Barriers to STI testing among youth in a Canadian oil and gas community

Compliance and Self-Reporting During the COVID-19 Pandemic: A Cross-Cultural Study of Trust and Self-Conscious Emotions in the United States, Italy, and South Korea

The coronavirus COVID-19 pandemic is an unprecedented health crisis. Many governments around the world have responded by implementing lockdown measures of various degrees of intensity. To be effective, these measures must rely on citizens' cooperation. In the present study, we drew samples from the United States (N = 597), Italy (N = 606), and South Korea (N = 693) and examined predictors of compliance with social distancing and intentions to report the infection to both authorities and acquaintances. Data were collected between April 6th and 8th 2020. We investigated the role of cultural orientations of horizontal and vertical individualism and collectivism, self-conscious emotions of shame and guilt related to the infection and trust in the government's action. Across all countries, vertical collectivism (VC) predicted stronger shame, whereas horizontal collectivism predicted stronger trust in the government. Only in the United States, VC was associated with stronger trust. Stronger feelings of shame predicted lower compliance and intentions to report the infection to both authorities and acquaintances. In contrast, guilt was associated with stronger intentions to report the infection to the authorities. Finally, trust was associated with stronger compliance and intentions to report the infection to the authorities. Unlike Italy and South Korea, the association between trust on compliance was not statistically significant in the United States, implications of the findings, and directions for future research are discussed.

Application of the COM-B model to barriers and facilitators to chlamydia testing in general practice for young people and primary care practitioners: a systematic review

Background

Chlamydia is a major public health concern, with high economic and social costs. In 2016, there were over 200,000 chlamydia diagnoses made in England. The highest prevalence rates are found among young people. Although annual testing for sexually active young people is recommended, many do not receive testing. General practice is one ideal setting for testing, yet attempts to increase testing in this setting have been disappointing. The Capability, Opportunity, and Motivation Model of Behaviour (COM-B model) may help improve understanding of the underpinnings of chlamydia testing. The aim of this systematic review was to (1) identify barriers and facilitators to chlamydia testing for young people and primary care practitioners in general practice and (2) map facilitators and barriers onto the COM-B model.

Methods

Qualitative, quantitative, and mixed methods studies published after 2000 were included. Seven databases were searched to identify peer-reviewed publications which examined barriers and facilitators to chlamydia testing in general practice. The quality of included studies was assessed using the Critical Appraisal Skills Programme. Data (i.e., participant quotations, theme descriptions, and survey results) regarding study design and key findings were extracted. The data was first analysed using thematic analysis, following this, the resultant factors were mapped onto the COM-B model components. All findings are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Four hundred eleven papers were identified; 39 met the inclusion criteria. Barriers and facilitators were identified at the patient (e.g., knowledge), provider (e.g., time constraints), and service level (e.g., practice nurses). Factors were categorised into the subcomponents of the model: physical capability (e.g., practice nurse involvement), psychological capability (e.g.: lack of knowledge), reflective motivation (e.g., beliefs regarding perceived risk), automatic motivation (e.g., embarrassment and shame), physical opportunity (e.g., time constraints), social opportunity (e.g., stigma).

Conclusions

This systematic review provides a synthesis of the literature which acknowledges factors across multiple levels and components. The COM-B model provided the framework for understanding the complexity of chlamydia testing behaviour. While we cannot at this juncture state which component represents the most salient influence on chlamydia testing, across all three levels, multiple barriers and facilitators were identified relating psychological capability and physical and social opportunity. Implementation should focus on (1) normalisation, (2) communication, (3) infection-specific information, and (4) mode of testing. In order to increase chlamydia testing in general practice, a multifaceted theory- and evidence-based approach is needed.

Trial registration

PROSPERO CRD42016041786

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0821-y) contains supplementary material, which is available to authorized users.

Differences in experiences of barriers to STI testing between clients of the internet-based diagnostic testing service GetCheckedOnline.com and an STI clinic in Vancouver, Canada

OBJECTIVES

Internet-based STI testing programmes may overcome barriers posed by in-clinic testing, though uptake could reflect social gradients. The role these services play in comparison to clinical testing services is unknown. We compared experiences of testing barriers between STI clinic clients to clients of GetCheckedOnline.com (GCO; where clients take a printed lab form to a lab).

METHODS

Our 10-month cross-sectional study was conducted after GCO was promoted to STI clinic clients and men who have sex with men (MSM). Clinic and GCO clients completed an online survey assessing testing barriers and facilitators; responses were compared using bivariate analysis (level of significance P<0.01; significant results below).

RESULTS

Compared with 321 clinic clients, the 73 GCO clients were more likely to be older (median 35 vs 30 years), MSM (45% vs 16%), be testing routinely (67% vs 39%), have delayed testing for any reason (76% vs 54%) and due to clinic distance (28% vs 9%), report delays due to wait times (50% vs 17%), embarrassment with testing (16% vs 6%), discomfort discussing sexual health where they usually go for testing (39% vs 22%), as well as discomfort discussing sexual history with (19% vs 5%) and fearing judgement from (30% vs 15%) any healthcare provider. GCO clients were less likely to have found clinic hours convenient (59% vs 77%) and clinic appointments easy to make (49% vs 66%), and more likely to report long wait times (50% vs 17%). We found no differences in technology skills/use.

