Digital interventions for STI and HIV partner notification: a scoping review.

BACKGROUND: Partner notification (PN) is key to the control of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). Digital interventions have been used to facilitate PN. A scoping review was conducted to describe the interventions used, user preferences and acceptability of digital PN interventions from patient and partner perspectives. METHODS: A systematic literature search was conducted of eight databases for articles published in English, available online with digital PN outcome data. Articles were assessed using the Mixed Methods Appraisal Tool. Quantitative and qualitative data were synthesised and analysed using thematic analysis. RESULTS: Twenty-six articles met the eligibility criteria. Articles were heterogeneous in quality and design, with the majority using quantitative methods. Nine articles focused solely on bacterial STIs (five on syphilis; four on chlamydia), one on HIV, two on syphilis and HIV, and 14 included multiple STIs, of which 13 included HIV. There has been a shift over time from digital PN interventions solely focusing on notifying partners, to interventions including elements of partner management, such as facilitation of partner testing and treatment, or sharing of STI test results (between index patients and tested sex partners). Main outcomes measured were number of partners notified (13 articles), partner testing/consultation (eight articles) and treatment (five articles). Relationship type and STI type appeared to affect digital PN preferences for index patients with digital methods preferred for casual rather than established partner types. Generally, partners preferred face-to-face PN. CONCLUSION: Digital PN to date mainly focuses on notifying partners rather than comprehensive partner management. Despite an overall preference for face-to-face PN with partners, digital PN could play a useful role in improving outcomes for certain partner types and infections. Further research needs to understand the impact of digital PN interventions on specific PN outcomes, their effectiveness for different infections and include health economic evaluations.

Shifting Norms and Value Conflicts: Exploring the Effects of HIV Status Disclosure Fields in Sex-Social Apps.

Sex-social applications used by men who have sex with men (MSM) often provide options to disclose HIV status to encourage more positive language and reduce stigma. Yet, little research has sought to understand how in-app disclosure fields impact on disclosure motivation. We interviewed MSM living with HIV and those who self-reported being HIV-negative ( N = 27 ) in the UK and applied a hierarchical model of motivation to interpret our data. We found conflicting motivations for disclosure and point to HIV status disclosure fields having shifted disclosure norms, limiting their perceived optionality. Moreover, the pairwise and location-aware nature of these apps fails to support narrative forms of disclosure, reducing motivation. We highlight an opportunity to support users in disclosing by linking apps more explicitly to the social narratives developed through public health campaigns. This could reduce the required effort to explain "the science" behind different treatment and prevention options and promote a more consistent narrative.

Improving digital partner notification for sexually transmitted infections and HIV through a systematic review and application of the Behaviour Change Wheel approach.

BACKGROUND: Partner notification (PN) is key to controlling sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). Digital PN options (e.g. social media, short message service (SMS), emails) are promising in increasing PN behaviour. However, their implementation is often challenging and studies report varied levels of acceptability and uptake of PN, highlighting the need to optimise digital PN interventions. METHODS: A systematic review of barriers and facilitators to digital PN interventions for STIs, including HIV, across eight research databases (from 2010 to 2023) identified eight relevant studies, two of which addressed HIV. Data extraction identified 98 barriers and 54 facilitators to the use of digital PN interventions. These were synthesised into 18 key barriers and 17 key facilitators that were each deemed amenable to change. We then used the Behaviour Change Wheel approach, the Acceptability, Practicability, Effectiveness, Affordability, Side-effects and Equity criteria, and multidisciplinary expert input, to systematically develop practical recommendations to optimise digital PN. RESULTS: Thirty-two specific recommendations clustered around three themes. Digital PN interventions should: (1) empower and support the index patient by providing a range of notification options, accompanied by clear instructions; (2) integrate into users' existing habits and the digital landscape, meeting contemporary standards and expectations of usability; and (3) address the social context of PN both online and offline through normalising the act of PN, combating STI-related stigma and stressing the altruistic aspects of PN through consistent messaging to service users and the public. CONCLUSIONS: Our evidence-based recommendations should be used to optimise existing digital PN interventions and inform the co-production of new ones.

