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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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Sexual health the internet the role of internet interventions current achievements and potential

Sexual Health & the InternetThe role of Internet interventions- current achievements and potential

Udi Davidovich, PhD

ORP – Online Research & Prevention unit

Amsterdam Public Health Service

Penetration in 2009 june
% 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

Udi davidovich phd

Sexual health & Internet

Brilliant match

for Research & for Sexual Health Promotion

Scientific research, Prevention interventions &

Screening/testing Services

Udi davidovich phd



all the time

Increasingly everywhere

Increasingly easier

with same set of rules as for sexual contact

Sexual health the internet what more
Sexual health & the internet, what more…

  • Anonymity

  • Comfort: physical & mental

    How does that help sexual-health related research and prevention?

Udi davidovich phd

Research (qualitative)

the case of online chat interviews with webcams

Udi davidovich phd


Examine barriers to protective behavior against

HIV and other STI among heterosexual youth aged 14-24 in the Netherlands.

Evaluation of the usability and acceptability
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

Udi davidovich phd

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”.

Udi davidovich phd

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”

Udi davidovich phd

Comfort & emotional ease


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”.

What other advantages
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

Udi davidovich phd

Health Promotion

The case of tailoring: why do we believe it works?

Tailoring process imb model



1st intervention module

4th intervention module

5th intervention module

7th intervention module

Defcy. 1


Defcy. 2

Not present

Defcy. 3

Not present



Defcy. 4


Defcy. 5


Defcy. 6

Not present



Defcy. 7


Defcy. 8

Not present

Defcy. 9

Not present

Tailoring process IMB model

Intervention output

Tailored versus non tailorted intervention rct
Tailored versus non-tailorted intervention – RCT

  • Stimulation ofsafe sexin steady relationships among MSM (negotiated safety)

  • Single men – cognitive vaccine approach

Udi davidovich phd

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

Udi davidovich phd

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

Behavioral effect at 6 months
Behavioral effect at 6 months

Practice of negotiated safety for the tailored condition:

OR=10.50 95%CI 1.19 - 92.72

Udi davidovich phd

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

Udi davidovich phd

Drop out during interventions…

How do we keep them interested?

Vrijlekker nl objectives - Objectives

  • To remove barriers to safe sex and STI screening among youth 16-24, (TG 18-19)

  • Evidence based

Theoretical background
Theoretical Background

  • Tailoring: based on IMB

  • Modeling for engagement & empowerment

  • Direct network/environment approach

  • TPB elements:

    • Beliefs

    • Perceived control

    • Actual behavioral control

Key features
Key features

  • No personal risk feedback

  • Tailoring (increase relevance and concision)

  • The love-coaches (modeling)

  • The films (as topic openers / contemplative – preparatory)

Key features for engagement
Key features for engagement

Interactive text: e.g. the Excuse-Fighter(communication skills)

Udi davidovich phd

GGD Amsterdam




Key features for engagement1
Key features for engagement

E-cards as conversation opener (sexual network)

Interactieve modules
Interactieve modules

Communicatie naar de seksuele omgeving

GGD Amsterdam




Interactieve modules1
Interactieve modules

Communicatie richting de seksuele partners

GGD Amsterdam




Key features for engagement2
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

Does it work
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]

Udi davidovich phd

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

Udi davidovich phd

Sexual Health Services

The case of HIV & STD testing online

Test lab procedures
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)


Test lab procedures test locations
Test Lab procedures: Test locations

Amsterdam Rotterdam


Test lab procedures1
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.


Test package

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


Procedure referral letter
Procedure: referral letter


Procedure back office
Procedure: Back office


Procedure email
Procedure: Email



Procedure results online
Procedure: Results online




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


% 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



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)


Results unique users
Results: Unique users


  • 31% never visited an STI clinic before

Results efficacy
Results: Efficacy

STI prevalence

Test Lab Amsterdam: 18% (59/334)

STI clinic Amsterdam: 15% (260/1701)

All positives visited the clinic for treatment & diagnosis


Results usability en acceptability
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


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


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!?

