E-HealthPowerON: The use of instant message counseling and the Internet to facilitate HIV/STD education and prevention
Introduction
Over the past few years researchers and healthcare service providers have recognized the possibilities for using the Internet as a venue for tailored prevention programs for those most at risk for contracting the human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) [1], [2], [3]. This recognition may be particularly important for men who have sex with men (MSM): this group consistently reports the highest prevalence of HIV and STDs [4]; almost one in two MSM report using the Internet to find sexual partners [5]; and research suggests such men who use the Internet to seek sex may increase their risks for HIV and STDs [6], [7]. However, only a handful of attempts have been made to study the Internet as a forum to reach high-risk communities [3], [8], [9], [10], [11]. Difficulties associated with measuring behavioral change (attributable to online interventions) have impeded research into online counseling programs for those most at-risk for HIV [12]. It is hard to retain individuals who begin an online program or initiate Internet-based counseling, and therefore tracking psychological and behavioral changes is problematic [9], [10]. Despite the lack of rigorous studies assessing the efficacy of online HIV prevention interventions, some community-based organizations, healthcare providers, and researchers remain devoted to bringing Internet-based programs, counseling, and other HIV/STD prevention techniques to MSM online [13].
While Internet HIV/STD interventions differ from offline prevention programs in their methods of reaching target populations, they still try to communicate the same prevention messages found in more traditional HIV prevention approaches [14]. For example, in Bowen and colleagues’ [8] randomized control of an Internet-delivered program, online participants watched modules of HIV-negative and HIV-positive men talking to each other about risky sex. These modules stimulated awareness of unsafe sex and encouraged condom use. Similarly, Bull and colleagues [9] attempted an Internet-mediated intervention in which MSM were exposed to either didactic messages regarding HIV and STDs or to first-person vignettes in which the characters were demographically matched to participants. In both cases, the Internet-based interventions had limited participant engagement: participants tended to passively watch or read online content. This model of intervention contrasts with what has been learned from efficacy studies of traditional offline interventions. Active participant engagement, such as through group interactive sessions [15], one-on-one counseling [16], and peer leadership [17] usually results in the most significant decreases in risk behavior.
Current technology can accommodate such active and live participant engagement. With the increased speed of Internet connections and proliferation of the interactive capabilities of websites, computer-mediated interpersonal communication between interventionists and at-risk individuals is available [2]. This online counseling has emerged in other realms as an effective way to assess and treat psychological conditions (e.g., post-traumatic stress), discuss maladaptive or unhealthy behaviors (e.g., sexual fetishes), and provide support for individuals or groups of individuals (e.g., cancer survivors) [18]. Community-based organizations have begun to use this sort of methodology to counsel MSM with respect to risk-taking behavior (e.g., Internet counseling and referrals by Howard Brown Health Center in Chicago, Illinois; the “IMsexED” program by the AIDS Resource Center of Wisconsin in Milwaukee). However, instant message counseling as applied to HIV/STD prevention has appeared only a few times in the literature [19].
The Prevention Organization with Empowerment Resources on the Net, or PowerON, was first designed in 2002 as a website that could meet the health information needs of the MSM community in Seattle, Washington. As part of PowerON, Washington State health education counselors visited various Internet “men-4-men” chatrooms, and when appropriate, referred participants to the website or to specific information on the site. In 2004, Kansas-based Healthy Living Projects, Inc. (HLP) adopted the PowerON model for the Kansas City metropolitan area. Poweronkansascity.org, a PowerON website, was created, and HLP outreach workers went through the PowerON HIV/STD training certification program. This certification program was not particularly different than that required for most offline workers in its content, however it had more of an emphasis on computer and Internet literacy. Counselors were instructed to orient any communication exchanges with the Kansas City MSM towards HIV/STD information dissemination. However, any topics could be introduced by the MSM (e.g., reconciling sexuality, depression) and the content of the instant message sessions had the potential to vary highly. Thus, the effectiveness of using instant message sessions to disseminate HIV/STD information and counsel MSM needed to be explored.
Our specific research questions were: what questions were introduced by MSM via instant messaging and what information was covered during the exchanges? Additionally, how often were questions or information exchanged in the sessions? Was instant messaging a good potential method for HIV/STD information interventions?
Section snippets
Methods
From 2005 to 2007, two counselors based in Kansas City created profiles on Gay.com in order to counsel MSM by using instant messaging. There was one main counselor, but another HLP worker trained to counsel occasionally worked online too; we received no complaints from MSM in the chatrooms about either of the counselors. Because no terms of service were broken and we were not advertising through banners or purchasable webspace, we did not need permission from, or need to negotiate with, Gay.com
The sample
Table 2 describes the demographic composite of MSM engaging in the instant message sessions. The mostly White sample tended to be between 20 and 50 years old. Though this was a largely gay self-identifying group of MSM, Table 2 shows that a little less than 10% reported a bisexual sexual orientation. Three-quarters of the men were HIV-negative.
Prevalence of the categories discussed in the sessions
Table 3 shows the number, percentages, and rank order of the topics discussed in the counseling sessions. Only 34 of the 279 sessions recorded, or 12.2%,
Discussion
Previous studies cite several effective ways in which the Internet can be used to actively counsel individuals [18], [23], [24]; however, such methods are only now being formally applied to HIV/STD counseling. PowerON counselors were available for MSM with sexual health questions, and the results showed that information relevant for HIV/STD prevention could be disseminated through instant messaging. Specifically, the process facilitated the transmission of sexual health information and/or
Conflict of interests
Npt Labs, LLC currently holds the license for PowerON. Npt Labs, LLC was not involved in the coding or analysis of any of the data reported in this article and in no way influenced the results. The company did not suggest any of the conclusions or practice implications discussed in this article. Data coding and analysis was given to an independent researcher (David Moskowitz) who had no financial, personal or other relationships with Npt Labs, LLC within 3 years of beginning the research. Thus,
Acknowledgements
Special thanks to Gerulf Rieger, PhD, Elizabeth Moore, PhD, Keith Horvath, PhD, Alex Westerfelt, PhD, Kristin Leathers, Pys. D, and Brad Clark, MPH for their advice, data collection, coding and critical feedback. Preparation of this article was supported, in part, by United Way Heartland AIDS Partnership Grant, center grant P30-MH52776 from the National Institute of Mental Health (PI: J.A. Kelly) and by NRSA postdoctoral training grant T32-MH19985 (PI: S. Pinkerton).
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