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The Journal of Primary Prevention

, Volume 39, Issue 4, pp 361–370 | Cite as

Publicly Available Internet Content as a HIV/STI Prevention Intervention for Urban Youth

  • Laura B. Whiteley
  • Larry K. Brown
  • Virginia Curtis
  • Hyeon Ju Ryoo
  • Nancy Beausoleil
Original Paper

Abstract

Sexual and racial minority adolescents and young adults account for the most substantial number of new HIV infections in the United States. Numerous publicly available websites and YouTube videos contain HIV/STI prevention information that is culturally tailored to racial and ethnic minorities, and gay and bisexual youth. However, the effect of this easily accessible Internet content on adolescent and young adult HIV/STI related knowledge, attitudes and behaviors is unknown. We assembled a HIV/STI Internet intervention from publicly available online sources, including YouTube and privately and publicly hosted websites. We tested the preliminary efficacy of this internet intervention by means of a randomized controlled pilot study with 60 diverse adolescents and young adults recruited in Providence, RI (mean age 18.6 years, 62% male, 52% Black/African American, 36% Hispanic, 47% non-heterosexual). Youth who received links to publicly accessible online prevention content by email had a significant improvement in HIV self-efficacy (p < .05) and a significant reduction in unprotected vaginal or anal sex (12.5 vs. 47.6%, AOR = 7.77, p < .05), as compared to a control group who did not receive the internet content by email. If these preliminary findings can be confirmed by future research, free online content could be inexpensively distributed to at risk youth in underserved communities and could hold promise as an inexpensive method of HIV/STI prevention.

Keywords

Websites YouTube Teens Sexual health 

Background

Youth (defined as adolescents and young adults ages 15–24) who are sexual, racial and ethnic minorities are disproportionally affected by infection with the human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs; CDC, 2015). Because youth engage frequently with online content, the Internet holds great potential for the dissemination of prevention information to diverse groups of adolescents and young adults. Additionally, the digital divide has disappeared so that racial and ethnic minorities have access to online resources at comparable rates to their non-minority peers (Lenhart, Purcell, Smith, & Zickuhr, 2010). There has also been a growth of online HIV/STI prevention content tailored to sexual minority youth including lesbian, gay, bisexual, transgender, queer and questioning (LGBTQQ) youth. However, the effect of this publicly available Internet content on HIV/STI knowledge, attitudes and behaviors has not been tested.

Our prior review of online STI/HIV content found numerous websites and YouTube videos with prevention information that were tailored to adolescents and young adults (Whiteley, Mello, Hunt, & Brown, 2012). A variety of sources, such as community, state, or for-profit agencies managed or built these websites. All of the sites were publicly accessible. Many websites targeted factors of the Information Motivation and Behavioral skills model (IMB), which has been shown to influence health behavior (Fisher & Fisher, 2000; Whiteley et al., 2012). Disseminating free, appealing, theoretically consistent internet content to diverse youth could be a novel and cost-effective way to prevent HIV.

Online and computer based HIV prevention interventions have shown promise (Lightfoot, Comulada, & Stover, 2007; Tortolero et al., 2010). However, the majority of computer based HIV prevention research has been with older adults and most studies have evaluated offline computer programs that are costly to buy, make, and distribute (Chiasson, Hirshfield, & Rietmeijer, 2010). Randomized trials of online HIV interventions, primarily targeted to adult men who have sex with men (MSM), have demonstrated some reduction in HIV risk behaviors (Carpenter, Stoner, Mikko, Dhanak, & Parsons, 2010; Rosser et al., 2010), short-term increases in knowledge, increases in HIV testing (Blas et al., 2010), and increased self-efficacy and outcome expectancies (Bowen et al., 2007). There is also promising data for computer-led prevention interventions in school based samples (Lightfoot et al., 2007; Tortolero et al., 2010). While these studies support the use of technology for HIV/STI prevention, there is no report of the efficacy of an intervention using free, publicly available online material.

We developed an HIV/STI Internet intervention from publicly available websites including YouTube. Material chosen for the study is relevant to minority youth and to the IMB model. The preliminary efficacy of the intervention was tested in a small, randomized controlled trial.

Methods

Participants

Study criteria for youth between the ages of 15–24 years were: (1) English speaking, (2) a history of vaginal or anal sex, (3) participant assent and/or consent, and (4) not participating in another HIV/STI intervention. The Institutional Review Board (IRB) approved all research activities.

Recruitment

In a 2014, trained research assistants recruited participants from bus stops, outside urban public schools, and outside a community center for LGBTQQ teens. All recruitment occurred in the same New England city. Individuals expressing interest were given a flyer with information about the focus of the project, eligibility criteria, and relevant contact information. Research staff screened participants for eligibility and informed consent was obtained in person in our research offices from youth ages 18 or older, and from parents/guardians of those under the age of 18 years. Participants received a $40 reimbursement for the pre-test assessments and a $40 reimbursement for the post-test assessments.

