Qualitative longitudinal research on the experience of implementing Covid-19 prevention in English schools.

Implementation studies rarely examine how health interventions are delivered in emergencies. Informed by May's general theory of implementation (GTI), we undertook qualitative longitudinal research to investigate how schools in England implemented Covid-19-prevention measures and how this evolved over the 2020-2021 school year in a rapidly changing epidemiological and policy context. We conducted 74 semi-structured interviews over two time-points with headteachers, teachers, parents and students across eight primary and secondary schools. School leaders rapidly made sense of government guidance despite many challenges. They developed and disseminated prevention plans to staff, parents and students. As defined by GTI, 'cognitive participation' and 'collective action' to enact handwashing, one-way systems within schools and enhanced cleaning were sustained over time. However, measures such as physical distancing and placing students in separated groups were perceived to conflict with schools' mission to promote student education and wellbeing. Commitment to implement these was initially high during the emergency phase but later fluctuated dependant on perceived risk and local disease epidemiology. They were not considered sustainable in the long term. Adherence to some measures, such as wearing face-coverings, initially considered unworkable, improved as they were routinised. Implementing home-based asymptomatic testing was considered feasible. Formal and informal processes of 'reflexive monitoring' by staff informed improvements in intervention workability and implementation. Leaders also developed skills and confidence, deciding on locally appropriate actions, some of which deviated from official guidance. However, over time, accumulating staff burnout and absence eroded school capacity to collectively enact implementation. Qualitative longitudinal research allowed us to understand how implementation in an emergency involved the above emergent processes. GTI was useful in understanding school implementation processes in a pandemic context but may need adaptation to take into account the changing and sometimes contradictory objectives, time-varying factors and feedback loops that can characterise implementation of health interventions in emergencies.

Engaging early career researchers in a global health research capacity-strengthening programme: a qualitative study.

BACKGROUND: Research capacity-strengthening is recognized as an important component of global health partnership working, and as such merits monitoring and evaluation. Early career researchers are often the recipients of research capacity-strengthening programmes, but there is limited literature regarding their experience. METHODS: We conducted a qualitative study as part of an internal evaluation of the capacity-strengthening programme of the international HERA (HEalthcare Responding to violence and Abuse) research group. Semi-structured interviews were conducted with group members, and thematic analysis was undertaken. RESULTS: Eighteen group members participated; nine of these were early career researchers, and nine were other research team members, including mid-career and senior researchers. Key themes were identified which related to their engagement with and experience of a research capacity-strengthening programme. We explored formal/planned elements of our programme: mentoring and supervision; training and other opportunities; funding and resources. Participants also discussed informal/unplanned elements which acted as important facilitators and/or barriers to engaging with research capacity-strengthening: English language; open relationships and communication; connection and disconnection; and diversity. The sustainability of the programme was also discussed. CONCLUSIONS: Our study gives voice to the early career researcher experience of engaging with a research capacity-strengthening programme in a global health group. We highlight some important elements that have informed adaptations to our programme and may be relevant for consideration by other global health research capacity-strengthening programmes. Our findings contribute to the growing literature and important discussions around research capacity-strengthening and how this relates to the future directions of global health partnership working.

(Not) talking about fertility: the role of digital technologies and health services in helping plan pregnancy. A qualitative study.

AIM: To explore how women and their partners navigate (pre)conception healthcare and the role of Natural Cycles fertility awareness technology in this process. METHODS: In-depth interviews with 24 cisgender women aged 24-43 years who had used Natural Cycles' 'Plan a Pregnancy' mode, and six partners of Natural Cycles users, all cisgender men aged 30-39 years. Participants were recruited via direct messaging in the Natural Cycles app, social media and, for partners, snowball sampling. Purposive sampling was conducted to ensure diversity among participants. Interviews were audio-recorded and transcribed verbatim. An iterative, inductive approach was adopted for thematic data analysis. RESULTS: Natural Cycles helped most users better understand their menstrual cycles and fertility. Fertility awareness and preconception counselling with healthcare providers were uncommon. Women felt discussions about planning pregnancy in healthcare settings were often fraught with difficulties. They described not wanting to be an extra burden to overworked staff, being concerned that their worries about trying for pregnancy would be dismissed, or feeling staff did not have expertise in fertility awareness. Some women had shared their Natural Cycles data with healthcare professionals to demonstrate their menstrual cycle data or time of conception. However, it was not always clear to those not accessing services when they should seek further advice, for example, those using the app for longer time periods who had not yet conceived. CONCLUSIONS: Digital technologies can provide information and support for those wanting to conceive. They should, however, complement care in statutory services, and be accompanied by greater investment in fertility awareness and preconception support.

Co-production of two whole-school sexual health interventions for English secondary schools: positive choices and project respect.

