Formative design and evaluation of patient-delivered partner therapy informational materials and packaging

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1 See Editorial, p 80 Additional information is published online only at sti.bmj.om/ontent/vol85/ issue2 1 Indiana University Shool of Mediine, Indianapolis, Indiana, USA; 2 Aademi Edge, In, Bloomington, Indiana, USA Correspondene to: Mr R Goldsworthy, Researh and Development, Aademi Edge, In, 108 E 14th Street, Bloomington, IN 47408, USA; rik@aademiedge.om Aepted 16 November 2008 Published online first 22 Deember 2008 Formative design and evaluation of patient-delivered partner therapy informational materials and pakaging K MBride, 1 R C Goldsworthy, 2 J D Fortenberry 1 ABSTRACT Objetive: To develop and evaluate instrutional and pakaging materials for patient-delivered partner therapy (PDPT). Methods: 64 patients partiipated from an urban US sexually transmitted infetion (STI) lini. The researh omprised three phases: individual interviews to eliit attitudes and beliefs regarding PDPT and to assess the understanding of key STI-related onepts and terminology; the development and rapid validation of prototype instrutional and pakaging materials for PDPT and interviews to assess the effetiveness, aeptability and usability of the prototype materials. Themati qualitative data analysis was used to examine interview responses. Results: Partiipants were willing to deliver and reeive PDPT and several potentially important related beliefs were identified. Partiipants indiated substantial unfamiliarity with words assoiated with STI treatment and some variability in definitions of sex partners. PDPT informational materials differentially affeted partiipant willingness to reeive (positively) and deliver (negatively) PDPT, positively influened self-effiay and understanding and were pereived as easy to use. Disussion: PDPT reates omplex hallenges for eduation, motivation and ommuniation. Issues suh as appropriate voabulary and interpersonal trust may be amplified when responsibility for a medial proedure dispensation of treatment is shifted to patients. STI PDPT implementation an be augmented with effetive, high-quality informational and pakaging materials; however, several hallenges exist. Untreated partners ontribute to the high rates of re-infetion among individuals with urable sexually transmitted infetions (STI). 1 However, studies of partner notifiation servies found that as few as 20% of ases were atually interviewed by a publi health worker. 2 A potential solution to reduing re-infetions and additional transmissions is for index patients to deliver antibiotis to their partners. Suh patient-delivered partner therapy (PDPT) shifts servies usually provided diretly by a healthare professional to patients themselves (although partiipants in PDPT are enouraged to be medially evaluated). 3 5 PDPT appears to be a ommon but informal pratie and is illegal or legally ambiguous in some areas. 6 9 Guidelines for PDPT implementation exist and it is presently reommended for unompliated gonorrhea and hlamydia infetions with populations other than men who have sex with men. 1 7 Three randomised ontrolled trials and two observational studies have found various forms of PDPT to be effetive for improving partner treatment for gonorrhea and hlamydia, although not all demonstrated statistially signifiant redutions in reinfetion rates Widespread, effetive implementation of PDPT is ontingent upon patient and partner willingness to partiipate: patients must deliver the mediine and partners must take it. A reent survey of the general population in the USA reported that healthare onsumers appear quite willing to partiipate as both deliverers and reeivers of PDPT, with the majority of partiipants indiating a strong willingness to partiipate. 3 It seems reasonable to suggest that pereptions of pakaging and instrutions aompanying PDPT mediine may affet willingness to partiipate as either a reeiver or a deliverer, and Tun and olleagues 15 provide some support for this possibility; however, no researh exists that examines the design and evaluation of informational and pakaging materials that aompany PDPT mediation or presriptions. To address this gap, an established, user-entered, iterative development methodology was used in ombination with qualitative researh onduted in a lini setting to develop and evaluate prototype information and pakaging materials to support PDPT delivery. This researh was onduted in three phases. In the first phase, patient and partner needs were determined by qualitatively examining attitudes and beliefs regarding PDPT as well as an understanding of STI-related onepts and terminology. In the seond phase, materials and pakaging were formatively developed. Finally, in the third phase, the materials were evaluated in a lini setting. METHODS Partiipants Partiipants were patients aged years attending an urban STI lini in Indianapolis, Indiana, USA. Sixteen men and 16 women partiipated in phase 1; three men and two women partiipated in phase 2 and 13 men and 14 women partiipated in phase 3. Forty-four per ent of the overall sample were Spanish-speaking Latino/a men and women (n = 28), whereas the remainder were English-speaking Afrian Amerian (n = 18) or white (n = 18). Proedure Patients were reruited from the lini waiting room by a researher and taken to a private room to omplete a minute individual interview. 150 Sex Transm Infet 2009;85: doi: /sti

