Sex Ed to Go: A Content Analysis of Comprehensive Sexual Education Apps

Health literacy needs and preferences for a technology-based intervention to improve college students' sexual and reproductive health

Objective: To explore health literacy needs and preferences for a technology-based intervention (app) to improve sexual and reproductive health (SRH) among college students. Participants: In Spring 2019, in-depth interviews were conducted with 20 participants (10 male, 10 female) from a large, public university. Methods: Interview guide was developed based on Integrated Model of Health Literacy domains and Diffusion of Innovation constructs. Data were analyzed in MaxQDA using applied thematic analysis. Results: Dominant themes included accessing health information and services, evaluating options to make decisions, intervention utility and characteristics, and the emergent theme of credibility. Specific topics included accessing STI testing, contraceptive decision making, information on human papillomavirus (HPV) and the HPV vaccine, patient-provider communication, app design and function elements, and modifying the app to meet the SRH needs of diverse college students. Conclusions: Findings identified areas where an app could address college students' SRH literacy, ultimately improving SRH outcomes among this population.

How the smartphone apps can improve your sexual wellbeing

The use of smartphones and other technological devices has rapidly increased in the last few years, along with the availability of various applications that can be downloaded on iOS or Android devices. In this narrative review, we included most of the literature found on the specific topic of smartphone apps related to sexual health. Using the two databases PubMed and PsycInfo, we conducted research by the following terms: "apps" and "sexual wellbeing"; "apps" and "sexual health"; "mhealth" and "sex"; "mhealth", "apps" and "sex". We selected all articles written in English within the last 6 years to ensure the accessibility and consider the rapid changes in this field. The article highlights that many populations are interested in gaining information on a wide range of topics relating to sexual practices, potential risks, coercion, sexual violence and the prevention and recognition of potentially dangerous situations. Some findings suggest that sex education for sexual minority adolescents should focus on online sexual safety. Despite their value, many concerns and limitations must be solved, and future research studies are needed to explore how to fix them.

Crush: A Randomized Trial to Evaluate the Impact of a Mobile Health App on Adolescent Sexual Health

PURPOSE

Mobile technology allows delivery of sexual and reproductive health (SRH) information directly to youth. We tested the efficacy of Crush, a mobile application aimed at improving sexual health by promoting the use of SRH services and contraception among female adolescents.

METHODS

We recruited 1,210 women aged 14-18 years through social media advertising and randomized them into a Crush intervention group and a control group that received a wellness app. At 3 and 6 months post randomization, we compared changes from baseline in behaviors, attitudes, self-efficacy, perceived social norms, birth control knowledge, perceived control and use intentions, and SRH service utilization. Odds ratios were estimated with multivariable logistic regression and adjusted for baseline outcome, age, race/ethnicity, mother's education, and sexual experience.

RESULTS

There was no difference in accessing SRH services according to study group. Three months post baseline, Crush users had higher odds (p < .05) than control participants of reporting confidence in accessing SRH services (adjusted odds ratio [aOR] = 1.6, 95% confidence interval [CI]: 1.1-2.3) and of believing that it is a good thing to use birth control consistently (aOR = 2.3, 95% CI: 1.4-3.8). Six months after baseline, Crush users had higher odds than control participants of reporting they can control whether birth control is used every time they have sex (aOR = 1.8, 95% CI: 1.2-2.6) and perceiving they would get pregnant if they did not use birth control (aOR: 1.5, 95% CI: 1.1-2.2). Impacts on other behavioral constructs were also found.

DISCUSSION

Crush was associated with improvements in knowledge, attitudes, and self-efficacy related to key SRH behaviors and may be a strategy to deliver SRH education to adolescent women. Studies including larger numbers of sexually active adolescents are needed to demonstrate behavioral impacts.

Environmental scan of mobile apps for promoting sexual and reproductive health of adolescents in low- and middle-income countries

Background

Adolescence is a period of emotional, mental, and physical change. To increase health seeking behaviors, reduce risky sexual behavior, and improve sexual and reproductive health (SRH) knowledge, adolescents require support and access to SRH services. Providing evidence-informed SRH knowledge to adolescents in low- and middle-income countries (LMICs) can be a challenge as they face unique barriers such as lack of confidentiality, fear of refusal, and stigma from cultural norms. Increasing availability of mobile apps necessitates a comprehensive evaluation of the quality and classification of these SRH mobile applications so that accurate and evidence-based information is reaching its users. Failure to provide SRH services can have damaging effects throughout their development.

