Masculinities and sexual and reproductive health and rights: a global research priority setting exercise.

Engaging men and boys in sexual and reproductive health and rights (SRHR) and doing so in a way that challenges harmful masculinities, is both neglected and vital for improving the SRHR of both women and men. To address this gap, WHO commissioned a global research priority setting exercise on masculinities and SRHR. The exercise adapted the quantitative child health and nutrition research initiative priority setting method by combining it with qualitative methods. Influenced by feminist and decolonial perspectives, over 200 diverse stakeholders from 60 countries across all WHO regions participated. The exercise forges a collaborative research agenda emphasising four key areas: gender-transformative approaches to men's and boys' engagement in SRHR, applied research to deliver services addressing diversity in SRHR among men and women and to generate gender-equality, research designs to support participation of target audiences and reach to policy makers, and research addressing the priorities of those in low-income and middle-income countries.

School-based relationship and sexuality education intervention engaging adolescent boys for the reductions of teenage pregnancy: the JACK cluster RCT.

Background: The need to engage boys in gender-transformative relationships and sexuality education (RSE) to reduce adolescent pregnancy is endorsed by the World Health Organization and the United Nations Educational, Scientific and Cultural Organization. Objectives: To evaluate the effects of If I Were Jack on the avoidance of unprotected sex and other sexual health outcomes. Design: A cluster randomised trial, incorporating health economics and process evaluations. Setting: Sixty-six schools across the four nations of the UK. Participants: Students aged 13-14 years. Intervention: A school-based, teacher-delivered, gender-transformative RSE intervention (If I Were Jack) versus standard RSE. Main outcome measures: Self-reported avoidance of unprotected sex (sexual abstinence or reliable contraceptive use at last sex) after 12-14 months. Secondary outcomes included knowledge, attitudes, skills, intentions and sexual behaviours. Results: The analysis population comprised 6556 students: 86.6% of students in the intervention group avoided unprotected sex, compared with 86.4% in the control group {adjusted odds ratio 0.85 [95% confidence interval (CI) 0.58 to 1.26], p = 0.42}. An exploratory post hoc analysis showed no difference for sexual abstinence [78.30% intervention group vs. 78.25% control group; adjusted odds ratio 0.85 (95% CI 0.58 to 1.24), p = 0.39], but more intervention group students than control group students used reliable contraception at last sex [39.62% vs. 26.36%; adjusted odds ratio 0.52 (95% CI 0.29 to 0.920), p = 0.025]. Students in schools allocated to receive the intervention had significantly higher scores on knowledge [adjusted mean difference 0.18 (95% CI 0.024 to 0.34), p = 0.02], gender-equitable attitudes and intentions to avoid unintended pregnancy [adjusted mean difference 0.61 (95% CI 0.16 to 1.07), p = 0.01] than students in schools allocated to receive the control. There were positive but non-significant differences in sexual self-efficacy and communication skills. The total mean incremental cost of the intervention compared with standard RSE was £2.83 (95% CI -£2.64 to £8.29) per student. Over a 20-year time horizon, the intervention is likely to be cost-effective owing to its impact on unprotected sex because it would result in 379 (95% CI 231 to 477) fewer unintended pregnancies, 680 (95% CI 189 to 1467) fewer sexually transmitted infections and a gain of 10 (95% CI 5 to 16) quality-adjusted life-years per 100,000 students for a cost saving of £9.89 (95% CI -£15.60 to -£3.83). Limitations: The trial is underpowered to detect some effects because four schools withdrew and the intraclass correlation coefficient (0.12) was larger than that in sample size calculation (0.01). Conclusions: We present, to our knowledge, the first evidence from a randomised trial that a school-based, male engagement gender-transformative RSE intervention, although not effective in increasing avoidance of unprotected sex (defined as sexual abstinence or use of reliable contraception at last sex) among all students, did increase the use of reliable contraception at last sex among students who were, or became, sexually active by 12-14 months after the intervention. The trial demonstrated that engaging all adolescents early through RSE is important so that, as they become sexually active, rates of unprotected sex are reduced, and that doing so is likely to be cost-effective. Future work: Future studies should consider the longer-term effects of gender-transformative RSE as students become sexually active. Gender-transformative RSE could be adapted to address broader sexual health and other settings. Trial registration: This trial is registered as ISRCTN10751359. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (PHR 15/181/01) and will be published in full in Public Health Research; Vol. 11, No. 8. See the NIHR Journals Library website for further project information.

