Catering to less concerned and more disillusioned constituents and communicating with others who are more demanding and less forgiving is no simple task.
But when it comes to health -- especially adolescents' well being -- giving up or failing to connect with constituents aren't options.
In California, when the San Francisco Department of Public Health (SFDPH) noticed an increase in certain sexually transmitted diseases (STDs) among African-American youths in a particular city neighborhood, the department looked into every possible way to reach this population and curb the beginnings of an epidemic.
Because of its popularity among teenagers and young adults, the SFDPH chose short message service (SMS) to spearhead its sexual education outreach.
The SFDPH launched SexInfo, as the text messaging service is known, on April 24, 2006. The project was created after epidemiology results indicated an alarming increase in gonorrhea -- 102 percent from 2005 -- as well as chlamydia cases among 15- to 19-year-old African-Americans. Most of these cases occurred in Bayview/Hunter's Point, a low-income San Francisco neighborhood.
"We took the increase in gonorrhea rates seriously because the long-term effect is infertility," said Jacqueline McCright, community-based STD service manager for the SFDPH. "We do not want that to happen to young women."
Though curable, if untreated, gonorrhea can cause scarring to the carrier's reproductive organs, leading to infertility in males and females. The disease can also spread to the blood and joints, and weaken one's immune system, making a person more susceptible to other diseases, such as HIV/AIDS. To make matters worse, gonorrhea -- like many other STDs -- is nearly asymptomatic in some cases, quietly causing irreversible health damage before one knows it.
In the face of these consequences, McCright and her team, who had long been educating the neighborhood on STD prevention, decided the situation warranted new methods. "We're currently conducting outreach, and distributing condoms in the streets, in community-based agencies, and in the community that a majority of [those affected] reside in," she said. "Something more needed to be done."
The SFDPH partnered with San Francisco-based Internet Sexuality Information Services Inc. (ISIS), a nonprofit organization specializing in delivering sexual health information via a range of Internet-related technologies.
After several focus groups with youths and health professionals pointed to cell phones -- particularly text messages -- as the target population's preferred means of communication, ISIS developed SexInfo as a free service.
Though potentially obscure to those with little text messaging experience, SexInfo is a straightforward service for regular texters. First, users enter a numerical code into their cell phones -- for Metro PCS users, the code is 917-957-4280, and for other users it's a five-digit number, 61827 -- type in SexInfo and send the message.
Within seconds of texting SexInfo, users receive a text message with a choice of 11 answers, each bearing a letter and a number. They choose the entry that matches their concern and enter the corresponding letter and number.
For instance, if a user has pregnancy concerns, she can choose B2 from the 11 options -- which corresponds to "if u think ur pregnant" -- and hit reply. After a short wait, she will receive the names, addresses and/or phone numbers of two local resources from which she can request assistance.
ISIS turned to Hip Cricket, an Australian mobile phone marketing company, to create the codes and numbers users enter on their keypads to access the service.
Hearing the Youths
The decision to use a text messaging service was collaborative, said Deb Levine, director and founder of ISIS.
"We did all of our research and said, 'A Web site is not the best way for young people to get their information right now,'" she said. "There are many excellent STD prevention and sexual health Web sites geared to youths online, with fine information; very accurate and teen-appropriate information. We didn't think developing another Web site was the way to go."
McCright agreed that an Internet intervention would likely be unsuccessful because of the persisting digital divide. "All African-American youths still do not have access to the Internet, or have a computer in their households. Trying to reach them through that medium, we would not be reaching them."
In addition, Levine pointed out that even young people with Internet access are reluctant to seek sexual health information online -- whether at home or on a public computer -- because of privacy reasons. Text messaging, she said, is ideal because it ensures confidentiality, keeps the youths in charge and is their preferred mode of communication.
"Most of the people that don't get it are over 30, because they don't text message much," McCright said. "But most teenagers, that's what they do, and they do it so fast, it's amazing. They have their own code system. It might take me a long time to type a sentence -- they already have the answer.
