Achieving health equity through conversational AI: A roadmap for design and implementation of inclusive chatbots in healthcare.

BACKGROUND: The rapid evolution of conversational and generative artificial intelligence (AI) has led to the increased deployment of AI tools in healthcare settings. While these conversational AI tools promise efficiency and expanded access to healthcare services, there are growing concerns ethically, practically and in terms of inclusivity. This study aimed to identify activities which reduce bias in conversational AI and make their designs and implementation more equitable. METHODS: A qualitative research approach was employed to develop an analytical framework based on the content analysis of 17 guidelines about AI use in clinical settings. A stakeholder consultation was subsequently conducted with a total of 33 ethnically diverse community members, AI designers, industry experts and relevant health professionals to further develop a roadmap for equitable design and implementation of conversational AI in healthcare. Framework analysis was conducted on the interview data. RESULTS: A 10-stage roadmap was developed to outline activities relevant to equitable conversational AI design and implementation phases: 1) Conception and planning, 2) Diversity and collaboration, 3) Preliminary research, 4) Co-production, 5) Safety measures, 6) Preliminary testing, 7) Healthcare integration, 8) Service evaluation and auditing, 9) Maintenance, and 10) Termination. DISCUSSION: We have made specific recommendations to increase conversational AI's equity as part of healthcare services. These emphasise the importance of a collaborative approach and the involvement of patient groups in navigating the rapid evolution of conversational AI technologies. Further research must assess the impact of recommended activities on chatbots' fairness and their ability to reduce health inequalities.

Women Reporting on Their Use of Pornography: A Qualitative Study Exploring Women's Perceived Precursors and Perceived Outcomes.

The aim of this study was to explore motivations women describe for using pornography. A qualitative online interview study was conducted with 30 women (Mean age 30.23, range 20-47; residing in the UK and in Greece; of varied sexual orientations and relationship status) about their pornography use, motivations for use, and preferences. Reflexive thematic analysis was used. Results were organized into four themes: Sexual Precursors, Non-sexual Precursors, Intended Outcomes, and Unintended Outcomes. The findings highlight that pornography use for women can have both positive and negative ramifications for women's sexual lives. Implications for clinical practice and education are discussed.

Reasons for incomplete STI vaccination among men who have sex with men in an English sexual health service.

BACKGROUND: In England, vaccination for human papillomavirus, hepatitis A, and hepatitis B is recommended for men who have sex with men (MSM). However, uptake is sub-optimal and some men do not complete all recommended vaccine doses. This service evaluation aimed to explore reasons for lack of uptake for each of these vaccines among MSM in one English sexual health service and to inform improvements in service delivery to increase full dose completion rates. METHODS: MSM, ≥18 years, who had previously attended NHS Solent Sexual Health for at least one vaccination, and who had not completed the full dosing regimen for at least one of these vaccines, were invited to participate in an anonymous, online survey between 14/12/2020-11/04/2021. RESULTS: Among 246 MSM (M = 42.1 years), the most common reason for non-vaccination was that participants thought it was unneeded and had not been recommended by a doctor or healthcare provider. None reported vaccine hesitancy. Likewise, the most common reasons for vaccination were doctor/healthcare provider recommendation (51.7-65.6%) and self-protection (60.9-68.1%). The most common reason for not having completed the full course of vaccination was being unaware that the next dose was due (30.0-37.8%). Many participants who had not completed vaccination indicated that a doctor/healthcare provider recommendation would be a motivating factor and that reminder messages and being able to book subsequent appointments in advance would facilitate vaccination. CONCLUSIONS: Sexual health clinicians should be encouraged to discuss STI vaccination with MSM and services should explore possibilities to improve ease and access to vaccine appointments to increase uptake and completion rates.

Sex and Relationships in Later Life: Older Adults' Experiences and Perceptions of Sexual Changes.

