- Email: [email protected]
Teens, Technology, and Health Care
Tee n s , Tec h n o l o g y, an d Health Care Francesco Leanza,
MD
a,b,
*, Diane Hauser,
a,b MPA
KEYWORDS Teens Technology Text messaging Computer-based or Web-based interventions Chronic disease management Social media Teen sexual health KEY POINTS Teens prefer to receive text messages rather than e-mails as a form of communication. Computer-based screenings are acceptable to teens and helpful to providers for identifying and preventing high-risk behaviors. Web sites that address specific domains of teen health care should be easy to use, youth centered, connected to an organization that is recommended by the provider, and trustworthy. Social media can play a role in teen health, but should be connected to the teen’s personal experience with a group or organization that focuses on the teen’s specific condition (ie, other teens with the same condition).
INTRODUCTION
The use of technology and social media is ubiquitous among teens. Ninety-five percent of American teens are online at least sometimes, and this connectivity increasingly moves with them on a rapidly developing array of mobile devices.1 It has been noted that trends in mobile connectivity among teens are a harbinger of future behaviors among adults, expanding the relevance of teen-focused technology initiatives. Smartphones, social media sites, and online videos and gaming have much potential to promote health and healthy behaviors in teens. There is a growing body of research on teens and the use of technology with regard to their health care. To date, studies are small and imperfect. As a result it is difficult to extrapolate to the general population given that most studies are not considered high
a Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA; b Institute for Family Health, 16 East 16th Street, New York, NY 10003, USA * Corresponding author. Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA E-mail address: [email protected]
Prim Care Clin Office Pract 41 (2014) 559–566 http://dx.doi.org/10.1016/j.pop.2014.05.006 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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quality from an evidence-based perspective. However, trends are emerging that are helpful when designing interventions for further study. Health Information Seeking Among Teens
In the general population of online teens, 31% obtain health, dieting, or physical fitness information from the Internet according to a 2010 survey of adolescents and young adults by the Pew Internet & American Life project.2 This survey also found that 17% of online teens report using the Internet to learn about health topics that are difficult to discuss with others, such as drug use and sexual health. Research on how teens search for and use health information is limited, with most studies using qualitative methods and small samples. One study found that adolescents do not search for health information with a critical eye.3 This small study showed that participants used a “trial-and-error approach to formulate search strings, scanned pages randomly instead of systematically, and did not consider the source of the content when searching for health information.”3 Another study that tracked use of suggested health Web sites for adolescents with asthma and diabetes found that 60% of participants accessed at least one site over a 6-month period. Perceived usefulness and content, particularly stories, targeted toward teens were predictors of continued use of a Web site. Teens were more likely to use sites for information than for self-management purposes.4 One study of sources of information about suicide found that teens often use online sources for information about suicide, with 59% citing online sources.5 A survey of more than 700 young people who had previously reported knowledge of others who had attempted or committed suicide and had associated experiences of hopelessness and suicidal ideation found that the Internet and social networking sites were important sources of suicide stories for this group. However, only discussion forums were associated with increased suicidal ideation. The investigators suggest that social networking sites may provide increased exposure to suicide, and also greater social support. Some Web sites contain low-quality and/or erroneous information. A study of sexual health information Web sites visited by teens found that 17% of sites reviewed contain at least one inaccuracy, and these were most likely to be related to complex (eg, contraception) or controversial (eg, abortion) topics.6 In another study, specifically of sexually transmitted infection (STI) sites available to teens, key information, such as primary prevention and partner testing, was often missing.7 To address concerns about the accuracy of online information, the organization Common Sense Media (commonsensemedia.org) draws on a national advisory board to rate media sites targeting children and teens, with specific reviews of health-related sites. Although teens are increasingly seeking health information online, the impact of the information on teen’s health behavior is unclear and may not always be accurate. Health care professionals and organizations that work with teens should identify online health information that is both accurate and teen friendly. Use of Technology for Health Care Engagement and Promotion Among Teens
A variety of technologies have been used to engage teens in their health both outside and inside the health care system. Because cell phone texting is currently the preferred form of communication among teens, a variety of adolescent health education initiatives involve texting.8 In San Francisco, Internet Sexuality Information, Inc partnered with the city’s Department of Public Health to publicize a text messaging program, SEXINFO, through traditional media, which enables adolescents to find services related to sexual health. Teens use their phones to choose from a menu of concerns (eg, D4 to find out about human immunodeficiency virus [HIV]), and receive
Teens, Technology, and Health Care
