Feminist sociology has illuminated how sexual violence both reflects and reproduces gendered inequalities, yet its intersection with social class remains comparatively under-theorised in health research, particularly in relation to healthcare and disclosure. This study advances critical social science research on health and healthcare by theorising classed gender stigma as a mechanism through which class and gender intersect to shape working-class women's willingness to disclose sexual violence within healthcare encounters. Drawing on episodic interviews with working-class women in Scotland, the analysis focuses on disclosure within healthcare and related professional support context, including specialist mental health services and third-sector provision. The findings show how classed histories of dismissal, material constraint and respectability norms shape women's expectations of being believed and their assessments of whether healthcare encounters are safe spaces for disclosure. Disclosure within healthcare emerges as a socially organised process shaped by classed relations of care and institutional practices, including appointment structures, referral pathways and access to paid support. The analysis develops the concept of classed gender stigma to show how healthcare encounters shape whose disclosures are recognised as credible and deserving of care following sexual violence. The paper advances understanding of how health inequalities are reproduced through silence within healthcare contexts and highlights the importance of integrating analyses of class and institutional practice into health-focused research on sexual violence disclosure.

Introduction People often consume alcohol following trauma, particularly in response to distressing memories. To date, little is known about how post-encoding alcohol consumption influences episodic memory recall for negative events. Understanding these effects may help to improve support for trauma victims – for example, witnesses and victims of crimes. Methods We tested 60 participants who self-described as heavy drinkers. After watching an analog trauma film, half were allocated to consuming a moderate dose of alcohol (Alcohol-Exposed group), while half received a placebo drink (Placebo-Control group). Immediately and after a one-week delay, participants recalled the event via free and cued recall tasks. Participants also gave remember-know responses and confidence ratings, elucidating alcohol’s effect on experiential memory. Results Free recall performance was similar for the Alcohol-Exposed group and the Placebo-Control group during Sessions 1 and 2. The Alcohol-Exposed group benefitted more from the delayed repeated retrieval attempt. For the cued recall task, the Alcohol-Exposed group provided more “Do not Know” responses compared to the Placebo-Control group in both sessions. For the Alcohol-Exposed group only “Correct Know” responses increased from Session 1 to 2. Although memory performance improved across sessions, confidence levels decreased from Session 1 to 2 in the Alcohol-Exposed group. Discussion Post-encoding alcohol consumption appears to impact immediate episodic memory retrieval; however, this effect is only temporary in nature. No evidence was found that alcohol primarily reduces remembering responses. Much like previous findings focusing on pre-encoding alcohol consumption (Hagsand et al., 2017), current findings suggest that providing individuals who drank alcohol after witnessing an incident with a delayed repeated retrieval attempt can lead to more complete and accurate testimonies.

Over the last twenty years, there has been a growing interest in measuring sexual wellbeing, including by a WHO/UNFPA working group in 2007, which sought clarity on key dimensions and asked for indicators of these to be devised. However, there remains a lack of conceptual clarity surrounding the concept of sexual wellbeing, which may create variation in what is being assessed and to what we are referring. This paper proposes one way in which to achieve conceptual clarity might be through the utilisation of a Capability Approach, thereby posing a new set of normative questions about what sexual wellbeing is. The central argument in this paper is for researchers, theorists and practitioners to focus more fully on a person’s freedom to achieve sexual wellbeing within a particular social and cultural context. We suggest the kinds of data that might need to be captured to operationalise and measure such an understanding. By offering new critical insights, we hope to drive forward empirical and methodological development in the evaluation of sexual wellbeing.

Background The scale and extent of sexual violence perpetrated in the United Kingdom is being increasingly acknowledged. Support after the initial disclosure is often sought in NHS sexual health clinics. The purpose of this service evaluation was to explore patient satisfaction and experience amongst sexual health clinic attendees who disclosed sexual violence and were subsequently managed in a specialist sexual abuse survivors clinic. Methods Semi-structured interviews were conducted with ten service users and interview transcripts were analysed using interpretative phenomenological analysis (IPA) to assess users’ experiences within the clinic. Results Participants were all female (aged 18–54 years) and had experienced sexual violence between 2 weeks and 15 years prior to interview, and the majority self-identified as White British (6/10). IPA analysis revealed three distinct overarching themes which were important to this group of patients when evaluating their care: delivery of care in the context of judgement and stigma, aspects of care identified as healing or harmful to recovery, and the importance of the processes of providing care. Conclusion Understanding the experiences of sexual violence survivors in healthcare settings can optimise the provision of patient-oriented care and support. This includes ensuring the service user is in control of the consultation, the risks of re-traumatisation are minimised, and individuals receive relevant and accurate information but in a manageable volume and format.