Adolescent pregnancy is often thought to be an issue for young women alone, but it is important to engage young men to tackle the problem and find solutions. The If I Were Jack intervention was especially designed to engage with boys as well as girls aged 14 years and to promote positive masculinity and gender equality to prevent adolescent pregnancy and promote positive sexual health. It uses tailored interactive films and resources, made with the help of students and teachers, to make it relevant to each of the four UK nations. This relationship and sexuality education intervention encourages adolescents to avoid unprotected sex by delaying sexual activity until they feel ready and to use reliable contraception once sexually active. It also promotes knowledge, attitudes (such as beliefs about gender and masculinities), skills and intentions for safe and pleasurable relationships. In this trial, we compared students in 33 schools randomly allocated to deliver the intervention with students in 33 schools that continued with their usual relationship and sexuality education practices. Four schools withdrew, two because of COVID-19 school closures. This left a total of 6556 students who completed questionnaires at the start of the study and 12­14 months later. Responses from all these students showed that If I Were Jack had a positive impact on knowledge, attitudes and intentions required for safe and pleasurable relationships, but did not have a significant effect on overall avoidance of unprotected sex. This was because the intervention had no effect on delaying sexual activity. However, we found that the intervention was effective in increasing the use of reliable contraception as students became sexually active, as well as for those who already were sexually active prior to receiving the intervention. We also found that If I Were Jack was likely to provide value for money by reducing unintended pregnancies and improving sexual health.

Reproductive, maternal, newborn, and child health intervention coverage in 70 low-income and middle-income countries, 2000-30: trends, projections, and inequities.

BACKGROUND: Monitoring the progress in reproductive, maternal, newborn, and child health (RMNCH) using the composite coverage index (CCI) is crucial to evaluate the advancement of low-income and middle-income countries (LMICs) towards the attainment of Sustainable Development Goal target 3. We present current benchmarking for 70 LMICs, forecasting to 2030, and an analysis of inequities within and across countries. METHODS: In this cross-sectional secondary data analysis, we extracted 291 data points from the WHO Equity Monitor, and Demographic and Health Survey Statcompiler for 70 LMICs. We selected countries on the basis of whether they belonged to LMICs, had complete information about the predictors between 2000 and 2030, and had at least one data point related to CCI. CCI was calculated on the basis of eight types of RMNCH interventions in four domains, comprising family planning, antenatal care, immunisations, and management of childhood illnesses. This study examined CCI as the main outcome variable. Bayesian hierarchical models were used to estimate trends and projections of the CCI at regional and national levels, as well as the area of residence, educational level, and wealth quintile. FINDINGS: Despite progress, only 18 countries are projected to reach the 80% CCI target by 2030. Regionally, CCI is projected to increase in all regions of Asia (in southern Asia from 51·8% in 2000 to 89·2% in 2030; in southeastern Asia from 58·8% to 84·4%; in central Asia from 70·3% to 87·0%; in eastern Asia from 76·8% to 82·1%; and in western Asia from 56·5% to 72·1%), Africa (in sub-Saharan Africa from 46·3% in 2000 to 72·2% in 2030 and in northern Africa from 55·0% to 81·7%), and Latin America and the Caribbean (from 67·0% in 2000 to 83·4% in 2030). By contrast, southern Europe is predicted to experience a decline in CCI over the same period (70·1% in 2000 to 55·2% in 2030). Across LMICs, CCIs are higher in urban areas, in populations in which women have higher education levels, and in populations with a high income. INTERPRETATION: Governments of countries where the universal target of 80% CCI has not yet been reached must develop evidence-based policies aimed at enhancing RMNCH coverage. Additionally, they should focus on reducing the extent of existing inequalities within their populations to drive progress in RMNCH. FUNDING: Hitotsubashi University and Japan Society for the Promotion of Science.

Men's mental health and the arts: perceived benefits and dynamics of engagement.

Arts engagement is gaining recognition as a non-clinical approach to promote mental health and well-being. However, the perceived utility of the arts to promote mental health among men with low socioeconomic status (SES) and how to best engage them is underexplored. This study explores the lived experiences of men with low SES who engage with the arts in Northern Ireland (n = 41). Data collected via focus groups (n = 5) and interviews (n = 11) were analysed using reflexive thematic analysis to inductively derive four themes. Theme 1 highlights how the arts facilitated friendship, a collective identity, peer support and a reason to socialize. Themes 2 and 3 explore how the arts enhanced self-esteem and emotional regulation by developing a routine, purpose, sense of mastery, a sense of catharsis through immersion in a soothing endeavour and an alternative outlet for self-expression. Theme 4 covers strategies that facilitate male engagement in the arts such as using a familiar space, delivering to an existing male group, framing the programme around male interests not health or creativity, building on existing strengths and capacities, enabling ownership, using tangible action-orientated activities, and being non-authoritative and flexible with delivery. This is one of the first studies to highlight the gendered dimensions in which men with low SES engage with and experience mental health benefits through arts engagement. This study points towards relevant theories to further understand the pathways between the arts and improved mental health among men which can inform development of tailored arts programmes for men.

