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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: There is no formal sexual and reproductive health (SRH) education currently offered in Saudi Arabia. Lack of knowledge and misconceptions are evident among Saudi women, which can lead to negative sexual and reproductive experiences. The aim of this study is to explore Saudi women's SRH knowledge, perceptions and experiences. Methods: Qualitative semi-structured interviews with Saudi women were conducted. Interviews took place in a public hospital in Riyadh, Saudi Arabia. Interviews were conducted in Arabic, recorded and transcribed verbatim, to allow for thematic analysis of the data. The following themes were identified: experience with menarche, deep-rooted negative views towards sex, difficulty discussing SRH topics, knowledge of sex and reproduction, generational gap, sources of SRH information and the role of the mother. Results: A total of 28 women, both married and unmarried, aged 20–50 years were interviewed. A profound lack of SRH knowledge was observed among Saudi women which contributed greatly to negative experiences both in childhood and adulthood. Lack of knowledge about menstruation often caused emotional distress for young girls, and menarche was associated with bad memories and negative emotions. Lack of knowledge about sexual intercourse and the deep-rooted negative views towards sex were linked with physical and psychological issues for women. Women rarely received information from their parents or teachers and preferred the internet for their SRH information. Conclusion: There is a substantial unmet need for SRH education for women in Saudi Arabia. It is our recommendation that SRH education should be tailored to meet Saudi women's unique needs, while understanding specific socio-cultural barriers to SRH education and discussions. Research and policy efforts should be directed towards regulating and producing evidence-based health information on the internet, particularly Arabic language websites.

BackgroundYoung people report higher levels of unsafe sex and have higher rates of sexually transmitted infections than any other age group. Schools are well placed to facilitate early intervention, but more effective approaches are required. Peer-led approaches can augment school-based education, but often fail to capitalise on mechanisms of social influence. The potential of using social media in sexual health has not been tested in school settings.ObjectivesFinalise the design of the Sexually Transmitted infections And Sexual Health (STASH) intervention; assess the recruitment and retention of peer supporters, and acceptability to participants and stakeholders; assess the fidelity and reach, in addition to the barriers to and facilitators of, implementation; refine programme theory; understand the potential of social media; determine design parameters for a future randomised controlled trial, including economic evaluation; and establish whether or not progression criteria were met.DesignThis was a feasibility study comprising intervention development and refinement of the STASH pilot and non-randomised feasibility trial in six schools. Control data were provided by students in the year above the intervention group.SettingSecondary schools in Scotland.ParticipantsStudents aged 14–16 years, teachers and intervention delivery partners.InterventionsThe STASH intervention was adapted from A Stop Smoking In Schools Trial (ASSIST) (an effective peer-led smoking intervention). Based on diffusion of innovation theory, the STASH study involves peer nomination to identify the most influential students, with the aim of recruiting and training 15% of the year group as peer supporters. The peer supporters deliver sexual health messages to friends in their year group via conversations and use of Facebook (www.facebook.com; Facebook, Inc., Menlo Park, CA, USA) to share varied content from a curated set of web-based resources. Peer supporters are given support themselves via follow-up sessions and via trainer membership of Facebook groups.Main outcome measuresThe primary outcome was whether or not progression criteria were met in relation to intervention acceptability and feasibility. The study also piloted indicative primary outcomes for a full-scale evaluation.Data sourcesPeer supporter questionnaire; observations of activities; interviews with trainers, teachers, peer supporters and students; monitoring log of peer supporter activities (including on Facebook and meeting attendance); questionnaire to control year group (baseline characteristics, social networks, mediators and sexual health outcomes); baseline and follow-up questionnaire (approximately 6 months later) for intervention year group.ResultsA total of 104 students were trained as peer supporters (just over half of those nominated for the role by their peers). Role retention was very high (97%). Of 611 students completing the follow-up questionnaire, 58% reported exposure to STASH study activities. Intervention acceptability was high among students and stakeholders. Activities were delivered with good fidelity. The peer supporters were active, representative of their year group and well connected within their social network. Carefully managed social media use by peer supporters augmented conversations. A primary outcome of ‘always safer sex’ was identified, measured as no sex or always condom use for vaginal or anal sex in the last 6 months. The intervention cost £42 per student. Six progression criteria were met. A seventh criterion (regarding uptake of role by peer supporters) was not.LimitationsSmall feasibility study that cannot comment on effectiveness.ConclusionsThe STASH intervention is feasible and acceptable within the context of Scottish secondary schools. The results support continuation to a full-scale evaluation.Future workSmall-scale improvements to the intervention, refinement to programme theory and funding sought for full-scale evaluation.Trial registrationCurrent Controlled Trials ISRCTN97369178.FundingThis project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

