Engaging Adolescents with Sexual Health Messaging: A Qualitative Analysis

Abstract

Purpose

Personalized and interactive text messaging interventions may increase participant engagement; yet, how to design messages that retain adolescent attention and positively affect sexual health behaviors remains unclear. The purpose of this study was to identify the characteristics of sexual health text messages perceived as engaging by sexually active adolescent females.

Methods

We conducted semi-structured, open-ended interviews with sexually active females aged 14–19 in one urban emergency department. Participants received automated sexual health information sent via an interactive, two-way texting format. The 343 messages viewed by participants were based on key stakeholder input, relevant theoretical models, and existing evidence-based guidelines. Interviews elicited feedback. Enrollment continued until saturation of themes. Interviews were recorded, transcribed, and coded based on thematic analysis using NVivo 10.

Results

Participants (n=31) were predominantly Hispanic (28;90%), insured (29;94%), and recently sexually active (24;77%). Themes were as follows: (1) Tone: Messages should be direct, factual, entertaining, and respect adolescent autonomy; messages should not be intrusive, presumptive or preachy. (2) Emotion evoked: Participants preferred messages that provoked thought, validated feelings, and empowered. Messages from a reliable source felt comforting, making participants feel cared for and special. (3) Interactivity: Participants favored messages that offered choices, like a mini-conversation. (4) Personalization: Messages should look similar to adolescent digital preferences but be individually tailored with relatable characters.

Conclusions

This study informs the tone, structure and style of sexual health text messages directed toward adolescent females in the emergency department. Future work should consider these characteristics when designing digital interventions to engage adolescent females.

INTRODUCTION

Nearly one in four women in the US become pregnant by age 20.¹ Despite pregnancy rate declines over several decades, adolescents living in poverty and of minority status disproportionally experience unplanned pregnancies, with birth rates among Hispanic and African American teens double that of White teens.² Geographic differences persist within and across states, and contraceptive access differs between rural, urban and suburban adolescents.² Innovative, effective pregnancy prevention strategies are thus needed.^3,4

Mobile health interventions have substantial potential to be a cost-effective and successful method for physicians to communicate with young adults.⁵ Young women send or receive an average of 3,339 text messages each month and are particularly amenable to text messaging to promote sexual health.^6,7 Text messaging can modify sexual health behaviors, such as adherence to oral contraception once initiated.⁸ However, results of prior trials using text messaging to increase contraceptive use among adolescents have shown inconsistent success.⁹

As digital technology expands into healthcare, further understanding of how to best design health messaging according to target populations preferences is needed in order to increase the success of digital interventions. New data suggest that the use of personalized, interactive, two-way messaging may be more likely to promote health behaviors among adolescents than older one-way messaging approaches.^10,11 Two-way interactive texts push information to a participant and then allows the user to actively choose a response based on their specific preferences and experiences. Such interactive texting exchanges can mirror elements of in-person counseling, such as tailored advice, goal setting, and feedback, thus creating a digital conversation.^12,13 Tailored messages are more likely to be read, understood, recalled, rated highly, and perceived as credible.^13,14 Yet, how to design such messages that attract and retain the attention of adolescents and motivate them to participate in healthy sexual behaviors remains unclear. Therefore, the objective of this study was to identify the characteristics of sexual health text messages perceived as engaging by sexually active adolescent female emergency department patients.

METHODS

Study Design

Using an observational qualitative research design, we conducted semi-structured interviews at an urban tertiary-care pediatric emergency department (ED) with 53,000 annual visits. The ED population is predominantly Hispanic, publicly insured, and of low socioeconomic status. The local Institutional Review Board approved the study with the requirement to obtain informed written consent or assent from the adolescent and a waiver of parental consent.

Study participants

We enrolled a convenience sample of sexually active female ED patients aged 14 through 19 years from June to August 2017. We excluded patients who were cognitively impaired, in foster care or wards of the state, did not speak English, were too ill for participation per the medical team, were pregnant, or did not own mobile phones.

Study Procedures

Participants completed a brief questionnaire regarding demographics, use of medical care and technology, sexual practices and behaviors, and pregnancy intentions. Survey questions were adapted from the Youth Risk Behavioral Surveillance System and the National Longitudinal Study of Adolescent to Adult Health, two national surveys with proven reliability and validity.^15,16 The investigators wrote and reviewed additional questions that did not undergo formal reliability and validity testing; however these questions were based on prior studies where they were pilot tested.^17,18 Then, interviews were conducted privately in the patient’s ED room. No other persons, such as partners or parents, were permitted to be present for the interview. Participants received a $10 gift card.

