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Try out PMC Labs and tell us what you think. Learn More. In an outbreak of hepatitis A among men who have sex with men MSM in Berlin and , patients frequently reported anonymous sex and use of dating applications to meet sexual contacts, hampering tracing and vaccination of contacts.

Our objective was to evaluate dating apps and websites as a means of spreading prevention messages among MSM during the ongoing outbreak. Advertisements in different formats were placed on three MSM dating apps and eight websites for anonymous dating during three weeks in March and April We calculated frequency of shown and click-through rates CTR and investigated the independent effect of format and platform on the of clicks using a negative binomial regression model.

Dating apps provided a means to rapidly reach and influence a substantial of MSM in Berlin and should complement case-based contact tracing among MSM in outbreak settings. Clicking on depended on platform and format used. Hepatitis A is an acute infection of the liver, usually with a self-limiting course. Hepatitis A virus HAV is predominantly transmitted from person to person via the fecal—oral route, or through ingestion of contaminated food or water [ 1 ]. Sexually transmitted hepatitis A outbreaks among men who have sex with men MSM have been frequently described [ 2 - 5 ].

The disease is vaccine-preventable and the vaccine is highly effective [ 6 ]. In Germany, hepatitis A vaccination recommendations by the Standing Committee on Vaccination include people whose sexual behaviour increases the likelihood of exposure to HAV including MSM and this is therefore covered by health insurance [ 7 ]. Similar to other western European countries, Germany is a low-endemicity area and annual hepatitis A incidence was 0. In Berlin, 35—88 cases were reported annually between and incidence: 0.

The main preventive measure in hepatitis A outbreak control is tracing of household contacts and other close contacts and their subsequent vaccination with a two-dose regimen of inactivated hepatitis A virus within 2 weeks [ 9 ]. Berlin was affected by this outbreak from mid-November to the end of , peaking in early [ 11 ]. The outbreak in Berlin comprised cases, of them male. In detailed case interviews with a subset of cases, the interviewees often reported having multiple sex partners while they were infective, often anonymously, and facilitated by the use of geosocial networking smartphone applications dating apps.

Tracing of sexual contacts can be challenging when there are multiple and or anonymous sexual partners. This is of particular relevance for local public health authorities, where staff, money and time resources are often limited.

There is evidence that MSM seeking anonymous sexual contacts predominantly use Internet-based communication technologies which may therefore serve as appropriate tools to reach that population [ 12 ]. A recent study showed that MSM websites and smartphone applications are popular platforms to find sexual partners; in particular, Grindr, Scruff and PlanetRomeo are the three most popular apps across Europe [ 13 ].

This included the distribution of posters and postcards containing information about the outbreak and the importance of vaccination. Campaign material was distributed in gay clubs, darkrooms, saunas and other sex-on-premises venues in Berlin.

Furthermore, we launched an advertising campaign on dating apps and MSM websites to inform MSM in Berlin, including those seeking anonymous sexual contacts, about the ongoing outbreak and personal prevention measures. With the widespread availability of smartphones and Internet access, the use of mobile-accessible apps has increased dramatically over the last decade, and geosocial networking apps for MSM facilitating anonymous sexual activities are known as potential drivers of recent outbreaks of syphilis, shigellosis and hepatitis A in Europe [ 14 - 16 ].

However, there is limited evidence on how to use those tools effectively as an intervention during infectious disease outbreaks among MSM. We evaluated the use of dating apps and websites as a means of spreading prevention messages among MSM during an ongoing outbreak of Hepatitis A in Berlin.

In addition, we tried to assess the overall impact of the campaign with a survey during a popular gay-lesbian festival in Berlin. Our campaign consisted of three parts that took place on different and partly overlapping dates as shown in the timeline in Figure 1 : i a campaign launched on MSM dating apps and websites, ii advertising on websites of gay events and clubs and iii a poster and postcard-based campaign in clubs and sex-on-premises venues and during a gay-lesbian street festival.

