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Udi Davidovich, PhD

Online public campaigning for sexual health The role of Internet interventions- current achievements and potential. Udi Davidovich, PhD. ORP – Online Research & Prevention unit Amsterdam Health Services, Department of Infectious Diseases. Brilliant match Sexual health & Internet

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Udi Davidovich, PhD

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  1. Online public campaigning for sexual healthThe role of Internet interventions- current achievements and potential Udi Davidovich, PhD ORP – Online Research & Prevention unit Amsterdam Health Services, Department of Infectious Diseases

  2. Brilliant match Sexual health & Internet for Research & for Health Promotion

  3. Interactivity 2way interaction – multi-type interactivity Connectivity all the time Increasingly everywhere Increasingly easier with same set of rules as for sex

  4. % penetration in 2008 NL – 91.1%, 285% (growth 2000-2008) NO – 87.7%, 85% US – 72.5%, 131% UK – 68.6%, 172% (Ref: Nielsen/Net ratings, ITU) Rural Uganda – adolsc. 45% ever, of whom 78% reg. Ybarra ML. Kiwanuka J. Emenyonu N. Bangsberg DR. Internet use among Ugandan adolescents: implications for HIV intervention. PLoS Medicine / Public Library of Science. 3(11):e433, 2006 Nov

  5. Internet & sexual health, what more… • Anonymity • Comfort: physical & mental How does that help sexual-health related research and intervention?

  6. Research (qualitative) the case of online chat interviews with webcams

  7. Goal Examine barriers to protective behavior against HIV and other STI among heterosexual youth aged 14-24 in the Netherlands.

  8. Evaluation of the usability and acceptability • N= 203 • Sex: 51% males • Age: 50% between 14-17 years, 50% between 18-24 years • Ethnicity: 40% Dutch, 32% Surinamese, 28% Dutch Antillean/ Aruban • Residence: 70% in urban, 30% in rural areas • Educational level: 37% low, 35% average, 28% high

  9. The anonymity paradox & emotional ease A: “ehm, well if you have to talk for real you might lie cause you have to tell it to the persons face”.  A:“It is anonymous but it is still personal cause you talk to someone”.

  10. Non-compromising visual contact Q:“but you also see me here via the cam”? A: “That’s different” Q: “Why”? A: “you see each other but not in reality”

  11. Comfort & emotional ease Comfort A: “Well, you're talking to someone and you see him and you have no sense of shame like on the street where everybody can hear what you say”. A: “I think if someone asked me to be there tomorrow at 1 o'clock for an interview – no fat chance”.

  12. What other advantages? • Geographically flexible • Simple logistics save effort, time & cost • No transcript : less bias, effort & cost • Higher inter-interviewer standardization via copy/paste functions. • Webcam increases the validity of chat interviews

  13. Health Promotion The case of tailoring: why do we believe it works?

  14. The Information - Motivation - Behavioral Skills Model of HIV Prevention HIV Prevention Information HIV Preventive Behavior HIV Prevention Behavioral Skills HIV Prevention Motivation (J. Fisher & Fisher, 1992, 2000; W. Fisher & Fisher, 1993)

  15. Knowledge deficiencies Intervention output 4 personal intervention modules addressing: Knowledge deficiency x1 Motivational deficiency x1 Motivational deficiency x2 Skill deficiency x1 Deficiency x1 Present Deficiency x2 Not present Deficiency x3 Not present Motivational deficiencies Deficiency x1 Present Deficiency x2 Present Deficiency x3 Not present Skill deficiencies Deficiency x1 Present Deficiency x2 Not present Deficiency x3. Not present Tailoring process

  16. Tailored versus non-tailorted intervention – RCT • Stimulation ofsafe sexin steady relationships among MSM (negotiated safety) • Single men – cognitive vaccine approach

  17. Effect evaluation • Online RCT: control x non-tailored x tailored • Cognitive effect (directly after intervention) & behavioral effect (6 months follow-up via e-mail) • N=1013; recruitment online via banners and links

  18. Cognitive effect: Univariate analysis of variance contrasting the control condition with the non-tailored and the tailored conditions

  19. Behavioral effect at 6 months Practice of negotiated safety for the tailored condition: OR=10.50 95%CI 1.19 - 92.72

  20. Bull SS, Lloyd L, Rietmeijer C. McFarlane M. (2004). Recruitment and retention of an online sample for an HIV prevention intervention targeting men who have sex with men: the Smart Sex Quest Project. AIDS Care, 16, 931-43. Ross MW. Rosser BR. Stanton J. Konstan J. Characteristics of latino men who have sex with men on the internet who complete and drop out of an internet-based sexual behavior survey. AIDS Education & Prevention. 16(6):526-37, 2004 Drop by & Drop out – trade off

