HIV and STD among youth
Youth remain at high risk for contracting and transmitting human immunodeficiency virus (HIV) and other sexually transmitted diseases (STD). In the U.S., over 5000 people under the age of 20 were diagnosed with HIV or AIDS from 2003–2006. Youth are also among those with the highest rates of STD, and having STD infection substantially increases risk for HIV acquisition and transmission (Centers for Disease Control and Prevention, 2008).
Use of the Internet and computers
Recent reports indicate that Internet use by youth is now nearly universal, with 93% of teens using the Internet (Pew Internet and American Life Project, 2006). Youth have been reported to reported to spend 40 minutes or more online per day (Gross, 2004; Madden, 2006), and although there are reports that health seeking online is common among youth (Pew Internet and American Life Project, 2006; Pew Internet and American Life Report, 2000; Roberts et al., 2005) data show youth online primarily spend their time multi-tasking, most often communicating through instant messaging (IM) (Gross, 2004; Rideout, 2001; Roberts et al., 2005). A 2005 study by the Kaiser Family Foundation showed that an overwhelming majority of youth have access to a computer in their home and spend an average of one hour on the computer daily. These data, however, include time spent on the Internet, with a substantial portion of the time spent on the computer is actually spent online. In their 1999 assessment of computer use among youth, the KFF documented computer use at an average of 27 minutes per day, and did not ask if any of this time was specific to online activities (Roberts et al., 2005).
The Internet and Computers as Intervention Tools
Rigorous studies using the Internet to promote healthy behavior show the promise of the medium for promotion of weight loss (Tate et al., 2001), diabetes self-management (Glasgow et al., 2003; Gottlieb, 2000; McKay et al., 2001), and healthy eating (Oenema et al., 2001). The Internet has also been used effectively to increase access to care among persons living with HIV and patients with eating disorders (Flatley-Brennan, 1998; Gustafson et al., 2002; Winzelberg et al., 2000). In a meta-analysis of interventions for physical activity and dietary behaviors that utilized some form of technology related intervention (e.g. computers, e-mail, Internet), Norman et al. showed that 21 of 41 studies reviewed showed positive effects of technology on diet and activity outcomes (Norman et al., 2007). Another meta-analysis of websites delivering physical activity interventions showed similar results, with eight of 15 interventions having a positive effect on physical activity (Vandelanotte et al., 2007).
To date, the only published trial of the efficacy of an Internet-based rather than a computerized HIV prevention delivered via kiosk is that describing a two session program for men who have sex with men (MSM) in rural Wyoming (Bowen et al., 2007a). Results from this trial show positive effects of the intervention on condom attitudes and self-efficacy at one week post intervention. This trial didn’t include long enough follow-up of participants to demonstrate an impact on HIV prevention behaviors.
There have been studies demonstrating the efficacy of computer-based interventions for HIV and STD prevention, delivered via kiosk or computer in various institutional and community settings. Kiene and colleagues showed that college students randomized to participate in two computer based sessions to reduce HIV and STD risk spaced two weeks apart had an increase in awareness regarding HIV and STD, more frequently carried condoms, and more frequently used condoms compared to those in the control group (Kiene and Barta, 2006). Lightfoot and colleagues showed that high risk youth participating in two 1.5 hour computer-based HIV prevention sessions were less likely to engage in sex and had fewer sex partners compared to controls (Lightfoot et al., 2007). Roberto and colleagues showed that high school students participating in six 15 minute computer-based HIV and STD prevention sessions spaced one week apart had greater delays in initiation of intercourse and improved attitudes and self-efficacy for safer sex behaviors compared to controls (Roberto et al., 2007).
Computer-based efforts in HIV prevention show promise, and have the advantages of standardization, fidelity and likely ease of replication. However, they can have small samples (Kiene and Barta, 2006; Lightfoot et al., 2007). The Internet offers an additional opportunity to reach larger numbers of people in diverse settings. The privacy offered by computers and the Internet is also an asset, as is the accessibility to interventions from multiple sites (e.g., home, clinic, library). The standardization, fidelity, ease of replication of computer-based interventions and the added potential benefits of reach and increased use of the Internet by youth, make both computers and Internet logical venues for HIV/STD research and prevention interventions.
Tailored, theoretically informed Internet Interventions
The emergence of computer software and “expert systems” allow for the production and dissemination of individually tailored print material (Bental et al., 1999; Campbell et al., 1994) (De Vries and Brug, 1999; Kreuter et al., 2000; Lipkus et al., 1999; Marcus et al., 1998; Rakowski et al., 2003; Rimer et al., 1999; Skinner et al., 1994; Strecher et al., 1994). This body of research has shown that tailoring increases the “self relevance” of print material for subjects, that such material is more likely to be read, comprehended and remembered, and that it can produce significant behavior change (Kreuter et al., 2000; Strecher, 1999) across a wide variety of behavioral outcomes (e.g., smoking cessation, diet and nutrition, cancer screening).
The Internet and computers are excellent modes of delivery for interactive, personalized or tailored HIV prevention intervention delivery. They offer opportunities for interventions that are grounded in behavioral science theory shown to have efficacy in HIV prevention (Centers for Disease Control and Prevention, 1999), including concepts highlighted in two theories: the Social Cognitive Theory (SCT) (Bandura, 1986; Bandura, 1997) and the Theory of Planned Behavior (TPB) (Azjen, 1991), which have been identified to empirically account for or explain most of the variation in HIV/STD prevention behaviors (Albarracin et al., 2001; Albarracin et al., 2003; Albarracin et al., 2004).
Challenges to implementation and evaluation of technology-based health promotion interventions
Despite the promise of the Internet and computers for health promotion, there are several challenges we face in meeting the potential of these media for health promotion. First, we face competition for time and interest—how can we get youth who are focused on instant messaging online to use our website or access our computer kiosks? Many researchers have presented data showing that it is difficult to achieve full compliance with multi-session health related programs that are on the Internet or are computerized. Participants may enroll but fail to complete multiple sessions over a long period of time (Linke et al., 2007; Verheijden et al., 2007) or will only do so as long as financial incentives are in place (Bowen et al., 2007b). A second concern is attrition from research—participants often fail to return to complete assessments of study efficacy, making interpretation of program effects difficult (Bull et al., 2004a; Severson et al., 2008). Finally, a third concern is that we have yet to do a good job in recruiting and retaining—both to complete program elements as well as assessments-- diverse audiences in our technology based health promotion efforts. Audiences tend to be well educated, middle class and higher income, and not representative of populations at high risk for the negative health outcomes studied (Bull et al., 2004b; Bull et al., 2008a; Feil et al., 2000; Glasgow et al., 2007).
How then can we capitalize on the potential of the Internet and computers, which are so widely used and popular with youth, to promote needed HIV and STD prevention? While the Internet and computers do have the potential to reach large numbers and standardize material, we face difficulties in program compliance, retention of study participants for assessment and in increasing diversity of program participants. We sought to overcome these difficulties with a single session, theoretically driven interactive computer program for HIV prevention delivered either a) exclusively on the Internet or b) in a clinic setting at a computer kiosk. Following is a description of our methods and findings.