For the campaign on dating apps and websites, we calculated the frequency of shown and click-through rates CTR and investigated the independent effect of format and platform on of clicks using a negative binomial regression model. on Grindr, PlanetRomeo and the website bundle were displayed with slightly differing running times between 10 March and 1 April week 10—13, the study period , targeted at users whose GPS was located within the geofence of Berlin at the time the ad was shown.

Geofencing of shown on the websites was based on browser submission of location city when a website was accessed. Tracking and counting of daily click s during the campaign was done by providers of the apps and websites using tracking pixels of the .

Ad formats used in a campaign on dating apps and websites about hepatitis A vaccination, Berlin, On Grindr, , banner impressions and 66, interstitial full-screen impressions were purchased. Interstitial full-screen covered the interface of their host app and were typically displayed at natural transition points in the flow of an app i.

The user had the choice to either tap on the full-screen ad and continue to its destination or close it and return to the app. Over PlanetRomeo and the website package, , impressions of different partial and full-screen were distributed. The bundle of websites included in the campaign consisted of gay online magazines as well as MSM social networking sites and dating websites: www. Scruff uses a free ad platform Benevol , available for non-profit and public health causes. Free of charge, geo-targeted are created with a self-service tool that requires a Google .

are deed by ing a picture and inserting a text line. Using the allows tracking of exact reach and engagement statistics of impressions and clicks which are updated on a daily basis during the campaign. Start and end dates of the Scruff campaign were not adjustable but automatically set to days; of impressions displayed during the campaign was not adjustable either.

To allow comparison between different digital media platforms, we included in the analysis only those statistics from Scruff that were obtained during the study period 10 March to 1 April. and statistics were recorded in spreheets containing the daily of impressions, clicks and daily click-through rates CTR; percentage of clicks among the total of impressions , stratified by ad size and platform each app and undifferentiated for the bundle of websites.

Data were obtained from each of the apps and from a marketing agency for the websites. from different sources were collated into one dataset containing of impressions, of clicks, CTR, ad size and platform specification by day of week. We considered the campaign on dating apps and websites as a cohort study of impressions where clicking on the ad was the outcome.

Because of overdispersion of the count data of clicks , a negative binomial regression model yielding incidence rate ratios IRR was used to investigate the independent effect of ad format banner, rectangle, full-screen and mobile media placement different apps vs website bundle on click s outcome variable.

Multivariable analysis was restricted to data obtained during the study period, when the campaign involved all media platforms. Model selection was performed by using the Akaike information criterion AIC within a stepwise regression procedure. Statistical ificance of the coefficients was determined using a z-score statistic. The model was adjusted for of impressions and for weekdays to control for potential variability in user behaviour causing different s of impressions and clicks.

Statistical analysis was carried out using Stata v. None of those collaborations involved any payments or fees. Overall, 13, postcards and posters, with the same de as the one used in the web campaigns, were distributed in gay clubs, darkrooms, gay saunas, pharmacies and shops between 5 May and 16 July Outcome variables that derived directly from the campaign i. Comprehensive website visitor tracking and traceback of the sources of website traffic was not possible. Impact was measured by the indirect consequences of the campaign including knowledge of the outbreak in the MSM community and decline in the of cases.

We determined the impact of the campaign with two following approaches, a survey at a gay-lesbian street festival and comparison of the outbreak course with other countries. The overall cost invested for both the digital and on-site campaigning was used to calculate the amount spent per impression digital and print material. We conducted a convenience-sampled face-to-face survey among male visitors of the festival during a large annual gay-lesbian street festival on 15 and 16 July The objective of the survey was to estimate the proportion of MSM who knew about the ongoing HAV outbreak, assess their source of information and estimate the proportion who got vaccinated as a consequence of the campaign.

