Teenagers, Sexual Health Information and the Digital Age

By Kerry Mckellar and Elizabeth Sillence

Teenagers, Sexual Health Information and the Digital Age examines the online resources available on teenagers, including games and digital interventions. In addition, it highlights current issues such as sexting and pornography. Information needs and provisions are examined, and existing sexual health interventions and digital interventions are discussed, gathering both teenagers’ and sexual health professionals’ views on these services. In addition to a review of the current literature on sexual health and teenagers, the book examines groups of teenagers, particularly those vulnerable to risky sex and asks what are the predictors of these behaviors and what can be done to address the behaviors.

Finally, the book will also provide reflections and practical advice on the ethical issues associated with research in this context.

• Provides guidance on the ethical issues with research associated with this topic
• Covers both teenagers’ information needs as well as their existing levels of knowledge
• Assesses how teenagers engage with, and evaluate, sexual health information
• Addresses the challenges inherent in the online environment, such as unreliable and misleading information

• Language: English
• Publisher: Academic Press
• Release date: Jan 6, 2020
• ISBN: 9780128169704

Kerry Mckellar

Dr. McKellar received her PhD from Northumbria University. Her research interests include teenagers’ knowledge and beliefs of sexual health intervention programs, including risky behaviors specifically using technology, such as cyber bullying and sexting behaviors. Her research explores teenagers’ beliefs, knowledge and attitudes towards sexual health, leading to a sexual health intervention program aimed at reducing the amount of unplanned pregnancies and STIs in the teenage population.

Book preview

Teenagers, Sexual Health Information and the Digital Age

Kerry Mckellar, BSC, MRES, PHD

Department of Psychology, Northumbria University, Newcastle, UK

Elizabeth Sillence, BSC (HONS), MSC, PHD

Department of Psychology, Northumbria University, Newcastle, UK

Table of Contents

Cover image

Title page

Copyright

Acknowledgments

Chapter 1. Introduction

Introduction

Contributions of this Book

Chapter 2. Current Research on Sexual Health and Teenagers

Sexual Health and Defining Risky Sexual Behaviors

Theoretical Models of Risky Sexual Behavior

Predictors of Risky Sexual Behaviors

Digital World Issues

Chapter 3. Sexual Health Education in and Outside of Schools and Digital Sexual Health Interventions

Current School-Based Interventions in the United Kingdom

Current Sexual Health Interventions Outside of Schools

Digital Sexual Health Interventions

Chapter 4. Sexual Health Professional Views of Sexual Health Education

Introduction

Methods

Results

Discussion

Chapter 5. Ethical Issues When Researching Sexual Health With Teenagers

A Brief Background to the Importance of Ethics

Existing Ethical Guidelines

Lessons from Our Own Research Projects

Reflections and Guidance

Chapter 6. Teenagers' Views of Sexual Health Education

Introduction

Methods

Results

Discussion

Chapter 7. Predictors of Risky Behaviors for Female Teenagers

Introduction

Method: Initial Phase: Pilot of Questionnaire

Chapter 8. Teenagers' Views of Sexual Health Education Websites and Apps

Introduction

Method

Results

Discussion

Chapter 9. Students' Views of Sexual Health Apps

Background

Small-Scale App Case Study Interviews

Results

Small-Scale Study Discussion

Chapter 10. A Brief Online Self-affirmation Intervention to Promote Safe sex Intentions

Introduction

The Study

Chapter 11. Reflections

Reflections: Key Messages

Reflections: Methodology

Index

Copyright

Teenagers, Sexual Health Information and the Digital Age   ISBN: 978-0-12-816969-8

Copyright © 2020 Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Publisher: Stacy Masucci

Acquisition Editor: Kattie Washington

Editorial Project Manager: Samantha Allard

Production Project Manager: Kiruthika Govindaraju

Cover Designer: Alan Studholme

Acknowledgments

I would first like to thank Elizabeth Sillence (coauthor) whose feedback, advice, and support is always valued and appreciated. Also, to Michael Smith, who supervised five of the studies presented in this book, and provided support and guidance throughout. In addition, without the funding from Northumbria University, the studies presented in this book would not have been possible.

A special mention to Kayleigh Richardson, who collected the data presented in chapter 9; her hard work and determination was shown throughout her MRes project. A particular thank you as well to all current and past colleagues in PaCT lab for their valuable feedback and advice. I would also like to thank all of the schools and youth groups who have participated in the studies presented in this book. This research would not have been possible without the cooperation and support from the staff, pupils, and parents.

