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Information Seeking from a Sexual Health Textline: Utilisation and Perceptions of Helpfulness among Young People

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Title: Information Seeking from a Sexual Health Textline: Utilisation and Perceptions of Helpfulness among Young People
Language: English
Authors: O'Malley, Teagen L., Horowitz, Katie Rose, Burke, Jessica G.
Source: Sex Education: Sexuality, Society and Learning. 2022 22(2):217-227.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 11
Publication Date: 2022
Document Type: Journal Articles
Reports - Research
Education Level: Junior High Schools
Middle Schools
Secondary Education
High Schools
Descriptors: Health Education, Sex Education, Prevention, Sexually Transmitted Diseases, Pregnancy, Barriers, Access to Education, Program Effectiveness, Telecommunications, Handheld Devices, Confidentiality, Adolescents, Middle School Students, High School Students, Peer Teaching
Geographic Terms: Pennsylvania
DOI: 10.1080/14681811.2020.1845642
ISSN: 1468-1811
Abstract: Comprehensive sexual health education is critical for the prevention of STIs and unintended pregnancy among young people. Yet, increasing barriers to comprehensive sexual health education in classroom settings underscore the importance of youth-friendly technologies to address sexual health among young people. "It's OK to Ask Someone" (IOTAS) uses a customised technology to expand Planned Parenthood of Western Pennsylvania's sexual health programming with a confidential sexual health textline designed to answer sexual health questions in a timely, user-friendly manner. This paper describes results from a process evaluation focused on assessing who uses IOTAS, how they use IOTAS and in what ways IOTAS is perceived to be helpful to texters. Results illustrate that a textline-approach is an acceptable and appropriate way to engage with young people. Findings demonstrate that young people are using the confidential textline to seek information about sexual health and report it as a helpful resource. Findings are relevant for sexual health educators and practitioners working with young people, including those interested in using a technology approach to expand health education opportunities. Additional research should continue to explore the potential of youth-friendly, technology-based approaches to support sexual health information seeking.
Abstractor: As Provided
Entry Date: 2022
Accession Number: EJ1335096
Database: ERIC
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  Value: <anid>AN0155633266;bf401mar.22;2022Mar11.08:07;v2.2.500</anid> <title id="AN0155633266-1">Information seeking from a sexual health textline: utilisation and perceptions of helpfulness among young people </title> <p>Comprehensive sexual health education is critical for the prevention of STIs and unintended pregnancy among young people. Yet, increasing barriers to comprehensive sexual health education in classroom settings underscore the importance of youth-friendly technologies to address sexual health among young people. It's OK to Ask Someone (IOTAS) uses a customised technology to expand Planned Parenthood of Western Pennsylvania's sexual health programming with a confidential sexual health textline designed to answer sexual health questions in a timely, user-friendly manner. This paper describes results from a process evaluation focused on assessing who uses IOTAS, how they use IOTAS and in what ways IOTAS is perceived to be helpful to texters. Results illustrate that a textline-approach is an acceptable and appropriate way to engage with young people. Findings demonstrate that young people are using the confidential textline to seek information about sexual health and report it as a helpful resource. Findings are relevant for sexual health educators and practitioners working with young people, including those interested in using a technology approach to expand health education opportunities. Additional research should continue to explore the potential of youth-friendly, technology-based approaches to support sexual health information seeking.</p> <p>Keywords: Adolescents; sexual health; textline; text messaging</p> <hd id="AN0155633266-2">Introduction</hd> <p>Public health and education professionals recognise the importance of comprehensive sexual health education for the prevention of sexually transmitted infections (STIs) and unintended pregnancy among youth (Hall et al. [<reflink idref="bib9" id="ref1">9</reflink>]). Yet, the delivery of sexual health education in school or community-based settings has declined in recent years (Lindberg, Maddow-Zimet, and Boonstra [<reflink idref="bib11" id="ref2">11</reflink>]) and young people often turn to the Internet for health information (Boyar, Levine, and Zensius [<reflink idref="bib3" id="ref3">3</reflink>]; Rideout and Fox [<reflink idref="bib17" id="ref4">17</reflink>]). While Internet searches may increase access to health information, a number of barriers potentially prevent access to high-quality, medically accurate information. Lack of knowledge about reliable online sources for health information, a high reliance on results found on the first page returned, difficulties sorting search results and a general mistrust of information found online are all issues of concern regarding young people's access to Internet-based sexual health information (Magee et al. [<reflink idref="bib12" id="ref5">12</reflink>]; Starling and Cheshire [<reflink idref="bib20" id="ref6">20</reflink>]; Wartella et al. [<reflink idref="bib21" id="ref7">21</reflink>]). Additionally, youth perceptions of stigma about 'being seen' searching for sexual health information or unintentionally accessing sexually explicit materials may prevent them from initiating a search for sexual health information, either through search engines or within social media and app-based platforms (Patterson et al. [<reflink idref="bib14" id="ref8">14</reflink>]).