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Journal of Child and Adolescent Psychiatric Nursing
ISSN 1073-6077
Preferred Health Resources and Use of Social Media to Obtain Health and Depression Information by Adolescent Mothers M. Cynthia Logsdon, PhD, WHNP-BC, FAAN, Gary Bennett, PhD, Rik Crutzen, PhD, LuAnn Martin, RN, BSN, Diane Eckert, RN, BSN, Ashley Robertson, BSN, MA, John Myers, PhD, MPH, Roselyn Tomasulo, RN, MSN, Jennifer Gregg, PhD, Michael Barone, PhD, MBA, Tania Lynch, MPH, BSN, MSN, and Laura Flamini, RN, BSN M. Cynthia Logsdon, PhD, WHNP-BC, FAAN, is Professor, School of Nursing, University of Louisville, and is Associate Chief, Nursing for Research, University of Louisville Hospital/Brown Cancer Center, Louisville, Kentucky; Gary Bennett, PhD, is Professor, Psychology, Global Health, and Medicine, and is Director, Duke Global Digital Health Sciences Center, and is Director, Duke Obesity Prevention Program, Duke University, Durham, North Carolina, USA; Rik Crutzen, PhD, is Post-Doctoral Fellow, School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands; LuAnn Martin, RN, BSN, is Maternal Child Health Coordinator and Manager, HANDS Program, Louisville Metro Department of Public Health and Wellness; Diane Eckert, RN, BSN, is Clinical Manager, Mother Baby Unit, University of Louisville Hospital; Ashley Robertson, BSN, MA, is Research Assistant, School of Nursing; John Myers, PhD, MPH, is Associate Professor, Department of Pediatrics, School of Medicine, University of Louisville; Roselyn Tomasulo, RN, MSN, is Perinatal Educator, University of Louisville Hospital; Jennifer Gregg, PhD, is Associate Professor, Department of Communications; Michael Barone, PhD, MBA, is Professor, College of Business and University Scholar; Tania Lynch, MPH, BSN, MSN, is Research Assistant, University of Louisville; Laura Flamini, RN, BSN, is Faculty, Sullivan University, Louisville, Kentucky, USA.
Search terms: Adolescent, Internet, social media Author contact: [email protected], with a copy to the Editor: [email protected] doi: 10.1111/jcap.12083
PROBLEM: Little is known about how adolescent mothers use social media and the Internet, especially to access health information. METHODS: In this cross-sectional, descriptive study, adolescent mothers were recruited from an academic medical center after the birth of their child (n = 94) or from a state-funded, home visitation program during the first year after birth (n = 91). They completed the Pew Internet Survey: 37 questions related to use of social media and Internet, particularly in regard to obtaining health information. FINDINGS: All adolescent mothers used a computer and almost all went online. Most accessed the Internet by cell phone (67.4%) and used social media. The health topics searched most frequently were pregnancy/birth control (85.8%), sexually transmitted diseases (n = 134, 72.6%) and HIV (66.3%). Response to survey questions differed between the two groups (adolescent mothers surveyed after birth from academic medical center and adolescent mothers surveyed in the first postpartum year in the community). CONCLUSIONS: Adolescent mothers spend significant time on the Internet including searching for health information. Cell phones are their preferred methods for accessing the Internet, and they use social media. Thus, social media and the Internet are potentially feasible and acceptable vehicles to deliver health interventions to adolescent mothers.
Adolescents continue to be an underserved population with little progress on accomplishing national health objectives to improve their health (Lawrence, Gootman, & Sim, 2009). The Internet may be replacing and/or supplementing health professionals as a source of health information for many adolescents. The Internet offers a convenient and confidential source of health information that adolescents generally regard as salient (Borzekowski & Rickert, 2001; Gould, Munfakh, Lubell, Kleinman, & Parker, 2002; Journal of Child and Adolescent Psychiatric Nursing 27 (2014) 163–168 © 2014 Wiley Periodicals, Inc.
