Virtual Clinic for Sexually Transmitted Diseases: Use of Avatars and Social Networks in Public Health Interventions

A total of 6 papers have been published and one more has been submitted. Three of these papers were published during 2013. From the 5 papers, two are level 1 and referenced in PubMED.

Dissemination activities in 2013: lectures on sexual health where sjekkdeg was a part of the curricula have been given at Tvibit (http://www.tvibit.net/) in Tromsø and several posters were placed in schools in Finmark.

A Facebook campaign has also been conducted during 2013 with visible results with a peak in the number of visits.

The following 2 publications have now been submitted in 2014:

“Play as a prevention strategy: Using a web app to teach youth about STDs”, Elia GABARRON, Thomas R. SCHOPF, J. Artur SERRANO, Rolf WYNN, submitted to MIE’2014, Istanbul, Turkey, 31.08-03-09, 2014. (submitted)

“Can a game-style web app prevent sexually transmitted diseases?”, E Gabarron, T Schopf, L Fernandez-Luque, JA Serrano, ATA’2014, Baltimore, Maryland, USA, May 17-20 2014. (accepted)

The game-style Webb app sjekkdeg.no consists of an avatar supported intervention, which as a first approach bypasses direct physical appointments but still provides access to reliable medical information available in a virtual space through written lessons and quizzes in the school; videos in the cinema and a STDs symptom checker and for guidance diagnosis in the clinic. In addition to the game aesthetic, gamification techniques have been implemented related to the customization of the avatar, that provides anonymity and lets the user interact with permanent inhabitants in the virtual space (wizard, teacher, and doctor); as well as achievement-based gifts such as new clothes and accessories for the avatar that are unlocked based on triggered events (i.e., read a lesson, make a quiz); and challenges between users on their results on quizzes that can be shared on Facebook and Twitter. Social media sharing buttons allow youngsters to share information in social media, and thus helping the Web app to be disseminated to more people. Users can reach the Web app equally from a laptop, a tablet computer or a smartphone and recover their own avatar and achievements using a unilink, a unique http address specifically created for the particular user that protects anonymity.

The results show that for the entire 2013 the web app had 3670 visits, and only for Norway since October 2012 to December 2013 there were a total of 2.363 visitors (38,6% returning visitors); with an average of 19,12 pages/visit and a total time on site of 4:43 minutes. Highest average time spent rates were in main page of cinema (3:20 minutes), school lessons “Can you have sex that you want?”, “Chlamydia” and “When guys have sex” (2:31; 1:49; and 1:48 minutes respectively); and customization of a female avatar (1:42 minutes).

These numbers on site use show the potential interest of visitors on this type of web app, according to the returning rates, average pages visited and time spent on it. The game-style could be encouraging users to explore more the website, having a higher exposure to the health educational material, and thereby learn more on sexual health. The results show that the game-style web app could be useful to encourage users to learn more on sexual health and STDs and thus changing their risky behaviours and preventing sexually transmitted diseases.

The project has also produced an invention disclosure report (DOFI).

Norway has one of the highest Internet penetration rates in the world (97.2%) and these media are among the most powerful influences in the lives of young people, therefore a virtual clinic on STD accessible on different technological platforms (laptop, smartphone, tablet) can be a good way for educating young people on preventing STDs and especially Chlamydia. This is specially worrying as in Norway there are diagnosed more than 20.000 new cases of Chlamydia every year. In the two northernmost counties (Troms and Finnmark) the incidence has previously been nearly twice the Norwegian average and in 2011, 68% of reported chlamydia cases were found in persons below 25 years of age.

With near 2000 website visits per year from Norway there can be a strong impact for the Norwegian Public Health Service, as the game-style Web app sjekkdeg.no shows a potential for STDs prevention and to promote healthier sexual practices among North-Norwegian youngsters:

a) the game-style could encourage users to explore the website and thereby learn how to avoid STDs and interactivity leads to a longer exposure to the health educational material;

b) avatars could give anonymity in the access to sensitive information and at same time could be an opportunity for avoiding risky sexual behaviours;

c) the social media could be a valuable resource for sexual health promotion to youngsters, recruiting users and reach even more people.

The main objective of this project is to achieve that North Norwegian youngsters become more aware of STDs and prevent their spread. To achieve it a Virtual Clinic for Sexually Transmitted Diseases (VCSTD) will be developed. The VCSTD will provide early guidance and reliable information sources concerning reproductive health, delivered in a novel and innovative way to the younger population.

The VCSTD consists of an “avatar” supported intervention in a serious gamming and e-learning

environment, which will bypass direct physical access (in person) to reliable medical information, as well as allowing the youngsters to share that information in social media, and thus helping the VCSTD to be disseminated to more people.