Objective

Provide an overview of current adolescent SRH (ASRH) mobile applications targeting adolescents in LMICs by evaluating their quality and classifying their characteristics.

Methods

21 search terms related to ASRH mobile apps was developed. These terms were searched in the Apple IOS store and Google Play stores. Inclusion and exclusion criteria were used to screen these apps. Resulting apps were assessed using the Mobile App Rating Scale (MARS) tool. Data extracted was used to rank order each app and identify any gaps in quality.

Results

Search strategy yielded 2,165 mobile apps. Of these, only 8 were assessed using the MARS tool. Functionality subdomain scored highest at 4.6, while Information scored lowest at 2.5. None of the assessed apps contained information on the MARS items: Evidence base and Goals. Too Shy to Ask had the highest individual app mean score of 4.1, while e-SRHR scored lowest at 2.3.

Conclusions

The goal of this study is to classify and rate the quality of mobile apps designed to promote ASRH behaviors and knowledge in LMICs. Numerous apps were reviewed and all of them failed to provide evidence-based and goal oriented SRH information. Strengths include ease of use, navigation, and gestural designs. Weaknesses include evidence base, goals, willingness to pay, customization, and interactivity. These findings can be potentially used to guide future app development and educate decision makers responsible for policy changes.

A Scoping Review of Digital Health Interventions to Promote Healthy Romantic Relationships in Adolescents

Despite a robust field of study in healthy romantic relationship education and risk prevention interventions that employ traditional forms of delivery, the field of digital health interventions (DHIs) in healthy relationship programming for adolescents remains undefined. The purpose of this scoping review was to summarize the scope of published research in DHIs that promote healthy romantic relationships in adolescents. We conducted database searches, 2000-2022; hand searches; reference list and literature review searches, and emailed study authors to identify articles. Included were experimental, development, and feasibility studies. We summarized features of selected studies and their healthy relationship aims/components and identified patterns of emphasis and areas of future need. Sixteen publications describing 15 unique DHIs were reviewed with interventions developed and or trialed in 11 countries. We identified 10 web-based or downloadable applications, four serious game applications, one video-voice program, and one social media-based program. DHIs focused on improving knowledge/attitudes/skills of healthy adolescent romantic relationships directly or through prevention-focused programs. Interventions that measured outcomes found small effects, primarily in healthy romantic relationship communication skills. DHIs offer unique opportunities to provide user-responsive and culturally specified programming for adolescents and to involve adolescents themselves in processes of program design, development, and evaluation. Further research is warranted to define relevant outcomes for adolescents and validated measures to evaluate them. Future research might seek to address the social ecology of adolescent romantic relationships beyond the individual and interpersonal and explore combinations of virtual and adult-moderated in-person delivery to ensure youth are adequately supported.