BACKGROUND: Whole-school interventions represent promising approaches to promoting adolescent sexual health, but they have not been rigorously trialled in the UK and it is unclear if such interventions are feasible for delivery in English secondary schools. The importance of involving intended beneficiaries, implementers and other key stakeholders in the co-production of such complex interventions prior to costly implementation and evaluation studies is widely recognised. However, practical accounts of such processes remain scarce. We report on co-production with specialist providers, students, school staff, and other practice and policy professionals of two new whole-school sexual heath interventions for implementation in English secondary schools. METHODS: Formative qualitative inquiry involving 75 students aged 13-15 and 23 school staff. A group of young people trained to advise on public health research were consulted on three occasions. Twenty-three practitioners and policy-makers shared their views at a stakeholder event. Detailed written summaries of workshops and events were prepared and key themes identified to inform the design of each intervention. RESULTS: Data confirmed acceptability of addressing unintended teenage pregnancy, sexual health and dating and relationships violence via multi-component whole-school interventions and of curriculum delivery by teachers (providing appropriate teacher selection). The need to enable flexibility for the timetabling of lessons and mode of parent communication; ensure content reflected the reality of young people's lives; and develop prescriptive teaching materials and robust school engagement strategies to reflect shrinking capacity for schools to implement public-health interventions were also highlighted and informed intervention refinements. Our research further points to some of the challenges and tensions involved in co-production where stakeholder capacity may be limited or their input may conflict with the logic of interventions or what is practicable within the constraints of a trial. CONCLUSIONS: Multi-component, whole-school approaches to addressing sexual health that involve teacher delivered curriculum may be feasible for implementation in English secondary schools. They must be adaptable to individual school settings; involve careful teacher selection; limit additional burden on staff; and accurately reflect the realities of young people's lives. Co-production can reduce research waste and may be particularly useful for developing complex interventions, like whole-school sexual health interventions, that must be adaptable to varying institutional contexts and address needs that change rapidly. When co-producing, potential limitations in relation to the representativeness of participants, the 'depth' of engagement necessary as well as the burden on participants and how they will be recompensed must be carefully considered. Having well-defined, transparent procedures for incorporating stakeholder input from the outset are also essential. Formal feasibility testing of both co-produced interventions in English secondary schools via cluster RCT is warranted. TRIAL REGISTRATION: Project Respect: ISRCTN12524938 . Positive Choices: ISRCTN65324176.

Fertility and digital technology: narratives of using smartphone app 'Natural Cycles' while trying to conceive.

Fertility awareness apps, which help to identify the 'fertile window' when conception is most likely, have been hailed as 'revolutionising' women's reproductive health. Despite rapidly growing popularity, little research has explored how people use these apps when trying to conceive and what these apps mean to them. We draw on in-depth, qualitative interviews, adopting a critical digital health studies lens (a sub-field of science and technology studies), to explore the experiences of cisgender women and partners with one such app, Natural Cycles, in the context of their daily lives. We found that many women valued the technology as a 'natural', inobtrusive alternative to biomedical intervention, and a means of controlling and knowing their bodies, amid a dearth of fertility-related education and care. Yet this technology also intervened materially and affectively into the spaces of their lives and relationships and privileged disembodied metrics (temperature) over embodied knowledge. Meanwhile, app language, advertising and cost have contributed to characterising 'typical' users as white, heterosexual, affluent, cisgender women without disabilities. In the context of neoliberal shifts towards bodily self-tracking, technologies appealing as novel, liberating and 'natural' to individuals who can access them may nevertheless reproduce highly gendered reproductive responsibilities, anxieties and broader health and social inequalities.

Comparing the effects of HIV self-testing to standard HIV testing for key populations: a systematic review and meta-analysis.

BACKGROUND: We update a previous systematic review to inform new World Health Organization HIV self-testing (HIVST) recommendations. We compared the effects of HIVST to standard HIV testing services to understand which service delivery models are effective for key populations. METHODS: We did a systematic review of randomised controlled trials (RCTs) which compared HIVST to standard HIV testing in key populations, published from 1 January 2006 to 4 June 2019 in PubMed, Embase, Global Index Medicus, Social Policy and Practice, PsycINFO, Health Management Information Consortium, EBSCO CINAHL Plus, Cochrane Library and Web of Science. We extracted study characteristic and outcome data and conducted risk of bias assessments using the Cochrane ROB tool version 1. Random effects meta-analyses were conducted, and pooled effect estimates were assessed along with other evidence characteristics to determine the overall strength of the evidence using GRADE methodology. RESULTS: After screening 5909 titles and abstracts, we identified 10 RCTs which reported on testing outcomes. These included 9679 participants, of whom 5486 were men who have sex with men (MSM), 72 were trans people and 4121 were female sex workers. Service delivery models included facility-based, online/mail and peer distribution. Support components were highly diverse and ranged from helplines to training and supervision. HIVST increased testing uptake by 1.45 times (RR=1.45 95% CI 1.20, 1.75). For MSM and small numbers of trans people, HIVST increased the mean number of HIV tests by 2.56 over follow-up (mean difference = 2.56; 95% CI 1.24, 3.88). There was no difference between HIVST and SoC in regard to positivity among tested overall (RR = 0.91; 95% CI 0.73, 1.15); in sensitivity analysis of positivity among randomised HIVST identified significantly more HIV infections among MSM and trans people (RR = 2.21; 95% CI 1.20, 4.08) and in online/mail distribution systems (RR = 2.21; 95% CI 1.14, 4.32). Yield of positive results in FSW was not significantly different between HIVST and SoC. HIVST reduced linkage to care by 17% compared to SoC overall (RR = 0.83; 95% CI 0.74, 0.92). Impacts on STI testing were mixed; two RCTs showed no decreases in STI testing while one showed significantly lower STI testing in the intervention arm. There were no negative impacts on condom use (RR = 0.95; 95% CI 0.83, 1.08), and social harm was very rare. CONCLUSIONS: HIVST is safe and increases testing uptake and frequency as well as yield of positive results for MSM and trans people without negative effects on linkage to HIV care, STI testing, condom use or social harm. Testing uptake was increased for FSW, yield of positive results were not and linkage to HIV care was worse. Strategies to improve linkage to care outcomes for both groups are crucial for effective roll-out.