2 Figure 1 Images of mok patient-delivered partner therapy pakaging. Interviews were onduted in the partiipant s primary language (English or Spanish), were digitally reorded and were later transribed for analysis. Partiipants were enrolled until themati saturation was reahed; that is, no new themes were emerging from the data. Partiipants reeived US$20 for their time. The study was approved by the Institutional Review Board at Indiana University/Purdue University at Indianapolis. Measures Semistrutured interview guides were designed for the study. In phase 1, partiipants responded to two ounterbalaned hypothetial situations: delivering presription mediation intended to treat hlamydia to a partner and reeiving suh mediation from a partner. Questions probed willingness, attitudes and beliefs regarding PDPT as well as understanding of words and onepts frequently enountered during STI PDPT implementation. In phase 2, the researhers drew upon the phase 1 results, published guidelines, existing mediation instrution and warning information and subjet matter expert input to generate prototype STI PDPT informational materials and pakaging. Development goals inluded low literay aessibility (6th grade or less) in both English and Spanish, ulturally appropriate phrasing, inonspiuousness and ease of use. The resulting mediation pakage inluded bakground information regarding PDPT, disease information, mediation usage instrutions, advie to seek further testing and soures for additional information. A prototype was evaluated by additional lini volunteers for aeptability, readability and omprehension, and was then modified for use in the phase 3 evaluation. In phase 3, partiipants followed a similar protool to phase 1, with the key differene being that when presented with the hypothetial situations, they were also given the PDPT information and pakaging prototype. As in phase 1, willingness, attitudes, beliefs and understanding were assessed. In addition, questions speifi to the impat, usability and understanding of the materials were asked. Analyses Spanish interviews were translated to English for analysis by a native Spanish speaker who onduted the interviews. In both phases 1 and 3, data were analysed to identify themes assoiated with the intention to deliver and reeive PDPT mediation. In Table 1 Desription of patient-delivered partner therapy pakaging ontent, by page Page no Content 1 Cover: This pamphlet ontains important information regarding your health (English and Spanish) 2 Introdutory information and a warning to read all information before taking mediine (English and Spanish) 3 What s this all about? You may have hlamydia and this mediine an ure you (English and Spanish) 4 What s hlamydia? (English and Spanish) 5 What else should I know? (English and Spanish) 6 Frequently asked questions (English) 7 Frequently asked questions (Spanish) 8 Warnings (English) 9 Warnings (Spanish) 10 What should I do? (English and Spanish) 11 This is your mediine (English and Spanish) 12 Be safe, get tested, get treated. Make a differene. Contat information (English and Spanish) the first stage of this analysis, open oding identified broad themati ategories within the partiipant responses. Subsequently, the oding sheme was revised to identify and organise subategories, eah representing speifi themes within the broader ategories. Finally, eah interview was annotated with these resulting ategories and subategories. Summary statistis were generated for ategory ounts as well as for phase 3 quantitative data from ratings and similar items. RESULTS Phase 1 Partiipants in phase 1 were largely willing to deliver mediation to a sex partner(s) (87.5%), but fewer partiipants were willing to reeive mediation from a sex partner (57%). Benefits most frequently assoiated with both PDPT reeipt and delivery were onveniene and ost. Lak of trust in a partner and the ontext of the relationship (eg, asual partner) were the primary reasons for being unwilling to reeive mediation from a partner. Partiipants also ited the need for testing and treatment by a healthare provider before reeiving treatment. In relation to the willingness to deliver, many partiipants indiated that they would make an effort to deliver mediation to sexual partners but that delivery would be ontingent upon the ability to ontat their partner(s). Partiipants also mentioned produt safety as a major onern in terms of delivering the mediine, partiularly the potential for side effets and allergi reations, whih is interesting beause this theme did not arise in relation to reeiving the mediine. Several partiipants indiated that they would not deliver PDPT beause presription mediation should only be dispensed by a healthare provider. Partiipant understanding and appliation of ommonly enountered sexual health-related onepts and terms was highly variable, espeially definitions of sex and sex partner. Many partiipants applied the term sex partner, for example, only to a asual partner (ie, one night stand), whereas others used the term for a long-term partner only (ie, boyfriend/girlfriend), whih suggests the need to larify the terms during use. There was also a general lak of understanding of terms related to STI diagnosis and treatment suh as azithromyin or asymptomati. Several partiipants did not understand bateria and infetion. Sex Transm Infet 2009;85: doi: /sti