Sexual Health Assessment Is Vital to Whole Health Models of Care

Sexual health is the state of well-being regarding sexuality. Sexual health is highly valued and associated with overall health. Overall health and well-being are more than the absence of disease or dysfunction. Health care systems adopting whole health models of care need to incorporate a holistic assessment of sexual health. This includes assessing patients' sexual orientation and gender identity (SOGI). If health systems, including but not limited to the Veterans Health Administration (VHA), incorporate sexual health into whole health they could enhance preventive care, promote healthy sexual functioning, and optimize overall health and well-being. Assessing sexual health can give providers important information about a patient's health, well-being, and health goals. Sexual concerns or dysfunction may also signal undiagnosed health conditions. Additionally, collecting SOGI information as part of a sexual health assessment would allow providers to address problems that drive disparities for lesbian, gay, bisexual, transgender, queer, and similar minority (LGBTQ+) populations. Health care providers do not routinely assess sexual health in clinical practice. One barrier is a gap in communication between patients and providers. Providers cite beliefs that patients will bring up sexual concerns themselves or might be offended by discussing sexual health. Patients often report an expectation that providers will bring up sexual health and being comfortable discussing sexual health with their providers. Within the VHA, the lack of a sexual health template within the electronic health record (EHR) adds an additional barrier. The VHA's transition toward whole health and updates to its EHR provide unique opportunities to integrate sexual health assessment into routine care. We highlight system modifications to address this within the VHA. These examples may be helpful for other health care systems interested in moving toward whole health. It will be vital for health care systems integrating a whole health approach to develop both practical and educational interventions to address the communication gap. These interventions will need to target both providers and patients in health care systems that transition to a whole health model of care, not just the VHA. Both the communication gap between providers and patients, and the lack of support within some EHR systems for sexual health assessment are barriers to assessing sexual health in primary care clinics. Routine sexual health assessment would benefit patient well-being and present an opportunity to address health disparities for LGBTQ+ populations. Health care systems (ie, both the VHA and other systems) can overcome these barriers by implementing educational interventions and updating their EHRs and back-end data structures. VHA's expertise in developing and implementing health education interventions and EHR-based quality improvements may help inform interventions beyond VHA.

The Effect of Psychosexual Education on Promoting Sexual Function, Genital Self-Image, and Sexual Distress among Women with Rokitansky Syndrome: A Randomized Controlled Clinical Trial

STUDY OBJECTIVE

To assess the effectiveness of psychosexual education on promoting sexual function and genital self-image and reducing sexual distress through e-learning among women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome.

DESIGN

Randomized controlled trial.

SETTING

Imam Khomeini Hospital "Pelvic Floor Clinic" in Tehran.

PARTICIPANTS

Thirty-eight 15- to 49-year-old women with MRKH syndrome who had undergone surgical or nonsurgical vaginal reconstruction techniques more than 6 months before the intervention were assigned to 2 parallel intervention and control groups of 19 each.

INTERVENTIONS

Psychosexual education was delivered through e-learning for the intervention group over an 8-week period, with no limitations of time and space. Sexual function, genital self-image, and sexual distress were evaluated at baseline, and at 4 and 8 weeks after the intervention.

MAIN OUTCOME MEASURES

The data collection tools included the Persian version of the Female Sexual Function Index, Female Genital Self-Image Scale, and the Revised Female Sexual Distress Scale.

RESULTS

The between group mean differences of sexual function, genital self-image, and sexual distress after 4 weeks (-1.2 [95% CI, -2.1 to -0.1], P = .025; -1.9 [95% CI, -2.9 to -0.9], P < .001; 4.2 [95% CI, 2.0-6.4], P < .001, respectively), as well as after 8 weeks (-1.8 [95% CI, -3.1 to -0.5], P = .009; -3.0 [95% CI, -4.5 to -1.5], P < .001; 6.7, 95% CI, 3.9-9.6], P <0.001, respectively) after baseline were significant.

CONCLUSION

Psychosexual education improved sexual function and genital self-image and reduced sexual distress in women with MRKH syndrome. Therefore, using this approach, we can raise individuals' sexual knowledge and skills and correct their sexual beliefs and attitudes.

Educators' Perspectives on Integrating Technology Into Sexual Health Education: Implementation Study

Background

In the last decade, the use of technology-based sexual health education has increased. Multiple studies have shown the feasibility of technology-based interventions, while a subset has also shown efficacy in improving youths’ sexual health outcomes such as increased condom use and knowledge. However, little is known about health educators’ experiences in integrating technology to augment sexual health curricula.

Objective

The purpose of this study was to assess the perceptions and experiences of health educators regarding the incorporation of technology into a sexual health education program designed for underserved youth in Fresno County, California, and to identify facilitators and challenges to incorporating technology into the in-person curriculum.

Methods

This implementation study used data collected as part of a cluster randomized controlled trial to evaluate In the Know (ITK), an in-person sexual health education curriculum that includes technology-based content, such as a resource locator, videos, and games, which can be accessed through a mobile app or website. Data from implementation logs from each cohort (n=51) and annual interviews (n=8) with health educators were analyzed to assess the health educators’ experiences using the technology and adaptations made during the implementation.