</p> <p>In the USA, barriers to comprehensive sexual health education in classroom settings (such as state funding or requirement decisions; incomplete, biased or inaccurate information in the classroom; or no sex education altogether) suggests that in order to improve sexual and reproductive health outcomes for adolescents, the use of youth-friendly technologies that reach young people beyond the classroom is critical (Hall et al. [<reflink idref="bib9" id="ref9">9</reflink>]). Mobile phone interventions employing technological approaches that engage youth using methods beyond online searches represent an opportunity to reach a broad population. Mobile phone ownership is ubiquitous among US youth. Ninety-five per cent of US teenagers ages 13–17 years had access to a smartphone by 2018 with almost identical rates among young people identifying as African-American, Hispanic and White (94%, 95%, and 94%, respectively) (Anderson and Jiang [<reflink idref="bib2" id="ref10">2</reflink>]). Furthermore, by 2016, when the Pew Research Center most recently conducted a national survey amongst teenagers younger than 18 years, 91% of teenage cell phone users reported using text messaging (Anderson [<reflink idref="bib1" id="ref11">1</reflink>]). Recently, 21% of teenagers reported in a 2018 survey that they texted 'almost constantly', with another 27% saying they did so 'a few times an hour' (Rideout and Robb [<reflink idref="bib18" id="ref12">18</reflink>]). Widespread use and comfort with cell phones and messaging suggests that SMS (short message service) interventions may offer a unique approach to expanded comprehensive sexual health education for youth.</p> <p>Youth-friendly interventions focused on sexual health to date have included components of cell phone engagement (e.g., two-way texting, automated text listservs), social media and gaming experiences (Chávez, Shearer, and Rosenthal [<reflink idref="bib5" id="ref13">5</reflink>]; DeSmet et al. [<reflink idref="bib6" id="ref14">6</reflink>]; Guse et al. [<reflink idref="bib8" id="ref15">8</reflink>]). Several approaches have demonstrated promise with respect to positive sexual health outcomes, including increased self-efficacy and/or knowledge about sexual health, delay in sexual initiation and increased intentions to use condoms (Chávez, Shearer, and Rosenthal [<reflink idref="bib5" id="ref16">5</reflink>]; DeSmet et al. [<reflink idref="bib6" id="ref17">6</reflink>]; Guse et al. [<reflink idref="bib8" id="ref18">8</reflink>]; Burns, Keating, and Free [<reflink idref="bib4" id="ref19">4</reflink>]). Targeted text message services provide an innovative approach to providing sexual health information to youth and are being implemented using varied approaches. Some have included information delivered on a set schedule (e.g., The Hook-Up (Perry et al. [<reflink idref="bib15" id="ref20">15</reflink>])). Other approaches allow adolescents to text requests for information on specific topics (e.g., SEXINFO (Levine et al. [<reflink idref="bib10" id="ref21">10</reflink>])) or text questions to a health educator (e.g., BrdsNBz, (Phillips [<reflink idref="bib16" id="ref22">16</reflink>]); Planned Parenthood Federation of America's Chat/Text (Giorgio et al. [<reflink idref="bib7" id="ref23">7</reflink>]); and In Case You're Curious[<reflink idref="bib1" id="ref24">1</reflink>]). Some interventions combine a number of these approaches. For example, TxTina,[<reflink idref="bib2" id="ref25">2</reflink>] utilises weekly sexual health tips and quizzes in combination with two afternoons per month during which young people can text their questions to a health educator.</p> <p>The <emph>It's OK to Ask Someone</emph> (IOTAS) programme uses customised software to expand Planned Parenthood of Western Pennsylvania's sexual health programming and successfully incorporates youth asking and answering sexual health questions (O'Malley et al. [<reflink idref="bib13" id="ref26">13</reflink>]). IOTAS offers a textline whereby young people seeking sexual health information can text a confidential question from their phone and receive a personalised answer within 24 hours. Planned Parenthood of Western Pennsylvania (PPWP) uses responses to IOTAS incoming sexual health questions as a peer education opportunity. Each year middle and high school students participate on a long-term basis in weekly sessions of comprehensive sexuality education and peer educator skills training, utilising evidence-based pregnancy prevention curricula and established sexuality education methodology and guidelines. In addition, PPWP peer education students are trained to staff IOTAS through an eight-lesson curriculum which includes discussion of topics such as how to read and interpret questions; best practices for researching answers to the question; and how to write an answer, including establishing a non-judgemental, friendly and normalising tone, using inclusive and accessible language and connecting texters to local resources. Through the use of cross-platform application technology, student peer educators are able to access IOTAS with any smart phone. Staffing IOTAS provides PPWP student peer educators with a unique opportunity to expand their knowledge of healthy sexual behaviours and to educate an extended network of peers.