Intervention Procedures

After participants completed baseline assessment, consent, and/or assent procedures, researchers randomized them (using a random number generator) to either receive the Internet intervention consisting of publicly available web content, or a waitlist/control group. Youth in the Internet intervention immediately received emails with links to online HIV/STI prevention websites and YouTube videos. Researchers sent participants eight HIPPA compliant emails (containing 2–3 links each) twice a week over 4 weeks. Youth could access the links from a computer, iPad, or phone. After opening the emails containing the links, participants rated each for acceptability by texting back a response on a scale from 1 (hated it) to 10 (loved it). This verified that the participants received the emails and engaged in rating the material, however, we could not confirm whether participants opened the intervention links. Youth in the control group received emails containing the online material after the final assessment.

Internet Intervention

The Internet intervention included links to interactive websites, some with games and quizzes, and YouTube videos. Examples of websites and videos are displayed in Table 1. Topics included puberty, basic anatomy, HIV/STI information (including gonorrhea, chlamydia, syphilis, trichomoniasis, genital warts/HPV, herpes), contraception, pre- and post-exposure prophylaxis, personal risk assessment, influence of peer norms, HIV’s impact on minority communities, benefits of abstinence and protected sex, condom skills, communication skills, and dangers of substance use. Links were consistent with the Information Motivation and Behavior (IMB) skills model since interventions driven by theory have been shown to be more effective than those that are not (Fisher & Fisher, 2000). Researchers organized website selections into topic areas of (1) relevant information, (2) personal motivation to stay safe and to take necessary actions, and (3) the confidence and skills needed for safer sex (Fisher & Fisher, 2000).
Table 1

Examples of publicly accessible websites and Youtube videos used in the IMB informed internet intervention

Information

http://www.plannedparenthood.org/teens/sex/the-ten-biggest-myths-about-sex (hosted by Planned Parenthood)

https://www.avert.org/professionals/hiv-programming/prevention/treatment-as-prevention

(hosted by AVERT; UK charity funded through supporters)

http://www.itsyoursexlife.com/gyt/the-most-common-stds/

(hosted by MTV with support from Advocates for Youth, The Kaiser Family Foundation, Love is Respect, Planned Parenthood Federation of America, Stay Teen, and The National Coalition for Sexual Health)

http://www.scarleteen.com/article/body/love_the_glove_10_reasons_to_use_condoms_you_might_not_have_heard_yet

(Scarleteen was founded by Heather Corinna and is funded solely through private, individual donations and grants)

Motivation

http://www.youtube.com/watch?v=T6pPfw7gmbM&feature=autoplay&list=PL328519886391D106&playnext=1

(hosted by Teen Impact Prevention Program a New York based program funded by The New York State, AIDS Institute and sponsored by The Child Center of New York, a non-profit organization, which services families and children)

http://hiv.drugabuse.gov/english/message/webisodes.html

(hosted by the National Institute of Drug Abuse funded by the NIH)

http://www.youtube.com/watch?v=ntsgOIfzeck

(hosted by Red Hot Organization)

Behavioral skills

http://www.avert.org/condom-quiz.php

(hosted by AVERT; UK charity funded through supporters)

https://sexetc.org/videos/josh-goes-for-his-first-hiv-test/

(hosted by Answer a national organization sponsored by Rutgers University)

These websites were last accessed by research staff on November 20, 2017

The research staff selected all of the websites for this intervention with methods based on the procedures developed for an earlier review of similar websites (Whiteley et al., 2012). Similar to methods described in that review, we rated websites for this intervention on appropriateness and comprehensiveness in HIV and sexuality content and format using criteria from the Sexuality Information and Education Council of the United States (SIECUS). We developed the measure used for assessing a website’s authority and credibility from the American Library Association Standards for Web Evaluation (Alexander & Tate, 1999). Using the following criteria, we rated each website on: clarity of what organization was responsible for the contents of the page, clear description of the goals of the organization, ability to verify the legitimacy of this organization (by phone number, postal address), authorship by qualified medical or health professional, statement that the content of the page had the official approval of the organization, clarity on whether the website was from a national or local chapter of an organization, and the existence of a statement giving the organization’s name as copyright holder. Each site received one point for each category that was successfully addressed for a total of seven possible points, and points were compiled to create a score for authority and credibility for each website. The websites required an authority score of at least five to be included in the intervention. Two child and adolescent psychiatrists grouped content according to its relevance to information, motivation, or behavioral skills constructs as described in the IMB model (Fisher & Fisher, 2000). We monitored websites throughout the intervention in case content changed.