Text message development

Data for the text message curriculum came from: (1) key stakeholders (e.g. health educators and social workers); (2) formative quantitative and qualitative work; (3) national and state sexual health curricula; (4) evidence-based sexual education guidelines; and (5) an extensive literature review.^19–21 We chose constructs of Social Cognitive Theory (SCT) and techniques of Motivational Interviewing (MI) to incorporate into each text message.^22–24 These behavior change frameworks augment engagement and a sense of independence and have been associated with successful contraception promotion interventions.^23–25 Using these theories, approaches, and key stakeholder input, we developed a curriculum that aimed to increase contraception initiation, sexual health counseling, condom use, healthy dating relationships, and communication with an adult, as well as decrease intention for pregnancy. This led to 30 text message streams (a series of texts with branching logic based on keyword response), leading to a total of 343 text messages. [Figure 1] Three investigators evaluated each message to ensure it contained curriculum content and to ensure adherence to SCT and MI principles.

Figure 1.

Example of one text message stream, its performance objectives, and the relevant Social Cognitive Theory constructs and Motivational Interviewing techniques used.

Interviews

Two research team members were present at each interview. The interviewer followed the interview guide [Appendix A] which consisted of open and closed ended questions; the recorder took notes and sent real-time text messages from a laptop to a handheld tablet using the iMessage® app. Interviews began with a brief introduction as to the goals of the interview and then each participant was handed a tablet that presented sample text messages. The ED patient room was decorated with pillows and stuffed animals to create a space where the participant would imagine receiving text messages in the comfort of her own home.²⁶

Participants read aloud each text received, explained their immediate reactions, including positive and negative feedback. The interview guide contained probes focused on comprehensibility, content, personal relevance, and ability of the text to attract attention and inform or motivate change in their sexual behaviors. Participants were also asked how each text could be improved. Impressions of texts and suggestions for improvement were hand recorded on an excel spreadsheet. At least 2 participants reviewed each text. Interviews were audio recorded and transcribed by a HIPAA-compliant company.

Data Analysis

Four investigators (LC, AG, AK, MB) performed descriptive content analysis to identify the characteristics of engaging sexual health text messages.²⁷ The data analysis process began with these four investigators reviewing the data and generating initial codes after 10 interviews. Memos of coding decisions were retained to provide consistency as the coding progressed. The four investigators then reviewed each additional interview and edited the codebook based on the new data. Next codes were compared and synthesized. A codebook was developed that included shared coding categories and sub-categories, all with definitions, inclusion and exclusion criteria, and examples. Discrepancies were discussed until consensus was achieved and codes were applied to the data using NVivo 10. Investigators then reviewed data for overarching themes, and interviews continued until saturation of perspectives was reached. Subsequently, exemplary quotes were organized by theme and confirmed by all investigators. We conducted data validity procedures, including peer debriefing (review of the data and research process by someone familiar with the research, SB) and triangulation of sources (comparing people with different viewpoints).^27,28

RESULTS

We enrolled 31 participants [Appendix B]. Table 1 displays participant characteristics.

Table 1.

Characteristics of adolescent females participating in interviews (N=31)

Characteristic	N (%)
Age
14–15	4 (13)
16–17	17 (55)
18–19	10 (32)
Current school level
College	7 (23)
High school	19 (61)
Middle school	1 (3)
Not in school	4 (13)
Hispanic	28 (90)
Race
Black or African American	3 (10)
Native Hawaiian or Other Pacific Islander	2 (6)
White	1 (3)
Other	25 (81)
Decline to answer	2 (6)
US residence
1–3 years	1 (3)
4–6 years	0 (0)
Over 7 years	6 (19)
All her life	24 (78)
Insured	29 (94)
Has regular doctor or other source of healthcare	28 (90)
Current contraception user*	8 (26)
Contraceptive methods ever used
DMPA (Shot)	12 (39)
OCPs (Birth control pills)	11 (35)
Intrauterine device	3 (10)
Patch	3 (10)
Ring	2 (6)
Implant	1 (3)
Never used any of these types of contraception	7 (23)
Not sure	2 (6)
Age of sexual debut (years)**
12	1 (3)
13	2 (6)
14	4 (13)
15	9 (29)
16	6 (19)
17 or older	8 (26)
Number of lifetime sexual partners*
1	15 (48)
2	5 (16)
3	5 (16)
4	3 (10)
5	2 (6)
Condom use during sexual intercourse over past 3 months*
Every time	6 (19)
Most of the time	6 (19)
About half the time	3 (10)
Some of the time	9 (29)
None of the time	5 (16)
Has not had sexual intercourse during past 3 months	1 (3)
Want to get pregnant now
Very much want to be pregnant	1 (3)
Doesn’t care if gets pregnant	3 (10)
Very much does not want to be pregnant	27 (87)

^*Effective contraception was defined as the intrauterine or implantable device, oral contraception, patch, ring, or DMPA.

