We explored STD (sexually transmitted disease) service preferences among 108 African-American adolescent males recruited from a high-morbidity neighborhood. Participants largely preferred to seek care at traditional STD testing venues (86.5%) rather than nontraditional venues. Additionally, most males preferred receiving STD test results from a clinician (61.1%) rather than online (11.1%) or through email or text message (12.0%). These results highlight the need for continued strengthening of traditional public health clinics to ensure capacity to meet young men's health needs and to improve outreach and access to traditional STD services for young men.
From the *San Francisco Department of Public Health, STD Prevention and Control Services, San Francisco, CA; †CSTE/CDC Applied Epidemiology Fellow; and ‡UCSF, Center for AIDS Prevention Studies, San Francisco, CA
Supported by an award from the UCSF Center for AIDS Prevention Studies (CAPS) Innovative Grants Program. Funding for CAPS and the Innovative Grants Program is provided by the United States National Institute of Mental Health (P30MH062246).
Correspondence: Kyle T. Bernstein, PhD, ScM, Epidemiology, Research and Surveillance, STD Prevention and Control Services, San Francisco Department of Public Health, 1360 Mission St, Suite 401, San Francisco, CA 94103. E-mail: email@example.com.
Received for publication May 26, 2011, and accepted January 5, 2012.
Although African-Americans account for a disproportionate percentage of sexually transmitted diseases (STDs) and HIV/AIDS cases in the United States,1 relatively little is known about the sexual health attitudes and service preferences of young African-American males. To aid local program planning and intervention development for this population, including planning for STD screening at alternative venues, we conducted a street-based intercept survey (the Viewpoints project) to assess preferences for services among young African-American men in a high-STD-morbidity neighborhood of San Francisco. The study neighborhoods have the highest adolescent rate of gonorrhea in San Francisco, the second highest adolescent chlamydia rate in the city.2 The area is characterized by high rates of poverty, crime, and unemployment3: 22.6% of families fall below the poverty level compared with 9.2% nationally.4
All Viewpoints participants were recruited in the southeast section of the city in June and July of 2010 and were eligible to participate if they were men who self-identified as residents of San Francisco, were African-American, and 15 to 24 years of age. We approximated a representative sample by mapping 13 recruitment routes that geographically covered the study target area, including both commercial and residential areas of the community (e.g., housing developments). Outreach workers walked these routes in the afternoon hours, systematically approaching all available young men, administering a brief eligibility checklist before acquiring verbal consent to participate. Participants self-administered a structured questionnaire on iPod Touch devices. Survey questions included sociodemographics, sexual behaviors, and preferences for STD service provision, including preference for venue, sample collection method, receipt of results, and partner notification services. Those completing the survey were offered a $10 gift card; those who chose not to participate were asked the reason for refusal. The study protocol was approved by the Committee for Human Research at the University of California San Francisco.
The team approached 193 potential subjects, of whom 34 subjects refused intercept (did not stop), and an additional 28 did not meet eligibility requirements. Among 131 screened and eligible men, 112 completed the survey. However, one survey was not saved correctly on the device, and 3 participants provided ineligible ages on the survey and were therefore not included in this analysis, leaving 108 (82.4% of eligible) participants completing the interview.
Most participants were aged between 15 and 21 years, and two-thirds were currently in school (Table 1). Nearly a quarter (26.9%) described their families as “Barely making ends meet” or “Poor and struggling.” About 4% of the Viewpoints participants reported male sex partners, and the mean age at first sex was 13.3 years (range: 6–23 years of age). Two-thirds of participants reported ever having been HIV tested, 73.2% reported ever having had an STD test, and 57.4% of participants reported being tested for an STD in the past year. Forty-two percent of Viewpoints respondents reported that they were “Very” concerned about STDs. However, only 11.1% described their STD risk as “High,” and nearly one-third of interviewed males said that they had no risk for STDs.
