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HIV is still the leading cause of death in Sub-Saharan Africa (SSA), despite medical advances. eHealth interventions are effective for HIV prevention and management, but it is unclear whether this can be generalised to resource-poor settings. This systematic review aimed to establish the effectiveness of eHealth interventions in SSA. Six electronic databases were screened to identify randomised controlled trials (RCTs) published between 2000 and 2020. Meta-analyses were performed, following Cochrane methodology, to assess the impact of eHealth interventions on HIV-related behaviours and biological outcomes. 25 RCTs were included in the review. Meta-analyses show that eHealth interventions significantly improved HIV management behaviours (OR 1.21; 95% CI 1.05–1.40; Z = 2.67; p = 0.008), but not HIV prevention behaviours (OR 1.02; 95% CI 0.78–1.34; Z = 0.17; p = 0.86) or biological outcomes (OR 1.17; 95% CI 0.89–1.54; Z = 1.10; p = 0.27) compared with minimal intervention control groups. It is a hugely important finding that eHealth interventions can improve HIV management behaviours as this is a low-cost way of improving HIV outcomes and reducing the spread of HIV in SSA. PROSPERO registration number: CRD42020186025.

Introduction In Saudi Arabia, sexual and reproductive health education is not offered in any formal setting, and there is a significant lack of knowledge amongst Saudi women. This study aimed to explore barriers to Saudi women’s sexual and reproductive wellbeing. Methods The study employed qualitative methods using semi-structured interviews with women in Riyadh, Saudi Arabia in 2019. The data were analysed using thematic analysis. Results Twenty-eight women were interviewed. Sexual and reproductive wellbeing is a complex matter affected by personal, familial, environmental, socio-cultural, religious, and institutional factors. Being unmarried is a significant barrier to accessing sexual and reproductive information and services, with ignorance signifying modesty and purity. Parental control acted as a barrier to acquiring knowledge and accessing essential healthcare services. Schools contribute to lack of awareness, with teachers omitting sexual and reproductive health-related subjects and evading answering questions. Conclusions There are multiple factors that restrict Saudi women’s access to sexual and reproductive health information and services, impacting their overall wellbeing. Research and policy efforts should be directed towards overcoming the complex barriers to Saudi women’s sexual and reproductive wellbeing. Public health initiatives are needed to improve youth, parents, and teacher’s knowledge, and improve public perceptions towards sexual and reproductive health education.

BACKGROUND Digital technology offers good opportunities for HIV prevention. This systematic review assesses the effectiveness of interactive digital interventions (IDIs) for prevention of sexually transmitted HIV. METHODS We conducted a systematic search for randomized controlled trials (RCTs) of IDIs for HIV prevention, defining 'interactive' as producing personally tailored material. We searched databases including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, grey literature, reference lists, and contacted authors if needed.Two authors screened abstracts, applied eligibility and quality criteria and extracted data. Meta-analyses used random-effects models with standardized mean differences (SMD) for continuous outcomes and odds ratios (OR) for binary outcomes, assessing heterogeneity using the I2 statistic. RESULTS We included 31 RCTs of IDIs for HIV prevention. Meta-analyses of 29 RCTs comparing IDIs with minimal interventions (e.g. leaflet, waiting list) showed a moderate increase in knowledge (SMD 0.56, 95% CI 0.33 to 0.80), no effect on self-efficacy (SMD 0.13, 95% CI 0.00 to 0.27), a small improvement in intention (SMD 0.16, 95% CI 0.06 to 0.26), improvement in HIV prevention behaviours (OR 1.28, 95% CI 1.04 to 1.57) and a possible increase in viral load, but this finding is unreliable.We found no evidence of difference between IDIs and face-to-face interventions for knowledge, self-efficacy, intention, or HIV-related behaviours in meta-analyses of five small RCTs. We found no health economic studies. CONCLUSION There is good evidence that IDIs have positive effects on knowledge, intention and HIV prevention behaviours. IDIs are appropriate for HIV prevention in a variety of settings.Supplementary Video Abstract, http://links.lww.com/QAD/B934.

Sexual difficulties are common, but there is limited access to specialist services. People concerned about their sexual functioning may not seek help, and patients and health professionals can find...

BackgroundHuman papillomavirus (HPV)-based cervical screening is now replacing cytology-based screening in several countries and many women in screening programmes will consequently receive HPV-positive results. Because of the sexually transmitted nature of HPV, receiving an HPV-positive result may raise questions about disclosing the infection to a sexual partner.ObjectiveTo review the quantitative and qualitative literature exploring women’s concerns about disclosing a high-risk cervical HPV infection to a sexual partner.MethodsWe searched MEDLINE, PsycINFO, CINAHL Plus, Web of Science and EMBASE for studies reporting at least one disclosure-related outcome among women with high-risk HPV. We also searched the grey literature and carried out forward/backward citation searches. A narrative synthesis for quantitative studies and a thematic synthesis for qualitative studies were conducted.ResultsThirteen articles met the inclusion criteria (12 qualitative, 1 quantitative). In the quantitative study, 60% of HPV-positive women felt disclosing an HPV result was ‘risky’. Concerns about disclosing HPV to a sexual partner were influenced by the stigma that is associated with having an STI and uncertainty about how their partner would respond. Women questioned how, when and to whom they should disclose their HPV-positive status.ConclusionsThe studies included in this review provide rich information about the range of concerns women have, the reasons for these concerns, and the questions women have about disclosing HPV to sexual partners. As studies were predominantly qualitative, the prevalence of concerns is unclear.

ObjectivesMany countries are implementing human papillomavirus (HPV)‐based cervical screening due to the higher sensitivity of the test compared with cytology. As HPV is sexually transmitted, there may be psychosexual consequences of testing positive for the virus. We aimed to review the literature exploring the psychosexual impact of testing positive for high‐risk cervical HPV.MethodsMEDLINE, PsycINFO, CINAHL Plus, Web of Science, and EMBASE were searched with no date limits. We also searched the grey literature, reference lists of included articles and carried out forward citation searching. Eligible studies reported at least one psychosexual outcome among HPV‐positive women. Qualitative and quantitative papers were included. We extracted data using a standardised form and carried out a quality assessment for each article. We conducted a narrative synthesis for quantitative studies and a thematic synthesis for qualitative studies.ResultsTwenty‐five articles were included. Quantitative study designs were diverse making it difficult to determine the impact that an HPV positive result would have in the context of routine screening. The qualitative literature suggested that psychosexual concerns cover a broad range of aspects relating to women's current and past relationships, both interpersonal and sexual.ConclusionsThe psychosexual impact of testing positive for high‐risk cervical HPV is unclear. This review highlights the need for further research in the context of HPV‐based cervical screening. As primary HPV testing is introduced more widely, it is important to understand women's responses to testing HPV positive in the cancer screening context to minimise any adverse psychosexual impact.