</p> <p>Findings from a feasibility study reported elsewhere show that IOTAS programming fills an existing gap for confidential and timely sexual health information by young people in the region, expands PPWP's reach beyond classroom interaction and offers peer educators an opportunity to expand their knowledge of healthy sexual behaviours and educate an extended peer network (O'Malley et al. [<reflink idref="bib13" id="ref27">13</reflink>]). This article reports on a cross-sectional, process evaluation aimed to understand utilisation and effectiveness of the IOTAS intervention among texters and high school peer educator staffers following intervention implementation, through survey and intervention administration data. We focus specifically on process evaluation results among IOTAS texters and provide a description of: (<reflink idref="bib1" id="ref28">1</reflink>) who uses IOTAS, (<reflink idref="bib2" id="ref29">2</reflink>) how IOTAS is used, and (<reflink idref="bib3" id="ref30">3</reflink>) whether IOTAS is perceived as helpful to texters.</p> <hd id="AN0155633266-3">Methods</hd> <p>All components of this cross-sectional, process evaluation including aims, objectives, key questions and data collection methodology, were developed by PPWP staff with input from a consultant evaluation researcher (TLO). Approximately 250 middle and high school students participated in the weekly comprehensive sexuality education sessions and peer educator skills training and were trained to staff IOTAS through an eight-lesson curriculum. In addition, a campaign of professionally branded materials was launched by PPWP in August 2016, which marketed IOTAS to young people aged 14 to 19 years. The campaign targeted a total of 200,000 young people in a four-county area of Western Pennsylvania and included targeted online (e.g., Pandora) and bus transit advertising, in-person outreach to youth-serving organisations (e.g., via student health clinics), extensive social media outreach (e.g., Instagram, Facebook, Twitter), peer educator and volunteer engagement at local events (e.g., concerts) and outreach to interested Planned Parenthood affiliates. IOTAS print materials (e.g., posters, brochures, palmcards) were also distributed. Advertisement language varied across strategy, but included information such as what IOTAS was (e.g., 'Have a question about STDs, pregnancy, or relationships? We'll send back an answer you can trust'), an example question (e.g., 'Can you get HIV from kissing?'), IOTAS contact details and other ways to connect with IOTAS via social media.</p> <hd id="AN0155633266-4">Data collection</hd> <p></p> <hd id="AN0155633266-5">Survey data</hd> <p>A SMS-survey was designed and administered to a sub-sample of IOTAS users over an 8-month period between December 2016 and July 2017. As part of a process evaluation of the programme, a 25% random sample of IOTAS users from the eight-month evaluation period was identified and contacted about the process evaluation survey. IOTAS users who submitted text messages during the evaluation period that were not questions (e.g., 'hello', 'thanks') were excluded. Duplicate phone numbers, as a result of repeat texters, were removed and replaced with a unique number to ensure that multiple surveys were not sent to the same texters. Eligible participants first received a text introducing the 5-question survey and potential to win prizes upon survey completion. Those interested in participating were instructed to text back 'ASK' to continue. Participants who completed the entire survey were entered into a raffle to win a small incentive (choice of iTunes or Amazon gift card). Participants were asked to answer five questions including their age and gender, what IOTAS helped with, referral source and postal code. To understand perceived usefulness of IOTAS by texters, a question also asked how helpful IOTAS was (Table 1). A total of 65 of the 230 eligible IOTAS users completed the SMS-survey representing a response rate of 28%.</p> <p>Table 1. SMS survey questions</p> <p> <ephtml> <table><tbody><tr><td>IOTAS:</td><td>Thanks again for texting IOTAS for answers about sexual health and relationships! We'd like to learn more about you to make sure we're doing the best we can. 4 questions coming your way. Answer all and you can win prizes. Text ASK to continue.</td></tr><tr><td>IOTAS:</td><td>Thanks for filling out the IOTAS survey! We have 2 raffles you can win! Amazon or iTunes? Text STUFF or MUSIC.</td></tr><tr><td>IOTAS:</td><td>What's your age and gender?</td></tr><tr><td>IOTAS:</td><td>What did the IOTAS answer help you with? For example, STD info, breaking up, got a pregnancy test.</td></tr><tr><td>IOTAS:</td><td>How did you hear about IOTAS? A friend tell u? Saw a bus poster? Social media? A palmcard?</td></tr><tr><td>IOTAS:</td><td>We want to know if we're reaching youth all over PGH. Text your zip code to tell us where u live!</td></tr><tr><td>IOTAS:</td><td>From 1–5 stars, how helpful was IOTAS?</td></tr><tr><td>IOTAS:</td><td>Thx 4 helping us make IOTAS better for you! Stay tuned to learn if u won the raffle!</td></tr></tbody></table> </ephtml> </p> <hd id="AN0155633266-6">Administrative data</hd> <p>Administrative data generated in the IOTAS interface and tracked by PPWP were used to assess how texters used IOTAS. The data included information about the number of questions, texter phone numbers, question topic and local health and social service linkages shared. This process evaluation involved an analysis of textline administration data over an 8-month period (December 2016 to July 2017) to measure how texters used IOTAS, including the number of questions received, the number of repeat users and the content of questions.