Improving recruitment and retention for an online randomized controlled trial: experience from the Youthnet study.

The objective of the study was to present recruitment and retention findings for an Internet based HIV prevention trial evaluated using a randomized controlled design among 15-25-year-olds accessing a website on the Internet. We used a combination of automated electronic and personalized approaches to increase and diversify recruitment, verify participant eligibility and increase retention. We posted 3.5 million banner advertisements, 9354 individuals clicked on the advertisement, 8950 completed an eligibility screener and 3298 a baseline survey; we flagged 675 of these as suspicious and enrolled 2623 individuals. Of these, 2082 (79%) completed a follow-up at one-month and 1398 (53%) completed a two-month follow-up. This retention rate is the highest we have seen for an Internet-based HIV-prevention trial. Our procedures can be replicated in other trials. We stress the importance of using a combination of automated and personalized techniques to increase enrollment, verify eligibility and promote retention.

Relation of health literacy to gonorrhoea related care.

OBJECTIVE: To assess the relation between health literacy and receipt of a screening test for gonorrhoea in the past year. METHODS: Study design was multisite, cross sectional survey of subjects enrolled from clinics, from community based organisations, and by street intercept. Data were obtained using face to face interview. The dependent variable was self reported receipt of a test for gonorrhoea in the past year. Health literacy was measured by the Rapid Estimate of Adult Literacy in Medicine (REALM), recoded to represent 8th grade or lower reading or 9th grade and higher reading level. Statistical analyses were adjusted to account for selection bias in literacy assessment. RESULTS: 54% of the sample reported at least one gonorrhoea test in the previous year. 65% of the sample read at a 9th grade level or higher. REALM score was moderately correlated with the respondent's years of education. After adjustment for missing REALM data, past suspicion of gonorrhoea, self inspection for gonorrhoea, self efficacy for care seeking, REALM score of 9th grade reading level or higher, and younger age were independently associated with gonorrhoea testing in the previous year. For the average respondent, REALM reading grade level of 9th grade or higher is associated with a 10% increase in the probability of having a gonorrhoea test in the past year. CONCLUSIONS: Low literacy appears to pose a barrier to care for sexually transmitted infections such as gonorrhoea.

Barriers to STD/HIV prevention on the Internet.

Using the Internet as a mode for health promotion is appealing. There are important methodological considerations to the approach, but there are also important reasons why people will and will not participate in Internet interventions. This is a report on data from 4601 people who completed an online survey of sexual risk behavior in 2000. Most indicated they would visit a website for STD/HIV prevention information (61%), but fewer would open an E-mail (45%) or chat (30%) about the topic. Top reasons for rejecting website, E-mail and chat room education about STD/ HIV are given. Logistic regression results showed men who have sex with men (MSM) and persons with a history of testing for STD are consistently more likely to endorse STD/HIV prevention through chat rooms (MSM 1.8, STD testers 1.3), E-mail (MSM 1.6, STD testers 1.2) and websites (MSM 1.8, STD testers 1.2). The data demonstrate the Internet may facilitate health promotion among MSM who may not be reached in a publicly funded STD prevention setting. The Internet may also act as a good adjunct to STD information obtained in clinic settings among those who seek STD testing.

Soliciting sex on the Internet: what are the risks for sexually transmitted diseases and HIV?

BACKGROUND: Strategies to meet sex partners have been augmented by the Internet. This medium is an environment of potential risk for acquiring or transmitting sexually transmitted disease (STD). GOAL: To document how the Internet is used to find sex partners and what risks such activity poses for STD infection. STUDY DESIGN: Participant observations of 175 chat rooms targeting men who have sex with men (MSM), heterosexuals, and couples seeking sex partners. RESULTS: Findings indicate evidence of past meetings (9% of MSM-room observations, 15% of couple-room observations) and solicitation of sex (9% of heterosexual-room observations, 17% of MSM-room observations, 36% of couple-room observations) by members of these groups. Safer sex or risk-reduction behaviors were not frequently mentioned, but were sometimes acknowledged through solicitation of drug-free and disease-free partners. CONCLUSIONS: Because people can use the Internet to solicit sex partners, it is a risk environment for sexually transmitted diseases. The Internet offers fast and efficient encounters resulting in sexual contact, which may translate into more efficient disease transmission. However, the Internet also offers many possibilities for innovative technologic approaches to promote STD and HIV prevention.

