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. Author manuscript; available in PMC: 2020 Aug 7.
Published in final edited form as: Int J Prison Health. 2019 Aug 20;16(1):38–44. doi: 10.1108/IJPH-01-2019-0002

Justice-involved women’s preferences for an internet-based Sexual Health Empowerment curriculum

Michelle L Pickett 1, Joi Wickliffe 2, Amanda Emerson 3, Sharla Smith 4, Megha Ramaswamy 5
PMCID: PMC7412955  NIHMSID: NIHMS1607036  PMID: 32040270

Abstract

Purpose –

The purpose of this paper is to gain insight into justice-involved women’s preferences for an internet-based Sexual Health Empowerment (SHE) curriculum.

Design/methodology/approach –

The authors analyzed data from four focus groups conducted with 52 women in a minimum-security county jail in a Midwestern US city.

Findings –

Women reported daily access to the internet while in the community and use of the internet for searching about health concerns. Four themes emerged in the discussion about preferences for an internet-based SHE curriculum, that it cover healthy sexual expression, how to access resources, video as an educational modality and a non-judgmental approach.

Practical implications –

Justice-involved women are potentially reachable through internet-based health education. Their preferences for content and modality can be used to inform internet-based sexual health programming designed specifically for this population. Using this modality could offer easily disseminated, low-cost and consistent messaging about sexual health for a vulnerable group of women.

Originality/value –

Though internet-based health education programming has been widely utilized in the general population, less attention has been paid to if and how these programs could be utilized with a vulnerable group of women who move between the justice system and communities. This exploratory study begins to fill that gap.

Keywords: Womens’ health, Qualitative research, Health promotion, Public health, Post-release care, Sexual health

Introduction

Internet-based education curricula have been shown to be not only cost-efficient but effective, because they can provide information to large groups of people compared to in-person educational programs (Noar et al., 2009; Rogers et al., 2017). Although previous research studies have shown that internet-based sexual health education programs have been found to lower risky sexual behaviors in a diverse population (Noar et al., 2009; Widman, Nesi, Kamke et al., 2018; Widman, Golin and Kamke et al., 2018; Wernette et al., 2018; Antonishak et al., 2015), an internet-based sexual health program focusing on women who are transitioning from jail into the community has yet to be developed. An opportunity exists to develop an internet-based curriculum that can reach these women.

Women with criminal justice histories have increased risk for many sexual health-related problems such as increased prevalence of sexually transmitted infections (STIs), high rates of unintended pregnancy, cervical cancer, and low rates of up-to-date cervical and breast cancer screening ( Javanbakht et al., 2014; Wiehe et al., 2015; Ramaswamy et al., 2017; Pickett et al., 2018; Binswanger et al., 2009; Clarke et al., 2006). As women transition back into the community, they are confronted with a host of competing priorities like seeking stable housing, reconnecting with children, reinstating state assistance, finding employment and meeting other probation and parole requirements (Peabody et al., 2014; Freudenberg et al., 2008). Their sexual health does not always factor high in the list (Ramaswamy, Upadhyayula, Chan et al., 2015), though the need for information, resources, and connections to care persist.

To meet this need, we developed the Sexual Health Empowerment (SHE) Project to increase jailed women’s cervical health literacy, thereby reducing their risks for negative sexual health outcomes once women leave short-term jail incarceration (Ramaswamy, Simmons and Kelly, 2015). SHE was a brief intervention delivered to women in jail focused specifically on cervical health literacy (including knowledge, beliefs, self-efficacy, and confidence for screening and follow-up) (Ramaswamy, Simmons and Kelly, 2015; Ramaswamy et al., 2017). Proven effective at increasing cervical health literacy and screening (Ramaswamy et al., 2017; Ramaswamy, Simmons and Kelly, 2015), SHE interventionists also observed the need for a broader sexual health curriculum for women post-incarceration. Women with justice involvement have complex sexual and reproductive health needs that go largely unmet (Fickenscher et al., 2001; Sufrin et al., 2015), in part, to lack of effective and sustainable programming due. A new program that is easily accessible post-incarceration that encompasses all of women’s sexual health is needed.

