AIDS and Behavior

, Volume 13, Issue 3, pp 474–487 | Cite as

Effects of an Internet-Based Intervention for HIV Prevention: The Youthnet Trials

  • Sheana Bull
  • Katherine Pratte
  • Nancy Whitesell
  • Cornelis Rietmeijer
  • Mary McFarlane
Original Paper


Youth use the Internet and computers in unprecedented numbers. We have yet to identify interventions that can reach and retain large numbers of diverse youth online and demonstrate HIV prevention efficacy. We tested a single session condom promotion Internet intervention for 18–24 year olds in two RCTs: one sample recruited online and one recruited in clinics. All study elements were carried out on the Internet. Using repeated measures structural equation models we analyzed change in proportion of sex acts protected by condoms (PPA) over time. Among sexually active youth in the Internet sample, persons exposed to the intervention had very slight increases in condom norms, and this was the only factor impacting PPA. We saw no intervention effects in the clinic sample. Internet-based interventions need to be more intensive to see greater effects. We need to do more to reach high risk youth online and keep their attention for multiple sessions.


Internet and HIV prevention Randomized controlled trial HIV prevention and youth Technology-based HIV prevention 



We gratefully acknowledge the partnership of the Denver Public Health Department and Planned Parenthood of the Rocky Mountains for their collaboration in recruitment of the clinic sample. We also acknowledge the National Institute of Mental Health and our Project Officer, Dr. Willo Pequegnat, for their support of this research, NIH/NIMH -RO1MH063690 and R01MH063690-S.


  1. Albarracin, D., Fishbein, M., Johnson, B. T., & Muellerleile, P. A. (2001). Theories of reasoned action and planned behavior as models of condom use: A meta-analysis. Psychological Bulletin, 127, 142–161. doi: 10.1037/0033-2909.127.1.142.PubMedCrossRefGoogle Scholar
  2. Albarracin, D., Kumkale, G. T., & Johnson, B. T. (2004). Influences of social power and normative support on condom use decisions: A research synthesis. AIDS Care, 16, 700–723. doi: 10.1080/09540120412331269558.PubMedCrossRefGoogle Scholar
  3. Albarracin, D., McNatt, P. S., Klein, C. T., Ho, R. M., Mitchell, A. L., & Kumkale, G. T. (2003). Persuasive communications to change actions: An analysis of behavioral and cognitive impact in HIV prevention. Health Psychology, 22, 166–177.PubMedCrossRefGoogle Scholar
  4. Azjen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179–211. doi: 10.1016/0749-5978(91)90020-T.CrossRefGoogle Scholar
  5. Babbie, E. (2003). The practice of social research (9th ed.). Belmont, CA: Wadsworth Publishing.Google Scholar
  6. Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs, NJ: Prentice Hall.Google Scholar
  7. Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman.Google Scholar
  8. Benotsch, E. G., Kalichman, S. C., & Weinhardt, L. S. (2004). HIV-AIDS patients’ evaluation of health information on the Internet: The digital divide and vulnerability to fraudulent claims. Journal of Consulting and Clinical Psychology, 72, 1004–1011. doi: 10.1037/0022-006X.72.6.1004.PubMedCrossRefGoogle Scholar
  9. Bental, D. S., Cawsey, A., & Jones, R. (1999). Patient information systems that tailor to the individual. Patient Education and Counseling, 2, 171–180. doi: 10.1016/S0738-3991(98)00133-5.CrossRefGoogle Scholar