How did the COVID-19 pandemic affect access to condoms, chlamydia and HIV testing, and cervical cancer screening at a population level in Britain? (Natsal-COVID).

OBJECTIVES: To investigate how differential access to key interventions to reduce STIs, HIV and their sequelae changed during the COVID-19 pandemic. METHODS: British participants (18-59 years) completed a cross-sectional web survey 1 year (March-April 2021) after the initial lockdown in Britain. Quota-based sampling and weighting resulted in a quasi-representative population sample. We compared Natsal-COVID data with Natsal-3, a household-based probability sample cross-sectional survey (16-74 years) conducted in 2010-2012. Reported unmet need for condoms because of the pandemic and uptake of chlamydia testing/HIV testing/cervical cancer screening were analysed among sexually experienced participants (18-44 years) (n=3869, Natsal-COVID; n=8551, Natsal-3). ORs adjusted for age and other potential confounders describe associations with demographic and behavioural factors. RESULTS: In 2021, 6.9% of women and 16.2% of men reported unmet need for condoms because of the pandemic. This was more likely among participants: aged 18-24 years, of black or black British ethnicity, and reporting same-sex sex (past 5 years) or one or more new relationships (past year). Chlamydia and HIV testing were more commonly reported by younger participants, those reporting condomless sex with new sexual partners and men reporting same-sex partners; a very similar distribution to 10 years previously (Natsal-3). However, there were differences during the pandemic, including stronger associations with chlamydia testing for men reporting same-sex partners; with HIV testing for women reporting new sexual partners and with cervical screening among smokers. CONCLUSIONS: Our study suggests differential access to key primary and secondary STI/HIV prevention interventions continued during the first year of the COVID-19 pandemic. However, there was not strong evidence that differential access has changed during the pandemic when compared with 2010-2012. While the pandemic might not have exacerbated inequalities in access to primary and secondary prevention, it is clear that large inequalities persisted, typically among those at greatest STI/HIV risk.

Sexual and reproductive health in Britain during the first year of the COVID-19 pandemic: cross-sectional population survey (Natsal-COVID-Wave 2) and national surveillance data.

OBJECTIVES: To assess sexual behaviour, and sexual and reproductive health (SRH) outcomes, after 1 year of the COVID-19 pandemic in Britain. METHODS: 6658 participants aged 18-59 and resident in Britain completed a cross-sectional web-panel survey (Natsal-COVID-Wave 2, March-April 2021), 1 year after the first lockdown. Natsal-COVID-2 follows the Natsal-COVID-Wave 1 survey (July-August 2020) which captured impacts in the initial months. Quota-based sampling and weighting resulted in a quasi-representative population sample. Data were contextualised with reference to the most recent probability sample population data (Natsal-3; collected 2010-12; 15 162 participants aged 16-74) and national surveillance data on recorded sexually transmitted infection (STI) testing, conceptions, and abortions in England/Wales (2010-2020). The main outcomes were: sexual behaviour; SRH service use; pregnancy, abortion and fertility management; sexual dissatisfaction, distress and difficulties. RESULTS: In the year from the first lockdown, over two-thirds of participants reported one or more sexual partners (women 71.8%; men 69.9%), while fewer than 20.0% reported a new partner (women 10.4%; men 16.8%). Median occasions of sex per month was two. Compared with 2010-12 (Natsal-3), we found less sexual risk behaviour (lower reporting of multiple partners, new partners, and new condomless partners), including among younger participants and those reporting same-sex behaviour. One in 10 women reported a pregnancy; pregnancies were fewer than in 2010-12 and less likely to be scored as unplanned. 19.3% of women and 22.8% of men were distressed or worried about their sex life, significantly more than in 2010-12. Compared with surveillance trends from 2010 to 2019, we found lower than expected use of STI-related services and HIV testing, lower levels of chlamydia testing, and fewer conceptions and abortions. CONCLUSIONS: Our findings are consistent with significant changes in sexual behaviour, SRH, and service uptake in the year following the first lockdown in Britain. These data are foundational to SRH recovery and policy planning.

Sexting among British adults: a qualitative analysis of sexting as emotion work governed by 'feeling rules'.

