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Bailey J, Mann S, Wayal S, et al. Sexual health promotion for young people delivered via digital media: a scoping review. Southampton (UK): NIHR Journals Library; 2015 Nov. (Public Health Research, No. 3.13.)

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Sexual health promotion for young people delivered via digital media: a scoping review.

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Chapter 6Implementing sexual health promotion interactive digital interventions in real-world settings

In this chapter we discuss what is known about optimum conditions for implementation and the structural barriers and facilitators that affect access, uptake and impact of digital sexual health promotion IDIs.

Chapter aims

  • To summarise the literature on engagement, adoption, maintenance and implementation of IDIs for sexual health promotion.
  • To identify barriers and facilitators to successful engagement, adoption, maintenance and implementation in different settings.
  • To assess the relative merits, as well as some of the problems and risks, of implementing digital interventions.

Chapter-specific methodology

Frameworks

We refer mainly to the RE-AIM framework206 for structuring discussions and identifying the key issues and gaps in the literature that might be important for implementation of sexual health promotion IDIs in clinics, schools or for self-access through the internet. RE-AIM considers reach, efficacy, adoption, implementation and maintenance of interventions as the necessary and important elements contributing to impact. In this context, these concepts are taken to mean the following:

  • Reach – how well it reaches its target audience. For IDIs this is influenced by factors that affect both access to and engagement with the intervention.
  • Efficacy of the intervention on targeted outcomes – this is addressed in Chapter 4.
  • Adoption – the types of setting in which interventions are implemented, the barriers and facilitators to their adoption in different settings and consideration of how they can be adapted appropriately.
  • Implementation – how well and consistently the intervention is delivered in a particular setting (health and education) by staff and how this should be facilitated and overseen. We also refer to Normalisation Process Theory,207 a conceptual framework that seeks to determine the mechanisms through which an intervention might become embedded within educational and health-care settings.
  • Maintenance – the factors influencing sustainability of interventions over time at individual, community and organisational levels. At an individual level this includes the degree to which behaviour change can be sustained over time. At an organisational level, this addresses how the use of interventions can be maintained over the longer term, what support would be needed including technical and financial and how institutionalisation of an intervention can be predicted.

In applying these frameworks, we found that the literature was weighted more heavily towards design and effectiveness studies, to a lesser extent towards reach and engagement and was very limited with respect to furthering understanding about the challenges of implementing sexual health IDIs in practice. We were, therefore, inclusive in our approach, incorporating a diversity of study designs and publication types for the narrative synthesis. We included any publication that gave insights into issues for implementation, an approach that precluded formal quality review of each paper. We have also drawn on expert interviews and symposia and user focus group discussions to supplement the literature where appropriate. Data were coded and analysed descriptively in relation to the RE-AIM and Normalisation Process Theory frameworks and triangulated with findings from the literature.

Results

Reach

Digital interventions have the flexibility to be implemented either in a defined setting, such as a school or clinic, or through self-access wherever people are located, via the internet or, for example, a smartphone app. While most evaluation studies have been conducted in school or clinic settings, as most interventions are internet based, there is flexibility about how they might be delivered in practice.

The proportion of the target population reached by the intervention is fundamental to its impact, with a potential trade-off between effectiveness and reach. The population impact of an intervention with relatively low effectiveness can be mitigated if it reaches relatively high proportions of its target population.144 However, little is known about the factors that might influence the reach of interventions in a real-world context and how this might differ for different target populations. Measures of recruitment to evaluation studies can be only a proxy measure for how well implementation might work (especially as incentives have often been used for research recruitment). In addition, studies from the USA strongly predominate in the literature, limiting the generalisability and learning for UK education and health contexts.

Reach: clinic and educational settings

The settings that have been most studied for sexual health promotion IDIs are schools and clinics, although other environments, such as youth facilities and young parent groups, could also be appropriate (expert symposium).