Background Effective sex education is the key to good sexual health. Peer-led approaches can augment teacher-delivered sex education, but many fail to capitalise on mechanisms of social influence. We assessed the feasibility of a novel intervention (STASH) in which students (aged 14–16) nominated as influential by their peers were recruited and trained as Peer Supporters (PS). Over a 5–10-week period, they spread positive sexual health messages to friends in their year group, both in-person and via social media, and were supported to do so via weekly trainer-facilitated meetings. The aims of the study were to assess the feasibility of STASH (acceptability, fidelity and reach), to test and refine the programme theory and to establish whether the study met pre-set progression criteria for continuation to larger-scale evaluation. Methods The overall design was a non-randomised feasibility study of the STASH intervention in 6 schools in Scotland. Baseline (n=680) and follow-up questionnaires (approx. 6 months later; n=603) were administered to the intervention year group. The control group (students in year above) completed the follow-up questionnaire only (n=696), 1 year before the intervention group. The PS (n=88) completed a brief web survey about their experience of the role; researchers interviewed participants in key roles (PS (n=20); PS friends (n=22); teachers (n=8); trainers (n=3)) and observed 20 intervention activities. Activity evaluation forms and project monitoring data also contributed information. We performed descriptive quantitative analysis and thematic qualitative analysis. Results The PS role was acceptable; on average across schools >50% of students nominated as influential by their friends, signed up and were trained (n=104). This equated to 13% of the year group. Trained PS rarely dropped out (97% completion rate) and 85% said they liked the role. Fidelity was good (all bar one trainer-led activity carried out; PS were active). The intervention had good reach; PS were reasonably well connected and perceived as ‘a good mix’ and 58% of students reported exposure to STASH. Hypothesised pre-conditions, contextual influences and mechanisms of change for the intervention were largely confirmed. All bar one of the progression criteria was met. Conclusion The weight of evidence supports continuation to full-scale evaluation. Trial registration Current controlled trials ISRCTN97369178

Background Effective use of contraception can reduce numbers of unintended pregnancies, but misunderstandings and concerns about contraception abound. Increasingly, women seek health-care information online. Objectives To develop an interactive website to aid informed choice of contraceptive method, including long-acting reversible contraception (Phase I), and test its effectiveness in a parallel, single-blind randomised trial (Phase II). Approval came from London – Camden & King’s Cross Research Ethics Committee (reference 17/LO/0112). Setting and participants For both phases, women aged 15–30 years were recruited from general practice, sexual health services, maternity services, community pharmacies and an abortion service. Design In Phase I, we conducted three systematic literature reviews, a review of YouTube (YouTube, LLC, San Bruno, CA, USA) videos about contraception, and focus groups and interviews with young women to explore barriers to and concerns and misperceptions about contraception. We then iteratively co-designed an interactive website, Contraception Choices [URL: www.contraceptionchoices.org (accessed June 2020)], with young women and a software company. In Phase II, we evaluated the website through a randomised trial that began as a feasibility trial. Early demand for Contraception Choices stimulated a design change from a feasibility to an efficacy trial, with follow-up for clinical outcomes at 3 and 6 months. A randomisation list was incorporated into the trial software program to allocate participants to the intervention (website) or control group (standard care). Intervention Contraception Choices is a co-designed, evidence-based, interactive website to aid informed choice of contraception. It provides information about different methods, addresses common concerns and offers tailored contraceptive options in response to individual preferences. Main outcome measures Qualitative – participant views and experience of the intervention, assessed through qualitative interviews. Quantitative primary outcomes – follow-up rate at 6 months in the initial feasibility trial, using a long-acting reversible contraception method, and satisfaction with contraceptive method at 6 months in the efficacy trial. Results A total of 927 women were randomised online to the website (n = 464) or control group (n = 463), of whom 739 (80%) provided follow-up data at 6 months [786 women (85%) provided data at 3 and/or 6 months that were included in the analysis of primary outcomes]. There was little difference between groups in the proportion using long-acting reversible contraception at 6 months [30.4% intervention vs. 31.0% control, adjusted odds ratio after imputation 0.87 (95% confidence interval 0.60 to 1.27)] or in satisfaction with contraceptive method [proportion being ‘satisfied’ or ‘very satisfied’, 82.6% intervention vs. 82.1% control, adjusted odds ratio 0.93 (95% confidence interval 0.69 to 1.25)]. Qualitative evaluation indicated highly positive views about the website and increased knowledge of contraceptive methods that could dispel misperceptions. Women appreciated having information tailored to their specific needs and felt better prepared before consultations. Limitations We did not include intermediate measures, such as knowledge of contraceptive methods, intention to change method or confidence in discussing contraception with a health-care professional, which may have indicated other benefits of using the website. In future, the website should be studied in different settings (e.g. schools and in routine practice) to see whether or not it improves the quality or efficiency of contraceptive consultations. Conclusions Our systematic review indicated wide-ranging influences on women’s use of contraception globally. The website, Contraception Choices, was very popular with young women and contraception service providers. It was not associated with statistically significant differences in use of long-acting reversible contraception or satisfaction with contraceptive method at 6 months. Trial registration Current Controlled Trials ISRCTN13247829. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 56. See the NIHR Journals Library website for further project information.

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

Background In Islamic societies, issues related to sexual and reproductive health (SRH) are rarely discussed and considered sensitive subjects. This review aimed to identify any personal, religious, cultural, or structural barriers to SRH service and education among Muslim women worldwide. Methods A search for qualitative and quantitative studies was conducted on seven electronic databases. A narrative synthesis using thematic analysis was conducted. Results Fifty-nine studies were included from 22 countries: 19 qualitative, 38 quantitative and two mixed methods. Many Muslim women have poor SRH knowledge, and negative attitudes which influence their access to, and use of SRH services. Barriers to contraception use among Muslim women included a lack of basic reproductive knowledge, insufficient knowledge about contraception, misconceptions, and negative attitudes. Women had negative attitudes towards family planning for limiting the number of children but not for child spacing, which reflected religious views towards family planning. Religious and cultural beliefs were barriers to contraception use and access to SRH services and information. Family and the community have a significant impact on women’s contraceptive use and access to SRH services. Husband and family opposition played a significant role in contraception access and use. Fear of stigmatization and being labelled as having pre-marital sexual relations among unmarried women acted as the main barrier to accessing contraception and seeking SRH information and services. Conclusion The findings reveal that there are multiple levels of factors that influence Muslim women’s SRH. Poor SRH knowledge and practices among Muslim women is complex matter that is affected by personal, community, cultural, religious factors and existing policies and regulations. All these factors overlap and are affected by each other. There is an urgent need for interventions addressing modifiable barriers to SRH education and services to improve knowledge, informed choice and access to services to facilitate better sexual and reproductive wellbeing for Muslim women. It is important to note that while this review aimed to report findings on Muslim women, we acknowledge that significant variations exist within every culture and religion.