information about services via text. Surveys found high awareness and use of services among the targeted youth.9 Through a program known as Hook-up, supported by the California Family Health Council, teens can sign up to receive weekly texts on “sex info and life advice.”10 A recent review of studies assessing the impact of digital media designed to prevent STIs and HIV found that study design issues, such as lack of biological outcomes and comparison groups, makes it difficult to determine whether the digital interventions were effective.11 Although use of texting has been studied to reach teens outside the clinic, the use of personal digital devices (PDAs) for health screening has been studied for use within the clinical setting. A study that used PDAs to conduct health screenings using a modified Guidelines for Adolescent Preventive Services (GAPS)12 indicated that teens were more likely to think that their visit was confidential, that they were listened to more carefully, and to be satisfied with the visit. The use of PDAs increased discussions of certain behaviors, such as fruit/vegetable intake, tobacco use, and alcohol use.13 A review article by Hassan and Fleegler14 highlighted several important studies regarding the use of technology to screen adolescents in clinics: A randomized study substantiated that teens self-disclose as accurately on computer surveys as they do on paper.15 Several studies have concluded that computer-based surveys are perceived as confidential and nonjudgmental, resulting in accurate answers to sensitive questions.13,16,17 Screening teens for psychosocial concerns just before a provider visit increases the number of concerns identified and addressed during the visit.18 These studies substantiate that computerized versions of the traditional paper screen are acceptable, valid, and increase concerns identified by teens and addressed by providers. Although the best technology for screening teens has not been established, PDAs show promise. Interventions to prevent risky behaviors or increase healthy behaviors have also been studied to some extent. In Hassan and Fleegler’s14 review article, several computerized interventions to decrease risky behavior were highlighted: In an efficacy study at the University of California, Los Angeles, of computerized HIV prevention for adolescents, Lightfoot and colleagues,19 found that teens in the computerized group were less likely to engage in sexual activity and reported fewer partners. In a screening and brief online intervention for college freshman at Boston University, unhealthy alcohol use was decreased.20 A systematic review of technology-based interventions (Web and computer) designed to increase preadolescent and adolescent physical activity found that increases in activity occurred. Location of interventions varied from school to camp to activities at home. The interventions included physical activity, improving diet, counseling, and group sessions. Half the studies were by self-report and the other half measured body mass index, body weight, percent body fat, and/or activity as measured by accelerometer. These findings were small and not sustained and require further study. The number of studies addressing physical activity did not adequately address the effectiveness of technology-based interventions.21 Technology is quickly becoming pervasive in the interaction between teens and their health. Texting is being used to reach out to teens, computer-based screens are being used to assess for high-risk behaviors, and studies show that teens respond to online or computer-based interventions.
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Tools to Manage Chronic Illness
Research on the use of technology to manage chronic illness in teens has mostly been limited to qualitative feasibility studies. Most studies show how technology improves knowledge about disease; a smaller number evaluate improvement of adherence or disease-based outcomes associated with a particular condition. Applebaum and colleagues,22 at the University of Chicago, performed surveys and focus groups with a small group of chronically ill teens and their parents in a pediatric university-based rheumatology practice and general pediatric practice. Several of the following themes emerged from the focus groups: Teens prefer appointment reminders by text, not e-mail, because they rarely check their inboxes. Online portals are acceptable as a means to store personal medical information and provide a forum for communication between patients and providers. Online portals should be presented in a fun, interactive, and customizable way. Teens in the study also wanted an easy way to retrieve medication lists, test results, and personal information with minimal data entry required. The patients in the study had chronic illness and felt uncomfortable searching the Internet on their own for information regarding their illnesses. They preferred to have their provider recommend reputable online sources; ideally sources that were interactive and provided easy-tounderstand information about their conditions and medications. Portable memory devices, such as thumb drives, for teens were discouraged because they are easily lost. Social media were acceptable as means to connect with other teens with similar conditions, but not as means to access information and communicate with providers, because this could affect the teens’ privacy. In addition, teens in the focus groups thought that they would not connect with other teens unless they had met them previously. Teens wanted peer-based support groups. Support groups are seen as a venue to share information and socialize with peers who understand what it means to have the same illness. The teens with chronic illness in the study did not want to engage with peers at their schools, because “They ask dumb questions and they do not understand.”22 Feasibility studies substantiate that texting to improve management and knowledge of chronic disease, such as type 1 diabetes and cystic fibrosis (CF), is acceptable. A small study using the Computerized Automated Reminder Diabetes System (CARDS) showed that teens are more likely to check their blood sugar if they are reminded by text rather than e-mail. However, response to texts waned after 3 months.23 In another study with young type 1 diabetic patients, Sweet Talk, a text messaging support system, sent text messages tailored to the individual. Messages from Sweet Talk included reminders to take medications and check blood sugars, provided lifestyle advice such as to eat healthily and exercise, and offered general newsletters and tips from other youth with diabetes. The Sweet Talk systems also allowed teens to text data and questions to their diabetes care teams. Patient messages were in several categories: blood glucose readings, diabetes questions, diabetes information, personal health administration, and social messages. The study did not find any associations with frequency of messaging and clinical or psychosocial outcomes.24 Although it is unclear whether texting improves clinical measures in diabetes, there is some indication that texting is a preferred method for reminders. Studies that addressed disease self-management, adherence to medication, and treatment in teens had mixed results. Many of the studies have small samples and few show improvement with adherence. A small, randomized controlled trial
Teens, Technology, and Health Care
