Using mobile technology to promote safe sex and sexual health in adolescents: current practices and future recommendations

Figures & data

Figure 1 Inclusion/exclusion data.

Table 1 Review of the literature

Authors/Year	Purpose	Design	Sample	Measures	Major findings	Limitations
Buhi, Klinkenberger, Hughes, Blunt, Rietmeijer (2013)^Citation11	Examine teens’ digital device ownership, online activities, and usage/frequency of communication modalities and the opportunities it presents for STD prevention and sexual health promotion	Quantitative Descriptive	N=273 February 2010 to January 2011, 13- to 19-year-old individuals recruited from a publicly funded teen clinic in Pinellas County, FL, USA	Adolescents completed ACASI which 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 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	1. 79% reported daily Internet use, with four of five teens reporting ever having accessed the Internet from a mobile phone 2. Almost a third of teens (31%) reported playing online games, and 8% reported participation in a virtual world 3. When asked about 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%) 4. 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	1. 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
Cornelius, St Lawrence, Howard, Shah, Poka, McDonald and White (2012)^Citation19	Examine African-American adolescents’ perceptions of a mobile cell phone (MCP)-enhanced intervention and development of an MCP-based HIV prevention intervention	Qualitative	Eleven adolescents (six female, five male) with a mean age of 15.4 years who participated in the Becoming a Responsible Teen Text Messaging project	Adolescents attended seven weekly BART face-to-face sessions, and then they received daily multimedia text messages (pictures, videos, and text messages) for 3 months. Focus group questions included items concerning: MCP-enhanced intervention How did the multimedia MCP text-messaging process make you feel? MCP-based intervention: We are thinking about sending information from the BART intervention solely to your cell phone so that you will not have to come in for the sessions each week. What do you think about this idea?	1. Adolescents said they benefited from the MCP-enhanced approach 2. Adolescents were receptive to the idea of developing an MCP-based intervention 3. Participants thought of videos as realistic and found this of importance to learning and responding to messages	1. The study targeted a small sample of African-American youth which may not be generalizable to the general population
Cornelius, Cato, St Lawrence, Boyer, and Lightfoot (2011)^Citation15	Develop MCP multimedia text-messaging boosters guided by content in the BART curriculum Assess the feasibility and acceptability of delivering the booster messages to African-American youth	Quantitative and Qualitative	12 African-American teens, aged 13–18 years	ADAPT-ITT model used to guide the process of adapting the BART curriculum for MCP multimedia text-messaging Delivery Data collected on the frequency of responses to text messages, pictures, and videos; research team’s attempts to reach participants who fell below an 80% response rate; teens’ recommendations for changes; and the number of teens who found the MCP messaging process intrusive	1. Average 3-week MCP multimedia text message response rate was 80% 2. Teens reported enjoying the process of the study and were accepting of using MCP multimedia text messages	1. Use of web browsers and text messaging can be costly 2. Implementation barriers occurred when failure of the internet hosted SMS to send the message at the specified time occurred but was corrected throughout the process
Cornelius, Cato, Toth, Bard, Moore, White (2011)^Citation23	The goal for this adaptation was to tailor the BART material for text-messaging boosters. The plan outlined the: a) process of adaptation, b) key information from each BART session for text-messaging delivery, c) materials for developing the messages, d) activities that would be appropriate and relevant for MCP multimedia text-messaging delivery, and e) development of a facilitator’s checklist for text message responses to teens	Quantitative	Website analysis of a sexual health promotion program (Becoming a Responsible Teen, plus text messaging, BART + TM)	Data collected on website traffic from March 2009 to April 2010 using advanced web statistics 1. How many unique visitors have visited the site? 2. On what days of the week do unique visitors visit the site? 3. At what hours of the day do unique visitors view the site? 4. How long do unique visitors stay on the site (duration)? 5. What are the keywords and phrases used to gain access to the site? 6. What are the entry and exit pages for the website? 7. Who are the unique visitors to the website?	1. The results indicated that teens were interested in receiving information about safer sex behaviors in their natural settings and with technology, using familiar language 2, 125 unique visitors with an average of 152 per month 3. Website was visited every day of the week but most frequently on Thursdays 4. The total number of pages viewed from March 2009 to April 2010 was 19,038 with an average of 1,360 pages viewed per month	1. Errors with message delivery and equipment problems, including failure of the Internet-hosted SMS to send the message at the specified time, and MCP problems, such as inability to access the web and inability to receive text messages, were identified and corrected 2. Use of web browsers and text messaging can be costly 3. Findings need to be generalized cautiously, given the small and convenient sample from one geographic area
