LISTENING TO ADOLESCENTS ABOUT TEXT MESSAGING IN SEXUAL HEALTH

1
LISTENING TO ADOLESCENTS ABOUT TEXT MESSAGING
IN SEXUAL HEALTH

• Vanessa N. Reynolds
• RN, BRS, BN
• Faculty of Nursing, University of Manitoba
• Masters of Nursing Program

2
ACKNOWLEDGEMENTS

• To Dr. Lynn Scruby, my thesis chairperson
• To Dr. Bev Temple, my internal committee member
• To Ms. Kim Bailey my external committee member
• To Klinic and New Directions Thank you to the
  executive, the program managers and other staff.
  Your willingness to open your doors and your arms
  to me has been a great source of support.
• To all the participants in this study Thank you
  for sharing your experiences with me. Your
  openness and candidness have been invaluable to
  this study.
• To Gisele Lapointe and lUniversité de
  Saint-Boniface
• To my family

3
PROBLEM

• Adolescents are among those at most risk for
  acquiring STIs.1
• Manitoba has the highest rate of chlamydia and
  gonorrhea of all provinces among 15-24 year
  olds.2
• Undetected and/or untreated STIs pose serious
  health consequences including pelvic inflammatory
  disease, cancer and infertility.
• STIs are largely treatable and preventable and
  testing is an effective means of reducing the
  disease burden.4
• Despite numerous strategies to increase STI
  knowledge and screening, adolescents are not
  being reached as well by traditional preventative
  effort.1
• 13-24 year olds largest group of wireless phone
  users in Canada and SMS is its most commonly used
  feature.40
• Teens send and receive over 3417 text messages
  per month, an average of 122 text messages/day.6
• Can new technologies be used to improve
  adolescent sexual health services?

4
Purpose of the study and research questions

• The objective of this study was to describe
  adolescents experiences of text messaging as
  well as explore their receptivity to the use of
  text messaging in sexual health services.
• Research question 1 How do Winnipeg adolescents
  describe their current use of text messaging?
• Research question 2 How do Winnipeg adolescents
  perceive the use of text messaging in sexual
  health services?

5
LITERATURE REVIEW ON ADOLESCENTS AND TEXT
MESSAGING/SMS

• Concerns about SMS
• sleep problems41,
• distracted driving42,
• texting tendinitis43, antisocial
• behaviours44.
• Pros gtsociability45,46
• social contacts45,46
• Independence47 and
• Privacy 48.
• Enhances literacy 50

6
Literature on sms in sexual health

• The use of text messaging has been promising in
  the clinical setting. San Francisco, North
  Carolina and Toronto departments of public health
  have launched sexual health information services
  disseminated via SMS.7
• SMS has been investigated for appt reminders,
  16,17,18, Partner Notification, 8,9,14,15 STI
  Results, 11,19 Health Promotion, 20,21
• A paucity of research or empirical evidence
  exists to widely support the use of text
  messaging in sexual health services.

7
CONCEPTUAL FRAMEWORKS UNDERPINNING THE STUDY
INTERPRETIVISM AND ANT

• ANT positioned between constructivist and
  technological determinist theories.
• ANT World is not just socially constructed.25
• Agency resides in both people and objects such as
  technical innovations.
• Technology can influence how humans perform
  certain tasks.
• ANT flat ontology. Actors speak for themselves
  which challenges a constructivist approach.33
• Interpretivism has a constructivist ontology
  meaning is constructed by the researcher.32
• Even with a purist application of ANT, the
  selection of participants or actors as well as
  the questions asked play a part in constructing
  the responses received.
• Reconciliation between the two by using ANT as an
  interpretative lens rather than a fundamental
  ontology.

