The effectiveness of text support for stopping smoking in pregnancy (MiQuit): multi-trial pooled analysis investigating effect moderators and mechanisms of action.

INTRODUCTION: Digital cessation support appeals to pregnant smokers. In two pooled RCTs, MiQuit, a pregnancy-specific tailored text messaging intervention, did not show effectiveness for validated prolonged abstinence. However, secondary outcomes and potential moderators and mediators have not been investigated. We aimed to determine, using pooled RCT data: 1) MiQuit effectiveness for a range of smoking outcomes; 2) whether baseline tobacco dependence or quit motivation moderate effectiveness; 3) whether hypothesized mechanisms of action (quitting determination, self-efficacy, baby harm beliefs, lapse prevention strategies) mediate effectiveness. METHODS: Pooled data analysis from two procedurally identical RCTs comparing MiQuit (N=704) to usual care (N=705). Participants were smokers, <25 weeks pregnant, recruited from 40 English antenatal clinics. Outcomes included self-reported seven-day abstinence at four weeks post-baseline and late pregnancy, and prolonged abstinence. Late pregnancy outcomes were also biochemically validated. We used hierarchical regression and Structural Equation Modelling. RESULTS: MiQuit increased self-reported, seven-day abstinence at four weeks (OR=1.73 [95% CI 1.10-2.74]) and was borderline significant at late pregnancy (OR=1.34 [0.99-1.82]) but not for prolonged or validated outcomes. Effectiveness was not moderated by baseline dependence (Heaviness of Smoking "low" versus "moderate-high") or motivation (planning to quit ≤30 days [high] versus >30days [low]), but effects on self-reported outcomes were larger for the high motivation sub-group. MiQuit had a small effect on mean lapse prevention strategies (MiQuit 8.6 [SE 0.17], UC 8.1 [SE 0.17]; P=0.030) but not other mechanisms. CONCLUSIONS: MiQuit increased short-term but not prolonged or validated abstinence and may be most effective for those motivated to quit sooner. IMPLICATIONS: Digital cessation support appeals to pregnant smokers. MiQuit, a tailored, theory-guided text messaging program for quitting smoking in pregnancy, has not shown effectiveness for validated prolonged abstinence in two previous RCTs but its impact on other smoking outcomes and potential mechanisms of action are unknown. When pooling trial data, MiQuit increased self-reported short-term abstinence, including making a quit attempt and abstinence at four-week follow-up, but not late pregnancy, sustained or validated abstinence. MiQuit appeared effective at late pregnancy for participants with high quitting motivation, but its mechanisms of action remain uncertain. Additional support components are likely required to enhance effectiveness.

Social marketing and mass media interventions to increase sexually transmissible infections (STIs) testing among young people: social marketing and visual design component analysis.

INTRODUCTION: Globally, sexually transmissible infections (STIs) continue to disproportionately affect young people. Regular STI testing is an important public health strategy but remains low among this age group. Raising awareness of testing is an essential step and requires effective interventions designed for young people. To inform the development of effective interventions that promote STI testing among young people, we conducted a systematic literature review to describe the social marketing and visual design components commonly found in STI testing interventions and explore associations of these components with intervention effectiveness. METHODS: We used a systemic review methodology to identify peer-reviewed articles that met pre-defined inclusion criteria. Social marketing and visual component analyses were conducted using structured data extraction tools and coding schemes, based on the eight key social marketing principles and 28 descriptive dimensions for visual analysis. RESULTS: 18 studies focusing on 13 separate interventions met the inclusion criteria. Most interventions used photograph-based images, using conventionally attractive actors, positioned centrally and making direct eye contact to engage the viewer. The majority of interventions featured text sparingly and drew on a range of tones (e.g. serious, humorous, positive, reassuring, empowering and informative) and three interventions used sexualised content. Four articles explicitly stated that the interventions was informed by social marketing principles, with two explicitly referencing all eight principles. Around half of the articles reported using a formal theoretical framework, but most were considered to have theoretical constructs implicit in interventions materials. Four articles provided detailed information regarding developmental consumer research or pre-testing. All articles suggested segmentation and development of materials specifically for young people. Explicit consideration of motivation and competition was lacking across all articles. This study found that there were some design elements common to interventions which were considered more effective. High social marketing complexity (where interventions met at least seven of the 11 criteria for complexity) seemed to be associated with more effective interventions. CONCLUSIONS: Our findings suggest that the incorporation of social marketing principles, could be more important for intervention effectiveness than specific elements of visual design. Effective and systematic use of social marketing principles may help to inform future evidence-informed and theoretically based interventions and should be employed within sexual health improvement efforts.