</p> <hd id="AN0155633266-7">Analysis</hd> <p>All data were de-identified by PPWP prior to analysis. SMS surveys were examined to check for missing data and descriptive statistics were used to describe findings. Missing data were included in the analysis and reported in the results. Text responses from the open-ended question exploring what IOTAS helped with were classified by one coder (TLO) using broad category codes consistent with PPWP tracking categories identified by PPWP staff educators during the early development of the IOTAS intervention, and expanded upon iteratively during the pilot period to include categories for those questions that did not fit well into the original set. For example, one category (PrEP) was added later as a tracking mechanism for a partnership with a regional initiative. Coding concerns were resolved in collaboration with another author (KRH). Illustrative qualitative quotes are documented below to provide context around texters' self-reported response on what IOTAS helped them with. Administrative data were examined for textline utilisation and sexual health question content. Descriptive statistics were used to report textline data. Data management and analysis for both data sources were conducted in Stata v14.2s.</p> <hd id="AN0155633266-8">Data security and confidentiality</hd> <p>Due to the sensitive nature of the textline, confidentiality and data security were important considerations as the IOTAS intervention was developed and implemented. The IOTAS software is an internal PPWP tool, not a public-facing app, and users of the software are granted differing levels of access, depending on whether they are adult staff or youth peer educators. Through their specific access, PPWP Education Department staff have oversight and grant approval of all incoming SMS before they are sent to peer educators to answer, and of all outgoing SMS before they are sent back to texters. Privacy and content protocols determine which texts will be approved for peer educators to view and which must be answered directly by staff. The protocols require adults to screen all texts and remove certain aspects before approving for students to view, including removing any personally identifiable information (PII) included by the texter (such as name, school attended and neighbourhood). Texters' phone numbers are only ever visible to adult staff who are trained only to access a texter's phone number when their question describes a reportable situation, based on US Federal Mandatory Reporter laws. Accessing the phone number requires several intentional clicks into a software setting not utilised within a typical workflow.</p> <p>Likewise, youth peer educators are protected by a number of safeguards. Each peer educator has to create a username for the software system and conducts their work solely within this system. A list maintained by PPWP staff which links student names to usernames is stored outside of the software interface on PPWP's secure network. Since peer educators interact with questions solely through the software interface, their names and personal phone numbers are never linked in any way, and since the replies sent from the software to texters come from one designated IOTAS phone number, student identities are obscured from texters, as well as within the system itself. Furthermore, since the software is an internal tool invisible to texters and external parties, permission is required from PPWP staff to create user accounts. Because data is encrypted at each level (SMS gateway, mail server, application programming interface [API] and web interface), the use of the software on their own mobile phones does not pose a substantial risk to the confidentiality of peer education students. These safeguards also protect the texters' expectation of confidentiality while using the IOTAS service.</p> <p>Survey data were handled with careful attention to data security and confidentiality. The only PII contained within the data that was collected through the survey API was the phone number connected to each respondent. Data were downloaded by PPWP staff on their secure network and de-identified (e.g. phone numbers removed) by PPWP prior to analysis. Additionally, as they identified quotes for use in reporting this data, the authors ensured the anonymity of the content of the answers. After review by PPWP, it was confirmed that the project was part of IOTAS programme refinement and findings were not generalisable beyond the population served by the textline. As such, the process evaluation was not classified as research and Institutional Review Board oversight was not required. Given the precautions taken to protect texter confidentiality described here and above, PPWP along with the authors determined that publication of evaluation data would not place the confidentiality or privacy of respondents at risk.</p> <hd id="AN0155633266-9">Results</hd> <p>Descriptive information about who used IOTAS during the evaluation period is presented in Table 2. Sixty-five previous IOTAS users completed the SMS survey. Most respondents from this randomly selected sub-sample of IOTAS texters were 16 to 19 years (35%) and the majority female (71%). Respondents ranged from 13 to 53 years in age, with an average age of 23 years. A majority of respondents came from areas within the IOTAS marketing campaign (92%); 7% came from areas outside of the four-county marketing area. Many respondents described hearing about IOTAS through marketing efforts (i.e., bus advertisements, social media and palmcards) with over 32% identifying bus advertisements as the source of IOTAS information. Fourteen per cent of respondents reported learning about IOTAS through word-of-mouth (e.g., from a doctor, school counsellor or Planned Parenthood employee); friends were the IOTAS referral source among 9% of respondents.