Effectiveness of eHealth Interventions for HIV Prevention and Management in Sub-Saharan Africa: Systematic Review and Meta-analyses.

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

Ethnic variations in sexual partnerships and mixing, and their association with STI diagnosis: findings from a cross-sectional biobehavioural survey of attendees of sexual health clinics across England.

OBJECTIVES: Ethnic differences in partnership types and sexual mixing patterns may contribute to elevated STI diagnosis rates among England's Black Caribbean (BC) population. We examined the differences between BC and White British/Irish (WBI) sexual health clinic (SHC) attendees' reported partnerships and sexual mixing, and whether these differences could explain ethnic inequalities in STI, focusing on attendees reporting only opposite-sex partners (past year). METHODS: We surveyed attendees at 16 SHCs across England (May to September 2016), and linked their survey responses to routinely collected data on diagnoses of bacterial STI or trichomoniasis ±6 weeks of clinic attendance ('acute STI'). Behaviourally-heterosexual BC and WBI attendees (n=1790) reported details about their ≤3 most recent opposite-sex partners (past 3 months, n=2503). We compared BC and WBI attendees' reported partnerships and mixing, in gender-stratified analyses, and used multivariable logistic regression to examine whether they independently explained differences in acute STI. RESULTS: We observed differences by ethnic group. BC women's partnerships were more likely than WBI women's partnerships to involve age-mixing (≥5 years age difference; 31.6% vs 25.5% partnerships, p=0.013); BC men's partnerships were more often 'uncommitted regular' (35.4% vs 20.7%) and less often casual (38.5% vs 53.1%) than WBI men's partnerships (p<0.001). Acute STI was higher among BC women than WBI women (OR: 2.29, 95% CI 1.24 to 4.21), with no difference among men. This difference was unaffected by partnerships and mixing: BC women compared with WBI women adjusted OR: 2.31 (95% CI 1.30 to 4.09) after adjusting for age and partner numbers; 2.15 (95% CI 1.07 to 4.31) after additionally adjusting for age-mixing, ethnic-mixing and recent partnership type(s). CONCLUSION: We found that differences in sexual partnerships and mixing do not appear to explain elevated risk of acute STI diagnosis among behaviourally-heterosexual BC women SHC attendees, but this may reflect the measures used. Better characterisation of 'high transmission networks' is needed, to improve our understanding of influences beyond the individual level, as part of endeavours to reduce population-level STI transmission.

Pathways to, and use of, sexual healthcare among Black Caribbean sexual health clinic attendees in England: evidence from cross-sectional bio-behavioural surveys.

BACKGROUND: In England, people of Black Caribbean (BC) ethnicity are disproportionately affected by sexually transmitted infections (STI). We examined whether differences in sexual healthcare behaviours contribute to these inequalities. METHODS: We purposively selected 16 sexual health clinics across England with high proportions of attendees of BC ethnicity. During May-September 2016, attendees at these clinics (of all ethnicities) completed an online survey that collected data on health service use and sexual behaviour. We individually linked these data to routinely-collected surveillance data. We then used multivariable logistic regression to compare reported behaviours among BC and White British/Irish (WBI) attendees (n = 627, n = 1411 respectively) separately for women and men, and to make comparisons by gender within these ethnic groups. RESULTS: BC women's sexual health clinic attendances were more commonly related to recent bacterial STI diagnoses, compared to WBI women's attendances (adjusted odds ratio, AOR 3.54, 95% CI 1.45-8.64, p = 0.009; no gender difference among BC attendees), while BC men were more likely than WBI men (and BC women) to report attending because of a partner's symptoms or diagnosis (AOR 1.82, 95% CI 1.14-2.90; AOR BC men compared with BC women: 4.36, 95% CI 1.42-13.34, p = 0.014). Among symptomatic attendees, BC women were less likely than WBI women to report care-seeking elsewhere before attending the sexual health clinic (AOR 0.60, 95% CI 0.38-0.97, p = 0.039). No ethnic differences, or gender differences among BC attendees, were observed in symptom duration, or reporting sex whilst symptomatic. Among those reporting previous diagnoses with or treatment for bacterial STI, no differences were observed in partner notification. CONCLUSIONS: Differences in STI diagnosis rates observed between BC and WBI ethnic groups were not explained by the few ethnic differences which we identified in sexual healthcare-seeking and use. As changes take place in service delivery, prompt clinic access must be maintained - and indeed facilitated - for those at greatest risk of STI, regardless of ethnicity.