"We definitely wanted it to be something quick," she continued. "This generation wants everything now. Everything is instant, and we wanted it to be quick and easy to use."
The focus groups were essential, Levine explained, adding that the participants' input played a large role in the service's development -- they said it was important for the youths to be in charge of the information.
"They did not want health officials, or anybody else for that matter, to send unsolicited text messages to their phone," Levine said of the focus group youths. "There's a lot of phone sharing among young people, so that's why they didn't want incoming messages that they hadn't asked for."
Another important feature for the participants in the focus groups was that with SexInfo, they could delete the information once they were done with it. "No one has to know you were seeking that information," McCright added.
Allowing youths this level of privacy has caused some concern among a handful of groups who believe this service may be trying to scrap parenting.
"For the last several decades, the safe sex community has tried to devise ways for teens to get around their parents," said Rob Knight, director of the Culture and Family Institute, an affiliate of Concerned Women for America. "They do not encourage kids to talk to their parents -- far from it. They encourage them to find information other ways, and this is another avenue."
Levine said the program tries to include parents as much as possible. "At the exact time we launched the SexInfo project, we launched a companion Web site for parents," she said of www.sextextsf.org. "We also made sure that the entire scripts are available on the Web site, and the Web address is on all of our marketing information as well, so that we are not hiding anything from parents."
Knight countered that the program provides teens and young adults with a skewed vision of sexuality. "The only thing new about this is the technology, since this is the same bad advice the kids have been getting for the past 30 years from Planned Parenthood and like-minded organizations," he said. "The consistent message is, 'Do anything you want at anytime, with anyone as long as you use condoms.'
"Kids should not be subjected to a monopoly on information -- particularly if it's inaccurate. So I would hope other organizations develop the same kind of technology to get kids the facts," Knight continued, and also suggested another Web site www.abstinenceclearinghouse.org.
Levine said it was important to give the youths various outlets and resources for information -- whether they chose to be sexually active or not. To do so, a committee of medical professionals, youth organizations such as the YMCA, and representatives from the largest church in Bayview/Hunter's Point participated in the project's development.
In addition, SexInfo offers resources for kids who need temporary housing, or simply someone to talk to.
Positive Results
The program is funded by the Centers for Disease Control and Prevention, McCright said, and has cost about $50,000 to date, including advertising -- billboards in the targeted neighborhood, flyers distributed to schools and in the streets, and posters on bus shelters, among other publicity tools.
"I don't think taxpayers should have to subsidize misinformation, and the corruption of children," Knight said, "and that's what's happening here."
Preliminary results, however, show that the service is successful in reaching out to adolescents.
With the Hip Cricket software, the SFDPH and ISIS can track the number of messages sent to SexInfo. In its first month, the service received 904 text messages to the five-digit number, followed by 1,212 secondary messages, in which youths chose one of the 11 answers.
In addition, McCright said, teenagers and young adults are using the resources recommended by the service. "The youths are going to those as a result of getting that information through the text-messaging program," she said.
Other cities have taken note, Levine said, and have shown interest in developing similar programs. Levine, however, said she would like to see the service expand to a wider scope.
"We are most interested in providing a national service where people would be able to go to SexInfo, type in their city or their ZIP code, and get local resources and information, rather than adding city by city, or area by area," she explained. "It's almost like a hotline, but via text messaging."
For now, the service is automated, but Levine said the software can let someone answer questions one by one, though funds aren't currently available to staff such a position.
After the four-month pilot, the SFDPH extended the program for another year. Further research after the year-long extension will determine whether the service successfully minimized gonorrhea rates among kids in Bayview/Hunter's Point.
Still, early results show the SFDPH's success in reaching out to youths on their own terms, and involving them in the development of a solution to a community problem that affects adolescents directly.
"Everything we do, we involve them in the planning," McCright said. "What might be cool to us as professionals might not be cool to youths."