Gray, Klein, Noyce, Sesselberg, & Cantrill, 2005; Lenhart, 2009). The advantages of using the Internet as a delivery mode for health promotion interventions are numerous. For users, an Internet intervention can be used at any pace, while the adolescent is alone, and anonymously (Napolitano & Marcus, 2002). Aloneness is about unobserved utilization: adolescents are able to obtain information without someone else observing them (Barak & Fisher, 2001). Anonymity is about 163
Preferred Health Resources and Use of Social Media to Obtain Health and Depression Information by Adolescent Mothers
unknown utilization. The term refers to the fact that the adolescent’s identity is publicly unknown. The factors anonymity and aloneness are very important because they limit potential embarrassment, which is related to the negative attitude and perceptions of stigmatization and shame (Moyer & Finney, 2004). Internet-delivered health interventions are accessible and may reach populations who otherwise do not receive treatment (Spek et al., 2007). From a health promoters’ point of view, using the Internet (a) offers improved opportunities for maintenance and updating of interventions (Atkinson & Gold, 2002), (b) can mimic expensive face-to-face sessions in providing an individual as well as interactive approach (Cummins et al., 2004; Neuhauser & Kreps, 2003), and (c) has the advantage of adjusting health information more easily to the needs of the user (Griffiths, Lindenmeyer, Powell, Lowe, & Thorogood, 2006). Data indicate that about 31% of adolescents between 12 and 17 years of age are using part of their time online to access health information (Lenhart, Purcell, Smith, & Zickuhr, 2010). In recent years, social media have become an undeniable part of the Internet. Using social media has the same advantages as using the Internet for health information, and, on top of that, extends the possibilities of adolescents to interact with each other. This might increase the personal relevance of the provided health information and therewith its effectiveness. These advantages have been acknowledged within the field of health promotion, which has resulted in an increased use of social media to reach adolescents (Gold et al., 2011, 2012; Pedrana et al., 2013). As a subpopulation of adolescents, adolescent mothers are in particular need of accurate and accessible health information in order to promote their own health and that of their baby. In 2010, there were 367,678 births to adolescents 15–19 years of age in the United States (cdc.gov/nchs/fastats/ teenbirth.htm). The Internet can be used to deliver interventions for adolescent mothers who are otherwise difficult to reach, which is essential to establish for interventions to have a public health impact (Glasgow, Vogt, & Boles, 1999). Little is known about how adolescent mothers use social media and the Internet to access health information, and more insight into this is needed in order to develop effective interventions to promote the health of the new family across the first postpartum year as the adolescent mother adjusts to the role of mother (Logsdon, 2008). Research questions were as follows: 1. What is the pattern of use of social media and the Internet by adolescent mothers? 2. How do adolescent mothers use social media and the Internet to obtain health information? 3. Do adolescent mothers differ in preferred health resources and use of social media and Internet when they are surveyed immediately after birth and later in the first postpartum year? 164
Methods In this cross-sectional, descriptive study, one group of adolescent mothers (n = 94) was recruited from an academic medical center within 3 days of birth of their child. The second group of adolescent mothers (n = 91) was recruited from a state-funded, home visitation program for first-time mothers during the first year after birth. Eligibility criteria included the following: 13–18 years of age, delivered live child, and child lives with adolescent mother. The study was approved by each healthcare organization and by the university institutional review board. Staff at each agency were trained by the research team in study procedures. After training, the agency staff then invited eligible adolescent mothers to participate in the study. If interested in study participation, adolescent mothers read a preamble indicating that completion of the questionnaire implied consent. Adolescent mothers read and completed a questionnaire. Agency staff was available for questions. The average time of questionnaire completion was 12 min. Each adolescent mother received a $15 retail card as a stipend for study participation. Adolescent mothers completed the Pew Internet Survey. The survey was used with permission and consists of 37 questions related to use of social media and Internet, particularly in regard to obtaining health information. The survey was developed by Pew Corporation Senior Researchers for use in the Pew Internet and American Life Project. It has previously been used in telephone interviews with a sample of 800 nationally representative teens (Lenhart et al., 2010). Data Analysis We first tested for any differences between the demographics of the two groups. Traditional chi-squared techniques were used to test for differences for categorical variables between the two groups (n = 94 adolescent mothers recruited from academic medical center and n = 91 adolescent mothers recruited from community), while t-test techniques were used to test for differences for the continuous variables. For those items where no differences occurred, data were combined for further analysis. In addition to data analysis related to the sample, descriptive data were calculated for each item on the instrument (number and percentage). T-tests were used to determine differences in the two groups (academic medical center and community groups) for research Question 3.
Results There were no differences in demographics between the two groups (see Table 1). The adolescent mothers surveyed were mostly Black (n = 94, 50.7%) or White (n = 62, 49.3%). The Journal of Child and Adolescent Psychiatric Nursing 27 (2014) 163–168 © 2014 Wiley Periodicals, Inc.
Preferred Health Resources and Use of Social Media to Obtain Health and Depression Information by Adolescent Mothers
Table 1. Demographics of the Adolescent Mothers Enrolled in the Current Study Demographics Ethnicity Black White Education Less than high school High school or less At least some college Parental education Less than high school High school or less At least some college Where they live With a single parent Alone Other
Overall N = 185 (%)
Hospital n = 94
Community n = 91
94 (50.7) 62 (49.3)
48 (51.1) 32 (48.9)
46 (50.5) 30 (49.5)
.946
42 (22.7) 58 (31.2) 85 (46.1)
21(22.3) 31 (33.0) 42 (44.7)
21 (23.1) 27 (29.7) 43 (47.3)
.887
54 (29.2) 52 (28.1) 79 (42.7)
28 (29.8) 28 (29.8) 38 (40.4)
26 (28.6) 24 (26.4) 41 (45.1)
.800
89 (48.3) 47 (25.6) 49 (26.1)
46 (48.9) 25 (26.6) 23 (24.5)
43 (47.3) 22 (24.2) 26 (28.6)
.807
adolescent mothers were more likely to have some college education (n = 85, 46.1%); similarly, their parents were also more likely to have some college education (n = 79, 42.7%). A majority lived with a single parent (n = 89, 48.3%) or alone (n = 47, 25.6%). Data analysis will now be presented for each research question.