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.

Finding sexual partners online: prevalence and associations with sexual behaviour, STI diagnoses and other sexual health outcomes in the British population.

OBJECTIVES: Online venues might facilitate sexual encounters, but the extent to which finding partners online is associated with sexual risk behaviour and sexual health outcomes is unclear. We describe use of the internet to find sexual partners in a representative sample in Britain. METHODS: The third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) was a cross-sectional probability survey of 15 162 adults (aged 16-74 years) undertaken 2010-2012. We estimated prevalence of, and identified factors associated with, finding sexual partners online among those reporting ≥1 new sexual partners in the past year. RESULTS: Finding sexual partners online in the past year was reported by 17.6% (95% CI 15.6 to 19.9) of men and 10.1% (8.5-11.9) of women, and most common among those aged 35-44 years. After age-adjustment, those reporting a non-heterosexual identity were more likely to report this. Finding partners online was also associated with reporting sexual risk behaviours: condomless sex with ≥2 partners (adjusted OR (aOR) men: 1.52 (1.03 to 2.23); women: 1.62 (1.06 to 2.49)), concurrent partnerships (aOR men: 2.33 (1.62 to 3.35); women: 2.41 (1.49 to 3.87)) and higher partner numbers (reporting ≥5 partners aOR men: 5.95 (3.78 to 9.36); women: 7.00 (3.77 to 13.00)) (all past year). STI diagnoses and HIV testing were more common among men reporting finding partners online (adjusted for age, partner numbers, same-sex partnerships), but not women. CONCLUSIONS: Finding partners online was associated with markers of sexual risk, which might be important for clinical risk assessment, but this was not matched by uptake of sexual health services. Online opportunities to find partners have increased, so these data might underestimate the importance of this social phenomenon for public health and STI control.

Meeting sexual partners online: associated sexual behaviour and prevalent chlamydia infection among adolescents in Norway: a cross-sectional study.

OBJECTIVES: Evidence is mixed as to whether meeting sexual partners online ('internet-partners') is associated with risky sexual behaviour and/or sexually transmitted infection transmission. Accordingly, we sought to estimate the prevalence of reporting various online romantic and sexual activities among Norwegian adolescents, including internet-partners, and the reason for meeting them and to examine differences in sexual behaviour, partnership characteristics and chlamydia infection prevalence among those reporting internet-partners versus those reporting only offline partners. METHODS: Population-based cross-sectional survey among sexually experienced girls and boys, 15-20 years, using electronic questionnaires and collecting urine samples for Chlamydia trachomatis PCR testing (79% provided both, n=1023). We used logistic regression to examine associations, adjusting for potentially confounding variables. RESULTS: Overall, 30% of both genders reported internet-partners (ever). Boys (but not girls) with internet-partners had higher chlamydia prevalence than those reporting meeting sexual partners only offline (8.1%, 95% CI 4.3% to 13.7% vs 1.6%, 0.5% to 3.7%). Two-thirds of girls and 37% of boys reported meeting their most recent internet-partner to start a romantic relationship, while the remainder did so with the specific intention of having sex. Among both genders, reporting sexual (vs romantic) reasons for meeting their most recent internet-partners was associated with reporting several risky sexual behaviours, including multiple recent sex partners (adjusted OR girls: 3.27, boys: 2.48) and three-fold higher chlamydia prevalence. CONCLUSIONS: This population-based study suggests that internet-partners are common among adolescents in Norway, and the reason for meeting them was more strongly associated with additionally reporting sexual risk behaviours and prevalent chlamydia infection than the internet itself as a meeting venue.

Young people's perceptions of smartphone-enabled self-testing and online care for sexually transmitted infections: qualitative interview study.