Involving men and boys in family planning: A systematic review of the effective components and characteristics of complex interventions in low- and middle-income countries.

Background: Involving men and boys as both users and supporters of Family Planning (FP) is now considered essential for optimising maternal and child health outcomes. Evidence on how to engage men and boys to meet FP needs is therefore important. Objectives: The main objective of this review was to assess the strength of evidence in the area and uncover the effective components and critical process- and system-level characteristics of successful interventions. Search Methods: We searched nine electronic databases, seven grey literature databases, organisational websites, and the reference lists of systematic reviews relating to FP. To identify process evaluations and qualitative papers associated with the included experimental studies, we used Connected Papers and hand searches of reference lists. Selection Criteria: Experimental and quasi-experimental studies of behavioural and service-level interventions involving males aged 10 years or over in low- and middle-income countries to increase uptake of FP methods were included in this review. Data Collection and Analysis: Methodology was a causal chain analysis involving the development and testing of a logic model of intervention components based on stakeholder consultation and prior research. Qualitative and quantitative data relating to the evaluation studies and interventions were extracted based on the principles of 'effectiveness-plus' reviews. Quantitative analysis was undertaken using r with robust variance estimation (RVE), meta-analysis and meta-regression. Qualitative analysis involved 'best fit' framework synthesis. Results: We identified 8885 potentially relevant records and included 127 in the review. Fifty-nine (46%) of these were randomised trials, the remainder were quasi-experimental studies with a comparison group. Fifty-four percent of the included studies were assessed as having a high risk of bias. A meta-analysis of 72 studies (k = 265) showed that the included group of interventions had statistically significantly higher odds of improving contraceptive use when compared to comparison groups (odds ratio = 1.38, confidence interval = 1.21 to 1.57, prediction interval = 0.36 to 5.31, p < 0.0001), but there were substantial variations in the effect sizes of the studies (Q = 40,647, df = 264, p < 0.0001; I 2 = 98%) and 73% was within cluster/study. Multi-variate meta-regression revealed several significant intervention delivery characteristics that moderate contraceptive use. These included community-based educational FP interventions, interventions delivered to women as well as men and interventions delivered by trained facilitators, professionals, or peers in community, home and community, or school settings. None of the eight identified intervention components or 33 combinations of components were significant moderators of effects on contraceptive use. Qualitative analysis highlighted some of the barriers and facilitators of effective models of FP that should be considered in future practice and research. Authors' Conclusions: FP interventions that involve men and boys alongside women and girls are effective in improving uptake and use of contraceptives. The evidence suggests that policy should continue to promote the involvement of men and boys in FP in ways that also promote gender equality. Recommendations for research include the need for evaluations during conflict and disease outbreaks, and evaluation of gender transformative interventions which engage men and boys as contraceptive users and supporters in helping to achieve desired family size, fertility promotion, safe conception, as well as promoting equitable family planning decision-making for women and girls.

Addressing sexual and reproductive health and rights with men in prisons: co-production and feasibility testing of a relationship, sexuality and future fatherhood education programme.

PURPOSE: Young incarcerated male offenders are at risk of poorer sexual health, adolescent parenthood and lack opportunities for formative relationship and sexuality education (RSE) as well as positive male role models. The purpose of this paper is to report the process of co-production and feasibility testing of a novel, gender-transformative RSE programme with young male offenders to encourage positive healthy relationships, gender equality, and future positive fatherhood. DESIGN/METHODOLOGY/APPROACH: Using a rights-based participatory approach, the authors co-produced an RSE programme with young offenders and service providers at two UK prison sites using a sequential research design of: needs analysis, co-production and a feasibility pilot. Core components of the programme are grounded in evidence-based RSE, gender-transformative and behaviour change theory. FINDINGS: A needs analysis highlighted the men's interest in RSE along with the appeal of film drama and peer-group-based activities. In the co-production stage, scripts were developed with the young men to generate tailored film dramas and associated activities. This co-production led to "If I Were a Dad", an eight-week programme comprising short films and activities addressing masculinities, relationships, sexual health and future fatherhood. A feasibility pilot of the programme demonstrated acceptability and feasibility of delivery in two prison sites. The programme warrants further implementation and evaluation studies. ORIGINALITY/VALUE: The contribution of this paper is the generation of an evidence-based, user-informed, gender-transformative programme designed to promote SRHR of young male offenders to foster positive sexual and reproductive health and well-being in their own lives and that of their partners and (future) children.

Effects of gender-transformative relationships and sexuality education to reduce adolescent pregnancy (the JACK trial): a cluster-randomised trial.

