Social marketing and mass media interventions to increase sexually transmissible infections (STIs) testing among young people: social marketing and visual design component analysis

INTRODUCTION

Globally, sexually transmissible infections (STIs) continue to disproportionately affect young people. Regular STI testing is an important public health strategy but remains low among this age group. Raising awareness of testing is an essential step and requires effective interventions designed for young people. To inform the development of effective interventions that promote STI testing among young people, we conducted a systematic literature review to describe the social marketing and visual design components commonly found in STI testing interventions and explore associations of these components with intervention effectiveness.

METHODS

We used a systemic review methodology to identify peer-reviewed articles that met pre-defined inclusion criteria. Social marketing and visual component analyses were conducted using structured data extraction tools and coding schemes, based on the eight key social marketing principles and 28 descriptive dimensions for visual analysis.

RESULTS

18 studies focusing on 13 separate interventions met the inclusion criteria. Most interventions used photograph-based images, using conventionally attractive actors, positioned centrally and making direct eye contact to engage the viewer. The majority of interventions featured text sparingly and drew on a range of tones (e.g. serious, humorous, positive, reassuring, empowering and informative) and three interventions used sexualised content. Four articles explicitly stated that the interventions was informed by social marketing principles, with two explicitly referencing all eight principles. Around half of the articles reported using a formal theoretical framework, but most were considered to have theoretical constructs implicit in interventions materials. Four articles provided detailed information regarding developmental consumer research or pre-testing. All articles suggested segmentation and development of materials specifically for young people. Explicit consideration of motivation and competition was lacking across all articles. This study found that there were some design elements common to interventions which were considered more effective. High social marketing complexity (where interventions met at least seven of the 11 criteria for complexity) seemed to be associated with more effective interventions.

CONCLUSIONS

Our findings suggest that the incorporation of social marketing principles, could be more important for intervention effectiveness than specific elements of visual design. Effective and systematic use of social marketing principles may help to inform future evidence-informed and theoretically based interventions and should be employed within sexual health improvement efforts.

Methodology of Natsal-COVID Wave 2: A large, quasi-representative, longitudinal survey measuring the impact of COVID-19 on sexual and reproductive health in Britain

Background

The National Surveys of Sexual Attitudes and Lifestyles COVID study (Natsal-COVID) was designed to understand the impact of COVID-19 on Britain's sexual and reproductive health (SRH). Natsal-COVID Wave 1 survey and qualitative follow-up interviews were conducted in 2020. The Wave 2 survey was designed to capture one-year prevalence estimates for key SRH outcomes and measure changes over the first year of the pandemic. We describe the Wave 2 survey methodology and assess the sample representativeness.

Methods

Natsal-COVID Wave 2 was conducted March-April 2021; approximately one year after the start of Britain's first national lockdown. Data were collected using an online web-panel survey administered by Ipsos. The sample comprised a longitudinal sample of Wave 1 participants who had agreed to re-contact plus a sample of participants residing in Britain, aged 18-59, including a boost sample comprising people aged 18-29. Questions covered reproductive health, relationships, sexual behaviour and SRH service use. Quotas and weighting were used to achieve a quasi-representative sample of the British population. Comparisons were made with recent national probability surveys, Natsal-3 (2010-12) and Natsal-COVID Wave 1 to understand bias.

Results

A total of 6,658 individuals completed the survey. In terms of gender, age, ethnicity, and rurality, the weighted Natsal-COVID Wave 2 sample was like the general population. Participants were less likely to be married or to report being in good health than the general population. The longitudinal sample (n=2,098) were broadly like participants who only took part in Wave 1 but were older. Among the sexually active, longitudinal participants were less likely to report multiple sexual partners or a new sexual partner in the past year compared to those who only took part in Wave 1.

Conclusions

Natsal-COVID collected longitudinal, quasi-representative population data to enable evaluation of the population-level impact of COVID-19 on SRH and to inform policy.

Contraceptive use and pregnancy planning in Britain during the first year of the COVID-19 pandemic: findings from a large, quasi-representative survey (Natsal-COVID)

BACKGROUND

Contraceptive services were significantly disrupted during the COVID-19 pandemic in Britain. We investigated contraception-related health inequalities in the first year of the pandemic.

METHODS

Natsal-COVID Wave 2 surveyed 6658 adults aged 18-59 years between March and April 2021, using quotas and weighting to achieve quasi-representativeness. Our analysis included sexually active participants aged 18-44 years, described as female at birth. We analysed contraception use, contraceptive switching due to the pandemic, contraceptive service access, and pregnancy plannedness.

RESULTS

Of 1488 participants, 1619 were at risk of unplanned pregnancy, of whom 54.1% (51.0%-57.1%) reported routinely using effective contraception in the past year. Among all participants, 14.3% (12.5%-16.3%) reported switching or stopping contraception due to the pandemic. 3.2% (2.0%-5.1%) of those using effective methods pre-pandemic switched to less effective methods, while 3.8% (2.5%-5.9%) stopped. 29.3% (26.9%-31.8%) of at-risk participants reported seeking contraceptive services, of whom 16.4% (13.0%-20.4%) reported difficulty accessing services. Clinic closures and cancelled appointments were commonly reported pandemic-related reasons for difficulty accessing services. This unmet need was associated with younger age, diverse sexual identities and anxiety symptoms. Of 199 pregnancies, 6.6% (3.9%-11.1%) scored as 'unplanned'; less planning was associated with younger age, lower social grade and unemployment.

CONCLUSIONS

Just under a third of participants sought contraceptive services during the pandemic and most were successful, indicating resilience and adaptability of service delivery. However, one in six reported an unmet need due to the pandemic. COVID-induced inequalities in service access potentially exacerbated existing reproductive health inequalities. These should be addressed in the post-pandemic period and beyond.

Adolescents' interactive electronic device use, sleep and mental health: a systematic review of prospective studies

Optimal sleep, both in terms of duration and quality, is important for adolescent health. However, young people's sleeping habits have worsened over recent years. Access to and use of interactive electronic devices (e.g., smartphones, tablets, portable gaming devices) and social media have become deep-rooted elements of adolescents' lives and are associated with poor sleep. Additionally, there is evidence of increases in poor mental health and well-being disorders in adolescents; further linked to poor sleep. This review aimed to summarise the longitudinal and experimental evidence of the impact of device use on adolescents' sleep and subsequent mental health. Nine electronic bibliographical databases were searched for this narrative systematic review in October 2022. Of 5779 identified unique records, 28 studies were selected for inclusion. A total of 26 studies examined the direct link between device use and sleep outcomes, and four reported the indirect link between device use and mental health, with sleep as a mediator. The methodological quality of the studies was generally poor. Results demonstrated that adverse implications of device use (i.e., overuse, problematic use, telepressure, and cyber-victimisation) impacted sleep quality and duration; however, relationships with other types of device use were unclear. A small but consistent body of evidence showed sleep mediates the relationship between device use and mental health and well-being in adolescents. Increasing our understanding of the complexities of device use, sleep, and mental health in adolescents are important contributions to the development of future interventions and guidelines to prevent or increase resilience to cyber-bullying and ensure adequate sleep.

Sexual and reproductive health in Britain during the first year of the COVID-19 pandemic: cross-sectional population survey (Natsal-COVID-Wave 2) and national surveillance data

OBJECTIVES

To assess sexual behaviour, and sexual and reproductive health (SRH) outcomes, after 1 year of the COVID-19 pandemic in Britain.