Male participants overwhelmingly reported that they would prefer to seek care at traditional clinical sites (86.5%), including general clinic or specialty clinics, such as STD or men's clinics, whereas a much smaller percentage would seek services only at nontraditional sites (8.7%), such as pharmacies, stores, schools, or work. Just under 5% would go to either a traditional or a nontraditional venue. Of those who had been tested for an STD, most (63.9%) were last tested in a traditional medical setting. Participants were also asked about their preferences for collection and drop-off of urine samples for STD testing: 43.5% preferred to collect urine at a clinic and 31.5% at home. If they could drop off specimens for testing, most respondents preferred to drop off urine specimens directly at the clinic (59.3%). Of note, most (61.1%) participants preferred to receive STD results at a clinic visit, with only 11.1% preferring online test results and another 12.0% preferring text message or email results.
Although others have found that young men underutilize clinical and public health resources,5–7 many of the Viewpoints participants have been tested and expressed interest in future testing. The majority (73.2%) said that they would get tested for an STD in the coming year, and an even larger proportion (88.9%) would get tested if they had an STD symptom. This finding has implications regarding young men's motivations for going to STD clinics, indicating that their use of clinical services may be in response to a current STD more often than a preventive measure. The young men participating in the Viewpoints study also seemed to be responsive to members of their social and sexual networks: 92.6% would get tested if their partner had STD symptoms, 89.8% would get tested if their partner reported having an STD, and 75.0% would get tested if a friend asked them to go with them for an STD test.
Our findings regarding venue preference are similar to a number of other studies of young, urban African-American men,8–11 in which men reported strong preferences for traditional testing venues and face-to-face contact with clinicians. Together, these studies highlight the importance of maintaining traditional venues, modes of STD testing, and STD result dissemination among young minority men. At the same time, providing a range of STD testing options is likely productive, with some studies also demonstrating that, despite a resounding preference for traditional testing sites, many at-risk young men are still open to community venues as possible alternatives8 as well as receipt of home testing kits.12,13
In addition, although young men in our study preferred to receive STD test results from a clinician as opposed to online or through text messaging, alternative uses of social media merit more exploration. Studies have demonstrated positive responses to new media services from both male and female youth.14–16 One such effort was SEXINFO, a sexual health text messaging service developed by the San Francisco Department of Public Health in response to rising gonorrhea rates among African-American youth. An evaluation of this service noted positive responses among both male and female youth to the possible incorporation of new media and technologies (such as alternative STD screening models) into existing public health service provision.14 Another study16 exploring reception to a Web-based test results system at an urban STD clinic among patients from diverse ethnic and racial backgrounds showed that as many as 74% of both young men and women used this method of obtaining results. However, the Viewpoints study showed that few African-American males in this setting preferred receiving test results through Web-based systems. This finding signals a need to be cognizant of differences in preferences and a need to continue to identify local preferences as services evolve to address the needs and preferences of local youth. The Viewpoints study provides some critical data regarding preferences for STD-related services in an understudied population; however, there are limitations to the study. The results may not be representative of all young males in the catchment neighborhood and may not be generalizable to other areas. At the same time, efforts were made to survey men systematically in both residential and commercial areas. The relatively small number of respondents prevented more complex analysis of the data, such as stratified analysis or multivariate modeling. Furthermore, our data measure only intentions and preferences and not actual behaviors. The population examined in Viewpoints may have little experience with newer modes of services, such as Internet-based testing and self-collection of specimens, and as a result may prefer more traditional services. It is possible that with more education and exposure to these modalities, the young men we surveyed may have a change in attitude and preference. Study strengths include the survey being self-administered and anonymous, on an easy to use and attractive ipod Touch device, which may increase the likelihood of accurate reporting of sensitive information.17
In sum, a combination approach that maintains the infrastructure of more traditional clinic-based STD services with the addition of innovative new media-based prevention options is likely to be most effective in reaching high-risk adolescents. The San Francisco Department of Public Health is using the results of this project to improve messaging around service availability in traditional clinical sites. Plans for the use of new media, as well as community-based screening projects in this community of young African-American males, are being reevaluated in light of the preferences indicated by the study participants. Evaluation of alternative screening and messaging approaches should continue; however, clinic-based services remain the cornerstone of youth prevention and merit continued support and improvement.
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