BACKGROUND: The need to engage boys in gender-transformative relationships and sexuality education (RSE) to reduce adolescent pregnancy is endorsed by WHO. We aimed to test an intervention which used a gender-transformative approach to engage adolescents in RSE to prevent unprotected sex. METHODS: This cluster-randomised trial with process and economic evaluations tested a school-based intervention entitled If I Were Jack versus standard RSE (control) for students (aged 14-15 years) in UK schools. Schools were randomly allocated (1:1) and masked to allocation at baseline. The primary outcome was self-reported avoidance of unprotected sex (sexual abstinence or use of reliable contraception at last sex) after 12-14-months. We analysed the data using intention-to-treat mixed effects regression models. FINDINGS: Of 803 schools assessed for eligibility, 263 schools were invited by letter, of which 66 schools agreed to be randomly assigned, of which 62 schools completed follow-up. The trial was done between Feb 1, 2018, and March 6, 2020. 8216 students participated at baseline in 2018; 6561 (79·85%) provided 12-14 months follow-up. There was no significant difference in the primary outcome of avoidance of unprotected sex: 2648 (86·62) of 3057 in the intervention group avoided unprotected sex versus 2768 (86·41%) of 3203 in the control group (adjusted odds ratio [aOR] 0·85 [95% CI 0·58-1·26], p=0·42). Exploratory post-hoc analysis of the two components of the primary outcome showed that significantly more intervention students used reliable contraception at last sex compared with control students and there was no significant difference between the groups for sexual abstinence. No adverse events were reported. INTERPRETATION: The intervention had a null effect on the primary outcome of preventing unprotected sex (increasing sexual abstinence or use of reliable contraception) in the whole student population. However, the results showed significant increases in use of reliable contraceptives for sexually active students. Engaging all young people early through RSE is important so that as they become sexually active, rates of unprotected sex are reduced. FUNDING: National Institute for Health Research.

The Positive Choices trial: update to study protocol for a phase-III RCT trial of a whole-school social-marketing intervention to promote sexual health and reduce health inequalities.

BACKGROUND: Positive Choices is a whole-school social-marketing intervention to promote sexual health among secondary school students. Intervention comprises the following: school health promotion council involving staff and students coordinating delivery, student survey to inform local tailoring, teacher-delivered classroom curriculum, student-run campaigns, parent information and review of sexual/reproductive health services to inform improvements. This trial builds on an optimisation/pilot-RCT study which met progression criteria, plus findings from another pilot RCT of the Project Respect school-based intervention to prevent dating and relationship violence which concluded such work should be integrated within Positive Choices. Young people carry a disproportionate burden of adverse sexual health; most do not report competence at first sex. Relationships and sex education in schools can contribute to promoting sexual health but effects are small, inconsistent and not sustained. Such work needs to be supplemented by 'whole-school' (e.g. student campaigns, sexual health services) and 'social marketing' (harnessing commercial marketing to social ends) approaches for which there is good review-level evidence but not from the UK. METHODS: We will conduct a cluster RCT across 50 schools (minimum 6440, maximum 8500 students) allocated 1:1 to intervention/control assessing outcomes at 33 months. Our primary outcome is non-competent first sex. Secondary outcomes are non-competent last sex, age at sexual debut, non-use of contraception at first and last sex among those reporting heterosexual intercourse, number of sexual partners, dating and relationship violence, sexually transmitted infections and pregnancy and unintended pregnancy for girls and initiation of pregnancy for boys. We will recruit 50 school and undertake baseline surveys by March 2022, implement the intervention over the 2022-2024 school years and conduct the economic and process evaluations by July 2024; undertake follow-up surveys by December 2024; complete analyses, all patient and policy involvement and draft the study report by March 2025 and engage in knowledge exchange from December 2024. DISCUSSION: This trial is one of a growing number focused on whole-school approaches to public health in schools. The key scientific output will be evidence about the effectiveness, costs and potential scalability and transferability of Positive Choices. TRIAL REGISTRATION: ISRCTN No: ISRCTN16723909 . Registered on 3 September 2021.

The acceptability, effectiveness and gender responsiveness of participatory arts interventions in promoting mental health and Wellbeing: a systematic review.

BACKGROUND: This mixed methods review synthesizes the evidence of acceptability, effectiveness and gender-responsiveness of participatory arts interventions (PAIs) in promoting mental health and wellbeing among adults. METHODS: The search was restricted to empirical studies of PAIs that reported on outcomes relating to common mental health problems and wellbeing among adults aged ≥18 years old. The mixed methods appraisal tool was used for quality appraisal. A narrative synthesis was conducted. RESULTS: Thirty-two studies were included (1,058 participants). Typical PAI features are discussed. The evidence for effectiveness is limited by methodological issues. PAIs are perceived to benefit mental health via improved connectedness; emotional regulation; meaning-making & re-defining identity; and personal growth & empowerment. CONCLUSION: The review highlights the dearth of studies focused on men. Research standards to establish the evidence of effectiveness and the need to expand the evidence of acceptability beyond the "perceived effectiveness" domain are discussed.