CONCLUSIONS

In this urban setting, an internet-based testing service effectively engaged individuals experiencing testing barriers, with few social gradients in uptake. While some testing barriers could be addressed through increasing access to clinical services, others require social and structural changes, highlighting the importance of internet-based STI testing services to increasing test uptake.

Influence of peer support on HIV/STI prevention and safety amongst international migrant sex workers: A qualitative study at the Mexico-Guatemala border

BACKGROUND

Migrant women engaged in precarious employment, such as sex work, frequently face pronounced social isolation alongside other barriers to health and human rights. Although peer support has been identified as a critical HIV and violence prevention intervention for sex workers, little is known about access to peer support or its role in shaping health and social outcomes for migrant sex workers. This article analyses the role of peer support in shaping vulnerability and resilience related to HIV/STI prevention and violence among international migrant sex workers at the Mexico-Guatemala border.

METHODS

This qualitative study is based on 31 semi-structured interviews conducted with international migrant sex workers in the Mexico-Guatemala border communities of Tapachula, Mexico and Tecún Umán and Quetzaltenango, Guatemala.

RESULTS

Peer support was found to be critical for reducing social isolation; improving access to HIV/STI knowledge, prevention and resources; and mitigating workplace violence, particularly at the initial stages of migration and sex work. Peer support was especially critical for countering social isolation, and peers represented a valuable source of HIV/STI prevention knowledge and resources (e.g., condoms), as well as essential safety supports in the workplace. However, challenges to accessing peer support were noted, including difficulties establishing long-lasting relationships and other forms of social participation due to frequent mobility, as well as tensions among peers within some work environments. Variations in access to peer support related to country of work, work environment, sex work and migration stage, and sex work experience were also identified.

CONCLUSIONS

Results indicate that peer-led and community empowerment interventions represent a promising strategy for promoting the health, safety and human rights of migrant sex workers. Tailored community empowerment interventions addressing the unique migration-related contexts and challenges faced by migrant sex workers should be a focus of future community-based research, alongside promotion of broader structural changes.

Facilitators and barriers to chlamydia testing in general practice for young people using a theoretical model (COM-B): a systematic review protocol

INTRODUCTION

Chlamydia is a key health concern with high economic and social costs. There were over 200 000 chlamydia diagnoses made in England in 2015. The burden of chlamydia is greatest among young people where the highest prevalence rates are found. Annual testing for sexually active young people is recommended; however, many of those at risk do not receive testing. General practice has been identified as an ideal setting for testing, yet efforts to increase testing in this setting have not been effective. One theoretical model which may provide insight into the underpinnings of chlamydia testing is the Capability, Opportunity and Motivation Model of Behaviour (COM-B model). The aim of this systematic review is to: (1) identify barriers and facilitators to chlamydia testing for young people in general practice and (2) use a theoretical model to conduct a behavioural analysis of chlamydia testing behaviour.

METHODS AND ANALYSIS

Qualitative, quantitative and mixed methods studies published after 2000 will be included. Seven databases (MEDLINE, PubMed, EMBASE, Informit, PsycInfo, Scopus, Web of Science) will be searched to identify peer-reviewed publications which examined barriers and facilitators to chlamydia testing in general practice. Risk of bias will be assessed using the Critical Appraisal Skills Programme. Data regarding study design and key findings will be extracted. The data will be analysed using thematic analysis and the resultant factors will be mapped onto the COM-B model components. All findings will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required. The results will be disseminated via submission for publication to a peer-review journal when complete and for presentation at national and international conferences. The review findings will be used to inform the development of interventions to facilitate effective and efficient chlamydia testing in general practice.

Get Checked… Where? The Development of a Comprehensive, Integrated Internet-Based Testing Program for Sexually Transmitted and Blood-Borne Infections in British Columbia, Canada

Background

Testing for sexually transmitted and blood-borne infections (STBBI) is an effective public health strategy that can promote personal control of one’s health and prevent the spread of these infections. Multiple barriers deter access to testing including fear of stigmatization, inaccurate health care provider perceptions of risk, and reduced availability of clinic services and infrastructure. Concurrent increases in sexually transmitted infection (STI) rates and demands on existing clinical services make this an even more pressing concern. Web-based testing offers several advantages that may alleviate existing clinical pressures and facilitate appropriate testing access.

Objective

This paper describes the planning, development, and usability testing of a novel Web-based testing service, GetCheckedOnline (GCO), as a complementary testing option integrated within existing sexual health services within British Columbia (BC).