  10. Bernhardt, J. M. (2000). Health education and the digital divide: Building bridges and filling chasms. Health Education Research, 15, 527–531. doi: 10.1093/her/15.5.527.PubMedCrossRefGoogle Scholar
  11. Bowen, A. M., Horvath, K. J., & Williams, M. L. (2007a). A randomized controlled trial of Internet-delivered HIV prevention targeting rural MSM. Health Education Research, 22, 120–127. doi: 10.1093/her/cyl057.PubMedCrossRefGoogle Scholar
  12. Bowen, A. M., Williams, M. L., Clayton, S., & Daniel, C. M. (2007b, July). Efficacy of Internet delivered HIV risk reduction for rural who have sex with men in the USA. Presented to the AIDS Impact Conference, Marseilles, France.Google Scholar
  13. Bryan, A. D., Schmiege, S. J., & Broaddus, M. R. (2007). Mediational analysis in HIV/AIDS research: Estimating multivariate path analytic models in a structural equation modeling framework. AIDS and Behavior, 11, 365–383. doi: 10.1007/s10461-006-9150-2.PubMedCrossRefGoogle Scholar
  14. Bull, S. S., Levine, D. K., Vallejos, D., & Ortiz, C. G. (2008a). Improving recruitment and retention for an online randomized controlled trial: Experience from the Youthnet study. AIDS Care, 20, 887–889. doi: 10.1080/09540120701771697.PubMedCrossRefGoogle Scholar
  15. Bull, S. S., Lloyd, L., Rietmeijer, C., & McFarlane, M. (2004a). Recruitment and retention of an online sample for an HIV prevention intervention targeting men who have sex with men: The Smart Sex Quest Project. AIDS Care, 16, 931–943. doi: 10.1080/09540120412331292507.PubMedCrossRefGoogle Scholar
  16. Bull, S. S., McFarlane, M., Lloyd, L., & Rietmeijer, C. (2004b). The process of seeking sex partners online and implications for STD/HIV prevention. AIDS Care, 16, 1012–1020. doi: 10.1080/09540120412331292426.PubMedCrossRefGoogle Scholar
  17. Bull, S. S., Pratte, K., & McFarlane, M. (2008b). Measures of condom attitudes, norms and self-efficacy in two computer-based studies. Journal of Nursing Measurement, under review.Google Scholar
  18. Campbell, M. K., DeVellis, B. M., Strecher, V. J., Ammerman, A. S., DeVellis, R. F., & Sandler, R. S. (1994). Improving dietary behavior: The effectiveness of tailored messages in primary care settings. American Journal of Public Health, 84, 783–787.PubMedCrossRefGoogle Scholar
  19. Centers for Disease Control, Prevention. (1999). Community-level HIV intervention in 5 cities: Final outcome data from the CDC AIDS Community Demonstration Projects. American Journal of Public Health, 89, 299–301.CrossRefGoogle Scholar
  20. Centers for Disease Control and Prevention. (2008). HIV/AIDS surveillance report (Rep. No. 18). Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.Google Scholar
  21. Chang, B. L., Bakken, S., Brown, S. S., Houston, T. K., Kreps, G. L., Kukafka, R., et al. (2004). Bridging the digital divide: Reaching vulnerable populations. Journal of the American Medical Informatics Association, 11, 448–457. doi: 10.1197/jamia.M1535.PubMedCrossRefGoogle Scholar
  22. Chiasson, M. A., Parsons, J. T., Tesoriero, J. M., Carballo-Dieguez, A., Hirshfield, S., & Remien, R. H. (2006). HIV behavioral research online. Journal of Urban Health, 83, 73–85. doi: 10.1007/s11524-005-9008-3.PubMedCrossRefGoogle Scholar
  23. Devineni, T., & Blanchard, E. B. (2005). A randomized controlled trial of an Internet-based treatment for chronic headache. Behaviour Research and Therapy, 43, 277–292. doi: 10.1016/j.brat.2004.01.008.PubMedCrossRefGoogle Scholar
