https://orcid.org/0000-0002-7864-9171
ABSTRACT
We sought to understand young men who have sex with men (YMSM) perspectives and preferred features for a mobile health (mHealth) tool designed to facilitate human papillomavirus (HPV) vaccination. YMSM were recruited on a popular social/sexual networking app to participate in online focus groups. Discussions were designed to elicit what the men would want in a mHealth tool specific for sexual health and HPV. Demographic data were analyzed using descriptive statistics and focus group data were analyzed using conventional content analysis. Forty-eight YMSM participated. Mean age was 23.4 years, and 70.0% reported their race as Black. Qualitative themes included general HPV knowledge and awareness, current patterns in technology use, desired app qualities, and desired app content. Youth described varying levels of HPV knowledge, utilized apps to engage socially, and for travel, banking, gaming, news and entertainment, and few used apps to facilitate personal health or engage with healthcare systems. Participants desired credible, relatable, secure, and easy to use interfaces that provided sexual health and HPV information in a positive context. They described ways to creatively engage and directly connect youth to health providers. We identified a culturally relevant youth driven approach to facilitate HPV vaccination and sexual health among YMSM.
Introduction
At the time of this study, the human papillomavirus (HPV) vaccine was recommended for men up through age 21 and young men who have sex with men (YMSM) up through age 26.Citation1Citation5 This recommendation, first made in 2011 (for the quadravalent vaccine and now for the nine-valent vaccine), was based on the high prevalence of HPV disease (specifically, genital warts and anal cancers) in men who have sex with men (MSM) (overall HPV prevalence: 64%, and above 90% for MSM who are also infected with HIV) as compared to men in general (40 to 50%).Citation1-Citation4 National rates of anal cancers are increasing,Citation5 and rates of anogenital HPV infection and cancers are the highest among YMSM.Citation2,Citation6 Of additional concern is the rapidly increasing rate of HPV-related oropharyngeal cancer (OPCs) among men in the U.S.7,Citation8 In fact, OPC has overtaken cervical cancer as the most frequently diagnosed HPV-related cancer in the U.S.8 Although prevention of OPC is not a label indication for HPV vaccine, there is indirect evidence that the vaccine may be effective.Citation9-Citation12 However, disparities in rates for HPV vaccination are evident for YMSM, with a recent article reporting on data from 2014, indicating that 17.2% of MSM 18–26 years of age had received one or more (≥1) doses of HPV vaccine.Citation13 These findings are echoed by 2013 data indicating only 13% HPV vaccine initiation among MSM 18–26 years of age.Citation14 In contrast, 2014 National Immunization Survey-Teen results show that 70.6% of 17 year old girls and 50.4% of 17 year old boys had received ≥1 dose of HPV vaccine.Citation15
Research on barriers to vaccination indicate that both attitudinal (e.g. health beliefs) and structural (e.g. health care provider recommendation and concerns about cost) factors can interfere with vaccine uptake.Citation16-Citation18 Studies that examined acceptance/rejection of vaccination by gay and/or gay and bisexual men have found that vaccination was related to provider recommendation as well as health beliefs (i.e. low perception of barriers to vaccination, worries about getting HPV-related diseases, and perceived social norms in favor of vaccination).Citation14,Citation19,Citation20 Additionally, work from this team and others describes YMSM lack of awareness of vaccine availability for men, lack of HPV knowledge,Citation21-Citation24 and stigma related to sexual orientation and seeking care, results reflected in a 2014 systematic review.Citation25 Many YMSM do not disclose their sexual orientation to their health care providersCitation26,Citation27 and that lack of disclosure decreases the likelihood that appropriate health services are offered,Citation28-Citation31 particularly when there have been differences in routine recommendations for YMSM. However, research indicates that YMSM are interested in receiving HPV vaccination.Citation23,Citation32
Possibly due to societal stigma and lack of comprehensive and sexual minority inclusive sexual health education in schools, YMSM often utilize online resources, including mobile application (app) technologies to obtain information about sexual health, as well as seek out sexual partners.Citation33-Citation36 The community of YMSM who utilize mobile social network apps for seeking social or sexual interactions (~6 million nationally) is dramatically on the rise,Citation35,Citation36 and this use has been associated with increased sexual risk (HPV risk) behaviors.Citation35,Citation37 In a recent study of YMSM, youth believed that use of mobile app technology could be a facilitator for HPV vaccination as well as access to MSM-affirming care.Citation22 Additionally, a recent pilot of a YMSM focused web-based HPV educational intervention found that those who utilized the website had higher subsequent vaccine initiation rates than those who did not.Citation38 The intervention also increased awareness of the risk for anal cancers among MSM and HPV vaccination self-efficacy, while at the same time decreasing perceived harms associated with the vaccine.Citation39 Another study noted that YMSM who searched for health information online had an increased odds of HPV vaccination.Citation29