^**1 participant did not answer these questions.

1.0. TONE

1.1. Direct and factual

Participants preferred educational messages containing truths about birth control methods, explaining “every corner of it”. One 17-year-old intrauterine device (IUD) user explained the following, after being shown a text message about the vaginal contraceptive ring:

“It’s like good, like you don’t go around, you got straight to the point…most teenagers we understand more when you go straight to the point and not…sugarcoat things.”

Participants also explained a desire to understand the information, which became difficult when texts included sarcasm or slang. (e.g. “Cap. Baby baggie. Jimmy Hat, Rubber, Raincoat. Call a condom what you want but having one is key.”)

1.2. Not intrusive, presumptive, or preachy

Three types of texts were not preferred because of the way they were written. First, messages that assumed a relationship between the program and the participant were perceived as too forward. The text, “Today we see your bright future ahead of you. Can you?” led to the response-- “You don’t know me...” In one interview, when asked about the introduction, “Hey Gorgeous,” an 18-year-old prior OCP user exclaimed,

“I just wouldn’t feel comfortable because I don’t know you like that. If I know you and we talk, you’re my nurse, or whatever, and we talk on and on, I’ll understand. But if it’s just a new friendship I would feel weird.”

Second, some texts were perceived as intrusive because of the way they were written. For example, when shown the text “It’s Dr. E again. Hoping you had a great weekend. Did you have sex and use that condom?” a 19-year-old, current OCP user said, “It makes me feel awkward…I would ask, ‘Did you protect yourself?” Third, texts that gave advice about drugs and alcohol were considered “preachy”, such as “Before heading out, let’s set some goals for the weekend, do you plan on using drugs or alcohol this weekend?” Instead, participants preferred abstract messages. As a 19-year-old current IUD user explained, after being shown a text about drugs and alcohols,

“It’s kind of nosy. My age people would be like--why do you want to know that?... I feel like you guys should be more on the, just, like, ‘Stay safe, yeah be mindful what you’re doing’ because I feel like you guys are saying you already know what we are going to do.”

1.3. Respectful of autonomy and non-judgmental

Participants favored messages that were not coercive, respected their independence, and offered advice but did not tell them what to do. As one 19-year-old currently using no effective contraception explained when asked about starting birth control, “I would have to be the one to decide if I wanted to [start contraception] or not, because someone could tell me something, but, if I don’t want to, I won’t.”

1.4. A mix of formal and friendly

Participants wanted a voice that was friendly but also professional, likened to an “in-between friend.” Introductions that started with “Hey girl!” caused participants to smile, but texts like, “What’s up, buttercup?” were perceived as too congenial. They enjoyed texts that balanced humor with seriousness, as well as camaraderie with expertise. As one 17-year-old who currently used no effective contraception noted,

“I think it’s good because you are talking to a doctor…You want to keep the relationship a certain way but you also want to feel comfortable...Like you are keeping it professional but also in like a close relationship type.”

1.5. Entertaining

Participants preferred texts which were amusing, interesting, and “caught my [their] attention.” One 17-year-old using no contraception explained, “It can’t be like a conversation where’s its boring—not an actual like education class—have to find like little stories or something to get them into it.” Participants enjoyed texts, videos, memes, and graphics interchange formats (GIFs) that were funny and held their attention, especially those that “made me laugh when I was about to complain about being in the ER [emergency room].”

2.0. EMOTION EVOKED

2.1. Thought-provoking, validating, and empowering

Participants felt inspired when a message asked them to reflect upon their current life and contemplate their future. For example, texts such as, “Its Friday! Can you see your bright future ahead of you? Let’s try this-- take 15 seconds and picture your life next year. Are you ready? Type OK.” led to the following reaction:

“I like this one…We don’t sit here and think about our future. It’s always just in the moment…it makes you think about birth control. What if something accidentally happens, and I am not on birth control?” – 17-year-old prior ring, OCPs, and depot medroxyprogesterone acetate (DMPA) user

Messages also asked participants to think about how they envisioned the perfect partner, such as “Let’s try something— Imagine your life 10 years from now. How do you imagine your partner? What do they look like? What kind of job do they have?” In reading these texts aloud, certain participants felt validated that their relationships were “healthy” and nodded their heads in agreement. Other participants felt empowered by texts that dispelled the myth that women do not buy condoms, saying “I think it will make a girl realize that they don’t really have to be afraid about doing it and that it is okay.” Overall, there was a fondness for introspective, open-ended messages, described by one 19-year-old as: “It’s on point. It asks you the questions, shows you the link, makes you think, so its spot on.”