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.

Partner abuse (PA) is common among young people, but is often missed by professionals working in health, social care, education and the criminal justice system. This paper explores the types of PA experienced by young people and links with sexual health to see whether there are factors which indicate greater vulnerability to abuse. Young people aged 16 to 20 from across the UK (n=1,754) completed an online survey in 2010–11. We report experience of emotional, physical and sexual partner abuse and model the associations with demographic and sexual health variables in bivariate analysis using logistic regression. A third of participants reported one or more types of PA within the previous three months, regardless of gender of partner. PA was significantly associated with sexually transmitted infection (Odds Ratios 1.6 and 2.9 for young women and young men respectively), regretted sex (OR 2.7 and 1.9), distress or worry about sex life (OR 2.7 and 4.6), sexual problems, numbers of sexual partners (OR 1.2 for each additional partner), and sexual health service use (for young men) (OR=1.9). These ‘indicators’ may be noticed by professionals who work with young people, and can act as prompts to ask about partner abuse.

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 There is a strong interest in the use of social media to spread positive sexual health messages through social networks of young people. However, research suggests that this potential may be limited by a reluctance to be visibly associated with sexual health content on the web or social media and by the lack of trust in the veracity of peer sources. Objective The aim of this study was to investigate opportunities and challenges of using social media to facilitate peer-to-peer sharing of sexual health messages within the context of STASH (Sexually Transmitted Infections and Sexual Health), a secondary school-based and peer-led sexual health intervention. Methods Following training, and as a part of their role, student-nominated peer supporters (aged 14-16 years) invited school friends to trainer-monitored, private Facebook groups. Peer supporters posted curated educational sex and relationship content within these groups. Data came from a feasibility study of the STASH intervention in 6 UK schools. To understand student experiences of the social media component, we used data from 11 semistructured paired and group interviews with peer supporters and their friends (collectively termed students; n=42, aged 14-16 years), a web-based postintervention questionnaire administered to peer supporters (n=88), and baseline and follow-up questionnaires administered to students in the intervention year group (n=680 and n=603, respectively). We carried out a thematic analysis of qualitative data and a descriptive analysis of quantitative data. Results Message sharing by peer supporters was hindered by variable engagement with Facebook. The trainer-monitored and private Facebook groups were acceptable to student members (peer supporters and their friends) and reassuring to peer supporters but led to engagement that ran parallel to—rather than embedded in—their routine social media use. The offline context of a school-based intervention helped legitimate and augment Facebook posts; however, even where friends were receptive to STASH messages, they did not necessarily engage visibly on social media. Preferences for content design varied; however, humor, color, and text brevity were important. Preferences for social media versus offline message sharing varied. Conclusions Invitation-only social media groups formed around peer supporters’ existing friendship networks hold potential for diffusing messages in peer-based sexual health interventions. Ideally, interactive opportunities should not be limited to single social media platforms and should run alongside offline conversations. There are tensions between offering young people autonomy to engage flexibly and authentically and the need for adult oversight of activities for information accuracy and safeguarding.