METHODS

6658 participants aged 18-59 and resident in Britain completed a cross-sectional web-panel survey (Natsal-COVID-Wave 2, March-April 2021), 1 year after the first lockdown. Natsal-COVID-2 follows the Natsal-COVID-Wave 1 survey (July-August 2020) which captured impacts in the initial months. Quota-based sampling and weighting resulted in a quasi-representative population sample. Data were contextualised with reference to the most recent probability sample population data (Natsal-3; collected 2010-12; 15 162 participants aged 16-74) and national surveillance data on recorded sexually transmitted infection (STI) testing, conceptions, and abortions in England/Wales (2010-2020). The main outcomes were: sexual behaviour; SRH service use; pregnancy, abortion and fertility management; sexual dissatisfaction, distress and difficulties.

RESULTS

In the year from the first lockdown, over two-thirds of participants reported one or more sexual partners (women 71.8%; men 69.9%), while fewer than 20.0% reported a new partner (women 10.4%; men 16.8%). Median occasions of sex per month was two. Compared with 2010-12 (Natsal-3), we found less sexual risk behaviour (lower reporting of multiple partners, new partners, and new condomless partners), including among younger participants and those reporting same-sex behaviour. One in 10 women reported a pregnancy; pregnancies were fewer than in 2010-12 and less likely to be scored as unplanned. 19.3% of women and 22.8% of men were distressed or worried about their sex life, significantly more than in 2010-12. Compared with surveillance trends from 2010 to 2019, we found lower than expected use of STI-related services and HIV testing, lower levels of chlamydia testing, and fewer conceptions and abortions.

CONCLUSIONS

Our findings are consistent with significant changes in sexual behaviour, SRH, and service uptake in the year following the first lockdown in Britain. These data are foundational to SRH recovery and policy planning.

Initial Impacts of COVID-19 on Sex Life and Relationship Quality in Steady Relationships in Britain: Findings from a Large, Quasi-representative Survey (Natsal-COVID)

Intimate relationships are ubiquitous and exert a strong influence on health. Widespread disruption to them may impact wellbeing at a population level. We investigated the extent to which the first COVID-19 lockdown (March 2020) affected steady relationships in Britain. In total, 6,654 participants aged 18-59 years completed a web-panel survey (July-August 2020). Quasi-representativeness was achieved via quota sampling and weighting. We explored changes in sex life and relationship quality among participants in steady relationships (n = 4,271) by age, gender, and cohabitation status, and examined factors associated with deterioration to a lower-quality relationship. A total of 64.2% of participants were in a steady relationship (of whom 88.9% were cohabiting). A total of 22.1% perceived no change in their sex-life quality, and 59.5% no change in their relationship quality. Among those perceiving change, sex-life quality was more commonly reported to decrease and relationship quality to improve. There was significant variation by age; less often by gender or cohabitation. Overall, 10.6% reported sexual difficulties that started/worsened during lockdown. In total, 6.9% reported deterioration to a "lower quality" relationship, more commonly those: aged 18-24 and aged 35-44; not living with partner (women only); and reporting depression/anxiety and decrease in sex-life quality. In conclusion, intimate relationship quality is yet another way in which COVID-19 has led to divergence in experience.

Impacts of COVID-19 on sexual behaviour in Britain: findings from a large, quasi-representative survey (Natsal-COVID)

OBJECTIVES

Physical restrictions imposed to combat COVID-19 dramatically altered sexual lifestyles but the specific impacts on sexual behaviour are still emerging. We investigated physical and virtual sexual activities, sexual frequency and satisfaction in the 4 months following lockdown in Britain in March 2020 and compared with pre-lockdown.

METHODS

Weighted analyses of web panel survey data collected July/August 2020 from a quota-based sample of 6654 people aged 18-59 years in Britain. Multivariable regression took account of participants' opportunity for partnered sex, gender and age, to examine their independent associations with perceived changes in sexual frequency and satisfaction.

RESULTS

Most participants (86.7%) reported some form of sex following lockdown with physical activities more commonly reported than virtual activities (83.7% vs 52.6%). Altogether, 63.2% reported sex with someone ('partnered sex') since lockdown, three-quarters of whom were in steady cohabiting relationships. With decreasing relationship formality, partnered sex was less frequently reported, while masturbation, sex toy use and virtual activities were more frequently reported. Around half of all participants perceived no change in partnered sex frequency compared with the 3 months pre-lockdown, but this was only one-third among those not cohabiting, who were more likely to report increases in non-partnered activities than those cohabiting. Two-thirds of participants perceived no change in sexual satisfaction; declines were more common among those not cohabiting. Relationship informality and younger age were independently associated with perceiving change, often declines, in sexual frequency and satisfaction.

CONCLUSIONS

Our quasi-representative study of the British population found a substantial minority reported significant shifts in sexual repertoires, frequency and satisfaction following the introduction of COVID-19 restrictions. However, these negative changes were perceived by some more than others; predominantly those not cohabiting and the young. As these groups are most likely to experience adverse sexual health, it is important to monitor behaviour as restrictions ease to understand the longer term consequences, including for health services.

How did the COVID-19 pandemic affect access to condoms, chlamydia and HIV testing, and cervical cancer screening at a population level in Britain? (Natsal-COVID)

OBJECTIVES

To investigate how differential access to key interventions to reduce STIs, HIV and their sequelae changed during the COVID-19 pandemic.

METHODS

British participants (18-59 years) completed a cross-sectional web survey 1 year (March-April 2021) after the initial lockdown in Britain. Quota-based sampling and weighting resulted in a quasi-representative population sample. We compared Natsal-COVID data with Natsal-3, a household-based probability sample cross-sectional survey (16-74 years) conducted in 2010-2012. Reported unmet need for condoms because of the pandemic and uptake of chlamydia testing/HIV testing/cervical cancer screening were analysed among sexually experienced participants (18-44 years) (n=3869, Natsal-COVID; n=8551, Natsal-3). ORs adjusted for age and other potential confounders describe associations with demographic and behavioural factors.

RESULTS

In 2021, 6.9% of women and 16.2% of men reported unmet need for condoms because of the pandemic. This was more likely among participants: aged 18-24 years, of black or black British ethnicity, and reporting same-sex sex (past 5 years) or one or more new relationships (past year). Chlamydia and HIV testing were more commonly reported by younger participants, those reporting condomless sex with new sexual partners and men reporting same-sex partners; a very similar distribution to 10 years previously (Natsal-3). However, there were differences during the pandemic, including stronger associations with chlamydia testing for men reporting same-sex partners; with HIV testing for women reporting new sexual partners and with cervical screening among smokers.

CONCLUSIONS

Our study suggests differential access to key primary and secondary STI/HIV prevention interventions continued during the first year of the COVID-19 pandemic. However, there was not strong evidence that differential access has changed during the pandemic when compared with 2010-2012. While the pandemic might not have exacerbated inequalities in access to primary and secondary prevention, it is clear that large inequalities persisted, typically among those at greatest STI/HIV risk.

Methodology of Natsal-COVID Wave 1: a large, quasi-representative survey with qualitative follow-up measuring the impact of COVID-19 on sexual and reproductive health in Britain

Background: Britain's National Surveys of Sexual Attitudes and Lifestyles (Natsal) have been undertaken decennially since 1990 and provide a key data source underpinning sexual and reproductive health (SRH) policy. The COVID-19 pandemic disrupted many aspects of sexual lifestyles, triggering an urgent need for population-level data on sexual behaviour, relationships, and service use at a time when gold-standard in-person, household-based surveys with probability sampling were not feasible. We designed the Natsal-COVID study to understand the impact of COVID-19 on the nation's SRH and assessed the sample representativeness. Methods: Natsal-COVID Wave 1 data collection was conducted four months (29/7-10/8/2020) after the announcement of Britain's first national lockdown (23/03/2020). This was an online web-panel survey administered by survey research company, Ipsos MORI. Eligible participants were resident in Britain, aged 18-59 years, and the sample included a boost of those aged 18-29. Questions covered participants' sexual behaviour, relationships, and SRH service use. Quotas and weighting were used to achieve a quasi-representative sample of the British general population. Participants meeting criteria of interest and agreeing to recontact were selected for qualitative follow-up interviews. Comparisons were made with contemporaneous national probability surveys and Natsal-3 (2010-12) to understand bias. Results: 6,654 participants completed the survey and 45 completed follow-up interviews. The weighted Natsal-COVID sample was similar to the general population in terms of gender, age, ethnicity, rurality, and, among sexually-active participants, numbers of sexual partners in the past year. However, the sample was more educated, contained more sexually-inexperienced people, and included more people in poorer health. Conclusions: Natsal-COVID Wave 1 rapidly collected quasi-representative population data to enable evaluation of the early population-level impact of COVID-19 and lockdown measures on SRH in Britain. Although sampling was less representative than the decennial Natsals, Natsal-COVID will complement national surveillance data and Natsal-4 (planned for 2022).

