Young Men’s Preferences for Sexually Transmitted Disease and Reproductive Health Services in San Francisco, California

Abstract

We explored STD service preferences among 108 African-American adolescent males recruited from a high morbidity neighborhood. Participants largely preferred to seek care at traditional STD testing venues (86.5%) rather than non-traditional venues. Additionally, most males preferred receiving STD test results from a clinician (61.1%) rather than online (11.1%) or through email or text message (12.0%). These results highlight the need for continued strengthening of traditional public health clinics to ensure capacity to meet young men’s health needs and to improve outreach and access to traditional STD services for young men.

Although African-Americans account for a disproportionate percentage of sexually-transmitted diseases (STD) and HIV/AIDS cases in the United States ¹, relatively little is known about the sexual health attitudes and service preferences of young African-American males. In order to aid local program planning and intervention development for this population, including planning for STD screening at alternative venues, we conducted a street-based intercept survey (the Viewpoints project) to assess preferences for services among young African-American men in a high STD-morbidity neighborhood of San Francisco. The study neighborhoods have the highest adolescent rate of gonorrhea in San Francisco, the second highest adolescent chlamydia rate in the city.² The area is characterized by high rates of poverty, crime and unemployment:³ 22.6% of families fall below the poverty level, compared to 9.2% nationally.⁴

All Viewpoints participants were recruited in the southeast section of the city in June and July of 2010 and were eligible to participate if they were men who self-identified as residents of San Francisco, were African-American, and 15–24 years of age. We approximated a representative sample by mapping 13 recruitment routes that geographically covered the study target area, including both commercial and residential areas of the community (e.g. housing developments). Outreach workers walked these routes in the afternoon hours, systematically approaching all available young men, administering a brief eligibility checklist before acquiring verbal consent to participate. Participants self-administered a structured questionnaire on iPod Touch devices. Survey questions included socio-demographics, sexual behaviors, and preferences for STD service provision, including preference for venue, sample collection method, receipt of results, and partner notification services. Those completing the survey were offered a $10 dollar gift card; those who chose not to participate were asked the reason for refusal. The study protocol was approved by the Committee for Human Research (CHR) at the University of California, San Francisco.

The team approached 193 potential subjects, of whom 34 subjects refused intercept (did not stop) and an additional 28 did not meet eligibility requirements. Among 131 screened and eligible men, 112 completed the survey. However, one survey was not saved correctly on the device and 3 participants provided ineligible ages on the survey and were therefore not included in this analysis, leaving 108 (82.4% of eligible) participants completing the interview.

Most participants were between 15 and 21 years old, and two-thirds were currently in school (Table 1). Nearly a quarter (26.9%) described their families as “Barely making ends meet” or “Poor and struggling.” About 4% of the Viewpoints participants reported male sex partners, and the mean age at first sex was 13.3 years old (range: 6–23 years of age). Two-thirds of participants reported ever having been HIV tested, 73.2% reported ever having had an STD test, and 57.4% of participants reported being tested for an STD in the past year. Forty-two percent of Viewpoints respondents reported they were “Very” concerned about STDs. However, only 11.1% described their STD risk as “High,” and nearly a third of interviewed males said they had no risk for STDs.

Table 1.

Demographics, Sexual Health History, Testing Knowledge and Preferences of Viewpoints Participants

	n (%)
Total	108
Age
15–17	42 (38.9)
18–21	50 (46.3)
22–24	16 (14.8)
Currently in School	72 (66.7)
Socioeconomic Status
Poor and struggling/Barely making ends meet	29 (26.9)
Making it	69 (63.9)
Well Off	10 (9.3)
Gender of Sex Partners
Only Men	1 (1.0)
Only Women	92 (85.2)
Both Men and Women	3 (2.8)
Not Sexually Active	12 (11.1)
Age at First Sex (Mean/Median)	13.3/13.0
Ever Tested for HIV	72 (66.7)
Ever Tested for STDs	79 (73.2)
STD Test in Past year	62 (57.4)
Will be tested for an STD in next year	79 (73.2)
Would get tested if had a symptom	96 (88.9)
Would get tested if told partner had STD symptoms	100 (92.6)
Would get tested if told partner had STD	97 (89.8)
Would get tested if friend asked to go along	81 (75.0)
Level of concern about STDs
Very	45 (41.7)
Pretty	15 (13.9)
Relatively	18 (16.7)
Little	17 (15.7)
Not concerned at all	13 (12.0)
Perceived level of STD risk
No risk	34 (31.5)
Low risk	62 (57.4)
High risk	12 (11.1)
Preference for STD testing venue*
Traditional venue only	90 (86.5)
Either traditional or non-traditional venue	5 (4.8)
Non-traditional venue only	9 (8.7)
Urine collection preference
At clinic	47 (43.5)
At home	34 (31.5)
Either clinic or home	25 (23.2)
Would not do	2 (1.9)
Urine Drop off preference
At clinic	64 (59.3)
At lab	19 (17.6)
At pharmacy	16 (14.8)
At school	7 (6.5)
Would not do	2 (1.9)
Results preference
Clinic	66 (61.1)
Online/Website	12 (11.1)
Text or Email	13 (12.0)
Telephone	8 (7.4)
Letter	3 (2.8)
Would not do	6 (5.6)

^*Traditional Venues include general clinics, Men’s clinics, or STD Clinics. Non-traditional Venues include pharmacy, work, school, or store. A total of 104 respondents mentioned a preference in venue type. Two respondents said they would not get tested and two responses were missing for this question.