Cornelius J Dmochkowski, Boyer, St Lawrence, Lightfoot, and Moore M (2012)^Citation7	Examine the feasibility and acceptability of an HIV prevention intervention for African-American adolescents delivered via MCPs and look at intervention-related changes in beliefs and sexual behaviors	Longitudinal One group design	40 African-American adolescents, 13–18 years of age, who provided verbal and written consent, had parental consent to participate, and had knowledge of MCP text-messaging technology	Data collected at three time points: baseline (T1), post-BART at 7 weeks (T2), and at 3-month follow-up post-BART (T3) Daily text messages for 3 months	1. Findings showed promise in terms of the feasibility and acceptability of this approach. One surprising finding was the high retention rate at the 3-month follow-up. Participants were in frequent contact with the research staff, which may have resulted in this high rate 2. The range of response time for teen participants was 33.7–79.9 minutes and for facilitators it was 29.81–76.78 minutes 3. We found that age was a primary factor in change, with greater increases in knowledge, more improved attitudes toward condoms, more perceived HIV risk, and more reduction in HIV risk behaviors among older participants (16–18 years of age) 4. The differential findings by age suggest that even when presented with the same program, younger adolescents may take away different messages and enact different behaviors	1. Our pilot feasibility study was limited to short-term follow-up (3 months) and lacked a control group, so we were unable to examine longer-term maintenance of outcomes or definitively say that the positive changes were caused by the intervention 2. Sample consisted of a small group from one geographic location and the results cannot be generalized to other geographic areas 3. The small sample size of study may have prevented detection of longitudinal changes and associations with covariates or interactive effects. Thus, the results of this study have to be interpreted with caution 4. We provided study participants with project Smartphones and, therefore, the acceptability of this approach is limited to the specific MCP used in this project
Devine, Bull, Dreisbach and Shlay (2014)^Citation16	Develop and pilot a theory-based, mobile phone texting component attractive to minority youth as a supplement to the Teen Outreach Program^® (TOP)	Qualitative and Quantitative	96 minority youth aged 14–18 years at four sites Before pilot, six focus groups of 59 teens were conducted (30 males and 29 females)	1. 4-week pilot including surveys (84 questions total) that evaluated values, social support, self-efficacy, and behaviors relating to school performance, trouble with the law, and sexual activity 2. Text sessions covered values, community service, contraception and condoms, and resisting pressure in romantic relationships 3. 11 messages per week sent	1. We successfully recruited and enrolled minority youth into the pilot 2. Teens were enthusiastic about text messages complementing TOP^®	1. About 15% did not have access to phones for various reasons
Fortune, Wright, Juzang, & Bull (2010)^Citation10	To describe methods used to recruit and retain young men in the Black men text messaging prevention program	Quantitative Non randomized two group pilot study with 3 and 6 month follow up	60 men in the Philadelphia area	Baseline assessments then sent text messages 3 times a week for 12 weeks	1. Enrolled 58% of the approached Participants 2. Retained 77% to the 3 month follow-up and 65% to the 6 month follow-up	1. Limited to one geographic location 2. Small sample size
France (2014)^Citation12	Text-messaging service was set up in two secondary schools to raise awareness of the school nurse and encourage teenagers to make contact for health advice and support	Quantitative Descriptive	Adolescents aged 11–16 years	Texts categorized by: Sexual health including puberty and relationships (56%) Emotional health (25%) Physical health (7%) Human papillomavirus (8%) Healthy eating (5%)	1. 44 out of the 202 text messages led to face-to-face contact with the nurse 2. 93% were aware of the school nurse text service and 63.5% were aware they could access the school nurse via the lunch-time drop-in; 3. 70.2% felt that the text service was a good way to seek help and advice about their health and 63.5% were aware that the school nurse offers a confidential service	1. Records of text messages were managed by keeping a spreadsheet log which was time- consuming and added administrative work
Katz, Rodan, Milligan, Tan, Courtney, Gantz et al (2011)^Citation8	To examine efficacy of a randomized cell phone-based counseling intervention in postponing subsequent pregnancy among teen mothers	Quantitative randomized two-group follow-up to 24 months	259 15–19-year-old primiparous pregnant teens in the Girl Talk intervention recruited in Washington, DC, USA	Based on the social contextual research tradition and youth asset development model Questionnaire Urine tests	1. Variability among intervention group teens as to the number of cell phone-based counseling sessions 2. Teens with lost or damaged phones were out of contact for extended periods of time 3. 31% of the intervention group and 36% of the usual care group became pregnant again within 24 months 4. Counseling sessions more effective with teen moms 15–17 years of age but not those of 18 years and older	1. Program closed before the second year of the operation 2. One geographic location 3. Many teens had few credits to graduate high school