Methodology of Natsal-COVID Wave 1: a large, quasi-representative survey with qualitative follow-up measuring the impact of COVID-19 on sexual and reproductive health in Britain

Background: Britain's National Surveys of Sexual Attitudes and Lifestyles (Natsal) have been undertaken decennially since 1990 and provide a key data source underpinning sexual and reproductive health (SRH) policy. The COVID-19 pandemic disrupted many aspects of sexual lifestyles, triggering an urgent need for population-level data on sexual behaviour, relationships, and service use at a time when gold-standard in-person, household-based surveys with probability sampling were not feasible. We designed the Natsal-COVID study to understand the impact of COVID-19 on the nation's SRH and assessed the sample representativeness. Methods: Natsal-COVID Wave 1 data collection was conducted four months (29/7-10/8/2020) after the announcement of Britain's first national lockdown (23/03/2020). This was an online web-panel survey administered by survey research company, Ipsos MORI. Eligible participants were resident in Britain, aged 18-59 years, and the sample included a boost of those aged 18-29. Questions covered participants' sexual behaviour, relationships, and SRH service use. Quotas and weighting were used to achieve a quasi-representative sample of the British general population. Participants meeting criteria of interest and agreeing to recontact were selected for qualitative follow-up interviews. Comparisons were made with contemporaneous national probability surveys and Natsal-3 (2010-12) to understand bias. Results: 6,654 participants completed the survey and 45 completed follow-up interviews. The weighted Natsal-COVID sample was similar to the general population in terms of gender, age, ethnicity, rurality, and, among sexually-active participants, numbers of sexual partners in the past year. However, the sample was more educated, contained more sexually-inexperienced people, and included more people in poorer health. Conclusions: Natsal-COVID Wave 1 rapidly collected quasi-representative population data to enable evaluation of the early population-level impact of COVID-19 and lockdown measures on SRH in Britain and inform policy. Although sampling was less representative than the decennial Natsals, Natsal-COVID will complement national surveillance data and Natsal-4 (planned for 2022).

Sexual harassment in secondary school: Prevalence and ambiguities. A mixed methods study in Scottish schools

BACKGROUND

Adolescence is characterized by identity formation, exploration and initiation of intimate relationships. Much of this occurs at school, making schools key sites of sexual harassment. Schools often lack awareness and understanding of the issue, and UK research on the topic is scarce. We explored prevalence and perceptions of sexual harassment in a school-based mixed-methods study of 13-17 year-old Scottish adolescents.

METHODS

A student survey (N = 638) assessed past 3-months school-based victimization and perpetration prevalence via 17 behavioral items based on the most commonly used school-based sexual harassment measure ('Hostile Hallways'). Eighteen focus groups (N = 119 students) explored which of 10 behaviors were perceived as harassing/unacceptable and why.

RESULTS

Two-thirds reported any victimization: 64.7% 'visual/verbal' (e.g. sexual jokes) and 34.3% 'contact/personally-invasive' behaviors (e.g. sexual touching; most of whom also reported experiencing visual/verbal types) in the past 3-months. Data suggested a gateway effect, such that contact/personally-invasive behaviors are more likely to be reported by those also reporting more common visual/verbal behaviors. Some survey participants reported being unsure about whether they had experienced certain behaviors; and in focus groups, participants expressed uncertainty regarding the acceptability of most behaviors. Ambiguities centered on behavioral context and enactment including: degree of pressure, persistence and physicality; degree of familiarity between the instigator-recipient; and perception of the instigator's intent. In attempting to resolve ambiguities, students applied normative schemas underpinned by rights (to dignity, respect and equality) and 'knowingness', usually engendered by friendship.

CONCLUSIONS

Our study confirms school-based sexual harassment is common but also finds significant nuance in the ways in which students distinguish between acceptable and harassing. School-based strategies to tackle sexual harassment must engage with this complexity.

Intimate physical contact between people from different households during the COVID-19 pandemic: a mixed-methods study from a large, quasi-representative survey (Natsal-COVID)

OBJECTIVES

Physical distancing as a non-pharmaceutical intervention aims to reduce interactions between people to prevent SARS-CoV-2 transmission. Intimate physical contact outside the household (IPCOH) may expand transmission networks by connecting households. We aimed to explore whether intimacy needs impacted adherence to physical distancing following lockdown in Britain in March 2020.

METHODS

The Natsal-COVID web-panel survey (July-August 2020) used quota-sampling and weighting to achieve a quasi-representative population sample. We estimate reporting of IPCOH with a romantic/sexual partner in the 4 weeks prior to interview, describe the type of contact, identify demographic and behavioural factors associated with IPCOH and present age-adjusted ORs (aORs). Qualitative interviews (n=18) were conducted to understand the context, reasons and decision making around IPCOH.

RESULTS

Of 6654 participants aged 18-59 years, 9.9% (95% CI 9.1% to 10.6%) reported IPCOH. IPCOH was highest in those aged 18-24 (17.7%), identifying as gay or lesbian (19.5%), and in steady non-cohabiting relationships (56.3%). IPCOH was associated with reporting risk behaviours (eg, condomless sex, higher alcohol consumption). IPCOH was less likely among those reporting bad/very bad health (aOR 0.54; 95% CI 0.32 to 0.93) but more likely among those with COVID-19 symptoms and/or diagnosis (aOR 1.34; 95% CI 1.10 to 1.65). Two-thirds (64.4%) of IPCOH was reported as being within a support bubble. Qualitative interviews found that people reporting IPCOH deliberated over, and made efforts to mitigate, the risks.

CONCLUSIONS

Given 90% of people did not report IPCOH, this contact may not be a large additional contributor to SARS-CoV-2 transmission, although heterogeneity exists within the population. Public health messages need to recognise how single people and partners living apart balance sexual intimacy and relationship needs with adherence to control measures.

Initial impacts of the COVID-19 pandemic on sexual and reproductive health service use and unmet need in Britain: findings from a quasi-representative survey (Natsal-COVID)

BACKGROUND

The COVID-19 pandemic has affected sexual and reproductive health (SRH) service use and unmet need, but the impact is unknown. We aimed to determine the proportion of participants reporting sexual risk behaviours, SRH service use and unmet need, and to assess remote sexually transmitted infection (STI) testing service use after the first national lockdown in Britain.

METHODS

We used data from the National Surveys of Sexual Attitudes and Lifestyles (Natsal)-COVID cross-sectional, quasi-representative web survey (Natsal-COVID Wave 1). Adults aged 18-59 years who resided in England, Scotland, or Wales completed the survey between July 29 and Aug 10, 2020, which included questions about the approximate 4-month period after announcement of the initial lockdown in Britain (March 23, 2020). Quota-based sampling and weighting were used to achieve a quasi-representative population sample. Participants aged 45-59 years were excluded from services analysis due to low rates of SRH service use. Among individuals aged 18-44 years, we estimated reported SRH service use and inability to access, and calculated age-adjusted odds ratios (aORs) among sexually experienced individuals (those reporting any sexual partner in their lifetime) and sexually active individuals (those reporting any sexual partner in the past year). Unweighted denominators and weighted estimates are presented hereafter.