Adolescents' interactive electronic device use, sleep and mental health: a systematic review of prospective studies.

Optimal sleep, both in terms of duration and quality, is important for adolescent health. However, young people's sleeping habits have worsened over recent years. Access to and use of interactive electronic devices (e.g., smartphones, tablets, portable gaming devices) and social media have become deep-rooted elements of adolescents' lives and are associated with poor sleep. Additionally, there is evidence of increases in poor mental health and well-being disorders in adolescents; further linked to poor sleep. This review aimed to summarise the longitudinal and experimental evidence of the impact of device use on adolescents' sleep and subsequent mental health. Nine electronic bibliographical databases were searched for this narrative systematic review in October 2022. Of 5779 identified unique records, 28 studies were selected for inclusion. A total of 26 studies examined the direct link between device use and sleep outcomes, and four reported the indirect link between device use and mental health, with sleep as a mediator. The methodological quality of the studies was generally poor. Results demonstrated that adverse implications of device use (i.e., overuse, problematic use, telepressure, and cyber-victimisation) impacted sleep quality and duration; however, relationships with other types of device use were unclear. A small but consistent body of evidence showed sleep mediates the relationship between device use and mental health and well-being in adolescents. Increasing our understanding of the complexities of device use, sleep, and mental health in adolescents are important contributions to the development of future interventions and guidelines to prevent or increase resilience to cyber-bullying and ensure adequate sleep.

Development of "Baby, Me, & NRT": A Behavioral Intervention to Improve the Effectiveness of Nicotine Replacement Therapy in Pregnancy.

BACKGROUND: The effectiveness of Nicotine Replacement Therapy (NRT) for smoking cessation in pregnancy is limited by inconsistent and incorrect use. This paper describes the development process for "Baby, Me, & NRT", a novel pregnancy-specific intervention aimed at enhancing adherence to NRT. METHODS: An integrated approach to intervention development was used, combining evidence, theory, stakeholders' feedback, and tailoring principles. The process involved six iterative steps: (1) synthesizing relevant published evidence and guidance, (2) collecting primary qualitative data on barriers and facilitators to NRT adherence along with potential intervention design features, (3) identifying relevant behavioral theories and mapping the evidence against these, (4) prioritizing behavioral determinants identified in steps 1 and 2, generating intervention objectives, and identifying behavior change techniques which target the prioritized determinants, (5) consulting with stakeholders on intervention components, key content and tailoring features, and (6) producing a prototype intervention along with implementation guidance. RESULTS: The prototype intervention comprises of a multi-component, 1-month cessation programme, which includes six enhanced behavioral support sessions delivered by a trained advisor, tailored text messages, a website, and an illustrated booklet. It promotes the uptake of high-dose and combination NRT, emphasizes the importance of adherence, addresses motivation to use NRT, proactively helps problem solve NRT use issues, and provides guidance on preventing and managing smoking lapses. CONCLUSION: The development process generated an evidence- and theory-guided intervention, designed with stakeholder input, aimed at improving NRT effectiveness for smoking cessation in pregnancy. The prototype intervention has since been optimized and is being evaluated in a randomized controlled trial.

Development and Content Validation of a Questionnaire for Measuring Beliefs About Using Nicotine Replacement Therapy for Smoking Cessation in Pregnancy.