3 Table 2 Phase 3 interviews: pereptions of reeiving and delivering patient-delivered partner therapy Phase 2 The prototype PDPT information and pakaging is shown in fig 1. The final pakage was a inh stapled pamphlet ontaining six pages (12 printed sides). Mediation was inorporated into the bak page of the pamphlet, as a pushthrough-type blister pak. For the phase 3 evaluation efforts, the mediation was represented by printed azithromyin tablets rather than the atual mediation. Pamphlet ontent is delineated in table 1. More information regarding the development proess and a portable doument file (PDF) of the prototype are published as a supplement available online only. Phase 3 Phase 3 repeated the phase 1 audiene analysis by again exploring willingness, attitudes and beliefs regarding PDPT Yes No It depends Don t know Reeiving mediation Q1: Would you take this mediine? 24 (88.9) 3 (11.1) Yes, if it is reommended by dotors and nurses it is OK. Yes, if it is going to help ure it. If you are going to be sexually ative with people you shouldn t walk around with an STD. No, I would want to get heked first. Q2: Is it OK for a sex partner to give you presription mediine for an 17 (63.0) 9 (33.3) 1 (3.7) STD? Is it legal? That is going to be my first question. Yes, as long as it is labelled and says what it is. No, beause it might not be right for my body. The dotor should give it. Q3: Would you trust your sex partner giving you mediine? 9 (33.3) 17 (55.6) 1 (3.7) No one you find out that your partner has an STD, the trust fator is gone. I wouldn t trust him to give me mediine. No, I want to know exatly what I am taking. It depends on the situation. Delivering mediation Q4: Would you take mediine to a partner if you were in this situation? 13 (48.1) 13 (48.1) 1 (3.7) Yes, it is a ure. It s free. If there was a hane they had it. It depends on how long I had been with that partner. No, I would want them to get tested to make sure they need the mediine. Q5: If your partner didn t take the mediation would you have sex with 2 (7.4) 25 (92.6) them? No, I don t want to be re-infeted. No, beause they an give me hlamydia again. And, I feel like if they were really in love with you, they would do it to help themselves. No, beause if I am infeted then they probably are too and what is the point of taking the mediine only to get re-infeted. Q6: If you had sex with more than one person, would you give mediine 16 (59.3) 11 (40.9) to everyone you had sex with? No, it is better to send them to the lini. Yes, if I had enough. No, I want them to get tested before they take any mediations. Q7: If you deided not to tell your sex partner that you had an STD, 12 (44.4) 15 (51.9) would you have someone else tell them for you? No, I would have to do it. Yes, a friend, lose friend or brother or sister. Yes, a physiian. delivery and reeipt, this time in the presene of the PDPT materials. Partiipants pereptions of those materials were also assessed. Primary outome measures inluded pereived ease of use, impat on PDPT performane and partiipants understanding of the materials. Reeiving Eighty-nine per ent of partiipants in phase 3 indiated that they would be willing to reeive mediation from a sex partner, with the primary reason for doing so being their own health. Among those who said they would deline the mediine, all ited the need to seek servies from a healthare provider as a primary reason. Themes were similar to phase 1. More than half of partiipants indiated that they would not trust their sex 152 Sex Transm Infet 2009;85: doi: /sti

4 Table 3 Willingness to partiipate in patient-delivered partner therapy, by phase Ation/phase Phase 1 (%) Phase 3 (%) Willingness to deliver Willingness to reeive partner to give them mediine. The most ommon reason for lak of trust was the impliation of infidelity assoiated with a STI diagnosis. Partiipants frequently stated that if a partner ould not be trusted to be monogamous then mediation reeived from that partner ould not be trusted. Other partiipants noted that they would be less likely to trust a asual partner ompared with a long-term partner. Apparent among both of these groups was the fear that partners might provide an illegal drug or unknown mediation that ould pose a danger to health. Another reason for lak of trust was assoiated with pereptions of legitimay. Individuals noted that their partner not being a healthare provider meant that they were not viewed as a legitimate soure of treatment. These partiipants viewed testing and treatment by a healthare provider as the only legitimate form of are. However, two-thirds of partiipants believed that it was OK to reeive mediation from a sex partner. The remaining third ited