FINDINGS

6654 individuals had complete interviews and were included in the analysis. Among 3758 participants aged 18-44 years, 82·0% reported being sexually experienced, and 73·7% reported being sexually active. 20·8% of sexually experienced participants aged 18-44 years reported using SRH services in the 4-month period. Overall, 9·7% of 3108 participants (9·5% of men; 9·9% of women) reported being unable to use a service they needed, although of the participants who reported trying but not being able to use a SRH service at least once, 76·4% of participants also reported an instance of successful use. 5·9% of 1221 sexually active men and 3·6% of 1560 sexually active women reported use of STI-related services and 14·8% of 1728 sexually experienced women reported use of contraceptive services, with SRH service use highest among individuals aged 18-24 years. Sexually active participants reporting condomless sex with new partners since lockdown were much more likely to report using STI-related services than those who did not report condomless sex (aOR 23·8 [95% CI 11·6-48·9]) for men, 10·5 [3·9-28·2] for women) and, among men, were also more likely to have an unsuccessful attempt at STI-service use (aOR 13·3 [5·3-32·9]). Among 106 individuals who reported using STI testing services, 64·4% accessed services remotely (telephone, video, or online). Among 2581 women aged 25-59 years, 2·4% reported cervical screening compared with an estimated 6% in a comparable 4-month period before the pandemic.

INTERPRETATION

Many people accessed SRH care during the initial lockdown; however, young people and those reporting sexual risk behaviours reported difficulties in accessing services and thus such services might need to address a backlog of need.

FUNDING

Wellcome Trust, The Economic and Social Research Council, The National Institute for Health Research, Medical Research Council/Chief Scientist Office and Public Health Sciences Unit, and UCL Coronavirus Response Fund.

Initial impacts of the COVID-19 pandemic on sexual and reproductive health service use and unmet need in Britain: findings from a quasi-representative survey (Natsal-COVID)

BACKGROUND

The COVID-19 pandemic has affected sexual and reproductive health (SRH) service use and unmet need, but the impact is unknown. We aimed to determine the proportion of participants reporting sexual risk behaviours, SRH service use and unmet need, and to assess remote sexually transmitted infection (STI) testing service use after the first national lockdown in Britain.

METHODS

We used data from the National Surveys of Sexual Attitudes and Lifestyles (Natsal)-COVID cross-sectional, quasi-representative web survey (Natsal-COVID Wave 1). Adults aged 18-59 years who resided in England, Scotland, or Wales completed the survey between July 29 and Aug 10, 2020, which included questions about the approximate 4-month period after announcement of the initial lockdown in Britain (March 23, 2020). Quota-based sampling and weighting were used to achieve a quasi-representative population sample. Participants aged 45-59 years were excluded from services analysis due to low rates of SRH service use. Among individuals aged 18-44 years, we estimated reported SRH service use and inability to access, and calculated age-adjusted odds ratios (aORs) among sexually experienced individuals (those reporting any sexual partner in their lifetime) and sexually active individuals (those reporting any sexual partner in the past year). Unweighted denominators and weighted estimates are presented hereafter.

FINDINGS

6654 individuals had complete interviews and were included in the analysis. Among 3758 participants aged 18-44 years, 82·0% reported being sexually experienced, and 73·7% reported being sexually active. 20·8% of sexually experienced participants aged 18-44 years reported using SRH services in the 4-month period. Overall, 9·7% of 3108 participants (9·5% of men; 9·9% of women) reported being unable to use a service they needed, although of the participants who reported trying but not being able to use a SRH service at least once, 76·4% of participants also reported an instance of successful use. 5·9% of 1221 sexually active men and 3·6% of 1560 sexually active women reported use of STI-related services and 14·8% of 1728 sexually experienced women reported use of contraceptive services, with SRH service use highest among individuals aged 18-24 years. Sexually active participants reporting condomless sex with new partners since lockdown were much more likely to report using STI-related services than those who did not report condomless sex (aOR 23·8 [95% CI 11·6-48·9]) for men, 10·5 [3·9-28·2] for women) and, among men, were also more likely to have an unsuccessful attempt at STI-service use (aOR 13·3 [5·3-32·9]). Among 106 individuals who reported using STI testing services, 64·4% accessed services remotely (telephone, video, or online). Among 2581 women aged 25-59 years, 2·4% reported cervical screening compared with an estimated 6% in a comparable 4-month period before the pandemic.

INTERPRETATION

Many people accessed SRH care during the initial lockdown; however, young people and those reporting sexual risk behaviours reported difficulties in accessing services and thus such services might need to address a backlog of need.

FUNDING

Wellcome Trust, The Economic and Social Research Council, The National Institute for Health Research, Medical Research Council/Chief Scientist Office and Public Health Sciences Unit, and UCL Coronavirus Response Fund.

Mental health, potential minority stressors and resilience: evidence from a cross-sectional survey of gay, bisexual and other men who have sex with men within the Celtic nations

BACKGROUND

Gay, bisexual and other men who have sex with men (GBMSM) are at a greater risk of mental health problems, such as anxiety and depression, than heterosexual adults. Numerous factors and stressors have been reported to impact men's mental health, although it has been suggested that resilience could have a protective effect. The aim of this study is to explore mental health, minority stressors, and resilience among a large online cross-sectional survey of GBMSM in the Celtic nations.

METHODS

Data for this cross-sectional study were collected from the Social Media, GBMSM and Sexual and Holistic Health (SMMASH2) self-report online survey. Participants (n = 3077) were recruited via gay sociosexual media in Scotland, Wales, Northern Ireland, and the Republic of Ireland. Binary logistic regression analyses were conducted to identify factors that increased the odds of moderate-to-severe anxiety and depression. Potentially relevant variables (p < 0.05) were carried forward in hierarchal logistic regression analyses.

RESULTS

The prevalence of moderate-to-severe anxiety and depression was 19.9 and 14.4%, respectively. Having a disability (OR = 1.73) and having financial worries sometimes/all of the time (OR = 1.93) increased the odds of having moderate-to-severe depression and anxiety, respectively. No minority stressors were associated with depression, whereas experiencing any form of relationship abuse in the last 12 months significantly increased the odds of anxiety (OR = 1.50). Resilience, namely a sense of coherence, had a protective effect and significantly reduced the odds of moderate-to-severe depression (OR = 0.85) and anxiety (OR = 0.89).

CONCLUSIONS

Disability and financial worries were associated with increased depression and anxiety, respectively, while resilience had a protective effect for GBMSM in the SMMASH2 study. Future research is needed to better understand the role of resilience and the challenges and stresses of everyday life and intersecting health problems. Future research is also needed that incorporates the perspectives of those most affected by mental ill-health to co-develop effective solutions that respond to their contextual surroundings.

COVID-19 pandemic and its impact on social relationships and health

This essay examines key aspects of social relationships that were disrupted by the COVID-19 pandemic. It focuses explicitly on relational mechanisms of health and brings together theory and emerging evidence on the effects of the COVID-19 pandemic to make recommendations for future public health policy and recovery. We first provide an overview of the pandemic in the UK context, outlining the nature of the public health response. We then introduce four distinct domains of social relationships: social networks, social support, social interaction and intimacy, highlighting the mechanisms through which the pandemic and associated public health response drastically altered social interactions in each domain. Throughout the essay, the lens of health inequalities, and perspective of relationships as interconnecting elements in a broader system, is used to explore the varying impact of these disruptions. The essay concludes by providing recommendations for longer term recovery ensuring that the social relational cost of COVID-19 is adequately considered in efforts to rebuild.