Objective Improving use of effective contraception to prevent unintended pregnancy is a global priority, but misperceptions and concerns about contraception are common. Our objective was to evaluate an interactive website to aid informed choice of contraception. Methods The Contraception Choices website is an interactive digital intervention which offers tailored advice to aid contraception decision-making ( www.contraceptionchoices.org ). In a parallel single-blind trial, we randomised 927 women aged 15–30 years from six clinic settings to access the intervention website (n = 464) or to a waiting-list control group (n = 463). The study was initially a feasibility trial, evolving into an evaluation of efficacy, with two primary outcomes at six months: long-acting reversible contraception (LARC) use, and satisfaction with contraceptive method. Secondary outcomes included self-reported pregnancy and sexually transmitted infection diagnoses. Free-text comments on the 3 and 6 month outcome surveys were analysed thematically. Findings There was no significant difference between intervention and control groups in the proportion of women using LARC [30.4% intervention versus 31.0% control; adjusted odds ratio 0.87 (95% confidence interval 0.60 to 1.28)]; satisfaction with contraceptive method [82.6% versus 82.1%; adjusted ordinal odds ratio 0.93 (95% CI 0.69 to 1.25)]; self-reported pregnancy [3.3% versus 4.1%; adjusted odds ratio 0.90 (95% CI 0.45 to 1.79)] nor sexually transmitted infection [5.3% versus 4.7%; adjusted odds ratio 0.72 (95% CI 0.55 to 2.36)]. Highly positive free-text comments from intervention participants indicated that the website facilitates contraception choice and can help women feel better prepared before consultation with healthcare providers. Interpretation The Contraception Choices website was popular for its design, trustworthy information and decision aids but it was not associated with significant differences in use of LARC or satisfaction with contraceptive method. An interactive website can aid contraception choice, but interventions that address factors beyond women’s control, such as access to services, and partner, family or community influences are needed to complement this approach. Research in context Preventing unintended pregnancy through effective use of contraception is essential for women’s health, but choosing between different contraceptive methods can be challenging, and the opportunity for adequate discussion during routine consultations is often constrained. Evidence before this study We conducted two systematic literature reviews: 1) Factors influencing contraception choice, uptake and use: a meta-synthesis of systematic reviews; and 2) Effectiveness of interactive digital interventions (IDI) for contraception choice, uptake and use. For the first review we searched PubMed, CDSR, Epistemonikos, DoPHER, DARE, NHS Economic Evaluation Database, Campbell Library, NIHR Health Technology Assessment, and Health Evidence Canada databases for systematic reviews which addressed contraceptive choice, uptake or use, from 2000 to 2017. PROSPERO registration number: CRD42017081521 https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=81521 . We synthesised the findings of 18 systematic reviews of mostly moderate or high quality. They highlighted the importance of women’s knowledge, beliefs, perceptions of side effects and health risks, as well as relationship status, social network, economic and healthcare factors on contraception choice and use. For the second review, we searched 23 electronic databases, trials registers and reference lists for randomised controlled trials of IDI for contraception, including CENTRAL, MEDLINE, EMBASE, CINAHL, ERIC, ASSIA and PsycINFO, from start date to June 2017. PROSPERO registration number: CRD42017081636. We found only five randomised trials of IDI, all from the USA. Risk of bias prevented synthesis of results. www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=81636 . Added value of this study Women’s common concerns about contraception – fear of hormones, weight gain, cancer, infertility, mood changes, breaks from contraception and changes in bleeding patterns – underpinned development of a new interactive website ( www.contraceptionchoices.org ). Contraception Choices addresses women’s concerns through succinct text; Q and A format ( Frequently Asked Questions, Did you Know?; videos of women and health professionals); an effectiveness infographic, and an interactive decision aid ( What’s right for me?). In an online randomised trial with 927 women attending clinics, we found no association of the Contraception Choices intervention with the primary outcomes – satisfaction with contraceptive method and uptake of long-acting reversible methods at 6 months. Nor did we find an association with secondary adverse outcomes – sexually transmitted infections or pregnancy. Comments from women indicated that the website can meet young women’s need for information on the benefits and drawbacks of contraception, help them to make informed decisions, and feel better prepared before healthcare consultations. Contraception Choices is now available on the NHS website: www.nhs.uk/conditions/contraception/which-method-suits-me Implications of all the available evidence Interactive digital interventions (websites) can aid contraception choice, but other intervention research is needed to address wider influences on unintended pregnancy, including partner views, friends, family, the media, wider society and experiences with healthcare professionals. Future research could examine the impact of the website in different settings, e.g. schools or different countries. We hypothesise that use of the website during contraceptive consultations might improve the efficiency or quality of consultation, for both patients and healthcare providers. Appropriate methodology and time-scale for evaluating digital health interventions remains a key question.

BACKGROUND: Young people aged 16-24 years are disproportionately affected by sexually transmitted infections (STIs). STIs can have serious health consequences for affected individuals and the estimated annual cost of treatment to the National Health Service is £620 million. Accordingly, the UK government has made reducing the rates of STIs among this group a priority. A missed opportunity to intervene to increase condom use is when young people obtain self-sampling kits for STIs via the internet.OBJECTIVE: Our aim was to develop a theory-based tailored intervention to increase condom use for 16-24-years-olds accessing chlamydia self-sampling websites.METHODS: The intervention, Wrapped, was developed using Intervention Mapping and was co-designed with young people. The following steps were performed: (1) identification of important determinants of condom use and evidence of their changeability using computer and digital interventions; (2) setting the intervention goal, performance objectives, and change objectives; (3) identification of Behavior Change Principles (BCPs) and practical strategies to target these determinants; and (4) development of intervention materials able to deliver the BCPs and practical strategies.RESULTS: Users of existing chlamydia self-sampling websites are signposted to Wrapped after placing an order for a sampling kit. Salient barriers to condom use are identified by each user and relevant intervention components are allocated to target these. The components include the following: (1) a sample box of condoms, (2) an online condom distribution service, (3) a product for carrying condoms, (4) a condom demonstration video, (5) a series of videos on communication about condom use, and (6) erotic films of real couples discussing and demonstrating condom use.CONCLUSIONS: This intervention will be directed at young people who may be particularly receptive to messages and support for behavior change due to their testing status.

Sexually transmitted infections (STIs) continue to represent a major public health challenge. There is evidence that behavioural interventions to reduce risky sexual behaviours can reduce STI rates in patients attending sexual health (SH) services. However, it is not known if these interventions are effective when implemented at scale in SH settings in England.The study (Santé) had two main objectives - (1) to develop and pilot a package of evidence-based sexual risk reduction interventions that can be delivered through SH services and (2) to assess the feasibility of conducting a randomised controlled trial (RCT) to determine effectiveness against usual care.The project was a multistage, mixed-methods study, with developmental and pilot RCT phases. Preparatory work included a systematic review, an analysis of national surveillance data, the development of a triage algorithm, and interviews and surveys with SH staff and patients to identify, select and adapt interventions. A pilot cluster RCT was planned for eight SH clinics; the intervention would be offered in four clinics, with qualitative and process evaluation to assess feasibility and acceptability. Four clinics acted as controls; in all clinics, participants would be consented to a 6-week follow-up STI screen.SH clinics in England.Young people (aged 16-25 years), and men who have sex with men.A three-part intervention package - (1) a triage tool to score patients as being at high or low risk of STI using routine data, (2) a study-designed web page with tailored SH information for all patients, regardless of risk and (3) a brief one-to-one session based on motivational interviewing for high-risk patients.The three outcomes were (1) the acceptability of the intervention to patients and SH providers, (2) the feasibility of delivering the interventions within existing resources and (3) the feasibility of obtaining follow-up data on STI diagnoses (primary outcome in a full trial).We identified 33 relevant trials from the systematic review, including videos, peer support, digital and brief one-to-one sessions. Patients and SH providers showed preferences for one-to-one and digital interventions, and providers indicated that these intervention types could feasibly be implemented in their settings. There were no appropriate digital interventions that could be adapted in time for the pilot; therefore, we created a placeholder for the purposes of the pilot. The intervention package was piloted in two SH settings, rather than the planned four. Several barriers were found to intervention implementation, including a lack of trained staff time and clinic space. The intervention package was theoretically acceptable, but we observed poor engagement. We recruited patients from six clinics for the follow-up, rather than eight. The completion rate for follow-up was lower than anticipated (16% vs. 46%).Fewer clinics were included in the pilot than planned, limiting the ability to make strong conclusions on the feasibility of the RCT.We were unable to conclude whether or not a definitive RCT would be feasible because of challenges in implementation of a pilot, but have laid the groundwork for future research in the area.Current Controlled Trials ISRCTN16738765.This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inReducing sexually transmitted infections (STIs) is a public health priority. Those most likely to be diagnosed with a STI are young people (aged 16–25 years) and men who have sex with men. Studies in other countries have shown that interventions aimed at changing sexual behaviour (e.g. increasing condom use) can reduce the chance of getting new STIs in patients attending sexual health (SH) clinics. However, it is not clear if these interventions will work in English sexual health clinics, or if they could be implemented within existing resources. This study aimed to find out if effective interventions could be adapted to an English setting and tested this in a randomised trial. The scientific literature was searched for potential interventions and 33 trials were found. Effective methods included videos, digital web-based interventions, self-testing kits and talking sessions (e.g. counselling). Patients and providers were asked which interventions were acceptable and preferences for digital and one-to-one talking interventions were found. Providers suggested that these were feasible to deliver. Data routinely collected from patients (e.g. number of partners) were used to select patients at a higher risk of having a STI, a computerised risk score calculation was developed, and the highest risk group was directed to a one-to-one counselling intervention. There were no appropriate digital interventions available; therefore, a stand-in web page was created to signpost users to appropriate SH resources. This was offered to all patients. The intervention package was piloted in two SH settings rather than the planned four because of a lack of clinic staff time and space. It was planned to follow up a subset of patients from all eight clinics 6 weeks after their visit to collect information on STI diagnoses. Patients were recruited from six clinics, but only 16% of patients completed the survey and returned a sample. It was not possible to conclude definitively whether or not a randomised trial is feasible because of challenges in implementation and recruitment.