INTRODUCTION: Improving adherence to nicotine replacement therapy (NRT) in pregnancy may result in higher smoking cessation rates. Informed by the Necessities and Concerns Framework, we developed an intervention targeting pregnancy NRT adherence. To evaluate this, we derived the NRT in pregnancy necessities and concerns questionnaire (NiP-NCQ), which measures perceived need for NRT and concerns about potential consequences. AIMS AND METHODS: Here we describe the development and content validation of NiP-NCQ. From qualitative work, we identified potentially modifiable determinants of pregnancy NRT adherence and classed these as necessity beliefs or concerns. We translated these into draft self-report items and piloted items on 39 pregnant women offered NRT and a prototype NRT adherence intervention, assessing distributions and sensitivity to change. After removing poorly performing items, smoking cessation experts (N = 16) completed an online discriminant content validation (DCV) task to determine whether retained items measure a necessity belief, concern, both, or neither construct. RESULTS: Draft NRT concern items encompassed safety for the baby, side effects, too much or insufficient nicotine, and addictiveness. Draft necessity belief items included perceived need for NRT for short- and longer-term abstinence, and desire to minimize or cope without NRT. Of 22 out of 29 items retained after piloting, four were removed following the DCV task: three were judged to measure neither construct and one possibly both. The final NiP-NCQ comprised nine items per construct (18 total). CONCLUSIONS: The NiP-NCQ measures potentially modifiable determinants of pregnancy NRT adherence within two distinct constructs and may have research and clinical utility for evaluating interventions targeting these. IMPLICATIONS: Poor adherence to NRT in pregnancy may result from low perceived need and concerns about consequences; interventions challenging these beliefs may yield higher smoking cessation rates. To evaluate an NRT adherence intervention informed by the Necessities and Concerns Framework, we developed the NiP-NCQ. Through the content development and refinement processes described in this paper, we derived an evidence-based, 18-item questionnaire measuring two distinct constructs within two nine-item subscales. Higher concerns and lower necessity beliefs indicate more negative NRT beliefs; NiP-NCQ may have research and clinical utility for interventions targeting these.

A peer-led, school-based social network intervention for young people in the UK, promoting sexual health via social media and conversations with friends: intervention development and optimisation of STASH.

BACKGROUND: The quality of school-based sex and relationships education (SRE) is variable in the UK. Digitally-based interventions can usefully supplement teacher-delivered lessons and positively impact sexual health knowledge. Designed to address gaps in core SRE knowledge, STASH (Sexually Transmitted infections And Sexual Health) is a peer-led social network intervention adapted from the successful ASSIST (A Stop Smoking in Schools Trial) model, and based on Diffusion of Innovation theory. This paper describes how the STASH intervention was developed and refined. METHODS: Drawing on the Six Steps in Quality Intervention Development (6SQuID) framework, we tested a provisional programme theory through three iterative stages -: 1) evidence synthesis; 2) intervention co-production; and 3) adaptation - which incorporated evidence review, stakeholder consultation, and website co-development and piloting with young people, sexual health specialists, and educators. Multi-method results were analysed in a matrix of commonalities and differences. RESULTS: Over 21 months, intervention development comprised 20 activities within the three stages. 1) We identified gaps in SRE provision and online resources (e.g. around sexual consent, pleasure, digital literacy), and confirmed critical components including the core ASSIST peer nomination process, the support of schools, and alignment to the national curriculum. We reviewed candidate social media platforms, ruling out all except Facebook on basis of functionality restrictions which precluded their use for our purposes. 2) Drawing on these findings, as well as relevant behaviour change theories and core elements of the ASSIST model, we co-developed new content with young people and other stakeholders, tailored to sexual health and to delivery via closed Facebook groups, as well as face-to-face conversations. 3) A pilot in one school highlighted practical considerations, including around peer nomination, recruitment, awareness raising, and boundaries to message sharing. From this, a revised STASH intervention and programme theory were co-developed with stakeholders. CONCLUSIONS: STASH intervention development required extensive adaptation from the ASSIST model. Although labour intensive, our robust co-development approach ensured that an optimised intervention was taken forward for feasibility testing. Evidencing a rigorous approach to operationalising existing intervention development guidance, this paper also highlights the significance of balancing competing stakeholder concerns, resource availability, and an ever-changing landscape for implementation. TRIAL REGISTRATION: ISRCTN97369178.

Improving HIV pre-exposure prophylaxis (PrEP) uptake and initiation: process evaluation and recommendation development from a national PrEP program†.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is key to HIV transmission elimination but implementation is challenging and under-researched. We undertook a process evaluation of the first 2years of a national PrEP program to explore barriers and facilitators to implementation and to develop recommendations to improve implementation, focusing on PrEP uptake and initiation. METHODS: Stage 1 involved semi-structured telephone interviews and focus groups (September 2018-July 2019) with geographically and demographically diverse patients seeking/using/declining/stopping PrEP (n =39), sexual healthcare professionals (n =54), community-based organisation service users (n =9) and staff (n =15) across Scotland. We used deductive thematic analysis, to derive and then map key barriers and facilitators to priority areas that experts agreed would enhance uptake and initiation. In Stage 2, we used analytic tools from implementation science to systematically generate evidence-based, theoretically-informed recommendations to enhance uptake and initiation of PrEP. RESULTS: Barriers and facilitators were multi-levelled and interdependent. Barriers included the rapid pace of implementation without additional resource, and a lack of familiarity with PrEP prescribing. Facilitators included opportunities for acquisition of practice-based knowledge and normalisation of initiation activities. We refined our 68 'long-list' recommendations to 41 using expert input and the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria. Examples include: provision of PrEP in diverse settings to reach all in need; co-produced, culturally sensitive training resources for healthcare professionals, with focused content on non-daily dosing; meaningful collaborative working across all stakeholders. CONCLUSIONS: These evidence-based, theory informed recommendations provide a robust framework for optimising PrEP uptake and initiation in diverse settings to ensure PrEP reaches all who may benefit.

