For some behaviours, like quitting smoking, text message health messages are efficient, affordable, and highly cost-effective; nevertheless, they might not be helpful for preventing STIs. In an effort to promote safer sex practises, researchers texted young individuals who had recently had a STI on a regular basis. However, they discovered that the messages had no effect on the rates of chlamydia and gonorrhoea reinfection.
The findings of the study, which was conducted by the London School of Hygiene and Tropical Medicine (LSHTM) and was published in The BMJ, prompted the researchers to call for improved evaluation of health communication interventions, especially given that the World Health Organization currently suggests digital health communication for sexual and reproductive health.
Their conclusions were based on a trial in which, between April 1, 2016, and November 23, 2018, 6248 individuals aged 16 to 24 who had recently had a chlamydia, gonorrhoea, or non-specific urethritis diagnosis or therapy were enrolled. This age group has the highest STI prevalence. Age, ethnicity, education level, and sexual orientation were similar between the groups at the beginning of the trial, and full data were available for 4675 (75%) of the participants. About 65% of individuals in each group were female, 78% were white, and 85% were heterosexual.
The “safetxt” intervention, which involved sending 3,123 individuals a series of texts to “better sex practises,” was compared to 3,125 control participants, who instead received a monthly text message for a year inquiring for any changes to their mailing or email addresses.
The Behavioral Psychology Texts
The COM-B model for influencing behaviour, created by co-author Susan Michie, advisor to the government’s behavioural insights team, and recently appointed chair of a WHO technical advisory group on behavioural insights, served as the foundation for the “Safetxt” message system.
The safetxt group received four messages per day for days 1 to 3, one or two per day for days 4 to 28, two or three times per week for month 2, and between two and five times per month for months 3 to 12. In contrast, the control group simply received a neutral monthly test. Before engaging in unprotected sex with a new partner, the messages urged participants to tell partners about their infection, use condoms, and get tested for STIs.
The messages were purposefully non-blaming and non-stigmatizing and were tailored to the participants’ sex, gender, and sexual orientation. Messages regarding how other people have negotiated condom use were sent to everyone who admitted to having sex with men. Messages regarding emergency contraception were sent to both women and men who had sex with women. Messages regarding HIV post-exposure prophylaxis were delivered to males who acknowledged having intercourse with other men. Condom-related texts were not sent to women who only had intercourse with other women.
Additional Recurrences in the Intervention Group
By enhancing three essential safer sex behaviors—partner notification at one month, condom use, and testing for STIs before engaging in unprotected sex with a new partner—the researchers anticipated that safetxt would lower the incidence of chlamydia and gonorrhoea reinfection at one year. In fact, their data showed that the safetxt group experienced higher reinfections than the control group.
Results revealed that at 4 weeks, 86% of individuals in the intervention group compared to 84% in the control group had informed their most recent partner that they needed to get therapy. Additionally, against the control group, 42% of participants in the intervention group reported wearing a condom during their most recent sex. At one year, 54% of participants in the intervention group and 49% in the control group reported using a condom at a first sexual encounter with their most recent new partner, respectively. At the same time, 34% of participants in the intervention group and 31% in the control group reported using a condom at their most recent sexual encounter.
At the end of the 12-month study period, participants were asked to submit a sample to the researchers and complete a home test for chlamydia and gonorrhoea infections. They discovered that 693 of 3,123 (22.2%) in the safetxt group had experienced chlamydia or gonorrhoea reinfection as opposed to 633 of 3,125 (20.3%) in the control group.
Texts might have raised the risk.
As a result, the researchers stated that “the number of STIs was not reduced” despite “some rise… in self-reported cautious behaviours such as condom use.” In fact, they acknowledged that the intervention “may have raised risk.” They proposed two potential explanations for this: diminished shame associated with having a STI and diminished sense of isolation associated with “not being the only one” to have a STI, both of which would result in diminished cautious behaviour.
The proportion of participants who reported having a new partner or two or more partners at one year was similarly greater in the intervention group, they added, despite the fact that the intervention did not specifically target sexual partnerships.
The authors claimed that despite being based on psychological theory and taking into account the most recent research on changing health behaviour, their text message intervention did not produce the results they had hoped for. In light of our findings, WHO should clarify which subjects and material it supports in its endorsement of digital behaviour change communication for enhancing health systems.