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Service Delivery Innovation Profile

Text Messaging Program Increases Awareness and Concern About Sexually Transmitted Diseases Among At-Risk Youth, Particularly African Americans


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Snapshot

Summary

Developed to address rising rates of sexually transmitted diseases among at-risk youth in San Francisco, SexInfo provided free basic information and referrals for inperson health consultations via an opt-in text messaging service. The program also provided a companion Web site where parents and other interested parties could see sample messages online. SexInfo continues to operate, but using a different model of weekly subscriptions to text message tips and advice. The program has enhanced access to information and referrals and increased awareness and concern about sexually transmitted diseases, particularly among African Americans.

Evidence Rating (What is this?)

Suggestive: The preliminary evidence consists of post-implementation data on service utilization, as well as surveys of patients at three clinics to which SexInfo most commonly offers referrals.
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Developing Organizations

Internet Sexuality Information Services, Inc. (ISIS-Inc.); San Francisco Department of Public Health
Information provided in June 2013 indicates that ISIS-Inc. is now doing business as YTH (youth+tech+health).end do

Use By Other Organizations

  • Since launching SexINFO in 2006, ISIS-Inc (now doing business as YTH) has provided strategic direction on program adoption to Metro Teen AIDS in Washington, DC, California Family Health Council, Oregon Health Authority, Planned Parenthood NYC, Arizona Family Planning Council and many others.

Date First Implemented

2006
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Patient Population

Age > Adolescent (13-18 years); Race and Ethnicity > Black or african americanend pp

Problem Addressed

Rates of sexually transmitted diseases (STDs) are on the rise among youth in the United States. In San Francisco, African Americans between the ages of 15 and 19 years face particularly high risks.
  • High rates among youth and minorities: STDs disproportionately affect adolescents, young adults, and minorities. Although 15- to 24-year-olds represent only one-fourth of the sexually active population, they account for nearly one-half of all new STDs each year.1 African Americans make up only 12 percent of the total U.S. population but account for approximately 70 percent of all gonorrhea and almost one-half of all chlamydia and syphilis cases in 2007.2
  • More barriers to testing and treatment: Sexually active teenagers often are reluctant to obtain STD services and/or may face serious obstacles when trying to obtain them. In addition, health care providers often feel uncomfortable discussing sexuality and risk reduction with patients, thus missing opportunities to counsel and screen young people for STDs.3
  • A growing local concern: In San Francisco, the number of cases of gonorrhea in African-American youths between the ages of 15 and 19 years increased by more than 100 percent in 2005, to 45 cases.4

What They Did

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Description of the Innovative Activity

SexInfo is a sexual health text-messaging program that provided free basic information on STDs and referrals for inperson health consultations to youth in San Francisco. Developed to address rising rates of STDs among at-risk teenagers, the program also provided a companion Web site where parents and other interested parties could see sample messages online. SexInfo continues to operate, but using a different model of weekly subscriptions to text message tips and advice. Key elements of the program included the following:
  • Free, opt-in text-messaging service: Youth wishing to access the service text the word, "SEXINFO," to a five-digit number. The service is confidential, and users remain anonymous. Resources were provided as follows:
    • Phone tree: Users received a phone tree consisting of four prompts regarding sexual health and behaviors, each with a corresponding code users could enter to retrieve more information. Prompts included the following:
      • Txt '1' if ur condom broke
      • Txt '3' if s/he's cheating on u
      • Txt '5' for STD info
      • Txt '6' if ur not sure u want 2 have sex
    • Automated responses, with information and referrals: Upon entering a code, users received an automated response message of up to 160 characters in length. Each response offered basic STD and/or HIV information and a referral to one of several teen-friendly clinics for inperson consultation. The system did not provide any diagnoses.
  • Companion Web site: A companion Web site (see References/Related Articles) served parents and others interested in learning more about the SexInfo service. Intended to provide transparent information for parents who may have concerns or questions about the service, the Web site listed all available prompts and automated responses, offered a blog of new developments and outreach campaigns related to the program, and provided contact information for the program's developing agencies. The site also featured basic sexual health information for youth, including links to the Web sites of referral clinics. (A modified version of the Web site is still in operation.)
  • Outreach and education: The SexInfo program periodically conducted a number of outreach campaigns, including bus shelter ads, posters, and palm cards placed in strategic locations in neighborhoods heavily populated by African-American youths. The program worked through the media; for example, banner ads were run on a popular online search engine for 2 weeks, and a media press release was featured in local and national news publications, including the San Francisco Chronicle and USA Today. The program also produced a public service announcement for television featuring a popular rap musician, Mistah F.A.B. This video was broadcast locally on Black Entertainment Television and MTV and can now be seen on YouTube and the SexInfo companion Web site.
  • Weekly subscription: After 2 years, the program was switched to a weekly subscription model of text message tips and healthy living advice for youth of color in California (Hookup) to reduce costs associated with long-term marketing efforts.