using Your Way, an Internet-based program to improve self-management in adolescents with type 1 diabetes, found that Web-based interventions may improve self-management through enhancing problem-solving skills. Glycemic control as measured by hemoglobin A1c remained stable in the intervention group and worsened in the control group. The sample size was small and the data were analyzed as treated rather than as intent to treat.25 In a small feasibility, usability, and utility pilot study at Columbia University in New York, the use of CFFONE, a cell phone technology that is Web enabled, provides education about CF, and connects teens with CF through social networking, showed that it was considered somewhat helpful by teens and helpful by parents and adults. Future studies will examine whether the program improves adherence and health outcomes of teens with CF.26 In a systematic review of Internet and cell phone–based smoking cessation programs among adolescents, the Internet was found to be more effective when used as an adjunct to multiple approaches (counseling, group counseling, acupressure, medications) to cessation versus using the Internet alone. Most interventions had specific Web sites about smoking cessation (chat rooms, Web-based curricula and interventions).27 Research is showing that teens with chronic health conditions are knowledgeable consumers of health care technology. There are clear themes that are consistent across the studies. Teens want reliable and trustworthy sources of information regarding their illnesses, and to interact with their providers through online portals. Reminders regarding specific disease treatment plans are acceptable. Social media are acceptable, but must be used in a controlled setting and with peers who have the same condition. SEXUAL AND REPRODUCTIVE HEALTH
Use of technology by teens with regard to sexual and reproductive health has been studied more than other domains of teen health. Texting is an acceptable mode of communication regarding sexual health if it is anonymous, confidential, and the information is reliable and from a trusted source.28 There are several innovative ways in which text messaging is being used to promote adolescent sexual health, including: Providing health education. Offering medication reminders (eg, birth control pill reminders). Providing information about available health care services.28 Although studies have looked at many ways to provide this information, there are limited effectiveness studies that measure whether there is an improvement in sexual health outcomes as a result of the text messaging. With sensitive topics such as sexual health, youth have increased concern about privacy, especially when they are potentially accessing the Internet on a public versus private computer. Data from a few qualitative studies assessing the use of the Internet among HIV-positive youth supported the use of the Internet for social support and education. A qualitative study of HIV-positive youth in Ontario, Canada, used semistructured interviews to understand their perspectives on the use of the Internet as a tool to learn about living with HIV. Although these teenagers primarily used the Internet for social networking and entertainment, they acknowledged that a youthcentered, interactive Web site with confidential chat rooms and message boards would be acceptable to them for health information. Privacy was very important.29 Another qualitative study focusing on HIV-positive African American youth showed that using remote videoconferencing, when privacy was maintained in a secure
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location, was convenient, efficient, and had a positive impact on their knowledge. The effect of this program on CD4 count and viral load was not studied.30 Another promising use of technology with teens is to improve treatment of STIs. Two studies assessed the use of text messaging to decrease time to treatment of chlamydia. Although 1 study found that texting decreased the time to treatment compared with phone or clinic follow-up and that fewer staff hours were needed to do follow-up as a result,31 the other study found no difference between texting and regular followup.32 Both studies were small and neither was a randomized controlled trial, but these studies indicate that texting is at least as useful as traditional methods for follow-up on abnormal tests, and it has the potential to be better. As software becomes more sophisticated and electronic health records use patient portals it may be more costeffective and efficient to use technology to notify patients of results and to schedule follow-up.31 SUMMARY
Although in its nascency, research in teens and technology has come far in a short period of time. There are already emerging patterns in the literature. Teens prefer text messaging for communication. Computer-based screenings are acceptable to teens and helpful to providers to increase identification and interventions based on high-risk behaviors. Web sites that address specific domains of teen health care should be easy to use, youth centered, connected to an organization that is recommended by the provider, and trustworthy. Social media can play a role in teens and health, but should be connected to the teen’s personal experience with a group or organization that focuses on the teen’s specific condition (ie, other teens with the same condition). Technology and its role in chronic disease management, including improvement of disease parameters and adherence to medications, shows promise as an intervention. In a recent article in the Journal of Adolescent Health summarizing a conference that set a research agenda for the intersection of youth, technology, and new media with regard to sexual health, scientists and technology experts made key recommendations that included: Partner with established community-based organizations skilled in the use of technology to do research Petition local institutional review boards to include members with expertise in technology research Use theoretic models to understand why technology and social media interventions work Use technology in research from the onset Use technology and incentives to recruit large, diverse sample sizes Conduct research projects that focus on health outcomes with large sample sizes33 Experts agree that further research on teens and technology is critical. To date, studies have been small and imperfect. As a result it is difficult to extrapolate to the general population given that most studies are not considered high quality from an evidence-based perspective. The body of research on patient-oriented outcomes that matter to teens is limited, but it is the area that needs the most development along with studies with larger sample sizes and vigorous research protocols. Teens use technology more than any other demographic and future study using interventions that intersect with teens, technology, and their health is important.