Table 2. Use of Electronic Communication
Computer access
Web use
Journal of Child and Adolescent Psychiatric Nursing 27 (2014) 163–168 © 2014 Wiley Periodicals, Inc.
N = 185 (%) or Mean (SD)
Variable
RQ1: Pattern of Use of Social Media and the Internet by Adolescent Mothers All adolescent mothers used a computer (n = 185, 100.0%) and almost all went online (n = 184, 99.4%), having the most frequent access to the Internet at the local library (n = 180, 97.2%), at home (n = 180, 97.2%), at school (n = 160, 86.6%), and on their cell phones (n = 144, 77.8%). Over half (n = 93, 50.3%) went online several times a day, while a fourth (n = 44, 23.9%) went online once a day. On average, adolescent mothers spent 6 hr a week online (5.92 ± 2.48 hr). They had access to 1.69 computers that had Internet access. Adolescent mothers reported that their easiest means of accessing the Internet was by cell phone (n = 125, 67.4%). A majority of adolescent mothers sent more than 50 texts a day (n = 128, 69.4%) and received more than 50 texts a day (n = 125, 67.4%). Most did not participate in chat rooms (n = 150, 81.3%; see Table 2). Adolescent mothers are likely to use a cell phone (n = 159, 86.1%) and have a social networking profile (n = 154, 83.3%), using their social network profile to add comments/pictures (n = 162, 87.6%), post messages on a wall/page (n = 143, 77.5%), send a private message to a friend (n = 133, 71.9%), and send instant messages/text messages through a social network (n = 131, 71.1%). They are most likely to communicate with their friends by sending a text message (n = 123, 66.7%), talking on a cell phone (n = 103, 55.6%), by instant
p-value
Text use Chat room use
Library Home School Phone Go online Go online several times a day Daily Sent more than 50 a day Receives more than 50 a day Visit a chat room
180 (97.2) 180 (97.2) 160 (86.6) 144 (77.8) 184 (99.4) 93 (50.3) 44 (23.9) 128 (69.4) 125 (67.4) 35 (18.7)
SD, standard deviation.
messages (n = 83, 44.9%), or using a landline (n = 79, 42.7%). Most feel social media has improved communication skills (n = 125, 67.4%). The adolescent mothers were nearly as likely (n = 85, 46.1%) to use the computer/Internet/social media for coping as they were to use direct contact with the family and friends (n = 100, 53.9%; see Table 3). RQ2: Use of Social Media and the Internet to Obtain Health Information The biggest health issues the adolescent mothers reported were sexual health issues (n = 160, 86.3%), sexual assault (n = 155, 84.0%), violence (n = 151, 81.7%), and depression (n = 147, 79.2%). They were most likely to use their parents (n = 129, 69.5%), doctors/nurses (n = 145, 78.2%), and the Internet (n = 117, 63.4%) as sources of health information. Adolescent mothers trusted their doctors/nurses (n = 145, 78.2%), parents (n = 129, 69.5%), and health class (n = 109, 58.9%) the most for the information provided. Most 165
Preferred Health Resources and Use of Social Media to Obtain Health and Depression Information by Adolescent Mothers
Table 3. Type of Electronic Communication Used by Adolescent Mothers
Table 5. Comparison of Internet and Other Sources of Health Information
Adolescent mothers are likely to . . .
N = 185 (%)
The Internet was . . .
Use a cell phone Have a social networking profile Use social network profile to add comments/pictures Post messages on a wall/page Private message a friend IM/text through a social network Communicate with friends by Text Cell phone IM Landline Feel social media has improved communication skills Use social media for coping
159 (86.1) 154 (83.3) 162 (87.6) 143 (77.5) 133 (71.9) 131 (71.1)
A better source of information than. . . . Newspaper/TV news Magazines Radio A worse source of information than. . . . Friends/family Library Doctor’s office
123 (66.7) 103 (55.6) 83 (44.9) 79 (42.7) 125 (67.4) 85 (46.1)
IM, instant message.
Table 4. Health Information
Major sources of information Trusted sources for information Most important when seeking information
Sexual health Sexual assault Violence Depression Parents Doctors/nurses Internet Doctors/nurses Parents Health class Confidentiality Being face to face Able to ask specific questions
160 (86.3) 155 (84.0) 151 (81.7) 147 (79.2) 129 (69.5) 145 (78.2) 117 (63.4) 145 (78.2) 129 (69.5) 109 (58.9) 161 (86.8) 161 (86.8) 160 (86.3)
important to adolescent mothers when seeking health information was confidentiality (n = 161, 86.8%), being able to ask face-to-face questions (n = 161, 86.8%), and being able to ask specific questions (n = 160, 86.3%; see Table 4). The health topics searched for most by adolescent mothers were pregnancy/birth control (n = 159, 85.8%), sexually transmitted diseases (n = 134, 72.6%), and HIV (n = 123, 66.3%). Google was the search engine of choice (n = 164, 88.8%) for the adolescent mothers, with most finding the information from Google to be useful (n = 149, 80.4%) and resulting in behavior change as a result of the information (n = 113, 61.1%). In addition, the adolescent mothers were likely to talk with their friends (n = 137, 74.0%) and parents (n = 129, 69.7%) about the information that they found online. On average, the adolescent mothers visited 3.2 websites (±1.2 websites) in retrieving information. The adolescent mothers felt the Internet was a better source of health information than the newspaper/TV news (n = 113, 60.9% versus n = 72, 39.1%), magazines (n = 130, 70.2% 166
113 (60.9) 130 (70.2) 156 (84.4) 73 (39.4) 91 (49.1) 18 (9.8)
versus n = 55, 29.8%) and radio (n = 156, 84.4% versus n = 29, 15.6%). They believed that the Internet was a worse source of information than friends/family (n = 73, 39.4% versus n = 112, 60.6%), the library (n = 91, 49.1% versus n = 94, 50.9%), and the doctor’s office (n = 18, 9.8% versus n = 167, 90.2%; see Table 5).