the potential for adverse reations (eg, drug allergies) and the need for testing and treatment by a healthare provider as reasons for believing that PDPT was not OK. Delivering Fewer than half of the respondents (48%) said that they would be willing to deliver mediation to a sex partner. Among these, the majority said that they would do so beause they would Table 4 Question want their partner(s) to be treated (see table 2). Partiipants also ited ost and onveniene as fators influening willingness to deliver. Of the partiipants who said they would not be willing to deliver the mediation, the primary reason was the belief that the partner needed to be treated by a dotor. Both testing and the idea that mediations should not be taken unless needed were primary themes among non-deliverers. Several themes not present in the first phase data also emerged: the legality of PDPT was questioned by some partiipants who noted that they would deliver mediation only if it was legal. Although stigma was not assessed diretly in relation to the willingness to deliver mediation, we did ask partiipants what would be the hardest part about delivering the mediine to a partner? The majority indiated that the stigma assoiated with having a STI and the assoiation of STI with sexual nonmonogamy were signifiant barriers. Themes related to embarrassment and shame were ommon, as were themes related to relationship infidelity blame. Beause sex with untreated partners ontributes to high reinfetion rates, we assessed individuals intent to have sex with an untreated partner. When asked if they would have sex with their partner again if the partner did not take the mediation, 93% of partiipants responded no, iting re-infetion as the primary fator, whih mirrored the phase 1 results. In order to explore the signifiane of multiple sexual partnerships on the willingness to deliver mediation, we asked partiipants if they would give mediation to all their sex partners in the event that they had more than one partner. Sixty per ent of partiipants said they would take mediation to eah of their sex partners. The primary reason for doing so was the desire for that person to reeive treatment. The majority of those who delined delivery did so beause they believed that their partners needed to be seen by a healthare provider. Phase 3 examples of qualitative information regarding patient-delivered partner therapy pakaging Q1: Now that you have read the information, what do you think it means? It is an explanation to someone who may or may not be sure they have the disease of what they should do and what they should inform their partner of. (Afrian-Amerian man, 25) Information about the mediine and how to prevent ontrating hlamydia. (Hispani man, 36) It is trying to make people aware of the infetion alled hlamydia. How long you an have it, some of the symptoms and the mediine that ures it. (Afrian-Amerian woman, 33) Q2: What are the three most important things that this pakaging is trying to tell you? Get tested. There is a ure for it. Call the lini. (Hispani woman, 35) Pratie safe sex. Get tested for diseases. Safe way to take the mediine. (White man, 22) Symptoms. How you an ure it. How it is spread. (Afrian-Amerian woman, 27) Q3: What did you like MOST about the pakaging? It gives you the information that hlamydia doesn t always have symptoms. (Afrian-Amerian woman, 21) Information about getting heked, that it is urable and the number to all. (White man, 40) Easy to read. (White woman, 21) Q4: What did you like LEAST about the pakaging? I have no lue what the names of the mediation are. (White man, 40) Not knowing how to pronoune the words. (Afrian-Amerian man, 21) Nothing. It was pretty self-explanatory. (Afrian-Amerian woman, 20) Q5: What would you CHANGE about the pakaging? More desriptive about symptoms. (Afrian-Amerian woman, 25) How to pronoune the words. Maybe written in the margins or something. (Afrian-Amerian man, 21) Nothing. Any information about a disease is good. (Afrian-Amerian woman, 32) Sex Transm Infet 2009;85: doi: /sti

5 To understand better the potential resoures for partner notifiation, we asked partiipants who they would ask to notify a sexual partner about a potential STI. Although 44% of the sample said no-one, many of those responses were preeded by a omment that the partiipant would do it her/ himself. Of those who said they would have another person do it for them, the three most frequent resoures for notifiation were family members, friends and healthare providers. Pakaging materials The partiipants in both phases 1 and 3 were asked about their willingness to deliver and reeive PDPT. The primary differene between those phases was the presene of the materials in phase 3. Willingness to deliver was substantially lower in phase 3 than in phase 1, whereas willingness to reeive was substantially higher (see table 3). Moreover, 90% of partiipants agreed that the pakaging materials would make them more able to approah partners than if they had only a presription or mediine by itself. In addition, 89% of partiipants agreed or strongly agreed that the materials were easy to understand. To assess partiipants understanding of the