Clinical settings

Offering interventions in clinical settings has the clear advantage of quick and easy access to a ‘captive’ audience, compared with purely self-accessed internet interventions.113,127,143,144,208 Locations that are frequently accessed by the target population can be identified to maximise reach, using face-to-face methods.118,127,153,209 This approach provides straightforward and quantifiable access where coverage and fidelity to the intervention (such as number of visits to the site and dosage) are generally higher and can be more easily measured. Nonetheless, sexual health clinic attendees also often attend on a once-only basis, limiting the opportunity for follow-up access and requiring either that interventions have impact in a single use or that ongoing online interaction is maintained. For example, interventions delivered by text message, initiated from a clinic visit, can continue to be delivered to people wherever they are located. There is, therefore, the potential to sustain and increase motivation for targeted behaviours over a longer time period.

For particular clinic populations, such as young substance misusers,127 placing the intervention in the appropriate specialist service is a ‘quick win’ for reaching those people who are in touch with services. Targeting populations with particular conditions in the clinical setting means that interventions reach them when they are a captive audience.118,128 Particular settings may favour the particular sociodemographic groups of interest, for example sexual health clinics can provide easy access to high numbers of young people at relatively high risk, but, again, the advantages may be offset by excluding a proportion of those not in touch with services and who may have the greatest needs. Assessing service-use characteristics of the target population is an essential part of intervention development, as reaching them in a clinical setting is a potentially quick, cheap and easy way to ensure that they are preferentially accessed.

Although there are a growing number of digitalised solutions within the area of sexual health care more broadly, there is little guidance or exploration of what would be needed, by whom and how for this to be an effective approach in practice for the area of sexual health promotion. Recruitment to studies in the clinic is not a good proxy for assuming reach of the intervention, as the research process is facilitated by researchers or clinical staff in a way that is unlikely to be replicated in practice. Additionally, study participants may differ in important but often unquantified ways from the whole-clinic or other target population. More investigation is needed about the strategies and mechanisms that could promote and maximise the reach of interventions in a non-study setting while minimising the impact on clinic flows.

There is increasing interest in online provision of services such as STI testing and emergency contraception provision via the internet, directing people to local face-to-face services where appropriate (interview, sexual health practitioner). Such novel forms of service delivery lend themselves to the provision of online sexual health promotion alongside service delivery.

Educational settings

Educational settings have been studied widely, particularly in the USA, as places where large numbers of young people can be reached in single or repeated sittings.94,141,166,210,211 As IDIs for sexual health promotion have been shown to be effective in increasing knowledge (see Chapter 4), they may be particularly appropriate for the delivery of school-based sex education. Digital methods in this context have the advantage of ensuring that all topics are covered and delivered similarly across schools. There is scant UK literature in this field and the potential for digital interventions in supporting school SRE provision is underexplored. Sexual health promotion IDIs in school may help to overcome reluctance and embarrassment by teachers to deliver aspects of SRE, especially if students can access programmes outside lesson times, but alternative settings are also needed to provide access for non-attenders or in instances where schools opt out of comprehensive SRE (interviews, education and health practitioners and e-health researcher).

Educational settings have the advantage of allowing virtually universal coverage (assuming parental permission) of a target population who can also be accessed repeatedly, in contrast to many clinical environments. For example, the intervention It’s Your Game: Keep It Real94 was designed for delivery to school students over eight sessions, and the students were largely retained throughout. By implementing interventions in particular schools, such as special educational settings (for pupils with disabilities or demanding behaviour), they can be further targeted to the needs of more disadvantaged populations.211

Reach: online interventions

Although online delivery depends on active searching and finding by users, this approach has the advantage of allowing interventions to be self-delivered at a self-determined pace and intensity. Offering interventions online may capture harder-to-reach populations who are not in touch with mainstream clinical services.112,123,212 Reach can be optimised for self-access by understanding:

  1. the use of different technologies by young people
  2. young people’s sexual health information needs
  3. the promotional strategies that are likely to be effective
  4. the appeal of intervention design and contexts.