Sexting has generated considerable public and professional interest with concerns centring on young people, and potential harms to mental and sexual health. Little research thus far has explored the practice among adults and none has focused on the cultural norms relating to the emotional experience of sexting across different ages and genders. We conducted 40 semi-structured interviews with a diverse sample of adults aged 18-59 years in Britain on the role of digital technologies in participants' sexual lives. In this paper, we draw on the accounts of 34 people with experience of sexting. We identified three main themes in participants' accounts related to the emotional aspects of sexting: (1) trust, (2) desire/intimacy and (3) shame. Under each theme, we identified motivations, 'feeling rules', and examples of 'emotion work' relating to the self, the other and the dyad. We conclude that there are shared cultural norms that constitute what appropriate sexting should feel like. Interventions aiming to minimise harms arising from sexting need to build on commonly held cultural conventions regarding the 'rules of the game' concerning feelings as well as behaviours.

Access to, usage and clinic outcomes of, online postal sexually transmitted infection services: a scoping review.

BACKGROUND: There has been considerable expansion in online postal self-sampling (OPSS) STI services in many parts of the UK, driven by increasing demand on sexual health services and developments in diagnostics and digital health provision. This shift in service delivery has occurred against a backdrop of reduced funding and service fragmentation and the impact is unknown. We explored characteristics of people accessing and using OPSS services for STIs in the UK, the acceptability of these services and their impact on sexual health inequalities. METHODS: A scoping review was conducted of studies published in English-language based on pre-agreed inclusion/exclusion criteria, between 01 January 2010 and 07 July 2021. Nine databases were searched, and 23 studies that met the eligibility criteria were included. Studies were appraised using the Mixed Methods Appraisal Tool. RESULTS: Study designs were heterogeneous, including quantitative, qualitative and mixed-methods analyses. The majority were either evaluating a single-site/self-sampling provider, exploratory or observational and of variable quality. Few studies collected comprehensive user demographic data. Individuals accessing OPSS tended to be asymptomatic, of white ethnicity, women, over 20 years and from less deprived areas. OPSS tended to increase overall STI testing demand and access, although return rates for blood samples were low, as was test positivity. There were varied results on whether services reduced time to treatment. OPSS services were acceptable to the majority of users. Qualitative studies showed the importance of trust, confidentiality, discretion, reliability, convenience and improved patient choice. CONCLUSION: OPSS services appear highly acceptable to users. However, uptake appears to be socially patterned and some groups who bear a disproportionate burden of poor sexual health in the UK are under-represented among users. Current provision of online self-sampling could widen health inequalities, particularly where other options for testing are limited. Work is needed to fully evaluate the impact and cost-effectiveness of OPSS services.

Impacts of COVID-19 on sexual behaviour in Britain: findings from a large, quasi-representative survey (Natsal-COVID).

OBJECTIVES: Physical restrictions imposed to combat COVID-19 dramatically altered sexual lifestyles but the specific impacts on sexual behaviour are still emerging. We investigated physical and virtual sexual activities, sexual frequency and satisfaction in the 4 months following lockdown in Britain in March 2020 and compared with pre-lockdown. METHODS: Weighted analyses of web panel survey data collected July/August 2020 from a quota-based sample of 6654 people aged 18-59 years in Britain. Multivariable regression took account of participants' opportunity for partnered sex, gender and age, to examine their independent associations with perceived changes in sexual frequency and satisfaction. RESULTS: Most participants (86.7%) reported some form of sex following lockdown with physical activities more commonly reported than virtual activities (83.7% vs 52.6%). Altogether, 63.2% reported sex with someone ('partnered sex') since lockdown, three-quarters of whom were in steady cohabiting relationships. With decreasing relationship formality, partnered sex was less frequently reported, while masturbation, sex toy use and virtual activities were more frequently reported. Around half of all participants perceived no change in partnered sex frequency compared with the 3 months pre-lockdown, but this was only one-third among those not cohabiting, who were more likely to report increases in non-partnered activities than those cohabiting. Two-thirds of participants perceived no change in sexual satisfaction; declines were more common among those not cohabiting. Relationship informality and younger age were independently associated with perceiving change, often declines, in sexual frequency and satisfaction. CONCLUSIONS: Our quasi-representative study of the British population found a substantial minority reported significant shifts in sexual repertoires, frequency and satisfaction following the introduction of COVID-19 restrictions. However, these negative changes were perceived by some more than others; predominantly those not cohabiting and the young. As these groups are most likely to experience adverse sexual health, it is important to monitor behaviour as restrictions ease to understand the longer term consequences, including for health services.