Introduction: Mindfulness meditation (MM) may be an effective self-management strategy for people living with HIV (PLWH); no such research has yet been conducted in the UK. The aim was to assess the feasibility and acceptability of Mindfulness-Based Stress Reduction (MBSR), a course in MM, for PLWH in the UK. Methods: Positively Mindful was the first UK study to explore MM in a sample of PLWH. This was a mixed method feasibility study of MBSR for PLWH. Participants were randomised to either MBSR (n = 16) or a waiting-list control (n = 6). Feasibility was assessed using questionnaires, semi-structured interviews, and by analysing study management data. Outcomes included perceived stress, blood pressure, pulse, salivary cortisol, quality of life, symptomatology, affect, and medication adherence. Data was analysed statistically and thematically. Results: Of 41 PLWH assessed for eligibility, 22 were recruited Referrals were low but the consent rate was high (76%). Both patients and staff identified an unmet need for psychosocial care options for PLWH; MM may address this need. Data demonstrated that methodological optimisations should be made in any future follow-up study, particularly with respect to recruitment and adherence. Effect sizes for perceived stress (d=0.29), social wellbeing (d=0.3), and cognitive functioning (d=0.3) suggested further attention may be warranted. Conclusions: MBSR could be feasible, acceptable, and potentially effective for PLWH in the UK; however, strategies for optimising recruitment and adherence should be employed in future research.

Attitudes towards sexual health and relationships are learned from a young age, and there is an ongoing need for innovative and comprehensive approaches to sex education that keep pace with rapidly changing contexts of people's lives. We used thematic analysis of data from two qualitative studies in Scotland to explore learning contexts from a multi-generational perspective, as well as the influence of different socio-cultural factors on provision, access to and experience of sex education. The importance, but inadequacy, of school as a source of learning, was a persistent theme over time. Participants' strategies to address perceived gaps in knowledge included experience, conversations, vicarious and online learning. Gender and age differences emerged, with younger participants more likely to go online for information, and prevailing gender norms shaping attitudes and behaviours across both study groups. Participants who identified as gay, lesbian or bisexual described feeling particularly unprepared for sex and relationships due to the narrow, heteronormative content received. Although schools continue to be a common source of information, it appears that they fail to equip young people for their post-school sexual life-course. We recommend the mandatory provision of comprehensive, positive, inclusive and skills-based learning to improve people's chances of forming and building healthy, positive relationships across the lifespan.

The period of adolescence represents a particularly critical and sensitive phase in relation to health. Emancipatory work on health inequalities and social justice suggests that understanding both social structures and individual human agency have important implications for how public health efforts should seek to improve the health and social well-being of young people. Despite a resurgence of interest in 'agency', there has been far less theorising of young people's agency and agentic practices in relation to health. In this article, we offer our conceptualisations of agency and agency practices, focusing particularly on non-performative and reflexive conceptualisations, which allow for agency and agency practices to be decoupled from one another. We consider forms of collective agency that may catalyse structural change and disrupt existing power relations, and explore how collective agency may have currency in the promotion of health and social wellbeing of young people. Ultimately, to move towards greater health equity and social justice for young people, it's vital to direct our attention towards a structurallytransformativeagency. We draw upon Sen's Capability Approach to firstly suggest the utility of such an approach to expanding our evaluative field to capture agency change and expansions in wellbeing freedom, and secondly as a way to identify policies and collective actions for transformative individual agency. We hope that new thinking in these areas may help fuel collective agency in ways that promote social justice for young people in relation to health and wellbeing.