Teens, Technology, and Health Care
REFERENCES
1. Madden M, Lenhart A, Duggan M, et al. Teens and technology 2013. Washington, DC: Pew Internet & American Life Project; 2013. Available at: http://www. pewinternet.org/w/media//Files/Reports/2013/PIP_TeensandTechnology2013.pdf. Accessed January 27, 2014. 2. Lenhart A, Purcell K, Smith A, et al. Social media & mobile internet use among teens and young adults. Washington, DC: Pew Internet & American Life Project; 2010. Available at: http://www.pewinternet.org/w/media//Files/Reports/ 2010/PIP_Social_Media_and_Young_Adults_Report_Final_with_toplines.pdf. Accessed January 27, 2014. 3. Hansen DL, Derry HA, Resnick PJ, et al. Adolescents searching for health information on the Internet: an observational study. J Med Internet Res 2003;5(4):e25. 4. Chisolm DJ, Johnson LD, McAlearney AS. What makes teens start using and keep using health information web sites? A mixed model analysis of teens with chronic illnesses. Telemed J E Health 2011;17(5):324–8. 5. Dunlop SM, More E, Romer D. Where do youth learn about suicides on the internet, and what influence does this have on suicidal ideation? J Child Psychol Psychiatry 2011;52(10):1073–80. 6. Buhi ER, Daley EM, Oberne A, et al. Quality and accuracy of sexual health information web sites visited by young people. J Adolesc Health 2010;47(2): 206–8. 7. Meyer KL, Ahlers-Schmidt CR, Harris KR, et al. STI testing information available to teens on the internet: what’s missing? J Pediatr Adolesc Gynecol 2011;24(2): e17–9. 8. Lenhart A, Ling R, Campbell S, et al. Teens and mobile phones. Washington, DC: Pew Internet & American Life Project; 2010. Available at: http://pewinternet.org/ w/media//Files/Reports/2010/PIP-Teens-and-Mobile-2010-with-topline.pdf. Accessed January 27, 2014. 9. Levine D, McCright J, Dobkin L, et al. SEXINFO: a sexual health text messaging service for San Francisco youth. Am J Public Health 2008;98(3):393–5. 10. Carroll JA, Kirkpatrick RL. Impact of social media on adolescent behavioral health. Oakland (CA): California Adolescent Health Collaborative; 2001. Available at: http:// www.californiateenhealth.org/wp-content/uploads/2011/09/SocialMediaAug2011. pdf. Accessed March 26, 2014. 11. Cha´vez NR, Shearer LS, Rosenthal SL. Use of digital media technology for primary prevention of STIs/HIV in youth. J Pediatr Adolesc Gynecol 2013. pii:S1083-3188(13):00239–8. 12. Elster A, Kuznets N, editors. AMA guidelines for adolescent preventive services (GAPS): recommendations and rationale. Baltimore (MD): Williams & Wilkins; 1994. 13. Olson AL, Gaffney CA, Hedberg VA, et al. Use of inexpensive technology to enhance adolescent health screening and counseling. Arch Pediatr Adolesc Med 2009;163(2):172–7. 14. Hassan A, Fleegler EW. Using technology to improve adolescent healthcare. Curr Opin Pediatr 2010;22(4):412–7. 15. Mangunkusumo RT, Moorman PW, Van Den Berg-de Ruiter AE, et al. Internetadministered adolescent health questionnaires compared with a paper version in a randomized study. J Adolesc Health 2005;36(1):70.e1–6. 16. Mackenzie SL, Kurth AE, Spielberg F, et al. Patient and staff perspectives on the use of a computer counseling tool for HIV and sexually transmitted Infection risk reduction. J Adolesc Health 2007;40(6):572.e9–16.
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17. Watson PD, Denny SJ, Adair V. Adolescents’ perceptions of a health survey using multimedia computer-assisted self-administered interview. Aust N Z J Public Health 2001;25(6):520–4. 18. Stevens J, Kelleher KJ, Gardner W, et al. Trial of computerized screening for adolescent behavioral concerns. Pediatrics 2008;121(6):1099–105. 19. Lightfoot M, Comulada WS, Stover G. Computerized HIV preventive intervention for adolescents: indications of efficacy. Am J Public Health 2007;97(6):1027–30. 20. Saitz R, Palfai TP, Freedner N, et al. Screening and brief intervention online for college students: the ihealth study. Alcohol Alcohol 2007;42(1):28–36. 21. Hamel LM, Robbins LB, Wilbur J. Computer- and web-based interventions to increase preadolescent and adolescent physical activity: a systematic review. J Adv Nurs 2011;67(2):251–68. 22. Applebaum MA, Lawson EF, von Scheven E. Perception of transition readiness and preferences for use of technology in transition programs: teens’ ideas for the future. Int J Adolesc Med Health 2013;25(2):119–25. 23. Hanauer DA, Wentzell K, Laffel N, et al. Computerized automated reminder diabetes system (CARDS): e-mail and SMS cell phone text messaging reminders to support diabetes management. Diabetes Technol Ther 2009;11(2):99–106. 24. Franklin VL, Greene A, Waller A, et al. Patients’ engagement with “Sweet Talk” - a text messaging support system for young people with diabetes. J Med Internet Res 2008;10(2):e20. 25. Mulvaney SA, Rothman RL, Wallston KA, et al. An internet-based program to improve self-management in adolescents with type 1 diabetes. Diabetes Care 2010;33(3):602–4. 26. Marciel K, Saiman L, Quittel L, et al. Cell phone intervention to improve adherence: cystic fibrosis care team, patient, and parent perspectives. Pediatr Pulmonol 2010;45(2):157–64. 27. Mehta P, Sharma M. Internet and cell phone based smoking cessation programs among adolescents. Acta Didactica Napocensia 2010;3(4):11–24. 28. Malbon K, Romo D. Is it ok 2 txt? Reaching out to adolescents about sexual and reproductive health. Postgrad Med J 2013;89(1055):534–9. 29. Flicker S, Goldberg E, Read S, et al. HIV-positive youth’s perspectives on the Internet and e-health. J Med Internet Res 2004;6(3):e32. 30. Saberi P, Yuan P, John M, et al. A pilot study to engage and counsel HIV-positive African American youth via telehealth technology. AIDS Patient Care STDS 2013; 27(9):529–32. 31. Menon-Johansson AS, McNaught F, Mandalia S, et al. Texting decreases the time to treatment for genital Chlamydia trachomatis infection. Sex Transm Infect 2006; 82(1):49–51. 32. Lim EJ, Haar J, Morgan J. Can text messaging results reduce time to treatment of Chlamydia trachomatis? Sex Transm Infect 2008;84(7):563–4. 33. Allison S, Bauermeister JA, Bull S, et al. The intersection of youth, technology, and new media with sexual health: moving the research agenda forward. J Adolesc Health 2012;51(3):207–12.