Most sexual health interventions for this group of women are labor and personnel intensive, much like the original face-to-face SHE intervention (Fogel et al., 2015; Ramaswamy et al., 2017). Thus, understanding justice-involved women’s preferences for an internet-based, more easily disseminated, and accessible sexual health program was a priority. Creating a new internet-based comprehensive sexual health curriculum would allow justice-involved women in the community to obtain information about a wide variety of sexual health topics from evidenced-based and trusted sources on one website.

The purpose of this exploratory study was to first understand how this group of women access and use the internet in the community, how they seek sexual health education, and their desire to utilize an internet-based sexual health program if provided the opportunity. Our study also seeks to fill a gap in the literature about how applicable internet-based health education programs are to women who live on the margins of society. We know little about internet use among marginalized populations, such as the homeless (McInnes et al., 2013), drug users (Genz et al., 2015), and justice-involved women, and even less about how internet-based interventions have been used with these groups (Lerch et al., 2017). For example, the limited research on homelessness, drug use, and internet use found that about half of the participants have computer access (McInnes et al., 2013) but drug users were the least likely to have access to the internet (Redpath et al., 2006). Although these studies highlight the need for additional research on the digital divide in delivering public health education, to our knowledge no research has been conducted to examine the digital delivery of sexual health education to vulnerable populations. Our study seeks to provide useable insights into this area, specifically as it relates to delivery of sexual health education for justice-involved women, to inform the development of a comprehensive internet-based women’s sexual health program for this group of women.

Methods

This was a qualitative study of women detained in a county jail in Kansas City, Missouri, which held women who, for the most part, had jail stays between one day and one year. Data were obtained through four 90-minute focus groups conducted March–August 2018. Flyers notifying the women of the upcoming focus groups were posted in the common area of the women’s housing unit. Women were able to sign up with the program director. Up to 20 women per focus group were allowed to sign up. For participating in the focus group, women received $25 incentive in the form of money added to their commissary accounts. This study was approved by the University of Kansas Medical Center Institutional Board Review.

Focus groups

The research team, from 3–4 staff per focus group, met privately with the women, in an unguarded, locked conference room. After informed consent was obtained, the focus groups started. Given the changeable nature of the correctional environment, audio recorders were initially allowed during the first focus group but confiscated about halfway through the group and not allowed again. Therefore, field notes (pen and paper) were taken for the remainder of the first focus group and the other three groups. Women were asked to repeat answers if needed by the research team. Direct quotes were taken when possible, but the field notes were mostly summary of group discussions. Each group was led by one moderator.

The focus group discussion questions were informed by the aim of this study. Questions focused on two main aspects: women’s general use of the internet while not in jail and their preferences concerning a prospective, internet-based women’s sexual health curriculum. The open-ended questions were developed by two of the authors and then revised by an eight-person research team with expertise in qualitative research. Participant demographic questions were not asked.

Analysis

The available audio data were transcribed word for word. All data were coded, with similar codes grouped into themes, separately by two of the authors. Discrepancies were discussed among all authors until a final group of themes was agreed upon. The number of focus groups completed (four) was selected to achieve thematic saturation. In other words, we conducted focus groups until themes converged.

Results

Participants

A total of 52 individual women participated: 6 in the first focus group, 26 in the second, 10 new women in the third and 10 new women in the fourth. There were repeat participants in the third and fourth groups, thus in total there were 12 women in the third group and 13 in the fourth. Although groups were to be limited to 20 women, the team allowed more during the second focus group, given the lower turn out for the first group. While demographic data were not collected, the research team did note that there was racial/ethnic diversity in each group. The racial and ethnic makeup of the jail was 40 percent Black, 40 percent White, 10 percent Latina and 10 percent other races or ethnicities. Additionally, the mean age of women in the facility was 34.