Juzang, Fortune, Black, Wright and Bull (2011)^Citation9	To explore the feasibility of recruiting and retaining young black men in a 12-week text-messaging program about HIV prevention	Quantitative Longitudinal Nonrandomized intervention groups	60 participants aged 16–20 years who self-identified as Black or African-American, sexually active, who own a mobile phone, and live in Philadelphia, PA, USA	Three text messages per week for 12 weeks were sent 3- and 6-month follow-up	1. The intervention participants showed trends in increased monogamy at follow-up compared to controls 2. Awareness of sexual health was significantly higher in the intervention group. Condom norms were significantly higher for the control group 3. There were no differences in the proportion of protected sex acts. The participants embraced the project, and were enrolled and retained in numbers that suggest such an intervention is worth examining for efficacy	1. Sample size was small 2. The intervention and control participants were not randomly assigned 3. Condom use levels did not change, but study focused on determination if the text message delivery feasibility
Mitchell, Bull, Kiwanuka and Ybarra (2011)^Citation18	Examine who is likely to use text messages, characteristics of adolescents who are utilizing health information via text, characteristics describing adolescents who are most likely to want to access an HIV intervention program via text	Quantitative	1,503 secondary school students in Mbarara, Uganda, collected in 2008–2009 1,738 adolescents 12–18 years of age were randomly recruited and 1,523 took the survey Survey data a part of the cyber senga study	Interest in accessing HIV/AIDS information via text messaging Sexual intercourse and HIV Psychosocial and somatic health	1. 19% of adolescents who had sent or received text messages in the past year indicated that they sent a text message on their cell phone to get information about health and disease in the last 12 months 2. Adolescents more commonly sent a text message to seek information about gossip (29%), television programs (30%), the latest news (45%), and sports (64%)	1. Rates of cell phone ownership among adolescents in Mbarara, Uganda, are lower than those found among adolescents living in other parts of the country or those living in South Africa
Perry, Kayekjian, Braun, Cantu, Sheoran and Chung (2012)^Citation20	To understand adolescents’ perspectives on the use of a preventive sexual health text-messaging service	26 adolescents aged 15–20 years recruited from two teen clinics in Los Angeles County, CA, USA Weekly text messages of the Hookup service Qualitative		1. Mixed sex focus groups including 6–13 participants per group for the discussions 2. Participants completed a self-administered written survey prior to groups with the intention for investigators to collect demographic data and stimulate pertinent thoughts before the focus group discussions 3. Items assessing their experiences with the Hookup offered responses on a 5-point Likert scale (from “strongly disagree” to “strongly agree”). Example items included: “The messages taught me new things,” “I was embarrassed about having messages related to sexual health in my phone,” and “I was concerned that my parents would see the messages from the Hookup in my phone”	1. Participants enjoyed receiving weekly text messages related to sexual health. They linked their enjoyment to the message content being informative (providing relevant and new information), simple (automatically limited to small words and short phrases), and sociable (easily able to be shared with friends) 2. Participants also pointed to the convenience and ubiquity of text messaging and generally felt that cost of messages was not a concern. Most felt that text messaging provided a sense of privacy for learning about sensitive health topics, although a few expressed concerns about stigma from peers seeing the messages	1. Study was limited by self-selection bias of enrollees. Participants were recruited from teen clinics and agreed to participate in a semipublic discussion, which likely shows their knowledge and comfort with sexual health issues is not generalizable to others within the population 2. Few males participated in the study
Schnall, Okoniewski, Tiase, Low, Rodriguez, and Kaplan (2013)^Citation17	The purpose of this study was to understand the health information needs of adolescents in the context of their everyday lives and assess how they meet their information needs	Mixed methods	60 adolescents aged 13–18 years	1. Adolescents were given Smartphones with unlimited text messaging and data for 30 days. Each Smartphone had applications related to asthma, obesity, HIV, and diet preinstalled on the phone 2. Text messages three times per week and asked the following questions: 1) What questions did you have about your health today? 2) Where did you look for an answer (mobile device, mobile application, online, friend, book, or parent)? 3) Was your question answered and how? 4) Anything else?	1. 90% response rate to text messages. Participants sent a total of 1,935 text messages in response to the ecological momentary assessment questions 2. Adolescents sent a total of 421 text messages related to a health information needs, and 516 text messages related to the source of information to the answers to their questions, which were related to parents, friends, online, mobile apps, teachers, or coaches 3. One participant’s cell phone was stolen but project staff replaced it 4. Two teens had cell phones turned off because they had used the allotted minutes for the month before the month ended 5. Privacy was a concern of the participants	1. Limitation to our study included a convenience sample that may not be representative of all ethnically diverse adolescents, particularly as they were recruited from one area of NYC 2. Another limitation of our study was the use of EMA. As with all self-report measures, there was no independent check on the veracity of the data because all data were collected in the absence of the experimenter 3. In addition, since the browsing history of our participants was not assessed, responses to the text messages could be inaccurate owing to a number of factors including stigma 4. Technology was limited and did not have a decision tree associated with it to provide responses and feedback to our participants. This may have limited participants’ willingness to continue sharing their health information needs
