Abstract
Background: The popularity of the Internet for health information and the growing availability of online access make the Internet a compelling medium for health promotion and HIV/STI prevention efforts for adolescents. Many private and federally funded programs have incorporated Web-based approaches and online technologies into their sexual education and HIV/STI prevention efforts for adolescents. These efforts have resulted in numerous Web sites and varied online content. This content is currently understudied and underevaluated. In this study, current sexual health Web sites targeted at adolescents were catalogued and coded. Methods Web sites targeted at adolescents were coded for educational content, credibility, usability, as well as interactivity. Results A significant amount of sexual health information geared toward teens is available online. All the Web sites reviewed showed deficiencies in educational content, as well as deficiencies in usability, authority, and interactivity. Planned Parenthood’s Web site was the most well rounded of the sites assessed.
Keywords
Background
The Internet is a powerful medium for communication and an innovative tool for facilitating health promotion messages. Access to the Internet continues to grow among adolescents in the United States and the Web has become a common source for youth seeking health information.1,2 A recent study showed that 41% of adolescents have changed their behavior in the past because of health information they found online, and almost half have contacted a health care provider as a result. 3 The Internet provides teens with a unique sense of anonymity when they are looking for information. The Internet also provides information on demand, at the time of need. These unique characteristics make it particularly compelling as a tool for communicating sensitive health information. 4 Because of the popularity and potential of the Internet, many private and federally funded programs and health departments have incorporated Web-based approaches into their pregnancy and HIV/STI (sexually transmitted infection) prevention efforts for adolescents. 5 These Web-based efforts have resulted in numerous and varied Web sites. This online content is currently understudied, underevaluated, and has at times been controversial.6-9
Although a large amount of Web-based sexual health information now exists, finding relevant and responsibly written content for adolescent audiences can be difficult and time consuming.10,11 In this study, current sexual health Web sites targeted at adolescents are catalogued and coded for educational content, credibility, usability, and interactivity. Internet addresses (URLs) to Web sites are provided in order to guide pediatricians and other clinicians when referring adolescents and families to online sexual health resources.
Methods
Searches on 9 keywords (teen, sex, HIV, STI, STD, pregnancy, contraception, birth control, adolescent, teenager, condom, safe sex) and combination phrases of keywords were conducted on each of the 4 most commonly used search engines in the United States (Google, Yahoo/BING, Ask, AOL). Search engine results were extensively reviewed for Web sites that were educational, that contained information about both STIs and HIV/AIDS, and that were specifically targeted toward teenagers. Both commercial and noncommercial sites were included, as long as the primary mission of the site was educating teens about health or sexual health. Additionally, the Web sites of well-known organizations (Unicef, the Centers for Disease Control and Prevention, the Kaiser Family Foundation, the National Institutes of Health, the Alan Guttmacher Institute, the Rural Center for AIDS/STD Prevention, the National Library of Medicine, the National Network of Libraries of Medicine, and the National Campaign to Prevent Teen Pregnancy) were searched for links or information about sexual health Web sites for teens.
Through this process, 29 Web sites were found to be relevant to this review. Three research assistants were trained to code and score the sites on measures of authority/reliability, interactivity, navigability, and how well content reflected the key concepts recommended by sexual health expert guidelines. Each coder worked independently. However, when particular questions arose, coders met as a group to discuss the classification and coding systems.
The Guidelines for Comprehensive Sexuality Education, Kindergarten–12th Grade was used to assess range and depth of sexual health content on each Web site. These guidelines reflect expert consensus on important topics that need to be covered for thorough and complete sexual health education. 12 Web sites were scored on a Likert-type scale on 40 recommended SIECUS (Sexuality Information and Education Council of the United States) categories (0 = not addressed, 1 = addressed but not in depth, 2 = addressed in depth) for a possible total of 80 points. The assessed categories were as follows: sexual anatomy and physiology, puberty, body image, sexual orientation, gender identity, relationships—including friendships, families, love, romantic relationships/dating, marriage, child rearing, values, decision making, communication, assertiveness, negotiation, skills for finding help, sexuality throughout life, masturbation, shared sexual behavior, sexual abstinence, human sexual response, sexual fantasy, sexual dysfunction, reproductive health, contraception, pregnancy and prenatal care, abortion, STIs, HIV and AIDS, sexual abuse, assault, violence and harassment, sexuality and society, gender roles, sexuality and the law, sexuality and religion, diversity, sexuality and the media, sexuality and the arts.
Categories for ranking each Web site’s usability were taken from the American Library Association Standards for Web Evaluation. 13 Each usability criteria was worth 1 point, for a possible total of 11 points. Usability criteria were as follows: consistent template design, internal hyperlinks work, requires personal user information, external hyperlinks work, includes search mechanism, option for fewer graphics or text-only version, additional software needed, content pages author name and/or credentials stated, moving images on site (text or graphics), availability of a site map.
Our measure for assessing a Web site’s authority and credibility was also developed from the American Library Association Standards for Web Evaluation. 13 Each Web site was rated on the following criteria: clarity of what organization is responsible for the contents of the page, authorship by qualified medical or health professional, clear description of the goals of the organization, ability to verify the legitimacy of this organization (by phone number, postal address), statement that the content of the page has the official approval of the organization, clarity on whether the Web site is from a national or local chapter of an organization, existence of a statement giving the organization’s name as copyright holder. Again, each site was given 1 point for each category that was successfully addressed for a total of 7 possible points, and points were compiled to create a score for authority and credibility for each Web site.