</p> <p>Table 2. Characteristics of IOTAS texters</p> <p> <ephtml> <table><thead><tr><td /><td>n (%)</td></tr></thead><tbody><tr><td>Age, years (mean (range))</td><td>22.8 (13–53)</td></tr><tr><td> 13 to 15 years</td><td>7 (10.8)</td></tr><tr><td> 16 to 19 years</td><td>23 (35.4)</td></tr><tr><td> 20 to 29 years</td><td>21 (32.3)</td></tr><tr><td> 30 years or older</td><td>12 (18.5)</td></tr><tr><td><italic>Missing</italic></td><td><italic>2 (3.10)</italic></td></tr><tr><td>Gender</td><td /></tr><tr><td> Female</td><td>46 (70.8)</td></tr><tr><td> Male</td><td>14 (21.5)</td></tr><tr><td><italic>Missing</italic></td><td><italic>5 (7.70)</italic></td></tr><tr><td>Heard of IOTAS (n = 57)</td><td /></tr><tr><td> Bus poster</td><td>21 (32.3)</td></tr><tr><td> Palmcard</td><td>6 (9.20)</td></tr><tr><td> Social media</td><td>15 (23.1)</td></tr><tr><td> Friend</td><td>6 (9.20)</td></tr><tr><td> Provider (e.g., doctor, school counsellor)</td><td>2 (3.10)</td></tr><tr><td> Planned Parenthood (e.g., programme, employee, website)</td><td>4 (6.20)</td></tr><tr><td> Other (e.g., school, STD info)</td><td>3 (4.60)</td></tr><tr><td><italic>Missing</italic></td><td><italic>8 (12.3)</italic></td></tr><tr><td>Texter areas of residence (n = 56)</td><td /></tr><tr><td> Within marketing campaign area</td><td>52 (92.9)</td></tr><tr><td> Outside of marketing campaign area</td><td>4 (7.10)</td></tr><tr><td><italic>Missing</italic></td><td><italic>9 (13.8)</italic></td></tr><tr><td>Helpfulness of IOTAS (mean (range))</td><td>4.58 (2–5)</td></tr><tr><td> 2 stars</td><td>1 (1.50)</td></tr><tr><td> 3 stars</td><td>4 (6.20)</td></tr><tr><td> 4 stars</td><td>11 (16.9)</td></tr><tr><td> 5 stars</td><td>36 (55.4)</td></tr><tr><td><italic>Missing</italic></td><td><italic>13 (20.0)</italic></td></tr></tbody></table> </ephtml> </p> <p>Table 3 presents information regarding how texters used IOTAS based on administrative data. Nine hundred and twenty questions were submitted to IOTAS during the 8-month process evaluation period by 492 individual texters. A majority (64%) of users texted just one question; 36% of users were repeat users and submitted two or more questions. Questions texted to IOTAS during this time period varied and were related to sex, contraception, relationships, LGBTQ issues, and sexual and reproductive health services. Most questions pertained to relationships (27%). Sex (13%), contraception (12%), bodies (11%), and sexually transmitted diseases (STDs) (10%) (e.g., 'How do I tell someone they gave me an STD?') were also the focus of a number of questions.</p> <p>Table 3. IOTAS utilisation (1 December 2016 – 31 July 2017)</p> <p> <ephtml> <table><thead><tr><td /><td>n (%)</td></tr></thead><tbody><tr><td><bold>Level of Utilisation</bold></td></tr><tr><td>Questions received, total</td><td>920 (100)</td></tr><tr><td>Unique users, total</td><td>492 (100)</td></tr><tr><td> Single user (1 question)</td><td>315 (64.0)</td></tr><tr><td> Repeat users (2 or more questions)</td><td>117 (36.0)</td></tr><tr><td>No. of questions, per user (mean (range))</td><td>1.87 (1–19)</td></tr><tr><td> 1 question</td><td>315 (64.0)</td></tr><tr><td> 2 questions</td><td>95 (19.3)</td></tr><tr><td> 3 to 4 questions</td><td>55 (11.2)</td></tr><tr><td> 5 to 6 questions</td><td>10 (2.04)</td></tr><tr><td> 7 to 8 questions</td><td>8 (1.64)</td></tr><tr><td> 9 or more questions</td><td>9 (1.83)</td></tr><tr><td><bold>Question Topic</bold> (n = 905)</td><td /></tr><tr><td> Relationships</td><td>250 (27.6)</td></tr><tr><td> Sex</td><td>119 (13.1)</td></tr><tr><td> Contraception</td><td>111 (12.3)</td></tr><tr><td> Bodies</td><td>101 (11.2)</td></tr><tr><td> STDS</td><td>91 (10.1)</td></tr><tr><td> Pregnancy</td><td>86 (9.50)</td></tr><tr><td> Values-based</td><td>47 (5.19)</td></tr><tr><td> Planned Parenthood services</td><td>38 (4.20)</td></tr><tr><td> LGBTQ+</td><td>36 (3.97)</td></tr><tr><td> PrEP (pre-exposure prophylaxis)</td><td>26 (2.87)</td></tr></tbody></table> </ephtml> </p> <p>A majority of respondents reported that IOTAS helped with questions around categories of STDs (26%), relationships (26%) and pregnancy (15%). Summary information on what IOTAS helped respondents with is shown in Table 4. Text response quotes detailing respondents' recollection of what IOTAS helped with are included as illustrative examples, as well as corresponding question category and percentages. When asked how helpful IOTAS was on scale of 1 to 5 stars, almost 55% of respondents reported 5 stars.</p> <p>Table 4. Question category of what IOTAS helped and illustrative quote (<emph>N</emph> = 60)</p> <p> <ephtml> <table><thead><tr><td>Category</td><td>n (%)</td><td>IOTAS helped with</td></tr></thead><tbody><tr><td>STDs</td><td>16 (26.6)</td><td><italic>HIV/STD testing</italic><italic>STD info</italic></td></tr><tr><td>Relationships</td><td>16 (26.6)</td><td><italic>Difference between a boyfriend and a husband</italic><italic>Boyfriend drama</italic><italic>Breaking up</italic><italic>Asking a girl out</italic></td></tr><tr><td>Pregnancy</td><td>9 (15.0)</td><td><italic>Pregnancy and available services/support</italic><italic>Morning after pills</italic><italic>Pregnancy test</italic></td></tr><tr><td>Bodies</td><td>6 (10.0)</td><td><italic>Personal hygiene</italic><italic>Discharge question</italic><italic>Genital health</italic></td></tr><tr><td>Contraception</td><td>6 (10.0)</td><td><italic>Birth