Can Internet increase condom
use among young adults?
$1 million study aims to find out

Despite ongoing education efforts, the rates for gonorrhea, chlamydia, syphilis and other sexually transmitted diseases are on the rise in Colorado.

In 2000 – the most recent year for which state statistics are available – gonorrhea increased 25 percent over the previous year, for a total of 3,089 cases.

Chlamydia increased 13.6 percent over 1999, for a total of 11,802 reported cases. And syphilis jumped 37.5 percent, though this percentage represents an increase of just three cases, from eight to 11.

For most STDs, young people aged 15-24 are at the highest risk, according to the Colorado Department of Public Health and Environment.

Short of abstinence, condoms have proven to be the best prevention against STDs, including for the more serious, incurable diseases like herpes and HIV. The challenge, however, continues to be finding a way to compel young people to actually use them.

An innovative approach to this problem came by accident in 1999, when some School of Medicine researchers were doing a study on gay male STD rates.

“Back in ’99 we were doing STD research online with the gay male population because we had learned, from anecdotal information from Denver STD clinics, that many men had met their partners online – that they were using the Internet to find sex partners,” said Sheana Bull, MPH, PhD, an associate professor in the School of Medicine’s Colorado Health Outcomes Program.

“That research prompted us to look into online sexual behaviors with the larger population, using an online sexual risk assessment. What we learned from this is that while the risks to women and youth are not as acute as they are to gay men, they are still there. And young adults are more at risk than older straight men or straight women.”

From left, research associate Charlene Ortiz, principle investigator Sheana Bull, and interns Irma Venegas and Dionne Lee.

Because young adults are so Internet savvy, Dr. Bull predicts that the use of the Internet for finding sex partners will only increase in future generations. But the same vehicle that can get kids into trouble can also be turned into a powerful tool of prevention.

What was born was a proposal – recently funded for $1 million by the National Institute of Mental Health – to use the Internet as a means of delivering STD-prevention messages.

In the four-year study, Dr. Bull and her team will “take what we know works for prevention in face-to-face settings and apply that to the Internet. The innovation isn’t so much what we are doing but that we are doing it online.”

The potential implications for this research are immense.

“In standard prevention efforts, you have to have counselors, and the success varies depending on the skills of the people involved,” she said. “It’s also very expensive. If what we are doing works, we will have a low-cost standardized intervention method that can be reproduced relatively easily.

“The implications are great for STD/HIV, where computers could be set up in STD or health clinics across the country. But it could also be mimicked in the primary care setting to promote things like diet and exercise.”

The Study
A total of 1,500 people aged 18-25 will participate in the study. They will be recruited from four Planned Parenthood clinics around the metro area, as well as the city of Denver’s STD clinic.

Participants will be randomized into one of two groups. Both groups will take a short online survey that provides key information about themselves: their race, age, gender, sexual behaviors and rate of condom use.

The control group will then receive Web-based information on STDs in the matter it is typically presented online – a list of diseases, the symptoms and dangers, and other statistics. The other half will receive personalized information –delivered by a “role model” – specifically tailored to their survey answers with tips on how to negotiate safer sex with partners and how to use condoms consistently and correctly.

The team’s hunch is that the latter will prove to be a more effective way of increasing the use of condoms among young people.

“Public health experts have determined the best ways to compel behavior changes in patients,” Dr. Bull said.

“It isn’t through scare tactics, or authoritarian messages; instead, it is having a person the patient relates to deliver the information in a way that mimics the patient’s own behavior and vocabulary.”

In other words, if a young woman sees someone who is like her doing something, she will gain confidence and might try to emulate that. In the same way, if the woman sees someone like her telling her that a certain behavior is bad or not cool, she is less likely to try it.

For Dr. Bull’s study, the team is developing an entire platform of role model stories that will be posted on a Web page and tailored for the individual patient.

So, a black woman going through the program who never uses condoms will hear the story of a black woman roughly her age who never used to use condoms, but has recently tried them and likes them. The message would not try to get her to use them all the time – drastic behavior changes aren’t likely to stick. Instead, it would focus on trying to get her to just try the condoms, to see that they aren’t so bad.

Alternately, a white man who uses condoms most but not all of the time would hear a message from another white man, urging him make it 100 percent. The approach might be: “You already know they don’t diminish the sexual experience. Why not go all the way and totally protect yourself?”

When the participants first enroll in the study, they will complete the preliminary portion in the health clinic they were recruited from. To complete the study – and see whether the online message influenced their condom use – they can access the study site from home, or from free Internet sites in libraries or schools.

Although the results of the study won’t be ready for another four years, the research team is leading a new trend in medical research.

“When we started doing Internet health prevention studies in 1999, there was no one doing it,” Dr. Bull said. “Now there are about 10 randomized controlled trails that have been published in the last three years on Internet-based health promotion. With the average clinic visit lasting only 12 minutes, there just isn’t time for good prevention messages from doctors to patients. People are starting to recognize that CDs and the Internet can be a great adjunct to clinical services.”

In addition to Dr. Bull, the research members include: Krista Anderson, co-investigator and vice president for education at Planned Parenthood of the Rocky Mountains; Charlene Ortiz, research associate; Stephanie Phibbs, MPH, research associate; Cornelis Rietmeijer, director of Denver Public Health STD Clinic; Mary McFarlane, Centers for Disease Control; and interns Irma Venegas and Dionne Lee.

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