Methods

From 2009 to 2014, we engaged a multidisciplinary team in the design and development of GCO. We conducted 3 initial research studies to ascertain the opinions of youth, men who have sex with men (MSM), and STI clinic clients regarding Web-based testing and elicited perspectives of sexual health care providers through focus groups. We developed an informed consent process, risk assessment questions, and test recommendations based on provincial and national guidelines and evaluated these through consultations with clinical and community stakeholders. We also conducted a preliminary health equity impact assessment whose findings also informed the GCO program mode. Finally, from April 2011 to December 2012 we gathered qualitative data from 25 participants on the functionality and usability of a GCO prototype and incorporated their recommendations into a final model.

Results

GCO launched in the fall of 2014 across 6 pilot sites in Vancouver, BC. The service involves 3 main steps: (1) create an account, complete an assessment, and print a laboratory requisition, (2) provide blood and urine specimens at participating laboratory locations, and (3) receive test results on the Internet or by phone. During this pilot phase, we promoted GCO to existing STI clinic clients and MSM in the Greater Vancouver region. A rigorous mixed-method evaluation of GCO’s uptake, acceptability, and health system impacts is currently underway.

Conclusions

GCO is the first comprehensive Web-based STBBI testing program in Canada that is integrated with existing sexual health services, with the potential to reduce pressures on existing clinical services and reach populations facing the greatest barriers to testing. Our experience highlights the facilitators and challenges of developing and implementing novel complex eHealth interventions within the health care system, and underscores the importance of considering broader implementation contexts.

Integrating gender and sex to unpack trends in sexually transmitted infection surveillance data in British Columbia, Canada: an ethno-epidemiological study

OBJECTIVES

Surveillance data frequently indicate that young men and women experience high-yet considerably different-reported rates of sexually transmitted infections (STIs), including bacterial infections such as chlamydia. We examined how several sex-based (eg, biological) and gender-based (eg, sociocultural) factors may interact to influence STI surveillance data trends.

METHODS

Employing ethno-epidemiological techniques, we analysed cross-sectional qualitative data collected between 2006 and 2013 about young people's experiences accessing STI testing services in five communities in British Columbia, Canada. These data included 250 semistructured interviews with young men and women aged 15-24 years, as well as 39 clinicians who provided STI testing services.

RESULTS

The findings highlight how young women are socially and medically encouraged to regularly test, while young men are rarely offered similar opportunities. Instead, young men tend to seek out testing services: (1) at the beginning or end of a sexual relationship; (2) after a high-risk sexual encounter; (3) after experiencing symptoms; or (4) based on concerns about 'abnormal' sexual anatomy. Our results illustrate how institutions and individuals align with stereotypical gender norms regarding sexual health responsibilities, STI testing and STI treatments. While these patterns reflect social phenomena, they also appear to intersect with sex-based, biological experiences of symptomatology in ways that might help to further explain systematic differences between young men's and women's patterns of testing for STIs.

CONCLUSIONS

The results point to the importance of taking a social and biological view to understanding the factors that contribute to the gap between young men's and women's routine engagement in STI care.

Enhancing the Ethical Conduct of HIV Research with Migrant Sex Workers: Human Rights, Policy, and Social Contextual Influences

BACKGROUND

Migrant sex workers are often highly marginalized and disproportionately experience health and social inequities, including high prevalence of HIV, sexually transmitted infections, and human rights violations. In recent years, research involving migrant sex workers has increased, yet many knowledge gaps remain regarding how best to protect research participant rights and welfare. Our objective was to identify key challenges and opportunities related to the responsible conduct of HIV research with migrant sex workers.

METHODS

Focus groups and interviews conducted with 33 female sex workers ≥18 years old at the Guatemala-Mexico border from June 2013-February 2014 were analyzed. Participants were recruited through community outreach by a local HIV prevention organization to sex work establishments such as bars, hotels, street corners, and truck stops.

RESULTS

Key themes influencing research engagement for migrant sex workers included researcher mistrust and fear related to research participation, rooted in the social isolation frequently faced by recent migrants; intersecting concerns related to immigration status, fear of criminalization, and compliance with sex work regulations; and perceived benefits and risks of HIV/STI testing for migrants (e.g., immigration implications, stigma) represent potential barriers and opportunities for the responsible conduct of research involving migrant sex workers.

CONCLUSIONS

Results highlight the intersection between the human rights vulnerabilities of migrant sex workers and barriers to research participation, including social isolation of migrants and policy/legal barriers related to immigration and sex work. Findings illustrate the need for researchers to develop population-tailored procedures to address fears related to immigration and criminalization, and to reinforce positive and non-stigmatizing relationships with migrant sex workers. Community-led efforts to reduce stigma and foster community organization and supports for migrant sex workers are recommended, as are broader policy shifts that move away from punitive legal approaches towards approaches that safeguard and prioritize the human rights of migrant sex workers.