Reports indicate that use of the internet by young people in the UK is almost universal and that most people have access in their own homes.213 Harder-to-reach groups (that may have lower levels of engagement with services) have the equivalent usage of internet and other platforms to non-disadvantaged groups. However, bandwidth and connectivity may be a limiting factor for some young people accessing the internet from home214 and the loading time for sophisticated graphics may be unacceptable for those with slower connections.212 The reach of interventions to young people is unlikely to be restricted by access to mobile phones or the internet, but is more likely to be limited by the technology itself or by controls by parents or schools. Privacy concerns may also prevent young people from searching for information about sex and sexual health on mobile phones or in public places.

By taking advantage of the range of digital modalities that young people use, interventions can be delivered through a range of formats, making information as widely accessible as possible for both those who do not attend mainstream services152 or to overcome any restrictions to access. Multimedia formats such as audio and graphics may facilitate access to content for populations with low literacy.83,127 Many of the currently available interventions could be adapted for internet, CD-ROM or mobile phone use, maximising their reach.127 Selection of the modality for use should be guided by understanding the technology usage of the target population. For example, the preferential use of mobile phone technologies by black MSM groups,70 the potential for technology-assisted social interaction games for Hispanic girls125 or the use of online sexual networking sites (interview, voluntary sector provider) have all been identified in preference assessments.

Assessing patterns of use of different types of technology, frequency, duration and preferred features and activities is, therefore, integral to intervention design.70,162 Formative work suggests that higher-risk groups, such as MSM (and young men in general), may be less inclined to access face-to-face services, but further work is needed to evaluate how successful targeted web-based interventions are in reaching these populations. This has been less well explored in young people and it is not known how applicable some interventions developed for an older target group are likely to be to younger MSM.

Use of technology: mobile phones

Mobile technology provides a high-reach delivery mechanism for health behaviour-change interventions. In the UK mobile phone use is almost universal in the 16- to 24-year-old age group.215 As most young people carry their mobile phones with them wherever they go, support can conveniently be delivered wherever people are and whenever it is needed. BCTs and personalised content can be delivered by mobile technology. There is the potential to personalise content according to the demographic characteristics of participants (e.g. gender or age) or their issues in changing behaviour. Content can be further personalised using interactive features. Health behaviour-change interventions delivered by mobile technology can be effective. Once developed, interventions can be low cost.

In lower- and middle-income countries sexual health interventions delivered by text message have achieved high reach. Some trials of interventions in lower- and middle-income countries and in the USA report statically significant and clinically important increases in contraception use.

Many interventions developed to date are, however, unlikely to be optimal, as they do not employ all of the BCTs needed to target the factors influencing behaviour. In the UK, despite high mobile phone ownership and usage and the potential to reach disadvantaged youth,70 sexual health promotion delivered by text messages is an under-researched area. A qualitative evaluation of a mobile phone intervention shows that the intervention is feasible and acceptable to young people (Box 5).

Box Icon

BOX 5

Mobile phone texting intervention In the UK, a theory-based IDI was delivered by text message to young people reporting unprotected sex with more than one partner in the past year or diagnosed with chlamydia. Messages targeted the correct treatment of (more...)

Young people’s mobile phone use is very high, for example for social interaction, to download videos and, potentially, for health information. Young people who received multimedia sexual health information via mobile phones found this very acceptable and it also enhanced peer-to-peer and parent-to-young-person discussions about sexual health.217 Initial evaluation of the Trelya fLASH initiative, which uses short textable videos for health promotion around alcohol awareness, also shows this type of intervention to be highly relevant and acceptable to young people, as well as motivating them to think about health behaviours. Further trials are needed to assess the reach of mobile phones compared with that of other platforms in reaching young people with sexual health IDIs.

Despite the potential of texting interventions and use of the mobile internet, a systematic review of currently available HIV and STI prevention mobile phone apps shows that these are rarely downloaded or used.70 Sexual health tools may be needed once or twice only (e.g. service locators, symptom checkers) and issues of privacy may discourage the downloading of sexual health apps. It may be that apps will be downloaded if they are developed in response to specific issues faced by participants. Such apps could be promoted in clinics or advertised more widely.