8
METHODOLOGY

• Qualitative Research
• Exploratory descriptive study design chosen
  investigate the meaning of a experience for a
  group of people with the intent of discovering
  themes or patterns.34
• Semi-structured focus group interviews
• Criterion sampling
• Setting and Recruitment (Klinic and New
  Directions)

9
DATA COLLECTION AND ANALYSIS

• Principal investigator (me!) was the research
  instrument.
• 4 focus groups were conducted
• Interview guide was used for focus group
  interviews.
• Field notes were taken by PI and graduate advisor
  (for the first focus group).
• Demographic questionnaire administered to all
  participants.
• Professional transcriptionist used
• Thematic analysis used to analyze the data
• Field notes, demographic data and transcriptions
  were uploaded to Dedoose, a mixed methods and
  qualitative software program.
• Dedoose browse, search and sort data.
• Themes confirmed by advisor.

10
DEMOGRAPHIC INFORMATION

• 21 participants 14 female, 7 male
• Age range 16-23
• Currently attending school 14/21
• Less than half working 9/21
• Owned a working cell phone 15/21
• Range of text messages sent/day 0-900
• Mean number of texts/day 161
• Median75
• Mode 10, 60 and 400 as all three of the
  aforementioned numbers occurred equally the most
  in the distribution.

11
FINDINGS HOW DO WPG ADOLESCENTS DESCRIBE THEIR
CURRENT USE OF TEXT MESSAGING?

• Text messaging as a connection to others and to
  self
• Embedded part of self
• Connection to others
• Exerting control
• Negotiating public space
• Controlling self-presentation and parental
  communications

12
GLOBAL THEME 1 TEXT MESSAGING AS A CONNECTION TO
OTHERS AND TO SELF

• Organizing theme 1 Embedded part of self
• Adolescents are intimately intertwined with
  their cell phones and SMS
• Convergence of humans and technology feeling
  lost, naked or the sense of going under a rock
  without phone
• Sleeping with phone under pillow or mattress
• Checking phone incessantly for new messages
  intuition
• Quotations
• kind of lost because then if something happens,
  like I dont really have, um, I dont know about
  it because I dont have my phone with me.
• when its dead or you dont have it or
  something, you feel like, like you dont know
  whats going on with your friends. And its like
  going under a rock or something
• For me its like any opportunity. Like if Im on
  the bus, Ill check it. If like Im waiting in
  line for something, Ill check it. Like any
  opportunity I get, like, I check it.
• Even if it doesnt go offyou basically feel it.
  I sense that I should look at it, just look at
  it.

13
GLOBAL THEME 1 TEXT MESSAGING AS A CONNECTION TO
OTHERS AND TO SELF

• Organizing theme 2 Connection to others
• SMS enhances communication
• Easier to communicate with others
• Connection that would not be possible through
  voice calls
• Expanding the social network
• Quotations
• it helps communicate with people easierbecause
  I dont have time to hang out with them (friends)
  lotsLike its easier to talk (text) to them and
  ask them how their day went rather than being
  with them every day because Im so busy.
• Like when I first got my phone, my sister said,
  when youre texting, its completely acceptable
  to be like in class and just text somebody
  whats up?Its fine to text anybody, whatever
  you want at any time of the day because its
  texting.
• Well, I actually, I was kind of a hermit. And,
  uh, now I find that I am spending a lot of time
  doing things for myself. Like going out, hanging
  out with friends or like you know, just doing
  things I never really did before. Like it
  definitely has something to do with texting
  because now I can communicate with people easier.
  

14
GLOBAL THEME 2 EXERTING CONTROL

• Organizing theme 1 Negotiating public space
• Texting under the desk phone on vibrate
• Beneficial because teens can text quietly and
  privately
• Privacy but Rubberneckers, strangers reading
  SMS
• Derisive of adults/people who do not respect
  public space
• Quotations
• What I did last year was, um, I would just come
  in with my jacket and then Id have it half on
  and I have my arm like not in my jacket and I
  just put the empty arm on the table so it looks
  like both my hands are on the table and then I
  would text. Thats what I used to do (laughter)
  in the wintertime.
• Nobody can hear you, what youre saying on a text
  message.
• I think its just a waste of time calling
  somebody when you can just text them. Its more
  quiet and you dont have to answer your phone
  ring, and go hello, like. People on the bus are
  nuts because they answer their phones loudly and
  you hear all their personal shit.

