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Indicative of some positive desired behaviour change i. Indicative of clear behaviour change in desired direction i. A total of articles were identified, with an additional two found during manual reference searches. Five studies were conducted in United States of America [ 24 , 25 , 26 , 27 , 28 ], three in Australia [ 14 , 29 , 30 ] and the rest conducted in Canada [ 31 ], South America [ 32 ], Italy [ 33 ] and China [ 34 ]. Twelve studies recruited participants with a total sample size of 10, range 50— , one study did not report on sample size [ 14 ].
As a result, the majority did not contain a control group. The 19 studies evaluated 22 separate interventions.
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The majority of studies used online methods to recruit participants e. The average response rate within the studies was The majority of studies included testing as a primary outcome routinely-collected or self-reported testing data, with some reporting both. Just two studies explicitly measured frequency of HIV testing [ 19 , 31 ], four included a measure of recency of previous HIV test [ 14 , 22 , 23 , 30 ] whilst the remaining studies used isolated self-reported HIV testing or intention to test or testing rates at clinics within a specific time period.
Additionally, five studies reported on antecedents of testing e. Ten studies [ 14 , 15 , 18 , 20 , 21 , 25 , 27 , 29 , 30 , 31 ] used routinely collected data clinic samples , with a total of 73, tests one study did not report actual numbers [ 27 ]. Twelve studies recruited participants [ 14 , 19 , 22 , 23 , 24 , 26 , 27 , 29 , 30 , 32 , 33 , 34 ] with a total sample size of 10, again one study did not report sample size [ 14 ]. Four studies merged participant self-reports and routinely collected data [ 14 , 27 , 29 , 30 ], with two evaluating the same intervention at different time points [ 29 , 30 ].
Six of the included studies gathered data only during the intervention period [ 15 , 18 , 20 , 25 , 30 ] whilst information was unclear about post intervention follow-up periods for four interventions [ 28 , 29 , 32 , 33 ]. Of the nine studies reporting clear follow-up periods there was a wide variety of time frames.
Very little could be gleaned from the studies about their behaviour change focus beyond a desire to increase HIV testing. This does not mean that actual mechanisms or techniques to change behaviour were not employed the contrary to which was evident and reported in the BCT and theory coding analyses reported elsewhere, but instead that this was often implicit in the materials employed rather than explicit in the descriptions of these.
However, studies generally included detailed descriptions of the nature of the intervention, the provider and the content. Most were delivered online or in gay venues and other community settings, with none delivered via one medium alone, and most relied on a variety of delivery media, including posters, leaflets and adverts. Three studies reported that delivery was supported by outreach workers or peer educators [ 22 , 25 , 28 ]. Most reported use of an intervention name, brand or logo and there was a considerable mix of tone e. Overall, the interventions used an array of different imagery, but the majority used photographs as the central image our visual analysis interrogated audience reading of this and the implications of it for future intervention design is reported elsewhere.
All but one of the interventions [ 21 ] featured actors who could be interpreted as representative of the target audience, implicitly or explicitly identifying actors as MSM. The interventions were primarily informal and direct in tone and all also featured text of some kind, most frequently phrased as an instruction or statement to convey key messages.
Quality appraisal was assessed for 15 studies, with no studies fulfilling all or most of the checklist criteria for both internal and external validity see Supplementary file 2. Within the current study, four of the included studies were graded as showing high internal validity, fulfilling all or most of the checklist criteria of internal validity.
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Three of these studies used a cross sectional design [ 22 , 29 , 30 ] whilst the remaining study used an interrupted time series design [ 19 ]. Only four studies were graded as low internal validity, fulfilling none or few of the checklist criteria for internal validity, three of which used a cross sectional or retrospective cohort study [ 23 , 25 , 31 ] and one was a pre-post design [ 24 ]. Those that scored poorly on internal validity were largely judged to do so based on a general lack of information about the population i.
Seven studies reported results that were indicative of behaviour change in the desired direction i.
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An additional five [ 18 , 19 , 20 , 25 , 32 ] reported results indicative of some positive desired behaviour change i. In one study, the increase in HIV testing was no longer statistically significant after adjusting for key demographics, sexual and testing history, and exposure to other health improvement interventions rate ratio 1. Two studies reported that the intervention had an effect on the antecedents of behaviour e.
None of the included studies reported a negative effect. Looking at effectiveness in relation to study design, of the three RCTs included within the current study, one was indicative of clear behaviour change in the desired direction [ 34 ], one was indicative of some positive desired behaviour change [ 32 ] and the final study showed no effect [ 24 ]. All were graded as medium internal validity, fulfilling at least some but not all of the checklist criteria for internal validity.