It is well known that young people seek information about sensitive matters, including reproductive

health, and is also been proven that the use of computer-mediated communication could minimize the social and cultural constraints relating to the communication of sensitive matters.

Work in 2012 and current status

Platform development

A platform has been specified and implemented (available online www.sjekkdeg.no ). The artwork was done by a teenager artist and the development has been performed by a spannish company. Two videos were produced for this platform by a youg norwegian film maker.

Scientific production

A PhD has started in February 2012. The study protocol has been defined and published in a PubMed indexed journal (see Del 2)

A second publication is under way were the aspects related to "The psychology behind the gamification for health promotion and behavior change".

Two more publications were planned: one related to the medical findings and another to explore the use of avatars.

The next steps for 2013 are:

• Perform a large scale evaluation through an online survey.

• Disseminate the platform through institutions performing STD testing in North Norway.

• Analyse platform usage through data collected in Google Analytics.

• Report the findings.

Bakgrunnen for prosjektet er den høye forekomsten av genitale klamydiainfeksjoner hos unge mennesker i de to nordligste fylkene. I Finnmark har man registrert den desidert høyeste forekomsten av genital klamydia i Norge med nesten dobbelt så mange tilfeller sammenlignet med landsgjennomsnittet. Sytti prosent av klamydiatilfellene opptrer hos personer under 25 år og andelen positive prøver var i 2009 høyest i aldersgruppen 15-19 år. Genital klamydiainfeksjon kan ha alvorlige langtidsvirkninger, med blant annet kroniske smerter og ufrivillig barnløshet. Flertallet av pasientene med klamydia kjenner ikke symptomer. Blant tiltakene for å begrense smittespredningen er økt testing av personer som ikke har symptomer. Men studier har vist at de yngste aldersgruppene bare i liten grad har latt seg teste. Dette gjelder spesielt for gutter.

Et annet viktig tiltak er økt bruk av kondom som er den eneste sikre metoden som kan hindre klamydiasmitte fra en person til en annen dersom man ser bort fra seksuell avholdenhet. Informasjon om smitteforebyggende tiltak og nødvendigheten av testing, selv når man ikke har symptomer, ser ut å være en viktig strategi for å forebygge klamydiainfeksjon.

I ungdomsskolen gis i dag undervisning om seksuelt overførbare sykdommer og prevensjonsveiledning. Målet er at ungdom skal lære hvordan man unngår å bli smittet av en seksuelt overførbar sykdom samt å forhindre uønskede svangerskap. Det synes å være et behov for å repetere denne undervisningen også på et senere tidspunkt slik at man har en reell mulighet til å påvirke ungdom over tid. Internett er en viktig lavterskel kanal for å spre helserelatert informasjon både til pasienter og helsepersonell. Man har påvist at sosiale nettverk kan være viktig i utvekslingen av helserelatert informasjon mellom ungdom.

Formålet med prosjektet er å utvikle og evaluere en ny nettside som skal brukes til forebyggende helsearbeid rettet mot ungdom under 18 år. Fokus rettes spesielt mot samspillet mellom en Internettside og sosiale nettverk. Tilbudet skal gjøres kjent i Troms og Finnmark via ordinære media (lokale og regionale aviser, lokal TV) og gjennom sosiale nettverk (for eksempel Facebook).

I tillegg vil man informere alle helsestasjoner for ungdom / helsesøstre i Troms og Finnmark om det nye tilbudet. Etter lanseringen vil vi undersøke om etableringen av en slik nettside har påviselige helseeffekter. I en observasjonsstudie ønsker vi å samle inn kvantitative og kvalitative data. Alle helserelaterte opplysninger som samles inn i studien er av en slik art at enkeltpersoner ikke kan kjennes igjen. Følgende variabler skal brukes: antall klamydiatester, salg av nødprevensjon og antall svangerskapsavbrudd. Man skal se på mulige endringer i variablene som opptrer i løpet av studieperioden. Data fra de to nordligste fylkene sammenlignes med landsgjennomsnittet i valgte periode.

Videre vil vi gjennom en spørreundersøkelse og intervju kartlegge brukererfaringer til ungdom som har brukt nettsiden. Hensikten med brukerundersøkelsen er å forbedre nettsiden. Deltagere til spørreundersøkelse og intervjue rekrutteres via nettsiden. Spørreundersøkelsen retter seg mot ungdom i alderen 15-20 år. Til intervjuene søkes personer i aldersgruppen 16-20 år. Deltagere i spørreundersøkelsen og intervjuene vil ikke bli spurt om helseopplysninger. Deltagelse er frivillig og gjøres etter informert samtykke.