2.2. Making them feel cared for and special

Such introspective, open-ended texts also caused participants to feel like the program “cared” about them “and they would rather me be more protected, instead of not out here getting pregnant.” One 14-year-old, who had tried OCPs and DMPA, was shown the text, “Think about your goals. How do you do in school? Who are your friends? Is there an activity that makes you happy? Now think of your vision of your life with a baby,” and reacted as follows:

“The text is good…Because it’s like asking me questions, so it’s making me think and making me interested…. Because you guys are actually asking how I feel and stuff…. [it makes me feel] special and interesting.”

Participants also discussed feeling isolated but how a sexual health texting program can fill that void. As a 17-year-old prior OCP user explained, “Because like when you are a teenager sometimes they feel alone, and don’t know who to talk to, so it’s like I could text you guys in the weekend and would give me advice or talk about it.”

2.3. Increasing comfort because information is from a trusted, reliable source

Participants trusted medical professionals as a “valid” and “reliable” source of information: “I personally would trust it because I signed up for it, so I know who will be texting me. It isn’t somebody unknown sending me unknown false information.” Often the program was compared with school-based sexual health education.

“Its [the texting program] like talking to a friend. Mostly, like, when you’re in school, in like lunch or gym whatever, and you have nobody else to talk to, doing this is better than health class in school…Because you can talk to your health teacher and they’re not going to talk to you like this. They’re going to read something off the textbooks or something.”- 17-year-old prior OCP user

3.0. INTERACTIVITY

3.1. Similar to active dialogue

Texts felt like a “mini-conversation” by asking for responses, much like non-automated, active dialogue. Using emojis to reply, or incorporating a participant’s nickname, increased interest in the texts that followed. One 19-year-old contraceptive non-user appreciated setting the pace of conversation with the automated system:

“I feel more comfortable maybe because it is on my phone and I can read the message, understand it, and then give you a response…I could think about stuff, not have a person staring at me, waiting for me to respond.”

Nevertheless, some participants also voiced a preference for live conversation, and an ability to not only ask questions in real time but respond with long answers.

“Because if it was just a computer, it would be dry, like, it wouldn’t be entertaining to no one…I would just ignore it. But it’s, like, when I know it’s another person talking to me, okay, they could probably help me with another question.” −17-year-old IUD user

3.2. Offering choices

Participants wanted to learn how different types of birth control methods will affect them, as they appreciated how “not ever,y method is for everyone.” They also preferred messages that respected their past sexual history and often did not want to be forced to read about methods which had not worked for them in the past.

4.0. PERSONALIZATION

4.1. Tailored by individual characteristics

Messages tailored to a participant’s personal interest, such as “anime” or “food,” were felt to be more engaging that those that felt generic. Additionally, despite wanting texts to feel private, and appreciating all participants will have a different “comfort zone,” participants often voiced an interest in having their names in messages because it led to trust in the sender. One 17-year-old IUD user explained—”Like, if I see a message that has my name on it, I would think it’s either someone that knows me…but, if it’s not addressed to me, it can be from anybody.” Incorporating personal information into the text, (“if you know my Instagram [name] then you kind of know [me]”), made them feel the texts were “directly toward me, not just automated.” As a 17-year-old prior OCP and DMPA user explained,

“I think that you, like, show them that you know a little bit of information about them, they will think that it’s personal. So, it’s not just a scam because they know things that others don’t know.”

4.2. Showing relatable characters

The majority of the text message algorithms ended with a link to a specific website, GIF, or video testimonial; the most important attribute of these digital graphics was that the main character or celebrity was relatable. Characters born in a similar location or talked “how we talk” resonated with participants because these characters felt local. Testimonials about experiences with contraceptives were favored when characters were “straight up” and shared their struggles with a method, such as how one might “remember to take them [OCPs].”

Lastly, participants were asked to envision who was sending them these texts. Bitmojis were popular as a way to put a face to the program. Participants described wanting a female physician who often matched their own race and ethnicity, with brown hair and white lab coat. One 17-year-old non-contraceptive user described her vision of how bitmojis could interact—

“It would be cool if it was, like, you know how they asked the person’s race…the bitmoji could be, like, if it was Hispanic, like curly hair like light skin color and stuff…and then like how Snapchat could do, like, the bitmoji…hugging each other.”