A qualitative examination of affect and ideology within mass media interventions to increase HIV testing with gay men garnered from a systematic review

OBJECTIVES

Increasing appropriate HIV testing among men who have sex with men (MSM) is crucial to HIV prevention. Mass media interventions are effective in promoting testing, but to date, there has been little examination of their active content.

DESIGN

We conducted a qualitative analysis of intervention materials (n = 69) derived from a systematic review of mass media interventions designed to improve testing with MSM.

METHODS

Visual data were analysed for their affective and ideological content using a novel method drawing on concepts from semiotics (i.e., broadly speaking, the analysis of signs).

RESULTS

Whilst affect was not explicitly theorized or examined in any of the studies, there are clearly identifiable affective elements implicitly at play in these interventions. Four thematic categories of affect/ideology were identified including (1) sexual desire and the 'pornographication' of the gay/bisexual male subject; (2) narratives of romance and love; (3) fear, threat, and regret; and (4) 'flattened' affect.

CONCLUSIONS

This is the first study to examine and detail the affective and ideological aspects of intervention content in this field. Using analytic techniques such as those reported here, in addition to approaches that focus on the manner in which intervention content address more proximal determinants of behaviour, can provide a rich and potentially more useful evidence base to assist with future interventions.

Mass media and communication interventions to increase HIV testing among gay and other men who have sex with men: Social marketing and visual design component analysis

Mass media and communication interventions can play a role in increasing HIV testing among gay, bisexual and other men who have sex with men (GBMSM). Despite the key role of social marketing principles and visual design within intervention development of this type, evidence is limited regarding interventions’ social marketing mix or visual design. As part of a systematic review, intervention content was assessed using social marketing theory and social semiotics. Data were extracted on the nature of the intervention, mode of delivery, use of imagery, content and tone and the eight key characteristics of social marketing. Data were synthesised narratively. Across the 19 included studies, reference to social marketing principles was often superficial. Common design features were identified across the interventions, regardless of effectiveness, including: the use of actors inferred to be GBMSM; use of ‘naked’ and sexually explicit imagery; and the use of text framed as statements or instructions. Our results suggest that effective interventions tended to use multiple modes of delivery, indicating high social marketing complexity. However, this is only part of intervention development, and social marketing principles are key to driving the development process. We identified consistent aspects of intervention design, but were unable to determine whether this is based on evidence of effectiveness or a lack of originality in intervention design. An openness to novel ideas in design and delivery is key to ensuring that evidence-informed interventions are effective for target populations.

What are mass media interventions made of? Exploring the active content of interventions designed to increase HIV testing in gay men within a systematic review

PURPOSE

Mass media HIV testing interventions are effective in increasing testing, but there has been no examination of their theory or behaviour change technique (BCT) content. Within a heterogeneous body of studies with weak evaluative designs and differing outcomes, we attempted to gain useful knowledge to shape future interventions.

METHODS

Within a systematic review, following repeated requests to the authors of included studies for intervention materials, the Theory Coding Scheme, the Theoretical Domains Framework (TDF), and Behaviour Change Technique Taxonomy (BCTT) were used to extract data relating to active intervention content.

RESULTS

Of 19 studies, five reported an explicit theoretical basis to their intervention. TDF analysis highlighted the key domains employed within the majority of interventions: 'knowledge', 'social roles and identities', and 'beliefs about consequences'. BCT analysis showed three BCT groupings commonly reported within interventions: 'Comparison of outcomes', 'Natural consequences', and 'Shaping knowledge'. Three individual BCTs formed the backbone of most interventions and can be considered 'standard' content: 'Instructions on how to perform behaviour'; 'Credible source'; and 'Information about health consequences'.

CONCLUSIONS

This is the first study to examine and detail active intervention content in this field. It suggests future interventions should improve knowledge about testing, and use well-branded and trusted sources that endorse testing. Future interventions should also provide clear information about the health benefits of testing. Our analysis also suggests that to improve levels of effectiveness characterizing the current field, it may be useful to elicit commitment, and action plans, relating to how to implement testing intentions.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Interventions are urgently needed to increase HIV testing among men who have sex with men (MSM) and enable increased access to effective treatment for HIV infection. There is some evidence of the effectiveness of mass media interventions in increasing HIV testing among MSM. Nothing is known about the active components of existing mass media interventions targeting HIV testing. What does this study add? It describes the available literature concerning evaluated mass media interventions to increase HIV testing. It shows few interventions report any explicit theoretical basis although many interventions share common components, including coherently connected causal mechanisms and behaviour change techniques to moderate them. As a minimum, future interventions should improve knowledge about testing; use well-branded and trusted sources that endorse testing; and provide clear information about the health benefits of testing. Our analysis also tentatively suggests it may be useful to elicit commitment and planning of how to implement testing intentions.

Women's experiences of more than one termination of pregnancy within two years: a mixed-methods study

OBJECTIVE

To examine the experiences of women seeking more than one termination of pregnancy (TOP) within 2 years.

DESIGN

Mixed methods study.

SETTING

Six TOP services across Scotland.

SAMPLE

Women presenting for TOP between July and December 2015.

METHODS

Descriptive and inferential analysis of quantitative survey data, thematic analysis of qualitative interview data and integrative analysis. In quantitative analysis, multinomial logistic regression was used to compare three groups: previous TOP within 2 years, previous TOP beyond 2 years and no previous TOP.

MAIN OUTCOME MEASURES

Characteristics and experiences of women seeking TOP.

RESULTS

Of 1662 questionnaire respondents, 14.6% (n = 242) and 19.8% (n = 329) reported previous TOP within and beyond 2 years, respectively. The previous TOP within 2 years group was significantly less likely to own their accommodation than the no previous TOP group (adjusted odds ratio [aOR] 0.34, 95% CI: 0.18-0.62) and previous TOP beyond 2 years group (aOR: 0.44, 95% CI: 0.23-0.85); and more likely to report inconsistent (aOR: 1.63, 95% CI: 1.04-2.57; aOR: 1.95, 95% CI: 1.16-3.28) and consistent (aOR: 2.13, 95% CI: 1.39-3.26; aOR: 1.71, 95% CI: 1.07-2.76) contraceptive use than the no previous TOP and previous TOP within 2 years groups, respectively. Twenty-three women from the previous TOP within 2 years group were interviewed. Qualitative and integrative analyses highlight issues relating to contraceptive challenges, intimate partner violence, life aspirations and socio-economic disadvantage.

CONCLUSIONS

Women undergoing more than one TOP within 2 years may experience particular challenges and vulnerabilities. Service provision should recognise this and move away from stigmatising discourses of 'repeat abortion'.

FUNDING

Scottish Government.

TWEETABLE ABSTRACT

Women having two or more terminations of pregnancy in 2 years may face key challenges/vulnerabilities including intimate partner violence and socio-economic disadvantage.

Preparedness for use of the rapid result HIV self-test by gay men and other men who have sex with men (MSM): a mixed methods exploratory study among MSM and those involved in HIV prevention and care

Objectives

The aim of the study was to explore preparedness for the HIV self‐test among men who have sex with men (MSM) and those involved in HIV prevention and care.

Methods

A mixed methods exploratory research design was employed, detailing awareness and willingness to use the self‐test and the perceived barriers and facilitators to implementation. Quantitative and qualitative data collection and analysis were completed in parallel. Descriptive and inferential analysis of cross‐sectional bar‐based survey data collected from MSM through a self‐completed questionnaire and oral fluid specimen collection (n = 999) was combined with qualitative, thematic, analysis of data collected through 12 expert focus groups (n = 55) consisting of gay men, National Health Service (NHS) staff, community organizations, entrepreneurs and activists. Findings were subsequently combined and assessed for synergies.