Hepatitis c internet project hip freke zuure
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

Hip strategy

Public, regional media campaign

HIP strategy

Supporting Health by Technology II

Hip strategy1

Public, regional media campaign

Tailored HCV risk assessment questionnaire

HIP strategy

Supporting Health by Technology II

FR Zuure, U Davidovich, GJ Kok, ACTM Depla, CJPA Hoebe, JAR van den Hoek, PLM Jansen, P van Leeuwen-Gilbert, CJ Weegink, RA Coutinho, M Prins. Evaluation of a risk assessment questionnaire to assist hepatitis C screening in the general population.Eurosurveillance, in press.

Questionnaire was evaluated before its online use in a study among liver patients with known HCV status (before HIP):

Sensitivity: 84.6%

Specificity: 63.8%

Hip strategy2

Public, regional media campaign

Tailored HCV risk assessment questionnaire at WWW.HEPTEST.NL

Free and anonymous blood test

HIP strategy

Supporting Health by Technology II

Hip strategy3

Open media campaign

Tailored HCV risk assessment questionnaire at WWW.HEPTEST.NL

Free and anonymous blood test

Free and anonymous confirmation test at the Public Health Service

Direct referral to a specialist at the hospital

HIP strategy

Supporting Health by Technology II

Additional online services
Additional online services

Free email and/or SMS reminder for blood testing

Free email and/or SMS alert when the test’s result could be obtained online

Results usability and acceptability n 2 154
Results usability and acceptability (n=2,154)

Supporting Health by Technology II

Hep prevalence update among msm anouk urbanus
HEP prevalence update among MSMAnouk Urbanus

  • 2/532 HIV-negative MSM were HCV infected (0.4%)

  • 28/157 HIV-positive MSM co-infected with HCV (18%)

  • Increasing trend over time

    • May 2007: 7/48 (14.6%) HCV/HIV co-infected

    • November 2007: 7/42 (16.7%) HCV/HIV co-infected

    • April 2008: 14/67 (20.9%) HCV/HIV co-infected

Results acute infections and hcv awareness
Results- acute infections and HCV awareness

  • 7/28 (25.0%) HCV/HIV co-infected MSM had an acute infection

    • 4 Anti-HCV negative, HCV RNA positive

    • 3 weak Anti-HCV response combined with negative (n=1) or indeterminate (n=2) immunoblot, HCV RNA positive

  • Increased over time

  • 31,8% is not aware of their HCV status (most had an acute infection)

Urbanus AT, van de Laar TJ, Stolte IG, Schinkel J, Heijman T, Coutinho RA, et al.Hepatitis C virus infections among HIV-infected men who have sex with men: an expanding epidemic. AIDS 2009; 23(12):F1-F7.

Udi davidovich phd

Where do we go from here?

Individuality within

the social network

Harnessing individuality and norm formation within online

social networks for sexual health promotion



  • Vrijlekker: Cityof Amsterdam & Hanna Uhr-Daal

  • Testlab: Rik Koekenbier, Wim Zuilhof & Pjer Vriens

Acknowledgements hep c heptest nl
Acknowledgements HEP C – HEPTEST.NL

Public Health Service of Amsterdam: Maria Prins, PhD

Udi Davidovich, PhD

Anneke van den Hoek, MD, PhD

South Limburg Public Health Service: Christian Hoebe, MD, PhD

Hans Frantzen

Natacha Gelissen

National Hepatitis Center: Paula van Leeuwen, MSc

Academic Medical Center, Amsterdam: Christine Weegink, MD, PhD

prof. Peter Jansen, MD

Center for Infectious Disease Control, National Institute

for Public Health and the Environment, Bilthoven: prof. Roel Coutinho, MD

School of Psychology, University of Maastricht: prof. Gerjo Kok

And all other participants and co-workers of the departments

This project is funded by

Roche Netherlands provided an unrestricted grant for broadcasting of the television commercial

Schering-Plough provided an unrestricted grant for the translation of

Supporting Health by Technology II