Eighteen ethnically and sexually diverse urban youth provided feedback on the relevance, comprehensibility, and acceptability of selected sites and content in focus groups. These procedures are similar to the use of focus groups in the development of other adolescent HIV prevention interventions (Horner et al., 2008). These processes resulted in selection of new websites with graphics and characters relevant for ethnic, racial, sexual minority adolescents 15–24 years old (See Table 1). Participants in the intervention condition received 19 links (from nine different websites and four YouTube videos) via email over the course of 4 weeks (4–5 links per week). The IMB model guided selection of links to specific games, videos and/or activities in different web sites. Researchers utilized a variety of sites in order for the intervention to be comprehensive and include informational, motivational and behavioral skills components.

Assessment

We used an audio-assisted computer self-interview (ACASI) to assess HIV-risk behavior, knowledge, and attitudes (Johnson et al., 2001) at baseline and 12 weeks after the intervention period. Trained research assistants monitored the interview sessions that participants completed in our research offices. Youth reported the occurrence of unprotected vaginal and anal sex acts (USAs) in the last 3 months (yes/no), which was the primary outcome measure. Because substance use is a proximal risk for unprotected sex, youth also indicated if they had used alcohol or other drugs before or at the time of sex during the past 3 months (yes/no). Youth completed the HIV-Related Knowledge Scale (Cronbach’s α = 0.97; Brown et al., 2014) and the Self-Efficacy for HIV Prevention Scale (Cronbach’s α = 0.89; Lawrence, Levy, & Rubinson, 1990).

Data Analysis

After initial inspection and cleaning of the pre- and posttest data, we compared the two trial conditions (intervention vs. control) on their baseline demographic and outcome variables using bivariate tests (Chi Square or t tests, as appropriate). We similarly compared posttest assessment to those not retained. Outcomes at the posttest compared intervention conditions accounting for baseline values using analysis of covariance for scale scores and logistic regression for categorical variables. Project statisticians performed analyses with SPSS Statistics for Windows, version 22.0.

Results

The current study enrolled and randomized 60 youth (mean age 18.6 years, 62% male, 52% Black/African American, 36% Hispanic, 47% non-heterosexual) to either the intervention (n = 31) or the control condition (n = 29) condition. Preliminary analyses did not reveal significant differences in demographic factors (age, race, ethnicity, sexual orientation) between conditions (See Table 2). All the youth in the study reported a history of vaginal and/or anal sex. Retention for the 12-week post-test assessment was 87 and 83% for the intervention and control conditions, respectively (not significantly different). Analysis did not show any baseline differences in demographic or outcome variables between those retained or missing at the follow-up assessment. An analysis of co-variance (controlling for baseline scores) found a significantly greater improvement in reported HIV self-efficacy at follow-up for those in the Internet intervention compared to the control condition (F [1,58] = 5.71, p = 0.021). Using logistic regression, we found a significant reduction in unprotected vaginal or anal sex at posttest: 12.5% (Internet intervention) versus 47.6% (control; AOR = 7.77, p < .05, adjusting for baseline scores). There were no statistically significant differences between groups in change in HIV knowledge or drug use at the time of sex (See Table 3). Twenty-eight participants in the intervention condition responded to queries in intervention emails about the acceptability of the links, and the mean rating was 8.9 (1 = hated it, 10 = loved it).
Table 2

Demographic and baseline characteristics

Variable

Total sample

N = 60

Internet intervention

n = 31

Control

n = 29

Test statistic

Age

Mean (SD)

18.6 (2.3)

18.5 (2.4)

18.7 (2.3)

t = − .399

Gender (% male)

62%

65%

59%

x2 = .220

Race (% AA)

52%

50%

54%

x2 = 2.85

Ethnicity

(% Hispanic)

36%

37%

36%

x2 = .006

Non-heterosexual orientation

(% yes)

47%

45%

48%

x2 = .058

HIV knowledge

Mean (SD)

58.3 (19.5)

56.5 (20.7)

60.3 (18.4)

t = − .769

HIV self-efficacy

Mean (SD)

41.7 (6.3)

40.6 (6.5)

42.8 (5.9)

t = − 1.309

Unprotected vaginal and anal sex in past 3 months (% yes)a

36%

30%

43%

x2 = .919

Alcohol or drug use before sex (% yes)a

36%

26%

48%

x2 = 1.217

aOf those recently sexually active

Table 3

Changes in knowledge, self-efficacy and behaviors associated with the internet intervention

 

Pre-intervention

Post-intervention

F (1,58)a

Intervention

Control

Intervention

Control

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Knowledge

56.7 (20.9)

59.6 (12.6)

62.8 (19.0)

61.6 (18.7)