control</italic><italic>Condoms</italic></td></tr><tr><td>Sex</td><td>5 (8.33)</td><td><italic>Sex advice</italic><italic>Having masturbation problems</italic></td></tr><tr><td>Other</td><td>3 (5.00)</td><td><italic>Why doctors ask if you're sexually active</italic><italic>Mental illness</italic></td></tr><tr><td>LGBTQ</td><td>1 (1.67)</td><td><italic>Coming out as trans</italic></td></tr><tr><td>Planned Parenthood services</td><td>1 (1.67)</td><td><italic>Health centre hours</italic></td></tr><tr><td>Values-based</td><td>1 (1.67)</td><td><italic>How to help my community</italic></td></tr><tr><td>PrEP</td><td>1 (1.67)</td><td><italic>The drug PrEP</italic></td></tr></tbody></table> </ephtml> </p> <hd id="AN0155633266-10">Discussion</hd> <p>This evaluation provides information about the value of a sexual health textline for young people. As the need to expand comprehensive sexual health information beyond classroom settings continues, these findings contribute to the opportunities to engage young people in sexual health education. The findings are particularly relevant for sexual health educators and practitioners working with young people, including those interested in utilising a technology approach to expand health education opportunities.</p> <p>Study findings highlight that IOTAS offers an acceptable and appropriate way to engage with young people, that young people use the confidential textline to seek information about sexual health, and that users report IOTAS is a helpful resource. In addition to providing an understanding of who is using IOTAS, results from the SMS-survey suggest that IOTAS is reaching the intended target population of young people in Pittsburgh and surrounding areas, while at the same time also reaching audiences beyond the original target population. IOTAS questions received during the evaluation are similar to those in existing research into the sexual health questions young people ask through technology, specifically contraception, STDs, physical development and unplanned pregnancy (Levine et al. [<reflink idref="bib10" id="ref31">10</reflink>]; Willoughby and Jackson [<reflink idref="bib22" id="ref32">22</reflink>]). In addition to seeking factual information, IOTAS texters also sought advice or guidance, particularly on relationships, indicating that IOTAS may be filling both a gap in the need for sexual health information, but also information and advice by people in the area.</p> <p>While text message services are increasingly used to provide sexual health information to young people seeking information, IOTAS is unique and expands upon prior models. In particular, IOTAS allows unique questions to be asked at any time and for users to receive a personalised message within 24 hours, generated by youth peer educators who answer the sexual health questions. Existing text messaging-based sexual health programmes primarily involve education and information through a subscription format (Sheoran et al. [<reflink idref="bib19" id="ref33">19</reflink>]), information requests on specific topics (Levine et al. [<reflink idref="bib10" id="ref34">10</reflink>]), or unique questions answered by an adult educator (Willoughby and Jackson [<reflink idref="bib22" id="ref35">22</reflink>]).</p> <p>The study also contributes to the support and benefit of using SMS or text message surveys. Previous research provides evidence of the feasibility of such an approach, particularly among sexual health text messaging programmes (Sheoran et al. [<reflink idref="bib19" id="ref36">19</reflink>]; Willoughby et al. [<reflink idref="bib23" id="ref37">23</reflink>]), and our findings provide additional support to its application. Given that IOTAS is an SMS intervention, and the comfort and frequency of text messaging among young people (Anderson [<reflink idref="bib1" id="ref38">1</reflink>]), a text-based survey provided an opportunity to collect effective and efficient evaluation data. Adolescents and young people are often hard to reach and text messaging may provide a valuable approach to do so. Compared to another SMS-survey among young people (Sheoran et al. [<reflink idref="bib19" id="ref39">19</reflink>]), our response rate was similar (28.2% vs. 33.6%); however, the drop-out rate was considerably lower with 80% of respondents completing all five questions (compared to 58% among Sheoran and colleagues). This study underscores that SMS surveys must be short, and the questions clear to minimise drop-out and require additional programming, capacity and technical infrastructure to create, manage and collect data.</p> <hd id="AN0155633266-11">Limitations</hd> <p>While this study provides important insights into IOTAS utilisation and the characteristics of users, there are several limitations worth noting. The SMS survey sample may not be representative of all IOTAS users. While our response rate was fairly similar to other SMS surveys among young people (Sheoran et al. [<reflink idref="bib19" id="ref40">19</reflink>]), only a proportion of total IOTAS users received the SMS-survey due to technical capacity, the resulting sample size was small, and a majority of respondents identified as female (Willoughby et al. [<reflink idref="bib23" id="ref41">23</reflink>]). Our retrospective study design, and the limitations of using an SMS-survey prohibited us from examining texters' short or medium-term behaviour change as a result of the IOTAS response received. Although the question 'What did the IOTAS answer help you with?' was designed to elicit responses indicating behaviour change, respondents' answers were either more descriptive of the information they received from the IOTAS answers or syntactically not able to be confirmed as a commenting on behaviour. As such, the responses to that item served instead to demonstrate that the sub-sample was substantially similar to the administrative data in terms of the topics respondents indicated having asked for help about. Finally, more favourable feedback may have been provided on SMS surveys given existing evidence around more favourable feedback received when evaluating a programme on the same device used to receive it (i.e., a cell phone) (Willoughby et al. [<reflink idref="bib23" id="ref42">23</reflink>]).