Of the eight cross sectional or retrospective cohort studies, one study which was indicative of clear behaviour change in the desired direction was graded as high internal validity [ 22 ].
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The final two studies graded as high internal validity used different analytical techniques and timescales to assess the impact of the same intervention Drama Down Under with different results [ 29 , 30 ]. The first suggested that there was some initial evidence of an increase in testing across the duration of the intervention [ 29 ], but the latter, when incorporating insights from more recent data sets, concluded that the increase in HIV testing suggested a continuation of temporal trends rather than more frequent testing among men [ 30 ].
Two of the cross sectional studies were graded as medium internal validity [ 14 , 15 ], although the results for these were mixed with McOwan et al. Three cross sectional or retrospective cohort studies were graded as low internal validity and yet reported results indicative of clear behaviour change [ 23 , 31 ] or some positive desired behaviour change [ 25 ]. The final cross sectional study was unable to be assessed for internal validity due to insufficient study detail, although their results did indicate some positive desired behaviour change [ 20 ].
The two pre-post studies included showed no intervention effect, although internal validity varied with the first graded as medium internal validity [ 33 ] and the second graded as low internal validity [ 24 ]. Both studies using the interrupted time series design had results indicative of some positive desired behaviour change [ 19 ] or an effect on the antecedents of behaviour [ 27 ]. These studies were both graded positively in terms of internal validity with the Hickson et al.
Studies using the non-comparative design were unable to be assessed for internal quality due to insufficient reported methodological detail, although their results did indicate some positive desired behaviour change [ 18 ] or an effect on the antecedents of behaviour [ 21 ]. Finally, the current study was unable to assess the internal validity of the Thackeray et al. Our review has demonstrated that there is now a growing body of evidence for the effectiveness of social marketing and mass media interventions to increase HIV testing among GBMSM. However, there was heterogeneity of interventions, study quality was mixed and few have adopted the most rigorous study designs.
Of seven studies reporting an increase in HIV testing, five were cross sectional studies two graded as high internal validity, one medium and two low internal validity , one was an RCT medium internal validity and one case study unable to be assessed for validity. This speaks to the challenge of evaluating this particular type of intervention. Within the context of the limitations of general effectiveness reviews, we need to know what works, for whom, when and how. Further details relating to the specific content of the interventions can be found in forthcoming papers relating to an analysis of mechanisms of change [ 35 ] and social marketing and visual design components of the interventions [ 36 ].
By reviewing the key processes involved in mass media consumption, and examining the role of theory and behaviour change techniques employed in message delivery, we have achieved a high quality integration of multi-source data from different theoretical perspectives. In this way we have optimized the potential content of social marketing interventions to increase HIV testing in evidence-based and theoretically-informed ways. A detailed logic model that sets out the key components of social marketing, visual design and theoretical mechanisms of behaviour change that the overall review has suggested are required as inputs for an intervention is shown in Fig.
Seven of the 19 studies reported results indicative of an increase in HIV testing and another five reported results indicative of some positive desired behaviour change. Previous reviews demonstrated a lack of evidence on the effectiveness of social marketing and mass media interventions to increase HIV testing among GBMSM. The Cochrane review called for more rigorous research designs and detailed process evaluation work to identify the social marketing intervention components that are most effective [ 7 ].
However, the studies included in this review were of relatively poor quality, with most study designs being cross-sectional and only three RCTs included. While two RCTs had results that were either indicative of behaviour change [ 34 ] or some positive desired behaviour change [ 32 ], the latter was judged to be of poor study quality.
Our findings, unsurprisingly, suggest that the study designs, analytical techniques and timescales used to assess the impact of interventions can influence interpretations of effectiveness. Changes in testing rates across a population or in cross-sectional studies might not be the result of the intervention, but instead indicative of temporal trends and may be affected by a variety of other factors. This is particularly evident in the competing conclusions on the effectiveness of one intervention by two studies using different analytical techniques [ 29 , 30 ].
Our review speaks to the challenge of evaluating this particular type of intervention, which has been discussed previously [ 22 ]. The lack of RCTs identified may be indicative of the difficulty of using this research design in the evaluation of population-level social marketing interventions. There is a need to consider and explore the potential for the development and use of alternatives, such as natural experiment designs, which are appropriate when evaluating population level and policy interventions [ 37 ], in order to overcome barriers associated with wide-population reach and exposure.
We found no qualitative studies or process evaluations, despite the importance of these to inform the design and implementation of future interventions.