The Positive Choices trial: study protocol for a Phase-III RCT trial of a whole-school social marketing intervention to promote sexual health and reduce health inequalities.

BACKGROUND: Positive Choices is a whole-school social marketing intervention to promote sexual health among secondary school students. Intervention comprises school health promotion council involving staff and students coordinating delivery; student survey to inform local tailoring; teacher-delivered classroom curriculum; student-run campaigns; parent information; and review of sexual/reproductive health services to inform improvements. This trial builds on an optimisation/pilot RCT study which met progression criteria, plus findings from another pilot RCT of the Project Respect school-based intervention to prevent dating and relationship violence which concluded such work should be integrated within Positive Choices. Young people carry a disproportionate burden of adverse sexual health; most do not report competence at first sex. Relationships and sex education in schools can contribute to promoting sexual health but effects are small, inconsistent and not sustained. Such work needs to be supplemented by 'whole-school' (e.g. student campaigns, sexual health services) and 'social marketing' (harnessing commercial marketing to social ends) approaches for which there is good review-level evidence but not from the UK. METHODS: We will conduct a cluster RCT across 50 schools (minimum 6440, maximum 8500 students) allocated 1:1 to intervention/control assessing outcomes at 33 months. Our primary outcome is non-competent first sex. Secondary outcomes are non-competent last sex, age at sexual debut, non-use of contraception at first and last sex among those reporting heterosexual intercourse, number of sexual partners, dating and relationship violence, sexually transmitted infections, and pregnancy and unintended pregnancy for girls and initiation of pregnancy for boys. We will recruit 50 school and undertake baseline surveys by March 2022; implement the intervention over the 2022-2024 school years and conduct the economic and process evaluations by July 2024; undertake follow-up surveys by December 2024; complete analyses, all patient and policy involvement and draft the study report by March 2025; and engage in knowledge exchange from December 2024. DISCUSSION: This trial is one of a growing number focused on whole-school approaches to public health in schools. The key scientific output will be evidence about the effectiveness, costs and potential scalability and transferability of Positive Choices. TRIAL REGISTRATION: ISRCTN No: ISRCTN16723909 . Trial registration summary: Date:. Funded by: National Institute for Health Research Public Health Research Programme (NIHR131487). SPONSOR: LSHTM. Public/scientific contact: Chris Bonell. Public title: Positive Choices trial. Scientific title: Phase-III RCT of Positive Choices: a whole-school social marketing intervention to promote sexual health and reduce health inequalities. Countries of recruitment: UK. INTERVENTION: Positive Choices. INCLUSION CRITERIA: Students in year 8 (age 12-13 years) at baseline deemed competent by schools to participate in secondary schools excluding pupil referral units, schools for those with special educational needs and disabilities, and schools with 'inadequate' Ofsted inspections. STUDY TYPE: interventional study with superiority phase III cluster RCT design. Enrollment: 1/9/21-31/3/22. SAMPLE SIZE: 50 schools and 6440-8500 students. Recruitment status: pending. PRIMARY OUTCOME: binary measure of non-competent first sex. SECONDARY OUTCOMES: non-competent last sex; age at sexual debut; non-use of contraception at first and last sex; number of sexual partners; dating and relationship violence (DRV) victimisation; sexually transmitted infections; pregnancy and unintended pregnancy for girls and initiation of pregnancy for boys using adapted versions of the RIPPLE measures. Ethics review: LSHTM research ethics committee (reference 26411). Completion data: 1/3/25. Sharing statement: Data will be made available after the main trial analyses have been completed on reasonable request from researchers with ethics approval and a clear protocol. Amendments to the protocol will be communicated to the investigators, sponsor, funder, research ethics committee, trial registration and the journal publishing the protocol. Amendments affecting participants' experience of the intervention or important amendments affecting the overall design and conduct of the trial will be communicated to participants.

Adaptation of a gender-transformative sexual and reproductive health intervention for adolescent boys in South Africa and Lesotho using intervention mapping.