Results

Among MSM, self‐test awareness was moderate (55%). Greater awareness was associated with increased educational attainment [adjusted odds ratio 1.51; 95% confidence interval (CI) 1.00–2.30; P = 0.05] and previous history of sexually transmitted infection (STI) testing (adjusted odds ratio 1.63; 95% CI 1.11–2.39; P = 0.01). Willingness to use the test was high (89%) and associated with meeting sexual partners online (unadjusted odds ratio 1.96; 95% CI 1.31–2.94; P < 0.001). Experts highlighted the overall acceptability of self‐testing; it was understood as convenient, discreet, accessible, and with a low burden to services. However, some ambivalence towards self‐testing was reported; it could reduce opportunities to engage with wider services, wider health issues and the determinants of risk.

Conclusions

Self‐testing represents an opportunity to reduce barriers to HIV testing and enhance prevention and access to care. Levels of awareness are moderate but willingness to use is high. Self‐testing may amplify health inequalities.

Frequency of HIV testing among gay and bisexual men in the UK: implications for HIV prevention

Objectives

The aim of the study was to explore HIV testing frequency among UK men who have sex with men (MSM) in order to direct intervention development.

Methods

Cross‐sectional surveys were completed by 2409 MSM in Edinburgh, Glasgow and London in 2011 and a Scotland‐wide online survey was carried out in 2012/13. The frequency of HIV testing in the last 2 years was measured.

Results

Overall, 21.2% of respondents reported at least four HIV tests and 33.7% reported two or three tests in the last 2 years, so we estimate that 54.9% test annually. Men reporting at least four HIV tests were younger and less likely to be surveyed in London. They were more likely to report higher numbers of sexual and anal intercourse partners, but not “higher risk” unprotected anal intercourse (UAI) with at least two partners, casual partners and/or unknown/discordant status partners in the previous 12 months. Only 26.7% (238 of 893) of men reporting higher risk UAI reported at least four tests. Among all testers (n = 2009), 56.7% tested as part of a regular sexual health check and 35.5% tested following a risk event. Differences were observed between surveys, and those testing in response to a risk event were more likely to report higher risk UAI.

Conclusions

Guidelines recommend that all MSM test annually and those at “higher risk” test more frequently, but our findings suggest neither recommendation is being met. Additional efforts are required to increase testing frequency and harness the opportunities provided by biomedical HIV prevention. Regional, demographic and behavioural differences and variations in the risk profiles of testers suggest that it is unlikely that a “one size fits all” approach to increasing the frequency of testing will be successful.

Men who have sex with men in Great Britain: comparing methods and estimates from probability and convenience sample surveys

Objective

To examine sociodemographic and behavioural differences between men who have sex with men (MSM) participating in recent UK convenience surveys and a national probability sample survey.

Methods

We compared 148 MSM aged 18–64 years interviewed for Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) undertaken in 2010–2012, with men in the same age range participating in contemporaneous convenience surveys of MSM: 15 500 British resident men in the European MSM Internet Survey (EMIS); 797 in the London Gay Men's Sexual Health Survey; and 1234 in Scotland's Gay Men's Sexual Health Survey. Analyses compared men reporting at least one male sexual partner (past year) on similarly worded questions and multivariable analyses accounted for sociodemographic differences between the surveys.

Results

MSM in convenience surveys were younger and better educated than MSM in Natsal-3, and a larger proportion identified as gay (85%–95% vs 62%). Partner numbers were higher and same-sex anal sex more common in convenience surveys. Unprotected anal intercourse was more commonly reported in EMIS. Compared with Natsal-3, MSM in convenience surveys were more likely to report gonorrhoea diagnoses and HIV testing (both past year). Differences between the samples were reduced when restricting analysis to gay-identifying MSM.

Conclusions

National probability surveys better reflect the population of MSM but are limited by their smaller samples of MSM. Convenience surveys recruit larger samples of MSM but tend to over-represent MSM identifying as gay and reporting more sexual risk behaviours. Because both sampling strategies have strengths and weaknesses, methods are needed to triangulate data from probability and convenience surveys.

Characteristics of women who present for abortion towards the end of the mid-trimester in Scotland: national audit 2013-2014

OBJECTIVES

Women in Scotland who request an abortion (for non-medical reasons) within the legal gestational limit (up to 24 weeks) but beyond the gestational limit of all abortion facilities in Scotland (only up to 20 weeks) must travel to England if they wish to terminate the pregnancy. We wished to determine the number and characteristics of women presenting at ≥16 weeks' gestation for abortion, and compare the characteristics of those proceeding to abortion with those continuing the pregnancy.

METHODS

Over a period of 12 months we conducted a prospective audit of women presenting at ≥16 weeks' gestation to abortion services throughout Scotland. The characteristics of women proceeding to abortion and those continuing the pregnancy were compared.

RESULTS

A total of 267 women presented for abortion at ≥16 weeks' gestation. Their median age was 22 years (range 14 to 47 years); 231 were from deprived areas (86.5%), 128 (47.9%) already had a child and 73 (27.3%) had previously undergone abortion. A total of 175 women (65.5%) proceeded to abortion, locally (n = 125; 46.8%) or in England (50; 18.7%). Those at ≥20 weeks' gestation were statistically more likely to continue the pregnancy than those at earlier gestations (p < 0.001).

CONCLUSIONS

Relatively few women present for abortion in Scotland at ≥16 weeks' gestation. Those who are over 20 weeks' gestation and would need to travel to England for abortion are more likely to continue the pregnancy, suggesting that travel is a barrier to accessing legal abortion for this group of women. Provision of abortion services up to 24 weeks' gestation should be considered within Scotland.

Adult patients with respiratory syncytial virus infection: impact of solid organ and hematopoietic stem cell transplantation on outcomes

BACKGROUND

Respiratory syncytial virus (RSV) is a common community-acquired pathogen responsible for a substantial disease burden in adults. We investigated the outcomes after RSV infection in hospitalized adults over a 3-year period.

METHODS

This single-center, retrospective study identified 174 patients hospitalized with RSV upper or lower respiratory tract infection (LRTI) between January 1, 2009 and June 30, 2012. Clinical data were extracted from medical records. The primary outcome analyzed was all-cause mortality, defined as death during the index hospital admission. Subjects were divided into 3 groups for comparison: hematopoietic stem cell transplant (HSCT) patients, solid organ transplant (SOT) patients, and non-transplant patients.

RESULTS

In our study, 41/174 (23.6%) were HSCT recipients and 28/174 (16.1%) were SOT recipients. Twelve of 174 (6.9%) died. Death occurred in 2/41 (4.9%) HSCT and 3/28 (10.7%) SOT recipients, compared to 7/106 (6.6%) non-transplant patients. When compared to the non-transplant cohort, HSCT and SOT were not found to be significant risk factors for mortality (P = 0.685 and 0.645, respectively). In multivariate logistic regression, age >60 was associated with mortality (P = 0.019), while lymphopenia on admission trended toward an association with death (P = 0.054). HSCT patients were less likely to be admitted to an intensive care unit (odds ratio [OR] 0.26, P = 0.04), but were significantly more likely to receive ribavirin therapy (OR 11.62, P < 0.0001).

CONCLUSION

Adults hospitalized with RSV LRTI are at significant risk of mortality, and this risk may be increased in patients age >60 or with lymphopenia on admission. This study did not identify any significant increased mortality or morbidity associated with RSV infection in immune suppressed transplant recipients vs. patients who had not received a transplant.