Results

The health educators reported that technological issues affected implementation to some degree: 87% of the time in the first year, which decreased to 47% in the third year as health educators’ familiarity with the app increased and functionality improved. Technology issues were also more common in non–school settings. Successes and challenges in 3 domains emerged: managing technology, usability of the ITK app, and youth engagement. The health educators generally had positive comments about the app and youth engagement with the technology-based content and activities; however, they also noted certain barriers to adolescents’ use of the mobile app including limited data storage and battery life on mobile phones.

Conclusions

Health educators require training and support to optimize technology as a resource for engaging with youth and providing sensitive information. Although technology is often presented as a solution to reach underserved populations, educational programs should consider the technological needs and limitations of the participants, educators, and settings.

International Registered Report Identifier (IRRID)

RR2-10.2196/18060

Improving online clinical sexual and reproductive health information to support self-care: A realist review

Self-care is the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a healthcare provider. In the field of sexual and reproductive health options for self-care predominantly include ordering contraceptives online, or testing and treating genital infections outside a healthcare setting. The shift to digitally facilitated self-care consequently requires information that was previously used by clinicians to be made available to those managing their own sexual and reproductive health. This review was specifically interested in how to optimise this informational enabling environment as self-care becomes more complex. Using a realist approach to facilitate collation, analysis and synthesis of research from multiple disciplines this review sought to enable the generation of a programme theory to inform service development. The majority of research we identified studied information to support the choice to self-care and access to self-care. In contrast to established areas of self-care, for example, the management of diabetes or hypertension, studies of the self-care process in sexual and reproductive health are lacking. There is significant potential to expand digital information resources to support sexual and reproductive health self-care, however, there are currently significant unmet informational needs. This review proposes six key recommendations for providers and key stakeholders involved with sexual and reproductive healthcare for the improvement of digital self-care services.

Improving methods of primary prevention of STIs and HIV infection among young people

Background. The article considers the possibility of raising awareness among young people about STIs and HIV infection. It presents the development of the mobile application Personal Sexual Health, which includes the following sections: Sexual Infections, Protect Yourself, Frequently Asked Questions, Get help and etc. Aim. Improving methods of primary prevention of STIs and HIV infection among young people using a mobile app. Materials and Methods. The mobile application (Personal Sexual Health) was developed taking into account previously conducted scientific (sociological) research on the level of awareness of STIs and HIV infection among young people in Novosibirsk. The development of the mobile application was carried out using Agile (agile software development) methodology. Results. It was found that young people trust online information and view the Internet as a reliable source of sexual health advice. In fact, the Internet is a useful tool for spreading the reliable information about sexual health and different events detecteded to prevention of STIs and HIV-infection. The concept of the mobile application Personal Sexual Health implies raising the awareness of young people on the prevention of STIs and HIV infection. The informational component of the mobile application Personal Sexual Health was developed taking into account the previously obtained results from a sociological survey of young people. Conclusion. The modern generation of young people is forming a new ethics of communication, and the Internet is a basic source of information about sexual health for most teens and young adults. However, the information from Internet is not always correct or sufficient. Using modern, relevant, and still gaining in popularity technology (mobile apps and social media) will help to better absorb information about STIs and HIV prevention programms among young people. Personal Sexual Health is the first mobile application in Russia dedicated to sexual health and primary prevention programms of STIs and HIV-infection among young people. Background. The article considers the possibility of raising awareness among young people about STIs and HIV infection. It presents the development of the mobile application Personal Sexual Health, which includes the following sections: Sexual Infections, Protect Yourself, Frequently Asked Questions, Get help and etc. Aim. Improving methods of primary prevention of STIs and HIV infection among young people using a mobile app. Materials and Methods. The mobile application (Personal Sexual Health) was developed taking into account previously conducted scientific (sociological) research on the level of awareness of STIs and HIV infection among young people in Novosibirsk. The development of the mobile application was carried out using Agile (agile software development) methodology. Results. It was found that young people trust online information and view the Internet as a reliable source of sexual health advice. In fact, the Internet is a useful tool for spreading the reliable information about sexual health and different events detecteded to prevention of STIs and HIV-infection. The concept of the mobile application Personal Sexual Health implies raising the awareness of young people on the prevention of STIs and HIV infection. The informational component of the mobile application Personal Sexual Health was developed taking into account the previously obtained results from a sociological survey of young people. Conclusion. The modern generation of young people is forming a new ethics of communication, and the Internet is a basic source of information about sexual health for most teens and young adults. However, the information from Internet is not always correct or sufficient. Using modern, relevant, and still gaining in popularity technology (mobile apps and social media) will help to better absorb information about STIs and HIV prevention programms among young people. Personal Sexual Health is the first mobile application in Russia dedicated to sexual health and primary prevention programms of STIs and HIV-infection among young people.