Use of technology: social networking sites

The frequent use of the internet by young people for networking both socially and sexually via sites such as Twitter, Facebook and YouTube and dating sites such as Grindr offers opportunities for intervention.139 MSM report regularly meeting contacts through digital sexual networks,123,212 and this may provide a critical ‘teachable’ moment to engage with sexual health promotion.139,218 However, although more than half of young people surveyed in the USA have looked up health information online,127 few (1 in 10) report use of social networking for any health-related issues and even fewer for sexual health-related issues.219

Other approaches to exploiting social networking opportunities include development of Facebook pages for communicating health information by health professionals92,220 or from the clinical setting.221 However, there was limited success of some of these initiatives in promoting the dialogues with at-risk groups.220 Attracting young people to relevant sites may be difficult.92

While the reach of social networking sites is expressed in terms of interactions such as ‘likes’, wall posts and comments, through which peaks and troughs of interaction can be charted, the public nature of social networking sites allows for greater opportunity for more personalised communication. The particular taboos of sexual health mean that social networking for sexual health behaviours or peer support may also not be appropriate. For example, someone increasing their physical exercise could post about this on a social networking site for some moral support and encouragement, but it may not be socially acceptable to report increased condom use in this way. Even if users like programmes and have found them useful, they may not be willing to publicly endorse sexual health apps, which makes it difficult to assess the popularity of sites and reduces the possibilities for viral dissemination of sexual health interventions.

There are ways to minimise the risks of breaches of privacy, confidentiality and data security on social networking sites: groups can be made secret and member-only, with all communications on a group ‘wall’ or in private messages,218 computer algorithms can detect telephone numbers or e-mail addresses to prevent exchange of contact details between site users, moderators can remove private information on bulletin boards or in chat rooms, for example, and can also monitor for bullying online.39

Although there is a lack of literature in this area and a lack of evidence of impact on behaviour, MSM in particular have been successfully engaged with sexual health promotion via social media sites (interview, voluntary sector provider). Exploiting different forms of digital media and their social networking potential across different platforms not only widens reach but may enhance their pro-social impacts (impacts on community and social networks).222

Sexual health information needs

Engaging young people in sexual risk reduction behavioural change is a challenge. Sexual behaviour is motivated by enjoyment, with risk to health a secondary concern (researcher, e-health). Interventions may need to adopt a more positive stance in which sexual enjoyment, as well as adverse consequences, is addressed.

Interventions are more likely to be attractive if they reflect the sexual health information needs of young people. Young people do use the internet to seek information about sensitive topics concerning their sexual health,219 but many feel that current information available online does not fully meet their needs.39 Analysis of online search threads representing young peoples’ sexual health concerns shows that they are interested in a wide range of topics and find a huge range of competing online information of variable quality. Topics include sexual pleasure, puberty, menstruation and transmission and mechanisms of infection. Some of the search terms and strategies used by young people may not generate the best-quality information. In the Sexunzipped study, the most frequently visited content on the website was about sexual pleasure.181 Where they have concerns, young people tend to search using symptoms rather than medical terminology.

Much of our learning about the information needs of young people is also gained from experience within sexual health services. Child sexual exploitation, abuse and violence, as well as mental and emotional health and well-being, are some of the problems for which young people seek help. The views of more marginalised groups are not easily captured and clinic intelligence is another mechanism through which to identify the needs of young people. Increasing the understanding of users and reflecting their common concerns within the content and textual strategies of web-based interventions, as well as through views and experiences of clinic users, will maximise the chance that they will be accessed through young people’s web searches.

Promoting access to interventions

One of the main challenges to adoption, particularly of primarily online interventions, is facilitating users to first perceive the need that they might want to address. While young people may actively seek (sexual) health information about specific problems through internet search engines, they are less likely to seek out sexual health promotional materials, and those who do are often those who are best at getting help and least likely to be those in need (researcher, e-health).