Regular use of dating apps, MSM status and nationality were also covered. Participants were given the choice of answering 10 short questions by themselves on a tablet computer or via the interviewer. Descriptive analysis focused on differences in demographic characteristics and source of outbreak information. We conducted logistic regression analysis to investigate the independent effect of different outbreak information sources on whether participants reported to have been vaccinated within the last 6 months because of the campaign.

Routine and enhanced surveillance of HAV in Berlin was performed based on notification data, using the case definition for surveillance purposes in Germany [ 18 ]. Local public health authorities were requested to systematically collect additional information from HAV cases on sexual contacts and sex in non-household venues during the assumed infectious period [ 11 ].

Outbreak cases were defined as: a person notified with hepatitis A since 14 November and self-identified MSM or a person with an HAV outbreak sequence variant, or a person epidemiologically linked to such cases. The street survey was conducted within the framework of the German Infection Protection Act as part of an outbreak response and public health practice. Mandatory regulations were respected, and thus review by an ethics committee was not required. Dating apps are location-based services and use of GPS data happens within the framework of their terms and conditions that users agree to.

From 10 March to 1 April , a total of 1,, impressions and 8, clicks on apps and websites were counted, reflecting an overall CTR of 0. An average of clicks on per campaign day was achieved along the 23 days of the campaign Table 1. Evaluating the entire time that were placed on Scruff it continued for altogether days from 11 March to 18 June , a total of 5,, impressions and 7, clicks were achieved. The website campaign with banner- and rectangle-sized ran over 18 days 10 to 27 March on eight websites, resulting in clicks. In the negative binomial regression model, both the platform and the ad format were independent predictors of the of clicks.

Effects of those parts of the campaign were measured by of visits on the SOHSA HAV outbreak website after the campaign on dating apps and websites i. Since those two campaign branches ran on partly overlapping timeframes, their individual effects on the SOHSA outbreak visits cannot be clearly separated. A large share 1, visits was counted the day the Christopher Street Day parade took place in Berlin.

More than five weeks before that day, we had placed an ad on the website for this event. Because the English version of the website was only accessible through the German version, the of clicks counted on the English version was subtracted from the counts of the website in German language. From 1 August to 31 December , once all campaign elements had ended, the visits dropped to an average per week of 58 on the German version and 14 on the English version Figure 1.

In addition, approximately EUR were spent on the de of and copyright of pictures used. An average of EUR 0. For the postcard and poster campaign in sex-on-premises venues and clubs, an average of EUR 0. In Berlin, cases per month declined from an average of 18 outbreak cases during the peak months January to March to an average of six cases from April to December Case s in other affected European countries 21 countries, excluding Germany peaked from March through June with an average of cases per month and started to decline in July and August average case per month from July to December personal communication: Margot Einoder-Moreno and Ettore Severi, ECDC, May Figure 3.

Where month of onset was unavailable, month of sampling or month of receipt by the reference laboratory was used. More than , people were estimated to have visited the gay-lesbian street festival. The median age of MSM was 39 years range: 16—73 years; interquartile range 29—48 years which was similar to the age distribution of cases in the hepatitis A outbreak in Berlin data not shown. The sources of information were age-dependent. Overall We investigated the use of dating apps and websites to disseminate prevention messages to MSM during an outbreak of hepatitis A in Berlin focusing on the influence of ad format and media platform used.

A total of 8, clicks received during a 3-week campaign on dating apps and websites, a decrease of case s and a broad knowledge among the Berlin MSM community about the outbreak suggest that the campaign had a wide reach and notable impact. Measured in clicks, the reach of our digital media campaign probably outweighed the reach of other channels such as the distribution of information material in sex-on-premises venues and traditional contact tracing by local health authorities. We found that both ad size and platform used influenced the of clicks on an ad and the use of full-screen and the dating app Grindr were most successful in achieving clicks.