Given prior research indicating interest in HPV vaccination among YMSMCitation25 and preliminary research on effectiveness of an HPV-focused app,Citation38 we were interested in examining preferences for an HPV and HPV vaccination app among YMSM users of a social/sexual networking app. Therefore, the aim of this qualitative study utilizing an online focus group methodology was to elicit YMSM’s interest, and preferred features, in an easy-to-use mHealth tool (web-enabled mobile app) which is being developed to provide HPV and HPV vaccine information as well as referral information and linkage to care. We specifically targeted YMSM who were users of a commonly used social/sexual networking app, as these young men represent a group at potentially high risk for HPV-related diseases.
Results
Demographic characteristics
The final sample consisted of 48 YMSM (13 to 19 per state; New York, Pennsylvania, Massachusetts). The mean age was 23.4 years, and 70% reported race/ethnicity as Black, 12% White, 4% Asian, 8% more than one race, 6% other, and 22% reported Hispanic ethnicity. Over 90% reported having health insurance and 53% had some college education (see ).
Table 1. Demographic characteristics.
Qualitative analysis
Four main categories emerged from the data: 1) general HPV knowledge and awareness, 2) current patterns of technology use, 3) desired qualities for a mHealth Tool, and 4) preferred content for a mHealth Tool. The youth were energized and engaged in the discussions, voiced excitement to be asked about their thoughts and desires related to a mHealth Tool, and over half desired to engage further by volunteering to test the mHealth Tool during its development. See for illustrative quotations across all categories.
Table 2. Illustrative quotes.
General HPV knowledge and awareness
The youth described variable levels of HPV knowledge and awareness. When asked what they knew about HPV, many youth stated “not much at all”, “I would like to know more”, and “not much, all the advertisements around it are targeted at women”; while others stated, “Men are common carriers with little to no symptoms. Women have a high cancer risk from HPV”, “I know you can get warts from HPV”, and “It can cause cancer and other diseases”. However, the majority were unaware that HPV was associated with cancer risks for men, MSM, or the types of HPV cancers that are prevalent among men. Overwhelmingly, the men were surprised to learn that HPV could cause cancers of the oropharynx, one stated “WOW!! Head/throat/neck cancer! I’m on my way to my doctor TOMORROW [to get vaccinated]”.
The participants expressed positive vaccine beliefs, describing that all men and women, no matter their sexual orientation, should and/or could get vaccinated for HPV, and that the vaccine required multiple doses. Several noted that they had been vaccinated, however many of the vaccinated men could not remember how many doses they had received. The belief that HPV affects women more than men was evident, and the men described experiences that reinforced this belief. For example, one youth stated, “I remember my health teacher stressing for the girls to get tested”. Additionally, men were surprised to learn that HPV was the most common sexually transmitted infection (STI) and voiced that they had always been more concerned about HIV.
Current patterns of technology use
Youth utilized mobile technology to stay engaged socially. The majority used multiple social and dating apps, described the strengths and weaknesses of these apps, and expressed partiality to dating apps that had a reputation for racial diversity. They also used apps for email, travel, banking, gaming, news and entertainment. Few used apps to enhance their personal health or engage with the healthcare system. The few health-associated apps they used included ones developed for fitness or meditation. One participant said he used an app developed by a health center and stated, “I have one for my doctor but never used it because it’s too complicated”. YMSM participants often described utilizing Google searches to seek information or find answers to health or sexual health questions, “I’m real quick to google anything health related”, one man noted. Participants said that if they were to use a health app, it needed to be easy to use, provide information about multiple health needs, be relevant to them as a user, overcome any fears they had about losing confidentiality, and connect them with health providers.