Although searches for sexual health-related information may lead to specific sites, users can also be proactively engaged through various promotional ‘push’ factors, such as face-to-face interventions (in services and elsewhere), word of mouth, flyers,114 banner adverts online or the placing of study descriptions on websites with high usage by target groups.139,223 However, these methods are generally deployed in the context of research studies and may be too costly and time-consuming to be sustainable in the long term for intervention implementation. The promotion of a website through online mechanisms and posters and flyers in clinics as part of local-level health promotion activities is a relatively low-cost option.

Integrating digital interventions with ongoing initiatives is one approach. For instance, young people already access well-known organisations and brands that they trust (including the NHS) for the information or services they need, and these avenues could be an important vehicle for the promotion of interventions or to expand access (interview, voluntary sector provider). There are also digitalised sexual health promotion initiatives, such as the ‘Come Correct’ condom distribution scheme (again a recognised brand), that remain unexploited as a vehicle for superimposing digital sexual health promotion initiatives (interview, voluntary sector provider).

Options for virtual sexual health diagnostics and treatment where the need for face-to-face consultation is replaced are increasingly being explored. This underexplored opportunity for sexual health promotion may represent a vehicle for the integration of more tailored interventions. One example, the eSTI (Electronic Self-Testing Instruments) Research Consortium led by St George’s Hospital in South London, is using microfluidics to develop novel point-of-care STI testing and a mobile phone-based diagnostic app that could link provision of results (positive and negative) with sexual health promotion initiatives (interview, sexual health researcher).

Little has been written in the literature about which methods to promote interventions are likely to be most effective in terms of reaching the target population. In practice, statutory budgets are likely to prohibit much investment, and services may find themselves competing with the much more highly resourced commercial sector. There are few studies that specifically examine barriers and facilitators to improving intervention access, which methods are likely to reach particular groups and how people who are reached via the internet or face to face exhibit different levels of risk. A multidimensional strategy is likely to be best but incurs greater costs and may be difficult to sustain in the longer term.

Intervention design features

The design of interventions that are reliant on self-access needs to take account of features of a website likely to facilitate access and adherence. Even if young people are recruited to an intervention, it may be more difficult to keep them engaged over multiple sessions and modules. Young people are likely to be multitasking and instant messaging online, which presents a challenge in terms of maintaining engagement with an intervention.214 If interventions require some degree of sustained and repeated engagement214 then greater understanding of the factors that facilitate this for sexual health interventions is needed. Building an initial rapport and situating the importance of the intervention may help to maintain engagement and encourage users to return to a site. Ensuring that the intervention website is embedded in sites that are already visited by the target group214 or the use of online peer facilitators as an adjunct to self-access218 are other strategies.

Complex design features require close collaboration between technical and research teams,224 as well as input from users about their preferences. The look and feel of a website is important for engagement but, in this rapidly changing field, may quickly become out of date.39 Young people may want social interaction via features such as discussion boards, but non-contribution may alienate young people from using a site.39

Reach: mixed delivery

Many interventions have the flexibility for use either in institutional settings or online, although evaluations commonly centre on those that have been delivered in schools, clinics or in controlled research settings.113,120,144,214 In practice, clinics or educational settings can attract users to internet interventions whether or not they were originally designed to be delivered there (Box 6).

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BOX 6

Self-access or kiosk-based intervention delivery Bull et al., seeking to capitalise on relative and contrasting advantages of self-access and ‘kiosk-based’ implementation, studied both modalities. The research team were more successful (more...)

