Online sexual health services: examining youth's perspectives.

Shoveller, Jean ; Knight, Rod ; Davis, Wendy 等

Youth ages 15-24 account for a disproportionate amount of the sexually transmitted infections (STI) in British Columbia, particularly with regard to chlamydia and gonorrhoea for which rates are high and rising. (1) Accordingly, there are strong public health (and personal) imperatives to develop new approaches to engage sexually active youth in routine STI/HIV testing practices. (2-4) Unfortunately, youth participation in STI/HIV testing remains a public health challenge. (2-7) As a result, public health interventions have increasingly turned towards new media such as the Internet to reach populations at risk for STIs/HIV, such as through educational websites, online counselling and/or social networking websites. (8-13) Online STI/HIV testing services (i.e., online risk self-assessment with access to self-collection kits or downloadable laboratory requisition forms) (14) are a promising new approach for improving access to testing, and have proven to be a feasible method for reaching youth and identifying positive STI cases (e.g., Ottawa Public Health's newly launched website, Get Tested--Why not?). However, online sexual health intervention approaches are relatively new in Canada and have received little research attention especially in terms of youth's perspectives on their readiness to engage with online sexual health services. Thus, the current study was undertaken to examine youth's perspectives on: online STI/HIV testing services and online counselling and education services (e.g., online sexual health counselling through chat, forums, or e-mail; referrals to other services).

METHODS

Recruitment

Men and women between the ages of 15 and 24 years old were recruited to participate in in-depth, semi-structured interviews (lasting approximately 1 to 1.5 hours) through advertisements posted at clinical (e.g., youth health clinics) and non-clinical (e.g., bus stops; online websites such as Facebook[TM]) sites so as to include those who had and had not previously accessed STI/HIV testing. Eligible youth included those: between the ages of 15-24; sexually active; living in Metro Vancouver; English-speaking; and who had either tested or considered testing. A purposive sampling strategy included youth from a variety of socio-economic and cultural backgrounds as well as sexual identities. (15) The study received ethical approval from the University of British Columbia. Informed consent was completed prior to interviews. Unique identifiers were removed from transcripts and each participant selected a pseudonym for use in the study.

Interviews

Research staff scheduled interviews in our research offices to take place at a time convenient for participants. The interviews included questions about youth's previous experiences in using online services and their perspectives on their preferred online communication practices. The interview was structured to be sufficiently open-ended so that youth had the opportunity to suggest specific features of online approaches and to discuss how these features might address the unique needs of young people. We also asked youth to compare online services with face-to-face services. Participants received a CDN$25 honorarium and an information package detailing locations that provide sexual health services in Metro Vancouver.

Data analysis

Interviews were audio-recorded, transcribed and uploaded to QSR Nvivo[TM] software to organize the data. Using a grounded theoretical approach, transcripts were read and re-read by co-authors to employ constant comparative techniques16 to develop detailed descriptions of youth's perceptions of the factors that affect their capacity and willingness to use online testing services. (17) We also examined their preferred communicative practices when using online services to identify patterns across the sample's responses (i.e., themes) as the coding progressed. We compared and contrasted accounts provided by study participants (within and across interviews) with those previously described in the literature, looking for points of convergence/divergence. Our findings were derived using a combination of inductive and deductive analysis (e.g., concepts that emerged from our data were compared with findings from previous research), which contributed to our efforts to 'unpack' our own as well as other perspectives, including adult oriented constructions of key aspects of young people's social context (e.g., stigma; gendered stereotypes). (18)

RESULTS

Study participants

We interviewed 38 male-identified and 14 female-identified youth. See Table 1 for the self-identified socio-demographic characteristics of participants. See Table 2 for the previous STI/HIV testing status of participants.

The results describe youth's perceptions of online STI/HIV interventions and their self-reported comfort with the process of engaging with online services as well as the salience and credibility of the following online services: 1) online STI/HIV risk assessment (e.g., sexual history questionnaire) and testing (e.g., downloading laboratory requisition forms to indicate specimen collection protocol); and 2) online counselling and education services (e.g., live chat with a nurse; e-mail with a nurse; moderated forums).

Online STI/HIV risk assessment and testing

We asked participants to discuss their perceptions of online STI/HIV risk assessment (e.g., a sexual history questionnaire) and testing (e.g., downloading laboratory requisition forms to indicate specimen collection protocol). Nearly all participants explained that online testing offers: 1) the convenience of being able to bypass clinic visits, especially for asymptomatic and/or routine testing; and 2) the opportunity to access testing options immediately and privately, especially for symptomatic and/or other urgent testing needs. As a 23-year-old woman explained:

"One thing that appeals to me is that you could do it immediately, as opposed to having to book an appointment with a clinician and maybe you won't be able to do that for a few days. Especially if I was very concerned about something and wanted answers immediately."

In addition to convenient and immediate access, online risk assessment and testing was also perceived to offer an alternative to a face-to-face clinical appointment with a doctor or nurse, which was associated with reduced anxiety and enhanced privacy. For example, a 24-year-old woman explained:

"Some people would prefer the anonymity of going online... Talking face-to-face, it's a lot more intimidating, worrying about what the other person thinks, even though you are trying to get help from them. Whereas online, they don't really know you."