A validation study of a clinical prediction rule for screening asymptomatic chlamydia and gonorrhoea infections among heterosexuals in British Columbia

BACKGROUND

One component of effective sexually transmitted infections (STIs) control is ensuring those at highest risk of STIs have access to clinical services because terminating transmission in this group will prevent most future cases. Here, we describe the results of a validation study of a clinical prediction rule for identifying individuals at increased risk for chlamydia and gonorrhoea infection derived in Vancouver, British Columbia (BC), against a population of asymptomatic patients attending sexual health clinics in other geographical settings in BC.

METHODS

We examined electronic records (2000-2012) from clinic visits at seven sexual health clinics in geographical locations outside Vancouver. The model's calibration and discrimination were examined by the area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (H-L) statistic, respectively. We also examined the sensitivity and proportion of patients that would need to be screened at different cut-offs of the risk score.

RESULTS

The prevalence of infection was 5.3% (n=10 425) in the geographical validation population. The prediction rule showed good performance in this population (AUC, 0.69; H-L p=0.26). Possible risk scores ranged from -2 to 27. We identified a risk score cut-off point of ≥8 that detected cases with a sensitivity of 86% by screening 63% of the geographical validation population.

CONCLUSIONS

The prediction rule showed good generalisability in STI clinics outside of Vancouver with improved discriminative performance compared with temporal validation. The prediction rule has the potential for augmenting triaging services in STI clinics and enhancing targeted testing in population-based screening programmes.

Complexities of short-term mobility for sex work and migration among sex workers: violence and sexual risks, barriers to care, and enhanced social and economic opportunities

Despite research on the health and safety of mobile and migrant populations in the formal and informal sectors globally, limited information is available regarding the working conditions, health, and safety of sex workers who engage in short-term mobility and migration. The objective of this study was to longitudinally examine work environment, health, and safety experiences linked to short-term mobility/migration (i.e., worked or lived in another city, province, or country) among sex workers in Vancouver, Canada, over a 2.5-year study period (2010-2012). We examined longitudinal correlates of short-term mobility/migration (i.e., worked or lived in another city, province, or country over the 3-year follow-up period) among 646 street and off-street sex workers in a longitudinal community-based study (AESHA). Of 646 sex workers, 10.84 % (n = 70) worked or lived in another city, province, or country during the study. In a multivariate generalized estimating equations (GEE) model, short-term mobility/migration was independently correlated with older age (adjusted odds ratio (AOR) 0.95, 95 % confidence interval (CI) 0.92-0.98), soliciting clients in indoor (in-call) establishments (AOR 2.25, 95 % CI 1.27-3.96), intimate partner condom refusal (AOR 3.00, 1.02-8.84), and barriers to health care (AOR 1.77, 95 % CI 1.08-2.89). In a second multivariate GEE model, short-term mobility for sex work (i.e., worked in another city, province, or country) was correlated with client physical/sexual violence (AOR 1.92, 95 % CI 1.02-3.61). In this study, mobile/migrant sex workers were more likely to be younger, work in indoor sex work establishments, and earn higher income, suggesting that short-term mobility for sex work and migration increase social and economic opportunities. However, mobility and migration also correlated with reduced control over sexual negotiation with intimate partners and reduced health care access, and mobility for sex work was associated with enhanced workplace sexual/physical violence, suggesting that mobility/migration may confer risks through less control over work environment and isolation from health services. Structural and community-led interventions, including policy support to allow for more formal organizing of sex work collectives and access to workplace safety standards, remain critical to supporting health, safety, and access to care for mobile and migrant sex workers.

Potential public health hazards, exposures and health effects from unconventional natural gas development

The rapid increase in unconventional natural gas (UNG) development in the United States during the past decade has brought wells and related infrastructure closer to population centers. This review evaluates risks to public health from chemical and nonchemical stressors associated with UNG, describes likely exposure pathways and potential health effects, and identifies major uncertainties to address with future research. The most important occupational stressors include mortality, exposure to hazardous materials and increased risk of industrial accidents. For communities near development and production sites the major stressors are air pollutants, ground and surface water contamination, truck traffic and noise pollution, accidents and malfunctions, and psychosocial stress associated with community change. Despite broad public concern, no comprehensive population-based studies of the public health effects of UNG operations exist. Major uncertainties are the unknown frequency and duration of human exposure, future extent of development, potential emission control and mitigation strategies, and a paucity of baseline data to enable substantive before and after comparisons for affected populations and environmental media. Overall, the current literature suggests that research needs to address these uncertainties before we can reasonably quantify the likelihood of occurrence or magnitude of adverse health effects associated with UNG production in workers and communities.

Self-collected versus clinician-collected sampling for sexually transmitted infections: a systematic review and meta-analysis protocol

BACKGROUND

Three meta-analyses and one systematic review have been conducted on the question of whether self-collected specimens are as accurate as clinician-collected specimens for STI screening. However, these reviews predate 2007 and did not analyze rectal or pharyngeal collection sites. Currently, there is no consensus on which sampling method is the most effective for the diagnosis of genital chlamydia (CT), gonorrhea (GC) or human papillomavirus (HPV) infection. Our meta-analysis aims to be comprehensive in that it will examine the evidence of whether self-collected vaginal, urine, pharyngeal and rectal specimens provide as accurate a clinical diagnosis as clinician-collected samples (reference standard).

