together, these materials detail, in highly specific and replicable ways, the optimal methods to reduce barriers to implementation of APT and utilise factors that facilitate implementation thereby potentially improving PN outcomes for chlamydia. Disclosure No significant relationships.

Background Black and minority ethnic (BME) women in the UK remain disproportionally affected by HIV, comprising 75% of new diagnoses among UK women. Pre-exposure prophylaxis (PrEP) could offer an effective, autonomous, and discreet HIV prevention method for these women. However, PrEP uptake, where available, has been significantly limited. We explored possible reasons for this limited uptake. Methods Using purposive sampling through community organizations, 32 in-depth semi-structured interviews were conducted with BME women living in London and Glasgow from June-August 2018. Participants (ages 18–60) included women of varied HIV statuses to explore their knowledge of HIV and sexual health, perceptions of sexual risk, and attitudes to PrEP. Interviews were transcribed and an inductive thematic analysis was used to explore how PrEP knowledge and opinions intersected with wider understandings of safer sex Results Women described extensive peer networks for sexual health advice that shaped their interactions with formal medical care. General HIV literacy was high, though PrEP-specific knowledge was low amongst non-HIV positive women. Participants expressed enthusiasm about PrEP for others but did not situate PrEP within their own safer sex narratives, often because of high levels of HIV stigma that caused women to ignore community risk factors and attribute infection to personal bad decisions. Alternately, some who were more familiar with PrEP believed it to be solely the domain of gay men. Many expressed concern that PrEP would undermine intimacy in their relationships by detracting from the shared responsibility of other HIV prevention practices, like joint testing. Conclusion Low PrEP awareness and limited notions of candidacy contribute to limited PrEP uptake. For PrEP to be a useful tool for UK BME women, wider discussions of community risk are needed. HIV stigma and gendered responsibility for HIV prevention should be addressed. Existing peer networks should be harnessed to encourage nuanced messaging around these issues. Disclosure No significant relationships.

Background STI/HIV self-sampling has the potential to improve sexual health by increasing access to testing, yet uptake and sample return rates are currently sub-optimal. Our inter-disciplinary research team explored home-based self-sampling from the user perspective, to inform its optimisation (within the context of LUSTRUM, a UK based trial of Accelerated Partner Therapy (APT)). We describe how implementation science approaches were used to reconcile user, professional and practical requirements for APT and to suggest a series of simple improvements. Methods 11 focus groups with the public (n=36), and those recently diagnosed with an STI (n =20), explored perceived barriers and facilitators to using prototype self-sampling packs and returning samples. Using the behaviour change wheel approach to direct intervention development, we engineered an optimised self-sampling and treatment pack and instructions, supported by audio-visual online materials. In this way we translated lay perspectives into evidence-based and theoretically informed, pragmatic recommendations. Results Using rich participant extracts we illustrate how our analysis suggests: the design of the package should physically separate and order components to be used at each stage in the self-sampling/treatment process; simple written and online audio-visual instructions, suitable for those with low literacy levels should be provided; the rationale for and health consequences of not testing for STIs, including HIV, should be clearly articulated, enabling users to opt-out of HIV testing without inadvertently opting-out of STI testing; specific information concerning the viability of both self-taken samples and postal delivery to laboratories is needed Conclusion This study represents the first evidence-based approach to improving the design of self-sampling packs and sample return. Using qualitative approaches and implementation science it is possible to systematically suggest refinements to product design and the need for additional sources of psychological and behavioural support to improve user experience, increase acceptability of self-sampling, broaden uptake and boost sample return Disclosure No significant relationships.

Background Clinical prediction rules (CPRs) estimate the probability of a health outcome to support decision-making in intervention and service delivery. Previously, a CPR was derived to maximize detection of chlamydia and/or gonorrhea (CT/GC) infections and minimize the number of screening tests offered among asymptomatic women and heterosexual men attending sexually-transmitted infection (STI) clinics in Vancouver, British Columbia, Canada. We assessed the external validity of using this clinic-derived CPR within GetCheckedOnline (GCO), a provincial online STI testing program in British Columbia. Methods Data used for calculating CPR scores, including age, race/ethnicity, number of sexual partners and previous CT/GC diagnoses, were collected prospectively on GCO from October 2015 to June 2018. Model calibration and discrimination were evaluated using the Hosmer-Lemeshow (H-L) statistic and the area under the receiver operating characteristic curve (AUC), respectively. Sensitivity and proportion of GCO clients screened were calculated at different CPR cut-off scores. In the original derivation population, the CPR had an AUC=0.74, with a cut-off risk score ≥6 identifying 91% of infections and screening 68% of testers. Results Among 2703 GCO CT/GC test episodes, the prevalence of CT/GC infection was 2.1%. The clinic CPR showed reasonable calibration (H-L p=0.952) and discrimination (AUC=0.64, 95%CI: 0.57–0.71). Using a CPR cut-off risk score of ≥6, we would have detected 79% of infections and screened 64% of testers. Lowering the cut-off risk score to ≥4 would have increased sensitivity to 95% while screening 85% of testers. Conclusion This is the first study validating the use of a clinic-derived CPR within an online setting. Our CPR showed reasonable accuracy and performance when applied to GCO data. Differences in model performance online compared with clinic-based settings highlight important differences in the populations who use online testing. Use of CPRs in online contexts offers unique and novel opportunities for public health and STI testing. Disclosure No significant relationships.

This article examines discourse on immunity in general public engagements with pandemic influenza in light of critical theory on immuno-politics and bodily integrity. Interview and focus group discussions on influenza with members of the general public reveal that, despite endorsement of government advice on how to avoid infection, influenza is seen as, ultimately, unavoidable. In place of prevention, members of the general public speak of immunity as the means of coping with influenza infection. Such talk on corporeal life under microbial threat is informed by self/not-self, network and ‘choice’ immunity, and therefore makes considerable allowance for cosmopolitan traffic with others, microbes, ‘dirt’ and immune-boosting consumer products. The immuno-political orientation of members of the general public, therefore, appears to trend towards a productive cosmopolitanism that contrasts with more orthodox bioscientific and governmental approaches to pandemic influenza. We reflect on the implications of the immuno-cosmopolitanism of everyday life for the advent of global public health emergency and for biopolitical rule in general.