Online services were especially appealing to participants who had previously experienced anxiety during face-to-face testing. For example, a 22-year-old man said: "I would do it when I get home, if it was that easy, instead of going to a doctor. I hate doctors. It's like a phobia." However, a small subset of participants who had frequently engaged with clinic-based testing in the past doubted that online risk assessment could be as nuanced compared to clinical judgement within face-to-face sexual history taking. For example, another 22-year-old man explained:

"They have a way of probing. they will see, like, an expression on your face and they will know when you're not telling the entire story. There's just this whole array of things that they can do that some questionnaire can't."

Youth also cautioned that, despite online services' general appeal, in order to realize their full potential (and therefore attain/retain saliency and credibility), online services must fully 'harness' online technological capabilities. For example, a 24-year-old man explained with respect to downloadable requisition forms: "It would be nice if you didn't need to print anything out. If you could just e-mail it to the lab, and. then just kind of show up." Youth described themselves as technologically savvy with low tolerance for outdated approaches.

Online counselling and education

We also asked youth about online counselling and education services (e.g., live chat with a nurse; e-mail with a nurse; clinician-moderated forums). Almost all participants had positive responses with regard to being able to ask clinicians questions online, citing that they considered nurses valuable and trusted sources of information. Many youth expressed favourable attitudes towards live, one-on-one, online chats with a nurse. As one 23-year-old man commented: "The opportunity to go and chat with sort of a faceless person, I think would work for a lot of people. Even if that's just to instigate questions like 'Should I go to a clinic?' You can just ask online without having to go all the way there." Youth also said that online chats with nurses would be useful for getting answers quickly and in an anonymous way; they suggested that the chat format allows for clarification and expansion when desired and/or required.

In general, youth were less enthusiastic about the opportunity to communicate via e-mail with a nurse. Most participants did not perceive e-mail as fitting well with the realities of their generation's information-seeking preferences, primarily because e-mail lacks expediency. As one 19-year-old woman indicated: "I think the conception with e-mail is that you're gonna have to wait a couple days for an answer. And, when you're looking for an answer, that can seem like a year."

Youth had mixed responses with regard to clinician-moderated online forums: many indicated that they would read a forum (e.g., to learn about what other youth are asking; to view responses from both clinicians and other youth), but they would be unlikely to post a question or a response. For example, an 18-year-old woman said: "I would be more likely to read than to post. I guess I would just feel weird knowing that anyone else can read it. It would be a mental thing, even though they don't know who you are." Participants also viewed forums as: being potentially inconvenient to use (e.g., having to create an account); providing opportunities for the spread of misinformation that could be difficult to correct through clinician moderation (e.g., myths; practical jokes); and demanding a level of engagement with others that might not align with one's sense of privacy (e.g., having to 'put yourself out there').

CONCLUSIONS

Globally, pilot programs for Internet-based sexual health services such as online testing and partner notification have shown promising results. (19-22) Internet-based services typically include: online testing services (e.g., online risk assessment questionnaires; downloadable lab test requisition forms); online counselling and education (e.g., online sexual health counselling through chat, forums, or e-mail; referrals to other services); and online partner notification (e.g., online greeting cards sent peer-to-peer with personal messages or anonymously). Youth (age<25) and MSM* have been shown to be particularly receptive to internet-based services. What has yet to be fully appreciated is how important social factors (e.g., social norms; stereotypes about men's and women's responsibilities for sexual health) affect experiences with online STI/HIV testing (particularly for youth).

The findings of the current study point to the importance of considering the effects of youth's social environments during the development and implementation of online STI/HIV testing services. Within the social realm, the intersections of multiple factors (e.g., one's gender, socio-economic status, sexual identity) are important influences on face-to-face clinical encounters; (2-4) how these forces relate to youth's experiences with online testing is only now beginning to receive research attention. However, as the findings of our study illustrate, youth appear to be familiar with, receptive to and have an affinity for online interventions; moreover, they are ideally positioned to contribute much-needed knowledge in this area. The current study highlights the ways in which online STI/HIV risk assessment and testing as well as online counselling and education can enhance opportunities for low-threshold service provision (e.g., services that appeal to youth's needs for convenience, privacy, expedient access). However, seeking STI/HIV testing remains a deeply stigmatized behaviour, (2-4) a reality that is unlikely to be fully remedied by online services (e.g., face-to-face enactments of judgemental attitudes can also be represented online through a text-based medium). Without an examination and accommodation of youth's perspectives on the saliency and credibility of online approaches, we risk exacerbating (or at the very least paralleling) the complaints of the "Millennial" or "Net" generation regarding existing STI/HIV testing services. (15) As well, our study illustrated the relatively low level of tolerance that youth appear to have with regards to the use of technologies that youth perceive to be antiquated (e.g., printing lab requisition forms), revealing the challenges of designing online approaches that will not quickly become outdated.