INCLUSION AND EXCLUSION CRITERIA

Eligible studies include both randomized and non-randomized controlled trials, pre- and post-test designs, and controlled observational studies.

SEARCH STRATEGY

The databases that will be searched include the Cochrane Database of Systematic Reviews, Web of Science, Database of Abstracts of Reviews of Effects (DARE), EMBASE and PubMed/Medline.

DATA COLLECTION AND ANALYSIS

Data will be abstracted independently by two reviewers using a standardized pre-tested data abstraction form. Heterogeneity will be assessed using the Q2 test. Sensitivity and specificity estimates with 95% confidence intervals as well as negative and positive likelihood ratios will be pooled and weighted using random effects meta-analysis, if appropriate. A hierarchical summary receiver operating characteristics curve for self-collected specimens will be generated.

DISCUSSION

This synthesis involves a meta-analysis of self-collected samples (urine, vaginal, pharyngeal and rectal swabs) versus clinician-collected samples for the diagnosis of CT, GC and HPV, the most prevalent STIs. Our systematic review will allow patients, clinicians and researchers to determine the diagnostic accuracy of specimens collected by patients compared to those collected by clinicians in the detection of chlamydia, gonorrhea and HPV.

Talk or text to tell? How young adults in Canada and South Africa prefer to receive STI results, counseling, and treatment updates in a wireless world

Young adults often lack access to confidential, long-lasting, and nonjudgmental interactions with sexual health professionals at brick-and-mortar clinics. To ensure that patients return for their STI test results, post-result counseling, and STI-related information, computer-mediated health intervention programming allows them to receive sexual health information through onsite computers, the Internet, and mobile phone calls and text messages. To determine whether young adults (age: M = 21 years) prefer to communicate with health professionals about the status of their sexual health through computer-mediated communication devices, 303 second-year university students (183 from an urban North American university and 120 from a periurban university in South Africa) completed a paper-based survey indicating how they prefer to communicate with doctors and nurses: talking face to face, mobile phone call, text message, Internet chat programs, Facebook, Twitter, or e-mail. Nearly all students, and female students in South Africa in particular, prefer to receive their STI test results, post-results counseling, and STI-related information by talking face to face with doctors and nurses rather than communicating through computers or mobile phones. Results are clarified in relation to gender, availability of various technologies, and prevalence of HIV in Canada and in South Africa.

Advances in sampling and screening for chlamydia

Chlamydia is the most commonly diagnosed bacterial sexually transmitted infection in the developed world, with diagnosis rates continuing to increase each year. As chlamydia is largely asymptomatic, screening and treatment is the main way to detect cases and reduce transmission. Recent advances in self-collected specimens and laboratory tests has made chlamydia screening easier to implement as well as possible in nonclinical settings. This review will discuss new approaches to specimen collection and how these have expanded opportunities for reaching target populations for chlamydia screening. Furthermore, it will discuss how advanced molecular microbiological methods can be used with self-collected specimens to further our knowledge of the epidemiology of chlamydia and the dynamics of transmission.

Young people and health: towards a new conceptual framework for understanding empowerment

In recent times, empowerment has become the focus of much work with young people amidst increasing concerns about their health. Empowerment is often offered as a 'solution' to such concerns, with the uncritical assumption being made that empowerment unproblematically results in positive health outcomes. While much of the health promotion literature advocates 'empowerment', it often does so without offering a clear conceptualisation of the word itself or indeed addressing the thorny theoretical tensions surrounding the concept's root word of power. In light of this omission, this article offers a more theoretically informed conceptualisation of empowerment and considers the relationship to young people's health. This article outlines a more dynamic and generative conceptualisation of empowerment than hitherto articulated in the literature, informed by Lukes' multidimensional perspective of power. Drawing on findings from an ethnographic study on empowerment and young people's health, this article develops six conceptually distinct forms of empowerment (impositional, dispositional, concessional, oppositional, normative and transformative). Data were collected from 55 young men and women aged 15-16 years through group discussions, individual interviews and observational work in a school and surrounding community settings in England. Crucially, these six new forms of empowerment capture and synthesise individual, structural and ideological elements of power that differentially, and sometimes inconsistently, shape the possibilities for young people's empowerment. Of significance is the way in which these different forms of empowerment intersect to (re)produce relations of power and may offer different possibilities for health promotion.

