Promoting Sexual Health With SMS Texting Technology

Promoting Sexual Health With SMS Texting Technology LYNN BLACKBURN, DNP, WHNP-BC ANITA BLATNIK, MSN, WHNP-BC EEighty-three percent of all adults in the United States own a cellular (cell) phone (Smith, 2011). Cell phones are used for making phone calls, of course, but emerging technologies allow them to be used for a wide variety of uses, from setting an alarm to watching videos. Outside of making voice calls, the most frequently used feature is the short messaging service (SMS), also known as the text message or texting. Young adults were the first to embrace this technology and remain the primary users (Raacke & Bonds-Raacke, 2011). While nearly three-fourths of cell phone users report using text messaging, this percentage increases to 95 percent for cell phone users between the ages 18 and 29 (Smith, 2011). Texting has become the preferred method of communication among college-age people in the United States (Skierkowski & Wood, 2012; U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion [HHS, ODPHP], 2010). These young adults who are the most comfortable with texting are the same demographic Abstract Most cell phone owners use the short message service (SMS), also known as texting. Most teens and young adults use text messages; they were the first users to embrace this technology and are still the most frequent users. Text messaging has the potential to provide them with information about preventing sexually transmitted infections. Several innovative programs that use text messaging to promote sexual health are described here. DOI: 10.1111/1751-486X.12074 Keywords SMS sexually transmitted infection STI text message texting http://nwh.awhonn.org 2013, AWHONN 465

who are at the greatest risk for contracting a sexually transmitted infection (STI), most commonly chlamydia. Chlamydia is the most frequently reported notifiable disease in the United States (Centers for Disease Control and Prevention [CDC], 2011). The highest rates of chlamydia cases (4,917.3 per 100,000) are found among 19-year-old women (CDC, 2011). Using SMS technology has the potential to be an important source for STI education and prevention. This article will explore and propose the idea of using electronic media to affect sexual behavior and health outcomes in the young adult population. Lynn Blackburn, DNP, WHNP-BC, is an instructor at the University of Tennessee College of Nursing in Knoxville, TN. Anita Blatnik, MSN, WHNP-BC, is a nurse practitioner at the University of Tennessee Student Health Center in Knoxville, TN. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: lblackbu@ utk.edu. Texting has become the preferred method of communication among college-age people in the United States Texting in Health Care Numerous research studies have found that text messaging is an effective strategy to decrease missed appointments at outpatient clinics or physician visits (Chen, Fang, Chen, & Dai, 2008; Da Costa, Salomão, Martha, Pisa, & Sigulem, 2010; Downer, Meara, Da Costa, & Sethuraman, 2006; Perron et al., 2010; Taylor, Bottrell, Lawler, & Benjamin, 2012). Patients who receive texted reminders consistently miss fewer appointments than those who receive no reminders or reminders by mail; and while some studies find results from texting similar to phoned reminders, the cost is significantly lower (Car, Gurol-Urganci, De Jongh, Vodopivec-Jamsek, & Atun, 2012; Chen et al., 2008). Text messaging has also been shown to be effective in helping people adhere to their clinical care management plan for chronic disease. People with diabetes who receive text messages are significantly more able to remain compliant with their prescribed regimen and to reduce their hemoglobin A1C levels (Franklin, Waller, Pagliari, & Greene, 2006; Kim, 2007; Rami, Popow, Horn, Waldhoer, & Schober, 2006). Kim (2007) found that sending text messages to clients with diabetes was associated not only with significant improvements in hemoglobin A1C levels, but also with compliance with taking diabetic medication, performing foot care and exercising. Improvements in the conditions of people with asthma or hypertension have also been found with text messaging interventions (Fjeldsoe, Marshall, & Miller, 2009). SMS-delivered interventions have been shown to have a positive outcome in affecting preventive health behavior changes, such as smoking cessation (Brendryen & Kraft, 2008), obtaining immunizations (Stockwell et al., 2012) and promoting physical activity (Lau, Lau, Wong, & Ransdell, 2011). Text Messaging for Sexual Health Promotion Teens and young adults are rarely without their phones; several innovative programs aimed at STI education and responsible sexual behavior have taken advantage of this fact. Several Australian studies of a text messaging intervention, which sent biweekly catchy texts to increase STI knowledge and promote STI testing, were found to be highly effective, especially among young women (Gold, Aitken et al., 2011; Gold, Lim et al., 2011, 2012). An interesting finding in all three studies was that the text receivers shared 466 Nursing for Women s Health Volume 17 Issue 6