Reach: engagement

Once a young person finds the sexual health intervention, it is not known which factors will maintain interest or encourage them to visit more than once. It may be easy to attract young people to an online intervention, but engagement tends to fall off over time.212 Although participants can be flexible about when they interact, there is little social pressure to return, unlike for face-to-face interventions. In one study, about 20% of those enrolled to one intervention119 did not complete it. One possibility is that this was due to poor internet connectivity. There needs to be a balance between sophistication of the programme and time taken for the intervention to load.119

There are challenges for health promotion interventions in both terms of attracting users’ attention214 and sustaining attention throughout one or multiple sessions, sufficient to be effective. Audiences that are most successfully retained tend to be female, middle class, well educated and have higher income and interventions may, therefore, miss those at highest risk.97 There may be an advantage in building trust through face-to-face recruitment, for example in clinic environments,143,211 where higher-risk individuals may be more likely to attend. Face-to-face engagement strategies may serve to build rapport and encourage users to stay with the intervention. In a climate where financial pressures require more to be delivered at lower cost, one model is to integrate a facilitator to support users in continued engagement with an online intervention for health promotion. While the active ingredient is in the digital intervention, a health-care assistant provides human interaction to support its delivery. Rather than replace services, this reduces costs, enabling more to be delivered for less and using the health-care setting mechanisms to foster adoption and ongoing engagement (interview, e-health researcher).

Online studies of web-delivered sexual health promotion interventions tend to direct participants to complete the intervention themselves over a finite period, typically 1 week.119,139,225

In social networking interventions, interest tends to decline over time or messages may be downloaded once without further engagement. Different delivery mechanisms may sustain interest, such as videos, quizzes, etc., but this runs the risk of fragmenting the message.89 Experience points towards a shorter time frame with a single standalone message; however, evidence of the effectiveness of this approach is lacking.89

Interventions delivered by mobile phone can have fewer problems with engagement with the intervention because messages can be delivered to participants wherever they are in order to boost and sustain waning motivation. This makes it imperative that messages are appropriately developed to ensure that they are not irritating or intrusive and that clear instructions are delivered to the participant regarding how to stop receiving messages if they wish. For interventions delivered by text or voice message, participants wanted a friendly, knowledgeable and non-judgemental tone.84 They asked for no more than three text messages per day. They also wanted short messages that gave practical advice and support. Participants diagnosed with STIs wanted information to cover what the problem is, what to do about it and where to get help. Messages that provided examples of how others had tackled problems or issues were considered especially helpful.88

It is important to assess the usability and perceived relevance of an intervention by the target group.120 Users (who completed interventions) tended to rate sexual health promotion interventions highly on usability, attractiveness and enjoyment.123,139,142 Completion of an intervention is a more objective marker. One study measured engagement through the number of webpages that were viewed. One-quarter of participants viewed more than 10 pages of the Sexunzipped website (which was available for self-directed use), one-quarter did not view any of the pages and the remainder explored a few pages of website content.181 There was minimal prompting to access the website.

Engagement with content is also an important consideration in maintaining interest and adherence. Users may scan content but it is difficult to assess the degree to which they are actively engaged and processing it. There is a suggestion that individual tailoring does have an independent effect on enhancing elaboration of health promotion messages (i.e. applying messages to personal situations).166 Understanding which particular elements of tailoring are needed for digital interventions to be effective is an area that needs more work. There is already evidence for factors that moderate the effect of print-based tailored health promotion interventions, such as having more than one intervention with closer follow-up,73 and some of these findings may be applied, with caution, here.

Use of humour is another technique that has been used to attract and maintain attention, although styles of humour, particularly in a sexual health context, differ, can potentially cause misunderstanding and can reduce credibility.150 Making a message memorable, however, also increases its potential for indirect effect through either social networking or face-to-face interaction with other young people.150 In terms of features and operationalising constructs, young people report that they favour sites with built in social interaction features, such as discussion boards.39

Gaming offers another avenue of engagement.141 A novel online gaming environment in which users interact with a virtual sexual health clinic via an avatar with personalised interactive features is currently under investigation.226 In India, mobile phone-based games promoting HIV awareness through ‘Safety Cricket’, ‘Life Choices’ and ‘The Great Escape’ achieved high reach, with 10.3 million game sessions in 15 months. Their non-randomised evaluation suggested it increased condom use, age at sexual debut and HIV awareness.227 Although young people frequently game online for entertainment, the acceptability and desirability of gaming for sexual health promotion interventions needs more exploration.

