Abstract and Introduction
Abstract
As the number of adolescents in the population is growing, it is even more important that healthcare practitioners are provided with the tools and resources that can best educate and connect with those patients at risk in this population, particularly with regard to sexual health behaviours. Notoriously, adolescents are difficult to engage in their own healthcare. However, with the advancement of technology and the ubiquitous use of cell phones, emerging studies suggest that there may be benefits to using text messaging within the adolescent health arena to encourage engagement, compliance and improve health knowledge. The use of text messaging has been implemented within adolescent healthcare in multiple ways but studies are needed to evaluate the content of messages, dosage and efficacy of text messaging in improving health outcomes in this population.
Introduction
Adolescence is a time when young people begin to explore their sexuality making access to sexual and reproductive health education and services a necessity for their well-being. Adolescents are vulnerable to sexually transmitted infections (STIs) for both biological and behavioural reasons. In the developed world, two-thirds of all STIs occur among men and women under the age of 25 years. In developing countries, the proportion is even bigger with many of these adolescents living in areas with a high HIV prevalence; hence education is especially important as well as engagement in care and compliance with medication for those already affected.
Failure to support adolescents and to help with all aspects of their developing sexuality has enormous consequences. Currently 11% of births worldwide occur to adolescent girls. Babies born to teenage mothers are more likely to be born preterm, to be of low birth weight and have higher rates of morbidity and mortality than those born to older women. Adolescent mothers often miss out on educational opportunities and the burden of young motherhood has immense psychosocial implications.
Additionally, over the past 50 years there has been a significant worldwide reduction in infant mortality, leading to a bulge in the number of adolescents. Young people aged between 10 and 24 years now comprise more than a quarter of the world's population. As a consequence, the burden of disease has shifted from infancy to adolescence.
Over time the major causes of morbidity and mortality in adolescence have changed from being largely biological in origin to being the result of environmental and psychosocial circumstances. Additionally, with the advancement of medicine, more children with chronic disease are surviving to adolescent years. This necessitates the ability to engage an adolescent in preventative services, a notoriously challenging task.
Multiple boundaries exist for adolescents seeking healthcare: financial, geographical, lack of knowledge regarding need for preventive healthcare and, perhaps above all, trust and confidentiality. Adolescents can feel uncomfortable talking about sexual and reproductive health or disclosing risk-taking behaviour to a life-long paediatrician or family doctor. Additionally, they may not be aware of their entitlement to seeing a doctor without the need for a parent in attendance. Accessing health education can also be confusing. With readily available information on the internet worldwide, adolescents are both helped as well as hindered; being able to distinguish correct from misleading information is challenging.
One key element to effectively engaging adolescents in their own healthcare is to approach them on their turf. The use of technologies and social media is widespread among adolescents and these tools have the potential for better healthcare delivery as well as improved health outcomes. For example, among adolescents aged 12–17 years in the USA, the average person owns 3.5 gadgets (cell phone, laptop, iPod/MP3 player, portable gaming device). Internet connectivity is increasingly moving off the desktop and into the mobile and wireless environment particularly among adolescents from lower socioeconomic class. Cell phone ownership has rocketed with 78% of 12–17-year-olds having one of their own. Ownership appears to cut across all demographic groups with little difference other than age. Overall, 55% of adolescents versus 30% of adults go online using cell phones. Currently, adolescents aged 13–17 years use an average of 320 MB of data per month on their phones, increasing 256% between 2011 and 2012.
Adolescents primarily use their cell phones for texting; the average adolescent sends seven messages per waking hour. Text messaging or short message service has several advantages over other modes of communication; it is transmitted between cell phones and so not dependent on fixed lines or equipment, it is fast, immediate and convenient. Young people may feel more comfortable asking questions in an anonymous way via text messages. The cost of sending a message is relatively low and messages can be sent to a single person or to multiple recipients, between cell phones or from a web-based platform to a cell phone(s). Furthermore, it has largely escaped the annoyance of advertising and spam. Use of text messaging is evenly distributed across social class and is increasingly available in developing countries.
In the following review, we will describe some recent worldwide research initiatives carried out within the adolescent sexual and reproductive health arena that use text messaging as an intervention. We will focus on the use of text messaging within 'Access to healthcare', 'Sexual health education, STIs and partner notification', 'HIV education, prevention and treatment' and 'Pregnancy prevention' sections. Each section will evaluate the quality of such initiatives and identify gaps within the literature, highlighting where and how future research may prove text messaging interventions to be beneficial for the health of adolescents.