Being the largest international all-male mobile dating app, Grindr has been involved in health prevention and promotion in the past and enables its users to include information on their HIV status and the last testing date in their profile. It is conceivable that its users are more sensitised regarding health-related issues and that outbreak-related benefit from a general credibility concerning prevention campaigns for sexually transmitted infections.

Using more versatile analytics programmes in future interventions could provide more information on conversion rates percentage of visitors who took action on the target website such as viewing a specific , downloading a particular file, duration of stay on the website and thus help quantify the actual reach, although data protection issues need to be considered.

The marked decline in HAV cases among MSM in Berlin in mid-April following the mobile media campaign cannot be explained by the overall decline in cases in the European outbreak, in which peak and decline occurred later [ 10 ]. Fifteen per cent of MSM in the survey reported that they had been vaccinated against hepatitis A within the past 6 months as a consequence of our information campaigns digital and posters or postcards , although bias through selective participation in our survey must be considered. MSM who had been informed by their physician general practitioner or treating physician specialised in HIV and infectious diseases treatment about the outbreak reported more frequently that they had been vaccinated against hepatitis A.

This highlights the crucial role of physicians in vaccination awareness among MSM, but possibly also reflects the fact that medical advice usually directly precedes a vaccination and is therefore more readily recalled. However, our survey was conducted 4 months after the campaign on dating apps and websites during the Gay Pride week i. This may have led to an underestimation of the role of dating apps in the survey. Taking delays for incubation period into , there is an apparent temporal relationship of both HAV vaccination uptake and case decline with our campaign.

However, quantifying the effect of the campaign on dating apps and websites remains difficult, as it took place in the context of a wide range of activities and interventions throughout the first half of in Berlin including information and surveys among physicians, information of patients and the broader public via newspapers and radio. Furthermore, MSM visiting Berlin as tourists and getting vaccinated because of the campaign after their return home would not have been captured in our data on vaccination uptake.

Despite a strong decrease in the weekly hepatitis A case s in Berlin, the outbreak continued at a lower level throughout , which underlines that, in the context of an international outbreak, interventions cannot rely on local efforts alone. They require concerted international interventions and communication channels tailored to specific target groups.

This is of even more concern given the highly interconnected sexual networks among MSM in Europe. According to notification data data not shown , the vast majority of the Berlin HAV outbreak cases were infected in Berlin, suggesting that the threshold needed to lower the average of onward infections per HAV-infected person below one was not reached at the time. We therefore consider this as a useful communication tool for future large-scale international events like the gay pride festivals occurring throughout Europe. Close collaboration with venues and organisers of large events as well as local public health offices to provide broad and up-to-date information channels for visitors was an integral part of the campaigns and the outbreak interventions.

Future interventions should also consider and evaluate other potential ways of smartphone app campaigning such as sending inbox and push messages or video . Because a part of the purchased ad bundles were not customisable, not all combinations of ad format and media placement were used and different formats were not evenly distributed over the platforms. The of impressions or clicks does not correspond to the actual of people receiving or clicking on the respective . Multiple displays of impressions on the same device were limited to a maximum of three for certain platforms i. Grindr and PlanetRomeo , but not for others.

Likewise, multiple clicks caused by the same user cannot be excluded. In addition, users who did not click on the ad may still have benefited from seeing the key message and have pursued the issue in other ways. Furthermore, it remains unknown to which extend the clicks of an ad reflect preventive action by the user. However, disentangling single effects of multiple simultaneous interventions that were launched as part of an immediate outbreak response was not possible; we therefore had to use other, less well suited, surrogate parameters.

Our findings suggest that MSM dating apps and websites can be an effective tool to promote infection prevention campaigns in outbreaks, with the potential to reach also otherwise hard-to-reach MSM seeking anonymous sex.

The wide reach of our digital campaign — embedded in other outbreak control activities — was indicated by a decline in cases as well as an increase in HAV vaccination uptake and knowledge about the outbreak in the MSM community.

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