NIHR Signal Video or Facebook pages describing normality seem to reduce sexually transmitted infections in youth

Published on 25 October 2016

Brief interventions of up to 30 mins that focus on what is normal healthy behaviour and include video or new media, may help reduce sexually transmitted infections in youth under 25. The rates of infections such as HIV and chlamydia fell in some examples. The uptake of testing improved and self-reported risky behaviour reduced in this review of programmes for young people. Another analysis looked at similar short counselling interventions for men who have sex with men.

Effective interventions tended to use videos and new media such as a Facebook page where “expectations for a healthy relationship” could be discussed. Some interventions ran alongside one-to-one counselling. This review is based on a small number of interventions and was unable to pool the size of effects to get an average. So further detailed analysis of the 16 that were proven effective is needed before deciding what should or should not be included in future programmes to prevent these infections.

The focus on media channels that young people use and the emphasis on healthy behaviours rather than providing information on risks only are nevertheless useful pointers.

Share your views on the research.

Why was this study needed?

In England there were 434,456 cases of sexually transmitted infections (STIs) in 2015. People under the age of 25 and men who have sex with men are most at risk.

Infections are spread through unprotected sex and genital contact. Common infections include chlamydia and gonorrhoea. Symptoms vary according to the infection and some people do not experience any at all. Although most can be treated with antibiotics, if left untreated, they can cause long term damage such as infertility.

Health promotion and education play a vital role in tackling this issue, and it is increasingly recognised that changing behaviour is key. An earlier study showed that brief (30 minutes or less), low intensity approaches for those attending clinics could help reduce infections. Shorter sessions may also be relatively cheap to provide and therefore good value if they work.

The review was designed to identify trials that showed what did or did not work. It looked especially at the question of whether shorter or cheaper digital interventions could work as well as longer one-to-one counselling. The main aim was to help researchers design future programmes.

What did this study do?

This systematic review included 33 randomised controlled trials of brief interventions delivered in a range of settings. All ten trials involving men who have sex with men were based in the USA, as were most aimed at people aged 14 to 25. Only three were set in the UK.

The researchers looked at whether elements such as providing information, condom use skills and behavioural skills training (equipping participants with the component skills they need to change behaviour) affected outcomes.

Trials were of fair to good quality but there was considerable variation between interventions so the results could not be pooled. It was not possible for the impact of delivery format to be clearly separated from the content which limits the ability to know which parts of the programmes were linked to success.

What did it find?

A variety of intervention types and content were effective, and the researchers looked to see if there were any common themes amongst these. Six elements were consistently associated with effectiveness, which were providing information, interpersonal training, STI tests and components that presented the arguments about attitudes, social norms and behavioural skills.

For young people:

  • Reduction in STIs occurred in 2/7 trials of one-to-one counselling, 1/5 trials of a video and 1/3 trials of an STI home-testing kit.
  • STI risk behaviour reduced in 3/6 trials of computer interventions, 3/5 video trials and 1/2 trials using printed materials but 0/7 trials of one to one counselling.

For men who have sex with men:

  • No trials reported a reduction in STIs.
  • STI risk behaviour decreased in 4/6 trials of online interventions and 2/4 trials of one to one counselling.

What does current guidance say on this issue?

NICE 2007 guidance on Sexually transmitted infections and under-18 conceptions: prevention: guidance (PH3) is aimed at primary care.

It states that risk assessment should be carried out at opportune moments. This could be when someone registers or when seeking contraceptive advice. One to one discussions based upon behaviour change theories are also recommended. These should be brief and last between 15 to 20 minutes and address factors such as risk taking.

What are the implications?

This review highlights the difficulty in trying to reduce STIs, but it may provide some useful pointers for those designing brief interventions in an area lacking robust evidence. For example prioritising the positive messages of normal behaviour rather than providing information on risk. Using a variety of different delivery formats including new media, one-to-one counselling, video presentations, digital offline computer software and online web-based interventions were promising. Notably, the inclusion of STI self-sampling increased STI testing in both groups.

Further research to look at quantifying the effects of the interventions and to focus on STIs in men who have sex with men appears warranted.  If designing such programmes here, it is worth bearing in mind that the research reported in this review was often conducted in sexual health clinics and set in the USA.

Citation and Funding

Long L, Abraham C, Paquette R, et al. Brief interventions to prevent sexually transmitted infections suitable for in-service use: A systematic review. Prev Med. 2016;91:364-382.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 12/191/05) and NIHR Leadership in Applied Health Research and Care of the South West Peninsula (PenCLAHRC).

Bibliography

NHS Choices. Sexually transmitted infections. London: Department of Health; 2015.

NICE. Sexually transmitted infections and under-18 conceptions: prevention PH3. London: National Institute for Health and Care Excellence; 2007.

PHE. Sexually transmitted infections and chlamydia screening in England, 2015. London: Public Health England; 2016.

Why was this study needed?

In England there were 434,456 cases of sexually transmitted infections (STIs) in 2015. People under the age of 25 and men who have sex with men are most at risk.

Infections are spread through unprotected sex and genital contact. Common infections include chlamydia and gonorrhoea. Symptoms vary according to the infection and some people do not experience any at all. Although most can be treated with antibiotics, if left untreated, they can cause long term damage such as infertility.

Health promotion and education play a vital role in tackling this issue, and it is increasingly recognised that changing behaviour is key. An earlier study showed that brief (30 minutes or less), low intensity approaches for those attending clinics could help reduce infections. Shorter sessions may also be relatively cheap to provide and therefore good value if they work.

