Buhi, Eric R. MPH, PhD*; Klinkenberger, Natalie MPH†; Hughes, Shana MPH*; Blunt, Heather D. MPH*; Rietmeijer, Cornelis MD, PhD, MSPH‡
From the *University of South Florida, Tampa, FL; †Physicians for Peace, Norfolk, VA; and ‡Colorado School of Public Health, University of Colorado Denver, CO
The authors thank Patricia Albright, BSN, MPH, FNP-BC, Suzy Reiter, MM, MSN, SANE-A, FAANP, and other staff at the Largo Center of Pinellas County Health Department. This research would not have been possible without their assistance.
Conflicts of interest and sources of funding: This research was supported by an American Sexually Transmitted Disease Association (ASTDA) Developmental Award. The authors have nothing to declare.
Correspondence: Eric R. Buhi, MPH, PhD, Department of Community and Family Health, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC 56, Tampa, FL 33612. E-mail: email@example.com.
Received for publication February 17, 2012, and accepted June 13, 2012.
Young people are disproportionately affected by sexually transmitted diseases (STDs). Although young people comprise only a quarter of the US population, almost half of all new STDs in the United States are acquired by 15 to 24-year-old individuals.1 Teens are also prolific users and early adopters of digital communication technologies, such as text messaging (short message service, or SMS) and social networking sites (SNSs).2 The percentage of 12- to 17-year-old individuals who report using the Internet (at least occasionally) or SNSs (ever) or owning a cell phone is more than 90%, 73%, and 75%, respectively.3 Youths are using these technologies to learn about sensitive and often stigmatized topics such as sexual health and STDs.4–7 Some evidence suggests that teens prefer to receive this information through SMS and social media sites, owing to their convenience and relative anonymity.5,8,9
To better understand teens’ communication technology use and the opportunities it presents for STD prevention/sexual health promotion, we report data from the Communication Health and Teens study. This study examined sexual health risk differences between teens who reported meeting sex partners online and teens who did not.10 This article reports on adolescent technology ownership and preferred means of locating/receiving STD prevention/sexual health information.
From February 2010 to January 2011, all 13- to 19-year-old individuals presenting at a publicly funded teen clinic in Pinellas County, Florida, were recruited for this study. In total, 302 teens provided assent/consent and completed an audio computer-assisted self-interview (ACASI). Twenty-nine teens acknowledged some dishonesty answering the survey questions or that they had never had oral, vaginal, or anal sex, and were removed from the data set, leaving 273 teens who comprised the final sample. Table 1 displays demographic and sexual characteristics of the sample. Of all teens who responded, 98% had biologic STD data from this clinic visit. Of these teens, 12% and 3% had a current chlamydia infection and gonorrhea, respectively (overall current STD = 14%).
This study was approved by the institutional review board of the Florida Department of Health. For privacy, eligible and consenting/assenting participants were assigned a study ID number. Participants met with a clinician for a physical examination, provided a urine sample for chlamydia and gonorrhea testing using nucleic acid amplification tests, and completed a 15- to 20-minute ACASI.11–13 The study ID number was later used to anonymously link participants’ self-reported survey data to their biologic STD results. On completion, participants were offered a $25 gift card.
The ACASI included 25 questions on demographics, digital device ownership, online activities (Internet access/frequency of use, participation in online games, and SNS activities), and usage/frequency of communication modalities for socializing or communicating with friends.14 To assess feasibility and acceptability, teens were asked how likely they would be to use a text messaging service, podcasts, blogs and/or videos either through the Internet or a cell phone for sexual health messages and services. Data were analyzed using IBM SPSS Statistics 20.0 (http://www.spss.com/). To understand the likelihood of using different technologies to find answers to sexual health questions (compared between teens with and without a current biologic STD), 5 separate cross-tabulations were conducted using phi (Pearson coefficient of mean square contingency)—a measure of association based on χ2 test.15
Digital device ownership varied among teens (Table 2); however, almost all participants reported having a cell phone. Teens in this study were heavy Internet users; the majority (79%) reported daily Internet use, with 4 of 5 teens reporting ever having accessed the Internet from a mobile phone. Almost one-third of teens (31%) reported playing online games, and 8% reported participation in a virtual world, such as Second Life (available at: http://secondlife.com/) or Habbo Hotel (available at: http://www.habbo.com/). Of teens reporting playing online games, 61% reported playing at least once a week.