N = 185 (%)
Variable Major health concerns
N = 185 (%)
RQ3: Preferred Health Resources and Use of Social Media in Adolescent Mothers Immediately After Birth (Academic Medical Center Cohort) and in the First Postpartum Year (Community Cohort) Responses of adolescent mothers to survey questions differed somewhat between the two groups (adolescent mothers surveyed immediately after birth from academic medical center and adolescent mothers surveyed in the first postpartum year in the community). For example, adolescent mothers who were surveyed in the first postpartum year (community) were more likely than adolescent mothers surveyed immediately after birth (academic medical center) to report weight loss/ eating disorders as a health issue of concern (n = 58, 64.0% versus n = 3, 2.8%, p < .001). They were more likely to use health class (n = 41, 44.9% versus n = 25, 27.8%, p = .002) and Twitter (n = 5, 5.6% versus n = 2, 2.8%, p = .012) as a source of health information. Adolescent mothers who were surveyed in the first postpartum year (community) trust the Internet more as a source of health information (n = 23, 24.7% versus n = 2, 2.8%, p = .001) than adolescent mothers surveyed immediately after birth (academic medical center). Adolescent mothers who were surveyed in the first postpartum year (community) were less likely than adolescent mothers surveyed immediately after birth (academic medical center) to view the Internet as a better source of health information than the library (n = 34, 37.1% versus n = 56, 61.1%, p = .018), magazines (n = 59, 65.2% versus n = 68, 75.0%, p = .022), and radio (n = 69, 76.4% versus n = 83, 91.7%, p = .010). They were less likely to have a social networking profile (n = 64, 70.8% versus n = 76, 83.3%, p = .011) and more likely to have a Twitter account (n = 13, 14.6% versus n = 5, 5.6%, p = .003) and to use Twitter to Journal of Child and Adolescent Psychiatric Nursing 27 (2014) 163–168 © 2014 Wiley Periodicals, Inc.
Preferred Health Resources and Use of Social Media to Obtain Health and Depression Information by Adolescent Mothers
communicate with friends (n = 10, 11.2% versus n = 3, 3.2%, p < .001). Adolescent mothers who were surveyed in the first postpartum year (community) were less likely than adolescent mothers surveyed immediately after birth (academic medical center) to use the computer/Internet/social media for coping than direct contact with the family and friends (n = 44, 48.9% versus n = 50, 54.4%, p = .046).
Discussion The study has several implications for healthcare providers. First, adolescent mothers spend significant time on the Internet both searching for health information and communicating with friends. Cell phones are their preferred methods for accessing the Internet. Thus, the Internet is potentially a feasible and acceptable vehicle to deliver health interventions to adolescent mothers (Park & Calamaro, 2013; Webb, Joseph, Yardley, & Michie, 2010). In developing health interventions on the Internet, consideration should be given to developing content that can be easily accessed with a variety of cell phone types. Our research and clinical experience has demonstrated that many adolescent mothers do not have more expensive smart phones. Adolescent mothers are likely to have a social networking profile (n = 154, 83.3%) and to send more than 50 texts a day (n = 128, 69.4%) and receive more than 50 texts a day (n = 125, 67.4%). Thus, social media and text are also potential vehicles for dissemination of health information and health interventions. In support of this recommendation, adolescent mothers were nearly as likely (n = 85, 46.1%) to use the computer/Internet/social media for coping as they were to use direct contact with the family and friends (n = 100, 53.9%) The biggest health issues the adolescent mothers reported were sexual health issues (n = 160, 86.3%), sexual assault (n = 155, 84.0%), violence (n = 151, 81.7%), and depression (n = 147, 79.2%). Nonpregnant adolescents report a need for online information about mental health problems (Havas, Nooijer, Crutzen, & Feron, 2011). Thus, the findings from this study provide the foundation for a future research study that includes testing of an Internet intervention for adolescent mothers with symptoms of depression. Confidentiality was very important to these adolescent mothers. Studies have demonstrated that it is possible to achieve confidentiality and active trust of adolescents by providing a health intervention through the Internet (Cugelman, Thelwall, & Dawes, 2011). Some health interventions on the Internet have also provided direct contact with healthcare providers (Crutzen et al., 2011). Responses of adolescent mothers to survey questions differed somewhat between the two groups (adolescent mothers surveyed immediately after birth from academic medical center and adolescent mothers surveyed in the first postparJournal of Child and Adolescent Psychiatric Nursing 27 (2014) 163–168 © 2014 Wiley Periodicals, Inc.