Physiological responses of lichens to factorial fumigations with nitric acid and ozone

This paper addresses the effects of gaseous nitric acid (HNO(3)) and ozone (O(3)), two important air pollutants, on six lichen species with different morphological, ecological, and biological characteristics. The treatment chambers were set up in a factorial design consisting of control chambers, chambers fumigated with HNO(3), with O(3), and with HNO(3) and O(3), together. Each species showed a different sensitivity to the fumigations, reflecting the physiological variation among species. Our results clearly indicate that HNO(3) is a strong phytotoxin to many lichens, and that O(3) alone has little effect on the measured parameters. The combined fumigation effects of HNO(3) and O(3) were not significantly different from HNO(3) alone.

Single dose Dexamethasone for Postoperative Nausea and Vomiting – a Matched Case-Control Study of Postoperative Infection Risk

Dexamethasone is an effective prophylaxis against postoperative nausea and vomiting but is immunosuppressive and may predispose patients to an increased postoperative infection risk. This matched case-control study examined the association between the administration of a single intraoperative anti-emetic dose of dexamethasone (4 to 8 mg) and postoperative infection in patients undergoing non-emergency surgery in a university trauma centre. Cases were defined as patients who developed infection between one day and one month following an operative procedure under general anaesthesia. Controls who did not develop infection were matched for procedure, age and gender. Exclusion criteria included immunosuppressive medications, chronic glucocorticoid therapy, cardiac surgical and solid-organ transplantation procedures. Sixty-three cases and 172 controls were identified. Cases were more likely to have received dexamethasone intraoperatively (25.4 vs 11%, P=0.006), and less likely to have received perioperative antibiotic prophylaxis (60.3 vs 84.3%, P=0.001). Stepwise, multivariate conditional logistic regression confirmed these associations, with adjusted odds ratios of 3.03 (1.06 to 19.3, P=0.035) and 0.12 (0.02 to 0.7, P=0.004) respectively for the associations between dexamethasone and perioperative antibiotic prophylaxis, with postoperative infection. We conclude that intraoperative administration of dexamethasone for anti-emetic purposes may confer an increased risk of postoperative infection.

Mycobacterium chelonae necrotizing pneumonia after allogeneic hematopoietic stem cell transplant: report of clinical response to treatment with tigecycline

We present a case of progressive Mycobacterium chelonae ssp. chelonae necrotizing pneumonia after hematopoietic stem cell transplantation (HSCT) in the presence of chronic graft-versus-host disease. The patient failed to respond to standard combination therapy with multiple agents and developed resistance to most drugs over the course of treatment. Tigecycline, a new glycylcycline antimicrobial agent with in vitro activity against M. chelonae, was then used with a clinical response to treatment. To our knowledge, this is the first reported case demonstrating tigecycline to have a degree of clinical effectiveness to treat refractory pulmonary infection with M. chelonae in an HSCT recipient.

Disseminated Scedosporium apiospermum infection in a previously healthy woman with HELLP syndrome

A previously healthy 33-year-old female died of disseminated infection with Scedosporium apiospermum in association with Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP) syndrome following the delivery of twins. Her postpartum course was complicated by multisystem organ failure managed with extracorporeal membrane oxygenation (ECMO). She also developed bowel and left lower extremity ischemia requiring surgical resection. Blood cultures yielded S. apiospermum, and histologic findings revealed in vivo adventitious sporulation, an unusual occurrence with this pathogen. Autopsy showed extensive fungal infection of brain, lungs, thyroid, heart, and kidneys.

Oral fluoroquinolone therapy results in drug adsorption on ureteral stents and prevention of biofilm formation

The oral administration of ciprofloxacin (250mg bid) and ofloxacin (300mg bid) in 40 patients with ureteral stents, led to drug levels on all the device surfaces that were higher than the minimum inhibitory concentration (MIC) of Escherichia coli (0.004--0.015 mg/l), the most common uropathogen. The drug levels in the film were higher than the MIC of other common pathogens, namely Pseudomonas aeruginosa (0.25--1.0 mg/l), Enterococcus faecalis (0.25--2.0 mg/l) and Staphylococcus aureus (0.12--0.5 mg/l) in a few cases (six, three and 14 cases out of 40, respectively). For both antibiotics, the concentrations were greater than the MIC of many uropathogens on the film surrounding the devices (0.89 vs 0.31 mg/l respectively, P=0.05), and on the devices themselves (0.22 vs. 0.12 mg/l, P=0.207). Adsorption of the antibiotics was higher to the film than to the stent (P<0.0001). Ciprofloxacin concentration on the film surrounding the stents was significantly higher than that of ofloxacin (P=0.05), while there was no statistical concentration difference between the two antibiotics adsorbed onto the actual devices (P=0.207). No bacteria were found in patients' urine and no biofilms were detected. This is the first report of an oral antibiotic being adsorbed onto medical devices. It potentially provides a new approach of preventing infection, and avoids the need to pre-coat devices with agents whose use will be restricted once bacteria develop resistance to them. If biomaterial properties can be enhanced to increase further the adsorptive concentration of drug, the risk of infections and recalcitrant biofilm formation could be significantly reduced in a highly susceptible patient population.

Has recombinant human erythropoietin therapy minimized red-cell transfusions in hemodialysis patients?

We have conducted a six-year (1986-1991) review of our transfusion service to identify the frequency of blood transfusions in patients undergoing chronic hemodialysis, before and after availability of recombinant human erythropoietin (EPO) as an alternative to allogeneic blood. Four hundred forty-nine patients who underwent a total of 54,929 dialysis events were reviewed. Overall, 343 (76%) of 449 patients received 4,864 red-cell transfusions during 54,929 dialysis events. Red-cell units transfused per patient were significantly lower in 1991 compared to the year (1988) prior to EPO (5.3 +/- 4.5, M+SD, vs 8.6 +/- 13.4, p = 0.02) but not compared to 1986 (6.4, p = 0.11). The frequency of red-cell transfusions per 100 dialysis events declined substantially when 1991 was compared to 1988 (4.11 vs 13.35, p < 0.01) but less so when 1991 was compared to 1986 (4.11 vs 6.20, p < 0.01). Overall, 4864 red-cell units transfused to dialysis patients accounted for 4.46% of 109,159 red-cell units released by our transfusion service, decreasing from 7.3% in 1988 to 2.0% in 1991. We conclude 1) the availability of EPO in 1989 was accompanied by a significant reduction in the frequency of red-cell exposure in patients undergoing dialysis from 1988, but the reduction was less impressive when compared to 1986. 2) Attention to EPO dosage, concomitant causes of anemia, and resistance to EPO therapy in this setting may be required to take full advantage of this biotechnologic alternative to blood transfusion.

Discharge haematocrit as clinical indicator for blood transfusion audit in surgery patients

Three cohorts of elective surgical patients were reviewed in order to develop a method in which the discharge haematocrit can serve as a clinical indicator for a subsequent study of the use of blood transfusion therapy. Three different levels of discharge haematocrit were evaluated: 36, 33, and 30% for 'generous', 'intermediate', and 'strict' criteria, respectively. Discharge haematocrits (%, mean +/- SD) for patients not transfused were 29.6 +/- 4.6, 33.7 +/- 5.0, and 33.6 +/- 3.4 for three different surgical groups (cardiac, orthopaedic, and urological surgical patients). When discharge haematocrits greater than 33% ('intermediate') were considered excessive due to previous transfusion, the prevalence of patients identified was 9, 6.5 and 13%, respectively. We found no relationship between the length of stay in hospital and the number of blood units transfused or patient discharge haematocrit levels. When the length of stay of patients identified by exceeding the clinical indicator was compared to that of patients not identified, orthopaedic and urological surgical patients showed no difference; however, cardiac surgical patients who exceeded the clinical indicator had shorter hospital stays compared to patients who were not so identified. We conclude the following: 1. The discharge haematocrit can be used as a clinical indicator for a subsequent review of use in order to evaluate the appropriateness of blood transfusion therapy. 2. The prevalence of patients identified who exceeded the clinical indicator, among three elective surgical patient groups, suggests that this indicator is applicable across elective surgical categories in order to target transfusion medicine education programmes and clinical outcome studies. 3. Additional factors important to the 'transfusion trigger', such as blood lost during hospitalization, may need to be included with the discharge haematocrit as clinical indicators in order to evaluate blood transfusion therapy in this setting.