When queried about ways in which they were most likely to socialize or communicate with friends during out-of-school time, 85% of teens reported using text messaging (Table 3). Fewer teens reported communicating through wireless phone calling (8%) or SNSs (5%), although most teens reported having an SNS profile (95%). Facebook (60%) and MySpace (30%) were the most commonly reported SNSs; three-quarters of teens reported visiting SNSs either “several times a day” (51%) or “about once a day” (23%).
Use of SNSs for health-related activities was uncommon. Approximately 1 in 10 teens reported following a friend’s personal health experiences or updates, or posting comments, queries, or information about health or medical matters on an SNS. Fewer teens reported getting any sexual health information (7%) or starting or joining a health-related group (6%) on SNSs.
When asked about their likelihood of using different technologies to find answers to sexual health questions, participants reported they would be likely/very likely to use a text messaging service (50%), read a blog (48%), watch an online video, such as on YouTube (43%), watch a video on their cell phone (35%), or listen to a podcast (29%).
Compared with teens without an STD, teens with a current STD were more likely to report they would be likely/very likely to use a text messaging service to have questions about sexual health information answered (χ2(1, N = 266) = 4.21, P = 0.04). No additional statistical differences, according to STD result, emerged for the other methods (e.g., listen to a podcast or watch a video on the Internet).
This study demonstrates that teens in this sample were both technologically engaged and willing to use most of these technologies to find answers to their sexual health questions. Almost all teens in this sample owned a cellular phone, and 79% accessed the Internet at least once a day. The majority also had an SNS profile, which most teens visit daily. However, the preponderance of social communication outside of school hours occurred through text messaging, and it is SMS that the majority of teens reported being likely to use to obtain answers to questions about sexual health.
Other studies confirm that, among teens, SMS is an acceptable means of receiving sexual health information7,16–18 and that texting efforts to reach youths with sexual health information can increase knowledge about, testing for, and conversations around sexual health (although no studies to date have shown a change in behavior). These efforts typically involve programs that send predetermined messages to enrolled youths.17 There are other texting efforts in which youths initiate the conversation by sending their sexual health questions to designated text lines staffed with outreach workers.18,19 The impact of this latter approach has not been evaluated to date.
This study is the first, to our knowledge, to identify which specific technologies teens report being most likely to use to receive sexual health information, and to stratify that preference by sexual health risk, measured through biologic STD test results. However, the current research is limited by a relatively small sample size, recruitment at a single clinic site, and exclusion of youths who did not get tested for STDs or who were not sexually active.
The availability of current STD data is a unique feature of this study. Our finding that teens with a current STD are even more likely than other teens in the sample to use text messaging to receive STD prevention/sexual health promotion information suggests that this intervention modality would likely reach those teens at greatest risk. Moreover, as documented in this study, SMS has become an important communication modality among teens. In a typical day, 46% of 8- to 18-year-old individuals report sending text messages and send, on average, 118 messages.20 It appears health departments and other STD testing centers might capitalize on using SMS to communicate with young people who undergo STD testing, as this at-risk population is already using this modality and is open to it for such purposes.
Our findings suggest that next-generation STD prevention/sexual health promotion initiatives for teens must make use of newer communication technologies to maximize effectiveness. Despite the frequency with which teens access SNSs, they did not generally report obtaining sexual health information through those types of sites. The prevalence of communication via SMS among this priority population, as well as teens’ expressed preferences regarding accessing sexual health information, indicates that platforms deploying multiple technologies may be particularly successful. Specifically, SMS coupled with online blogs written in accessible language, and informational videos posted on Web sites like YouTube, may provide the anonymity and convenience teens value, while being interactive enough to respond to their informational needs.9
Research on the relationship between digital technology use and sexual health indicators should be conducted with larger and more statistically representative samples of youths, and should examine the modality of SMS, comparing the content, timing, and the ways in which teens receive the information (program- or youth-initiated) to determine what approach or combination of approaches produces the greatest impact. The great advantage of the new communication technologies that occupy such a prominent place in teens’ lives, such as texting and cellular Internet access, is their mobility. Sexual health interventions capitalizing on this mobility can not only reach those at highest risk but also go wherever the priority population goes. The opportunity to reach teens “where they are,” and thereby have a decisive real-time impact, has never been more feasible.
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