Context of the Innovation

SexInfo is the result of a collaboration between the San Francisco Department of Public Health and Internet Sexuality Information Services, Inc. (ISIS-Inc.), a nonprofit organization in San Francisco dedicated to developing technology for the promotion of sexual health and healthy relationships and the prevention of disease transmission; information provided in June 2013 indicates that ISIS-Inc. is now doing business as YTH (youth+tech+health). ISIS-Inc. and the San Francisco Department of Public Health have worked in partnership since 2001, with the Department of Public Health identifying epidemiological needs and ISIS-Inc. developing interventions to address those needs. In 2005, the department approached ISIS-Inc. to develop a project to address rising rates of STDs among at-risk youth in San Francisco. ISIS-Inc. staff noted the growing popularity of mobile phone use among adolescents and young adults for both calling and texting and developed SexInfo as a way to mobilize that popularity into a health awareness and disease prevention tool.

Did It Work?

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Results

Post-implementation data, including usage figures and patient surveys, suggest that SexInfo has enhanced access to information and referrals and increased awareness and concern about STDs, particularly among African Americans.
  • High usage rates: During its first 25 weeks of service, the program received more than 4,500 inquiries, 2,500 of which resulted in the provision of information and/or a referral. The service remained popular, receiving 7,262 inquiries between October 2007 and April 2009, 84 percent of which resulted in an individual being given access to information and referrals. Further analysis showed that usage spikes were directly related to marketing and outreach efforts, prompting the program to modify their model to reduce marketing costs (updated June 2013).
  • Greater awareness, particularly among African Americans: The San Francisco Department of Public Health conducted an anonymous survey of 322 patients between the ages of 12 and 24 years in three clinics to which SexInfo users were most commonly referred. Eleven percent of those surveyed reported awareness of the SexInfo service, with African-American youths being more likely to be aware of it than those of all other races (16 vs. 9 percent).
  • Increased concern about STDs: An additional survey of 214 youth between the ages of 12 and 24 years conducted at 10 San Francisco community locations found that those who had seen SexInfo's outreach campaign were more likely to report being concerned about STDs, with 79 percent indicating extreme concern. Of those who saw the campaign, nearly 10 percent sent a text message to the SexInfo service. Ninety-three percent of those who reported awareness of the campaign were African American.

Evidence Rating (What is this?)

Suggestive: The preliminary evidence consists of post-implementation data on service utilization, as well as surveys of patients at three clinics to which SexInfo most commonly offers referrals.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Forming advisory board: ISIS-Inc. and the San Francisco Department of Public Health identified key representatives from community organizations (e.g., staff from high school health programs and clinics serving African-American youth, juvenile probation officers, and local clergy) to serve on an advisory board. The advisory board met regularly to provide guidance to staff during SexInfo's development and continued to play a consultative role after the program's launch.
  • Holding focus groups: Program leaders held four focus groups of African-American youths to discuss their sexual health information needs and preferences, as well as to gauge the feasibility of the program. Focus group members were enthusiastic about using text messaging as a tool to access information but stressed the importance of making the service "opt-in" (meaning that users could control the type of information they received and when they received it).
  • Developing message content: Health educators at ISIS-Inc. used information from the focus group sessions to develop content for SexInfo's automated scripts, including a list of key questions that youth commonly ask about their sexual health. They used these questions to create 11 text message prompts, each no longer than 160 characters. The Department of Public Health medically vetted all prompts before the program's launch.
  • Identifying referral sites: With help from the advisory board, ISIS-Inc. staff identified youth-oriented clinics and community organizations where young people accessing the SexInfo service could be referred for free, confidential sexual health services. Staff and teens then visited the clinics to make sure they were youth-friendly.
  • Establishing technology: ISIS-Inc. worked with a mobile marketing firm to develop the messaging service and ensure confidentiality for users. Working through an aggregator, ISIS-Inc. and the marketing firm then obtained a short code (the number users enter to access the service).
  • Developing outreach materials: ISIS-Inc. worked with Youth United Through Health Education, a program of the San Francisco Department of Public Health, to develop and test outreach materials.
  • Conducting usability test and refining service: After the launch of the program, ISIS-Inc. received support from the Full Circle Fund, a San Francisco area philanthropy organization, to conduct a usability test. Students from the Youth United Through Health Education program, accompanied by a professional market researcher, went into the streets to interview and videotape youths using the SexInfo service. They found that roughly one-half of users had difficulty accessing the service and navigating the phone tree's menu of options. As a result, ISIS-Inc. narrowed the number of possible prompts from 11 to 4.
  • Switching to a weekly subscription service: After the service had been running for 2 years, it was clear that usage spikes in the campaign were directly related to marketing and outreach efforts. Without continued marketing and outreach efforts, usage dipped to significant lows. The program was then switched to a weekly subscription model of text message tips and healthy living advice for youth of color in California (Hookup) to reduce costs associated with long-term marketing efforts.