tum year in the community). Thus, it is clear that communication patterns and health concerns differ over the first postpartum year. Once again, this information can be used to tailor health interventions for this group. A strength of the study is that information was collected from one group of adolescent mothers immediately after delivery and from a second group of adolescent mothers across the first postpartum year. To our knowledge, these are the first data to be reported regarding use of the Internet by adolescent mothers at either time frame. In addition, a standard instrument developed by the Pew Corporation was used for data collection, allowing comparison of data. Limitations of the study include the cross-section design. In the community group, data were not collected on time since delivery. In the data analysis, the confidence intervals were wide, indicating small numbers of participants in each category and a potential limitation. Results of the study can only be generalized to similar populations.
Acknowledgments The project was supported by a research grant from the Improved Health Outcome Program, Passport Health Services. Preliminary findings from the study were presented at the Nurse Practitioner in Women’s Health Conference in Austin, Texas, October 2011.
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Glasgow, R., Vogt, T., & Boles, S. (1999). Evaluating the public health impact of health promotion interventions. American Journal of Public Health, 89, 1322–1327. Gold, J., Pedrana, A. E., Sacks-Davis, R., Hellard, M. E., Chang, S., Howard, S., . . . Stoove, M. A. (2011). A systematic examination of the use of online social networking sites for sexual health promotion. BMC Public Health, 11, 583. Gold, J., Pedrana, A., Stoove, M., Chang, S., Howard, S., Asselin, J., . . . Hellard, M. (2012). Developing health promotion interventions on social networking sites: Recommendations from the FaceSpace Project. Journal of Medical Internet Research, 14, e30. Gould, M. S., Munfakh, J. L., Lubell, K., Kleinman, M., & Parker, S. (2002). Seeking help from the internet during adolescence. Journal of the American Academy Child & Adolescent Psychiatry, 41, 1182–1189. Gray, N. J., Klein, J. D., Noyce, P. R., Sesselberg, T. S., & Cantrill, J. A. (2005). Health information-seeking behaviour in adolescence: The place of the internet. Social Science & Medicine, 60, 1467–1478. Griffiths, F., Lindenmeyer, A., Powell, J., Lowe, P., & Thorogood, M. (2006). Why are health care interventions delivered over the internet? A systematic review of the published literature. Journal of Medical Internet Research, 8, e10. Havas, J., Nooijer, J., Crutzen, R., & Feron, F. (2011). Adolescent’s views about an internet platform for adolescents with mental health problems. Health Education, 111, 164–176. Lawrence, R. S., Gootman, J. A., & Sim, L. J. (Eds.). (2009). Adolescent health services: Missing opportunities. Washington, DC: National Academies Press. Lenhart, A. (2009). Teens and mobile phones over the past five years: Pew internet looks back. Retrieved from http://authoring .pewinternet.org/Reports/2009/14-Teens-and-Mobile -Phones-Data-Memo.aspx
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Lenhart, A., Purcell, K., Smith, A., & Zickuhr, K. (2010). Social media & mobile internet use among teens and young adults. Retrieved from http://pewinternet.org/Reports/ 2010/Social0Media-and-young-adults.aspz Logsdon, M. C. (2008). Maternal role functioning in adolescents at 12 months postpartum. Women’s Health Care: A Practical Guide for Nurse Practitioners, 7, 27–32. Moyer, A., & Finney, J. (2004). Brief interventions for alcohol problems: Factors that facilitate implementation. Alcohol Research & Health, 28, 44–50. Napolitano, M., & Marcus, B. (2002). Targeting and tailoring physical activity information using print and information technologies. Exercise and Sports Scientific Review, 30, 122–128. Neuhauser, L., & Kreps, G. (2003). Rethinking communication in the eHealth era. Journal of Health Psychology, 8, 7–23. Park, B. K., & Calamaro, C. (2013). A systematic review of social networking sites: Innovative platforms for health research targeting adolescents and young adults. Journal of Nursing Scholarship, 45, 256–264. Pedrana, A., Hellard, M., Gold, J., Chang, S., Howard, S., Asselin, J., . . . Stoove, M. (2013). Queer as F**k: Reaching and engaging gay men in sexual health promotion through social networking sites. Journal of Medical Internet Research, 15, e25. Spek, V., Cuijpers, P., Nyklícˇek, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based cognitive behavior therapy for mood and anxiety disorders: A meta-analysis. Psychological Medicine, 37, 319–328. Webb, T. L., Joseph, J., Yardley, L., & Michie, S. (2010). Using the internet to promote health behavior change: A systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. Journal of Medical Internet Research, 12(1), e4.
Journal of Child and Adolescent Psychiatric Nursing 27 (2014) 163–168 © 2014 Wiley Periodicals, Inc.