Also, I would like to thank my husband, David McKellar, for his patience, proofreading, and editing skills.

Finally, to you, the reader, I hope you find this book an enjoyable read.

Kerry McKellar

Chapter 1

Introduction

Abstract

This chapter provides an overview of the contributions of this book. In this book, we aim to highlight current research on teenagers, sexual health, and the digital age. Teenagers are surrounded by information about sexual health, and access to digital technology has made it possible to envisage exciting opportunities for innovative and creative ways of providing teenagers with reliable information in a confidential manner. However, the online environment also poses challenges for teenagers, parents, and health practitioners with access to unreliable, misleading and potentially dangerous information. This book examines the current information landscape for teenagers. It examines the online resources available including games and digital interventions and highlights current issues such as sexting and pornography. Information needs and provision will be examined, and existing sexual health interventions and digital interventions will be discussed, gathering both teenagers’ and sexual health professionals’ views on these services. In addition to a review of the current literature on sexual health and teenagers, the book examines groups of teenagers particularly vulnerable to risky sex and asks what are the predictors of these behaviours and what can be done to address the behaviours. This book will also provide reflections and practical advice on the ethical issues associated with research in this context. This chapter provides an overview of the contributions of each of the following chapters.

Keywords

Digital sexual health interventions; Teenagers; Sexual health; Sexual health intervention programs

Introduction

Contributions of this Book

Current Research on Sexual Health and Teenagers (Chapter 2)

Sexual Health Education in Schools and Digital Interventions (Chapter 3)

Sexual Health Professional Views of Sexual Health Education (Chapter 4)

Ethical Issues When Researching Teenagers and Sexual Health (Chapter 5)

Teenagers' Views of Sexual Health Education (Chapter 6)

Predictors of Risky Sexual Behaviors for Female Teenagers (Chapter 7)

Teenagers' Views of Sexual Health Education Websites and Apps (Chapter 8)

Students' Views of Sexual Health Apps (Chapter 9)

A Brief Online Self-affirmation Intervention to Promote Safe sex Intentions (Chapter 10)

Reflections and Conclusions (Chapter 11)

Introduction

First sexual initiation is a normal and expected aspect of adolescent development (Heywood, Patrick, Smith, & Pitts, 2015). However, risky sexual behaviors are also prevalent among teenagers. In the UK, teenagers are becoming sexually active at an earlier age (Mercer et al., 2010). A large survey in Britain found that although the average age of first heterosexual intercourse was 16, nearly a quarter of girls had sex before they were 16. Furthermore, half of the girls said they wish they had waited longer to have sex, and were twice as likely to say this if they were under age 15   at first sexual initiation (FPA, 2016).

It is important to reduce teenage risk taking, as the consequences of teenage sexual risk taking are unplanned pregnancies and sexually transmitted infections (STIs). Teenage pregnancy rates in the UK have shown a downward trend in the last decade and are currently at the lowest level since records began. Despite this, the UK continues to have one of the highest rates of teenage conceptions in Western Europe (ONS, 2014). One of the reasons for the reduction in teenage pregnancy is that contraception use is improving in this age group. A recent survey found a small reduction in the overall number of new STIs in the teenage population; however, overall levels remained very high (Health Protection Report, 2017). Teenage abortion rates have not decreased, although the rise is only slight, 0.6% since 2014 (FPA, 2016).

There are many teenage sexual health intervention programs in the UK. General practitioners and school nurses offer free and confidential services for teenagers across the country (Baxter, 2010), and teenagers have widespread access to free contraceptives. However, teenagers generally do not report using these services and often report reluctance to use these because of worries about confidentiality and feeling judged (Iyer & Baxter-MacGregor, 2010). In addition, teenagers believe it is embarrassing to discuss sexual health with sexual health professionals and parents (Buhi, 2013). Therefore, despite the confidential and free sexual health services available, teenagers are still reluctant to use them. This may be one of the reasons that there is still a high number of unplanned pregnancies and STIs in the teenage population.

Teenagers are known for their early adoption of the Internet, and teenagers report that the Internet is their primary source when seeking health information (Gray & Klein, 2006), likely because of the anonymity it affords. Discussing sex with teachers, parents, or even friends is considered embarrassing in a society that problematizes teenage sexuality (Kendall & Funk, 2012; Moran, 2000). The Internet is an appealing source of sexual health information because teens can access the information without the embarrassment of anyone finding out (Kanuga & Rosenfeld, 2004). Therefore, it is worthwhile to consider current digital interventions and whether technology is contributing to teenage sexual health knowledge.