  24. de Vries, H., & Brug, J. (1999). Computer-tailored interventions motivating people to adopt health promoting behaviors: Introduction to a new approach. Patient Education and Counseling, 36, 99–105. doi: 10.1016/S0738-3991(98)00127-X.PubMedCrossRefGoogle Scholar
  25. DiIorio, C., Maibach, E., O’Leary, A., Sanderson, C. A., & Celentano, D. (1997). Measurement of condom use self-efficacy and outcome expectancies in a geographically diverse group of STD patients. AIDS Education and Prevention, 9, 1–13.PubMedGoogle Scholar
  26. Elford, J., Bolding, G., Davis, M., Sherr, L., & Hart, G. (2004). Web-based behavioral surveillance among men who have sex with men: A comparison of online and offline samples in London, UK. Journal of Acquired Immune Deficiency Syndromes, 35, 421–426. doi: 10.1097/00126334-200404010-00012.PubMedCrossRefGoogle Scholar
  27. Feil, E. G., Glasgow, R. E., Boles, S. M., & McKay, H. G. (2000). Who participates in Internet-based self-management programs? A study among novice computer users in a primary care setting. The Diabetes Educator, 26, 806–811. doi: 10.1177/014572170002600509.PubMedCrossRefGoogle Scholar
  28. Flatley-Brennan, P. (1998). Computer network home care demonstration: A randomized trial in persons living with AIDS. Computers in Biology and Medicine, 28, 489–508. doi: 10.1016/S0010-4825(98)00029-8.PubMedCrossRefGoogle Scholar
  29. Galavotti, C., & Cabral, R. (1995). Validation of measures of condom and other contraceptive use among women at high risk for HIV infection and unintended pregnancy. Health Psychology, 14, 570–578. doi: 10.1037/0278-6133.14.6.570.PubMedCrossRefGoogle Scholar
  30. Glasgow, R. E., Boles, S. M., McKay, H. G., Feil, E. G., & Barrera, M. (2003). The D-Net diabetes self-management program: Long-term implementation, outcomes, and generalization results. Preventive Medicine, 36, 410–419. doi: 10.1016/S0091-7435(02)00056-7.PubMedCrossRefGoogle Scholar
  31. Glasgow, R. E., Bull, S. S., Gillette, C., Klesges, L. M., & Dzewaltowski, D. A. (2002). Behavior change intervention research in health care settings: A review of recent reports, with emphasis on external validity. American Journal of Preventive Medicine, 23, 62–68. doi: 10.1016/S0749-3797(02)00437-3.PubMedCrossRefGoogle Scholar
  32. Glasgow, R. E., Klesges, L. M., Dzewaltowski, D. A., Bull, S. S., & Estabrooks, P. (2004). The future of health behavior change research: What is needed to improve translation of research into health promotion practice? Annals of Behavioral Medicine, 27, 3–12. doi: 10.1207/s15324796abm2701_2.PubMedCrossRefGoogle Scholar
  33. Glasgow, R. E., McKay, H. G., Piette, J. D., & Reynolds, K. D. (2001). The RE-AIM framework for evaluating interventions: What can it tell us about approaches to chronic illness management? Patient Education and Counseling, 44, 119–127. doi: 10.1016/S0738-3991(00)00186-5.PubMedCrossRefGoogle Scholar
  34. Glasgow, R. E., Nelson, C. C., Kearney, K. A., Reid, R., Ritzwoller, D. P., Strecher, V. J., et al. (2007). Reach, engagement and retention in an Internet-based weight loss program in a multi-site randomized controlled trial. Journal of Medical Internet Research, 9, e11. doi: 10.2196/jmir.9.2.e11.PubMedCrossRefGoogle Scholar
  35. Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health, 89, 1322–1327.PubMedCrossRefGoogle Scholar
  36. Gottlieb, S. (2000). Study explores Internet as a tool for care of diabetic patients. BMJ (Clinical Research Ed.), 320, 892. doi: 10.1136/bmj.320.7239.892.CrossRefGoogle Scholar