The Internet as a newly emerging risk environment for sexually transmitted diseases.

CONTEXT: Transmission of sexually transmitted diseases (STDs) such as human immunodeficiency virus (HIV) infection is associated with unprotected sex among multiple anonymous sex partners. The role of the Internet in risk of STDs is not known. OBJECTIVE: To compare risk of STD transmission for persons who seek sex partners on the Internet with risk for persons not seeking sex partners on the Internet. DESIGN: Cross-sectional survey conducted September 1999 through April 2000. SETTING AND PARTICIPANTS: A total of 856 clients of the Denver Public Health HIV Counseling and Testing Site in Colorado. MAIN OUTCOME MEASURES: Self-report of logging on to the Internet with the intention of finding sex partners; having sex with partners who were originally contacted via the Internet; number of such partners and use of condoms with them; and time since last sexual contact with Internet partners, linked to HIV risk assessment and test records. RESULTS: Of the 856 clients, most were white (77. 8%), men (69.2%), heterosexual (65.3%), and aged 20 to 50 years (84. 1%). Of those, 135 (15.8%) had sought sex partners on the Internet, and 88 (65.2%) of these reported having sex with a partner initially met via the Internet. Of those with Internet partners, 34 (38.7%) had 4 or more such partners, with 62 (71.2%) of contacts occurring within 6 months prior to the client's HIV test. Internet sex seekers were more likely to be men (P<.001) and homosexual (P<.001) than those not seeking sex via the Internet. Internet sex seekers reported more previous STDs (P =.02); more partners (P<.001); more anal sex (P<.001); and more sexual exposure to men (P<.001), men who have sex with men (P<.001), and partners known to be HIV positive (P<.001) than those not seeking sex via the Internet. CONCLUSIONS: Seeking sex partners via the Internet was a relatively common practice in this sample of persons seeking HIV testing and counseling (representative of neither Denver nor the overall US population). Clients who seek sex using the Internet appear to be at greater risk for STDs than clients who do not seek sex on the Internet. JAMA. 2000;284:443-446

Practice patterns for the elicitation of sexual history, education, and counseling among providers of STD services: results from the gonorrhea community action project (GCAP).

BACKGROUND: The frequently asymptomatic nature and high incidence of severe complications of sexually transmitted diseases (STD) calls for targeted efforts to identify those at greatest risk. Earlier studies have shown inconsistencies regarding STD evaluation by primary care clinicians and physicians. However, the literature regarding the consistency of practice patterns regarding elicitation of sexual history is limited. We examined practice patterns for the elicitation of sexual history among providers across seven sites nationwide. METHODS: As part of a multisite study to encourage health seeking for populations specifically at risk for gonorrhea (GC) and other STDs, semistructured interviews that included questions regarding sexual history elicitation were conducted with 208 service providers in a total of 121 publicly and privately funded clinics, managed care organizations (MCOs), hospital clinics, community- and school-based clinics in Denver, New York, Los Angeles, Birmingham, St. Louis, Indianapolis, and Prince Georges County, MD. RESULTS: Among the providers interviewed, practice patterns for the elicitation of sexual history were inconsistent. Sexual histories were described as routine (i.e., solicited from every client regardless of reason for visit) in 57% of sites. Providers most frequently asked clients their number of sex partners (57%), their contraceptive history (55%), and STD history (34%). Client discomfort among 46% and provider discomfort among 13% was cited as barriers to the elicitation of sexual history. A quarter (26%) of providers agreed that the elicitation of sexual history can be fostered by improved provider communication skills and 16% agreed increasing training and experience for providers is needed. CONCLUSIONS: These findings suggest that interventions with providers to standardize sexual history elicitation can help to reduce barriers to prevention, diagnosis, and treatment of STD.

Patterns of general health care and STD services use among high-risk youth in Denver participating in community-based urine chlamydia screening.