Web sites were also scored on the following interactive components: video clips, sound clips or audio footage, animation, e-greeting cards or ability to e-mail or text to another person with a personalized/customized note, click-through modules, video games, quizzes, surveys, polls, available e-mail or text to a linked expert, available hotline, message board, chat rooms. 5 Each site was given 1 point for each category that was successfully addressed for a total of 13 possible points to create a score for interactivity. If a site used social networks or social video such as Facebook, Myspace, or Youtube, the number of followers or “Likes” and the frequency of posts were recorded.
Results
All the sites showed deficiencies in sexual health content as recommended by SIECUS—usability, authority, and interactivity. No site received a perfect score in any category (Table 1, scores were converted to percentages for ease of interpretation).
Authority, Interactivity, Usability, and Educational Content Scores for Sexual Health Web Sites for Teens
Only 7 sites had individually tailored features or games based on an individual’s input. There was no statistically significant relationship between Web sites’ interactivity scores and educational content scores (r = .2, P = .3). Therefore, sites that had more interactive applications were not more likely to have more comprehensive content. Many of the sites that were the most interactive had large deficiencies in the number of SIECUS categories covered. For example, the MTV Web site www.itsyoursexlife.com and the Web site www.Stayteen.org by the National Campaign to Prevent Teen and Unplanned Pregnancy had high interactivity scores because of many interactive applications such as videos, text messaging options, games, and sound clips. The Web site Stayteen.org had role-playing exercises in which teens are assigned a cartoon character and can practice making safe decisions in risky situations. However, these 2 sites covered, respectively, only 23.4% and 27.5% of the SIECUS categories recommended for comprehensive sexual health education.
Planned Parenthood’s Web site, www.plannedparenthood.org, which received a score of 53.8 and 78.7 on the interactivity and educational content scales, respectively, was the most well rounded of the sites assessed. The Web sites www.Scarleteen.com (a privately funded site) and www.avert.org (an international HIV and AIDS charity, based in the United Kingdom) were also well rounded with high overall scores. Both these sites scored highly in authority and educational content, and each had average interactivity scores (see Table 2).
Top 10 Highest Cumulative Scoring Web Sites
In all, 62% of the Web sites assessed used social networking sites to enhance the primary site’s content and reach. Among the Web sites we reviewed, many had less than 5000 followers and some had as few as 59 likes or followers. The exception to this trend was teen sexual health microsites of larger organizations (UNICEF, Planned Parenthood). Only 2 sites had mobile phone compatibility (www.plannedparenthood.org and www.avert.org).
Conclusions
This study showed that 29 valuable sex education Web sites designed for teenagers can be found by combining sexual health terms with adolescent-specific identifiers on popular search engines. Many sites had difficulty covering all the topics areas needed for comprehensive sexual health information recommended by sexual health experts. However, highly informative sexual health information for teens is available on varied Web sites. Overall, the highest scoring site in all categories assessed was Planned Parenthood’s microsite for teens.
Most sites delivered sexual health content in a relatively static way using predominantly text and nonmoving graphics. This was an interesting finding because of the Internet’s potential for interactivity. This interactive potential is what makes the delivery of health messages online unique from other health promotion materials, such as brochures. One of the distinctive characteristics of the Internet is its flexibility and ability to incorporate individually tailored feedback into the delivery of messages. 5 Prior research has shown that written and computer based messages specifically tailored to and based on an individuals’ knowledge and beliefs are most effective in achieving behavior change.14,15 Specifically, there is evidence that interactive games and interactions via e-mail with experts can be effective in changing health-related behaviors and attitudes.16,17 Many sites that had good scores on educational content were deficient in interactive applications and highly interactive sites often had less educational content. More interactivity is not necessarily better if adequate sexual health information is not also available.
The paucity of sites with mobile compatibility was also an interesting finding. Many adolescents access the Internet through their mobile phones. Furthermore, minority adolescents that are statistically the most at risk for STIs are more likely to access the Internet by mobile phone. 18 For example, Black/African Americans represented approximately 17% of all teenagers but accounted for 72% of HIV/AIDS cases in this age group in 2007, and there are disparities in rates of other STIs for minority youth. In 2007, the rates of gonorrhea among adolescent African American females (15-19 years) was 14.7 times greater than those for white females and the rate for adolescent African American males (15-19 years) was 38.7 times higher than for white males.19-21 According to the National Institutes of Health and the Centers for Disease Control and Prevention, HIV and STI prevention efforts focused on minority adolescents are of the highest priority. Mobile phone compatibility must be prioritized for these sites to reach their target audience of minority youth. Currently, 51% of Hispanics and 46% of Blacks use their phones to access the Internet, compared with 33% of Whites. 18
In total, 61% of the Web sites studied used social networks. However, many of the sites did not use these popular resources fully. Among the Web sites reviewed, many had less than 5000 followers on Myspace or Facebook and some had as few as 59 likes or followers. This finding suggests that although publicly accessible Internet-based HIV/STI prevention content for adolescents exists, it is most likely underutilized. Organizations funding and designing sexual health content online should explore further the potential of social networks for dissemination purposes.
Overall, a significant amount of sexual health information geared toward teens is available online. This content has the potential to make a positive and beneficial impact on adolescent health. More research is needed to evaluate the mechanisms in which online sexual health information for adolescents influences knowledge and behavior. Although the Internet is increasingly being viewed as a mechanism for health promotion and disease prevention, little is known about how adolescents are using these online resources or which online resources are most effective. Future studies are needed to further explore the possibilities and promise of online sexual health content for youth.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors received no financial support for the research, authorship, and/or publication of this article.