</p> <hd id="AN0155633266-12">Future research</hd> <p>Additional research should continue to explore the potential of youth-friendly, technology-based approaches to support sexual health information seeking. For example, future research should examine if information received through the textline is shared with others since peers are a key information source for young people (Boyar, Levine, and Zensius [<reflink idref="bib3" id="ref43">3</reflink>]) and textline information received may impact a network of young people beyond the individual texter. Future research might also explore opportunities to investigate behaviour change and health outcomes following sexual health textline utilisation.</p> <hd id="AN0155633266-13">Conclusion</hd> <p>Young people desire sexual health information and advice and are comfortable using a confidential, texline approach. Sexual health educators and practitioners should consider technology-based approaches to promoting sexual health among young people. Future research is needed to understand the impact of such approaches on behaviour change and health outcomes.</p> <hd id="AN0155633266-14">Acknowledgments</hd> <p>We thank Nick Hall for developing and managing the technology behind the SMS survey, and without whose assistance we could not have completed this research.</p> <hd id="AN0155633266-15">Disclosure statement</hd> <p>No potential conflict of interest was reported by the authors.</p> <ref id="AN0155633266-16"> <title> Notes </title> <blist> <bibl id="bib1" idref="ref11" type="bt">1</bibl> <bibtext> In Case You're Curious (https://responsiblesexedinstitute.org/icyc/).</bibtext> </blist> <blist> <bibl id="bib2" idref="ref10" type="bt">2</bibl> <bibtext> TxTina (<ulink href="http://www.asktxtina.com/">http://www.asktxtina.com/</ulink>).</bibtext> </blist> </ref> <ref id="AN0155633266-17"> <title> References </title> <blist> <bibtext> Anderson, M. 2016. Parents, Teens, and Digital Monitoring. Pew Research Center. Washington, DC.</bibtext> </blist> <blist> <bibtext> Anderson, M., and J. Jiang. 2018. Teens, Social Media, & Technology 2018. Pew Research Center. Washington, DC.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref3" type="bt">3</bibl> <bibtext> Boyar, R., D. Levine, and N. Zensius. 2011. TECHsex USA: Youth Sexuality and Reproductive Health in the Digital Age. Oakland, CA : ISIS.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref19" type="bt">4</bibl> <bibtext> Burns, K., P. Keating, and C. Free. 2016. " A Systematic Review of Randomised Control Trials of Sexual Health Interventions Delivered by Mobile Technologies." BMC Public Health 16 (1): 778. doi: 10.1186/s12889-016-3408-z.</bibtext> </blist> <blist> <bibl id="bib5" idref="ref13" type="bt">5</bibl> <bibtext> Chávez, N., L. S. Shearer, and S. L. Rosenthal. 2014. " Use of Digital Media Technology for Primary Prevention of STIs/HIV in Youth." Journal of Pediatric and Adolescent Gynecology 27 (5): 244 – 257. doi: 10.1016/j.jpag.2013.07.008.</bibtext> </blist> <blist> <bibl id="bib6" idref="ref14" type="bt">6</bibl> <bibtext> DeSmet, A., R. Shegog, D. Van Ryckeghem, G. Crombex, and I. De Bourdeaudhuij. 2015. " A Systematic Review and Meta-Analysis of Interventions for Sexual Health Promotion Involving Serious Digital Games." Games for Health 4 (2): 78 – 90. doi: 10.1089/g4h.2014.0110.</bibtext> </blist> <blist> <bibl id="bib7" idref="ref23" type="bt">7</bibl> <bibtext> Giorgio, M. M., L. M. Kantor, D. S. Levine, and W. Arons. 2013. " Using Chat and Text Technologies to Answer Sexual and Reproductive Health Questions: Planned Parenthood Pilot Study." Journal of Medical Internet Research 15 (9): e203. doi: 10.2196/jmir.2619.</bibtext> </blist> <blist> <bibl id="bib8" idref="ref15" type="bt">8</bibl> <bibtext> Guse, K., D. Levine, S. Martins, A. Lira, J. Gaarde, W. Westmorland, and M. Gilliam. 2012. " Interventions Using New Digital Media to Improve Adolescent Sexual Health: A Systematic Review." Journal of Adolescent Health 51 (6): 535 – 543. doi: 10.1016/j.jadohealth.2012.03.014.</bibtext> </blist> <blist> <bibl id="bib9" idref="ref1" type="bt">9</bibl> <bibtext> Hall, K. S., J. McDermott Sales, K. A. Komro, and J. Santelli. 2016. " The State of Sex Education in the United States." Journal of Adolescent Health 58 (6): 595 – 597. doi: 10.1016/j.jadohealth.2016.03.032.</bibtext> </blist> <blist> <bibtext> Levine, D., J. McCright, L. Dobkin, A. J. Woodruff, and J. D. Klausner. 2008. " SEXINFO: A Sexual Health Text Messaging Service for San Francisco Youth." American Journal of Public Health 98 (3): 393 – 395. doi: 10.2105/AJPH.2007.110767.</bibtext> </blist> <blist> <bibtext> Lindberg, L. D., I. Maddow-Zimet, and H. Boonstra. 2016. " Changes in Adolescents' Receipt of Sex Education, 2006–2013." Journal of Adolescent Health 58 (6): 621 – 627. doi: 10.1016/j.jadohealth.2016.02.004.</bibtext> </blist> <blist> <bibtext> Magee, J. C., L. Bigelow, S. Dehaan, and B. S. Mustanski. 2012. " Sexual Health Information Seeking Online: A Mixed-methods Study among Lesbian, Gay, Bisexual, and Transgender Young People." Health Education & Behavior 39 (3): 276 – 289. doi: 10.1177/1090198111401384.