Background: Rates of adolescent HIV and unintended pregnancy in southern Africa are amongst the highest in the world. Gender-transformative interventions that address underlying gender inequalities and engage both males and females have been emphasised by the World Health Organisation, amongst others, to target prevention. However, few such gender-transformative interventions have been rigorously developed or evaluated.Objective: To expedite potential impact and reduce development costs, we conducted a needs assessment to inform the co-design, in consultation with local stakeholders, of adapted versions of an existing gender-transformative Relationships and Sexuality Education intervention for use in South Africa and Lesotho.Methods: Adaptation of the intervention was guided by a modified version of Intervention Mapping (IM). This process involved consultation with separate adolescent, community and expert advisory groups and a collaboratively conducted needs assessment, which drew on focus groups with adolescents (8 groups, n = 55) and adults (4 groups, n = 22) in South Africa and Lesotho, and was informed by our systematic review of the literature on the determinants of condom use among adolescents in the region.Results: The findings clarified how the intervention should be adapted, which individual- and environmental-level determinants of condom use to target, and actions for facilitating successful adoption, evaluation and implementation in the new settings.Conclusions: The IM approach allows for a systematic appraisal of whether components and processes of an existing intervention are appropriate for a new target population before costly evaluation studies are conducted. The findings will be of interest to those wishing to rigourously develop and evaluate gender-transformative interventions engaging men to improve health for all.

Adolescent condom use in Southern Africa: narrative systematic review and conceptual model of multilevel barriers and facilitators.

BACKGROUND: Adolescent HIV and pregnancy rates in Southern Africa are amongst the highest in the world. Despite decades of sexual and reproductive health (SRH) programming targeting adolescents, recent trends suggest there is a continued need for interventions targeting condom use for this age group. METHODS: This review synthesises evidence from qualitative studies that describe the determinants of condom use among adolescents in Southern Africa. We conducted systematic searches in four databases. Data were extracted, appraised for quality and analysed using a 'best-fit' framework synthesis approach. RESULTS: We coded deductively findings from 23 original studies using an a priori framework and subsequently conducted thematic analysis. Synthesised findings produced six key themes relating to: 1) pervasive unequal gender norms and restrictive masculinities favouring male sexual decision-making and stigmatising condom use in committed relationships; 2) other social norms reflecting negative constructions of adolescent sexuality and non-traditional family planning; 3) economic and political barriers including poverty and a lack of policy support for condom use; 4) service-level barriers including a lack of youth-friendly SRH services and comprehensive sex education in schools; 5) interpersonal barriers and facilitators including unequal power dynamics in sexual partnerships, peer influences and encouraging condoning condom use, and inadequate communication about SRH from parents/caregivers; and 6) negative attitudes and beliefs about condoms and condom use among adolescents. A conceptual model was generated to describe determinants of condom use, illustrating individual-, interpersonal- and structural-level barriers and facilitating factors. CONCLUSION: SRH programming targeting barriers and facilitators of condom use at multiple levels is recommended in Southern Africa. We present a multilevel integrated model of barriers and facilitators to guide adolescent SRH decision-making, programme planning and evaluation. Given the existence of multilevel barriers and facilitators, interventions should, likewise, take a multilevel approach that incorporates locally relevant understanding of the individual-, interpersonal- and structural-level barriers and facilitators to condom use among adolescents in the region.

Nothing so practical as theory: a rapid review of the use of behaviour change theory in family planning interventions involving men and boys.

BACKGROUND: There is growing recognition of the need for interventions that effectively involve men and boys to promote family planning behaviours. Evidence suggests that the most effective behavioural interventions in this field are founded on theoretical principles of behaviour change and gender equality. However, there are few evidence syntheses on how theoretical approaches are applied in this context that might guide best practice in intervention development. This review addresses this gap by examining the application and reporting of theories of behaviour change used by family planning interventions involving men and boys. METHODS: We adopted a systematic rapid review approach, scoping findings of a previously reported evidence and gap map of intervention reviews (covering 2007-2018) and supplementing this with searches of academic databases and grey literature for reviews and additional studies published between 2007 and 2020. Studies were eligible for inclusion if their title, abstract or keywords referred to a psychosocial or behavioural intervention targeting family planning behaviours, involved males in delivery, and detailed their use of an intervention theory of change. RESULTS: From 941 non-duplicate records identified, 63 were eligible for inclusion. Most records referenced interventions taking place in low- and middle-income countries (65%). There was a range of intervention theories of change reported, typically targeting individual-level behaviours and sometimes comprising several behaviour change theories and strategies. The most commonly identified theories were Social Cognitive Theory, Social Learning Theory, the Theory of Planned Behaviour, and the Information-Motivation-Behaviour Skills (IMB) Model. A minority of records explicitly detailed gender-informed elements within their theory of change. CONCLUSION: Our findings highlight the range of prevailing theories of change used for family planning interventions involving men and boys, and the considerable variability in their reporting. Programmers and policy makers would be best served by unified reporting and testing of intervention theories of change. There remains a need for consistent reporting of these to better understand how complex interventions that seek to involve men and boys in family planning may lead to behaviour change.