Male participants overwhelmingly reported that they would prefer to seek care at traditional clinical sites (86.5%), including general clinic or specialty clinics such as STD or men’s clinics, while a much smaller percentage would seek services only at non-traditional sites (8.7%), such as a pharmacies, stores, schools, or work. Just under 5% would go to either a traditional or a nontraditional venue. Of those that had been tested for an STD, most (63.9%) were last tested in a traditional medical setting. Participants were also asked about their preferences for collection and drop-off of urine samples for STD testing: 43.5% preferred to collect urine at a clinic and 31.5% at home. If they could drop of specimens for testing, most respondents preferred to drop off urine specimens directly at the clinic (59.3%). Of note, most (61.1%) participants preferred to receive STD results at a clinic visit, with only 11.1% preferring online test results and another 12.0% preferring text message or email results.

While others have found that young men underutilize clinical and public health resources^{5, 6, 7}, many of the Viewpoints participants have been tested and expressed interest in future testing. The vast majority (73.2%) said they would be tested for an STD in the coming year, and an even larger proportion (88.9%) would get tested if they had an STD symptom. This finding has implications regarding young men’s motivations for going to STD clinics, indicating that their use of clinical services may be in response to a current STD more often than a preventive measure. The young men participating in the Viewpoints study also appeared to be responsive to members of their social and sexual networks: 92.6% would get tested if their partner had STD symptoms, 89.8% would get tested if their partner reported having an STD, and 75.0% would get tested if a friend asked them to go with them for an STD test.

Our findings regarding venue preference are similar to a number of other studies of young, urban African-American men ^8–11, in which men reported strong preferences for traditional testing venues and face-to-face contact with clinicians. Together these studies highlight the importance of maintaining traditional venues, modes of STD testing, and STD result dissemination among young minority men. At the same time, providing a range of STD testing options is likely productive, with some studies also demonstrating that, despite a resounding preference for traditional testing sites, many at-risk young men are still open to community venues as possible alternatives⁸ as well as receipt of home testing kits.^{12, 13}

In addition, while young men in our study preferred to receive STD test results from a clinician as opposed to on-line or through text messaging, alternative uses of social media merit more exploration. Studies have demonstrated positive responses to new media services from both male and female youth ^14–16. One such effort was SEXINFO, a sexual health text messaging service developed by the San Francisco Department of Public Health in response to rising gonorrhea rates among African-American youth. An evaluation of this service noted positive responses among both male and female youth to the possible incorporation of new media and technologies (such as alternative STD screening models) into existing public health service provision ¹⁴. Another study ¹⁶ exploring reception to a web-based test results system at an urban STD clinic among patients from diverse ethnic and racial backgrounds showed that as many as 74% of both young men and women used this method of obtaining results. However, the Viewpoints study showed that few African-American males in this setting preferred receiving test results through web-based systems. This finding signals a need to be cognizant of differences in preferences and a need to continue to identify local preferences as services evolve in order to address the needs and preferences of local youth. The Viewpoints study provides some critical data regarding preferences for STD related services in an understudied population, however, there are limitations to the study. The results may not be representative of all young males in the catchment neighborhood and may not be generalizable to other areas. At the same time, efforts were made to survey men systematically in both residential and commercial areas. The relatively small number of respondents prevented more complex analysis of the data, such as stratified analysis or multivariate modeling. Furthermore, our data measure only intentions and preferences and not actual behaviors. The population examined in Viewpoints may have little experience with newer modes of services such as internet based testing and self-collection of specimens and as a result may prefer more traditional services. It is possible that with more education and exposure to these modalities, the young men we surveyed may have a change in attitude and preference. Study strengths include the survey being self-administered and anonoymous, on an easy to use and attractive Ipod touch device, which may increase the likelihood of accurate reporting of sensitive information ¹⁷.

In sum, a combination approach that maintains the infrastructure of more traditional clinic-based STD services with the addition of innovative new media based prevention options is likely to be most effective in reaching high-risk adolescents. The San Francisco Department of Public Health is using the results of this project to improve messaging around service availability in traditional clinical sites. Plans for the use of new media, as well as community-based screening projects in this community of young African-American males, are being re-evaluated in light of the preferences indicated by the study participants. Evaluation of alternative screening and messaging approaches should continue, however, clinic-based services remain the cornerstone of youth prevention and merit continued support and improvement.