15
GLOBAL THEME 2 EXERTING CONTROL

• Organizing theme 2 Self-presentation
• Projecting an alternate identity through text- at
  once more revealing and inauthentic
• Transcending temporality Asynchronous
  communication. Pause to think before answering
  avoid awkward silences, stuttering, thinking of
  something funny to say.
• Preferred method for initiating romantic
  relationship
• As a prop or a secret language to manipulate
  self-presentation
• Downfall contributes to mixed signals
• Quotations
• Ive had people talk to me wholl like say
  something over text that like I just cant say
  the same thing in real lifeIts just different.
  Its most like two personalities with people.
• Like you can text meInstead of making those
  awkward phone calls or silence. And like, you
  dont want to go out with me tonight? Like, oh
  because I freaking stuttered (chuckle).
• If you walk in the wrong direction and you
  realize youre walking in the wrong direction,
  you can pretend you got a text, pull it out, and
  be like, oh, and then turn around even though you
  were walking in the wrong direction all the
  timeI did that a few times(helps you) not look
  like an idiot.

16
GLOBAL THEME 2 EXERTING CONTROL

• Organizing theme 2 Parental domain
• Less contentious way of communicating with
  parents
• Males completely ignoring SMS from parents,
  setting parents to different ring tone
  communicating hurtful comments with impunity
• Females communicating with parents throughout
  the day better relationship since SMS
• Quotations
• They text you, you just ignore themIts easy.
• I keep them updated too but this (texting) is
  better, because youre not in front of their,
  youre not talking to them if you say something
  mean. Like if youre texting and you want to say
  something mean, it doesnt sound mean. Like
  youre just reading it normally.
• I didnt really have a relationship with my mom
  because shes like a hard person to talk to in
  personbecause shes scaryTexting it makes
  everything easier, you know. Now were cool.

17
FINDINGS HOW DO WINNIPEG ADOLESCENTS PERCEIVE
THE USE OF TEXT MESSAGING IN SEXUAL HEALTH
SERVICES?

• Adolescents are generally receptive
• Text messaging for sexual health programs
• Sexual health promotion via text messaging
• STI services
• Need to Feel Safe
• Anonymity and Privacy
• Protection

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ADOLESCENTS ARE GENERALLY RECEPTIVE

• Organizing theme 1 Text messaging for sexual
  health programs
• Most participants would like a service like TO
  Health or HOOKUP in SF.
• Dont like Health Links- It takes like an hour
  to get through.
• Rather text a question and receive an answer via
  text. Time concerns, embarrassment.
• Organizing theme 2 Sexual health promotion via
  SMS
• Receptive to SMS in lieu of health promotion
  class or as an adjunct. Classes are boring and
  awkward, taught by some senior.
• Divided on population sexual health promotion
  campaign. Concerns re. how cell phone is
  obtained, messages could be viewed by others,
  junk mail, annoying.
• Organizing theme 3 STI services
• Most would prefer to receive STI results over
  text, as long as it is kept confidential
• Partner Notification want to send anonymous text
  if they are the index case but want to be told in
  person or over the phone if they are the partner!
• Males less concerned about anonymity. Many would
  consider non-anonymous texting or even voice
  call.

19
FINDINGS TO RESEARCH QUESTION 2 CONTINUED

• Need to Feel Safe
• Anonymity and Privacy
• like 100 anonymous
• Partner Notification most important
• Need to ensure teens privacy when using any
  communication media
• Protection
• Confirmation of identity
• i.e. code, full name, etc.
• SMS must be sent from legitimate
• source confirmed by teens