MD
a,b,
*, Diane Hauser,
a,b MPA
KEYWORDS Teens Technology Text messaging Computer-based or Web-based interventions Chronic disease management Social media Teen sexual health KEY POINTS Teens prefer to receive text messages rather than e-mails as a form of communication. Computer-based screenings are acceptable to teens and helpful to providers for identifying and preventing high-risk behaviors. Web sites that address specific domains of teen health care should be easy to use, youth centered, connected to an organization that is recommended by the provider, and trustworthy. Social media can play a role in teen health, but should be connected to the teen’s personal experience with a group or organization that focuses on the teen’s specific condition (ie, other teens with the same condition).
INTRODUCTION
The use of technology and social media is ubiquitous among teens. Ninety-five percent of American teens are online at least sometimes, and this connectivity increasingly moves with them on a rapidly developing array of mobile devices.1 It has been noted that trends in mobile connectivity among teens are a harbinger of future behaviors among adults, expanding the relevance of teen-focused technology initiatives. Smartphones, social media sites, and online videos and gaming have much potential to promote health and healthy behaviors in teens. There is a growing body of research on teens and the use of technology with regard to their health care. To date, studies are small and imperfect. As a result it is difficult to extrapolate to the general population given that most studies are not considered high
a Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA; b Institute for Family Health, 16 East 16th Street, New York, NY 10003, USA * Corresponding author. Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA E-mail address: [email protected]
Prim Care Clin Office Pract 41 (2014) 559–566 http://dx.doi.org/10.1016/j.pop.2014.05.006 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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quality from an evidence-based perspective. However, trends are emerging that are helpful when designing interventions for further study. Health Information Seeking Among Teens
In the general population of online teens, 31% obtain health, dieting, or physical fitness information from the Internet according to a 2010 survey of adolescents and young adults by the Pew Internet & American Life project.2 This survey also found that 17% of online teens report using the Internet to learn about health topics that are difficult to discuss with others, such as drug use and sexual health. Research on how teens search for and use health information is limited, with most studies using qualitative methods and small samples. One study found that adolescents do not search for health information with a critical eye.3 This small study showed that participants used a “trial-and-error approach to formulate search strings, scanned pages randomly instead of systematically, and did not consider the source of the content when searching for health information.”3 Another study that tracked use of suggested health Web sites for adolescents with asthma and diabetes found that 60% of participants accessed at least one site over a 6-month period. Perceived usefulness and content, particularly stories, targeted toward teens were predictors of continued use of a Web site. Teens were more likely to use sites for information than for self-management purposes.4 One study of sources of information about suicide found that teens often use online sources for information about suicide, with 59% citing online sources.5 A survey of more than 700 young people who had previously reported knowledge of others who had attempted or committed suicide and had associated experiences of hopelessness and suicidal ideation found that the Internet and social networking sites were important sources of suicide stories for this group. However, only discussion forums were associated with increased suicidal ideation. The investigators suggest that social networking sites may provide increased exposure to suicide, and also greater social support. Some Web sites contain low-quality and/or erroneous information. A study of sexual health information Web sites visited by teens found that 17% of sites reviewed contain at least one inaccuracy, and these were most likely to be related to complex (eg, contraception) or controversial (eg, abortion) topics.6 In another study, specifically of sexually transmitted infection (STI) sites available to teens, key information, such as primary prevention and partner testing, was often missing.7 To address concerns about the accuracy of online information, the organization Common Sense Media (commonsensemedia.org) draws on a national advisory board to rate media sites targeting children and teens, with specific reviews of health-related sites. Although teens are increasingly seeking health information online, the impact of the information on teen’s health behavior is unclear and may not always be accurate. Health care professionals and organizations that work with teens should identify online health information that is both accurate and teen friendly. Use of Technology for Health Care Engagement and Promotion Among Teens
A variety of technologies have been used to engage teens in their health both outside and inside the health care system. Because cell phone texting is currently the preferred form of communication among teens, a variety of adolescent health education initiatives involve texting.8 In San Francisco, Internet Sexuality Information, Inc partnered with the city’s Department of Public Health to publicize a text messaging program, SEXINFO, through traditional media, which enables adolescents to find services related to sexual health. Teens use their phones to choose from a menu of concerns (eg, D4 to find out about human immunodeficiency virus [HIV]), and receive
Teens, Technology, and Health Care