pakaging information and pereptions of usability further, five open-ended items (see table 4) were used. Partiipants largely interpreted the materials to mean that they may have been exposed to hlamydia, a urable disease, and that the mediation provided with the materials was used to treat hlamydia infetions. Speifi themes entered around desriptions of hlamydia and its symptoms, mediation side effets and ontraindiations, the importane of testing and/or treatment and resoures for additional information. Partiipants also mentioned general messages suh as pratie safe sex and get tested regularly for STI. Aspets of the materials that partiipants liked most were also assessed. Most respondents indiated that they liked the information provided, frequently mentioning the details about hlamydia infetion and the mediation to treat infetion. A few requested additional information about side effets and mediation pronuniation. DISCUSSION Several issues of relevane to STI prevention and treatment efforts emerged. First, language and understanding is of onern. Some ommonly used phrases suh as sexual partner were insuffiient in that some partiipants did not identify asual sexual ontats as partners. This issue interseted with variation in definitions of sex as well as dereased motivation to deliver mediation to or reeive mediation from a asual partner. This suggests that PDPT may be more effetive for the prevention of re-infetions within more established relationships than for the prevention of additional transmission within Key messages Healthare onsumers are willing to partiipate in PDPT. Willingness appears to be related to partner trust, pereptions of mediation legitimay and onerns for produt safety. Partner informational materials positively affeted willingness to reeive PDPT but negatively affeted willingness to deliver PDPT. Further researh regarding patient, partner and perhaps provider informational and eduational materials is merited if PDPT pratie is to beome more widespread. sexual networks. Attention should be paid to inreasing patient and partner understanding through provider ounselling and/or PDPT materials. Seond, lini visitors appear willing to engage in PDPT and several potentially important beliefs were identified, inluding partner trust, mediation legitimay and the pereived need to see a provider before treatment. Stigma, in partiular, may be an important barrier to PDPT, espeially on the part of the mediation deliverer. Stigma in relation to STI are-seeking and treatment is well desribed but has reeived little attention in the emerging literature related to PDPT. This issue requires attention by providers in order to maximise the likelihood that the provided STI treatment will be delivered. Third, pakaging and instrutions appear to be important. There is presently no aepted standard for suh materials and we are unaware of any ommerially available pakaging or informational materials designed espeially for PDPT. Clinial trials and anedotal reports of typial PDPT pratie implement an array of solutions ranging from simply handing over presriptions and/or mediations, to using plasti or paper bags aompanied by typed materials, to more formal aompanying materials suh as letters on lini stationery. Previous studies suggest that a ertain level of home-made pakaging is suboptimal, reduing the likelihood of patient and partner partiipation. 15 In the present study, arefully designed informational materials affeted the willingness to reeive and, inversely, deliver PDPT as well as the themes identified in relation to suh willingness. Willingness to reeive may go up in the presene of ommerial materials beause pereptions of illegitimay of the mediation and other issues mentioned in the phase 1 data as reasons for not taking the mediine are, in fat, addressed and overome in the presene of arefully designed pakaging. On the other hand, having atual mediine in hand may deter willingness to deliver the mediine beause the situation beomes more real and the warnings and instrutions trigger patient retiene. Beause patients were handed the PDPT pakaging with little ontext and no ounselling, we believe the latter finding is of less onern than the former, whih strongly indiates that well-pereived materials may improve PDPT uptake among partners. The majority of partiipants also indiated that suh materials would make it easier to approah partner(s). The study sought to explore several subjetive aspets of PDPT and to develop and evaluate prototype PDPT materials formatively. The researhers did not expet or intend a representative sample. The data are intended to portray issues that must be addressed in the suessful implementation of PDPT and to provide guidane for the future development and use of PDPT informational and eduational materials. Feasibility and dissemination researh is not addressed here. The materials used were designed to be information plus mediation pakaging in one solution. This approah has merits but faes signifiant, although not insurmountable, manufaturing and regulatory hurdles; alternatively, the information omponents ould be presented as standardised trifold brohures, a move that sidesteps the manufaturing issue but leaves pakaging to individual praties. Further researh is required to determine the most optimal and adoptable solutions. CONCLUSION PDPT is an aeptable and effetive alternative linial pratie for partner treatment, the implementation of whih is 154 Sex Transm Infet 2009;85: doi: /sti