Collective pause: improving staff performance in acute medicine through a brief mindfulness-based group programme.

BACKGROUND: Hospital wards are a complex and dynamic environment that rely on optimal staff performance. However, there is little research evaluating group interventions to improve staff attention and teamwork. AIMS: To evaluate whether a regular, short and guided group mindfulness practice for staff in an acute general medicine team improves attention and teamwork. METHODS: A 10-min programme comprising mindfulness exercises and techniques was delivered daily to a multidisciplinary general medicine team based in a tertiary hospital for 4 weeks. This was undertaken immediately prior to the team's interdisciplinary ward round. We used a mixed-method design, with self-rated surveys to measure mindfulness and staff perception of hospital safety culture, and a focus group to understand participants' experiences. We estimated mean differences using Kruskal-Wallis tests across 10 time-points and thematically analysed recorded transcripts. RESULTS: There was an increase in staff attention to the team meeting as measured by the decentering domain across time (P < 0.001). There was a trend to greater staff openness with a non-significant increase in curiosity (P = 0.14). We identified two overarching qualitative themes: feasibility of the programme and impact on staff and workplace. The programme was a calming circuit breaker to staff's day, which aided in feeling more connected to the group and subjectively better ward round experience. The logistics of the programme, including timing, and the facilitator developing trust with the participants, appear important in implementation. CONCLUSION: A brief mindfulness-based intervention delivered to a general medical team improves staff attention at a multidisciplinary team meeting and team functioning.

Measuring and evaluating sexual health in the era of digital health: challenges and opportunities.

Digital health has become increasingly embedded within sexual health service delivery and is now an established part of the user journey. It can support the provision of information and access to care across the sexual health continuum and facilitate the delivery of differentiated care with tailored and layered interventions that meet an individual's and target populations' need. However, despite advances in digital health, many challenges remain in the measurement and evaluation of sexual health. Reaching underserved populations, ensuring that both the intervention and the outcomes being measured are appropriate, and consistent collection of data (across settings and over time) are all potential obstacles to a full realisation of these opportunities. In order for digital health to improve sexual health and wellbeing, and reduce morbidity, the following need to occur: (1) ensure the necessary digital, health care, laboratory, legal and regulatory and surveillance infrastructure is in place to provide access to those with a sexual health need; (2) empowerment of end users and communities to take control of their own health through engagement in the development of interventions, and to ensure that outcomes of importance are measured; (3) tailoring and layering of interventions to provide equitable access to care; (4) integrating the digital ecosystem with the existing healthcare and external ecosystem; (5) measure and evaluate the unmet needs, gaps and quality of the experience, taking a realist evaluation approach; and (6) measure and evaluate the economic and distributional impacts associated with digital services or interventions in sexual health.

Priorities in the implementation of partner services for HIV/STIs in high-income nations: a narrative review of evidence and recommendations.

Partner notification (PN) remains a crucial prevention tool to reduce sexually transmitted infection (STI) transmission and prevent STI-related morbidity. Although there have been a variety of different approaches taken to facilitate the notification, testing and management of sexual contacts of STIs and HIV, there is an increasing acknowledgement that these interventions are unscalable and have relatively little impact on disease transmission. At the same time, an expanding body of evidence supports a shift in the emphasis of STI outreach-related work from an exclusive focus on PN to an approach that incorporates epidemiologic data collection, case management, and PN, an approach that is sometimes called partner services (PS). In this review, we appraise the current evidence base for different PN interventions for STIs in high-income nations, make recommendations for best practices, present a schema for how public health programs might prioritise PS for different programs, and identify priority research questions related to PN.

Mindfulness-based intervention to reduce burnout and psychological distress, and improve wellbeing in psychiatry trainees: a pilot study.