them with others; Lim et al. found that over three-quarters of participants who received SMS had shown them to someone, generally a friend or partner (2012, p. 71). This is important in that it means that these young people are communicating accurate sexual information to their peers. In fact, one of the strategies proposed by the U.S. Department of Health and Human Services to increase health literacy is the use of technology to support patient-provider communication (HHS, ODPHP, 2010). Text messages are more likely to be shared and remembered if they are short, positive, witty and use language similar to that used by the target audience (Gold, Lim, Hellard, Hocking, & Keogh, 2010). Text receivers appreciated the casual language in the texts; one reported, It s not like one of those things the teachers say, When you are having intercourse make sure It s If you get lucky (Gold et al., 2010, p. 5). Other attributes of text messages that receivers found appealing were messages that rhymed, were humorous or connected to a current event, such as an upcoming holiday. A text message sent on Valentine s Day, for example, said, Roses are red, daisies are white, use a condom if you get lucky tonight ; and another sent for Easter said, Protect your or your partner s eggs this Easter with a condom. Chlamydia can cause infertility. Enjoy the long weekend (Gold et al., 2010, p. 3). Another approach to promoting responsible sexual behavior is the Grab a Condom program in the United Kingdom, which allows people to order condoms by text message; the condoms arrive at the texter s home in an unmarked package, thus bypassing the embarrassment many people feel when obtaining condoms in person (Lim, Hocking, Hellard, & Aitken, 2008). There are also text messaging services in the United Kingdom that will text women daily to remind them to take their birth control pills (2008). A statewide program in California that sends weekly text messages about sex info and life advice is managed by TeenSource.org, which is a nonprofit organization funded in part by the Federal Office of Population Affairs, Title X grant and the California Wellness Foundation. TeenSource s weekly texting service is called The Hookup. To initiate receiving weekly texts, participants text hookup to a telephone number advertised on billboards. Hookup users are also directed to the TeenSource.org web site, which provides additional information on a variety of topics that were identified by youth focus groups in high schools and teen clinics. For example, users can access information that directs them to local clinics that offer free or low-cost sexual and reproductive health services. The web site also includes many additional topics of interest to teens and young adults, such as healthy relationships and communication skills, substance abuse, cervical cancer prevention and pregnancy options. Implications for Nurses The clinical setting has traditionally been the primary point of contact for nurses to implement sexual health education. However, extending this venue makes economic sense and can provide continuity of care in an era of shortened time for face-to-face interaction. The use of text-based communication can decrease client phone calls and free up time and resources, while providing automated and systematic information to promote public as well as individual health. Nurses knowledge of the communication patterns and educational needs of their particular client populations, as well as familiarity with the practice workflow, provide an important perspective in helping to choose and implement accurate, informative and easy to understand SMS messages. Educational messages are simple to generate and many companies offer SMS services with features that can be tailored as necessary. Once the software is in place, implementation of new or Patients who receive texted reminders consistently miss fewer appointments than those who receive no reminders or reminders by mail; and while some studies find results from texting similar to phoned reminders, the cost is significantly lower modifications of existing programs can begin. For example, the health department of a mid-sized Southeastern city developed an SMS program in which anyone can opt in through a textable access code or by scanning a link directly to their phone. This program is based in part on an National Institutes of Health (NIH) funded project, which showed the feasibility of text messaging as a format to deliver HIV prevention interventions. Participants receive texted information on protecting themselves not just from HIV, but also from other STIs, peer pressure and teen pregnancy. Links allow participants to pass on the information providing easy access for others to participate in the program and producing a wave effect for the dissemination of information (K. Brown, personal communication, October 10, 2012). Many private practices have already replaced, or are in the process of replacing, paper charts with electronic health records (EHRs). EHRs typically include software that automatically sends out reminders for appointments and offers a way to securely communicate with clients. The SMS function of EHRs is an efficient way for nurses to send clientspecific content. Consent for text-based December 2013 January 2014 Nursing for Women s Health 467

Text messages are more likely to be shared and remembered if they are short, positive, witty and use language similar to that used by the target audience communication can be obtained during initial paperwork, with clients having to opt out in order to not participate. Examples of automatically generated texts can include reminders for HPV vaccine boosters, repeat cervical cancer screenings and renewal of contraception prescriptions or injections. More individualized messages, such as those explaining lab results, can be composed and sent at less busy times of the workday and read by clients at their convenience. Sending short messages that contain links to specific web sites for further information is a way to engage clients in learning more about a particular health topic, such as coping with herpes, HPV or new developments in the treatment of hepatitis C. In this era of ever-expanding Internet content, sending a link for a specific web site can also help ensure access to accurate and evidence-based information. Electronic nurse-client interactions not only affect population and individual health outcomes, but can also meaningfully impact the function of the health care system. It s beyond the scope of this article to explain the Medicare and Medicaid EHR incentive program in detail; however, participating health care agencies have been implementing requirements in stages. One of the Stage 2 requirements is to demonstrate the meaningful use of electronic exchanges. Some of the core objectives for this stage include using SMS technology for prevention and follow-up care reminders, for providing patientspecific education resources and for communicating relevant health information (Centers for Medicare & Medicaid Services, 2012). Conclusion SMS has been used in many areas of health care for health promotion and maintenance activities. This seems an especially appropriate way to deliver sexual health promotion to teens and young adults, because they have fully embraced the technology of text messaging and are very comfortable receiving information on their cell phones. We contend that developing sexual health promotion text messages that target young adults has the potential to increase knowledge of STIs, decrease high-risk sexual behavior and increase screening for STIs. Although text messaging is unlikely to replace traditional face-to-face counseling, it s one avenue to reach this population that is at high risk for adverse outcomes such as unwanted pregnancies or STIs, and it should be studied further. NWH 468 Nursing for Women s Health Volume 17 Issue 6

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