BACKGROUND: Control of sexually transmitted infections (STI) is a global public health priority. Despite the UK's free, confidential sexual health clinical services, those at greatest risk of STIs, including young people, report barriers to use. These include: embarrassment regarding face-to-face consultations; the time-commitment needed to attend clinic; privacy concerns (e.g. being seen attending clinic); and issues related to confidentiality. A smartphone-enabled STI self-testing device, linked with online clinical care pathways for treatment, partner notification, and disease surveillance, is being developed by the eSTI(2) consortium. It is intended to benefit public health, and could do so by increasing testing among populations which underutilise existing services and/or by enabling rapid provision of effective treatment. We explored its acceptability among potential users. METHODS: In-depth interviews were conducted in 2012 with 25 sexually-experienced 16-24 year olds, recruited from Further Education colleges in an urban, high STI prevalence area. Thematic analysis was undertaken. RESULTS: Nine females and 16 males participated. 21 self-defined as Black; three, mixed ethnicity; and one, Muslim/Asian. 22 reported experience of STI testing, two reported previous STI diagnoses, and all had owned smartphones. Participants expressed enthusiasm about the proposed service, and suggested that they and their peers would use it and test more often if it were available. Utilizing sexual healthcare was perceived to be easier and faster with STI self-testing and online clinical care, which facilitated concealment of STI testing from peers/family, and avoided embarrassing face-to-face consultations. Despite these perceived advantages to privacy, new privacy concerns arose regarding communications technology: principally the risk inherent in having evidence of STI testing or diagnosis visible or retrievable on their phone. Some concerns arose regarding the proposed self-test's accuracy, related to self-operation and the technology's novelty. Several expressed anxiety around the possibility of being diagnosed and treated without any contact with healthcare professionals. CONCLUSIONS: Remote STI self-testing and online care appealed to these young people. It addressed barriers they associated with conventional STI services, thus may benefit public health through earlier detection and treatment. Our findings underpin development of online care pathways, as part of ongoing research to create this complex e-health intervention.

Use of the Internet for Sexual Health Among Sexually Experienced Persons Aged 16 to 44 Years: Evidence from a Nationally Representative Survey of the British Population.

BACKGROUND: Those who go online regarding their sexual health are potential users of new Internet-based sexual health interventions. Understanding the size and characteristics of this population is important in informing intervention design and delivery. OBJECTIVE: We aimed to estimate the prevalence in Britain of recent use of the Internet for key sexual health reasons (for chlamydia testing, human immunodeficiency virus [HIV] testing, sexually transmitted infection [STI] treatment, condoms/contraceptives, and help/advice with one's sex life) and to identify associated sociodemographic and behavioral factors. METHODS: Complex survey analysis of data from 8926 sexually experienced persons aged 16-44 years in a 2010-2012 probability survey of Britain's resident population. Prevalence of recent (past year) use of Internet sources for key sexual health reasons was estimated. Factors associated with use of information/support websites were identified using logistic regression to calculate age-adjusted odds ratios (AORs). RESULTS: Recent Internet use for chlamydia/HIV testing or STI treatment (combined) was very low (men: 0.31%; women: 0.16%), whereas 2.35% of men and 0.51% of women reported obtaining condoms/contraceptives online. Additionally, 4.49% of men and 4.57% of women reported recent use of information/support websites for advice/help with their sex lives. Prevalence declined with age (men 16-24 years: 7.7%; 35-44 years: 1.84%, P<.001; women 16-24 years: 7.8%; 35-44 years: 1.84%, P<.001). Use of information/support websites was strongly associated with men's higher socioeconomic status (managerial/professional vs semiroutine/routine: AOR 1.93, 95% CI 1.27-2.93, P<.001). Despite no overall association with area-level deprivation, those in densely populated urban areas were more likely to report use of information/support websites than those living in rural areas (men: AOR 3.38, 95% CI 1.68-6.77, P<.001; women: AOR 2.51, 95% CI 1.34-4.70, P<.001). No statistically significant association was observed with number of sex partners reported after age adjustment, but use was more common among men reporting same-sex partners (last 5 years: AOR 2.44, 95% CI 1.27-4.70), women reporting sex with multiple partners without condoms (last year: AOR 1.90, 95% CI 1.11-3.26), and, among both sexes, reporting seeking sex online (last year, men: AOR 1.80, 95% CI 1.16-2.79; women: AOR 3.00, 95% CI 1.76-5.13). No association was observed with reporting STI diagnosis/es (last 5 years) or (after age adjustment) recent use of any STI service or non-Internet sexual health seeking. CONCLUSIONS: A minority in Britain used the Internet for the sexual health reasons examined. Use of information/support websites was reported by those at greater STI risk, including younger people, indicating that demand for online STI services, and Internet-based sexual health interventions in general, may increase over time in this and subsequent cohorts. However, the impact on health inequalities needs addressing during design and evaluation of online sexual health interventions so that they maximize public health benefit.