BACKGROUND:Obtaining perspectives from those seeking healthcare after sexual violence on care and how it is delivered is important.OBJECTIVES:To systematically identify any existing patient-reported outcome and experience measures (PROMs and PREMs) for patients attending healthcare services after sexual violence. Also, to identify key themes regarded by patients as priorities for delivering a high-quality service.DESIGN:Systematic review (PROSPERO registration RD42016050297).DATA SOURCES:Eight electronic bibliographic databases from inception to March 2017. 'Grey' literature also searched. Search words included patient view, patient experience, PROM/PREM, sexual violence, rape.REVIEW METHODS:Studies of any design, with participants of any gender and aged 13 years or older were included; studies only assessing the views of service providers were excluded. Appraisal tools assessed for study quality. Healthcare outcome data were assessed across the quantitative studies and key experiences across qualitative papers; Framework Analysis was used to synthesise the qualitative studies.RESULTS:From 4153 identified papers, 20 fulfilled criteria for inclusion: 10 qualitative, 8 quantitative and 2 mixed methods. No validated measure of assessing patient experience or outcome was identified. The synthesis of qualitative studies led to the assignment of two overarching themes around the importance of patient-focused and trauma-focused communication, and of care which enhances patient empowerment. A paucity of research within certain patient groups who experience sexual violence, in particular men and LGBT (lesbian, gay, bisexual and trans) patients was noted.LIMITATIONS:A broad definition of 'healthcare setting' incorporated a wide variety of venues limiting the applicability of findings in specific settings.CONCLUSION:A validated and standardised approach to assess patient experience and outcome in healthcare settings after sexual violence is needed. Themes identified should be incorporated into PROM or PREM development. The review also suggests the need for a change in approach towards those who attend for healthcare after sexual violence to ensure patient autonomy.

An increasing number of studies refer to sexual wellbeing and/or seek to measure it, and the term appears across various policy documents, including sexual health frameworks in the UK. We conducted a rapid review to determine how sexual wellbeing has been defined, qualitatively explored and quantitatively measured. Eligible studies selected for inclusion from OVID Medline, PsychInfo, PubMed, Embase, CINAHL were: in English language, published after 2007, were peer-reviewed full articles, focused on sexual wellbeing (or proxies for, e.g. satisfaction, function), and quantitatively or qualitatively assessed sexual wellbeing. We included studies with participants aged 16–65. Given study heterogeneity, our synthesis and findings are reported using a narrative approach. We identified 162 papers, of which 10 offered a definition of sexual wellbeing. Drawing upon a socio-ecological model, we categorised the 59 dimensions we identified from studies under three main domains: cognitive-affect (31 dimensions); inter-personal (22 dimensions); and socio-cultural (6 dimensions). Only 11 papers were categorised under the socio-cultural domain, commonly focusing on gender inequalities or stigma. We discuss the importance of conceptualising sexual wellbeing as individually experienced but socially and structurally influenced, including assessing sexual wellbeing freedom: a person's freedom to achieve sexual wellbeing, or their real opportunities and liberties.

There is a growing evidence base for the need for a holistic approach to sexual health improvement, but the challenges for realising this in the ‘real world’ may be harder in some communities than others. We examined sexual health understandings and behaviours among adult men and women in deprived areas of Scotland. Thematic analysis, using the constant comparative method, of qualitative, semi-structured in-depth interviews with 19 men and 16 women aged 18–40 years from the most deprived areas of Glasgow, Edinburgh, Dundee, and three Highland towns. Even though most had been shown images designed to facilitate discussion about sexual consent and verbal/physical abuse, when first asked, participants overwhelmingly equated ‘sexual health’ with the avoidance of sexually transmitted infections (STIs) and pregnancy. Most of the women interviewed went on to locate their accounts of sexual health within a broader, social account of relationships that in an ideal world, in contrast with their everyday lives, were based on respect and freedom from violence. They expressed desires for more positive relationships, based on open communication and trust, choice and freedom from coercion. A few men did accept a broader definition of sexual health, but others actively resisted it and placed the onus to enact choices and freedom from coercion on women rather than men. In the first UK study to examine understandings of holistic sexual health among adults living in deprived areas, we found a disjuncture between men and women. These findings suggest that, as a society, we are failing to equip people to enhance their own, and others’, sexual health and wellbeing in its broadest sense. New efforts to emphasise the breadth of sexual health are required, but addressing these complex issues, especially where there are negative underlying gender norms to challenge, will require multi-level interventions targeting individual, community and system levels.