Background Online sexual health research can be convenient, efficient and low cost, but there are debates about the adequacy of online informed consent, privacy, and the acceptability of different methods of follow-up. Objectives To explore women's views and experiences of the Contraception Choices feasibility trial procedures and the place of digital interventions for contraception decision making. Methods We analysed data from two sources: (1) Qualitative interviews. Eighteen interviews were conducted with women who had taken part in the Contraception Choices pre-trial feasibility study, to evaluate recruitment and online trial procedures. (2) Free-text comments. Women in the main Contraception Choices randomised controlled trial were followed up at 3 and 6 months, and asked ‘Please tell us what you liked or disliked about the website’ and ‘Has being in the study had any good or bad effects on your life?’ A total of 387 and 414 comments were made at 3 and 6 months respectively. Data were analysed thematically. Results Participants liked being involved in a study about contraception, although recruitment from an abortion clinic was less acceptable than in other sexual health settings. Women found the trial procedures straightforward, and expressed no major concerns about online self-registration, informed consent or online data collection. Online survey questions about contraception and fertility were acceptable, and participants liked the convenience of being followed up by email or text. Conclusions Participants appreciated the advantages of the online research design and did not express concerns about consent or privacy. Women would welcome digital interventions for contraception in a variety of settings.

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.

This study assessed a newly developed Sexual Communication Self-Efficacy Scale designed to measure the sexual communication self-efficacy of adolescent men and women. Three-hundred and seventy-four U.K. adolescents completed this new scale, along with several other validity measures. Factor analysis revealed that the Sexual Communication Self-Efficacy Scale consisted of five underlying factors: contraception communication, positive sexual messages, negative sexual messages, sexual history, and condom negotiation. These factors demonstrated high internal consistency and presents evidence to support construct validity. This scale may have utility in assessing the effectiveness of interventions designed to enhance sexual communication and sexual health behaviors among young people.

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.

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.

Background Young people are at risk of poor sexual health and are in need of comprehensive, effective sexual health education. Young people are confident users of digital technology such as the Internet and mobile phones, and there are many innovative possibilities for sexual health education. Sexual health promotion IDIs have been shown to be effective in improving knowledge and intention. However significant impact will only be achieved by maximising their Reach (proportion of the target population reached), Adoption (within the target setting) Implementation (how well it is delivered) and Maintenance (sustainability) (RE-AIM). Aims To synthesise the evidence on the barriers and facilitators to the implementation of digital interventions for sexual health promotion for young people Methods We conducted a scoping review of evidence on digital interventions for sexual health promotion for young people aged 13 to 24 years in the UK, defining sexual health in holistic terms, to include physical, emotional, mental and social well-being in relation to sexuality. Interactive digital interventions (IDI) are defined as digital media programmes that provide sexual health information and tailored decision support, behaviour-change support, and/or emotional support for sexual health issues. We conducted a thorough review of literature to locate and synthesise available evidence on digital interventions for sexual health spanning the last ten years, integrating the findings with the views of key informants (young people, parents, and experts in digital media/sexual health). Results and conclusions There were few studies that assess the factors related to successful implementation of sexual health promotion IDIs. Potential barriers and facilitators to implementation of IDI should be addressed at the very beginning of an intervention development process. Engaging with sexual health promotion interventions online allows private and convenient access as well as potentially reaching populations who engage less frequently with mainstream services. However, it is difficult to ensure that users will find the intervention, or engage for long enough for them to be effective. The reach of online IDI could be enhanced by linking sexual health promotion interventions with existing digital systems such as STI self-test websites, or with trusted branded websites or popular social networking sites. Offering interventions in static settings such as the clinic or classroom encourages engagement and enables interventions to be delivered with fidelity but potentially at the expense of the privacy and convenience offered by online interventions. Using the knowledge of local staff is vital for both successful intervention development and successful implementation. An effective intervention usually requires some adaptation for local contexts, but care is needed to identify and preserve the core components so that effectiveness is maintained. Technical support, moderation/monitoring and updating are further challenges for implementing sustainable digital interventions. Facilitated engagement (e.g. with teachers or clinicians) could encourage young people to access interventions and may be more likely to facilitate engagement. There is great enthusiasm for digital health interventions for health at national policy level in the UK, and many local initiatives, but few national policy levers to drive implementation of sexual health promotion IDIs in practice. Responsibility for sexual health is now increasingly devolved to local healthcare and local authority commissioning groups, meaning that national initiatives are difficult. Collaboration is needed between users, developers, researchers and local and national stakeholders.

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 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.