BACKGROUND: Healthcare professionals including psychiatry trainees experience high amounts of occupational stress. This pilot study aims to assess the impacts and feasibility of a mindfulness-based intervention program as an occupational intervention in a metropolitan hospital. METHOD: Psychiatry trainees participated in an mindfulness-based intervention training program consisting of 1-h weekly sessions over 8 weeks. Levels of psychological distress and mindfulness were measured pre and post-intervention. Qualitative data through an open-ended feedback survey were also collected. RESULTS: There was an improved level of mindfulness and a decreased level of burnout among trainees post-intervention. Advantages of the program included having a compassionate facilitator and the program being tailored to healthcare staff. Limiting factors included time restraints and clinical responsibilities. CONCLUSION: Psychiatry trainees can benefit from an occupational MBI program. This can positively impact their health as well as improve their work performance. A number of factors important for implementation of a mindfulness-based intervention program were also identified.

Mixed-methods evaluation of a novel online STI results service.

OBJECTIVES: Evidence on optimal methods for providing STI test results is lacking. We evaluated an online results service, developed as part of an eSexual Health Clinic (eSHC). METHODS: We evaluated the online results service using a mixed-methods approach within large exploratory studies of the eSHC. Participants were chlamydia- positive and negative users of online postal self-sampling services in six National Chlamydia Screening Programme (NCSP) areas and chlamydia-positive patients from two genitourinary medicine (GUM) clinics between 21 July 2014 and 13 March 2015. Participants received a discreetly worded National Health Service 'NHS no-reply' text message (SMS) informing them that their test results were ready and providing a weblink to a secure website. Participants logged in with their date of birth and mobile telephone or clinic number. Chlamydia-positive patients were offered online management. All interactions with the eSHC system were automatically logged and their timing recorded. Post-treatment, a service evaluation survey (n=152) and qualitative interviews (n=36) were conducted by telephone. Chlamydia-negative patients were offered a short online survey (n=274). Data were integrated. RESULTS: 92% (134/146) of NCSP chlamydia-positive patients, 82% (161/197) of GUM chlamydia-positive patients and 89% (1776/1997) of NCSP chlamydia-negative participants accessed test results within 7 days. 91% of chlamydia-positive patients were happy with the results service; 64% of those who had tested previously found the results service better or much better than previous experiences. 90% of chlamydia-negative survey participants agreed they would be happy to receive results this way in the future. Interviewees described accessing results with ease and appreciated the privacy and control the two-step process gave them. CONCLUSION: A discreet SMS to alert users/patients that results are available, followed by provision of results via a secure website, was highly acceptable, irrespective of test result and testing history. The eSHC results service afforded users privacy and control over when they viewed results without compromising access.

Using the eSexual Health Clinic to access chlamydia treatment and care via the internet: a qualitative interview study.

OBJECTIVE: We developed the eSexual Health Clinic (eSHC), an innovative, complex clinical and public health intervention, embedded within a specialist sexual health service. Patients with genital chlamydia access their results online and are offered medical management via an automated online clinical consultation, leading to antibiotic collection from community pharmacy. A telephone helpline, staffed by Sexual Health Advisers, is available to support patients and direct them to conventional services if appropriate. We sought to understand how patients used this ehealth intervention. METHODS: Within exploratory studies of the eSHC (2014-2015), we conducted in-depth interviews with a purposive sample of 36 patients diagnosed with chlamydia, who had chosen to use the eSHC (age 18-35, 20 female, 16 male). Thematic analysis was conducted. RESULTS: Participants described choosing to use this ehealth intervention to obtain treatment rapidly, conveniently and privately, within busy lifestyles that hindered clinic access. They described completing the online consultation promptly, discreetly and with ease. The information provided online was considered comprehensive, reassuring and helpful, but some overlooked it in their haste to obtain treatment. Participants generally described being able to collect treatment from pharmacies discreetly and promptly, but for some, poor awareness of the eSHC by pharmacy staff undermined their ability to do this. Those unsuitable for remote management, who were directed to clinic, described frustration and concern about health implications and clinic attendance. However, the helpline was a highly valued source of information, assistance and support. CONCLUSION: The eSHC is a promising adjunct to traditional care. Its users have high expectations for convenience, speed and privacy, which may be compromised when transitioning from online to face-to-face elements of the eSHC. Managing expectations and improving implementation of the pharmacy process, could improve their experiences. Positive views on the helpline provide further support for embedding this ehealth intervention within a specialist clinical service.