The aim of this study was to explore the sexual lives of older adults in the UK to elucidate their experiences of sexual changes and problems, and the role of intimacy and interpersonal support in coping with these changes. We conducted in-depth semi-structured interviews with 31 participants (aged 66-92, mean = 74, 16 women and 15 men), analyzed using reflexive thematic analysis. Our analysis generated three themes: Sexual Changes are "Natural," Sex is the Icing on the Cake, and Maintaining Sexual Connection and Relationship Satisfaction. The participants often rationalized and accepted sexual changes and problems as part of the natural aging process, or as a consequence of other age-related health issues. Sexual activity was seen by many as the "icing on the cake" of a satisfying romantic relationship, built on strong foundations of intimacy, connection, and companionship. Relationship satisfaction and sexual wellbeing can be maintained despite changes to sexual function by retaining a sexual connection through shared experiences, emotional closeness, and support. The findings have important implications for researchers and health providers, and suggest that adopting an "affirmative older age" perspective would be useful for not only future research but also when providing support for older adults with sexual difficulties.

Three-site screening for STIs in men who have sex with men using online self-testing in an English sexual health service.

OBJECTIVES: Among men who have sex with men (MSM) in the UK,Chlamydia trachomatis (CT) and Neisseria gonorrhoea (NG) infections commonly occur asymptomatically at extragenital sites. Therefore, MSM seeking sexual health services are offered three-site (oropharyngeal, rectal and urogenital) STI screening. To increase access to screening, some UK sexual health services enable asymptomatic service users to order free STI screening kits online for self-sampling at home. We sought to assess prevalence of overall and extragenital CT/NG infection among asymptomatic MSM who used online self-testing in Hampshire, UK. METHODS: We assessed prevalence of CT/NG infections from non-pooled samples among asymptomatic cisgender MSM using an administrative database with results from 5601 STI screening kits returned between 20 December 2016 and 31 January 2020. We compared number of diagnoses of extragenital infection with urogenital results of the same individuals to determine prevalence of infection that would have been missed with urine testing alone. RESULTS: Among 5051 valid CT and 5040 valid NG asymptomatic test results, overall prevalence was 5.9% (298/5051) and 4.5% (228/5040), respectively. Among MSM with asymptomatic CT, 71.8% (214/298) had extragenital infection only, χ2 (1, n=298)=56.71, p<0.001. Among those with asymptomatic NG, 89.9% (205/228) had extragenital infection only, χ2 (1, n=228)=145.281, p<0.001. CONCLUSIONS: Overall, most CT/NG infections among asymptomatic MSM who used online self-testing were extragenital. Given this and the likelihood of onward transmission from asymptomatic infection, it is recommended that three-site testing remain standard for MSM and free screening services be expanded in easily accessible ways.

The Role of Mutual Masturbation within Relationships: Associations with Sexual Satisfaction and Sexual Self-Esteem.

Objectives: We explored mutual masturbation among women and men and investigated associations with sexual satisfaction and sexual self-esteem. Methods: 117 women and 151 men (Mage = 29.7 years), mostly heterosexual, all in current relationships, completed an online survey covering experiences of solo and partnered sexual activities, feelings about mutual masturbation, sexual self-esteem, and sexual satisfaction. Results: Mutual masturbation was common among both genders. Men reported significantly higher positive feelings about mutual masturbation than women. Recent mutual masturbation was positively associated with sexual satisfaction but not with sexual self-esteem. Conclusions: These findings have implications for sex and couple therapy and research.

Reducing New Chlamydia Infection Among Young Men by Promoting Correct and Consistent Condom Use: Protocol for a Randomized Controlled Trial.