A qualitative study of young people's lived experiences of suicide and self-harm: intentionality, rationality and authenticity.

BACKGROUND: Suicide is a leading cause of death amongst young people and a major public health concern. Although increasing research has identified contributory and protective factors affecting youth suicide, less is known about how young people make sense of suicidal distress themselves. METHODS: Using semi-structured interview methods and reflexive thematic analysis, this study explores how 24 young people aged 16-24 in Scotland, UK made sense of their lived experiences of suicidal thoughts and feelings, self-harm, and suicide attempts. RESULTS: Intentionality, rationality, and authenticity formed our central themes. Suicidal thoughts were categorised by participants dependent on their intention to act on them; a distinction often used to downplay the significance of early suicidal thoughts. Escalating suicidal feelings were then described as almost rational responses to adversities; whereas suicide attempts appeared to be described as more impulsive. These narratives seemed to be somewhat shaped by dismissive attitudes participants experienced in response to their suicidal distress, both from professionals and within their close networks. This impacted how participants articulated distress and asked for support. CONCLUSION: Suicidal thoughts that participants articulated as lacking the intention to act could represent key opportunities for early clinical intervention to prevent suicide. In contrast, stigma, difficulties communicating suicidal distress and dismissive attitudes could serve as barriers to seeking help, and, therefore, additional efforts should be made to ensure young people feel comfortable seeking help.

Uneven impacts of COVID-19 on the attendance rates of secondary school students from different socioeconomic backgrounds in Australia: A quasi-experimental analysis of administrative data.

This paper contributes to the growing body of research that demonstrates uneven impacts of the COVID-19 pandemic on educational outcomes of students from different socioeconomic status (SES) backgrounds. We evaluate the early impacts of COVID-19 on student attendance in secondary school and show how these impacts depend on students' SES. We employ a quasi-experimental design, using difference-in-differences (DiD) estimation extended to incorporate third-order differences over time between low-SES and other students, and pre- versus during-COVID-19, leveraging robust administrative data extracted from the registers of the Tasmanian Department of Education. Using data from multiple cohorts of secondary school students in government schools in Tasmania (N = 14,135), we find that while the attendance rates were similar pre- and during-COVID-19 for high-SES students, there was a significant drop in attendance rates during COVID-19 among socioeconomically disadvantaged students, demonstrating the more pronounced impacts of COVID-19 for these students. The findings demonstrate that even "relatively short" lockdowns, as those in Tasmania in 2020 (30-40 days of home learning), can significantly affect the learning experiences of students from socioeconomically disadvantaged backgrounds. We discuss the implications of this for future pandemic planning in educational policy and practice and how this needs to be addressed in Australia's COVID-19 recovery.

Connection, connectivity and choice: Learning during COVID-19 restrictions across mainstream schools and Flexible Learning Programmes in Australia.

The COVID-19 pandemic and associated school closures may have constrained educational participation particularly for students in disadvantaged circumstances. We explore how 30 disadvantaged students in secondary school (14 mainstream/16 Flexible Learning Programme) from Queensland, New South Wales and Tasmania experienced home learning during the first wave of COVID-19, teasing out nuances across two educational models. Drawing on semi-structured interviews with these students, our analysis revealed three interconnected themes inflecting their learning: connection, connectivity and choice. Connection captures the desire for belonging and practices that facilitated meeting this desire during system-wide disruptions to school routines and face-to-face learning. Connectivity captures the impact of digitally facilitated learning at home on students' ability to engage with curriculum content and with their learning community. Choice captures the availability of viable options to overcome barriers students encountered in their learning and possibilities to flexibly accommodate student preferences and learning needs. Students from Flexible Learning Programmes appeared generally better supported to exercise agency within the scope of their lived experience of home-based learning. Findings indicate a need for strengthening student-centred policy and practices aimed at leveraging the affordances of information technology, balancing self-directed and structured learning and providing holistic support to enable meaningful student choice.