.589

HIV self-efficacy

40.3 (6.5)

42.4 (6.2)

44.8 (4.5)

42.6 (6.1)

5.71*

 

n/tot (%)

n/tot (%)

n/tot (%)

n/tot (%)

AOR b

Unprotected vaginal/anal sexc

7/24 (30%)

9/21 (43%)

4/24 (17%)

10/21 (48%)

7.77*

Alcohol and drug use before sexc

7/27 (26%)

11/23 (48%)

4/27 (15%)

8/23 (35%)

3.12

aAnalysis of variance controlling for baseline scores

bAOR, odds ratio adjusted for baseline

cIn the past 3 months

*p < .05

Discussion

This brief online intervention, assembled from content from nine publicly accessible websites and four YouTube videos, resulted in improved HIV self-efficacy and reduced unprotected sex 3 months later. These findings suggest that the intervention affected youth as it was designed. Although the study cannot determine the elements that were responsible for its success, the intervention was designed for urban youth, and content was consistent with a well-known theory of behavior change (IMB). Researchers developed the Internet intervention at low cost and made it easily accessible. The intervention was also easily emailed, which is an efficient and cost-effective distribution method.

The intervention showed some improvement in HIV knowledge and a slight reduction in drug use at the time of sex, although neither was statistically significant. Given the preliminary nature of the study with a small sample size, it is worth noting the impact since the findings are consistent with the aims of the intervention. However, the complexity of the relationship between changes in knowledge and behavior must be recognized. For example, youth in both conditions may have had sufficient knowledge about HIV and STIs, but only youth in the intervention group demonstrated change in behavior. The intervention did have links with material pertaining to substance use and its relationship to HIV/STI risk, but this material was limited and was not a major emphasis of the intervention.

This research has several limitations. The measures were based on self-report, so the impact of social desirability cannot be excluded. Additionally, there were no biological outcomes (such as sexually transmitted infections). We did not assess the extent of each participant’s engagement with the intervention content and therefore could not determine the impact of differing levels of participation with the online content. However, 90% (28/31) of participants replied with ratings of the Internet content. We could not assess the longer-term impact of the intervention beyond 3 months, and groups were not matched for attention and time because the control group did not receive emails during the study period. There were no steps taken to avoid contamination (e.g., intervention participants could have emailed links to one another), although any such contamination would have biased the study towards a null finding. Although the initial findings were positive, the study was small and not powered to discern potential significant moderators of the intervention’s impact such as gender, age, and sexual orientation. Also, researchers did not collect data on participant’s use of the websites. It is possible that some participants explored the websites beyond the page or link and found material that was helpful or deleterious. Concerns about possible harm should also be carefully addressed in future research. Free online content is easily available but may be difficult to monitor and could cause harm to impressionable youth.

Conclusion

Despite limitations, this study approximates the real world impact of youth engagement with free, online sexual health content. If these preliminary findings can be confirmed by future research, free online content could be inexpensively distributed to at risk youth and may hold promise as an inexpensive method of HIV/STI prevention. Content could be distributed or disseminated by community based organizations, posted on an organization’s website or used by educators without cost. Interventions that rely on publicly available websites and information will need processes for monitoring the material as it can evolve and change over time, resulting in content that may not be accurate, helpful, or relevant. For example, in the time since the intervention occurred, some of the websites have evolved to contain content inappropriate for the intervention.

Despite the study’s small sample size, the significant changes we found in measures of self-efficacy and the reduction in unprotected sex acts suggest that this easily disseminated Internet content could result in changed attitudes and behavior. This compiled intervention, chosen for its appeal for urban minority youth with diverse sexual, ethnic and racial backgrounds, may hold promise as a low-cost intervention method. Future research will need to confirm its efficacy before it is disseminated, and also determine the most effective ways to engage youth with online content.

Notes

Acknowledgements

Drs. Whiteley and Brown have received support from Grant Number P30AI042853 from the National Institute of Allergy and Infectious Diseases. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Allergy and Infectious Diseases or the National Institute of Health. Dr. Brown has received support for this project from the Lifespan/Tufts/Brown Center for AIDS Research (CFAR).

Compliance With Ethical Standards

Conflict of Interest

The authors declare they have no conflicts of interest.

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Laura B. Whiteley
    • 1
    • 2
  • Larry K. Brown
    • 2
  • Virginia Curtis
    • 2
  • Hyeon Ju Ryoo
    • 1
  • Nancy Beausoleil
    • 2
  1. 1.Department of Psychiatry and Human BehaviorWarren Alpert Medical School of Brown University, Rhode Island HospitalProvidenceUSA
  2. 2.Young Adult Behavioral Health Program Coro EastRhode Island HospitalProvidenceUSA

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