The review was designed to identify trials that showed what did or did not work. It looked especially at the question of whether shorter or cheaper digital interventions could work as well as longer one-to-one counselling. The main aim was to help researchers design future programmes.

What did this study do?

This systematic review included 33 randomised controlled trials of brief interventions delivered in a range of settings. All ten trials involving men who have sex with men were based in the USA, as were most aimed at people aged 14 to 25. Only three were set in the UK.

The researchers looked at whether elements such as providing information, condom use skills and behavioural skills training (equipping participants with the component skills they need to change behaviour) affected outcomes.

Trials were of fair to good quality but there was considerable variation between interventions so the results could not be pooled. It was not possible for the impact of delivery format to be clearly separated from the content which limits the ability to know which parts of the programmes were linked to success.

What did it find?

A variety of intervention types and content were effective, and the researchers looked to see if there were any common themes amongst these. Six elements were consistently associated with effectiveness, which were providing information, interpersonal training, STI tests and components that presented the arguments about attitudes, social norms and behavioural skills.

For young people:

  • Reduction in STIs occurred in 2/7 trials of one-to-one counselling, 1/5 trials of a video and 1/3 trials of an STI home-testing kit.
  • STI risk behaviour reduced in 3/6 trials of computer interventions, 3/5 video trials and 1/2 trials using printed materials but 0/7 trials of one to one counselling.

For men who have sex with men:

  • No trials reported a reduction in STIs.
  • STI risk behaviour decreased in 4/6 trials of online interventions and 2/4 trials of one to one counselling.

What does current guidance say on this issue?

NICE 2007 guidance on Sexually transmitted infections and under-18 conceptions: prevention: guidance (PH3) is aimed at primary care.

It states that risk assessment should be carried out at opportune moments. This could be when someone registers or when seeking contraceptive advice. One to one discussions based upon behaviour change theories are also recommended. These should be brief and last between 15 to 20 minutes and address factors such as risk taking.

What are the implications?

This review highlights the difficulty in trying to reduce STIs, but it may provide some useful pointers for those designing brief interventions in an area lacking robust evidence. For example prioritising the positive messages of normal behaviour rather than providing information on risk. Using a variety of different delivery formats including new media, one-to-one counselling, video presentations, digital offline computer software and online web-based interventions were promising. Notably, the inclusion of STI self-sampling increased STI testing in both groups.

Further research to look at quantifying the effects of the interventions and to focus on STIs in men who have sex with men appears warranted.  If designing such programmes here, it is worth bearing in mind that the research reported in this review was often conducted in sexual health clinics and set in the USA.

Citation and Funding

Long L, Abraham C, Paquette R, et al. Brief interventions to prevent sexually transmitted infections suitable for in-service use: A systematic review. Prev Med. 2016;91:364-382.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 12/191/05) and NIHR Leadership in Applied Health Research and Care of the South West Peninsula (PenCLAHRC).

Bibliography

NHS Choices. Sexually transmitted infections. London: Department of Health; 2015.

NICE. Sexually transmitted infections and under-18 conceptions: prevention PH3. London: National Institute for Health and Care Excellence; 2007.

PHE. Sexually transmitted infections and chlamydia screening in England, 2015. London: Public Health England; 2016.

Brief interventions to prevent sexually transmitted infections suitable for in-service use: A systematic review

Published on 5 July 2016

Long, L.,Abraham, C.,Paquette, R.,Shahmanesh, M.,Llewellyn, C.,Townsend, A.,Gilson, R.

Prev Med , 2016

BACKGROUND: Sexually transmitted infections (STIs) are more common in young people and men who have sex with men (MSM) and effective in-service interventions are needed. METHODS: A systematic review of randomized control trials (RCTs) of waiting-room-delivered, self-delivered and brief healthcare-provider-delivered interventions designed to reduce STIs, increase use of home-based STI testing, or reduce STI-risk behaviorwas conducted. Six databases were searched between January 2000 and October 2014. RESULTS: 17,916 articles were screened. 23 RCTs of interventions for young people met our inclusion criteria. Significant STI reductions were found in four RCTs of interventions using brief one-to-one counselling (2 RCTs), video (1 RCT) and a STI home-testing kit (1 RCT). Increase in STI test uptake was found in five studies using video (1 RCT), one-to-one counselling (1 RCT), home test kit (2 RCTs) and a web-based intervention (1 RCT). Reduction in STI-risk behavior was found in seven RCTs of interventions using digital online (web-based) and offline (computer software) (3 RCTs), printed materials (1 RCT) and video (3 RCTs).Ten RCTs of interventions for MSM met our inclusion criteria. Three tested for STI reductions but none found significant differences between intervention and control groups. Increased STI test uptake was found in two studies using brief one-to-one counselling (1 RCT) and an online web-based intervention (1 RCT). Reduction in STI-risk behavior was found in six studies using digital online (web-based) interventions (4 RCTs) and brief one-to-one counselling (2 RCTs). CONCLUSION: A small number of interventions which could be used, or adapted for use, in sexual health clinics were found to be effective in reducing STIs among young people and in promoting self-reported STI-risk behavior change in MSM.

Expert commentary

Changing sexual behaviour to reduce the risk of sexually transmitted infections is difficult. This systematic review of brief interventions provides a very helpful summary of randomised controlled trials which evaluated a variety of approaches including one-to-one counselling, video presentations and online/offline packages. Some of these worked but success was variable and was not clearly linked to specific content or method of delivery. Few of the trials were performed in the UK and their generalisability to the NHS in general, and sexual health clinics in particular, are uncertain but they do provide a firm evidence base to develop future targeted interventions.

Jonathan Ross, Professor of Sexual Health and HIV, Birmingham City University