20
RESEARCH QUESTION 1 RELEVANCE TO CURRENT
LITERATURE

• Confirmed findings
• Embedded part of self The cell phone has become
  integrated with the adolescent cell identity
  (Walsh et al. 2010) the equivalent of missing a
  limb (Cawley et al., 2008) and cell phone and
  teen have become a cyborg (Thompson Cupples,
  2010).
• Connecting to others Bridging of physical
  distance (Broege, 2009) and increasing intimacy
  (Igarashi et al.,2005).
• Negotiating public space Reconfiguring space by
  using body to carve out a private area in which
  texting can be hidden (Grinter et al., 2006)
  Talking in public is an invasion of public space
  (Ishii, 2006).
• Controlling self-presentation SMS as the
  preferred method for screening and rejecting
  unwanted suitors (Berdall et al,. 2011).
• Contradictory findings
• Connecting to others Teens are not creating more
  ties socially isolated teens were not creating
  any relationships through SMS (Bryant et al.,
  2006).
• Parental domain SMS and cell phone as an
  electronic leash (Cambell, 2006 Craft, 2010)
  SMS and cell phone as a tool to obtain freedom
  from the family grip (Kennedy et al., 2008
  Oksman et al., 2006).

21
RESEARCH QUESTION 2 RELEVANCE TO CURRENT
LITERATURE

• Confirmed findings
• SMS acceptable for sexual health info and
  preferred over SNS (Coker et al., 2010 Samal et
  al., 2009).
• SMS suitable for disseminating STI results (Dhar,
  Leggat Bonas, 2006)
• Partner notification Increasing of people
  sending SMS through agency-provided website (i.e.
  inspot). (Bilardi et al., 2010a Bilardi et al.,
  2010b).
• Contradictory findings
• Teens would not be embarrassed if SMS viewed by
  others (Perry et al., 2010).
• SMS unsuitable for partner notification (Apoola
  et al., 2006 Hopkins et al., 2010).
• SMS acceptable for population sexual health
  promotion (Gold et al., 2011a Gold et al.,
  2011b Lim et al., 2011).

22
Limitations

• Small sample size. The findings represents ideas
  and feedback of participants and cannot be
  generalized to larger population of 15-20 year
  olds in Winnipeg or Canada.
• Unequal of male and female focus groups may
  have over-represented the views/opinions of the
  females.
• Unintended inclusion of two 23 year-old males may
  have also contributed to the differences between
  this group and the other 3.

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FUTURE DIRECTIONS

• Organizations that offer sexual health services
  should be aware that text messaging can and
  should be considered in certain instances but
  that concerns pertaining to how these services
  will be offered exist.
• If text messaging is to be used in sexual health
  promotion campaigns, future research should be
  conducted to determine the specifics of an
  effective text messaging campaign such as timing,
  length of message, number of messages and message
  content (including language and style).
• Future research may consider evaluating
  adolescents receptivity and subsequent use of
  text messaging in sexual health services from a
  gender analysis perspective.
• Due to the overwhelming receptivity to receiving
  STI results via text messaging, and past research
  indicating potential health and administrative
  gains, a cost-benefit analysis of the use of text
  messaging to disseminate STI results should be
  measured.

24
KNOWLEDGE TRANSLATION

• Presentation at each community setting for
  managers, executives, staff and participants.
• Already presented to management, executives at
  New Directions as well as to front-line staff and
  adolescents.
• One page executive summary sent to participants
  (as requested on the informed consent letter)
• Submit research for publication

25
SIGNIFICANCE OF THE STUDY

• The findings of this study may demonstrate how
  texting can be used to communicate with
  adolescents about health-promotion and
  disease-prevention.
• May permit others to further investigate SMS in
  adolescent sexual health research.
• Contribute to the emerging body of research on
  SMS in sexual health services in particular from
  a Canadian perspective.

26
QUESTIONS?

• Thank you!

27
References

• 1 Centers for Disease Control and Prevention
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28
REFERENCES

• 8Apoola, A., Radcliffe, K. W., Das, S., Robshaw,
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• 9Bilardi, J. E., Fairley, C. K., Hopkins, C. A.,
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  (2010a). Let them know Evaluation of an online
  partner notification service for chlamydia that
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• 10Dhar, J., Leggat, C., Bonas, S. (2006).
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• 11Brown, L., Copas, A., Stephenson, J., Gilleran,
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• 13Gold, J., Lim, M., Hocking, J., Keogh, L.,
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29
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