  21. Drop out during interventions… How do we keep them interested?

  22. www.vrijlekker.nl

  23. Vrijlekker.nl - Objectives • To remove barriers to safe sex and STI screening among youth 16-24, (TG 18-19) • Evidence based

  24. Theoretical Background • Tailoring: based on IMB • Modeling for engagement & empowerment • Direct network/environment approach • TPB elements: • Beliefs • Perceived control • Actual behavioral control

  25. Key features for engagement • No personal risk feedback • Tailoring (increase relevance and concision) • The love-coaches (modeling) • The films (as topic openers / readiness / cue)

  26. Key features for engagement • Interactive text: e.g. the Excuse-Fighter(communication skills) • E-cards as conversation opener (environmental) • Condoms and lube supply online. Pay with the mobile or regular phone - 10 condoms voor 99 euro cent! (Actual behavioral control

  27. Sexual Health Services The case of HIV & STD testing online

  28. Sexual Health Services The case of HIV & STD testing online

  29. Test Lab procedures Participants visit the website for an intake Selection: online test procedure or referral to the STI clinic (symptomatic or partner with STI) Print referral letter (personal code) Participants visits one of the diagnostic laboratory’s in the city Collection of urine, blood, (self)-swabs ( anal, throat) Anonymous and free (registration on personal code and Nickname) 33

  30. Test Lab procedures: Test locations Amsterdam Rotterdam 34

  31. Test Lab procedures The test results are sent to the STI clinic. Diagnosed by the dermatologist of the STI clinic and put online. Participants obtain test result online with their personal code Man who tested positive visit the STI clinic for further examination and treatment. 35

  32. Chlamydia: urogenital (urine PCR), Proctum (self-swab PCR) Gonorrhea:urogenital (urine PCR), Proctum (self-swab PCR), throat (swab PCR) Syphilis:anti-TP + => VDRL and FTA HIV (opting-out):combo Antibody & Antigen test Amsterdam and Rotterdam Test package 36

  33. Procedure: referral letter 37

  34. Procedure: Back office 38

  35. Procedure: Email 39 Soa*Hiv

  36. Procedure: Results online 40 Soa*Hiv

  37. Evaluation The use and feasibility of Test Lab What is the efficacy of Test Lab in finding MSM with an STI or HIV infection What is the usability and acceptability of Test Lab 41

  38. Method Data collection for 11 months, from February 2008 till January 2009 Use & feasibility User data: number of visits, visitors, referred to online procedure or STI clinic, men tested, results put online, results viewed Efficacy % positives in Test Lab compared to % positives at the STI-clinic Data selection: Test Lab: users from Amsterdam STI-clinic Amsterdam: asymptomatic, same period, same STI tests 42

  39. Method Usability and acceptability As operationalized by Davis [1998]. Usability: the perceived ease of use Acceptability: the level in which the service corresponds to the needs and beliefs of the user. Answers on a 5 point scale; (negative O O O O O positive) Usability 12 items(Cronbach’s alpha .84) Acceptability 16 items(Cronbach’s alpha .83) 43

  40. Use of Testlab 44

  41. Results: Unique users 45 • 31% never visited the STI clinic before

  42. Results: Efficacy STI prevalence Test Lab Amsterdam: 18% (59/334) STI clinic Amsterdam: 15% (260/1701) 46

  43. Results: Usability en Acceptability Questionnaires offered: 532 Questionnaires completed: 265 Usability: N Total: 4.5 (SD = 0.6) 265 Negative test result: 4.6 (SD = 0.5) 227 Positive test result: 4.0 (SD = 0.7) 38 Acceptability Total: 4.0 (SD =0.5) 265 Negative test result: 4.1 (SD = 0.5) 227 Positive test result: 3.6 (SD = 0.6) 38 47

  44. Conclusions 48 • The online procedure is feasible: • High % of the referred get tested • almost all results are obtained online • everyone with a positive result visited the STI clinic • The online procedure is efficient in selecting the right population • Positive rate equivalent to that of the STI clinic • Men who never visited the STI clinic before

  45. Conclusion 49 • Test Lab has a high Usability and Acceptability level: • Clients with a positive test result lower but still high • - due to the non specific test result? • - not enough post-test support? • - or simply ‘killing the bad news messenger’ • In-depth interviews to investigate these issues.

  46. Where do we go from here? Individuality in an Hyper-social environment

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