Use of effective contraception following provision of the progestogen-only pill for women presenting to community pharmacies for emergency contraception (Bridge-It): a pragmatic cluster-randomised crossover trial.

BACKGROUND: Unless women start effective contraception after oral emergency contraception, they remain at risk of unintended pregnancy. Most women in the UK obtain emergency contraception from community pharmacies. We hypothesised that pharmacist provision of the progestogen-only pill as a bridging interim method of contraception with emergency contraception plus an invitation to a sexual and reproductive health clinic, in which all methods of contraception are available, would result in increased subsequent use of effective contraception. METHODS: We did a pragmatic cluster-randomised crossover trial in 29 UK pharmacies among women receiving levonorgestrel emergency contraception. Women aged 16 years or older, not already using hormonal contraception, not on medication that could interfere with the progestogen-only pill, and willing to give contact details for follow-up were invited to participate. In the intervention group, women received a 3-month supply of the progestogen-only pill (75 µg desogestrel) plus a rapid access card to a participating sexual and reproductive health clinic. In the control group, pharmacists advised women to attend their usual contraceptive provider. The order in which each pharmacy provided the intervention or control was randomly assigned using a computer software algorithm. The primary outcome was the use of effective contraception (hormonal or intrauterine) at 4 months. This study is registered, ISRCTN70616901 (complete). FINDINGS: Between Dec 19, 2017, and June 26, 2019, 636 women were recruited to the intervention group (316 [49·6%], mean age 22·7 years [SD 5·7]) or the control group (320 [50·3%], 22·6 years [5·1]). Three women (one in the intervention group and two in the control group) were excluded after randomisation. 4-month follow-up data were available for 406 (64%) participants, 25 were lost to follow-up, and two participants no longer wanted to participate in the study. The proportion of women using effective contraception was 20·1% greater (95% CI 5·2-35·0) in the intervention group (mean 58·4%, 48·6-68·2), than in the control group (mean 40·5%, 29·7-51·3 [adjusted for recruitment period, treatment group, and centre]; p=0·011).The difference remained significant after adjusting for age, current sexual relationship, and history of effective contraception use, and was robust to the effect of missing data (assuming missingness at random). No serious adverse events occurred. INTERPRETATION: Provision of a supply of the progestogen-only pill with emergency contraception from a community pharmacist, along with an invitation to a sexual and reproductive health clinic, results in a clinically meaningful increase in subsequent use of effective contraception. Widely implemented, this practice could prevent unintended pregnancies after use of emergency contraception. FUNDING: National Institute for Health Research (Health Technology Assessment Programme project 15/113/01).

Mental health, potential minority stressors and resilience: evidence from a cross-sectional survey of gay, bisexual and other men who have sex with men within the Celtic nations.

BACKGROUND: Gay, bisexual and other men who have sex with men (GBMSM) are at a greater risk of mental health problems, such as anxiety and depression, than heterosexual adults. Numerous factors and stressors have been reported to impact men's mental health, although it has been suggested that resilience could have a protective effect. The aim of this study is to explore mental health, minority stressors, and resilience among a large online cross-sectional survey of GBMSM in the Celtic nations. METHODS: Data for this cross-sectional study were collected from the Social Media, GBMSM and Sexual and Holistic Health (SMMASH2) self-report online survey. Participants (n = 3077) were recruited via gay sociosexual media in Scotland, Wales, Northern Ireland, and the Republic of Ireland. Binary logistic regression analyses were conducted to identify factors that increased the odds of moderate-to-severe anxiety and depression. Potentially relevant variables (p < 0.05) were carried forward in hierarchal logistic regression analyses. RESULTS: The prevalence of moderate-to-severe anxiety and depression was 19.9 and 14.4%, respectively. Having a disability (OR = 1.73) and having financial worries sometimes/all of the time (OR = 1.93) increased the odds of having moderate-to-severe depression and anxiety, respectively. No minority stressors were associated with depression, whereas experiencing any form of relationship abuse in the last 12 months significantly increased the odds of anxiety (OR = 1.50). Resilience, namely a sense of coherence, had a protective effect and significantly reduced the odds of moderate-to-severe depression (OR = 0.85) and anxiety (OR = 0.89). CONCLUSIONS: Disability and financial worries were associated with increased depression and anxiety, respectively, while resilience had a protective effect for GBMSM in the SMMASH2 study. Future research is needed to better understand the role of resilience and the challenges and stresses of everyday life and intersecting health problems. Future research is also needed that incorporates the perspectives of those most affected by mental ill-health to co-develop effective solutions that respond to their contextual surroundings.