Background: \ud Young people in the UK are at highest risk of sexually transmitted infections and report higher levels of unsafe sex than any other age group. Involving peer supporters in intervention delivery is acceptable to students and effective in reducing risk behaviours via ‘diffusion of innovation’, particularly where peer supporters are influential in their networks. Informal peer-led interventions offer a useful alternative to peer-led didactic teaching, which has shown limited effects. Building on the successful ASSIST anti-smoking intervention, the ‘STis And Sexual Health’ (STASH) intervention involves identification and recruitment of the most influential students as peer supporters, training and support to these students by specialist trainers, positive sex and relationships messages, spread by peer supporters to their friendship groups in person and via social media.\ud \ud Methods/design: \ud This protocol describes a feasibility trial of the STASH intervention in six schools. It builds on an earlier study phase of intervention co-development using patient and public involvement (PPI) activities, followed by a pilot of intervention components and evaluation tools in one school. Participants are fourth year (S4) students (aged 14–16) in state-funded Scottish secondary schools who have received some level of teacher-led sex education. The previous cohort of S4 students (those completing S4 in the year prior to the intervention) will serve as controls. Data will be collected from controls (month 16), baseline (month 20–21) and follow-up (month 27–30) via a web-based questionnaire, which will measure (and test the reliability of) primary outcome measures for a phase III trial (delayed initiation of/abstinence from sex and consistent condom use), secondary outcomes and mediators of sexual behaviour (including school climate and social networks). The main feasibility outcome is whether the study meets pre-set progression criteria regarding feasibility and acceptability, measured largely via a process evaluation (basic measures in all 6 schools and in-depth in 2-4 schools). An economic evaluation reporting costs alongside consequences will be conducted.\ud \ud Discussion: \ud This study will inform decisions on the feasibility, design and sample size for a phase III effectiveness trial to assess whether the STASH intervention is effective in reducing the risk of sexually transmitted infections in young people.\ud \ud Trial registration: \ud ISRCTN97369178.

ObjectiveBehavioural interventions have been shown to reduce sexual behaviours associated with increased risk of sexually transmitted infections in young people (MethodsWe conducted a sequential mixed methods study with sexual health service providers and users in 2015/2016. Qualitative interviews with providers and service users (heterosexual young people and MSM) in London and Brighton allowed us to explore a range of experiences and expectations. A subsequent national web-survey of service providers measured the feasibility of delivery within existing resources and preferences for intervention attributes.ResultsWe conducted 35 service user (15 heterosexual young people; 20 MSM) and 26 provider interviews and had 100 web-survey responses. We found considerable heterogeneity in prevention services offered. Service users and providers were broadly supportive of tailoring interventions offered, but service users raised concerns about automated, data-driven triage, particularly around equity and fairness of service delivery. Digital technologies, including social media or apps, were appealing to providers, being less resource intensive. However, one-to-one talking interventions remained popular with both service users and providers, being familiar, trustworthy and personal. Key tensions between desirability of interventions and availability of resources to deliver them were acknowledged/recognised by providers and users.ConclusionOverall, behavioural interventions to reduce sexual behaviour risks were viewed favourably by service providers and users, with key considerations including: privacy, personalisation and convenience. However, introducing desirable targeted interventions within heterogeneous sexual health settings will require resources to adapt interventions and research to fully understand the barriers and facilitators to use within routine services.

BackgroundThis report details the development of the Men’s Safer Sex website and the results of a feasibility randomised controlled trial (RCT), health economic assessment and qualitative evaluation.Objectives(1) Develop the Men’s Safer Sex website to address barriers to condom use; (2) determine the best design for an online RCT; (3) inform the methods for collecting and analysing health economic data; (4) assess the Sexual Quality of Life (SQoL) questionnaire and European Quality of Life-5 Dimensions, three-level version (EQ-5D-3L) to calculate quality-adjusted life-years (QALYs); and (5) explore clinic staff and men’s views of online research methodology.Methods(1) Website development: we combined evidence from research literature and the views of experts (n = 18) and male clinic users (n = 43); (2) feasibility RCT: 159 heterosexually active men were recruited from three sexual health clinics and were randomised by computer to the Men’s Safer Sex website plus usual care (n = 84) or usual clinic care only (n = 75). Men were invited to complete online questionnaires at 3, 6, 9 and 12 months, and sexually transmitted infection (STI) diagnoses were recorded from clinic notes at 12 months; (3) health economic evaluation: we investigated the impact of using different questionnaires to calculate utilities and QALYs (the EQ-5D-3L and SQoL questionnaire), and compared different methods to collect resource use; and (4) qualitative evaluation: thematic analysis of interviews with 11 male trial participants and nine clinic staff, as well as free-text comments from online outcome questionnaires.Results(1) Software errors and clinic Wi-Fi access presented significant challenges. Response rates for online questionnaires were poor but improved with larger vouchers (from 36% with £10 to 50% with £30). Clinical records were located for 94% of participants for STI diagnoses. There were no group differences in condomless sex with female partners [incidence rate ratio (IRR) 1.01, 95% confidence interval (CI) 0.52 to 1.96]. New STI diagnoses were recorded for 8.8% (7/80) of the intervention group and 13.0% (9/69) of the control group (IRR 0.75, 95% CI 0.29 to 1.89). (2) Health-care resource data were more complete using patient files than questionnaires. The probability that the intervention is cost-effective is sensitive to the source of data used and whether or not data on intended pregnancies are included. (3) The pilot RCT fitted well around clinical activities but 37% of the intervention group did not see the Men’s Safer Sex website and technical problems were frustrating. Men’s views of the Men’s Safer Sex website and research procedures were largely positive.ConclusionsIt would be feasible to conduct a large-scale RCT using clinic STI diagnoses as a primary outcome; however, technical errors and a poor response rate limited the collection of online self-reported outcomes. The next steps are (1) to optimise software for online trials, (2) to find the best ways to integrate digital health promotion with clinical services, (3) to develop more precise methods for collecting resource use data and (4) to work out how to overcome barriers to digital intervention testing and implementation in the NHS.Trial registrationCurrent Controlled Trials ISRCTN18649610.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 91. See the NIHR Journals Library website for further project information.