Contributions of this Book

In this book, we aim to highlight current research on teenagers, sexual health, and the digital age. Teenagers are surrounded by information about sexual health, and access to digital technology has made it possible to envisage exciting opportunities for innovative and creative ways of providing teenagers with reliable information in a confidential manner. However, the online environment also poses challenges for teenagers, parents, and health practitioners with access to unreliable, misleading, and potentially dangerous information. Examining our teenagers' information needs and existing levels of knowledge is important, but we also need to understand how they engage with and evaluate sexual health information both offline and in a digital context so that we can improve the provision of useful information.

This book examines the current information landscape for teenagers. It examines the online resources available including digital interventions and highlights current issues such as sexting and pornography. Information needs and provision are examined, and existing sexual health interventions and digital interventions are discussed, gathering both teenagers' and sexual health professionals' views on these services. In addition to a review of the current literature on sexual health and teenagers, this book examines groups of teenagers particularly vulnerable to risky sex and asks what are the predictors of these behaviors and what can be done to address the behaviors. Our own research studies presented throughout this book are conducted within the North East England in the UK, with low socioeconomic status (SES) female teenagers, as we identified that these were a high-risk group for unplanned teenage pregnancies and STIs. However, teenage sexual risk taking, unplanned pregnancies, and STIs are issues facing many countries. The background literature explores teenage sexual risk taking from a worldwide perspective, and the ideas discussed within this book are generalizable beyond the UK and to non-SES populations. This book also provides reflections and practical advice on the ethical issues associated with research in this context.

Overall, the book comprises 11 chapters, with Chapters 2–11 outlined below.

Current Research on Sexual Health and Teenagers (Chapter 2)

Chapter 2 provides current literature around teenager's sexual health. The chapter is split into five sections: (1) an overview of teenage sexual health and consideration of risky sexual behaviors; (2) an overview of the main theoretical models in the literature; (3) an examination of the predictors of risky sexual behaviors; (4) an overview of sexual health issues in the digital world; and finally (5) the particular issues associated with females from low SES areas. Taken together, these sections provide an overview of current research on sexual health and teenagers.

Sexual Health Education in Schools and Digital Interventions (Chapter 3)

Chapter 3 presents an overview of the research on commonly cited sexual health intervention programs. This chapter is in three sections to provide greater clarity of the research literature. The first section provides an overview of sexual health education within schools, the second section provides an overview of external sexual health intervention programs, and the final section considers digital sexual interventions.

Sexual Health Professional Views of Sexual Health Education (Chapter 4)

Chapter 4 presents a qualitative study exploring sexual health professionals' views of female teenagers' sexual health information seeking practices and barriers and reexamines the sexual health predictors suggested by previous literature. The focus on sexual health professionals is important given their position as key stakeholders in implementing sexual health interventions, yet their views are largely absent from the literature. The barriers identified were environment and family, society and media, peer influences, self-esteem, and moving forward with intervention programs. In terms of the sexual health predictors, sexual health professionals ranked 33 of the 57 identified as key predictors in the extant literature as highly important, thus supporting previous research. Some of the barriers identified were consistent with previous research, while others were particularly novel. Interestingly, sexual health professionals identified self-esteem as a highly important factor influencing teenagers' likelihood to seek sexual health information, while also being an important predictor of risky sexual behaviors. Yet, limited evidence for self-esteem has been found in previous quantitative studies. This suggests that going forward, sexual health interventions that build self-esteem and address socioeconomic stigma may encourage adolescents to feel confident to make their own informed sexual health decisions.

Ethical Issues When Researching Teenagers and Sexual Health (Chapter 5)

Chapter 5 considers the importance of ethical issues when conducting sexual health research with teenagers. The chapter is divided into four sections. Section 1 discusses the importance and background of ethics. Section 2 considers existing ethical guidelines and Section 3 provides a consideration of our own personal experiences of the ethical issues encountered in sexual health research. The final section draws together the key issues and provides guidance on how to implement ethical procedures when researching sexual health with teenagers.