  37. Gross, E. (2004). Adolescent Internet use: What we expect, what teens report. Applied Developmental Psychology, 25, 633–649. doi: 10.1016/j.appdev.2004.09.005.CrossRefGoogle Scholar
  38. Gustafson, D. H., Hawkins, R. P., Boberg, E. W., McTavish, F., Owens, B., Wise, M., et al. (2002). CHESS: 10 years of research and development in consumer health informatics for broad populations, including the underserved. International Journal of Medical Informatics, 65, 169–177. doi: 10.1016/S1386-5056(02)00048-5.PubMedCrossRefGoogle Scholar
  39. Gustafson, D. H., Hawkins, R. P., Pingree, S., McTavish, F., Arora, N. K., Mendenhall, J., et al. (2001). Effect of computer support on younger women with breast cancer. Journal of General Internal Medicine, 16, 435–445. doi: 10.1046/j.1525-1497.2001.016007435.x.PubMedCrossRefGoogle Scholar
  40. Jaccard, J., Helbig, D. W., Wan, C. K., Gutman, M. A., & Kritz-Silverstein, D. C. (1996). The prediction of accurate contraceptive use from attitudes and knowledge. Health Education Quarterly, 23, 17–33.PubMedGoogle Scholar
  41. Jaccard, J., & Wan, C. K. (1995). Measurement error in the analysis of interaction effects between continuous predictors using multiple regression: Multiple indicator and structural equation approaches. Psychological Bulletin, 117, 348–357. doi: 10.1037/0033-2909.117.2.348.CrossRefGoogle Scholar
  42. Katz, S. J., Nissan, N., & Moyer, C. A. (2004). Crossing the digital divide: Evaluating online communication between patients and their providers. The American Journal of Managed Care, 10, 593–598.PubMedGoogle Scholar
  43. Kiene, S. M., & Barta, W. D. (2006). A brief individualized computer-delivered sexual risk reduction intervention increases HIV/AIDS preventive behavior. The Journal of Adolescent Health, 39, 404–410. doi: 10.1016/j.jadohealth.2005.12.029.PubMedCrossRefGoogle Scholar
  44. Koo, M., & Skinner, H. (2005). Challenges of Internet recruitment: A case study with disappointing results. Journal of Medical Internet Research, 7, e6. doi: 10.2196/jmir.7.1.e6.PubMedCrossRefGoogle Scholar
  45. Kreuter, M. W., Farrell, D., Olevitch, L., & Brennan, L. (2000). Tailoring health messages: Customizing communication with computer technology. Mahweh, NJ: Lawrence Erlbaum.Google Scholar
  46. Lenhart, A., & Horrigan, J. B. (2003). Re-visualizing the digital divide as a digital spectrum. IT and Society, 1, 23–39.Google Scholar
  47. Lightfoot, M., Comulada, W. S., & Stover, G. (2007). Computerized HIV preventive intervention for adolescents: Indications of efficacy. American Journal of Public Health, 97, 1027–1030. doi: 10.2105/AJPH.2005.072652.PubMedCrossRefGoogle Scholar
  48. Linke, S., Murray, E., Butler, C., & Wallace, P. (2007). Internet-based interactive health intervention for the promotion of sensible drinking: Patterns of use and potential impact on members of the general public. Journal of Medical Internet Research, 9, e10. doi: 10.2196/jmir.9.2.e10.PubMedCrossRefGoogle Scholar
  49. Lipkus, I. M., Lyna, P., & Rimer, B. K. (1999). Using tailored interventions to enhance smoking cessation among African-Americans at a community health center. Nicotine & Tobacco Research, 1, 77–85. doi: 10.1080/14622299050011181.CrossRefGoogle Scholar
  50. Madden, M. (2006). Young and wired: How today’s young tech elite will influence the libraries of tomorrow. Presented to the 2006 Tampa Bay Library Consortium Meetings, Tampa, FL.Google Scholar