Family planning (FP) programmes aim to enable people to achieve their desired family size. Successful programmes are essential for encouraging better health outcomes for individuals and families. Historically, FP programmes have focused on the sexual and reproductive health and rights of women and girls, and while this is necessary, it has also contributed to the exclusion of men and boys from FP programmes. There is growing evidence to suggest, however, that involving men and boys in FP may increase its uptake and improve health outcomes for all. However, we still know relatively little about the best ways to involve men and boys in FP programmes in order to ensure success. Research is ongoing to rectify this.When we look at public health behaviour change programmes in general, we find that many successful programmes incorporate theories of behaviour change into their design. These theories guide the kinds of activities and materials that the programme employs in order to promote behaviour change. In the field of FP, there is little information about the kinds of behaviour change theories that might be used to design programmes. This review aimed to address this by reviewing the global literature on FP programmes that involved men and boys to identify relevant behaviour-change theories. We found a range of theories that will be of use to programme planners. We also found, however, that there was lots of variability in the way theories were reported. We make recommendations for how this problem might be resolved.

Gender-transformative programming with men and boys to improve sexual and reproductive health and rights: a systematic review of intervention studies.

BACKGROUND: Global health organisations advocate gender-transformative programming (which challenges gender inequalities) with men and boys to improve sexual and reproductive health and rights (SRHR) for all. We systematically review evidence for this approach. METHODS: We previously reported an evidence-and-gap map (http://srhr.org/masculinities/wbincome/) and systematic review of reviews of experimental intervention studies engaging men/boys in SRHR, identified through a Campbell Collaboration published protocol (https://doi.org/10.1002/CL2.203) without language restrictions between January 2007 and July 2018. Records for the current review of intervention studies were retrieved from those systematic reviews containing one or more gender-transformative intervention studies engaging men/boys. Data were extracted for intervention studies relating to each of the World Health Organization (WHO) SRHR outcomes. Promising programming characteristics, as well as underused strategies, were analysed with reference to the WHO definition of gender-transformative programming and an established behaviour change model, the COM-B model. Risk of bias was assessed using Cochrane Risk of Bias tools, RoB V.2.0 and Risk of Bias In Non-randomised Studies of Interventions. FINDINGS: From 509 eligible records, we synthesised 68 studies comprising 36 randomised controlled trials, n=56 417 participants, and 32 quasi-experimental studies, n=25 554 participants. Promising programming characteristics include: multicomponent activities of education, persuasion, modelling and enablement; multilevel programming that mobilises wider communities; targeting both men and women; and programmes of longer duration than three months. Six of the seven interventions evaluated more than once show efficacy. However, we identified a significant risk of bias in the overall available evidence. Important gaps in evidence relate to safe abortion and SRHR during disease outbreaks. CONCLUSION: It is widely acknowledged by global organisations that the question is no longer whether to include boys and men in SRHR but how to do so in ways that promote gender equality and health for all and are scientifically rigorous. This paper provides an evidence base to take this agenda for programming and research forward.

Engaging parents in digital sexual and reproductive health education: evidence from the JACK trial.

BACKGROUND: Research evidence and international policy highlight the central role that parents play in promoting positive sexual behaviour and outcomes in their children, however they can be difficult to engage in sexual and reproductive health (SRH) education programmes. Digital health promotion that uses online and mobile technologies (OMTs) to promote parent-child communication may offer an innovative solution to reach parents, however, few programmes have used OMTs to involve parents in SRH, and none have reported lessons learned in relation to optimising engagement. This study addresses this gap in the literature by reporting acceptability and feasibility of using OMTs to engage parents in SRH education. Findings will be relevant for those wishing to develop and implement digital SRH programmes with parents internationally. METHODS: The Jack Trial is a UK-wide cluster randomised controlled trial recruiting over 8000 adolescents from 66 socially and religiously diverse post-primary schools. An embedded mixed-methods process evaluation explored user engagement with parent components of the If I Were Jack SRH education programme, which include online animated films and a parent-teen homework exercise. RESULTS: A total of 109 adolescents, teachers, parents and SRH policy experts took part in semi-structured interviews and focus groups, 134 parents responded to an online survey, and 3179 adolescents completed a programme engagement and satisfaction questionnaire. Parents who accessed the materials were positive about them; 87% rated them as 'good or excellent' and 67% said they helped them have conversations with their child about SRH. Web analytics revealed that 27% of contacted parents accessed the digital materials, with 9% viewing the animated films. Only 38% of teachers implemented the homework exercise, mainly because they assumed that students would not complete it or it might result in backlash from parents. CONCLUSIONS: While digital parental materials show promise for engaging parents in SRH education, this study suggests that in order to optimise engagement, parental components that give parents the necessary skills to have conversations with their children about sex should be coupled with efforts to increase school and teacher confidence to communicate with parents on sensitive topics. TRIAL REGISTRATION: ISRCTN99459996 .