Internet use

Participants reported regular daily access and use of the internet while not incarcerated. However, only one participant stated, “I don’t get on computers.” The women endorsed using the internet at a variety of locations: “I usually use my home computer, my laptop,” and “You can basically go anywhere and get Wi-Fi nowadays.” Some participants were not comfortable using the internet outside of their home: “I don’t feel safe using public Wi-Fi,” “I have a fear of hackers, the world is dangerous,” and “I am paranoid to use public internet.” The women who expressed concerns about using Wi-Fi outside of their home had no issues with access inside their home or were comfortable using data but not Wi-Fi in public. Google and social media sites were among the favorite Web tools of participants, with some saying, “Google’s my best friend” and “You can Google anything in the library; you can google anything.” However, women did mention that on certain sites, “Everything is opinion” and that “People don’t check for accuracy” when using Google. This prompted a discussion on the legitimacy of websites and how to tell if they are legit or not. Many women admitted they do not have a way and they “Just Google it”, however some women said, “I take the answer (to my question) and ask Google two or three different ways,” and “(A website) is safe if it’s got a lock icon.” In addition to Google, for health-related information women mentioned using WebMD and MedHealth.

Obtaining sexual health education

Participants were asked how they have learned or currently learn about sexual health, mainly STIs. The three main themes that emerged were self-learning/online research, family and school. Two women described self-learning/online research as such: “My personal opinion is people don’t go researching until they have […] uh […] there’s a trigger, or symptoms, or ‘oh, I just slept with him, I wonder if […],’ you know what I mean. I don’t think I is straight and then just let me start googling STDs” and “There’s a lot of stuff on Facebook like on my timeline and Snapchat […] like snap stories […] there’s sometimes like stuff about STDs.” One participant described how her mother was brief when talking about sex, “My mom just basically said be safe.” Women stated that, while school education is good, there needs to be continued education and education for women of different ages, as summed up by this participant: “4th and 5th grade, and then never again. They start it at a young age and then just stop, they didn’t continue. I could have learned about it in 6th grade, middle school, high school and I didn’t.” Most often, women said information was obtained from a combination of sources, as described by one woman who said, “I learned about [STIs] in school because my mother was grossing me out, she really was, God forgive me, but she made it very difficult to talk about it with her […] I talked about it with my father and at school […] and I learned a lot on my own.”

Women’s suggestion for an internet-based program

Many women had no concerns about substituting an internet-based educational program for the face-to-face, small group format that we used in the original SHE study, with one noting, “Some people don’t want to be in a group, and I’m on my phone 24/7.” One woman did share that groups offer a sense of community that single-user online formats might lack: “Groups allow you to share in people’s experience, that they are in the same boat as you, you’re not alone, it’s not your fault.” This prompted the question, “How would you feel about a program that includes an (internet-based) section that allows women to share their stories or experiences?” Most women acknowledged that such a section would be “powerful and encouraging,” that “sometimes your story can help someone else,” and that knowing about others’ experiences “might make somebody else come forward.” Privacy was a concern woman had, and suggestions were made to obscure faces and change names if videos were used. Others said they would be willing to share their stories only if paid. In discussions about program content, four themes emerged (Table I).

Table I.

Internet-based program content preferences

Theme Representative quote
Healthy sexual expression “Masturbating, how to express myself with myself”
“Butt stuff, [it] don’t shame me”
“Sex drive by age, how does it change”
How to access resources “Where to get help if needed”
“Links to local places to get treatment”
Video as an educational modality “Some people don’t like to read, like me, I rather watch the video”
“Videos that guide you through the material”
Non-judgmental approach “You’re not a bad person because you do that, if you gave it to someone else, or you have it”
“We are living in a day and age where we have to protect ourselves”
“We have all made mistakes about using contraception”
Open in a new tab

Women expressed a desire to include topics relating to a healthy sex life, not just ‘what can go wrong’ and how a women’s sex life changes over time. A section on local resources was seen as necessary, including information on how to get to locations (i.e. bus route). “Videos that guide you through the material,” as one woman said, were preferred to all text as some women expressed they do not like to read and noted not all women with justice-involvement can read. Lastly, the women felt very strongly about the need to have an internet-based sexual health curriculum that destigmatizes sexual health and does not leave the participant feeling shameful about their behaviors.