</bibtext> </blist> <blist> <bibtext> O'Malley, T. L., K. R. Horowitz, J. Garth, C. Mair, and J. G. Burke. 2017. " A Technology-Based Peer Education Intervention: Results from A Sexual Health Textline Feasibility Study." American Journal of Sexuality Education 12 (4): 383 – 394. doi: 10.1080/15546128.2017.1372831.</bibtext> </blist> <blist> <bibtext> Patterson, S. P., S. Hilton, P. Flowers, and L. M. McDaid. 2019. " What are the Barriers and Challenges Faced by Adolescents When Searching for Sexual Health Information on the Internet? Implications for Policy and Practice from a Qualitative Study." Sexually Transmitted Infections 95 (6): 462 – 467.</bibtext> </blist> <blist> <bibtext> Perry, R. C., K. C. Kayekjian, R. A. Braun, M. Cantu, B. Sheoran, and P. J. Chung. 2012. " Adolescents' Perspectives on the Use of a Text Messaging Service for Preventive Sexual Health Promotion." Journal of Adolescent Health 51 (3): 220 – 225. doi: 10.1016/j.jadohealth.2011.11.012.</bibtext> </blist> <blist> <bibtext> Phillips, K. R. 2010. " BrdsNBz: A Text-messaging Forum for Improving the Sexual Health of Adolescents in North Carolina." North Carolina Medical Journal 71 (4): 368 – 371.</bibtext> </blist> <blist> <bibtext> Rideout, V., and S. Fox. 2018. Digital Health Practices, Social Media Use, and Mental Well-Being among Teens and Young Adults in the U.S. Hopelab & Well Being Trust. San Francisco, CA.</bibtext> </blist> <blist> <bibtext> Rideout, V., and M. B. Robb. 2018. Social Media, Social Life: Teens Reveal Their Experiences. San Francisco, CA : Common Sense Media.</bibtext> </blist> <blist> <bibtext> Sheoran, B., R. A. Braun, J. P. Gaarde, and D. K. Levine. 2014. " The Hookup: Collaborative Evaluation of a Youth Sexual Health Program Using Text Messaging Technology." JMIR mHealth and uHealth 2 (4): e51. doi: 10.2196/mhealth.3583.</bibtext> </blist> <blist> <bibtext> Starling, S., and C. Cheshire. 2016. " Information Seeking and Evaluation of Online Sexual Health Resources among Late Adolescents." Proceedings of the 2016 CHI Conference Extended Abstracts on Human Factors in Computing Systems, Santa Clara, California, May 7–12.</bibtext> </blist> <blist> <bibtext> Wartella, E., V. Rideout, H. Montague, L. Beaudoin-Ryan, and A. Lauricella. 2016. " Teens, Health and Technology: A National Survey." Media and Communication 4 (3): 13 – 23. doi: 10.17645/mac.v4i3.515.</bibtext> </blist> <blist> <bibtext> Willoughby, J. F., and K. Jackson Jr. 2013. " 'Can You Get Pregnant When U R in the Pool?': Young People's Information Seeking from a Sexual Health Text Line." Sex Education 13 (1): 96 – 106. doi: 10.1080/14681811.2012.677746.</bibtext> </blist> <blist> <bibtext> Willoughby, J. F., K. L. L'Engle, K. Jackson, and J. Brickman. 2018. " Using Text Message Surveys to Evaluate a Mobile Sexual Health Question-and-Answer Service." Health Promotion Practice 19 (1): 103 – 109. doi: 10.1177/1524839917691945.</bibtext> </blist> </ref> <aug> <p>By Teagen L. O'Malley; Katie Rose Horowitz and Jessica G. Burke</p> <p>Reported by Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib11" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib17" firstref="ref4"></nolink> <nolink nlid="nl3" bibid="bib12" firstref="ref5"></nolink> <nolink nlid="nl4" bibid="bib20" firstref="ref6"></nolink> <nolink nlid="nl5" bibid="bib21" firstref="ref7"></nolink> <nolink nlid="nl6" bibid="bib14" firstref="ref8"></nolink> <nolink nlid="nl7" bibid="bib18" firstref="ref12"></nolink> <nolink nlid="nl8" bibid="bib15" firstref="ref20"></nolink> <nolink nlid="nl9" bibid="bib10" firstref="ref21"></nolink> <nolink nlid="nl10" bibid="bib16" firstref="ref22"></nolink> <nolink nlid="nl11" bibid="bib13" firstref="ref26"></nolink> <nolink nlid="nl12" bibid="bib22" firstref="ref32"></nolink> <nolink nlid="nl13" bibid="bib19" firstref="ref33"></nolink> <nolink nlid="nl14" bibid="bib23" firstref="ref37"></nolink>
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  Data: <searchLink fieldCode="SO" term="%22Sex+Education%3A+Sexuality%2C+Society+and+Learning%22"><i>Sex Education: Sexuality, Society and Learning</i></searchLink>. 2022 22(2):217-227.
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  Data: Comprehensive sexual health education is critical for the prevention of STIs and unintended pregnancy among young people. Yet, increasing barriers to comprehensive sexual health education in classroom settings underscore the importance of youth-friendly technologies to address sexual health among young people. "It's OK to Ask Someone" (IOTAS) uses a customised technology to expand Planned Parenthood of Western Pennsylvania's sexual health programming with a confidential sexual health textline designed to answer sexual health questions in a timely, user-friendly manner. This paper describes results from a process evaluation focused on assessing who uses IOTAS, how they use IOTAS and in what ways IOTAS is perceived to be helpful to texters. Results illustrate that a textline-approach is an acceptable and appropriate way to engage with young people. Findings demonstrate that young people are using the confidential textline to seek information about sexual health and report it as a helpful resource. Findings are relevant for sexual health educators and practitioners working with young people, including those interested in using a technology approach to expand health education opportunities. Additional research should continue to explore the potential of youth-friendly, technology-based approaches to support sexual health information seeking.
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