"You're Going to Have to Think a Little Bit Different" Barriers and Facilitators to Using mHealth to Increase Physical Activity among Older, Rural Cancer Survivors

Wearable activity trackers (WATs) hold great promise in increasing physical activity among older cancer survivors. However, older cancer survivors who reside in rural regions are at increased risk of being digitally marginalized. The goal of this study was to learn about WATs adoption motivation and needs of rural older cancer survivors who live in New Mexico, one of the most rural states with the lowest broadband Internet connectivity in the United States. We conducted six key informant interviews and recruited 31 older cancer survivors from rural counties statewide who participated in interviews and focus groups. Our results show great interest in using WATs as part of an intervention to alleviate barriers associated with the digital divide. Participants were offered diverse modalities to support them in adoption of the trackers. These results will be used to inform future interventions and policies focusing on increasing physical activity in older cancer survivors who reside in rural communities.

A scoping review of the information provided by fertility smartphone applications

The growth of smartphone application use across areas of female reproductive health has led to increased interest into their functions and benefits. This scoping review aims to determine the nature and extent of the peer-reviewed literature presented on fertility-based apps, to identify the reliability of the information within the apps, and to determine the ability of this information to educate users. A systematic search of six databases was conducted in April 2020, returning a total of 21,158 records. After duplicate removal, title and abstract screening exclusionary steps, 27 records were reviewed and charted. Records covered a variety of reproductive health themes including contraception, sexual health, and family planning, and used a range of methodologies. The accuracy of fertility information within the apps reported in these studies was variable, but overall there was a lack of depth in the coverage of content in apps. It was common for studies in this review to base fertile window algorithms on stringent cycle length and variability requirements, limiting the applicability of information delivered to users. Furthermore, studies from app affiliates often lacked collaborations with researchers, minimising the potential for fertility knowledge improvements integrated across the suite of female reproductive health apps.

African American Emerging Adult Perspectives on Unintended Pregnancy and Meeting Their Needs With Mobile Technology: Mixed Methods Qualitative Study

BACKGROUND

In the United States, a disproportionate number of unintended pregnancies occur among African Americans, particularly those in their later teenage years and early 20s. Mobile technology is becoming more ubiquitous as a method for health promotion; however, relatively little research has been done with this population to determine their perspectives about unintended pregnancy, the potential of successfully using mobile technology to prevent unintended pregnancy, and the content of such programs.

OBJECTIVE

The purpose of this study was to obtain the perspectives of African American emerging adults about unintended pregnancy and the use of mobile technology to reduce unintended pregnancy rates.

METHODS

Focus groups and interviews were conducted with 83 African Americans, aged 18-21 years. Data were analyzed using an open coding process. Emergent codes were then added as needed, and themes and subthemes were identified.

RESULTS

Participants cited the social environment and lack of education as primary reasons for disproportionate rates of unintended pregnancy. They noted that unintended pregnancy is an important issue and that they desire more sexual health information. They enthusiastically supported mobile technology as a means to communicate unintended pregnancy prevention programming and offered many suggestions for program content, look, and feel.

CONCLUSIONS

Young and emerging adult African Americans want and need sexual health resources, and a mobile-based platform could be widely accepted and address needs to lower disproportionate rates of unintended pregnancy. An essential next step is to use these findings to inform the development of a mobile-based unintended pregnancy prevention and sexual health program prototype to determine feasibility.