Within and across areas of high deprivation, we explored constructions of masculinity in relation to sexual health and wellbeing, in what we believe to be the first UK study to take this approach. Our sample of 116 heterosexual men and women age 18-40 years took part in individual semi-structured interviews (n = 35) and focus group discussions (n = 18), across areas in Scotland. Drawing on a socio-ecological framework, findings revealed experience in places matter, with gender practices rooted in a domestically violent milieu, where localised, socio-cultural influences offered limited opportunities for more egalitarian performances of masculinity. We discuss the depths of the challenge in transforming masculinities in relation to sexual health and wellbeing in such communities.

IntroductionRates of sexually transmitted infections (STIs) among adults over 45 are rising in the UK and other Western countries. While STI rates are higher among men who have sex with men and young people, there is increased fluidity of sexual partnerships across the life course, exemplified by mid-life divorce and re-partnering, with sexual activity continuing beyond the age of 80. In order to develop a risk-reducing intervention for this age group, this qualitative study sought to understand the socio-cultural factors influencing late middle-aged adults’ knowledge of STIs.MethodsRecently sexually active heterosexual adults aged 45–65 (n=31) were recruited from a large city sexual health service and sport and leisure centres. In-depth individual interviews explored how STI-related knowledge was acquired across the life course. Interview data were transcribed and analysed thematically.ResultsMost participants (n=19) lived in areas of high deprivation and most were divorced, separated or bereaved from partners (n=24). Two key themes revealed that STI-related knowledge was acquired over the life course through personal social circumstances and wider cultural influences: 1) early stigmatisation of STIs influenced current understandings and 2) women in particular learned about STIs through parenting their adolescent children. Further themes showed that 3) knowledge of STIs was stated tentatively and 4) current STI knowledge did not necessarily facilitate health-seeking behaviour.DiscussionEngagement with STI-related knowledge among middle-aged adults is influenced by socio-cultural factors including the enduring stigmatisation of STIs. Interventions tackling stigma should aim to recognise and legitimate changing sexual partnerships across the life course.

BACKGROUND:Men who have sex with men (MSM) experience significant inequalities in health and well-being. They are the group in the UK at the highest risk of acquiring a human immunodeficiency virus (HIV) infection. Guidance relating to both HIV infection prevention, in general, and individual-level behaviour change interventions, in particular, is very limited. OBJECTIVES:To conduct an evidence synthesis of the clinical effectiveness of behaviour change interventions to reduce risky sexual behaviour among MSM after a negative HIV infection test. To identify effective components within interventions in reducing HIV risk-related behaviours and develop a candidate intervention. To host expert events addressing the implementation and optimisation of a candidate intervention. DATA SOURCES:All major electronic databases (British Education Index, BioMed Central, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Educational Resource Index and Abstracts, Health and Medical Complete, MEDLINE, PsycARTICLES, PsycINFO, PubMed and Social Science Citation Index) were searched between January 2000 and December 2014. REVIEW METHODS:A systematic review of the clinical effectiveness of individual behaviour change interventions was conducted. Interventions were examined using the behaviour change technique (BCT) taxonomy, theory coding assessment, mode of delivery and proximity to HIV infection testing. Data were summarised in narrative review and, when appropriate, meta-analysis was carried out. Supplemental analyses for the development of the candidate intervention focused on post hoc realist review method, the assessment of the sequential delivery and content of intervention components, and the social and historical context of primary studies. Expert panels reviewed the candidate intervention for issues of implementation and optimisation. RESULTS:Overall, trials included in this review (n = 10) demonstrated that individual-level behaviour change interventions are effective in reducing key HIV infection risk-related behaviours. However, there was considerable clinical and methodological heterogeneity among the trials. Exploratory meta-analysis showed a statistically significant reduction in behaviours associated with high risk of HIV transmission (risk ratio 0.75, 95% confidence interval 0.62 to 0.91). Additional stratified analyses suggested that effectiveness may be enhanced through face-to-face contact immediately after testing, and that theory-based content and BCTs drawn from 'goals and planning' and 'identity' groups are important. All evidence collated in the review was synthesised to develop a candidate intervention. Experts highlighted overall acceptability of the intervention and outlined key ways that the candidate intervention could be optimised to enhance UK implementation. LIMITATIONS:There was a limited number of primary studies. All were from outside the UK and were subject to considerable clinical, methodological and statistical heterogeneity. The findings of the meta-analysis must therefore be treated with caution. The lack of detailed intervention manuals limited the assessment of intervention content, delivery and fidelity. CONCLUSIONS:Evidence regarding the effectiveness of behaviour change interventions suggests that they are effective in changing behaviour associated with HIV transmission. Exploratory stratified meta-analyses suggested that interventions should be delivered face to face and immediately after testing. There are uncertainties around the generalisability of these findings to the UK setting. However, UK experts found the intervention acceptable and provided ways of optimising the candidate intervention. FUTURE WORK:There is a need for well-designed, UK-based trials of individual behaviour change interventions that clearly articulate intervention content and demonstrate intervention fidelity. STUDY REGISTRATION:The study is registered as PROSPERO CRD42014009500. FUNDING:The National Institute for Health Research Health Technology Assessment programme.