Women on men's sexual health and sexually transmitted infection testing: a gender relations analysis

Sexual health and sexually transmitted infection (STI) testing is typically portrayed as a women's issue amid men's estrangement from healthcare services. While the underreporting of men's STIs has been linked to masculinities, little is known about how women interpret and respond to heterosexual men's sexual health practices. The findings drawn from this qualitative study of 34 young women reveal how femininities can be complicit in sustaining, as well as being critical of and disrupting masculine discourses that affirm sexual pleasure and resistance to health help-seeking as men's patriarchal privileges. Our analysis revealed three patterns: looking after the man's libido refers to women's emphasised femininity whereby the man's preference for unprotected sex and reticence to be tested for STIs was accommodated. Negotiating the stronger sex refers to ambivalent femininities, in which participants strategically resist, cooperate and comply with men's sexual health practices. Rejecting the patriarchal double standard that celebrates men as 'studs' and subordinates women as 'sluts' for embodying similar sexual practices reflects protest femininities. Overall, the findings reveal that conventional heterosexual gender relations, in which hegemonic masculinity is accommodated by women who align to emphasised femininity, continues to direct many participants' expectations around men's sexual health and STI testing.

Masculinities, 'guy talk' and 'manning up': a discourse analysis of how young men talk about sexual health

Sexually transmitted infection testing rates among young men remain low, and their disengagement from sexual health services has been linked to enactments of masculinity that prohibit or truncate discussions of sexual health. Understanding how men align with multiple masculinities is therefore important for tailoring interventions that appropriately respond to their needs. We draw on 32 in-depth interviews with 15-24-year-old men to explore the discourses that facilitate or shut down sexual health communication with peers and sex partners. We employ a critical discourse analysis to explore how men's conversations about sexual health are constituted by masculine hierarchies (such as the ways in which masculinities influence men's ability to construct or challenge and contest dominant discourses about sexual health). Men's conversations about sexual health focused primarily around their sexual encounters - something frequently referred to as 'guy talk'. Also described were situations whereby participants employed a discourse of 'manning up' to (i) exert power over others with disregard for potential repercussions and (ii) deploy power to affirm and reify their own hyper-masculine identities, while using their personal (masculine) power to help others (who are subordinate in the social ordering of men). By better understanding how masculine discourses are employed by men, their sexual health needs can be advanced.

Heteronormativity hurts everyone: experiences of young men and clinicians with sexually transmitted infection/HIV testing in British Columbia, Canada

Heteronormative assumptions can negatively influence the lives of young gay and bisexual men, and recent sociological analyses have identified the negative impacts of heteronormativity on heterosexual men (e.g. 'fag discourse' targeted at heterosexual adolescents). However, insights into how heteronormative discourses may be (re)produced in clinical settings and how they contribute to health outcomes for gay, bisexual and heterosexual men are poorly understood. This analysis draws on in-depth interviews with 45 men (15-25 years old) and 25 clinicians in British Columbia, Canada, to examine how heteronormative discourses affect sexually transmitted infection testing. The sexually transmitted infection/HIV testing experience emerged as a unique situation, whereby men's (hetero)sexuality was explicitly 'interrogated'. Risk assessments discursively linked sexual identity to risk in ways that reinforced gay men as the risky 'other' and heterosexual men as the (hetero)normal and, therefore, relatively low-risk patient. This, in turn, alleviated concern for sexually transmitted infection/HIV exposure in heterosexual men by virtue of their sexual identity (rather than their sexual practices), which muted discussions around their sexual health. The clinicians also positioned sexual identities and practices as important 'clues' for determining their patients' social contexts and supports while concurrently informing particular tailored clinical communication strategies. These findings highlight how men's experiences with sexually transmitted infection/HIV testing can (re)produce heteronormative assumptions and expectations or create opportunities for more equitable gendered relations and discourses.

Young people's perspectives on the use of reverse discourse in web-based sexual-health interventions

Web-based sexual-health promotion efforts often utilise reverse discourse - the acknowledgement and rejection of shame associated with stigmatised terms - both to challenge judgments about 'risky' behaviours (e.g., casual sex) and to appeal to young people. This study examines the use of reverse discourse in Internet-based sexual-health promotion and analyses young people's perspectives on this approach. During in-depth interviews and focus groups with young people (aged 15-24), participants shared their perspectives on written (e.g., clinical language; colloquial language) and visual (e.g., generic, stock images; sexualised images) depictions of sexual-health topics on the websites. More explicit styles elicited negative responses from young people in terms of perceived appeal, trust and quality of websites. Negative social mores were associated with some of the more explicit portrayals of young people's sexual lives on the websites, revealing how reverse discourse re-stigmatises young people by re-emphasising young people's sexual activity as inherently risky or immoral. Reverse discourse was perceived to have negative effects on the saliency and credibility of online sexual-health information. We discuss the theoretical basis for the operationalisation of reverse discourse in this context, and discuss the importance of considering sociotechnical aspects of Internet-based sexual-health interventions.

STI service delivery in British Columbia, Canada; providers' views of their services to youth

Background

Little is known about service providers’ knowledge, attitudes, and experiences in relation to the assessment, diagnosis, and treatment of individuals seeking care for sexually transmitted infections (STIs), and how they influence the delivery of services. The purpose of this study was to explore the perceptions of STI care providers and the ways they approached their practice.