BACKGROUND: In the United States, youth are at highest risk for STDs, and innovative programs have been called for to increase their access to essential STD-related services. To guide the development of such programs, locally relevant information is needed on current use of general health care and STD services in this population. GOAL: To study access to and use of general health care and STD services in a purposive sample of high-risk youth in inner-city Denver. STUDY DESIGN: An interview-based survey conducted as part of a community program for urine chlamydia screening targeting black and Hispanic youth 13 years to 25 years. RESULTS: Of 221 sexually experienced youth in the survey, 72% had accessed general health services in the past year and 39% reported an STD evaluation at any time in the past. Community and school clinics were reported by 50% as a source for general health care and by 62% as a source for STD services. STD clinics were reported by only 14% as a source for STD services. Routine checkups were the most important reasons to seek general health care, yet of those who went for a routine checkup, only 34% reported an STD evaluation. Although few barriers appeared to exist in accessing general health care, anticipated anxiety about procedures and results formed the major barrier to accessing STD services. CONCLUSIONS: Use of general health services was common in this population of high-risk adolescents; however, the provision of STD services as part of general health care visits appeared to be low. On the basis of these findings, a comprehensive STD prevention strategy may be envisioned, which would include provider interventions to increase the provision of STD prevention services in general health care settings; community interventions to enhance access to general health care and STD services; and community-based screening programs for those not able or willing to seek clinic-based services.

PIP: To guide the development of innovative programs to increase the access of US adolescents and young adults to sexually transmitted disease (STD) prevention and treatment services, data should be obtained at the local level from nonclinic-based samples comprised of those at greatest risk. Such a survey was conducted in Denver, Colorado, in 1996-97 by Youth in Action--a community-level chlamydia urine screening program. Questionnaires were completed by 221 of the 277 predominantly Black and Hispanic inner-city youth 13-25 years of age who underwent urine analysis during the study period. 25 (11%) reported a history of an STD. On urine screening, 10.7% of males and 12.9% of females tested positive for chlamydia. 72% had accessed general health services in the past year, primarily for routine checkups, and 39% reported an STD evaluation at any time in the past. Community and school clinics were identified by 50% as a source for general health care and by 62% as a source for STD services. Only 14% of respondents attended STD clinics. In multivariate analysis, the following factors were associated with an STD evaluation: recruitment in field settings, female gender, age above 16 years, non-Hispanic ethnicity, vaginal sex in the past 30 days, presence of chlamydia on urine screening, and a general health visit in the past year. Of concern was the finding that only 34% of youth who went for a general checkup reported an STD evaluation. These findings indicate needs for interventions to increase the provision of STD prevention services in general health care settings and community-based screening programs for those unable or unwilling to seek clinic-based services.

Contraception and culture: the use of yuyos in Paraguay.

The use of herbs (yuyos) as contraception is common practice in Paraguay. This report analyzes data from the 1995-1996 Paraguayan Reproductive Health Survey. The analysis reveals that women are more familiar with yuyos (88%) than any other method of family planning. Modeling the determinants of ever having relied on yuyos as contraception demonstrates that older women (OR = 1.043) and women with more children (OR = 2.283) are significantly more likely to have used yuyos, but an interaction between older women with more children shows they are less likely to have used this method (OR = .982). Women living in rural areas (OR = .664) and those with more education (OR = .883) are less likely to have used the method. These findings show widespread acceptance and use of yuyos for contraception in Paraguay. More research into the chemical properties of yuyos is needed to determine their contraceptive efficacy and to prevent harmful effects from their misuse.

PIP: According to the 1995-96 Paraguayan Reproductive Health Survey of 6465 reproductive-age females, women are more familiar with herbs (yuyos) than any other method of contraception. These herbs are prepared most frequently as teas and drunk every day. 88% of respondents were aware of yuyos. Bivariate analysis indicated that current yuyo users were geographically isolated, older, less educated, poorer, and more likely to speak Guarani in the home than non-users. In the multivariate analysis, ever-use of yuyos was significantly associated with older age (odds ratio (OR), 1.043) and more children (OR, 2.283), while high education (OR, 0.883) and urban residence (0.664) were inversely related to ever-use. Since no protocol exists for yuyo use for contraception, indigenous women rely on word-of-mouth advice and may be at risk of toxic side effects from improper use. Needed, to reduce this risk, are research studies on the use of herbs in other countries for contraceptive purposes and more rigorous testing of the chemical agents found in plants used for fertility control. If efficacy is discovered, additional research is recommended to identify the conditions under which and for how long yuyos should be taken for contraception or menstrual regulation. Any program that builds on yuyo use to promote use of modern contraceptive methods must proceed in a culturally sensitive way.