BACKGROUND: The health, social, and economic costs of sexually transmitted infections (STIs) represent a major public health concern. Young people are considered one of the groups most at risk for acquiring and transmitting STIs. Correct and consistent condom use has been shown to be the most effective method for reducing STIs; however, condoms are often not used properly. Evidence shows that brief behavior change interventions that focus on skills, communication, and motivation to acquire safe sex practices should be adopted into routine care to reduce STIs. Funding for sexual health services in England has declined dramatically, so novel ways of reducing clinic attendance are being sought. The home-based intervention strategy (HIS-UK) to promote condom use among young men has shown promise in feasibility and pilot studies by demonstrating high acceptability of the intervention in participant and health professional feedback, including aiding men to find condoms they like and feel more confident when using condoms. OBJECTIVE: The aim of this study is to determine the effectiveness and cost-effectiveness of HIS-UK when compared to usual condom distribution care among young men. METHODS: The 3 trial arms consisting of "e-HIS" (HIS-UK delivered digitally), "ProHIS" (HIS-UK delivered face-to-face), and control condition (usual National Health Service [NHS] care) will be compared against the following 3 primary outcomes: the extent to which correct and consistent condom use is increased; improvement of condom use experiences (pleasure as well as fit and feel); and decrease in chlamydia test positivity. Eligibility criteria include men aged 16-25 years at risk of STIs through reporting of condom use errors (ie, breakage or slippage) or condomless penile-vaginal or penile-anal intercourse with casual or new sexual partners during the previous 3 months. Prospective participants will be recruited through targeted advertisements and an opportunistic direct approach at selected sexual health and genitourinary medicine services and university-associated health centers and general practitioner practices. Community and educational establishments will be used to further advertise the study and signpost men to recruitment sites. Participants will be randomly allocated to 1 of 3 trial arms. A repeated measures design will assess the parallel arms with baseline and 12 monthly follow-up questionnaires after intervention and 3 chlamydia screening points (baseline, 6, and 12 months). RESULTS: Recruitment commenced in March 2020. Due to the COVID-19 pandemic, the study was halted and has since reopened for recruitment in Summer 2021. A 30-month recruitment period is planned. CONCLUSIONS: If effective and cost-effective, HIS-UK can be scaled up into routine NHS usual care to reduce both STI transmission in young people and pressure on NHS resources. This intervention may further encourage sexual health services to adopt digital technologies, allowing for them to become more widely available to young people while decreasing health inequalities and fear of stigmatization. TRIAL REGISTRATION: ISRCTN Registry ISRCTN11400820; https://www.isrctn.com/ISRCTN11400820.

Exploring structure/property relationships to health and environmental hazards of polymeric polyisocyanate prepolymer substances-2. Dermal sensitization potential in the mouse local lymph node assay.

The sensitization potencies of twenty custom-designed monomer-depleted polymeric polyisocyanate prepolymer substances and their associated toluene diisocyanate (TDI), methylene diphenyl diisocyanate (MDI), hexamethylene diisocyanate (HDI), and isophorone diisocyanate (IPDI) monomer precursors were investigated by means of the mouse Local Lymph Node Assay (LLNA). These polymeric prepolymers were designed to represent the structural features and physical-chemical properties exhibited by a broad range of commercial polymeric polyisocyanate prepolymers that are produced from the reaction of aromatic and aliphatic diisocyanate monomers with aliphatic polyether and polyester polyols. The normalization of LLNA responses to the applied (15-45-135 mM) concentrations showed that the skin sensitization potency of polymeric polyisocyanate prepolymers is at least 300 times less than that of the diisocyanate monomers from which they are derived. The sensitization potency of the prepolymers was shown to be mainly governed by their hydrophobicity (as expressed by the calculated octanol-water partition coefficient, log Kow) and surfactant properties. Neither hydrophilic (log Kow <0) nor very hydrophobic (log Kow >25) prepolymers stimulated lymphocyte proliferation beyond that of the dosing vehicle control. The findings of this investigation challenge the generally held assumption that all isocyanate (-N=C=O) bearing substances are potential skin (and respiratory) sensitizers. Further, these findings can guide the future development of isocyanate chemistries and associated polyurethane applications toward reduced exposure and health hazard potentials.

Using Video Games to Improve the Sexual Health of Young People Aged 15 to 25 Years: Rapid Review.