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Journal of Child and Adolescent Psychiatric Nursing
ISSN 1073-6077
Preferred Health Resources and Use of Social Media to Obtain Health and Depression Information by Adolescent Mothers M. Cynthia Logsdon, PhD, WHNP-BC, FAAN, Gary Bennett, PhD, Rik Crutzen, PhD, LuAnn Martin, RN, BSN, Diane Eckert, RN, BSN, Ashley Robertson, BSN, MA, John Myers, PhD, MPH, Roselyn Tomasulo, RN, MSN, Jennifer Gregg, PhD, Michael Barone, PhD, MBA, Tania Lynch, MPH, BSN, MSN, and Laura Flamini, RN, BSN M. Cynthia Logsdon, PhD, WHNP-BC, FAAN, is Professor, School of Nursing, University of Louisville, and is Associate Chief, Nursing for Research, University of Louisville Hospital/Brown Cancer Center, Louisville, Kentucky; Gary Bennett, PhD, is Professor, Psychology, Global Health, and Medicine, and is Director, Duke Global Digital Health Sciences Center, and is Director, Duke Obesity Prevention Program, Duke University, Durham, North Carolina, USA; Rik Crutzen, PhD, is Post-Doctoral Fellow, School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands; LuAnn Martin, RN, BSN, is Maternal Child Health Coordinator and Manager, HANDS Program, Louisville Metro Department of Public Health and Wellness; Diane Eckert, RN, BSN, is Clinical Manager, Mother Baby Unit, University of Louisville Hospital; Ashley Robertson, BSN, MA, is Research Assistant, School of Nursing; John Myers, PhD, MPH, is Associate Professor, Department of Pediatrics, School of Medicine, University of Louisville; Roselyn Tomasulo, RN, MSN, is Perinatal Educator, University of Louisville Hospital; Jennifer Gregg, PhD, is Associate Professor, Department of Communications; Michael Barone, PhD, MBA, is Professor, College of Business and University Scholar; Tania Lynch, MPH, BSN, MSN, is Research Assistant, University of Louisville; Laura Flamini, RN, BSN, is Faculty, Sullivan University, Louisville, Kentucky, USA.
Search terms: Adolescent, Internet, social media Author contact: [email protected], with a copy to the Editor: [email protected] doi: 10.1111/jcap.12083
PROBLEM: Little is known about how adolescent mothers use social media and the Internet, especially to access health information. METHODS: In this cross-sectional, descriptive study, adolescent mothers were recruited from an academic medical center after the birth of their child (n = 94) or from a state-funded, home visitation program during the first year after birth (n = 91). They completed the Pew Internet Survey: 37 questions related to use of social media and Internet, particularly in regard to obtaining health information. FINDINGS: All adolescent mothers used a computer and almost all went online. Most accessed the Internet by cell phone (67.4%) and used social media. The health topics searched most frequently were pregnancy/birth control (85.8%), sexually transmitted diseases (n = 134, 72.6%) and HIV (66.3%). Response to survey questions differed between the two groups (adolescent mothers surveyed after birth from academic medical center and adolescent mothers surveyed in the first postpartum year in the community). CONCLUSIONS: Adolescent mothers spend significant time on the Internet including searching for health information. Cell phones are their preferred methods for accessing the Internet, and they use social media. Thus, social media and the Internet are potentially feasible and acceptable vehicles to deliver health interventions to adolescent mothers.
Adolescents continue to be an underserved population with little progress on accomplishing national health objectives to improve their health (Lawrence, Gootman, & Sim, 2009). The Internet may be replacing and/or supplementing health professionals as a source of health information for many adolescents. The Internet offers a convenient and confidential source of health information that adolescents generally regard as salient (Borzekowski & Rickert, 2001; Gould, Munfakh, Lubell, Kleinman, & Parker, 2002; Journal of Child and Adolescent Psychiatric Nursing 27 (2014) 163–168 © 2014 Wiley Periodicals, Inc.