Sexual health literacy among gay, bisexual and other men who have sex with men: a conceptual framework for future research.

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

Configuring the PrEP user: framing pre-exposure prophylaxis in UK newsprint 2012-2016.

Pre-exposure prophylaxis (PrEP) has been hailed as a revolutionary intervention for HIV prevention. PrEP's controversial status in the UK has generated significant media coverage. It is important to understand what role the media plays in framing PrEP policy issues. We undertook a qualitative analysis of UK newsprint articles between 2012 and 2016 to examine how PrEP was framed as a public health intervention up until a controversial policy decision not to provide PrEP in England. We identified how scientific evidence was deployed to shape two narratives: ir/responsible citizens focused on imagined PrEP users and their capacity to use PrEP effectively; and the public health imperative, which described the need for PrEP. Our analysis demonstrates the particular ways in which scientific evidence contributed to the certainty of PrEP as an effective intervention within UK newsprint. Scientific evidence also played a key role in framing PrEP as an intervention specifically for cis-gendered gay and bisexual men, playing into wider debates about who is a deserving patient and the appropriate use of public resources. Practitioners in the UK and elsewhere should be aware of these constructions of the PrEP user to ensure equitable access to PrEP beyond gay and bisexual men.

Peer-to-Peer Sharing of Social Media Messages on Sexual Health in a School-Based Intervention: Opportunities and Challenges Identified in the STASH Feasibility Trial.

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.

How can HIV/STI testing services be more accessible and acceptable for gender and sexually diverse young people? A brief report exploring young people's perspectives in Queensland.

ISSUE ADDRESSED: Gender and sexually diverse young people (GSDYP) are an important target group for HIV/sexually transmitted infection (STI) prevention and there is an immediate need to explore ways to make testing interventions accessible and appropriate for this group. METHODS: We used a modified World Café workshop with 14 GSDYP in Brisbane Australia, to inform the development of a pilot community-based testing intervention. RESULTS: The workshop identified the key features of an ideal service, which would include multiple, accessible sites that offer holistic, affordable services and confidential care by respectful and knowledgeable providers. The service would allow young people to engage in decision-making processes, have a culturally inclusive, comfortable and friendly atmosphere, and provide free sexual and reproductive health technologies. CONCLUSION: When designing HIV/STI testing interventions for key groups, health promotion practitioners need to be cognisant of localised and nuanced expectations and ensure that services are tailored to the needs and experiences of the local population. SO WHAT?: This study provides insights into the needs and expectations of HIV/STI testing interventions for GSDYP in Australia, a key at-risk group whose perspectives are not adequately voiced in sexual health research and intervention design. SUMMARY: This study explores facilitators and current barriers to HIV/STI testing with a group of gender and sexually diverse young people in Brisbane, Australia. Outcomes provide insights into the needs and expectations of HIV/STI testing services for this group.

What are the barriers and challenges faced by adolescents when searching for sexual health information on the internet? Implications for policy and practice from a qualitative study.

OBJECTIVES: As sexual health information is increasingly presented digitally, and adolescents are increasingly seeking sexual health information on the internet, it is important to explore the challenges presented by this developing source of information provision. This study examined the key barriers and challenges faced by young people when accessing and using sexual health information online. METHODS: A novel qualitative approach was used which combined paired interviews with real-time online activities. A purposive sample of 49 young people aged between 16 and 19 years and diverse in terms of gender, sexuality, religion and socio-demographic background were recruited from areas across Scotland. Data analysis comprised framework analysis of conversational data (including pair interactions), descriptive analysis of observational data, and data integration. RESULTS: This study highlighted practical and socio-cultural barriers to engagement with online sexual health content. Key practical barriers included difficulty filtering overabundant content; limited awareness of specific, relevant, trusted online sources; difficulties in finding locally relevant information about services; and difficulties in navigating large organisations' websites. Key socio-cultural barriers included fear of being observed; wariness about engaging with visual and auditory content; concern about unintentionally accessing sexually explicit content; and reticence to access sexual health information on social networking platforms or through smartphone applications. These practical and socio-cultural barriers restricted access to information and influenced searching practices. CONCLUSION: This study provides insights into some of the key barriers faced by young people in accessing and engaging with sexual health information and support online. Reducing such challenges is essential. We highlight the need for sexual health information providers and intervention developers to produce online information that is accurate and accessible; to increase awareness of and promote reliable, accessible sources; and to be sensitive to young people's concerns about 'being seen' accessing sexual health information regarding audio-visual content and platform choice.