BACKGROUND: Sexually transmitted infections and unintended pregnancies among young people remain public health concerns in many countries. To date, interventions that address these concerns have had limited success. Serious games are increasingly being used as educational tools in health and professional public education. Although acknowledged as having great potential, few studies have evaluated the use of serious games in sexual health education among young people, and to date, there have been no published reviews of these studies. OBJECTIVE: This study aims to assess the effects of video game-based sexual health interventions for risky sexual behavior in young people aged between 15 and 25 years. METHODS: A rapid review of randomized controlled trials and quasi-randomized controlled trials was performed. The search included the following bibliographic databases: Cochrane Central Register of Controlled Trials, Embase, MEDLINE, PsycINFO, and Scopus. A total of 2 reviewers independently screened 50% (35/70) of the retrieved articles during the full-text screening phase. RESULTS: From a total of 459 identified citations, after removing duplicates, 327 (71.2%) articles were deemed eligible for title and abstract screening. Of the 327 articles, 70 (21.4%) full texts were screened, from which 10 (3.1%) articles (evaluating 11 different games) were included in the review. The findings highlighted the considerable diversity in video game-based interventions and assessed sexual health outcomes. Although there were some promising findings in outcome studies using game-based interventions, the results across studies were mixed. CONCLUSIONS: Although game interventions for sexual health have been in existence for almost three decades, relatively few studies have evaluated them, and the results of previous outcome studies have been mixed. Moreover, there is little clarity regarding which specific elements of a game facilitate positive outcomes. We provide recommendations for future researchers developing video game-based interventions to improve sexual health in young people.

An exploratory test of a couples-based condom-use intervention designed to promote pleasurable and safer penile-vaginal sex among university students.

Objective: Dual use of male condoms and female contraceptives is widely advocated for unplanned pregnancy prevention, yet college students often neglect condoms. This feasibility and acceptability study assessed the efficacy of a self-guided home-based condom-promotion intervention among college students in heterosexual relationships. Participants: Fifty-nine couples who had been together at least 30 days and had penile-vaginal sex at least twice weekly. Methods: Assessments were done at baseline and 6 months later. Outcomes were frequency of condom-unprotected penile-vaginal sex and four psychosocial mediators of condom use. Results: Frequency of unprotected penile-vaginal sex decreased over time. Several corresponding psychosocial mediators showed change, particularly among women. Using actor-partner interdependence modeling, men's increase in condom use was associated with an increase in women's sexual pleasure. Conclusion: Findings support implementation of a brief, self-guided, home-based condom-use intervention that could lower incidence of unplanned pregnancy and STIs among heterosexually active college students.

Prevalence of Masturbation and Associated Factors Among Older Adults in Four European Countries.

Solitary sexual activity is a free, safe, and accessible way to experience sexual pleasure. Despite these advantages, research on masturbation in later life is highly understudied. Using data from a cross-sectional probability-based survey of 3816 European adults (mean age 67 years; range 60-75 years), we explored several sociodemographic, health, attitudinal, and sexual behavioral factors associated with reported masturbation frequency. Across all countries, between 41% and 65% of men and 27% and 40% of women reported any masturbation in the preceding month. Satisfaction with sexual activity and attitudes related to disapproval of sex without love were significant predictors of reported masturbation in almost all countries and in both genders. Age, education, self-perceived health, and depression were for the most part predictive of men's reported masturbation, but not women's. Generally, those believing sex is beneficial to older people were more likely to masturbate, while less permissive attitudes decreased the likelihood of reporting masturbation. To improve healthy sexual aging, misinformation about masturbation and sexual attitudes in older people need to be addressed.

Older adults' embodied experiences of aging and their perceptions of societal stigmas toward sexuality in later life.

RATIONALE: Sexuality is an important part of life for many older adults, and research is beginning to demonstrate the diversity of sexual agency and sexual expression in middle and later life. There is a lack of qualitative research, however, on the lived experiences of older adults concerning this topic. OBJECTIVE: The aim of this study was to explore older adults' embodied experiences and perceptions of aging in relation to sexuality, and whether differences based on gender and/or sexual orientation exist amongst this participant group. METHODS: Thirty-one United Kingdom adults aged 66-92 years (M age 74; 16 women and 15 men) completed in-depth semi-structured interviews; these were analysed using reflexive thematic analysis. RESULTS: Three themes were generated. Changing Body; Media and Society; and "I still feel the same inside." Older adults reported being seen as "past it" and irrelevant, but some saw this as freedom from societal expectations. Health and functional aspects of their bodies were prioritised over aesthetics and "overly glamourous" older celebrities were rejected as appropriate role models. Aging "well" meant resisting decline, but outward appearances did not always align with internal perceptions and experience. Many of our participants had internalised narratives of "successful aging" that centred around retaining youth. CONCLUSIONS: Findings support affirmative aging narratives. Aging as a time of difference without a sense of loss or decline. Implications for how later life is presented in advertising and service provision are discussed.

