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Internet use and health information seeking behavior of adolescents in Mbarara, Uganda: Implications for HIV prevention
1. South African-United States Workshop on
Behavioural HIV/STI Prevention and Mental Health Research:
Emerging Research Priorities
Durban, South Africa; June 3, 2007
Internet use and health information seeking
behavior of adolescents in Mbarara, Uganda:
Implications for HIV prevention
Michele L Ybarra MPH PhD
Internet Solutions for Kids, Inc.
* Thank you for your interest in this presentation. Please note that analyses
included herein are preliminary. More recent, finalized analyses can be
found in: Ybarra ML, Emenyonu N, Nansera D, Kiwanuka J, & Bangsberg
D. R. Health information seeking among Mbararan adolescents: results from
the Uganda Media and You survey. Health Educ Res. 2008; 23(2):249-258.
2. Acknowledgement
Any well-conducted project is a team effort.
This is no exception. I would like to thank
colleagues who have contributed to the
Uganda Media and Youth survey.
David Bangsberg, MD MPH
Nneka Emenyonu, MPH
Julius Kiwanuka, MD
Denis Nansera, MD
3. Background
As more and more people are online
78% of Americans 12 years of age and
older are online (USC Annenberg School Center for the
Digital Future, 2007).
An estimated 97% of youth use the Internet
(Lenhart, Madden & Hitlin, 2005; USC Annenberg School Center for
the Digital Future, 2005).
The Internet is fast gaining recognition
as a feasible HIV prevention tool
4. Background: The advantages of
Internet-based programs
Low-cost
Easily scalable
Overcome facilitator issues (discomfort
with topics, incomplete implementation)
Overcome individual issues (need for
transportation, child care, health insurance,
physical limitations)
5. Background: Internet-based HIV
prevention programs
Bull et al (Smart Sex Quest):
Men who have sex with men recruited online
Increasing risk awareness for STD, HIV testing and condom use
1700 adults enrolled
20% retained at 3-months (3 messages)
Bowen et al:
Men who have sex with men living in rural areas recruited online
Outcome expectancies, self-efficacy, HIV knowledge
90 adults enrolled
80% retained at 1-week (2 sessions)
Kok et al (Gay Cruise):
Men who have sex with men recruited in chat rooms
HIV knowledge, attitudes, subjective norms, self-efficacy, accurate risk
perceptions
5,982 adults enrolled
94% retention at study end (7 sessions)
6. Background: the need for innovative
prevention programs in Uganda
HIV/AIDS is a major contributor to morbidity and
mortality in Uganda (UNAIDS, 2004).
Despite years of consistent decline in incidence
rates, recent data suggest rising incidence (USAID,
2002; Shafer, Biraro, Kamali et al., 2006).
This may be especially true for adolescents (UNAIDS,
2004):
Among young adults, 38% of men and 56% of women did not use a
condom.
HIV knowledge is on the decline compared to their same-aged
counterparts surveyed in 1990.
7. Problem statement
New and innovative interventions are needed
to reinvigorate HIV rate decline.
These programs must be cost-effective and
easily scalable.
But:
Do adolescents have access to the Internet?
In the absence of interventions, where do they
‘naturally’ look for health information?