4.3. Presenting information in a way that is similar to their digital preferences

Text messaging was ubiquitously favored as a “pretty dope” way to communicate with friends, family, and a doctor. With each participant texting “100” to “1000” times a day, and one even labeled as a “texting queen,” there was a desire for the program to look similar to their texts with their friends, such as using “emojis that go with the text,” and “funny memes.” For most, especially those who “cannot even text without emojis,” emojis “make the conversation better and not boring,” as well as less robotic. However, the emojis had to have the “right fit” with the tone of the text and be intentional, as a way to “lighten the conversation.”

DISCUSSION

In this qualitative analysis of predominantly Hispanic adolescent females, we discovered that sexual health messages that feel personal and evoke a sense of emotion leads to individual introspection and empowerment. Adolescent females trusted facts coming from a medical provider that were straightforward, not presumptive, and respectful of autonomy. Popular texts mirrored a digital style similar to typical adolescent texting behaviors. Furthermore, incorporating personal attributes and relatable characters into the texts increased not only participant attention but also amplified the intended lesson of the message.

Along with these preferences, our data highlight three areas to consider in designing future sexual health messaging interventions. First, our findings highlight differences between private and privacy. Adolescent females feel comfortable receiving sexual health information via mobile technology, interpreting such communication as confidential; however, in our study, when texts asked for responses to direct, sensitive questions, such as recent condom use, we found that participants felt uncomfortable disclosing that information.^18,29–31 Sharing of their sexual health information via text message led to unease and a possible risk to privacy, despite participants welcoming generic texts urging the use of the condom. This finding contrasts with other texting interventions, such as those that promote alcohol use cessation by goal setting.³² Goal setting for sexual health situations, such as condom use, seems to be too intrusive. Given the emergence of sexual feelings and identity development during adolescence, direct questions about sexual activity using text messaging may cross a line, leading toward immediate discomfort and non-responsiveness.³³

The second area to consider is the preferred voice of the intervention. Rather than favoring one particular character sending the text messages, we found that participants desired the balanced voice of both a professional and friend. Future sexual health interventions might consider involving more than one character in the intervention—one that maintains the reliable doctor role while another fills the role of the relatable friend. For example, the incorporation of video testimonials, comic cartoons, and links to reliable websites can each have a unique voice, a role one particular “texter” cannot achieve.

The third area to consider is how to augment a digital intervention to respond to real-time questions from adolescents. Automated interventions allow for reproducibility and scalability; however, adolescents are interested in live chat or live texting sexual health programs, as seen in this study and prior literature.³⁴ For example, a national chat and live texting program in existence since 2010 has conducted more than 1,000,000 sexual and reproductive health conversations with users.³⁴ Either incorporating or creating such live programs can enhance the potential of mobile health interventions because they can address the questions of each individual and deliver an intervention when and where it is most needed. Just-in-time adaptive interventions (JITAIs), which are interventions with explicit decision rules for when to prompt users with specific intervention components (e.g. prompt a person to buy condoms when their GPS alerts their location to be in a pharmacy), hold promise to change health behaviors.³⁵

Study limitations include that our population was a convenience sample and predominantly Hispanic; however, Hispanic adolescents are among the largest users of text messaging and show disproportionately higher rates of unintended teen pregnancy than other ethnicities.² Also, we interviewed participants regarding texts being received by a tablet in the ED rather than their own phone in their daily lives, possibly affecting their perceptions and opinions. Lastly, recruiting from one ED may limit generalizability, including to non-urban, not sexually active, or male adolescent populations or other clinical settings.

Conclusion

This study details the characteristics of text messages containing sexual and reproductive health information that are preferred by adolescent females. The data presented inform the content, tone, structure, and style for the design of digital messages directed toward adolescent females. Adolescent females in this study preferred personalized and interactive messages that evoked emotion, respected autonomy, and were a mix of friendly and formal. Future ED-based interventions for sexually active adolescent females should consider these preferences in order to increase adolescent engagement and responsiveness.

Supplementary Material

1

Appendix A. Semi-structured Interview Guide

2

Appendix B. Flow diagram of enrollment.

Implications and Contribution.

This study identifies the characteristics of sexual health text messages perceived as engaging by adolescent females. Digital interventions with messaging that attract and retain adolescent attention may motivate them to participate in healthy sexual behaviors.

Abbreviations

ED

emergency department

ER

emergency room

SCT

social cognitive theory

MI

motivational interviewing

IUD

intrauterine device

OCP

oral contraceptive pill

DMPA

depot medroxyprogesterone acetate

GIF

graphics interchange format

JITAIs

just-in-time adaptive interventions