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

Objectives We aimed to determine the feasibility of an online randomised controlled trial (RCT) of the Men’s Safer Sex website, measuring condom use and sexually transmitted infection (STI). Methods For this study 159 men aged ≥16 with female sexual partners and recent condomless sex or suspected STI were recruited from three UK sexual health clinics. Participants were randomised to the intervention website plus usual clinic care ( n = 84), or usual clinic care only ( n = 75). Online outcome data were solicited at 3, 6, and 12 months. Results Men were enrolled via tablet computers in clinic waiting rooms. Software errors and clinic Wi-Fi access presented significant challenges, and online questionnaire response rates were poor (36% at 3 months with a £10 voucher; 50% at 12 months with £30). Clinical records (for STI diagnoses) were located for 94% of participants. Some 37% of the intervention group did not see the intervention website ( n = 31/84), and (as expected) there was no detectable difference in condomless sex with female partners (IRR = 1.01, 95% CI 0.52 to 1.96). New acute STI diagnoses were recorded for 8.8% (7/80) of the intervention group, and 13.0% (9/69) of the control group over 12 months (IRR = 0.75, 95% CI 0.29 to 1.90). Conclusion It is likely to be feasible to conduct a future large-scale RCT to assess the impact of an online intervention using clinic STI diagnoses as a primary outcome. However, practical and technical challenges need to be addressed before the potential of digital media interventions can be realised in sexual health settings. Trial registration number: ISRCTN18649610

This systematic review was conducted to determine the effects of self-help interactive computer-based interventions (ICBIs) for sexual health promotion. We searched 40 databases for randomized controlled trials (RCTs) of computer-based interventions, defining ‘interactive’ as programmes that require contributions from users to produce personally relevant material. We conducted searches and analysed data using Cochrane Collaboration methods. Results of RCTs were pooled using a random-effects model with standardized mean differences for continuous outcomes and odds ratios (ORs) for binary outcomes, with heterogeneity assessed using the I2 statistic. We identified 15 RCTs of ICBIs (3917 participants). Comparing ICBIs to minimal interventions, there were significant effects on sexual health knowledge (standardized mean difference [SMD] 0.72, 95% confidence interval [CI] 0.27–1.18); safer sex self-efficacy (SMD 0.17, 95% CI 0.05–0.29); safer-sex intentions (SMD 0.16, 95% CI 0.02–0.30); and sexual behaviour (OR 1.75, 95% CI 1.18–2.59). ICBIs had a greater impact on sexual health knowledge than face-to-face interventions did (SMD 0.36, 95% CI 0.13–0.58). ICBIs are effective tools for learning about sexual health, and show promising effects on self-efficacy, intention and sexual behaviour. More data are needed to analyse biological outcomes and cost-effectiveness.

These are commentaries of a Cochrane review, published in this issue of EBCH, first published as: Bailey JV, Murray E, Rait G, Mercer CH, Morris RW, Peacock R, Cassell J, Nazareth I. Interactive computer-based interventions for sexual health promotion. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD006483. DOI: 10.1002/14651858.CD006483.pub2. Further information for this Cochrane review is available in this issue of EBCH in the accompanying Summary article. Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. The Cochrane Collaboration

Background Sexual health promotion is a major public health challenge; there is huge potential for health promotion via technology such as the Internet. Objectives To determine effects of interactive computer-based interventions (ICBI) for sexual health promotion, considering cognitive, behavioural, biological and economic outcomes. Search strategy We searched more than thirty databases for randomised controlled trials (RCTs) on ICBI and sexual health, including CENTRAL, DARE, MEDLINE, EMBASE, CINAHL, British Nursing Index, and PsycINFO. We also searched reference lists of published studies and contacted authors. All databases were searched from start date to November 2007, with no language restriction. Selection criteria RCTs of interactive computer-based interventions for sexual health promotion, involving participants of any age, gender, sexual orientation, ethnicity or nationality. 'Interactive' was defined as packages that require contributions from users to produce tailored material and feedback that is personally relevant. Data collection and analysis Two review authors screened abstracts, applied eligibility and quality criteria and extracted data. Results of RCTs were pooled using a random-effects model with standardised mean differences (SMDs) for continuous outcomes and odds ratios (ORs) for binary outcomes. We assessed heterogeneity using the I2 statistic. Separate meta-analyses were conducted by type of comparator: 1) minimal intervention such as usual practice or leaflet, 2) face-to-face intervention or 3) a different design of ICBI; and by type of outcome (cognitive, behavioural, biological outcomes). Main results We identified 15 RCTs of ICBI conducted in various settings and populations (3917 participants). Comparing ICBI to 'minimal interventions' such as usual practice, meta-analyses showed statistically significant effects as follows: moderate effect on sexual health knowledge (SMD 0.72, 95% CI 0.27 to 1.18); small effect on safer sex self-efficacy (SMD 0.17, 95% CI 0.05 to 0.29); small effect on safer-sex intentions (SMD 0.16, 95% CI 0.02 to 0.30); and also an effect on sexual behaviour (OR 1.75, 95% CI 1.18 to 2.59). Data were insufficient for meta-analysis of biological outcomes and analysis of cost-effectiveness. In comparison with face-to-face sexual health interventions, meta-analysis was only possible for sexual health knowledge, showing that ICBI were more effective (SMD 0.36, 95% CI 0.13 to 0.58). Two further trials reported no difference in knowledge between ICBI and face-to-face intervention, but data were not available for pooling. There were insufficient data to analyse other types of outcome. No studies measured potential harms (apart from reporting any deterioration in measured outcomes). Authors' conclusions ICBI are effective tools for learning about sexual health, and they also show positive effects on self-efficacy, intention and sexual behaviour. More research is needed to establish whether ICBI can impact on biological outcomes, to understand how interventions might work, and whether they are cost-effective. Plain Language Summary Computer programmes for sexual health promotion Sexual health promotion is a major public health challenge. There is huge potential for health promotion via technology such as the Internet, but it is not known whether interventions are effective. An interactive computer-based intervention provides information, and also offers personalised feedback. We searched databases for studies which were randomised controlled trials (RCTs) of computer/Internet-based interventions which aimed to improve sexual health. We included trials of computer-based interventions delivered to people of any age, gender, sexual orientation, ethnicity or nationality. The review evaluated 15 RCTs involving 3917 participants. Results showed that computer-based interventions have a moderate effect in improving people's knowledge about sexual health in comparison to minimal interventions such as ‘usual practice’ or a leaflet. We also found a small effect on safer sex self-efficacy (a person's belief in their capacity to carry out a specific action), a small effect on safer-sex intentions, and also an effect on sexual behaviour (such as condom use for sexual intercourse). We found that computer-based interventions seem better than face-to-face interventions at improving sexual health knowledge, but there were insufficient data to analyse other outcomes. No studies measured potential harms (apart from reporting any deterioration in outcomes). Interactive computer-based interventions for sexual health promotion are feasible in a variety of settings. They are effective tools for learning about sexual health, and they also improve self-efficacy, intention and sexual behaviour, but more research is needed to establish whether computer-based interventions can change outcomes such as sexually transmitted infections and pregnancy, to understand how interventions might work, and to assess whether they are cost-effective.