6 ontingent on omplex issues surrounding patient and partner willingness, attitudes and beliefs. Carefully developed informational materials appear to foster PDPT partiipation, although their relationship with willingness appears omplex. Appropriate investment in researh-based provider training and patient support, as well as the development of standardised pakaging and/or information materials is neessary if PDPT is to be maximally effetive. Well-designed, professional-appearing PDPT materials will improve partiipation. However, given the omplex interpersonal issues involved in patient delivery and partner reeipt, suh improvements may be best realised as part of a broader system of adoption and implementation strategies and tools, addressing the needs of patients, partners and providers alike. Aknowledgements: The authors would like to thank Arturo J Carrillo for onduting and transribing the Spanish-language interviews. Funding: This study was supported in part by ontrat no M from the Centers for Disease Control and Prevention (CDC). The information and opinions expressed herein do not neessarily reflet those of the CDC. Competing interests: None. Ethis approval: The study was approved by the Institutional Review Board at Indiana University/Purdue University at Indianapolis. Contributors: KMB partiipated in protool design and onduted the qualitative interviews and, along with JDF, the analysis. RCG and JDF jointly oneived of the researh efforts and guided protool development. RCG is the prinipal investigator and has direted the design and evaluation of the materials. REFERENCES 1. Centers for Disease Control and Prevention, National Center for HIV STD and TB Prevention. Expedited partner therapy in the management of sexually transmitted diseases: review and guidane, EPTFinalReport2006.pdf (aessed 10 Feb 2008). 2. Golden MR, Hogben M, Handsfield HH, et al. Partner notifiation for HIV and STD in the United States: low overage for gonorrhea, hlamydial infetion, and HIV. Sex Transm Dis 2003;30: Goldsworthy RC, Fortenberry JD. Patterns and determinants of patient-delivered partner therapy uptake among healthare onsumers. Sex Transm Dis 2009;36: White PJ, Golden MR, Turner KM, et al. Can patient delivered partner therapy help us regain ontrol of sexually transmitted infetions in the UK? Sex Transm Infet 2006;82(Suppl 2):A2. 5. Golden MR. Expedited partner therapy for sexually transmitted diseases. Clin Infet Dis 2005;1: Golden MR, Anukam U, Williams DH, et al. The legal status of patient-delivered partner therapy for sexually transmitted infetions in the United States: a national survey of state medial and pharmay boards. Sex Transm Dis 2005;32: Hodge JG Jr, Pulver A, Hogben M, et al. Expedited partner therapy for sexually transmitted diseases: assessing the legal environment. Am J Publi Health 2008;98: Hogben M, MCree DH, Golden MR. Patient-delivered partner therapy for sexually transmitted diseases as pratied by U.S. physiians. Sex Transm Dis 2005;32: Rogers ME, Opdyke KM, Blank S, et al. Patient-delivered partner treatment and other partner management strategies for sexually transmitted diseases used by New York City healthare providers. Sex Transm Dis 2007;34: Ramstedt K, Forrsman L, Johannisson G. Contat traing in the ontrol of genital Chlamydia trahomatis infetion. Int J STD AIDS 1991;2: Kissinger P, Brown R, Reed K, et al. Effetiveness of patient delivered partner mediation for preventing reurrent Chlamydia trahomatis. Sex Transm Infet 1998;74: Golden MR, Whittington WL, Handsfield HH, et al. Partner management for gonooal and hlamydial infetion: expansion of publi health servies to the private setor and expedited sex partner treatment through a partnership with ommerial pharmaies. Sex Transm Dis 2001;28: Golden MR, Whittington WLH, Handsfield HH, et al. Effet of expedited treatment of sex partners on reurrent or persistent gonorrhea or hlamydial infetion. N Engl J Med 2005;352: Kissinger P, Mohammed H, Rihardson-Alston G, et al. Patient-delivered partner treatment for male urethritis: a randomized, ontrolled trial. Clin Infet Dis 2005;41: Tun W, Walsh C, Siller J, et al. Aeptane of patient-delivered partner-therapy for syphilis among men who have sex with men (MSM). Proeedings of the 2004 National STD Prevention Conferene; 8 11 Marh 2004, Philadelphia. Atlanta: Centers for Disease Control and Prevention, Goldsworthy RC, Kaplan B. Warning symbol development: a ase study on teratogen symbol design and evaluation. In: Wogalter MS, ed. Handbook of warnings. Mahwah, NJ: Lawrene Erlbaum, 2006: Goldsworthy RC, Shwartz NC. Preliminary development and evaluation of a multimedia enhaned HIVSTD urriulum for middle shools. J Eduat Multimedia Hypermedia 2008;17: Sex Transm Infet: first published as /sti on 22 Deember Downloaded from on 13 April 2019 by guest. Proteted by opyright. Sex Transm Infet 2009;85: doi: /sti