Methods

We used a qualitative approach drawing on methods used in thematic analysis. Individual semi-structured in-depth interviews were conducted with 21 service providers delivering STI services in youth clinics, STI clinics, reproductive health clinics, and community public health units in British Columbia (BC), Canada.

Results

Service providers’ descriptions of their activities and roles were shaped by a number of themes including specialization, scarcity, and maintaining the status quo. The analysis suggests that service providers perceive, at times, the delivery of STI care to be inefficient and inadequate.

Conclusion

Findings from this study identify deficits in the delivery of STI services in BC. To understand these deficits, more research is needed to examine the larger health care structure within which service providers work, and how this structure not only informs and influences the delivery of services, but also how particular structural barriers impinge on and/or restrict practice.

Online sexual health services: examining youth's perspectives

OBJECTIVES

Sexually transmitted infections (STIs) are high and rising in British Columbia, Canada, and youth ages 15-24 account for a disproportionate amount of the infections. As a result, new public health interventions have increasingly turned towards media such as the internet to reach youth populations at risk for STIs/HIV. We describe youth's perceptions about online sexual health services.

METHODS

We used data from in-depth, semi-structured interviews with 38 men and 14 women between the ages of 15 and 24 who discussed: online STI/HIV testing services and online counselling and education services.

RESULTS

In general, youth are familiar with, receptive to and have an affinity for online sexual health services. Youth in the current study suggested that online STI/HIV risk assessment and testing as well as online counselling and education could enhance opportunities for low-threshold service provision. Online services appealed to youth's needs for convenience, privacy, as well as expedient access to testing and/or counselling; however, youth also appear to have relatively low tolerance for technologies that they perceive to be antiquated (e.g., printing lab requisition forms), revealing the challenges of designing online approaches that will not quickly become outdated.

CONCLUSION

Globally, pilot programs for Internet-based sexual health services such as online testing and partner notification have shown promising results. As Canadian interventions of this type emerge, research with youth populations can provide relevant insights to help program planners launch effective interventions.

Disclosure of STI testing activities by young adults: the influence of emotions and social networks

Thirty young adults (between 18 and 29 years of age) who had sought STI testing were interviewed about their experiences of 'passing' during the STI testing process (keeping their testing practices a secret from other individuals), and also their experiences of disclosing to other individuals the fact that they had sought STI testing. Respondents kept their STI testing practices secret from others in order to preserve their identities as 'normal' individuals. They feared that their identities would become stigmatised if other people were to find out about their testing practices. Keeping their practices a secret was difficult and emotionally draining. Consequently, respondents usually chose to inform a few key individuals about their testing activities. These individuals provided respondents with emotional support and helped them to pass as normal. Healthcare professionals were a particular, valued group to whom respondents disclosed their need for STI testing. A number of respondents reported experiencing stigmatising reactions from healthcare professionals, however, which had deleterious consequences for these respondents' willingness to seek treatment for their STI. Findings are discussed in relation to Goffman's impression management framework (1959, 1963) and develop Goffman's work by highlighting the roles played by emotions and social networks in impression management activities.

Triggers of self-conscious emotions in the sexually transmitted infection testing process

Background

Self-conscious emotions (shame, guilt and embarrassment) are part of many individuals' experiences of seeking STI testing. These emotions can have negative impacts on individuals' interpretations of the STI testing process, their willingness to seek treatment and their willingness to inform sexual partners in light of positive STI diagnoses. Because of these impacts, researchers have called for more work to be completed on the connections between shame, guilt, embarrassment and STI testing. We examine the specific events in the STI testing process that trigger self-conscious emotions in young adults who seek STI testing; and to understand what it is about these events that triggers these emotions.

Semi-structured interviews with 30 adults (21 women, 9 men) in the Republic of Ireland.

Findings

Seven specific triggers of self-conscious emotions were identified. These were: having unprotected sex, associated with the initial reason for seeking STI testing; talking to partners and peers about the intention to seek STI testing; the experience of accessing STI testing facilities and sitting in clinic waiting rooms; negative interactions with healthcare professionals; receiving a positive diagnosis of an STI; having to notify sexual partners in light of a positive STI diagnosis; and accessing healthcare settings for treatment for an STI. Self-conscious emotions were triggered in each case by a perceived threat to respondents' social identities.

Conclusion

There are multiple triggers of self-conscious emotions in the STI testing process, ranging from the initial decision to seek testing, right through to the experience of accessing treatment. The role of self-conscious emotions needs to be considered in each component of service design from health promotion approaches, through facility layout to the training of all professionals involved in the STI testing process.

The correlates of HIV testing and impacts on sexual behavior: evidence from a life history study of young people in Kisumu, Kenya

Background

HIV counseling and testing is considered an important component of HIV prevention and treatment. This paper examines the characteristics of young males and females at the time of first reported HIV test, including the influence of recent sexual partnerships, and investigates how HIV testing and the cumulative number of tests are associated with sexual behaviors within six months of testing.