Serial monogamy and biologic concurrency: measurement of the gaps between sexual partners to inform targeted strategies.

Having multiple sexual partners concurrently increases the risk of transmission of a sexually transmitted infection. Even if partnerships do not overlap, transmission potential exists when the gap between partnerships is shorter than the remaining infectious period. In the present article, we quantify the gap between partners to assess transmission potential using data collected by a cross-sectional survey of 2,203 genitourinary medicine clinic patients in England in 2009. Questionnaires asked about patients' 3 most recent partnerships. Gaps were calculated as time (days) between the last sexual encounter with a former partner and the first sexual encounter with the next partner. Among 1,875 patients who reported 1 or more partners in the previous 3 months, 47.6% of men and 27.7% of women reported 2 or more partners. Forty-two percent of the gaps were negative (i.e., partnerships that were concurrent); the median gaps were -7 and -17 days for men and women, respectively (i.e., overlaps were 7 and 17 days for men and women, respectively). Although half of the gaps were positive (serially monogamous partnerships), many were of short duration; the median gaps were 14 and 24 days for men and women, respectively. In over half of the gaps, condoms were used inconsistently with one or both partners, and in one-quarter, condoms were never used with either partner. There is thus a high potential for sexually transmitted infections, as even if partnerships are not behaviorally concurrent, they may be biologically concurrent. These data have important implications for designing and targeting effective health promotion messages.

Improving questions on sexual partnerships: lessons learned from cognitive interviews for Britain's third National Survey of Sexual Attitudes and Lifestyles ("Natsal-3").

Patterns of sexual partnership formation and dissolution are key drivers of sexually transmitted infection transmission. Sexual behavior survey participants may be unable or unwilling to report accurate details about their sexual partners, limiting the potential to capture information on sexual mixing and timing of partnerships. We examined how questions were interpreted, including recall strategies and judgments made in selecting responses, to inform development of a module on recent sexual partnerships in Britain's third National Survey of Sexual Attitudes and Lifestyles ("Natsal-3"). Face-to-face cognitive interviews were conducted with 14 men and 18 women aged 18-74 years, during development work for Natsal-3. People with multiple recent partners were purposively sampled and questions were presented as a computer-assisted self-interview. Participants were generally agreeable to answering questions about their sexual partners and practices. Interpretation of questions designed to measure concurrent (overlapping) partnerships was broadly consistent with the epidemiological concept of concurrency. Partners' ages, genders, ethnicity, and participants' perceptions of whether partner(s) had had concurrent partnerships were reported without offense. Recall problems and lack of knowledge were reported by some participants (of all ages), especially about former, casual, and/or new partnerships, and some reported guessing partners' ages and dates of sex. Generally, participants were able to answer questions about their sexual partners accurately, even when repeated for multiple partners. Cognitive interviews provided insight into the participants' understanding of, ability to answer, and willingness to answer questions. This enabled us to improve questions used in previous surveys, refine new questions, and ensure the questionnaire order was logical for participants.

Designing a brief and simple intervention to help young people with type 1 diabetes to live well: Protocol for developing a novel intervention with participation from young people.