Desired qualities for a mHealth tool
They desired credible, relatable, secure, and easy to use interfaces that provided basic general and sexual health information in a positive context. The men described three primary qualities that a developed mHealth tool would need: 1) positive engagement, 2) a sense of credibility, and 3) a sense of security.
Participants thought the tool should have a very positive context that was non-judgmental and affirming for sexual minorities. They wanted sexual health information provided in a positive, direct, and engaging way. They expressed interest in an interactive platform that provided the latest health information via weekly updates, videos, or a way to blog or post questions with experts or peers. They also thought the tool engagement should be easy to use, simple, and to the point, one stated “[regarding an app] something with a straight forward interface. Not too complicated. Something simple and to the point”. They wanted a tool to be relatable with imagery representative of diverse races/ethnicities.
Perceived credibility was also deemed very important. The participants thought a tool would be more credible if it was associated with reputable health centers where providers were known to be knowledgeable about health for sexual minority groups. Additionally, if actual providers from a partner health center posted educational videos, or if there were opportunities for real-time engagement, the youth thought that would be very useful. Highlighting up-to-date statistics from well-known sources and educational information in a professional, but friendly and inclusive, manner was also viewed as desirable, “I like them [an app] as long as the information is up to date and backed by real medical professionals”. The participants desired a tool that was peer driven and relevant. Participants noted “I would like to see people that look like me as far as image”. They felt that developers should “[use] young people who are content creators”. When discussing potential videos, they wanted “stories of people that maybe others can relate to”.
Finally, a sense of security was imperative. The men described wanting a tool that could have a passcode and/or other markers of security including assurances of anonymity, icons to verify trust/security, or other confidentiality statements within the tool. The men were also concerned for themselves or other men in terms of making sure a mHealth tool on their phone would not mistakenly “out” someone. In particular, they voiced concerned regarding the name or icon on their phone itself not appearing “LGBT [lesbian, gay, bisexual, transgender] or health related”, “I would hate for someone looking at my phone and see a health app”, one man stated. The men thought that partnering with a MSM dating app would help with a sense of comfort and security, on participant stated “I think a health related app on Grindr or Jack’d or the like would ease the stigma- I know I never tell my doctor the exact truth [referring to his sexual practices]”. Additionally, when asked about what would make them want to download a mHealth tool, men agreed that the way in which it was advertised was important, and if it was advertised on a MSM dating app with youthful, fun, and culturally relevant ads they would be more likely to download it.
Preferred content for a mHealth tool
The participants detailed two aspects of content that they would desire in a tool: 1) sexual health/health information, and 2) linkages to care/health providers. The men described wanting educational information about HPV, HPV-associated diseases, and HPV vaccination including vaccination scheduling. They wanted practical guidance on cost as well as ways a partnered health center could support them via cost assistance programs or setting up health insurance. Additionally, they wanted other general sexual health information including information on safe sex practices, condom use and where to go for free condoms, and recommended lubricants or safe sexual toys. They thought a tool would be useful if it provided information other STIs and HIV prevention including pre-exposure prophylaxis (PrEP) and HIV testing. One participant described wanting a “guide to all STDs”. Participants also desired practical tips to promote sexual health, including how to talk to partners about condoms or testing. Lastly, fewer also desired information about what other resources a partnered health center could provide, including social support, housing, and mental health services.
The men described ways to creatively engage and directly connect youth to sexual minority affirming/friendly health providers. The young men wanted a tool that could book appointments (so they would not have to make a phone call), have a reminder system, and facilitate their connection to a local health center. They wanted maps, options for transportation, times the health center is open, and lists for all of the resources available at the local health center. They viewed geolocation capabilities as positive and perceived them to be a facilitator for access to care (via maps) as well as reminders for care (geo-locating men and sending a message via the tool if they are within a select distance to the health center for a drop in appointment). They also described wanting connections and information about other health or social events in the local community.