Methods

The study uses data from a random sample of youth aged 18-24 years living in Kisumu, Kenya, who were interviewed using a 10-year retrospective life history calendar. Cox regression models were used to examine the correlates of the timing of first HIV test. Variance-correction models for unordered repeated events were employed to examine whether having an HIV test in the previous six months and the cumulative number of tests predict unsafe sexual practices in a given month.

Results

Sixty-four percent of females and 55% of males reported at least one HIV test in the last 10 years and 40% of females were pregnant the month of first test. Significant correlates of first HIV test included marital aspirations among non-pregnant females, unprotected sex in the previous six months among pregnant females, and concurrency in the previous six months among males. Having a recent HIV test was associated with a decreased likelihood of unprotected sex among ever-pregnant females, an increased likelihood of unprotected sex and "risky" sexual partnerships among never-pregnant females, and an increased likelihood of concurrency among males. Repeated HIV testing was associated with a lower likelihood of concurrency among males and involvement in "risky" sexual partnerships among males and never-pregnant females.

Conclusions

The high rate of pregnancy at first test suggests that promotion of HIV testing as part of prevention of mother-to-child transmission is gaining success. Further research is warranted to examine how and why behavior change is influenced by client- versus provider-initiated testing. The influence of different sexual partnership variables for males and females suggests that interventions to assess risk and promote testing should be gender- and relationship-specific. The findings also suggest that encouraging repeat or routine testing could potentially increase the uptake of safer sexual behaviors.

A pilot qualitative analysis of the psychosocial factors which drive young people to decline chlamydia testing in the UK: implications for health promotion and screening

The main objectives of this study are to investigate the psychosocial issues for young people who decline chlamydia testing as part of the national chlamydia screening programme in the UK and to consider the implications for future opportunistic screening. Transcripts of qualitative semi-structured interviews were analysed using interpretative phenomenological analysis to identify themes. The study involved 14 young people aged 16–24 years who declined chlamydia tests in non-health-care settings as part of the chlamydia screening programme. The study was conducted in educational settings where chlamydia screening is available. Four interlinked themes were identified: stigmatization of young people with chlamydia and who take a test, the feeling of embarrassment, their perception of risk and their beliefs of what the test involves. These beliefs and feelings were pervasive and negatively affected their personal decisions of having a test. In conclusion, understanding psychosocial cultural phenomena in the context of screening programmes for sexually transmitted infections (STIs) in young people are important for their success. Chlamydia and STIs remain stigmatized; testing is poorly understood and embarrassing for young people, which impacts the poor uptake for opportunistic screening. Strategies are needed to normalize and de-stigmatize chlamydia and the chlamydia test.

'Show me the money': financial incentives increase chlamydia screening rates among tertiary students: a pilot study

Background: We hypothesise that text-messaging and financial incentives would increase tertiary student participation in chlamydia screening. Methods: A cross-sectional study was conducted over two phases on eight tertiary campuses during 2007. During Phase 1 (6 months) study activities were advertised through student organisations and media. Education and screening were offered during a range of student activities. During Phase 2 (4 days) education and screening were offered via text messages. Non-financial incentives were offered during Phase 1 and a $10 cash incentive was offered during Phase 2. Rates of specimens provided by students and the direct costs incurred during each phase were compared. Results: 2786 students attended the 31 activities conducted in Phase 1. Of these, 627 students (22.5%) provided urine specimens for chlamydia testing. During Phase 2, the dissemination of 866 text messages resulted in urine specimens from 392 students (45.3%). Costs per test were AUD $175.11 in Phase 1 and AUD $27.13 in Phase 2. Conclusions: Compared with more labour intensive (and therefore more expensive) screening activities conducted over a 6-month period, offering a small financial incentive to tertiary students through text messaging over a 4-day period significantly increased participation in on-campus chlamydia screening. This model could readily be applied to other populations to increase participation in chlamydia screening.

'Not the swab!' Young men's experiences with STI testing

In Canada, STI rates are high and rising, especially amongst young men. Meanwhile, the needs of young men regarding STI testing services are poorly understood, as are the socio-cultural and structural factors that influence young men's sexual health-seeking behaviours. To better understand this phenomenon, we draw on interviews with 45 men (ages 15-25) from British Columbia, Canada. Our research reveals how structural forces (e.g. STI testing procedures) interact with socio-cultural factors (e.g. perceptions of masculinities and feminities) to shape young men's experiences with STI testing. STI testing was characterised as both a potentially sexualised experience (e.g. fears of getting an erection during genital examinations), and as a process where young men experience multiple vulnerabilities associated with exposing the male body in clinical service sites. In response, participants drew on dominant ideals of masculinity to reaffirm their predominately hetero-normative gender identities. Despite growing up in an era where sexual health promotion efforts have been undertaken, participants did not feel they had permission to engage in discussions with other men about sexual health issues. Attending to young men's perspectives on STI testing represents a starting point in reforming our approaches to addressing how socio-cultural and structural factors shape these experiences.