Teenagers' Views of Sexual Health Education (Chapter 6)

Chapter 6 discusses a qualitative study designed to explore low SES female teenagers' sexual health knowledge and information sources. The study utilized a 4-week diary produced three themes: (1) Can I ask you a question? (2) The social consequences of sex; (3) Information sources. The first two themes explored teenagers lack of knowledge and misunderstandings around the biological and social experiences of sexual health. The third theme explored the limited ways in which teenagers encounter sexual health information currently despite their desire to understand more. The findings of this study highlight the juxtaposition between teenagers' lack of understanding about the biological and social aspects of sex and at the same time their curiosity and thirst for knowledge. This point was emphasized in the teenagers' use of the diaries as a confidential way of seeking sexual health information. This study concluded that teenagers do not have access to reliable sexual health information, and have very limited sexual health knowledge, but are thinking about sex. Furthermore, teenagers from low SES areas do not have any strategies for actively seeking sexual information, and as such sexual health practitioners need to think more creatively about how to provide teenagers with access to reliable sexual health information in a convenient and confidential way.

Predictors of Risky Sexual Behaviors for Female Teenagers (Chapter 7)

Chapter 7 discusses a quantitative study that aimed to investigate the predictors of early sexual behavior and intentions to have sex for low SES female teenagers. A large online questionnaire was administered to 318 low SES female teenagers measuring the high-risk predictors found from Chapters 4 and 6 and current literature. The analysis showed that higher sensation seeking and more high-quality sexual health information, lower self-esteem, lower delayed gratification, and lower sexual health knowledge significantly predict early sex before age 16. Further, the analysis showed that higher peer pressure and higher pornography use significantly predict intention to have sex in the next year. By contrast, none of the predictors significantly predicted intention to have safe sex in the next year. Therefore, this study provided further evidence for an intervention that targets both self-esteem and reliable sexual health information. In addition, sexual health information sources should focus on a wide range of sexual health issues including peer pressure and pornography.

Teenagers' Views of Sexual Health Education Websites and Apps (Chapter 8)

Chapter 8 investigates female teenagers' views of current sexual health websites and mobile apps. This research aimed to explore whether Internet-based sexual health resources via websites and mobiles apps are meeting teenagers' sexual health needs and to explore, for the first time, teenagers' perceptions of the design features of sexual health mobile apps. Twenty-three female participants aged 13–16 years either viewed six existing sexual health websites or three existing sexual health mobile apps chosen to be representative of the range and variety currently available. Participants then took part in focus groups evaluating each of the websites and mobile apps. The findings indicate that adolescents currently use their phones to access sexual health information due to ease of access and privacy. However, none of the adolescents were aware of sexual health apps. Participants believed apps should have similar design features to websites but apps should contain an appropriate interactive element paired with accurate sexual health information. At the moment, female adolescents are not using sexual health mobile apps, they believe they are more convenient and private compared with websites, yet they trust sexual health websites more than mobile apps.

Students' Views of Sexual Health Apps (Chapter 9)

Chapter 9 explores the current literature on menstrual tracking apps and considers students' views of menstrual tracking apps. Three female students were asked to download and use the app ‘moody month’ for 8   weeks and then take part in an interview exploring their experiences and perceptions of using the app. We found three key themes explained users' experiences of the app: reliable information, ease of use, trust and privacy. Users liked that they had access to reliable information about the menstrual cycle in an accessible and convenient way, and they realized that they did not know a lot about the menstrual cycle. Participants found the app easy to use and trusted the information. Overall, participants believed it was suitable for younger adolescents and that teenagers would benefit from learning more about the menstrual cycle.

A Brief Online Self-affirmation Intervention to Promote Safe sex Intentions (Chapter 10)

Chapter 10 discusses our research evaluating a self-affirmation and sexual health intervention for low SES female teenagers aged 13–16   years. A self-affirmation intervention was chosen because of its links with self-esteem. Self-esteem has been found to be a highly important predictor of early sexual initiation in our earlier studies (described in Chapters 3 and 7). A sexual health website was used to deliver the sexual health information as it was perceived to be reliable by teenagers in the study described in Chapter 8. The website included information about all areas of sexual health, including peer pressure and pornography, which were identified as important predictors of risky sexual behavior. The results showed that the self-affirmation intervention significantly increased self-esteem for the self-affirmed group compared with the nonaffirmed group. In addition, the self-affirmed group had significantly higher intentions to have safe sex postintervention and at a 1   week follow-up compared with the nonaffirmed group. However, there were no significant postintervention differences in sexual health knowledge between the self-affirmed and nonaffirmed groups.