Discussion
Many of our findings can help to inform future mHealth development for YMSM, and to meet their sexual health needs. The YMSM in this study identified using their mobile technology primarily for socializing/networking, dating, and entertainment. Social apps and websites are also potentially a novel way to recruit and engage youth for health promotion interventions or research, and this method has been found to be an effective way to reach YMSM.Citation16,Citation20,Citation39-Citation41 The young men in this study were less likely to utilize health related apps, but when they did, the apps were likely focused on fitness or meditation. Similarly, among a national sample of adults (mean age 40 years), participants who downloaded health apps tended to by younger and utilize fitness or nutrition apps.Citation42
Participants were excited by the opportunity to help shape the content and look/feel of a mHealth tool focused on the sexual health needs of YMSM. Youth were open to the idea of having a sexual health focused app on their phones and did not yet know of any available applications that provided this type of content, especially YMSM-focused health content. They described wanting tools that 1) were affirming, credible, and secure, and 2) provided culturally competent sexual health education in positive and youth driven approach. The YMSM described wanting connections to facilitate obtaining care from local health centers for vaccination. Previously reported barriers to vaccination among YMSM and transgender women have included not knowing where to go for vaccination.Citation43 Lastly, youth also identified a need to obtain care from competent and affirming health providers.
Sexual and gender minority affirming care and health education appear to be mediators for HPV vaccination. Among YMSM, disclosure of same-sex behaviors to health providers and providers’ open and inclusive communication about sexual orientation and sexual behaviors have been noted as facilitators of HPV vaccination.Citation29,Citation30,Citation43 Additionally, provider sexual minority-competent care and access to affirming and inclusive health settings have been described by youth [inclusive of women who have sex with women (WSW)] as facilitators to HPV vaccine initiation and completion.Citation31 HPV vaccine initiation rates among WSW aged 18 to 26 years are higher than MSM, ranging from 35.2 to 45%.Citation44-Citation46 However, one study similarly indicated that WSW more likely to vaccinate if they perceived positive LGBT community vaccination norms.Citation44
Web and app based tools have emerged as useful way to disseminate health information or meet informational needs for targeted groups;Citation47,Citation48 however, credibility and security of apps, in particular sexual health apps, appear to be imperative for youth.Citation49 In this study, the young men described wanting information from sources that were reputable and legitimate (i.e. information from a health provider or health center ensured trust and credibility). This reflects findings to-date reporting that a health provider recommendation is a major factor in vaccine acceptance,Citation16,Citation18,Citation50 and potentially a provider recommendation online or within an app might be an effective approach. In work by Gatzido et al, credibility and legitimacy were also highlighted as a concern for youth, indicating that design and content were cues to determine credibility as well as expertise for those providing content or services.Citation49 Additionally, security and confidentiality were of equal importance in the design of mHealth tools in our study and in previous research.Citation48,Citation49 YMSM described wanting their information safeguarded, they did not want others to know the types of apps or content of apps they had on their mobile device, nor did they want an app to “out” them.
Lastly, consistent with prior research this study highlights the continued lack of knowledge and awareness about HPV infection and diseases among YMSM, despite the importance of HPV vaccination for men.Citation23,Citation24 Others have reported findings in which men believed HPV was principally a concern for females, and were unable to accurately articulate the negative health outcomes for men, including implications for penile, anal, or oral/pharyngeal cancers.Citation21,Citation22,Citation25 Clearly, ongoing novel efforts are needed disseminate HPV and HPV vaccine education among males and YMSM.
The online focus group methodology provided a confidential and safe space for YMSM to discuss their sexual health knowledge, needs, and desires for a HPV and sexual health focused mHealth tool. The sample was strengthened by the racial diversity, particularly with the majority being from ethnic and racial minorities, and the recruitment approach provides evidence that novel strategies can facilitate representation of young Black MSM in sexual health research. Despite these strengths, findings from our sample are limited by a potential for bias as we limited recruitment to one geographic (Northeast) region and participants were recruited entirely online from the same social/sexual networking dating app. In addition, our participants had relatively high levels of health insurance and education; however, we did not assess current health seeking behaviors, vaccine status, or level of engagement in care. Results from this study should be viewed in terms of our limitations and may not be generalizable to other groups of YMSMs.