Selkie, Benson, and Moreno (2011)^Citation21	Determine adolescents’ views regarding how new technologies could be used for sexual health education	Qualitative	29 adolescents aged 14–19 years	Facilitators asked participants for their views regarding use of social networking websites (SNSs) and text messaging for sexual health education. Tape-recorded data were transcribed; transcripts were manually evaluated then discussed to determine thematic consensus	1. Adolescents preferred sexual health education resources that are accessible 2. Adolescents preferred online resources that are trustworthy 3. Adolescents discussed preference for “safe” resources	1. Limitations of the study include the small sample size and thus limited generalizability of findings 2. Researchers did not have a reliable method of determining socioeconomic status; thus, results may not be applicable to adolescents from families of all income levels
Whiteley, Brown, Swenson, DiClemente, Vanable, Carey, Valois (2011)^Citation14	Examine frequency of cell phone and online media use and its relationship to psychosocial variables and STI/HIV risk behavior	Quantitative	1,518 African-American, 13–18 years of age From two Northeast US cities (Providence, RI; Syracuse, NY) and two Southeast US cities (Columbia, SC; Macon, GA) Assessed from 2008 to 2009	Adapted version of Annenberg Media survey assessed Internet and other media frequency Internet Frequency Scale was created to assess frequency of using the Internet for news, instant messaging, chatting, online journals, social networks, and email 8-item form of Center for Epi Studies Depression scale used to assess symptoms of depression Life Satisfaction Scale Impulsivity Scale Sexual Sensation Seeking Scale Subjective Peer Norms for Sexual Risk Behavior scale	1. Over 90% of African-American adolescents used cell phones every day or most days and 60% used social networking sites every day or most days (96% used Myspace) 2. Greater frequency of cell phone use was associated with sexual sensation seeking (P=0.000), riskier peer sexual norms (P=0.000), and impulsivity (P=0.016). Greater frequency of Internet use was associated with a history of oral/vaginal/anal sex (OR =1.03, 95% CI=1.0–1.05) and sexual sensation seeking (P=0.000) 3. Riskier youth are online and using cell phone frequently	1. Measures used are derived from a parent study – Project iMPPACS; limited measurement of specific types of Internet and cell phone interactions 2. Participants enrolled in HIV preventive-intervention and may not be representative of the entire African American adolescent population
Willoughby & Jackson, (2013)^Citation13	Analysis of text messages from the BrdsNBz text message service	Quantitative Descriptive	1,351 text messages sent to a sexual health text message service	Topics: Sexual health Sexual technique Relationship Service Other	1. Majority of questions were about sexual health (81.6%) and sexual acts 2. Questions about STDs did not come up as frequently as other topics (unplanned pregnancy) 3. Half of the STD questions were of general knowledge	1. Analysis of one text message service 2. Unable to obtain demographic characteristics of participants
Wright, Fortune, Juzang and Bull (2011)^Citation22	Examine the feasibility of using cell phones for HIV prevention in the population	Qualitative	43 men aged 16–20 years	Six focus groups conducted over a 3-month period to document reactions to and preferences for a text message-based HIV prevention program Feedback was sought on how to best convey outcomes for our intervention pertaining to sexual health: increasing condom use, practicing monogamy, and/or staying abstinent Feedback sought on how to operationalize five theoretical constructs in text messages: providing information on and awareness of HIV/AIDS, promoting positive attitudes toward sexual health, condom use norms, intentions to stay safe, and skills that would best help achieve positive outcomes	1. Young black men were receptive to the idea of receiving text messages for an HIV prevention campaign 2. Participants suggested that the men involved in the pilot study should receive only three messages a week, preferably after they had finished school for the day 3. Men wanted to be challenged to think critically about the messages and preferred messages that would “ask more of a question” than make a comment 4. Participants helped shape operationalization of key theoretical constructs, such as incorporating aspects of empowerment and social capital into the campaign	1. Focus group findings represent only the ideas and feedback of the men who participated in the groups, and cannot be generalized to the larger population of 16- to 20-year-old men in the US 2. Not all of the young men owned cell phones who gave feedback on the program despite being an inclusion criterion for the program

Abbreviations: CI, confidence interval; OR, odds ratio; SMS, short messaging service; STI, sexually transmitted infection; NYC, New York city; EMA, ecological moment assessment; ACASi, audio computer assisted self-interview.

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