Feasibility study of the Home-based Exercises for Responsible Sex (HERS) intervention to promote correct and consistent condom use among young women.

BACKGROUND: Male condoms are effective in preventing common sexually transmitted infections (STIs) and unintended pregnancy, if used correctly and consistently. However, condom use errors and problems are common and young people report negative experiences, such as reduced pleasure. The Kinsey Institute Home-Based Exercises for Responsible Sex (KIHERS) is a novel condom promotion intervention for young women, which aims to reduce condom errors and problems, increase self-efficacy and improve attitudes towards condoms, using a pleasure-focussed approach. The study objective was to test the operability, viability and acceptability of an adapted version of the KIHERS intervention with young women aged 16-25 years in the United Kingdom (UK) (Home-Based Exercises for Responsible Sex-UK (HERS-UK). METHODS: A repeated-measures single-arm design was used, with a baseline (T1) and two follow-up assessments (T2 and T3), conducted 4 weeks and 8 weeks post intervention over a 3-month period. Participants were provided a condom kit containing different condoms and lubricants and were asked to experiment with condoms alone using a dildo and/or with a sexual partner. Ten process evaluation interviews were conducted post intervention. RESULTS: Fifty-five young women received the intervention; 36 (65%) completed T2 and 33 (60%) completed T3. Condom use errors and problems decreased, self-efficacy increased and attitudes towards condoms improved significantly. The proportion of participants who reported using a condom for intercourse in the past 4 weeks increased from T1 (20; 47%) to T2 (27; 87%) and T3 (23; 77%) and using lubricant with a condom for intercourse increased from T1 (6; 30%) to T2 (13; 48%)) and T3 (16; 70%). However, motivation to use condoms did not change. Cronbach's alpha scores indicated good internal consistency of measures used. Qualitative data provided strong evidence for the acceptability of the intervention. CONCLUSIONS: HERS-UK was implemented as intended and the recruitment strategy was successful within a college/university setting. This feasibility study provided an early indication of the potential effectiveness and acceptability of the intervention, and the benefits of using a pleasure-focussed approach with young women. Measures used captured change in outcome variables and were deemed fit for purpose. Future research should explore cost-effectiveness of this intervention, in a large-scale controlled trial using a diverse sample and targeting young women most at risk of STIs.

Disrupted prevention: condom and contraception access and use among young adults during the initial months of the COVID-19 pandemic. An online survey.

BACKGROUND: The initial response to COVID-19 in the UK involved a rapid contraction of face-to-face sexual and reproductive health (SRH) services and widespread use of remote workarounds. This study sought to illuminate young people's experiences of accessing and using condoms and contraception in the early months of the pandemic. METHODS: We analysed data, including open-text responses, from an online survey conducted in June-July 2020 with a convenience sample of 2005 16-24-year-olds living in Scotland. RESULTS: Among those who used condoms and contraception, one quarter reported that COVID-19 mitigation measures had made a difference to their access or use. Open-text responses revealed a landscape of disrupted prevention, including changes to sexual risk-taking and preventive practices, unwanted contraceptive pathways, unmet need for sexually transmitted infection (STI) testing, and switches from freely provided to commercially sold condoms and contraception. Pandemic-related barriers to accessing free condoms and contraception included: (1) uncertainty about the legitimacy of accessing SRH care and self-censorship of need; (2) confusion about differences between SRH care and advice received from healthcare professionals during the pandemic compared with routine practice; and (3) exacerbation of existing access barriers, alongside reduced social support and resources to navigate SRH care. CONCLUSIONS: Emerging barriers to STI and pregnancy prevention within the context of COVID-19 have the potential to undermine positive SRH practices, and widen inequalities, among young people. As SRH services are restored amid evolving pandemic restrictions, messaging to support navigation of condom and contraception services should be co-created with young people.

Women in Relationships and Their Pornography Use: A Systematic Review and Thematic Synthesis.