information about services via text. Surveys found high awareness and use of services among the targeted youth.9 Through a program known as Hook-up, supported by the California Family Health Council, teens can sign up to receive weekly texts on “sex info and life advice.”10 A recent review of studies assessing the impact of digital media designed to prevent STIs and HIV found that study design issues, such as lack of biological outcomes and comparison groups, makes it difficult to determine whether the digital interventions were effective.11 Although use of texting has been studied to reach teens outside the clinic, the use of personal digital devices (PDAs) for health screening has been studied for use within the clinical setting. A study that used PDAs to conduct health screenings using a modified Guidelines for Adolescent Preventive Services (GAPS)12 indicated that teens were more likely to think that their visit was confidential, that they were listened to more carefully, and to be satisfied with the visit. The use of PDAs increased discussions of certain behaviors, such as fruit/vegetable intake, tobacco use, and alcohol use.13 A review article by Hassan and Fleegler14 highlighted several important studies regarding the use of technology to screen adolescents in clinics: A randomized study substantiated that teens self-disclose as accurately on computer surveys as they do on paper.15 Several studies have concluded that computer-based surveys are perceived as confidential and nonjudgmental, resulting in accurate answers to sensitive questions.13,16,17 Screening teens for psychosocial concerns just before a provider visit increases the number of concerns identified and addressed during the visit.18 These studies substantiate that computerized versions of the traditional paper screen are acceptable, valid, and increase concerns identified by teens and addressed by providers. Although the best technology for screening teens has not been established, PDAs show promise. Interventions to prevent risky behaviors or increase healthy behaviors have also been studied to some extent. In Hassan and Fleegler’s14 review article, several computerized interventions to decrease risky behavior were highlighted: In an efficacy study at the University of California, Los Angeles, of computerized HIV prevention for adolescents, Lightfoot and colleagues,19 found that teens in the computerized group were less likely to engage in sexual activity and reported fewer partners. In a screening and brief online intervention for college freshman at Boston University, unhealthy alcohol use was decreased.20 A systematic review of technology-based interventions (Web and computer) designed to increase preadolescent and adolescent physical activity found that increases in activity occurred. Location of interventions varied from school to camp to activities at home. The interventions included physical activity, improving diet, counseling, and group sessions. Half the studies were by self-report and the other half measured body mass index, body weight, percent body fat, and/or activity as measured by accelerometer. These findings were small and not sustained and require further study. The number of studies addressing physical activity did not adequately address the effectiveness of technology-based interventions.21 Technology is quickly becoming pervasive in the interaction between teens and their health. Texting is being used to reach out to teens, computer-based screens are being used to assess for high-risk behaviors, and studies show that teens respond to online or computer-based interventions.
561
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Tools to Manage Chronic Illness
Research on the use of technology to manage chronic illness in teens has mostly been limited to qualitative feasibility studies. Most studies show how technology improves knowledge about disease; a smaller number evaluate improvement of adherence or disease-based outcomes associated with a particular condition. Applebaum and colleagues,22 at the University of Chicago, performed surveys and focus groups with a small group of chronically ill teens and their parents in a pediatric university-based rheumatology practice and general pediatric practice. Several of the following themes emerged from the focus groups: Teens prefer appointment reminders by text, not e-mail, because they rarely check their inboxes. Online portals are acceptable as a means to store personal medical information and provide a forum for communication between patients and providers. Online portals should be presented in a fun, interactive, and customizable way. Teens in the study also wanted an easy way to retrieve medication lists, test results, and personal information with minimal data entry required. The patients in the study had chronic illness and felt uncomfortable searching the Internet on their own for information regarding their illnesses. They preferred to have their provider recommend reputable online sources; ideally sources that were interactive and provided easy-tounderstand information about their conditions and medications. Portable memory devices, such as thumb drives, for teens were discouraged because they are easily lost. Social media were acceptable as means to connect with other teens with similar conditions, but not as means to access information and communicate with providers, because this could affect the teens’ privacy. In addition, teens in the focus groups thought that they would not connect with other teens unless they had met them previously. Teens wanted peer-based support groups. Support groups are seen as a venue to share information and socialize with peers who understand what it means to have the same illness. The teens with chronic illness in the study did not want to engage with peers at their schools, because “They ask dumb questions and they do not understand.”22 Feasibility studies substantiate that texting to improve management and knowledge of chronic disease, such as type 1 diabetes and cystic fibrosis (CF), is acceptable. A small study using the Computerized Automated Reminder Diabetes System (CARDS) showed that teens are more likely to check their blood sugar if they are reminded by text rather than e-mail. However, response to texts waned after 3 months.23 In another study with young type 1 diabetic patients, Sweet Talk, a text messaging support system, sent text messages tailored to the individual. Messages from Sweet Talk included reminders to take medications and check blood sugars, provided lifestyle advice such as to eat healthily and exercise, and offered general newsletters and tips from other youth with diabetes. The Sweet Talk systems also allowed teens to text data and questions to their diabetes care teams. Patient messages were in several categories: blood glucose readings, diabetes questions, diabetes information, personal health administration, and social messages. The study did not find any associations with frequency of messaging and clinical or psychosocial outcomes.24 Although it is unclear whether texting improves clinical measures in diabetes, there is some indication that texting is a preferred method for reminders. Studies that addressed disease self-management, adherence to medication, and treatment in teens had mixed results. Many of the studies have small samples and few show improvement with adherence. A small, randomized controlled trial
Teens, Technology, and Health Care