This paper aims to illustrate what discourse analysis is and how it can contribute to our understanding of family practice. Firstly, we describe what ‘discourse analysis’ is, mapping the discourse analysis terrain by discussing four studies relevant to primary care to illustrate different methodological approaches and key concepts. We then address the practicalities of how to actually do discourse analysis, providing readers with a worked example using one particular approach. Thirdly, we touch on some common debates about discursive research. We conclude by advocating that researchers and practitioners take up the challenge of understanding, utilizing and extending the field of discourse studies within family practice.

Medical discourse positions patients with coughs and colds negatively, so consulting health services with ‘minor’ respiratory illness is therefore more accountable than for other medical problems. Patients face dilemmas since they must persuade doctors of the doctorability of their illness without being seen as hypochondriacal, and they risk losing face if doctors decide that there is nothing much wrong. It is known that the placement of non-lexical features of talk such as laughing or crying can have interactional meaning. Using a data set of videorecorded doctor–patient cough and cold consultations, this study explores whether patients’ coughing could have communicative significance. The study is a qualitative analysis of 33 consultations drawing on a constructionist, sociolinguistic analytic approach. Coughing is co-ordinated with talk rather than occurring randomly. Coughing helps patients to demonstrate the doctorability of their symptoms and to legitimize their claims for medical attention. Coughing is also associated with resistance to ‘no problem’ diagnoses, resulting in changes in the trajectory of talk (for example, soliciting more explanation from doctors and/or re-negotiation of doctors’ investigation or treatment plans). Coughing is undoubtedly a manifestation of respiratory illness, but also has communicative significance in consultations for coughs and colds.

Qualitative research in primary care deepens understanding of phenomena such as health, illness and health care encounters. Many qualitative studies collect audio or video data (e.g. recordings of interviews, focus groups or talk in consultation), and these are usually transcribed into written form for closer study. Transcribing appears to be a straightforward technical task, but in fact involves judgements about what level of detail to choose (e.g. omitting non-verbal dimensions of interaction), data interpretation (e.g. distinguishing 'I don't, no' from 'I don't know') and data representation (e.g. representing the verbalization 'hwarryuhh' as 'How are you?'). Representation of audible and visual data into written form is an interpretive process which is therefore the first step in analysing data. Different levels of detail and different representations of data will be required for projects with differing aims and methodological approaches. This article is a guide to practical and theoretical considerations for researchers new to qualitative data analysis. Data examples are given to illustrate decisions to be made when transcribing or assigning the task to others.

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

OBJECTIVE—To compare guidelines on diabetes from different countries in order to examine whether differences in recommendations could be explained by use of different research evidence. RESEARCH DESIGN AND METHODS—We analyzed 15 clinical guidelines on type 2 diabetes from 13 countries using qualitative methods to compare the recommendations and bibliometric methods to measure the extent of overlap in citations used by different guidelines. A further qualitative analysis of recommendations and cited evidence for two specific issues in diabetes care explored the apparent discrepancy between recommendations and evidence. RESULTS—The recommendations made in the guidelines were in agreement about the general management of type 2 diabetes, with some important differences in treatment details. There was little overlap in evidence cited by the guidelines, with 18% (185/1,033) of citations shared with any other guideline, and only 10 studies (1%) appearing in six or more guidelines. The measurable overlap in evidence between guidelines increases if multiple publications from the same study and the use of reviews are taken into account. Research originating from the U.S. predominated (40% of citations); however, nearly all (11/12) guidelines were significantly more likely to cite evidence originating from their own countries. CONCLUSIONS—Despite the variation in cited evidence and preferential citation of evidence from a guideline’s country of origin, we found a high degree of international consensus in recommendations made for the clinical care of type 2 diabetes. The influence of professional bodies such as the American Diabetes Association may be an important factor in explaining international consensus. Globalization of recommended management of diabetes is not a simple consequence of the globalization of research evidence.

Objectives The aim of the study was to gather the views of sexual health clinic staff and male clinic users regarding digital sexual health promotion and online trial procedures. Methods The Men’s Safer Sex website was offered on tablet computers to men in the waiting rooms of three sexual health clinics, in a feasibility online randomised controlled trial (RCT). Interviews were conducted with 11 men who had participated in the trial and with nine clinic staff, to explore their views of the website and views of the online trial. Interviews were audio-recorded and transcribed, and we conducted a thematic analysis of interviews and of 281 free text comments from the online RCT outcome questionnaires. Results Clinic users and staff felt that digital interventions such as the Men’s Safer Sex website are useful, especially if NHS endorsed. Pre-appointment waiting time presents a good opportunity for intervention but clinic users and staff felt that a website should supplement rather than replace face-to-face healthcare. The RCT procedures fitted well around clinical activities, but men did not self-direct to the tablet computers. Staff were more concerned about consent and confidentiality than clinic users, and staff and patients were frustrated by multiple technical problems. The trial outcome questionnaire was thought-provoking and could constitute an intervention in itself. Participants felt that clinics would need to promote a digital intervention and/or offer the site routinely to promote engagement. Conclusion Digital interventions could usefully supplement in-person sexual health care, but there are important obstacles in terms of IT access in NHS settings, and in promoting engagement.

Background/introduction Sante is a study to improve targeted sexual health promotion in UK sexual health (SH) clinics. Aim(s)/objectives We explored opportunities and challenges for delivering interventions including 1:1 and group sessions, digital and video interventions. Methods Semi-structured interviews were conducted by telephone with healthcare providers (HCPs) from a range of clinics, by location, size, and patient mix. Data were analysed thematically using a framework approach. A web-survey was sent to key HCP contacts in SH services in England. Results Interviews (n = 26) showed that digital interventions were viewed as logistically and financially feasible; some clinics reported already using them. All clinics provided brief 1:1 sessions, but challenges to delivery were identified as: lack of evidence for effectiveness on behaviours; costs and staff resourcing; and patient motivation. Videos received mixed opinions, they were seen as a practical option for providing STI information while patients wait, but issues about appropriateness were raised. HCPs had concerns about the feasibility of group sessions within clinic-based settings, while acknowledging their usefulness for outreach. The web-survey is ongoing; preliminary data indicates that clinics would like to be able to offer mobile apps, online education and videos (Table 1). Discussion/conclusion Staff time, costs and logistics were universal challenges, while group sessions and videos raised issues of privacy in particular. Brief 1:1 interventions are currently widely delivered, and can be tailored to the patient’s needs, but are resource-intensive while digital methods despite being uncommon were seen as desirable.