International comparative study of cefepime and ceftazidime in the treatment of serious bacterial infections

In this randomized multicentre study, we compared the safety and efficacy of cefepime, 2.0 g bd i.v., with that of ceftazidime, 2.0 g tid i.v., as initial treatment of adult patients with serious infections of bacterial aetiology. Three hundred and forty-eight patients were entered into the study, 173 received cefepime and 175 ceftazidime. The treatment groups were comparable with respect to demographic characteristics, including the types of infection (cefepime/ceftazidime: urinary tract, 55/72; lower respiratory tract, 83/74; skin and soft tissue, 23/14; septicaemia, 81/81; and others, 15/5). Gram-positive bacteria were identified as pathogens on 86 occasions (cefepime/ceftazidime: 48/41), including 20 Staphylococcus aureus isolates (13/7) and 27 Streptococcus pneumoniae isolates (14/13). Gram-negative bacilli were isolated on 261 occasions (126/135), and included 219 Enterobacteriaceae (cefepime/ceftazidime: 108/111) and 34 strains of Pseudomonas aeruginosa (14/20). An intention-to-treat analysis revealed satisfactory clinical response rates of 80% and 79% for the cefepime and ceftazidime groups, respectively, and bacteriological eradication rates of 85% and 88% for the cefepime and ceftazidime groups, respectively. Of patients with microbiologically documented infections, 86% (84 of 98) treated with cefepime and 87% (94 of 108) treated with ceftazidime responded satisfactorily. Thirty-two patients (19%) treated with cefepime and 26 (15%) treated with ceftazidime died. Thirty-six patients in the cefepime group and 23 in the ceftazidime group experienced adverse events; therapy was discontinued prematurely in four and two patients in the cefepime and ceftazidime groups, respectively. Of the patients experiencing adverse events, 22 (13%) treated with cefepime developed intolerance at the injection site, compared with 11 (6%) treated with ceftazidime (P = 0.045). In conclusion, twice-daily cefepime (2 g bd) is at least as effective as ceftazidime (2 g tid), as initial empirical therapy for serious bacterial infections in non-neutropenic patients.

Prevalence of platelet transfusion reactions before and after implementation of leukocyte-depleted platelet concentrates by filtration

To determine the impact of platelet leukodepletion by filtration on the overall prevalence of reported transfusion reactions associated with platelet concentrates, we audited platelet transfusion reactions after infusion of platelet concentrates reported at University Hospitals of Cleveland over 6 months before (interval 1, July 1, 1989 to December 31, 1989) and after (interval 2, July 1, 1990 to December 31, 1990) implementation of the Pall PL 50 filter on our adult Hematology-Oncology inpatient unit (Division 60). Thirty-two (1.7%) of 1,901 random, pooled platelet transfusion events resulted in blood bank transfusion reaction workups in interval 1, compared to 90 (5.3%) of 1,704 in interval 2 (p < 0.001). The Division 60 service accounted for more of our hospital-wide platelet reactions after implementation of the filter in interval 2 (84%) than before filtration in interval 1 (42%), p = 0.002. The prevalence of reaction workups for Division 60 was 0.6% for interval 1, compared to 4.3% for interval 2 (p < 0.001). No differences were found between interval 1 and interval 2 for the rate of discontinuation of platelet transfusion (36 vs. 32%, p = 0.14), rate of premedication for platelet transfusion (72 vs. 65%, p = 0.6), percentage of direct antiglobulin test-positive reactions (17 vs. 5.4%, p = 0.09), percentage showing icteric/hemolyzed serum (15 vs. 4.4%, p = 0.09), or reactions believed to be due to red blood cell incompatibility (8.8 vs. 1.1%, p = 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Blood transfusions in hip fracture patients: implications for blood conservation programs

To address the potential role of innovative blood conservation interventions in nonelective surgery, we reviewed blood transfusions and blood losses during hospitalization of patients undergoing open reduction internal fixation of an intratrochanteric hip fracture. Sixty-four orthopaedic patients consecutively admitted over a 3-year interval were analyzed for transfusion needs by calculating red blood cell (RBC) volume lost during hospitalization. Overall, 39 (61%) patients received blood. We found that the "transfusion-trigger" was higher for females compared to males. Fifteen (23%) of 64 patients were identified to have been transfused with RBC volumes in excess of RBC volumes lost. The remaining 49 patients determined to be untransfused or to be transfused appropriately received 1.4 +/- 2.1 blood units (M +/- SD). Of these, 30 (60%) received < or = 1 U. We found no evidence that patients who received blood transfusions in excess of blood losses benefited compared to those whose blood replacement was less than blood lost. We conclude that innovative blood conservation interventions such as recombinant human erythropoietin (EPO) therapy can be incorporated into this nonelective surgical setting and may permit a significant percentage of hip fracture patients to avoid homologous blood transfusion. An algorithm for physician education programs that can address blood transfusion practices is provided so that patients can benefit from new blood conservation approaches.

Utilization and efficacy of autologous blood predeposit in radical prostatectomy with lymphadenectomy: implications for blood conservation and physician education programs

Autologous blood predeposit is a widely used transfusion practice that has become a standard of care for elective surgery. Despite the support for this practice there are unanswered questions in the usage and efficacy of autologous blood programs. This study is a prospective analysis of 52 consecutively audited urologic patients undergoing elective, radical prostatectomy with lymphadenectomy in which all 52 patients predonated autologous blood. Preoperative blood donation, blood transfused, surgical blood lost, and the "transfusion trigger" were evaluated for each of these patients. We conclude (1) the rate of homologous blood exposure (15%) despite preoperative autologous blood donation in every patient indicates a need for innovative blood conservation strategies to minimize homologous blood transfusion in this surgical group. (2) Unnecessary autologous transfusions could be identified in 8 (15%) of 52 patients, all of which were single unit autologous blood transfusions. (3) Physician education programs that emphasize increased procurement of autologous blood along with more conservative transfusion of this blood are needed to avoid necessary homologous blood and unnecessary autologous blood transfusion.

Identifying elective orthopedic surgical patients transfused with amounts of blood in excess of need: the transfusion trigger revisited

The discharge hematocrit has been analyzed as a clinical indicator of the transfusion trigger by which to identify patients undergoing elective orthopedic surgery who were transfused with blood in excess of need. The volume of red cells lost by each patient during surgical hospitalization was compared to the volume of red cells transfused. Three clinical indicator levels were considered. Red cell losses of 10, 20, and 30 percent of each patient's baseline red cell volume at admission were considered to be appropriate before subsequent blood transfusion replacement, representing generous, intermediate, or strict clinical indicator levels, respectively. With Level I as a generous clinical indicator, 110 (25%) of 525 patients were transfused in excess of blood needs; by Level II (intermediate) and Level III (strict) criteria, 221 (42%) and 314 (60%) of 525 patients, respectively, were transfused in excess of blood needs. Significant differences were found for transfused patients analyzed by gender (26% of women vs. 13% of men; Level I, p less than 0.001) and preoperative autologous blood donation (25% of autologous blood donors vs. 11% of those who did not donate autologous blood; Level I, p less than 0.001). It can be concluded that the discharge hematocrit and amount of blood lost during hospitalization can be used as clinical indicators with which to identify patients receiving transfusions in excess of needs in the elective surgical setting. With this method, it was found that the transfusion trigger is different for women and for men as well as for autologous blood donors and those who did not donate autologous blood undergoing elective orthopedic surgery [corrected].