8. Uganda Media and You Survey
Conducted in June-July, 2005
500 adolescents 12-18 years of age
(Secondary 1-4)
100 participants randomly identified from
each of 5 local schools:
1 Muslim (mixed sex)
2 Public all-boys schools
1 Public school (mixed sex)
1 Catholic all-girls school
9. Methods
93% participation rate
Pencil-and-paper
Completed after school (on average 20
minutes)
Reviewed and approved by Mbarara IRB
Adult consent provided by principals; youth
consent provided by participants
10. Characteristics of Mbarara
4 hours drive from Kampala (capital)
6th
largest urban center (population:
69,000)
2nd
most populous district, but in bottom
half in terms of population density
Municipality serving a mainly rural
population
11. Characteristics of youth participants
61% Male
46% between 15-16 years of age
71% thought they would probably or
definitely finish secondary school
44% of fathers attended/completed
university
29% of mothers attended/completed
university
13. Exposure to the Internet (n=500)
88% of youth have been exposed to the Internet
45% of youth have used the Internet
(ever)
An additional 43% knew someone who
had gone online
14. Use of the Internet (n=223)
Among Internet users:
78% logged on in the previous week
41% were online for 1 hour or longer the
last time they logged on
15. Location of log-in (n=223)
82%
57%
17%
11%
10%
20%
30%
40%
50%
60%
70%
80%
90%
School Internet café Home Another house
16. Characteristics associated with
Internet use
Youth characteristics AOR P-value
Male 2.5 0.08
Age
12-14 y.o. 1.0 (Reference)
15-16 y.o. 1.9 .05
17-18 y.o. 2.1 .05
Mother’s educational level
Less than secondary school 1.0 (Reference)
Secondary school 2.4 0.03
Attended university 4.4 0.002
17. Reasons for not using the Internet
(n=277)
43%
39%
15%
12%
9% 8%
0%
10%
20%
30%
40%
50%
Too
expensive
Don't
know
where to
access it
Don't
know how
to use it
Too slow Don't want
to
Parental
rules
19. Health information seeking (n=500)
81%
56%
50%
38%
75%
45%
56%
20%
79%
59%
51%
35%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Adult Book/library Sibling Computer/Internet
Health and disease
Sexual health
HIV/AIDS
20. Number of sources for HIV/AIDS
information (n=500)
26%
30%
29%
13%
3%
0
1
2
3
4
21. Number of sources by type of
information resource (n=500)
19%
9%
4%
28%
26%
24%
22%
36%
44%
47%
16%
22%
25%
37%
10%
31%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
A
dult
Book/library
Sibling
C
om
puter/Internet
1
2
3
4
Number of different sources
*13 youth indicated they did not use any of the 4 sources for HIV/AIDS information
22. Characteristics of
computer/Internet health
information seekers (n=223)
Youth characteristics AOR P-value
Going online in the past week 2.4 0.04
Accessing the Internet at school 0.2 0.002
Online activities
Visiting chat rooms 3.8 <.001
Emailing 2.5 0.03
Playing games 2.8 0.002
23. Summary
In this smaller municipality, outside of the
capital city,
the Internet is a familiar technology:
Most (4 in 5) have used or know someone
who has used the Internet
35% of all youth (78% of Internet users) used
the Internet in the last week
24. Summary
The desire to go online is apparent:
Less than 10% of non-users say they have no
desire to use the Internet
Access issues (cost, nearby location) are most
frequently cited barriers
25. Summary
One in three youth (35%) have used the
Internet or computer to access information
about HIV/AIDS.
Although school is the most frequently cited log
in location, school computers area associated
with significantly reduced odds of health
information seeking.
26. Summary
Internet health information seekers are likely to
use multiple sources for health information.
Adults are the most common source of health
information for adolescents.
27. Limitations of the data
Measures of sources of health information are
somewhat crude and include only the four
options. It is likely youth get information from
additional sources (e.g., newspapers,
television)
Internet use and health information seeking are
not tied to health or risk behaviors.
28. Limitations of the data
Although this is one of the few surveys of youth
living outside of a major city in sub-Saharan
Africa, it is possible that youth living in more
rural areas (especially those without access
to the electrical grid) would have less
familiarity with the Internet.
29. Implications
The Internet appears to be a feasible tool for
HIV/AIDS prevention programs for
adolescents.
It will not be the only tool however. Multiple
delivery methods are needed.
30. Implications
Schools are a good source for recruitment of
Internet-familiar youth.
Internet-based interventions should be
designed for and tested outside of the school
environment.
31. Discussion: Designing an Internet
intervention
Go local
Local researchers
Local interventions that have successfully
integrated cultural norms (e.g., Sengas)
Get personal
Recruit from schools
Involve the community
Notas do Editor
28% report 31-1hour 24% report half hour or less 22% report 1-2 hours
28% report 31-1hour 24% report half hour or less 22% report 1-2 hours
Explain methods n-=1585
Note, these questions were randomized for each participant to adjust for response bias due to ordering
Note, these questions were randomized for each participant to adjust for response bias due to ordering
Father’s educational level and likelihood of finishing school not significant (if anything, it looks like there’s an inverse relationship between father’s school and likelihood of using the Internet). Adjusted also for school characteristics
Explain methods n-=1585
55% of 15-18 year olds asked siblings as compared to 41% of 12-14 year olds – so they are especially influenced by peers
Father’s educational level and likelihood of finishing school not significant (if anything, it looks like there’s an inverse relationship between father’s school and likelihood of using the Internet). Adjusted also for school characteristics
You don’t know the answer unless you ask – it’s a strength that we have this data and are able to analyze it’s influence