The use, acceptability and potential of different delivery platforms for interactive sexual health promotion interventions remain underexplored in this rapidly changing field. As new forms of social media and their usage for sexual health intervention are likely to outpace detailed investigation, pragmatic evaluation of innovations is needed to generate learning about the modes of delivery that are popular for this type of intervention and the factors that facilitate and inhibit their reach.

Adoption

Sexual health promotion IDIs may be implemented in schools, clinics or any other setting either to complement existing services or to replace elements of the sexual health promotion currently delivered face to face. Aims, likely impacts on current ways of working and anticipated benefits all need to be conveyed to frontline staff in advance in order for adoption to be effective.207 Some adaptation of the intervention to local context is necessary for this process to be successful;228 however, this can also create tensions where retaining fidelity to theory may be at odds with the needs of context: the ‘local adaptation-fidelity’ debate.229 It also assumes an understanding of which of the intervention ‘ingredients’ are active and must, therefore, be preserved in this process of adaptation. Initiatives arising from stakeholders ‘on the ground’ in clinic or educational settings have the advantage of being grounded in existing contexts and constraints, but are less likely to be underpinned by Behaviour-Change Theory (interview, e-health researcher).

In a clinical setting, there is huge potential for digital interventions to replace the simpler elements of clinical care, but there is anxiety among stakeholders about how this might threaten important functions of the face-to-face consultation [service providers, SASH (Studies in Adolescent Sexual Health) workshop]. ‘Buy-in’ from implementing staff is important for the effective implementation of technology, and a significant cultural change is still needed in both clinical and educational settings (interview, voluntary sector provider).

Implementation

We did not identify theory-based sexual health promotion IDIs from the literature that had actually been implemented in original or adapted form in practice in either a research or a real-world health or education setting. However, there are pockets of innovation in this area in both statutory and voluntary sector settings, and there is increasing motivation among some policy-makers and people on the front line for exploring this area further.

Adaptation of face-to-face interventions

One example of a school intervention currently under development aims to combine inputs from users with the expertise and experience of voluntary sector professionals in face-to-face delivery using pre-existing materials to develop a digital intervention. The face-to-face intervention involves young people moving around themed learning zones and participating in a range of facilitated discussions and activities. For example, one area might be about discussing health promotion facts, another about discussing different dilemmas and another about talking about identity and sexuality and challenging some of the myths and preconceptions. This resource is being translated into a series of digital approaches using tablet computers and mobile apps so that it can be delivered using digital media. The resource will then be marketed and promoted to schools and teachers can be trained to use it (interview, voluntary sector provider).

Such initiatives as these, which have been developed in collaboration with stakeholders, potentially have an advantage of being grounded in the direct experience of young people’s needs, as well as having an understanding of the context for implementation. Implementers are likely to understand from the outset how the intervention adds value and can drive development in a way that complements existing initiatives. However, less is known about the degree to which face-to face initiatives can be directly translated and remain effective, how they can be introduced and the settings in which they are likely to be most effective.

While these examples most often hail from the voluntary and commercial sector, the NHS has not kept pace with technological development in other settings. Implementing interventions has often been hampered by difficulties regarding access to the internet and cumbersome processes to enable interventions to interface with current systems (interview, e-health researcher). This is a very real barrier to ensuring that interventions are implemented (and also to evaluation in target settings). Implementation may be easier if a sexual health promotion IDI can be linked with existing digital health systems, especially if systems are meeting particular needs of users or if systems are already integral components of clinical care pathways, for example:

  • online symptom checkers
  • service locators
  • free condom schemes
  • internet-postal self-test services (e.g. for chlamydia testing)
  • digital results services
  • contact tracing by mobile phone or e-mail
  • social networking sites (e.g. dating or hook-up websites)
  • social support online (e.g. herpes or HIV support groups).

Wider policy-level support and financing

Policy, legislation and standards are important determinants of whether or not an intervention is likely to be implemented. The lack of national mandatory SRE beyond biology, coupled with constraints on health-care and education financing, is a barrier to the provision of comprehensive sexual health promotion interventions in schools or clinics. Similarly, without explicit sexual health promotion standards to drive improvements in this area, perceived upstream preventative initiatives may not take precedence in local priority setting processes.