Young people living with type 1 diabetes (T1D) navigate daily complex diabetes related tasks as they take on increasing (and eventually full) responsibility for managing their condition, in addition to developing their lives as independent adults. Alongside the need for careful day-to-day diabetes management, the psychosocial burden and mental health impact and stigma are well recognised. Despite advances in psychological care, many young people with diabetes still experience a greater mental health burden than those without diabetes. This study aims to develop a brief and simple intervention for young people with T1D that will support their wellbeing day to day, as required, and grow their ability to live confidently with their condition that requires lifelong meticulous management. Insights gained in this participatory study will guide the development and focus of the intervention which may involve a toolkit containing self-guided resources or which could be a series of recommendations on how to design a healthcare service with a support network that is tailored to the needs of young people. This study will consist of qualitative research and collaboration with young people with T1D and their siblings, friends, and peers to co-create a testable intervention. In Part 1, research interviews will be conducted with young people (16-24 years old) with T1D and, where possible, their siblings/peers to understand the day-to-day challenges of type 1 and what a novel intervention should address. Thematic analysis of interviews will inform the generation of a prototype intervention to take into part two, focus group discussions. Focus groups with (i) young people with T1D and, separately (ii) carers (comprising parents, carers, teachers, specialist nurses). Collaborative principles will be used to review, redesign and evolve the intervention to meet user needs. A blend of narrative and thematic analysis will inform the findings and report. Insights from Parts 1 and 2 will shape a user-defined and formatively analysed brief and simple intervention and future study design ready for pilot testing. The aim of this part of the research is to maximise acceptability and usability of a testable intervention by the target population. To aim of the future intervention will be to demonstrate effectiveness in helping young adults to live well with T1D.

Building the bypass--implications of improved access to sexual healthcare: evidence from surveys of patients attending contrasting genitourinary medicine clinics across England in 2004/2005 and 2009.

OBJECTIVE: The objective of this study was to examine changes in patient routes into genitourinary medicine (GUM) clinics since policy changes in England sought to improve access to sexual healthcare. METHODS: Cross-sectional patient surveys at contrasting GUM clinics in England in 2004/2005 (seven clinics, 4600 patients) and 2009 (four clinics, 1504 patients). Patients completed a short pen-and-paper questionnaire that was then linked to an extract of their clinical data. RESULTS: Symptoms remained the most common reason patients cited for attending GUM (46% in both surveys), yet the proportion of patients having sexually transmitted infection (STI) diagnosis/es declined between 2004/2005 and 2009: 38%-29% of men and 28%-17% of women. Patients in 2009 waited less time before seeking care: median 7 days (2004/2005) versus 3 days (2009), in line with shorter GUM waiting times (median 7 vs 0 days, respectively). Fewer GUM patients in 2009 first sought care elsewhere (23% vs 39% in 2004/2005), largely from general practice, extending their time to attending GUM by a median of 2 days in 2009 (vs 5 days in 2004/2005). Patients with symptoms in 2009 were less likely than patients in 2004/2005 to report sex since recognising a need to seek care, but this was still reported by 25% of men and 38% of women (vs 44% and 58%, respectively, in 2004/2005). CONCLUSIONS: Patient routes to GUM shortened between 2004/2005 and 2009. While GUM patients in 2009 were less likely overall to have STIs diagnosed, perhaps reflecting lower risk behaviour, there remains a substantial proportion of high-risk individuals requiring comprehensive care. Behavioural surveillance across all STI services is therefore essential to monitor and maximise their public health impact.

Strategies for improving the acceptability and acceptance of the copper intrauterine device.