Gray, Klein, Noyce, Sesselberg, & Cantrill, 2005; Lenhart, 2009). The advantages of using the Internet as a delivery mode for health promotion interventions are numerous. For users, an Internet intervention can be used at any pace, while the adolescent is alone, and anonymously (Napolitano & Marcus, 2002). Aloneness is about unobserved utilization: adolescents are able to obtain information without someone else observing them (Barak & Fisher, 2001). Anonymity is about 163
Preferred Health Resources and Use of Social Media to Obtain Health and Depression Information by Adolescent Mothers
unknown utilization. The term refers to the fact that the adolescent’s identity is publicly unknown. The factors anonymity and aloneness are very important because they limit potential embarrassment, which is related to the negative attitude and perceptions of stigmatization and shame (Moyer & Finney, 2004). Internet-delivered health interventions are accessible and may reach populations who otherwise do not receive treatment (Spek et al., 2007). From a health promoters’ point of view, using the Internet (a) offers improved opportunities for maintenance and updating of interventions (Atkinson & Gold, 2002), (b) can mimic expensive face-to-face sessions in providing an individual as well as interactive approach (Cummins et al., 2004; Neuhauser & Kreps, 2003), and (c) has the advantage of adjusting health information more easily to the needs of the user (Griffiths, Lindenmeyer, Powell, Lowe, & Thorogood, 2006). Data indicate that about 31% of adolescents between 12 and 17 years of age are using part of their time online to access health information (Lenhart, Purcell, Smith, & Zickuhr, 2010). In recent years, social media have become an undeniable part of the Internet. Using social media has the same advantages as using the Internet for health information, and, on top of that, extends the possibilities of adolescents to interact with each other. This might increase the personal relevance of the provided health information and therewith its effectiveness. These advantages have been acknowledged within the field of health promotion, which has resulted in an increased use of social media to reach adolescents (Gold et al., 2011, 2012; Pedrana et al., 2013). As a subpopulation of adolescents, adolescent mothers are in particular need of accurate and accessible health information in order to promote their own health and that of their baby. In 2010, there were 367,678 births to adolescents 15–19 years of age in the United States (cdc.gov/nchs/fastats/ teenbirth.htm). The Internet can be used to deliver interventions for adolescent mothers who are otherwise difficult to reach, which is essential to establish for interventions to have a public health impact (Glasgow, Vogt, & Boles, 1999). Little is known about how adolescent mothers use social media and the Internet to access health information, and more insight into this is needed in order to develop effective interventions to promote the health of the new family across the first postpartum year as the adolescent mother adjusts to the role of mother (Logsdon, 2008). Research questions were as follows: 1. What is the pattern of use of social media and the Internet by adolescent mothers? 2. How do adolescent mothers use social media and the Internet to obtain health information? 3. Do adolescent mothers differ in preferred health resources and use of social media and Internet when they are surveyed immediately after birth and later in the first postpartum year? 164
Methods In this cross-sectional, descriptive study, one group of adolescent mothers (n = 94) was recruited from an academic medical center within 3 days of birth of their child. The second group of adolescent mothers (n = 91) was recruited from a state-funded, home visitation program for first-time mothers during the first year after birth. Eligibility criteria included the following: 13–18 years of age, delivered live child, and child lives with adolescent mother. The study was approved by each healthcare organization and by the university institutional review board. Staff at each agency were trained by the research team in study procedures. After training, the agency staff then invited eligible adolescent mothers to participate in the study. If interested in study participation, adolescent mothers read a preamble indicating that completion of the questionnaire implied consent. Adolescent mothers read and completed a questionnaire. Agency staff was available for questions. The average time of questionnaire completion was 12 min. Each adolescent mother received a $15 retail card as a stipend for study participation. Adolescent mothers completed the Pew Internet Survey. The survey was used with permission and consists of 37 questions related to use of social media and Internet, particularly in regard to obtaining health information. The survey was developed by Pew Corporation Senior Researchers for use in the Pew Internet and American Life Project. It has previously been used in telephone interviews with a sample of 800 nationally representative teens (Lenhart et al., 2010). Data Analysis We first tested for any differences between the demographics of the two groups. Traditional chi-squared techniques were used to test for differences for categorical variables between the two groups (n = 94 adolescent mothers recruited from academic medical center and n = 91 adolescent mothers recruited from community), while t-test techniques were used to test for differences for the continuous variables. For those items where no differences occurred, data were combined for further analysis. In addition to data analysis related to the sample, descriptive data were calculated for each item on the instrument (number and percentage). T-tests were used to determine differences in the two groups (academic medical center and community groups) for research Question 3.
Results There were no differences in demographics between the two groups (see Table 1). The adolescent mothers surveyed were mostly Black (n = 94, 50.7%) or White (n = 62, 49.3%). The Journal of Child and Adolescent Psychiatric Nursing 27 (2014) 163–168 © 2014 Wiley Periodicals, Inc.
Preferred Health Resources and Use of Social Media to Obtain Health and Depression Information by Adolescent Mothers
Table 1. Demographics of the Adolescent Mothers Enrolled in the Current Study Demographics Ethnicity Black White Education Less than high school High school or less At least some college Parental education Less than high school High school or less At least some college Where they live With a single parent Alone Other
Overall N = 185 (%)
Hospital n = 94
Community n = 91
94 (50.7) 62 (49.3)
48 (51.1) 32 (48.9)
46 (50.5) 30 (49.5)
.946
42 (22.7) 58 (31.2) 85 (46.1)
21(22.3) 31 (33.0) 42 (44.7)
21 (23.1) 27 (29.7) 43 (47.3)
.887
54 (29.2) 52 (28.1) 79 (42.7)
28 (29.8) 28 (29.8) 38 (40.4)
26 (28.6) 24 (26.4) 41 (45.1)
.800
89 (48.3) 47 (25.6) 49 (26.1)
46 (48.9) 25 (26.6) 23 (24.5)
43 (47.3) 22 (24.2) 26 (28.6)
.807
adolescent mothers were more likely to have some college education (n = 85, 46.1%); similarly, their parents were also more likely to have some college education (n = 79, 42.7%). A majority lived with a single parent (n = 89, 48.3%) or alone (n = 47, 25.6%). Data analysis will now be presented for each research question.