While face-to-face interactions have the benefit of being contextualized by body language, conversation flow, and setting (be they positive or negative), online interactions are constructed and interpreted differently. (17,23) Thus, the intersections of the social and the technical aspects of online approaches need to be investigated, especially as they pertain to sensitive matters like STIs in youth populations, in order to avoid reinforcing or exacerbating youth's disaffection for current STI/HIV testing services. (24) While previous reports describe online interventions (e.g., static website content; interactive question/answer sections of webpages; online risk/knowledge assessments; personalized e-mail outreach; and live chat room), (15,25) few have characterized what should be considered 'effective' from youth's perspectives.

Online STI/HIV testing is relatively new within the Canadian context. For example, the BC Centre for Disease Control (BCCDC) is developing a new Online Sexual Health Services Program (OSHSP). Insights generated through research with youth populations will be helpful, and by focusing on youth as one important audience for the OSHSP, the BCCDC is responding to the needs of a subgroup of the population that could benefit from Internet-based interventions in unprecedented ways (over 90% of Canadian youth aged 12-29 have used the Internet recently). (26,27) For example, the new information generated during the current study could be used to develop new training resources to help clinicians reshape their own practices to complement online services and to respect contemporary youth culture. Also, because many previous studies have focused on youth's engagement with clinics, general practitioners and/or family doctors, (2,28,29) with prevailing commentaries focusing on a lack of fit between existing services and youth's needs, our findings offer some much-needed empirical evidence about new avenues--specifically, new sites where youth might reasonably be expected to go in order to seek help with sexual health concerns, especially in our contemporary, net-savvy world.

There are several limitations to this study design, including: sampling and participation biases; socially desirable responses; and relatively small sample size. Consequently, 'saturation' could not be reached, as our sample of youth does not fully reflect all possible variations among this group (especially the multi-faceted intersections of social positioning and geography).

Acknowledgements: This study was funded by the Canadian Institutes of Health Research (CIHR). We are thankful to the youth who took part in this study. Dr. Shoveller holds a CIHR/PHAC Applied Public Health Chair.

Conflict of Interest: None to declare.

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Received: May 19, 2011

Accepted: July 12, 2011

Jean Shoveller, PhD, [1] Rod Knight, MSc, [1] Wendy Davis, BSc, [1] Mark Gilbert, MD, MHSc, [2] Gina Ogilvie, MD, MSc [2]

Author Affiliations

[1.] School of Population and Public Health, University of British Columbia, Vancouver, BC

[2.] BC Centre for Disease Control, Vancouver, BC

Correspondence: Jean Shoveller, School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Tel: 604-822-3724, Fax: 604-822-4994, E-mail: jean.shoveller@ubc.ca

* MSM: men who have sex with men. Table 1. Self-identified Socio-demographic Characteristics of Participants Male Female Total (n=38, 73%) (n=14, 27%) (N=52, 100%) n % n % n % Age group (years) 15-18 7 13.5 4 7.7 11 21.1 19-24 31 59.6 10 19.2 41 78.9 Ethnicity Aboriginal 4 7.7 2 3.8 6 11.5 East Asian 6 11.5 2 3.8 8 15.4 Euro-Canadian 18 34.6 8 15.4 26 50 South East Asian 2 3.8 0 0 2 3.9 Other 8 15.4 2 3.8 10 19.2 Country of birth Canada 22 42.3 10 19.2 32 61.5 Other 16 30.8 4 7.7 20 38.5 Length of stay in Vancouver <1 year 7 13.5 2 3.8 9 17.3 1-5 years 13 25 3 5.8 16 30.8 5-10 years 6 11.6 1 1.9 7 13.5 11-15 years 4 7.7 0 0 4 7.7 >15 years/Entire life 8 15.4 8 15.4 16 30.8 Living arrangement Alone 4 7.7 0 0 4 7.7 University residence 5 9.6 3 5.8 8 15.4 With friends 15 28.8 1 1.9 16 30.8 With parents/family 11 21.1 7 13.5 18 34.6 Other 3 5.8 3 5.8 6 11.6 Sexual orientation Bisexual 6 11.5 1 1.9 7 13.5 Gay 7 13.5 1 1.9 8 15.4 Lesbian 0 0 1 1.9 1 1.9 Straight 25 48.1 10 19.2 35 67.3 Two-spirit 0 0 1 1.9 1 1.9 Current sexual activity Not currently sexually 12 23.1 3 5.8 15 28.8 active With one partner 13 25 9 17.3 22 42.3 With more than one partner 13 25 2 3.8 15 28.8 Table 2. STI Testing Status Male Female Total (n=38, 73%) (n=14, 27%) (N=52, 100%) n % n % n % Tested previously No 14 26.9 4 7.7 18 34.6 Yes 24 46.2 10 19.2 34 65.4 Male Female Total (n=24, 71%) (n=10, 29%) (N=34, 100%) Last tested Within 1 month 6 17.6 4 11.8 10 29.4 Within 6 months 9 26.5 4 11.8 13 38.2 Within 1 year 6 17.6 2 5.9 8 23.5 1 year or more 3 8.8 0 0 3 8.8