  51. Marcus, B. H., Emmons, K. M., Simkin-Silverman, L. R., Linnan, L. A., Taylor, E. R., Bock, B. C., et al. (1998). Evaluation of motivationally tailored vs. standard self-help physical activity interventions at the workplace. American Journal of Health Promotion, 12, 246–253.PubMedGoogle Scholar
  52. McKay, H. G., Feil, E. G., Glasgow, R. E., & Brown, J. E. (1998). Feasibility and use of an Internet support service for diabetes self-management. The Diabetes Educator, 24, 174–179. doi: 10.1177/014572179802400207.PubMedCrossRefGoogle Scholar
  53. McKay, H. G., King, D., Eakin, E. G., Seeley, J. R., & Glasgow, R. E. (2001). The diabetes network Internet-based physical activity intervention: A randomized pilot study. Diabetes Care, 24, 1328–1334. doi: 10.2337/diacare.24.8.1328.PubMedCrossRefGoogle Scholar
  54. Mundfrom, D., Shaw, D., & Ke, T. (2005). Minimum sample size recommendations for conducting factor analyses. International Journal of Testing, 5, 159–168. doi: 10.1207/s15327574ijt0502_4.CrossRefGoogle Scholar
  55. Noar, S. M., Cole, C., & Carlyle, K. (2006). Condom use measurement in 56 studies of sexual risk behavior: Review and recommendations. Archives of Sexual Behavior, 35, 327–345. doi: 10.1007/s10508-006-9028-4.PubMedCrossRefGoogle Scholar
  56. Norman, G. Z., Zabinski, M. F., Adams, M. A., Rosenberg, D. E., Yaroch, A. L., & Atienza, A. A. (2007). A review of eHealth interventions for physical activity and dietary behavior change. American Journal of Preventive Medicine, 33, 336–345. doi: 10.1016/j.amepre.2007.05.007.PubMedCrossRefGoogle Scholar
  57. Oenema, A., Brug, J., & Lechner, L. (2001). Web-based tailored nutrition education: Results of a randomized controlled trial. Health Education Research, 16, 647–660. doi: 10.1093/her/16.6.647.PubMedCrossRefGoogle Scholar
  58. Pequegnat, W., Rosser, B. R., Bowen, A. M., Bull, S. S., Diclemente, R. J., Bockting, W. O., et al. (2007). Conducting Internet-based HIV/STD prevention survey research: Considerations in design and evaluation. AIDS and Behavior, 11, 505–521. doi: 10.1007/s10461-006-9172-9.PubMedCrossRefGoogle Scholar
  59. Pew Internet and American Life Project (2006). Latest Trends: February 15–April 6, 2006. Retrieved from
  60. Pew Internet and American Life Report (2000). The online health care revolution: How the Web helps Americans take better care of themselves. Retrieved from
  61. Posner, S. F., Bull, S. S., Ortiz, C., & Evans, T. (2004). Factors associated with condom use among young Denver inner city women. American Journal of Preventive Medicine, 39, 1227–1233. doi: 10.1016/j.ypmed.2004.04.037.CrossRefGoogle Scholar
  62. Rakowski, W., Lipkus, I. M., Clark, M. A., Rimer, B. K., Ehrich, B., Lyna, P., et al. (2003). Reminder letter, tailored stepped-care, and self-choice comparison for repeat mammography. American Journal of Preventive Medicine, 25, 308–314. doi: 10.1016/S0749-3797(03)00215-0.PubMedCrossRefGoogle Scholar
  63. Rhodes, S. D., Diclemente, R. J., Cecil, H., Hergenrather, K. C., & Yee, L. J. (2002). Risk among men who have sex with men in the United States: A comparison of an Internet sample and a conventional outreach sample. AIDS Education and Prevention, 14, 41–50. doi: 10.1521/aeap. Scholar
  64. Rideout, V. (2001). Generation How young people use the Internet for health information. Menlo Park, CA: Henry J. Kaiser Family Foundation.Google Scholar
  65. Rimer, B. K., Conway, M., Lyna, P., Glassman, B., Yarnall, S. H., Lipkus, I., et al. (1999). The impact of tailored interventions on a community health center population. Patient Education and Counseling, 37, 125–140. doi: 10.1016/S0738-3991(98)00122-0.PubMedCrossRefGoogle Scholar