using Your Way, an Internet-based program to improve self-management in adolescents with type 1 diabetes, found that Web-based interventions may improve self-management through enhancing problem-solving skills. Glycemic control as measured by hemoglobin A1c remained stable in the intervention group and worsened in the control group. The sample size was small and the data were analyzed as treated rather than as intent to treat.25 In a small feasibility, usability, and utility pilot study at Columbia University in New York, the use of CFFONE, a cell phone technology that is Web enabled, provides education about CF, and connects teens with CF through social networking, showed that it was considered somewhat helpful by teens and helpful by parents and adults. Future studies will examine whether the program improves adherence and health outcomes of teens with CF.26 In a systematic review of Internet and cell phone–based smoking cessation programs among adolescents, the Internet was found to be more effective when used as an adjunct to multiple approaches (counseling, group counseling, acupressure, medications) to cessation versus using the Internet alone. Most interventions had specific Web sites about smoking cessation (chat rooms, Web-based curricula and interventions).27 Research is showing that teens with chronic health conditions are knowledgeable consumers of health care technology. There are clear themes that are consistent across the studies. Teens want reliable and trustworthy sources of information regarding their illnesses, and to interact with their providers through online portals. Reminders regarding specific disease treatment plans are acceptable. Social media are acceptable, but must be used in a controlled setting and with peers who have the same condition. SEXUAL AND REPRODUCTIVE HEALTH
Use of technology by teens with regard to sexual and reproductive health has been studied more than other domains of teen health. Texting is an acceptable mode of communication regarding sexual health if it is anonymous, confidential, and the information is reliable and from a trusted source.28 There are several innovative ways in which text messaging is being used to promote adolescent sexual health, including: Providing health education. Offering medication reminders (eg, birth control pill reminders). Providing information about available health care services.28 Although studies have looked at many ways to provide this information, there are limited effectiveness studies that measure whether there is an improvement in sexual health outcomes as a result of the text messaging. With sensitive topics such as sexual health, youth have increased concern about privacy, especially when they are potentially accessing the Internet on a public versus private computer. Data from a few qualitative studies assessing the use of the Internet among HIV-positive youth supported the use of the Internet for social support and education. A qualitative study of HIV-positive youth in Ontario, Canada, used semistructured interviews to understand their perspectives on the use of the Internet as a tool to learn about living with HIV. Although these teenagers primarily used the Internet for social networking and entertainment, they acknowledged that a youthcentered, interactive Web site with confidential chat rooms and message boards would be acceptable to them for health information. Privacy was very important.29 Another qualitative study focusing on HIV-positive African American youth showed that using remote videoconferencing, when privacy was maintained in a secure
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location, was convenient, efficient, and had a positive impact on their knowledge. The effect of this program on CD4 count and viral load was not studied.30 Another promising use of technology with teens is to improve treatment of STIs. Two studies assessed the use of text messaging to decrease time to treatment of chlamydia. Although 1 study found that texting decreased the time to treatment compared with phone or clinic follow-up and that fewer staff hours were needed to do follow-up as a result,31 the other study found no difference between texting and regular followup.32 Both studies were small and neither was a randomized controlled trial, but these studies indicate that texting is at least as useful as traditional methods for follow-up on abnormal tests, and it has the potential to be better. As software becomes more sophisticated and electronic health records use patient portals it may be more costeffective and efficient to use technology to notify patients of results and to schedule follow-up.31 SUMMARY
Although in its nascency, research in teens and technology has come far in a short period of time. There are already emerging patterns in the literature. Teens prefer text messaging for communication. Computer-based screenings are acceptable to teens and helpful to providers to increase identification and interventions based on high-risk behaviors. Web sites that address specific domains of teen health care should be easy to use, youth centered, connected to an organization that is recommended by the provider, and trustworthy. Social media can play a role in teens and health, but should be connected to the teen’s personal experience with a group or organization that focuses on the teen’s specific condition (ie, other teens with the same condition). Technology and its role in chronic disease management, including improvement of disease parameters and adherence to medications, shows promise as an intervention. In a recent article in the Journal of Adolescent Health summarizing a conference that set a research agenda for the intersection of youth, technology, and new media with regard to sexual health, scientists and technology experts made key recommendations that included: Partner with established community-based organizations skilled in the use of technology to do research Petition local institutional review boards to include members with expertise in technology research Use theoretic models to understand why technology and social media interventions work Use technology in research from the onset Use technology and incentives to recruit large, diverse sample sizes Conduct research projects that focus on health outcomes with large sample sizes33 Experts agree that further research on teens and technology is critical. To date, studies have been small and imperfect. As a result it is difficult to extrapolate to the general population given that most studies are not considered high quality from an evidence-based perspective. The body of research on patient-oriented outcomes that matter to teens is limited, but it is the area that needs the most development along with studies with larger sample sizes and vigorous research protocols. Teens use technology more than any other demographic and future study using interventions that intersect with teens, technology, and their health is important.