Local organisations may be reluctant to commission sexual health promotion interventions when they are juggling service imperatives, their organisational capacity to provide, financial barriers and a lack of short-term measurable outcomes. Current sexual health quality standards are based on biomedical outcome measures, such as reduction in teenage pregnancy and STIs.55 As there is no performance-managed requirement for service-based sexual health improvement, this significantly reduces the likelihood of adoption of sexual health promotion initiatives. However, some policy-makers and clinicians are prepared to take a longer-term view, recognising the future benefits on sexual ill health and service use (interview, NCSP manager). As sexual health promotion is a cross-cutting issue, potentially linking with other health agendas such as mental health and substance misuse, as well as cross-sectorally with, for example, education, opportunities to share financial risk are already being explored which can make investment more appealing (interview, policy-maker).

Maintenance

Ongoing management and financing digital interventions after implementation has been underexplored. Websites need continuous maintenance and review. Interventions incorporating a social networking element require posts to be checked for accuracy and relevance, as well as provision of moderation of discussions. One approach to moderation via social networking sites has been the use of the peer-led HIV prevention education via Facebook that has been adopted in the HOPE (Harnessing Online Peer Education) study, training peer educators in methods likely to be effective.218

Small, regular updates of digital interventions are needed to incorporate new facts and research. The look and feel of a website also dates rapidly, meaning that more major revisions are required. These maintenance issues are costly in terms of financing and time and present a challenge for a low-resource environment.89

Key points

  • The impact of a sexual health promotion IDI is determined by its reach (proportion of the target population reached), efficacy, adoption (within the target setting), implementation (how well it is delivered) and maintenance (sustainability) – RE-AIM.
  • Educational and clinical settings provide a captive audience for delivery of interventions but may miss higher-risk individuals who did not attend the services.
  • Health promotion interventions should take advantage of the digital devices and functions that the target population most commonly use, such as mobile phones, social networking and gaming.
  • Young people are most likely to search the internet for information about pleasure, relationships or symptoms, or to use ‘brands’ viewed as legitimate, such as the NHS. This is should be taken into account in deciding where to place digital sexual health promotion initiatives.
  • Implementation strategies should combine online promotion with face-to-face methods in education, clinical or other settings used by young people for maximum impact.
  • Engagement with an intervention tends to diminish over time. Face-to-face methods of recruitment and ongoing support encourage continuation, but little is known about the most effective strategies.
  • A cultural shift is needed within both education and clinical settings before digital sexual health promotion interventions are widely adopted. Frontline staff need a clear understanding of how interventions will both benefit and impact on current ways of working.
  • Adaptation of interventions to local context is needed, but the important core components of an intervention must be preserved during this process.
  • Interactive digital interventions could be offered in conjunction with currently existing digital health systems, for example online service locators, online services (for condoms or STI testing), clinic results systems and sexual health or dating websites.
  • There are organisational and structural challenges to implementing interventions, particularly in relation to the structure of IT within the NHS.
  • There are few national educational and health policy levers to support the implementation of sexual health promotion IDIs. Commissioning decisions are taken locally and do not have a mandated sexual health promotion commitment. However, this is strong policy support for deploying digital technology in health in future.
  • Maintenance contracts for updating and maintaining the hardware and moderating social interaction are required in order for sexual health IDIs to be implemented sustainably in practice.
  • Implementation studies are needed in order to understand the factors associated with effective implementation of sexual health promotion IDIs.
  • Research is needed into the contextual opportunities and constraints for the adoption and implementation of digital sexual health promotion IDIs within education and clinic settings.
  • Closer cross-sectoral working between health and social care and voluntary and commercial sectors in this field is needed for shared financing of digital initiatives, as national policy levers and funding options are limited.
Copyright © Queen’s Printer and Controller of HMSO 2015. This work was produced by Bailey et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK326978

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