Evaluating the Effectiveness of an Intervention Integrating Technology and In-Person Sexual Health Education for Adolescents (In the Know): Protocol for a Cluster Randomized Controlled Trial

Background

Access to a smartphone is nearly universal among American adolescents, and most of them have used the internet to seek health information. Integrating digital technologies into health program delivery may expand opportunities for youth to receive important health information, yet there are few rigorous studies assessing the effectiveness of this type of intervention.

Objective

The purpose of this study is to assess the effectiveness of In the Know (ITK), a program integrating in-person and technology-based sexual health education for underserved adolescents.

Methods

Youth were engaged in the development of the intervention, including the design of the digital technology and the curriculum content. The intervention focuses on 3 main areas: sexual health and contraceptive use, healthy relationships, and educational and career success. It includes an in-person, classroom component, along with a web-based component to complement and reinforce key content. A cluster randomized controlled trial is in progress among adolescents aged 13-19 years living in Fresno County, California. It is designed to examine the differences in self-reported health and behavioral outcomes among youth in the intervention and control groups at 3 and 9 months. Primary outcomes are condom and contraceptive use or no sex in the past 3 months and use of any clinical health services in the past 3 months. Secondary outcomes include the number of sexual partners in the past 3 months and knowledge of local clinical sexual health services. We will use mixed-effects linear and logistic regression models to assess differences between the intervention and control groups.

Results

Trial enrollment began in October 2017 and ended in March 2020 with a total of 1260 participants. The mean age of the participants is 15.73 (SD 1.83) years, and 69.98% (867/1239) of the participants report being Hispanic or Latino. Study results will be available in 2021.

Conclusions

ITK has the potential to improve contraceptive and clinic use among underserved youth. This trial will inform future youth-focused health interventions that are considering incorporating technology.

International Registered Report Identifier (IRRID)

DERR1-10.2196/18060

Use of Evidence-Based Best Practices and Behavior Change Techniques in Breast Cancer Apps: Systematic Analysis

Background

Theoretically designed mobile health (mHealth) breast cancer interventions are essential for achieving positive behavior change. In the case of breast cancer, they can improve the health outcomes of millions of women by increasing prevention and care efforts. However, little is known about the theoretical underpinnings of breast cancer apps available to the general public.

Objective

Given that theories may strengthen mHealth interventions, this study aimed to identify breast cancer apps designed to support behavior change, to assess the extent to which they address content along the cancer care continuum and contain behavior change techniques, and to assess the degree to which star rating is related to theory-based design.

Methods

Using a criteria-based screening process, we searched 2 major app stores for breast cancer apps designed to promote behavior change. Apps were coded for content along the cancer care continuum and analyzed for behavior change techniques. The Mann-Whitney U test was used to examine the relationship between star ratings and the use of behavior change techniques in apps with star ratings compared to those without ratings.

Results

The search resulted in a total of 302 apps, of which 133 were identified as containing breast cancer content. Only 9.9% (30/302) of apps supported behavior change and were further analyzed. These apps were disproportionally focused on behaviors to enhance early detection, whereas only a few apps supported care management, treatment, and posttreatment behaviors. Regarding theories, 63% (19/30) of apps customized content to users, 70% (21/30) established a health-behavior link, and 80% (24/30) provided behavior change instructions. Of the 30 apps, 15 (50%) prompted intention formation whereas less than half of the apps included goal setting (9/30, 30%) and goal reviewing (7/30, 23%). Most apps did not provide information on peer behavior (7/30, 23%) or allow for social comparison (6/30, 20%). None of the apps mobilized social norms. Only half of the apps (15/30, 50%) were user rated. The results of the Mann-Whitney U test showed that apps with star ratings contained significantly more behavior change techniques (median 6.00) than apps without ratings. The analysis of behavior change techniques used in apps revealed their shortcomings in the use of goal setting and social influence features.

Conclusions

Our findings indicate that commercially available breast cancer apps have not yet fully realized their potential to promote behavior change, with only a minority of apps focusing on behavior change, and even fewer including theoretical design to support behavior change along the cancer care continuum. These shortcomings are likely limiting the effectiveness of apps and their ability to improve public health. More attention needs to be paid to the involvement of professionals in app development and adherence to theories and best practices in app design to support individuals along the cancer care continuum.