Background: UK sexual health surveillance data shows a recent rise in sexually transmitted infections [STIs] among women in the 45+ age group. However, current government policies and services that aim to reduce STIs are not typically tailored for the specific needs of this population. Further, the existing evidence base of condom use interventions for older women is restricted to one study from the USA. Aims: Using an extended two-component TPB, the aims of this study were to: (1) determine the significant independent predictors of ‘at-risk’ online older women’s condom use intentions; and (2) identify the key beliefs underlying the significant independent TPB predictors. Methods: A cross-sectional online survey was employed. 109 UK-based sexually active single women that were 45+ years and looking for a new sexual partner(s) were recruited through Facebook adverts. Participants completed measures of direct and belief-based (established via an elicitation study) two-component TPB constructs, anticipated regret, moral norm, self-identity, future time perspective, and past behaviour. A three-step hierarchical regression analysis was conducted for the first aim, while correlational analyses were undertaken for the second aim. Findings: The extended two-component TPB accounted for 78% of the variance in condom use intention. Experiential attitude, injunctive norm, perceived behavioural control - capacity, anticipated regret, and self-identity emerged as significant independent predictors. A total of seven key beliefs (one behavioural, one normative, and five control) were identified. Discussion: This study addresses a gap in the literature and provides guidance for the development of condom use interventions for ‘at-risk’ online older women.

Objective To assess the awareness and acceptability of pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) and use sociosexual media at high risk of HIV infection in four Celtic nations. Design Cross-sectional study. Methods Online self-complete survey of 386 HIV-negative/status unknown MSM who reported condomless anal intercourse (CAI) with ≥2 men in the last year, recruited from gay sociosexual media. Results One-third (34.5%, 132/386) of the participants were aware of PrEP but over half (58.5%, 226/356) reported that they would be willing to use PrEP if it were available to them. Only men who regularly tested for HIV every 6 months (adjusted OR 2.89, 95% CI 1.54 to 5.42) were more likely to be aware of PrEP. PrEP acceptability was only associated with reporting ≥5 CAI partners (OR 2.04, 95% CI 1.2 to 3.46) in the last year. Conclusions Low levels of PrEP awareness were reported across these Celtic nations. Only one-third of high-risk MSM had heard of PrEP but over one-half would be willing to take a daily pill to prevent HIV infection. Sociodemographic factors, commercial gay scene proximity and social network use were unrelated to considering PrEP use. However, those reporting most CAI partners were more likely to consider PrEP use.

There has been a recent global increase in sexually transmitted infections (STIs) including HIV among adults aged over 45. Limited evidence exists regarding middle-aged adults' knowledge of STIs other than HIV. This qualitative study sought to understand middle-aged adults' knowledge of STIs within a socio-cultural context. Individual interviews, based on a life-course approach, were conducted with 31 recently sexually active heterosexual men and women. Participants were aged between 45 and 65 and of mixed relationship status (14 were single, 17 in a relationship). Thematic analysis identified four key findings, including: "engagement with STI-related knowledge"; "general knowledge of STIs"; "learning about STIs from children"; and "limited application of knowledge". The findings allow insight into a neglected area, and indicate that socio-cultural factors influence middle-aged adults' STI-related knowledge acquisition throughout the life course. These are important implications for the prevention of STIs, particularly in addressing the on-going stigmatisation of STIs in older age groups.