A systematic review and thematic synthesis were conducted on the motivations, purposes, and influence of pornography use among women who are in committed relationships. Pornography use was identified as having both positive and negative outcomes for women's sexual and relationship lives. Women watched pornography for diverse reasons: to feel sexually empowered, to enhance sexual arousal, and for masturbation purposes. Shared use of pornography with partners provided variety in sexual activities, could aid communication about sexual issues and helped improve intimacy. Pornography use can help some women feel sexually empowered, relaxed and better able to enjoy their sexual lives.

Acceptability of remote prescribing and postal delivery services for contraceptive pills and treatment of uncomplicated Chlamydia trachomatis.

OBJECTIVES: The digitalisation of sexual and reproductive health (SRH) services offers valuable opportunities to deliver contraceptive pills and chlamydia treatment by post. We aimed to examine the acceptability of remote prescribing and 'medication-by-post' in SRH. STUDY DESIGN: An online survey assessing attitudes towards remote management was distributed in three UK SRH clinics and via an integrated sexually transmitted infection (STI) postal self-sampling service. Logistic regressions were performed to identify potential correlates. RESULTS: There were 1281 participants (74% female and 49% <25 years old). Some 8% of participants reported having received medication via post and 83% were willing to receive chlamydia treatment and contraceptive pills by post. Lower acceptability was observed among participants who were: >45 years old (OR 0.43 (95% CI 0.23-0.81)), screened for STIs less than once annually (OR 0.63 (0.42-0.93)), concerned about confidentiality (OR 0.21 (0.90-0.50)), concerned about absence during delivery (OR 0.09 (0.02-0.32)) or unwilling to provide blood pressure readings (OR 0.22 (0.04-0.97)). Higher acceptability was observed among participants who reported: previously receiving medication by post (OR 4.63 (1.44-14.8)), preference for home delivery over clinic collection (OR 24.1 (11.1-51.9)), preference for home STI testing (OR 10.3 (6.16-17.4)), ability to communicate with health advisors (OR 4.01 (1.03-15.6)) and willingness to: register their real name (OR 3.09 (1.43-10.6)), complete online health questionnaires (OR 3.09 (1.43-10.6)) and use generic contraceptive pills (OR 2.88 (1.21-6.83)). CONCLUSIONS: Postal treatment and entering information online to allow remote prescribing were acceptable methods for SRH services and should be considered alongside medication collection in pharmacies. These methods could be particularly useful for patients facing barriers in accessing SRH. The cost-effectiveness and implementation of these novel methods of service delivery should be further investigated.

A home-practice intervention for increasing condom use among university undergraduates.

The consistently high rate of sexually transmitted infections among people 18-24 years old warrants novel strategies promoting condom use among large segments of this population. Ample opportunity exits to employ such strategies in university settings. This study evaluated a sex-positive, home-practice intervention designed to promote condom use among university undergraduates engaging in penile-vaginal intercourse (PVI). A sample of 29 opposite-sex undergraduate couples, engaging in PVI, was recruited from a large university. After teaching couples about condom use, a health educator helped couples select condoms/lubricants from options comprising various sizes, fits, shapes, textures, and other features. A 30-day 'homework assignment' was made to use these products while reducing condom use errors/problems and enhancing sexual pleasure. A repeated measures design, with a six-month observation period, was used to evaluate the program. Over the six-month period, the mean frequency of condomless PVI decreased from 26.4 to 3.9 times (P < .001). Significant and favorable changes were also found relative to attitudes toward condom use (P = .027) and in condom use self-efficacy (P < .001). Most students completing the follow-up assessment indicated the intervention would favorably impact their future condom use. Findings suggest this intervention program may be important to promoting condom use among university couples engaging in PVI.

What Does Research Tell Us About Women's Experiences, Motives and Perceptions of Masturbation Within a Relationship Context?: A Systematic Review of Qualitative Studies.

This systematic review provides an overview of what qualitative research has revealed about partner-related factors around women's masturbation and explores how these factors relate to women's behavior, perceptions, and motives toward masturbation. Eleven studies were identified and secondary thematic analysis was used for synthesis. Women's perceptions often focus on the (potential) negative influences of masturbation on current or future relationships. Motivations some women reported for masturbating due to partner-related factors were diverse. Findings suggested that some women modify their masturbation behavior when in a relationship. The implications of these findings for sexual health educators and clinicians are discussed.