Women were asked about the usefulness of a health educator available through the internet-based program. All women felt this would be a helpful feature, with many suggesting that 24-hour assistance would be nice. One woman said, “I wouldn’t feel embarrassed to video chat, especially if it’s a state of emergency.” With respect to the health educator, the participants were divided as to gender preference for the health educator, though some preferred women. One participant said, “I would rather hear it from a women, compared to a man, but that me,” and some did not care. One woman did note that others may not feel comfortable with a man because “some people have been taken advantage of by a male.” In general, women did not have preferences about the occupation or educational level of the health educator, “just as long as it’s correct information,” as one woman said. Lastly, participants suggested a catchy title and design to keep viewers’ interest. One title suggestion was “Are you ready to talk about the naked truth?”

Discussion

The results of this exploratory study indicate that incarcerated women do have regular access to the internet when not in jail and are interested in having a comprehensive online women’s sexual health curriculum available while in the community. It is known that women re-entering the community following incarceration have high rates of STIs (Wiehe et al., 2015) and that many have competing needs, of which sexual healthcare may not be the highest priority (Peabody et al., 2014; Freudenberg et al., 2008). Internet-based education has the benefit of reaching large groups of people at a low cost with a consistent message. For example, the Bedsider program, an online birth control support network, has been proven to reduce pregnancy scare, increase contraceptive use, and decrease unintended pregnancies (Antonishak et al., 2015). These benefits, coupled with the results from our focus groups, provide strong rationale for development of online, easily accessible, women’s health curricula for justice-involved women.

Women identified four themes regarding the content of an internet curriculum: healthy sexual expression, how to access resources, video as an educational modality, and a non-judgmental approach. While some areas were not unexpected to the research team, one thing the team did not expect was the women’s desire for healthy sex life topics including how sex changes throughout a woman’s lifetime. In fact, even for the general population, there are limited examples of evidence-based sexual health education programs geared towards adults (Planned Parenthood, 2017a, b; ETR, 2018; American Sexual Health Association, 2019). Those that do exist are often text heavy, which may limit the usefulness to justice-involved women who may have limited reading proficiency, a theme that emerged from our focus groups. Hence, there is the need to develop an evidenced-based, comprehensive internet-based sexual health program designed specifically to consider the needs of justice-involved women.

The primary limitation of this study is its exploratory nature and singular focus on developing an internet-based sexual health education program for justice-involved women. However, we collected information that may be applicable to others working to develop and disseminate health education interventions with this group of women. Another site-specific limitation was that audio recording was not allowed in the jail. Data collection was dependent on the research staff’s notetaking, which may have resulted in the loss of valuable data. The moderator tried to compensate by asking the women to repeat themselves, especially if an important quote was stated. There were data not collected that could have been beneficial, such as participant demographics. Another possible limitation is focus groups were only conducted with women at one urban jail. Results are not generalizable, though they give researchers a starting point for where further data collection may be needed with respect to internet-based educational programs with vulnerable populations.

In conclusion, after leaving jail, even women in highly constrained circumstances do have access to the internet, whether it be through personal access or through free, public access. Most women in the focus groups were open to an internet-based curriculum that offered sexual health education. The results from this study will be used to develop a comprehensive internet-based program to include sexual health throughout a woman’s lifespan, breast cancer, cervical cancer, birth control and STIs. Public health interventionists working with justice-involved women may also find some utility in study findings, as they apply new techniques of health education delivery to vulnerable groups.

Acknowledgments

This study was supported by the National Cancer Institute, National Institutes of Health, through Grant No. R01 CA181047 (PI Ramaswamy), National Cancer Institute, National Institutes of Health, through Grant No. R01 CA181047-S1 Diversity Supplement (Trainee Smith) and National Cancer Institute, National Institutes of Health, through Grant No. R01 CA181047-S2 Diversity Supplement (Trainee Pickett).

Contributor Information

Michelle L. Pickett, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.

Joi Wickliffe, Preventive Medicine and Public Health, University of Kansas School of Medicine, Kansas City, Kansas, USA..

Amanda Emerson, School of Nursing and Health Studies, University of Missouri-Kansas City, Missouri, USA..

Sharla Smith, Preventive Medicine and Public Health, University of Kansas School of Medicine Wichita, Wichita, Kansas, USA..

Megha Ramaswamy, Preventive Medicine and Public Health, University of Kansas School of Medicine, Kansas City, Kansas, USA..

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