Improving sexual healthcare delivery for men in prison: A nurse-led initiative.

AIMS AND OBJECTIVES: The study aim was to develop and evaluate a nurse-led sexual health service and health promotion intervention for men in prison. BACKGROUND: Men in prison are particularly marginalised members of our society, negatively impacting on their ability to making healthy choices. In relation to sexual health, prison provides an opportunity for curative and preventive care, for an otherwise often hard-to-reach, priority population. DESIGN: Practice development, audit and evaluation. METHODS: Employing a practice development and participatory methodology, we empowered prison nursing staff to provide robust asymptomatic testing for sexually transmitted infections, including the management of chlamydia, with appropriate treatment and partner notification. Collaboratively with young men and nursing staff, a short animation video to promote the service was developed. A case note audit of 172 patients seen in the service during the 6-month period 1 July 2018-31 December 2018 was undertaken. The Standards for Quality Improvement Reporting Excellence (SQUIRE, see Supplementary Material) checklist was followed. RESULTS: National outcome measures were exceeded for some clinical outcomes. During the 6-month period, there were 12 chlamydia-positive (7% positivity rate) and 3 gonorrhoea-positive results. In addition, two new cases of syphilis were detected and a further two cases of known HIV were highlighted. There were seven cases of hepatitis C (3 previously diagnosed) and three cases of hepatitis B. A short animation Dick Loves Doot was developed. CONCLUSION: Successful partnerships between sexual health and prison healthcare services, in partnership with service users, can achieve well-coordinated services and health promotion interventions. RELEVANCE TO CLINICAL PRACTICE: This nurse-led model of care increased detection and early treatment of asymptomatic STIs among men in prison, impacting positively the men, their partner (s) and the public health of the society to which they return.

Immigrant parents' experiences of accessing child healthcare services in a host country: A qualitative thematic synthesis.

AIM: To explore voluntary immigrant parents' experiences of child healthcare services in host countries. DESIGN: Thomas and Harden's qualitative thematic synthesis method. DATA SOURCES: Five electronic databases (CINAHL, Medline, PubMed, Psych INFO and Web of Science), were systematically searched from January 2000 - October 2018. REVIEW METHODS: Included studies focused on voluntary migrant/immigrant parents' experiences of child healthcare services. Data were abstracted independently by two authors. Critical Appraisal Skills Programme tools were applied, and qualitative thematic synthesis was performed. FINDINGS: Nine studies were eligible for inclusion. Five descriptive themes were identified: (a) seeking information and reassurance, (b) seeking information from "people like me", (c) comparison between child healthcare services in home and host countries, (d) effective communication, and (e) cultural isolation and perceived discrimination. Three analytical themes emerged: navigation of parenting in a health context in a new environment; trust; and balance. CONCLUSIONS: Many immigrant families reported positive experiences, others felt patronized and disrespected, leading to a lack of trust and making them less willing to access universal child health care. Trusted advocates, who are culturally competent, have a role in helping immigrant parents navigate the child healthcare system and negotiate with healthcare professionals. Health registration of children of immigrants may encourage the uptake of universal healthcare services. More research is required into the specific health needs of voluntary immigrants. IMPACT: Less is known about the experiences of voluntary immigrants than those of refugees/asylum seekers in accessing child healthcare. Navigating health systems is difficult. This can be due to language difficulties, differences in systems of healthcare, and differences in culture/health beliefs. When both parties have some understanding of the others' healthcare practices and beliefs, balance can be found; helping the families to positively compare healthcare and incentivising them to engage in universal child healthcare.

Young people's sexual readiness: insights gained from comparing a researchers' and youth advisory group's interpretation.

This study explored young people's understandings of sexual readiness and what influenced their decision to initiate first sex. Interviews conducted with 20 heterosexual young people aged 16-18 years, attending sexual health clinics in Northern Ireland, were analysed using a combined approach. This included comparing a researchers and youth advisory group's interpretations of the same data. Thematic analysis enabled comparison to draw out insights across both interpretations. Three themes emerged from each analysis that aligned closely with one another: Mental/Intimate Contact; People/Peer Influences; Self/Socio-Cultural Influences. One additional theme, Adult Control, emerged from the researchers' understanding alone. Results suggest that young people actively deliberate about sex as inevitable and find it difficult to resist the peer and social influences that regulate their lives, with many initiating sex 'to-get-it-over-with'. Gender ideologies and relationship status influenced expectations, motivations and the context surrounding first sex. Sexual readiness was informed by whether first sex was 'good', 'not so good' or 'bad', highlighting the gaps in young people's understanding. Health, law, and education sectors should co-produce interventions with young people to provide relevant and realistic information that explores the effects of gender equality in everyday life on related concepts such as respect, rights, responsibility and resilience.