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REFERENCES
1. Madden M, Lenhart A, Duggan M, et al. Teens and technology 2013. Washington, DC: Pew Internet & American Life Project; 2013. Available at: http://www. pewinternet.org/w/media//Files/Reports/2013/PIP_TeensandTechnology2013.pdf. Accessed January 27, 2014. 2. Lenhart A, Purcell K, Smith A, et al. Social media & mobile internet use among teens and young adults. Washington, DC: Pew Internet & American Life Project; 2010. Available at: http://www.pewinternet.org/w/media//Files/Reports/ 2010/PIP_Social_Media_and_Young_Adults_Report_Final_with_toplines.pdf. Accessed January 27, 2014. 3. Hansen DL, Derry HA, Resnick PJ, et al. Adolescents searching for health information on the Internet: an observational study. J Med Internet Res 2003;5(4):e25. 4. Chisolm DJ, Johnson LD, McAlearney AS. What makes teens start using and keep using health information web sites? A mixed model analysis of teens with chronic illnesses. Telemed J E Health 2011;17(5):324–8. 5. Dunlop SM, More E, Romer D. Where do youth learn about suicides on the internet, and what influence does this have on suicidal ideation? J Child Psychol Psychiatry 2011;52(10):1073–80. 6. Buhi ER, Daley EM, Oberne A, et al. Quality and accuracy of sexual health information web sites visited by young people. J Adolesc Health 2010;47(2): 206–8. 7. Meyer KL, Ahlers-Schmidt CR, Harris KR, et al. STI testing information available to teens on the internet: what’s missing? J Pediatr Adolesc Gynecol 2011;24(2): e17–9. 8. Lenhart A, Ling R, Campbell S, et al. Teens and mobile phones. Washington, DC: Pew Internet & American Life Project; 2010. Available at: http://pewinternet.org/ w/media//Files/Reports/2010/PIP-Teens-and-Mobile-2010-with-topline.pdf. Accessed January 27, 2014. 9. Levine D, McCright J, Dobkin L, et al. SEXINFO: a sexual health text messaging service for San Francisco youth. Am J Public Health 2008;98(3):393–5. 10. Carroll JA, Kirkpatrick RL. Impact of social media on adolescent behavioral health. Oakland (CA): California Adolescent Health Collaborative; 2001. Available at: http:// www.californiateenhealth.org/wp-content/uploads/2011/09/SocialMediaAug2011. pdf. Accessed March 26, 2014. 11. Cha´vez NR, Shearer LS, Rosenthal SL. Use of digital media technology for primary prevention of STIs/HIV in youth. J Pediatr Adolesc Gynecol 2013. pii:S1083-3188(13):00239–8. 12. Elster A, Kuznets N, editors. AMA guidelines for adolescent preventive services (GAPS): recommendations and rationale. Baltimore (MD): Williams & Wilkins; 1994. 13. Olson AL, Gaffney CA, Hedberg VA, et al. Use of inexpensive technology to enhance adolescent health screening and counseling. Arch Pediatr Adolesc Med 2009;163(2):172–7. 14. Hassan A, Fleegler EW. Using technology to improve adolescent healthcare. Curr Opin Pediatr 2010;22(4):412–7. 15. Mangunkusumo RT, Moorman PW, Van Den Berg-de Ruiter AE, et al. Internetadministered adolescent health questionnaires compared with a paper version in a randomized study. J Adolesc Health 2005;36(1):70.e1–6. 16. Mackenzie SL, Kurth AE, Spielberg F, et al. Patient and staff perspectives on the use of a computer counseling tool for HIV and sexually transmitted Infection risk reduction. J Adolesc Health 2007;40(6):572.e9–16.
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17. Watson PD, Denny SJ, Adair V. Adolescents’ perceptions of a health survey using multimedia computer-assisted self-administered interview. Aust N Z J Public Health 2001;25(6):520–4. 18. Stevens J, Kelleher KJ, Gardner W, et al. Trial of computerized screening for adolescent behavioral concerns. Pediatrics 2008;121(6):1099–105. 19. Lightfoot M, Comulada WS, Stover G. Computerized HIV preventive intervention for adolescents: indications of efficacy. Am J Public Health 2007;97(6):1027–30. 20. Saitz R, Palfai TP, Freedner N, et al. Screening and brief intervention online for college students: the ihealth study. Alcohol Alcohol 2007;42(1):28–36. 21. Hamel LM, Robbins LB, Wilbur J. Computer- and web-based interventions to increase preadolescent and adolescent physical activity: a systematic review. J Adv Nurs 2011;67(2):251–68. 22. Applebaum MA, Lawson EF, von Scheven E. Perception of transition readiness and preferences for use of technology in transition programs: teens’ ideas for the future. Int J Adolesc Med Health 2013;25(2):119–25. 23. Hanauer DA, Wentzell K, Laffel N, et al. Computerized automated reminder diabetes system (CARDS): e-mail and SMS cell phone text messaging reminders to support diabetes management. Diabetes Technol Ther 2009;11(2):99–106. 24. Franklin VL, Greene A, Waller A, et al. Patients’ engagement with “Sweet Talk” - a text messaging support system for young people with diabetes. J Med Internet Res 2008;10(2):e20. 25. Mulvaney SA, Rothman RL, Wallston KA, et al. An internet-based program to improve self-management in adolescents with type 1 diabetes. Diabetes Care 2010;33(3):602–4. 26. Marciel K, Saiman L, Quittel L, et al. Cell phone intervention to improve adherence: cystic fibrosis care team, patient, and parent perspectives. Pediatr Pulmonol 2010;45(2):157–64. 27. Mehta P, Sharma M. Internet and cell phone based smoking cessation programs among adolescents. Acta Didactica Napocensia 2010;3(4):11–24. 28. Malbon K, Romo D. Is it ok 2 txt? Reaching out to adolescents about sexual and reproductive health. Postgrad Med J 2013;89(1055):534–9. 29. Flicker S, Goldberg E, Read S, et al. HIV-positive youth’s perspectives on the Internet and e-health. J Med Internet Res 2004;6(3):e32. 30. Saberi P, Yuan P, John M, et al. A pilot study to engage and counsel HIV-positive African American youth via telehealth technology. AIDS Patient Care STDS 2013; 27(9):529–32. 31. Menon-Johansson AS, McNaught F, Mandalia S, et al. Texting decreases the time to treatment for genital Chlamydia trachomatis infection. Sex Transm Infect 2006; 82(1):49–51. 32. Lim EJ, Haar J, Morgan J. Can text messaging results reduce time to treatment of Chlamydia trachomatis? Sex Transm Infect 2008;84(7):563–4. 33. Allison S, Bauermeister JA, Bull S, et al. The intersection of youth, technology, and new media with sexual health: moving the research agenda forward. J Adolesc Health 2012;51(3):207–12.