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Udi Davidovich, PhD

Sexual Health & the Internet The role of Internet interventions- current achievements and potential. Udi Davidovich, PhD. ORP – Online Research & Prevention unit Amsterdam Public Health Service. % penetration in 2009 (June). NL,NO – 85% UK – 80%, US – 74% PT – 42%

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Udi Davidovich, PhD

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  1. Sexual Health & the InternetThe role of Internet interventions- current achievements and potential Udi Davidovich, PhD ORP – Online Research & Prevention unit Amsterdam Public Health Service

  2. % penetration in 2009 (June) NL,NO – 85% UK – 80%, US – 74% PT – 42% (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

  3. Sexual health & Internet Brilliant match for Research & for Sexual Health Promotion Scientific research, Prevention interventions & Screening/testing Services

  4. Interactivity Connectivity all the time Increasingly everywhere Increasingly easier with same set of rules as for sexual contact

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

  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 for example copy/paste functions. • Webcam increases the validity of chat interviews

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

  14. Knowledge deficiencies 1st intervention module 4th intervention module 5th intervention module 7th intervention module Defcy. 1 Present Defcy. 2 Not present Defcy. 3 Not present Motivational deficiencies Defcy. 4 Present Defcy. 5 Present Defcy. 6 Not present Skill deficiencies Defcy. 7 Present Defcy. 8 Not present Defcy. 9 Not present Tailoring process IMB model Intervention output

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

  16. 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

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

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

  19. 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

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

  21. www.vrijlekker.nl

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

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

  24. Key features • No personal risk feedback • Tailoring (increase relevance and concision) • The love-coaches (modeling) • The films (as topic openers / contemplative – preparatory)

  25. Key features for engagement Interactive text: e.g. the Excuse-Fighter(communication skills)

  26. GGD Amsterdam Galjaard Prijs 2009

  27. Key features for engagement E-cards as conversation opener (sexual network)

  28. Interactieve modules Communicatie naar de seksuele omgeving GGD Amsterdam Galjaard Prijs 2009

  29. Interactieve modules Communicatie richting de seksuele partners GGD Amsterdam Galjaard Prijs 2009

  30. Key features for engagement Condoms and lube supply online. Pay with the mobile or regular phone - 10 condoms voor 99 euro cent! (Actual behavioral control

  31. Does it work? 6 months follow-up intervention versus control: baseline: n=2944, follow-up: n=1553 (mean age 19, SD 2.4). • Significantly more condom use with the last casual partner [OR=1.82 95%CI 1.08 - 3.04, n=311] • Significant more condom use with the steady partner [OR=2.17 95%CI 1.48 - 3.18, n=765]

  32. Sexual Health Services • The case of HIV & STD testing online • The case of Hep C screening online • The case of population-based mass-screening for Chlamydia

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

  34. 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) 35

  35. Test Lab procedures: Test locations Amsterdam Rotterdam 36

  36. 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. 37

  37. 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 38

  38. Procedure: referral letter 39

  39. Procedure: Back office 40

  40. Procedure: Email 41 Soa*Hiv

  41. Procedure: Results online 42 Soa*Hiv

  42. Evaluation 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 43

  43. 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) 44

  44. Use of Testlab 45

  45. Results: Unique users 46 • 31% never visited an STI clinic before

  46. Results: Efficacy STI prevalence Test Lab Amsterdam: 18% (59/334) STI clinic Amsterdam: 15% (260/1701) All positives visited the clinic for treatment & diagnosis 47

  47. 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 48 Koekenbier RH, Davidovich U, van Leent EJ, Thiesbrummel HF, Fennema HS. Online-mediated syphilis testing: feasibility, efficacy, and usage. Sex Transm Dis. 2008 Aug;35(8):764-9. • Qualitative research among non-users & users • Int. AIDS conference Vienna July 2010 • Test-specific results –how!?

  48. Hepatitis C Internet Project (HIP) – Freke Zuure Overall aim: To evaluate whether a hidden population of HCV-infected individuals can be identified through a public media campaign alongside an internet risk assessment and low-threshold blood screening procedure

  49. Public, regional media campaign HIP strategy Supporting Health by Technology II

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