  66. Roberto, A. J., Zimmerman, R. S., Carlyle, K. E., Abner, E. L., Cupp, P. K., & Hansen, G. L. (2007). The effects of a computer based pregnancy, STD and HIV prevention intervention: A nine-school trial. Health Communication, 21, 115–124.PubMedGoogle Scholar
  67. Roberts, D. F., Foehr, U. G., & Rideout, V. (2005). Generation M: Media in the lives of 8–18 year olds. San Francisco: Kaiser Family Foundation.Google Scholar
  68. Severson, H. H., Gordon, J. S., Danaher, B. G., & Akers, L. (2008). Evaluation of a Web-based cessation program for smokeless tobacco users. Nicotine & Tobacco Research, 10, 381–391. doi: 10.1080/14622200701824984.CrossRefGoogle Scholar
  69. Sheeran, P., Abraham, C., & Orbell, S. (1999). Psychosocial correlates of heterosexual condom use: A meta-analysis. Psychological Bulletin, 125, 90–132. doi: 10.1037/0033-2909.125.1.90.PubMedCrossRefGoogle Scholar
  70. Skinner, C. S., Strecher, V. J., & Hospers, H. (1994). Physician recommendation for mammography: Do tailored messages make a difference? American Journal of Public Health, 84, 43–49.PubMedCrossRefGoogle Scholar
  71. Strecher, V. J. (1999). Computer-tailored smoking cessation materials: A review and discussion. Patient Education and Counseling, 36, 107–117. doi: 10.1016/S0738-3991(98)00128-1.PubMedCrossRefGoogle Scholar
  72. Strecher, V. J., Kreuter, M., Den Boer, D. J., Kobrin, S., Hospers, H. J., & Skinner, C. S. (1994). The effects of computer-tailored smoking cessation messages in family practice settings. The Journal of Family Practice, 39, 262–268.PubMedGoogle Scholar
  73. Tate, D. F., Wing, R. R., & Winett, R. A. (2001). Using Internet technology to deliver a behavioral weight loss program. Journal of the American Medical Association, 285, 1172–1177. doi: 10.1001/jama.285.9.1172.PubMedCrossRefGoogle Scholar
  74. Vandelanotte, C., Spathonis, K. M., Eakin, E. G., & Owen, N. (2007). Website-delivered physical activity interventions: A review of the literature. American Journal of Preventive Medicine, 33, 54–64. doi: 10.1016/j.amepre.2007.02.041.PubMedCrossRefGoogle Scholar
  75. Verheijden, M. J., Jans, M. P., Hildebrandt, V. H., & Hopman-Rock, M. (2007). Rates and determinants of repeated participation in a web-based behavior change program for healthy body weight and healthy lifestyle. Journal of Medical Internet Research, 9, e1. doi: 10.2196/jmir.9.1.e1.PubMedCrossRefGoogle Scholar
  76. Winzelberg, A. J., Eldredge, K. L., Eppstein, D., Wilfley, D., Dasmahapatra, R., Dev, P., et al. (2000). Effectiveness of an Internet-based program for reducing risk factors for eating disorders. Journal of Consulting and Clinical Psychology, 68, 346–350. doi: 10.1037/0022-006X.68.2.346.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Sheana Bull
    • 1
    • 2
  • Katherine Pratte
    • 1
    • 3
  • Nancy Whitesell
    • 3
  • Cornelis Rietmeijer
    • 2
    • 4
  • Mary McFarlane
    • 5
  1. 1.Colorado Health Outcomes ProgramUniversity of Colorado at Denver and Health Sciences CenterAuroraUSA
  2. 2.Community and Behavioral Health, Colorado School of Public HealthUniversity of Colorado DenverAuroraUSA
  3. 3.American Indian and Alaska Natives ProgramUniversity of Colorado DenverAuroraUSA
  4. 4.Denver Public Health DepartmentDenver Health and Hospital AuthorityDenverUSA
  5. 5.Division of STD PreventionCenters for Disease Control and PreventionAtlantaUSA

Personalised recommendations