Resources Used and Skills Needed

  • Staffing: Three existing full-time ISIS-Inc. staff worked on the planning and implementation stages of the SexInfo program. Currently, maintenance of the service, including managing data and updating/distributing materials, requires approximately 10 percent of one full-time staff member's time.
  • Costs: The service cost $20,000 to develop, while initial marketing and evaluation ran an additional $15,000. Ongoing maintenance costs average $500 per month for the weekly subscription program.
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Funding Sources

San Francisco Department of Public Health; Full Circle Fund
The San Francisco Department of Public Health is the primary funder for the SexInfo service. The Full Circle Fund provided additional grant money during the program's second year of operation.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Evaluate appropriateness of text messaging to program goals: Because text messages can contain no more than 160 characters, including spaces, they are best suited for delivery of succinct packages of information. Programs considering adding a text message component to communicate with participants or patients must evaluate their goals to determine whether they can be met within this format.
  • Build on what works: Consider using text messaging as a motivating tool to support ongoing prevention and treatment activities that are working. For instance, SexInfo uses text messages to mobilize teenagers to get tested for STDs, so as to help prevent the spread of disease.
  • Form partnerships: Collaborate with local stakeholders and experts to help inform, guide, and support the program.

Sustaining This Innovation

  • Conduct ongoing marketing: To remain visible within the target community, stay in touch with current trends among adolescents and young adults, and concentrate marketing efforts within those areas.
  • Keep up with technology: Regularly survey the target population to identify how and why they use technology. Responding to patterns and trends identified in these surveys can help to keep the program fresh and relevant. For the SexInfo service, ISIS-Inc. surveys teens every 6 months to determine what mobile phones and carriers they use and how they use their phones.

Use By Other Organizations

  • Since launching SexINFO in 2006, ISIS-Inc (now doing business as YTH) has provided strategic direction on program adoption to Metro Teen AIDS in Washington, DC, California Family Health Council, Oregon Health Authority, Planned Parenthood NYC, Arizona Family Planning Council and many others.

More Information

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Contact the Innovator

Deborah Levine, MA
Executive Director and Founder
YTH
409 13th Street, 14th Floor
Oakland, CA 94612-2607
Phone: (510) 835-9400
Fax: (510) 835-9402
E-mail: deb@yth.org

Innovator Disclosures

Ms. Levine reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

References/Related Articles

The SexInfo companion Web site, featuring the program's televised public service announcement, is available at http://www.sextextsf.org/.

More information about Youth + Tech + Health (formerly Internet Sexuality Information Services, Inc. or ISIS-Inc.) is available at http://yth.org/.

Levine D, McCright J, Dobkin L, et al. SexINFO: A text messaging service for San Francisco youth. Am J Public Health. 2008;98(3):393–5. [PubMed]

Perry RC, Kayekjian KC, Braun RA, et al. Adolescents' perspectives on the use of a text messaging service for preventive sexual health promotion. J Adolesc Health. 2012;51(3):220-5. [PubMed]

Footnotes

1 National Prevention Information Network. STDs Today Web site. Available at: http://www.cdcnpin.org/scripts/std/std.asp
2 Centers for Disease Control and Prevention. Sexually transmitted diseases surveillance, 2007. Available at: http://www.cdc.gov/std/stats07/default.htm
3 U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health, 2nd ed. Washington, DC: U.S. Government Printing Office; November 2000. Available at: http://www.healthypeople.gov/2010/document/pdf/uih/2010uih.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
4 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. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 09, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 16, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.