Age-related factors influence HIV testing within subpopulations: a cross-sectional survey of MSM within the Celtic nations.

OBJECTIVES: Despite a recent fall in the incidence of HIV within the UK, men who have sex with men (MSM) continue to be disproportionately affected. As biomedical prevention technologies including pre-exposure prophylaxis are increasingly taken up to reduce transmission, the role of HIV testing has become central to the management of risk. Against a background of lower testing rates among older MSM, this study aimed to identify age-related factors influencing recent (≤12 months) HIV testing. METHODS: Cross-sectional subpopulation data from an online survey of sexually active MSM in the Celtic nations-Scotland, Wales, Northern Ireland and Ireland (n=2436)-were analysed to compare demographic, behavioural and sociocultural factors influencing HIV testing between MSM aged 16-25 (n=447), 26-45 (n=1092) and ≥46 (n=897). RESULTS: Multivariate logistic regression demonstrated that for men aged ≥46, not identifying as gay (OR 0.62, CI 0.41 to 0.95), location (Wales) (OR 0.49, CI 0.32 to 0.76) and scoring higher on the personalised Stigma Scale (OR 0.97, CI 0.94 to 1.00) significantly reduced the odds for HIV testing in the preceding year. Men aged 26-45 who did not identify as gay (OR 0.61, CI 0.41 to 0.92) were also significantly less likely to have recently tested for HIV. For men aged 16-25, not having a degree (OR 0.48, CI 0.29 to 0.79), location (Republic of Ireland) (OR 0.55, CI 0.30 to 1.00) and scoring higher on emotional competence (OR 0.57, CI 0.42 to 0.77) were also significantly associated with not having recently tested for HIV. CONCLUSION: Key differences in age-related factors influencing HIV testing suggest health improvement interventions should accommodate the wide diversities among MSM populations across the life course. Future research should seek to identify barriers and enablers to HIV testing among the oldest and youngest MSM, with specific focus on education and stigma.

The Effectiveness of Social Marketing Interventions to Improve HIV Testing Among Gay, Bisexual and Other Men Who Have Sex with Men: A Systematic Review.

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

Absence of holistic sexual health understandings among men and women in deprived areas of Scotland: qualitative study.

BACKGROUND: There is a growing evidence base for the need for a holistic approach to sexual health improvement, but the challenges for realising this in the 'real world' may be harder in some communities than others. We examined sexual health understandings and behaviours among adult men and women in deprived areas of Scotland. METHODS: Thematic analysis, using the constant comparative method, of qualitative, semi-structured in-depth interviews with 19 men and 16 women aged 18-40 years from the most deprived areas of Glasgow, Edinburgh, Dundee, and three Highland towns. RESULTS: Even though most had been shown images designed to facilitate discussion about sexual consent and verbal/physical abuse, when first asked, participants overwhelmingly equated 'sexual health' with the avoidance of sexually transmitted infections (STIs) and pregnancy. Most of the women interviewed went on to locate their accounts of sexual health within a broader, social account of relationships that in an ideal world, in contrast with their everyday lives, were based on respect and freedom from violence. They expressed desires for more positive relationships, based on open communication and trust, choice and freedom from coercion. A few men did accept a broader definition of sexual health, but others actively resisted it and placed the onus to enact choices and freedom from coercion on women rather than men. CONCLUSIONS: In the first UK study to examine understandings of holistic sexual health among adults living in deprived areas, we found a disjuncture between men and women. These findings suggest that, as a society, we are failing to equip people to enhance their own, and others', sexual health and wellbeing in its broadest sense. New efforts to emphasise the breadth of sexual health are required, but addressing these complex issues, especially where there are negative underlying gender norms to challenge, will require multi-level interventions targeting individual, community and system levels.