Background/introduction A variety of risk-reduction interventions may be suitable for sexual health clinic attendees. Aim(s)/objectives In the SANTE project, we explored service users’ (SU) perceptions of their STI risk, and experiences and preferences for risk reduction interventions. Methods Semi-structured interviews were conducted with 15 young people (YP) (16–25 years) and 20 MSM (≥16 years) from two SH clinics. Data were analysed thematically. Based on these, a Discrete Choice Experiment (DCE) to quantitatively assess YP and MSM preferences for interventions was designed and conducted in three clinics (n = 371). Results Most participants, despite presenting with symptoms or concerned about STIs, did not perceive themselves to be at risk. Most reported receiving SH promotion but felt access to accurate information was lacking. While short advert-like videos were acceptable, onscreen material in waiting rooms was deemed inappropriate by some SUs. Opinions on group sessions were mixed. 1:1 sessions were favoured, with talking therapies acceptable if needed. Privacy around mobile apps was a concern while online materials from a reputable source were acceptable. DCE results demonstrated preferences for ‘talking interventions’, while all interventions were generally preferred to ‘nothing’. People strongly disliked peer-led interventions compared to others, and preferred 1:1 to group sessions. Latent class analysis identified three respondent groups, those that preferred talking (56%), email/text (29%) or nothing (15%). Discussion/conclusion Young people and MSM welcome SH promotion offered through SH clinics. Triangulation demonstrated strong preferences for 1:1 talking interventions. Awareness of sexual risk was not commensurate with actual risk, suggesting that providers need to direct service users to appropriate interventions.

Background Digital technology offers potential for sexual health promotion. Aims We conducted systematic review examining effectiveness of sexual health promotion interactive digital interventions (IDI) compared to 1) minimal interventions (e.g. leaflet); 2) face-to-face interventions; 3) different IDI designs. Methods IDI require users’ contributions to produce personally relevant feedback. We searched 40 electronic databases for randomised controlled trials (RCT) of IDI for sexual health promotion from start dates to 30/04/2013. Separate meta-analyses were conducted for comparisons 1, 2, and 3, by outcome types (knowledge, self-efficacy, intention, sexual behaviour, biological outcomes) using random effects models. Subgroup analyses tested: age, risk grouping, setting (online, healthcare, educational). Results We identified 36 RCTs (11,818 participants) from developed countries. Comparison 1: IDI improved knowledge ((standardised mean difference (SMD) 0.48, 95% CI 0.19 to 0.76)); self-efficacy (SMD 0.11, 95% CI 0.04 to 0.19), intention (SMD 0.13, 95% CI 0.05 to 0.22), sexual behaviour ((Odds Ratio (OR) 1.20, 95% CI 1.02 to 1.41)), but not biological outcomes (OR 0.81, 95% CI 0.56 to 1.16). IDI delivered in educational settings improved sexual behaviour (OR 2.09, 95% CI 1.43 to 3.04), but not in healthcare settings (OR 1.17, 95% CI 0.94 to 1.45), or online (OR 0.96, 95% CI 0.79 to 1.17). Comparison 2: IDI improved knowledge (SMD 0.36, 95% CI 0.13 to 0.58), intention (SMD 0.46, 95% CI 0.06 to 0.85), but not self-efficacy (SMD 0.38, 95% CI -0.01 to 0.77). Comparison 3: Tailoring had no effect on outcomes. Conclusion IDIs can enhance knowledge, self-efficacy, intention, and sexual behaviour.

A great way to reach people, particularly those at increased risk of sexual ill health Promoting sexual health is a public health priority in the UK, but there are many challenges. For example, universal access to comprehensive sex and relationships education in schools is lacking; prevention and health promotion are less of a funding priority than diagnosis and treatment; sexual health services struggle to meet demand; and teachers, pupils, clinicians, and patients can be reluctant to discuss sexual health in school or clinic settings. Interventions delivered through the internet or mobile phone could help with some of these challenges. Most people in the UK have access to these technologies,1 and some of those at highest risk of sexual ill health (young people, men who have sex with men, sex workers) may also be heavy users of digital technology. Digital media are particularly appropriate for promoting sexual health because access can be private and convenient and learning can be self paced and personalised.2 The reach and scalability of digital interventions is …

Background Sexual ill-health is a global concern. Digital technology offers enormous potential for health promotion. This systematic review assessed the effectiveness of interactive digital interventions (IDIs) for sexual health promotion compared with minimal interventions (eg, waiting list), face-to-face interventions, and compared effectiveness of different designs of digital intervention. Methods IDIs are interactive programmes that require users' contributions (eg, entering personal data, making choices) to produce personally relevant information, decision support, and behaviour change, emotional support, or both. We searched 40 electronic databases for randomised controlled trials of IDIs for sexual health promotion from start dates to April 30, 2013, with no language restrictions (appendix). Separate meta-analyses were conducted using Cochrane Collaboration methods for all comparisons by type of outcome (knowledge, self-efficacy, intention, sexual behaviour, and biological outcomes). Results were pooled using random effects models to calculate standardised mean differences (SMDs) and odds ratios (ORs). Subgroup analyses tested the following prespecified factors: age, risk grouping, and setting (online, health care, educational). Findings We identified 36 randomised controlled trials (11 818 participants) conducted in developed countries. Compared with minimal interventions, IDIs had beneficial effects on knowledge (SMD 0·48, 95% CI 0·19–0·76), safer sex self-efficacy (SMD 0·11, 0·04–0·19), intention (SMD 0·13, 0·05–0·22), and sexual behaviour (OR 1·20, 1·02–1·41), but had no effect on biological outcomes (OR 0·81, 0·56–1·16). IDIs delivered in educational settings significantly improved sexual behaviour (OR 2·09, 95% CI 1·43–3·04), but not when delivered in health-care settings (OR 1·17, 0·94–1·45) or online (OR 0·96, 0·79–1·17) (p interaction =0·005). Compared with face-to-face interventions, IDIs improved knowledge (SMD 0·36, 95% CI 0·13–0·58) and intention (SMD 0·46, 0·06–0·85), but not self-efficacy (SMD 0·38, −0·01 to 0·77). No difference in effectiveness of tailored IDIs compared with non-tailored IDIs for knowledge, intention, or sexual behaviour was observed. No data were available for cost-effectiveness. Interpretation IDIs can effectively enhance knowledge, self-efficacy, intention, and sexual behaviour. Further evidence is needed to understand how IDIs work, their cost-effectiveness, and how these positive effects can be translated into improved sexual health. Funding This project was funded by the National Institute for Health Research Public Health Research Programme (reference PHR - 11/3009/04)