BACKGROUND: Intrauterine devices (IUDs) are highly effective and are the most widely used reversible contraceptive method in the world. However, in developed countries IUDs are among the least common methods of contraception used. We evaluated the effect of interventions to increase uptake of the copper IUD, a long-acting, reversible contraceptive method. OBJECTIVES: To determine effectiveness of interventions to improve uptake and continuation of the copper IUD. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, PsycINFO, PubMed, ClinicalTrials.gov, International Clinical Trials Registry Platform (ICTRP) and OpenSIGLE. We also handsearched references of relevant reviews and included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and controlled before and after studies of interventions which measured use and uptake of contraception including copper IUD as an outcome. DATA COLLECTION AND ANALYSIS: Two authors independently screened the search results for relevant studies and extracted data from included studies. We used RevMan 5.1 to calculate Peto odd ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes. We conducted meta-analysis by pooling data for similar types of intervention where possible. We used the GRADE system to evaluate the quality of evidence. MAIN RESULTS: Nine studies representing 7960 women met our inclusion criteria, including seven randomised controlled trials and two controlled before and after studies that reported IUD uptake postintervention. We evaluated the quality of evidence as moderate to low. Three studies on contraceptive counselling and referrals by community workers showed an increase in uptake of the IUD among intervention groups (Peto OR 2.00; 95% CI 1.40 to 2.85). Two studies on antenatal contraceptive counselling also favoured the intervention groups (Peto OR 2.33; 95% CI 1.39 to 3.91). One study on postnatal couple contraceptive counselling also showed an increase in IUD uptake compared to control (Peto OR 5.73; 95% CI 3.59 to 9.15). The results of one study evaluating postnatal home visits and two studies on enhanced postabortion contraceptive counselling did not reach statistical significance. AUTHORS' CONCLUSIONS: Community-based interventions and antenatal contraceptive counselling improved uptake of copper IUD contraception. Since the copper IUD is one of the most effective reversible contraceptive methods, primary care and family planning and practitioners could consider adopting these interventions. Although our review suggests these interventions are clinically effective, a cost-benefit analysis may be required to evaluate applicability.

Barriers and opportunities for evidence-based health service planning: the example of developing a Decision Analytic Model to plan services for sexually transmitted infections in the UK.

BACKGROUND: Decision Analytic Models (DAMs) are established means of evidence-synthesis to differentiate between health interventions. They have mainly been used to inform clinical decisions and health technology assessment at the national level, yet could also inform local health service planning. For this, a DAM must take into account the needs of the local population, but also the needs of those planning its services. Drawing on our experiences from stakeholder consultations, where we presented the potential utility of a DAM for planning local health services for sexually transmitted infections (STIs) in the UK, and the evidence it could use to inform decisions regarding different combinations of service provision, in terms of their costs, cost-effectiveness, and public health outcomes, we discuss the barriers perceived by stakeholders to the use of DAMs to inform service planning for local populations, including (1) a tension between individual and population perspectives; (2) reductionism; and (3) a lack of transparency regarding models, their assumptions, and the motivations of those generating models. DISCUSSION: Technological advances, including improvements in computing capability, are facilitating the development and use of models such as DAMs for health service planning. However, given the current scepticism among many stakeholders, encouraging informed critique and promoting trust in models to aid health service planning is vital, for example by making available and explicit the methods and assumptions underlying each model, associated limitations, and the process of validation. This can be achieved by consultation and training with the intended users, and by allowing access to the workings of the models, and their underlying assumptions (e.g. via the internet), to show how they actually work. SUMMARY: Constructive discussion and education will help build a consensus on the purposes of STI services, the need for service planning to be evidence-based, and the potential for mathematical tools like DAMs to facilitate this.

Estimating the likely public health impact of partner notification for a clinical service: an evidence-based algorithm.

OBJECTIVES: We present the first evidence-based method for estimating public health and cost impacts of partner notification (PN) that takes account of sexual partnership type. METHODS: Our algorithm uses routine clinical data, probability survey data, and transmission parameters. We propose 2 new epidemiological concepts to quantify PN impact: "[the] absolute reduction in onward transmission" and its reciprocal, "[the] number needed to treat to interrupt transmission" (i.e., the number of partners who need to be treated to interrupt 1 onward transmission). We demonstrate these concepts for 273 chlamydia cases diagnosed at a UK genitourinary medicine clinic. RESULTS: The number needed to treat to interrupt transmission (overall, for casual partners, and for regular partners, respectively) was 1.47, 1.11, and 2.50, respectively, for men younger than 25 years; 1.60, 0.83, and 1.25, respectively, for women younger than 25 years; 2.35, 1.39, and 2.08, respectively, for men older than 25 years; and 2.14, 0.93, and 2.08, respectively, for women older than 25 years. CONCLUSIONS: PN that targets casual partners, rather than regular or live-in partners, prevents more secondary transmissions per partnership; it is also more resource intensive, but the public health benefit is greater.

Alcohol misuse, sexual risk behaviour and adverse sexual health outcomes: evidence from Britain's national probability sexual behaviour surveys.