'Can you recommend any good STI apps?' A review of content, accuracy and comprehensiveness of current mobile medical applications for STIs and related genital infections.

OBJECTIVE: Seeking sexual health information online is common, and provision of mobile medical applications (apps) for STIs is increasing. Young people, inherently at higher risk of STIs, are avid users of technology, and apps could be appealing sources of information. We undertook a comprehensive review of content and accuracy of apps for people seeking information about STIs. METHODS: Search of Google Play and iTunes stores using general and specific search terms for apps regarding STIs and genital infections (except HIV), testing, diagnosis and management, 10 September 2014 to 16 September 2014. We assessed eligible apps against (1) 19 modified Health on The Net (HON) Foundation principles; and (2) comprehensiveness and accuracy of information on STIs/genital infections, and their diagnosis and management, compared with corresponding National Health Service STI information webpage content. RESULTS: 144/6642 apps were eligible. 57 were excluded after downloading. 87 were analysed. Only 29% of apps met ≥6 HON criteria. Content was highly variable: 34/87 (39%) covered one or two infections; 40 (46%) covered multiple STIs; 5 (6%) focused on accessing STI testing. 13 (15%) were fully, 46 (53%) mostly and 28 (32%) partially accurate. 25 (29%) contained ≥1 piece of potentially harmful information. Apps available on both iOS and Android were more accurate than single-platform apps. Only one app provided fully accurate and comprehensive information on chlamydia. CONCLUSIONS: Marked variation in content, quality and accuracy of available apps combined with the nearly one-third containing potentially harmful information risks undermining potential benefits of an e-Health approach to sexual health and well-being.

The eClinical Care Pathway Framework: a novel structure for creation of online complex clinical care pathways and its application in the management of sexually transmitted infections.

BACKGROUND: Despite considerable international eHealth impetus, there is no guidance on the development of online clinical care pathways. Advances in diagnostics now enable self-testing with home diagnosis, to which comprehensive online clinical care could be linked, facilitating completely self-directed, remote care. We describe a new framework for developing complex online clinical care pathways and its application to clinical management of people with genital chlamydia infection, the commonest sexually transmitted infection (STI) in England. METHODS: Using the existing evidence-base, guidelines and examples from contemporary clinical practice, we developed the eClinical Care Pathway Framework, a nine-step iterative process. Step 1: define the aims of the online pathway; Step 2: define the functional units; Step 3: draft the clinical consultation; Step 4: expert review; Step 5: cognitive testing; Step 6: user-centred interface testing; Step 7: specification development; Step 8: software testing, usability testing and further comprehension testing; Step 9: piloting. We then applied the Framework to create a chlamydia online clinical care pathway (Online Chlamydia Pathway). RESULTS: Use of the Framework elucidated content and structure of the care pathway and identified the need for significant changes in sequences of care (Traditional: history, diagnosis, information versus Online: diagnosis, information, history) and prescribing safety assessment. The Framework met the needs of complex STI management and enabled development of a multi-faceted, fully-automated consultation. CONCLUSION: The Framework provides a comprehensive structure on which complex online care pathways such as those needed for STI management, which involve clinical services, public health surveillance functions and third party (sexual partner) management, can be developed to meet national clinical and public health standards. The Online Chlamydia Pathway's standardised method of collecting data on demographics and sexual behaviour, with potential for interoperability with surveillance systems, could be a powerful tool for public health and clinical management.

User interface design for mobile-based sexual health interventions for young people: design recommendations from a qualitative study on an online Chlamydia clinical care pathway.