Background There is a high prevalence of people with sexual problems (eg, erectile problems or reduced sexual desire) within general practice and sexual health services, and many more people have sexual problems but do not seek help for them. Barriers to seeking help include discomfort and embarrassment discussing sexual problems with health professionals, geographic barriers, and time constraints due to work or childcare commitments, or both. A way to overcome some of these barriers might be to offer help and support via the internet. This systematic review aimed to assess the effectiveness of interactive digital interventions (IDIs) for sexual problems in adults, with the primary outcomes of interest being sexual function, satisfaction, and level of distress. Methods 16 databases were searched for randomised controlled trials of IDIs for sexual problems, including CINAHL, CENTRAL, Embase, ERIC, IBSS, Medline, PsycINFO, and Web of Science. Hand searching, reference and citation tracking, and consultation with experts were also used to identify further studies. Relevant authors were contacted for missing information. Searching took place between September, 2012, and January, 2013, with no language or date restrictions. Selection criteria were randomised controlled trials of IDIs for sexual problems, affecting adults aged 18 years or older, irrespective of sex, sexuality, ethnicity, nationality, and type of sexual problem. Two review authors independently screened titles and abstracts, applied eligibility criteria, and extracted full text data. Study quality was assessed with the Cochrane risk of bias assessment method. Separate meta-analyses were done by type of comparator (minimal intervention, face-to-face intervention, different design of IDI) and type of outcome (sexual function, relationship satisfaction, emotional states, quality of life). Findings Nine studies met the inclusion criteria for the review, providing a total sample size of 575 participants with available outcome data. All interventions were cognitive–behavioural in approach. Study investigators reported significant positive effects on sexual and relational outcomes (but not emotional states) in all studies with low risk of bias. The results of meta-analyses comparing IDIs to waitlist controls showed IDIs to have a moderate effect on sexual function (standardised mean difference 0·60, 95% CI 0·03 to 1·17) and a non-significant effect on relationship satisfaction (0·35, −0·34 to 1·04). There were insufficient data available to run meta-analyses on emotional state and quality of life outcomes. There were only two studies that compared IDIs to face-to-face therapy, but one study was deemed high risk in terms of bias and therefore could not be entered into a meta-analysis. We are awaiting further information from authors before running the meta-analyses comparing IDIs to other forms of IDI. Interpretation The evidence suggests that users can benefit from IDIs for sexual problems. However, well-designed studies with larger numbers of participants are needed to be certain of effects. We also need to understand the effects of different types of digital interventions on a broader range of sexual problems. Funding NIHR SPCR PhD studentship.

Background Effective interventions for sexually transmitted infections (STIs) are more likely to have made extensive use of behaviour change theory and techniques and to have involved users in intervention design than those that are not effective; however, how to include theory in the design of behaviour change interventions is not clear. Recently, a framework for intervention has been developed that is a synthesis of the theoretical ideas depicted in 19 other frameworks (the behaviour change wheel [BCW]). The BCW defines behaviour change as requiring capability, opportunity, and motivation. These factors form the hub of the BCW around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these factors. We are developing a digital intervention to increase condom use in men in sexual health clinics, drawing on published work on barriers to condom use, behaviour change theory, and the views of men attending clinics to design the content and interactive features of the intervention. We present our experience of use of the BCW to incorporate these three sources of information into the design of a behaviour change intervention. Methods Information from three sources was combined: a review of the published work on barriers and facilitators to condom use; workshops with clinical and academic experts in sexual health; and semi-structured interviews with men attending sexual health clinics. This information was combined with use of the BCW framework to identify what theoretical domains needed to be targeted to change behaviour (eg, condom use skills, beliefs about consequences of behaviour) and how these should be targeted (eg, interactive features and behaviour change techniques). Findings Findings from the review of publications and interviews with men affected the intervention content. Reduced pleasure was the most prominent barrier to condom use. Other barriers included absence of accurate knowledge about risk (eg, believing that one can make judgments about risk), and difficulty using condoms in "the heat of the moment". The intervention was therefore designed to target these factors. Furthermore, published work suggests that many people make errors when using condoms, and so an activity training people in condom use was included. Men who were interviewed wanted information about STI symptoms and consequences, and so this was also included. Combining information from different sources is essential in designing a complex intervention; however, managing such a wealth of data can prove challenging. BCW helped to provide structure for this process, by sorting the findings into the categories set out by it. It was helpful in perceiving how each intervention target maps onto a theoretical domain and to guide decisions about how to prompt behaviour change. For example, inaccurate beliefs about ability to judge the risk of STIs is a psychological capability that we targeted by developing an interactive activity that depicts scenarios for asymptomatic chlamydia acquisition within a sexual network. This activity draws on the behaviour change techniques, including giving information about health consequences, comparative imagining of future outcomes, and vicarious consequences. Interpretation The BCW provides a good starting point for intervention development and is a good framework for integration of information. The BCW integrates theoretical principles from multiple models of health behaviour, providing a systematic way of considering several influences on behaviour and planning the ways that an intervention may seek to change behaviour. Getting consensus between experts about which dimensions were most important was sometimes difficult. To overcome this limitation, we used data from the review of published work and the interviews to make informed decisions within the research team. Funding This research was part of a wider project, which was funded by a NIHR Health Technology Assessment grant.

Increasing condom use to prevent sexually transmitted infections is a key public health goal. Interventions are more likely to be effective if they are theory- and evidence-based. The Behaviour Change Wheel (BCW) provides a framework for intervention development. To provide an example of how the BCW was used to develop an intervention to increase condom use in heterosexual men (the MenSS website), the steps of the BCW intervention development process were followed, incorporating evidence from the research literature and views of experts and the target population. Capability (e.g. knowledge) and motivation (e.g. beliefs about pleasure) were identified as important targets of the intervention. We devised ways to address each intervention target, including selecting interactive features and behaviour change techniques. The BCW provides a useful framework for integrating sources of evidence to inform intervention content and deciding which influences on behaviour to target.

Background Sexual health promotion is a major public health challenge; there is huge potential for health promotion via technology such as the Internet. Objectives To determine effects of interactive computer-based interventions (ICBI) for sexual health promotion, considering cognitive, behavioural, biological and economic outcomes. Search methods We searched more than thirty databases for randomised controlled trials (RCTs) on ICBI and sexual health, including CENTRAL, DARE, MEDLINE, EMBASE, CINAHL, British Nursing Index, and PsycINFO. We also searched reference lists of published studies and contacted authors. All databases were searched from start date to November 2007, with no language restriction. Selection criteria RCTs of interactive computer-based interventions for sexual health promotion, involving participants of any age, gender, sexual orientation, ethnicity or nationality. 'Interactive' was defined as packages that require contributions from users to produce tailored material and feedback that is personally relevant. Data collection and analysis Two review authors screened abstracts, applied eligibility and quality criteria and extracted data. Results of RCTs were pooled using a random-effects model with standardised mean differences (SMDs) for continuous outcomes and odds ratios (ORs) for binary outcomes. We assessed heterogeneity using the I2 statistic. Separate meta-analyses were conducted by type of comparator: 1) minimal intervention such as usual practice or leaflet, 2) face-to-face intervention or 3) a different design of ICBI; and by type of outcome (cognitive, behavioural, biological outcomes). Main results We identified 15 RCTs of ICBI conducted in various settings and populations (3917 participants). Comparing ICBI to 'minimal interventions' such as usual practice, meta-analyses showed statistically significant effects as follows: moderate effect on sexual health knowledge (SMD 0.72, 95% CI 0.27 to 1.18); small effect on safer sex self-efficacy (SMD 0.17, 95% CI 0.05 to 0.29); small effect on safer-sex intentions (SMD 0.16, 95% CI 0.02 to 0.30); and also an effect on sexual behaviour (OR 1.75, 95% CI 1.18 to 2.59). Data were insufficient for meta-analysis of biological outcomes and analysis of cost-effectiveness. In comparison with face-to-face sexual health interventions, meta-analysis was only possible for sexual health knowledge, showing that ICBI were more effective (SMD 0.36, 95% CI 0.13 to 0.58). Two further trials reported no difference in knowledge between ICBI and face-to-face intervention, but data were not available for pooling. There were insufficient data to analyse other types of outcome. No studies measured potential harms (apart from reporting any deterioration in measured outcomes). Authors' conclusions ICBI are effective tools for learning about sexual health, and they also show positive effects on self-efficacy, intention and sexual behaviour. More research is needed to establish whether ICBI can impact on biological outcomes, to understand how interventions might work, and whether they are cost-effective.