Materials & methods
Study population and procedures
A purposive sample of YMSM, aged 18 to 26 years, were recruited across 3 northeastern states (Massachusetts, New York, & Pennsylvania) in April, 2017, for 6 online focus groups (2 groups per state). English speaking participants were recruited via pop-up advertisements on a popular mobile app oriented to men of color seeking social and sexual interactions with other men. When the youth activated (touched) the advertisement, potential participants were taken to a separate webpage that explained the study purpose and procedures, provided an electronic informed consent, and included a survey to assess eligibility (including availability for the planned focus groups). Eligible and consenting participants were invited to attend one 60-minute online focus group. Participants were given instructions on how to attend the group (e.g. date, time, and login instructions) and were sent email plus telephone or text reminders on the day of the focus group. Up to 20 invitations were sent for each focus group, with a goal of 10 participants per group (20 per state; 60 total participants).
The online focus group discussions were conducted in a secure virtual focus group web platform. Participants logged in to the study specific chat room interface with chosen pseudonyms. The discussions were text based only (interactive real time typed questions and answers) with each participant on their own computer or cell phone in a place of their choosing. These discussions provided rich data and our participants freely engaged with each other during the discussions. This methodology has demonstrated effectiveness yielding high quality, in-depth data, with high levels of open and direct participant engagement. In addition this online method is known to overcomes barriers to participation such as 1) feeling of safe and anonymous for sexual health discussions and 2) scheduling difficulties, particularly for young adults.Citation51-Citation53
All data collected remained anonymous and de-identified. As participants arrived for the discussion, the study purpose and procedures were reviewed, questions were answered, and each participant privately completed his demographic questionnaire (via a link to our secure Qualtrics® questionnaire). The principal investigator, experienced in online focus group methods, moderated all discussions. During the discussions, all participants were actively involved, responded to question prompts, and engaged with each other by posting text. If a participant had not answered a question or commented on another’s post, the online platform allowed the moderator to privately message any participant to continue engaging if necessary. Study protocols and procedures were approved by the Fenway Health IRB, and participants received $50 as remuneration.
Measures and analysis
The focus groups utilized a semi-structured script primarily designed to elicit what the YMSM would like to see in a mHealth tool related to sexual health in general and HPV specifically. Questions were guided by results from previous workCitation22 and included questions on what preferred features and information the men may like in a tool. We also included questions on look and feel, ease of use, as well as ease of download (See for examples of questions developed for this study). Demographic characteristics collected included: age, race/ethnicity, and educational, employment, and health insurance status.
Table 3. Focus group questions.
Focus group data were downloaded from the secure online platform onto the investigator’s research computer. Data were managed with HyperResearch version 3.0.3 (Research-Ware, Randolph, MA), and were analyzed using conventional content analysis.Citation54,Citation55 Three study investigators reduced the raw data into preliminary codes. Investigators discussed the emerging codes, concepts, and developed a final code book with definitions. The principal investigator and a research assistant then coded the complete data set independently and reviewed data for accuracy across coders. The entire team met again to review the coded data, examine relationships in the data and combine codes to broader categories and themes. Exemplar quotes were extracted and are highlighted in this report. Demographic questionnaire data was downloaded to SPSS version 22 (IBM, Armonk, NY) for management and analysis. Descriptive analyses included mean and standard deviations for continuous variables and percentages for nominal data.
Conclusion
This study was the first step in the development a novel app-based approach to promote sexual health and facilitate HPV vaccination. The recruitment methodology led to success in capturing the voice of a racially diverse sample of YMSM, an underrepresented population in sexual health research. Findings suggest mHealth tools are acceptable and a culturally relevant and youth driven approach to provide sexual health information to YMSM. We gained insight into YMSM’s unique needs and desires for a mHealth tool, and learned that this tool might help to facilitate youth’s connection to health resources for HPV vaccination. The youth were energized by the idea and engaged in our focus group discussions. They shared key insights and specific ideas for important content and features that will be incorporated in the larger project’s next phase. This next phase will include mHealth Tool development and trial in one Northeast city to determine if YMSM recruitment on a social/sexual networking app for our mHealth Tool will facilitate HPV vaccine initiation at a local LGBT focused health center.
Disclosure of potential conflicts of interest
No potential conflicts of interest were disclosed
Financial disclosure
Within the last year GZ received an honorarium from Sanofi Pasteur for work on the Adolescent Immunization Initiative.
Additional information
Funding
References
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