BACKGROUND: The increasing pervasiveness of mobile technologies has given potential to transform healthcare by facilitating clinical management using software applications. These technologies may provide valuable tools in sexual health care and potentially overcome existing practical and cultural barriers to routine testing for sexually transmitted infections. In order to inform the design of a mobile health application for STIs that supports self-testing and self-management by linking diagnosis with online care pathways, we aimed to identify the dimensions and range of preferences for user interface design features among young people. METHODS: Nine focus group discussions were conducted (n = 49) with two age-stratified samples (16 to 18 and 19 to 24 year olds) of young people from Further Education colleges and Higher Education establishments. Discussions explored young people's views with regard to: the software interface; the presentation of information; and the ordering of interaction steps. Discussions were audio recorded and transcribed verbatim. Interview transcripts were analysed using thematic analysis. RESULTS: Four over-arching themes emerged: privacy and security; credibility; user journey support; and the task-technology-context fit. From these themes, 20 user interface design recommendations for mobile health applications are proposed. For participants, although privacy was a major concern, security was not perceived as a major potential barrier as participants were generally unaware of potential security threats and inherently trusted new technology. Customisation also emerged as a key design preference to increase attractiveness and acceptability. CONCLUSIONS: Considerable effort should be focused on designing healthcare applications from the patient's perspective to maximise acceptability. The design recommendations proposed in this paper provide a valuable point of reference for the health design community to inform development of mobile-based health interventions for the diagnosis and treatment of a number of other conditions for this target group, while stimulating conversation across multidisciplinary communities.

Exploring the concept of unmet need within sexual and reproductive health in England: A qualitative Delphi exercise.

BACKGROUND: Unmet need within sexual and reproductive health (SRH) is a concept that is difficult to define and measure. This qualitative Delphi exercise was used to ascertain the opinions of SRH professionals on the conceptualisation and measurement of unmet need within SRH. METHODS: This exercise was carried out in two rounds. In the first round, respondents responded narratively to three prompts, which were then used to create a series of statements. In the second round, participants responded narratively to the statements created in the first round. Responses from both rounds were then coded and analysed thematically. RESULTS: Participants felt that an understanding of unmet need is an important part of SRH service design and provision, and believed that certain populations are often underrepresented within the datasets that are used to assess unmet need. Many respondents felt that a full understanding of unmet need within SRH would only come from involvement of relevant stakeholders in the process of investigating unmet need, and that qualitative methods may also have a role to play in gaining a more holistic understanding of unmet need within SRH. CONCLUSIONS: Respondents within this study felt that unmet need is complex concept that has a significant impact on service delivery and the outcomes and experiences of the most vulnerable populations. We need to improve our understanding of unmet need and prioritise stakeholder voices if we want to create interventions that address unmet need within SRH.

Inequalities in sexual and reproductive outcomes among women aged 16-24 in England (2012-2019).

BACKGROUND: Women aged 16-24 in England have a high burden of sexual and reproductive morbidity, with particularly poor outcomes among people living in more deprived areas (including racially minoritised populations). This analysis used national data to examine the disparities within sexual and reproductive outcomes among this population and to assess whether the patterns of inequality were consistent across all outcomes. METHODS: Within this ecological study, univariable and multivariable Poisson regression analyses of neighbourhood-level data from national data sets were carried out to investigate the relationships of deprivation and ethnicity with each of six dependent variables: gonorrhoea and chlamydia testing rates, gonorrhoea and chlamydia test positivity rates, and abortion and repeat abortion rates. RESULTS: When comparing Index of Multiple Deprivation (IMD) decile 1 (most deprived) and IMD decile 10 (least deprived), chlamydia (RR 0.65) and gonorrhoea (0.79) testing rates, chlamydia (0.70) and gonorrhoea (0.34) positivity rates, abortion rates (0.45) and repeat abortion rates (0.72) were consistently lower in IMD decile 10 (least deprived). Similarly, chlamydia (RR 1.24) and gonorrhoea positivity rates (1.92) and repeat abortion rates (1.31) were higher among black women than white women. Results were similar when both ethnicity and deprivation were incorporated into multivariable analyses. CONCLUSION: We found similar patterns of outcome inequality across a range of sexual and reproductive outcomes, despite multiple differences in the drivers of each outcome. Our analysis suggests that there are broad structural causes of inequality across sexual and reproductive health that particularly impact the health of deprived and black populations.