BACKGROUND: Evidence for relationships between alcohol misuse, sexual risk behaviour and adverse sexual health outcomes exists from both population-level data and studies undertaken in specific groups. We examine changes in these associations using representative data from two consecutive surveys. METHODS: Probability surveys conducted in 1990/91 and again in 2000/01 involving interviews with British residents aged 16-44. RESULTS: The proportion reporting being drunk as their main reason for first heterosexual intercourse increased from 2.5% among those born in 1946-49 to 6.4% of those born in 1980-84. These respondents were more likely to report intercourse before 16, that sex had occurred too soon, and contraception non-use. Usual alcohol consumption in excess of recommended limits ('heavy drinkers') was more common among those reporting larger partner numbers and unprotected sex with 2+ partners/past year but not with STD clinic attendance/diagnosis. Male heavy drinkers were more likely to report sexual function problems and female heavy drinkers using emergency contraception. The magnitude of these relationships did not significantly increase between 1990/91 and 2000/01. CONCLUSION: In Britain, sexual risk behaviours and some adverse sexual health outcomes continue to be associated with excess alcohol consumption. These findings support addressing the link between alcohol misuse and sexual health in health services and through broader health promotion.

Rationale and development of a survey tool for describing and auditing the composition of, and flows between, specialist and community clinical services for sexually transmitted infections.

BACKGROUND: National health strategies have called for an expansion of the role of primary care in England to increase access to sexual health services. However, there is little guidance for service planners and commissioners as to the public health impact of different combinations of specialist genitourinary medicine (GUM) clinics and primary care based services for local populations. Service planning for infectious diseases like sexually transmitted infections (STI) is further complicated because the goal of early detection and treatment is not only to improve the health of the individual, but to benefit the wider population and reduce future treatment costs by preventing onward transmission. Therefore, we are developing a survey tool that will enable service planners to better understand the needs of their local STI care-seeking population and which will help inform evidence-based decision-making about current and future service configurations. Here we describe the rationale and development of this survey tool. METHODS/DESIGN: A pen-and-paper questionnaire asking about sociodemographics, reasons for attendance, care pathways, and recent sexual risk behaviours, is being developed for patients to complete in waiting rooms of diverse clinical services, including GUM clinics and primary-care based services in sociodemographically- and geographically-contrasting populations in England. The questionnaire was cognitively tested before being piloted. In the pilot, 67% of patients participated, of whom 84% consented to our linking their questionnaire to data on STI testing and diagnosis and partner notification outcomes from their clinical records. DISCUSSION: The pilot study suggests that both the questionnaire and its linkage to routinely-collected clinical data are likely to be acceptable to patients. By supplementing existing surveillance, data gathered by the survey tool will inform service planners' and providers' understanding of the needs and care-pathways of their patients, facilitating improved services and greater public health benefit.

'This Adds Another Perspective': Qualitative Descriptive Study Evaluating Simulation-Based Training for Health Care Assistants, to Enhance the Quality of Care in Nursing Homes.

Much of the UK's ageing population lives in care homes, often with complex care needs including dementia. Optimal care requires strong clinical leadership, but opportunities for staff development in these settings are limited. Training using simulation can enable experiential learning in situ. In two nursing homes, Health Care Assistants (HCAs) received training in clinical communication skills (Situation-Background-Assessment-Recommendation Education through Technology and Simulation, SETS: group training with an actor simulating scenarios); and dementia (A Walk Through Dementia, AWTD: digital simulation, delivered one-to-one). In this qualitative descriptive study, we evaluated the potential of this training to enhance HCAs' clinical leadership skills, through thematic analysis of 24 semi-structured interviews with HCAs (before/after training) and their managers and mentors. Themes were checked by both interviewers. HCAs benefitted from watching colleagues respond to SETS scenarios and reported greater confidence in communicating with registered healthcare professionals. Some found role-play participation challenging. AWTD sensitised HCAs to the experiences of residents with dementia, and those with limited dementia experience gained a fuller understanding of the disease's effects. Staffing constraints affected participation in group training. Training using simulation is valuable in this setting, particularly when delivered flexibly. Further work is needed to explore its potential on a larger scale.

Interactive digital interventions for prevention of sexually transmitted HIV.

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