Reflections and Conclusions (Chapter 11)

The final chapter moves onto some final reflections and conclusions. It provides a summary and conclusion based on each of our studies presented throughout the book and an overview and summary of the main research literature. Finally, future research ideas and design implications for moving forward with online self-esteem and sexual health intervention programs are discussed.

Chapter 2

Current Research on Sexual Health and Teenagers

Abstract

This chapter examines the literature around teenagers' sexual health. The chapter is split into five sections to provide greater clarity around the research problem. The first section provides an overview of teenage sexual health and discusses the different definitions of risky sexual behaviors. The second section provides an overview of the main theoretical models that are discussed in the literature, while the third section examines the predictors of risky sexual behaviors. The fourth section discusses sexual health issues in the digital world, and the final section focuses specifically on the issue of females from low socioeconomic status areas, as discussed briefly in the previous chapter, is the target group for our own research. Taken together, these sections provide an overview of the current research on sexual health and teenagers.

Keywords

Digital health interventions; Sexual health; Sexual health education; Sexual health interventions; Teenagers

Sexual Health and Defining Risky Sexual Behaviors

Theoretical Models of Risky Sexual Behavior

The Theory of Planned Behavior

Health belief model

Problem behavior theory

Predictors of Risky Sexual Behaviors

Parental and Peer Influences

The Self

Personality

Situational Factors

External Factors

Digital World Issues

Pornography

Sexting

What is sexting?

Prevalence of sexting?

Teenagers' views of sexting

Professional's views of sexting

Sexting and risky sexual behavior

Best practices—guidelines from research

Spotlight on: Female Teenagers from low SES Areas

Pressure, coercion, and consent

Chapter Summary

Sexual Health and Defining Risky Sexual Behaviors

The term, sexual health, is frequently used in the applied context of sexual education and health promotion; according to the current working definition from the World Health Organization, sexual health is

…a state of physical, emotional, mental and social well-being in relation sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.

WHO (2006), p. 6

First sexual initiation is a normal and expected aspect of adolescent development, which usually takes place during adolescence or young adulthood (Heywood, Patrick, Smith, & Pitts, 2015) and marks the beginning of an individual's sexual and reproductive life. The majority of these first sexual connections are with the opposite sex (Diamond, 2004; Diamond & Lucas, 2004; Horne & Zimmer-Gembeck, 2005). Healthy teenage sexuality is defined as teenagers accepting their bodies, gender identity, and sexual orientation; communicating effectively with family, peers, and partners, as well as possessing accurate knowledge of sexual health, understanding the risks, responsibilities, and outcomes of sexual actions, possessing skills needed to take action to reduce their risk, knowing how to access and seek sexual health information, and forming and maintaining healthy relationships (Department of Health, 2011). Healthy teenage sexuality is central to well-being and entails active exploration of identity, values, goals, and behavior (Halpern, 2010). Healthy and positive attitudes toward sexual health are significantly associated with better general overall health for teenagers (Hensel, Nance, & Fortenberry, 2016).

However, risky sexual behaviors are also prevalent among teenagers. The number of pregnancies and prevalence of sexually transmitted infections (STIs) in the teenage population are still high despite the development of numerous sexual health intervention programs (Health Protection Agency, 2010).

Teenage sexual risk-taking has been conceptualized in various ways:

• Early age at first intercourse (Heywood et al., 2015)

• Multiple sexual partners (Kuortti & Kosunen, 2009; Valois, Kammermann, & Drane, 1997a)

• Type of partner or length of relationship (Potard, Courtois, & Rusch, 2008)

• Frequency of intercourse (Valois, Kammermann, & Drane, 1997b)

• Consistency of condom use (Morrison et al., 2009)

• Sexual intercourse and alcohol/drug use (Brown & Vanable, 2007)

Consequently, there are various ways that sexual risk-taking has been measured, and while these can be considered an aspect of risk-taking, it has been argued that these do not measure the construct, as sexual risk-taking usually involves a combination of these behaviors (Casey & Beadnell, 2010). For example, inconsistent condom use is less of a risk with one partner if they do not have an STI; however, inconsistent condom use becomes a greater risk with multiple sexual partners. Furthermore, there are contrasting findings in the literature. Stone and Ingham (2003) found condom use but not number of partners to be a significant predictor of STIs. In contrast, Beadnell et al. (2005) found number of partners but not condom use to be a significant predictor of STIs.

Much of this research is correlational and has not established cause and effect. Further research has sought to establish causality using longitudinal designs, and subsequent research has found that early age of sexual intercourse is associated with poorer social environmental factors, such as poor connections with family and peer