Table 2. Use of Electronic Communication
Computer access
Web use
Journal of Child and Adolescent Psychiatric Nursing 27 (2014) 163–168 © 2014 Wiley Periodicals, Inc.
N = 185 (%) or Mean (SD)
Variable
RQ1: Pattern of Use of Social Media and the Internet by Adolescent Mothers All adolescent mothers used a computer (n = 185, 100.0%) and almost all went online (n = 184, 99.4%), having the most frequent access to the Internet at the local library (n = 180, 97.2%), at home (n = 180, 97.2%), at school (n = 160, 86.6%), and on their cell phones (n = 144, 77.8%). Over half (n = 93, 50.3%) went online several times a day, while a fourth (n = 44, 23.9%) went online once a day. On average, adolescent mothers spent 6 hr a week online (5.92 ± 2.48 hr). They had access to 1.69 computers that had Internet access. Adolescent mothers reported that their easiest means of accessing the Internet was by cell phone (n = 125, 67.4%). A majority of adolescent mothers sent more than 50 texts a day (n = 128, 69.4%) and received more than 50 texts a day (n = 125, 67.4%). Most did not participate in chat rooms (n = 150, 81.3%; see Table 2). Adolescent mothers are likely to use a cell phone (n = 159, 86.1%) and have a social networking profile (n = 154, 83.3%), using their social network profile to add comments/pictures (n = 162, 87.6%), post messages on a wall/page (n = 143, 77.5%), send a private message to a friend (n = 133, 71.9%), and send instant messages/text messages through a social network (n = 131, 71.1%). They are most likely to communicate with their friends by sending a text message (n = 123, 66.7%), talking on a cell phone (n = 103, 55.6%), by instant
p-value
Text use Chat room use
Library Home School Phone Go online Go online several times a day Daily Sent more than 50 a day Receives more than 50 a day Visit a chat room
180 (97.2) 180 (97.2) 160 (86.6) 144 (77.8) 184 (99.4) 93 (50.3) 44 (23.9) 128 (69.4) 125 (67.4) 35 (18.7)
SD, standard deviation.
messages (n = 83, 44.9%), or using a landline (n = 79, 42.7%). Most feel social media has improved communication skills (n = 125, 67.4%). The adolescent mothers were nearly as likely (n = 85, 46.1%) to use the computer/Internet/social media for coping as they were to use direct contact with the family and friends (n = 100, 53.9%; see Table 3). RQ2: Use of Social Media and the Internet to Obtain Health Information The biggest health issues the adolescent mothers reported were sexual health issues (n = 160, 86.3%), sexual assault (n = 155, 84.0%), violence (n = 151, 81.7%), and depression (n = 147, 79.2%). They were most likely to use their parents (n = 129, 69.5%), doctors/nurses (n = 145, 78.2%), and the Internet (n = 117, 63.4%) as sources of health information. Adolescent mothers trusted their doctors/nurses (n = 145, 78.2%), parents (n = 129, 69.5%), and health class (n = 109, 58.9%) the most for the information provided. Most 165
Preferred Health Resources and Use of Social Media to Obtain Health and Depression Information by Adolescent Mothers
Table 3. Type of Electronic Communication Used by Adolescent Mothers
Table 5. Comparison of Internet and Other Sources of Health Information
Adolescent mothers are likely to . . .
N = 185 (%)
The Internet was . . .
Use a cell phone Have a social networking profile Use social network profile to add comments/pictures Post messages on a wall/page Private message a friend IM/text through a social network Communicate with friends by Text Cell phone IM Landline Feel social media has improved communication skills Use social media for coping
159 (86.1) 154 (83.3) 162 (87.6) 143 (77.5) 133 (71.9) 131 (71.1)
A better source of information than. . . . Newspaper/TV news Magazines Radio A worse source of information than. . . . Friends/family Library Doctor’s office
123 (66.7) 103 (55.6) 83 (44.9) 79 (42.7) 125 (67.4) 85 (46.1)
IM, instant message.
Table 4. Health Information
Major sources of information Trusted sources for information Most important when seeking information
Sexual health Sexual assault Violence Depression Parents Doctors/nurses Internet Doctors/nurses Parents Health class Confidentiality Being face to face Able to ask specific questions
160 (86.3) 155 (84.0) 151 (81.7) 147 (79.2) 129 (69.5) 145 (78.2) 117 (63.4) 145 (78.2) 129 (69.5) 109 (58.9) 161 (86.8) 161 (86.8) 160 (86.3)
important to adolescent mothers when seeking health information was confidentiality (n = 161, 86.8%), being able to ask face-to-face questions (n = 161, 86.8%), and being able to ask specific questions (n = 160, 86.3%; see Table 4). The health topics searched for most by adolescent mothers were pregnancy/birth control (n = 159, 85.8%), sexually transmitted diseases (n = 134, 72.6%), and HIV (n = 123, 66.3%). Google was the search engine of choice (n = 164, 88.8%) for the adolescent mothers, with most finding the information from Google to be useful (n = 149, 80.4%) and resulting in behavior change as a result of the information (n = 113, 61.1%). In addition, the adolescent mothers were likely to talk with their friends (n = 137, 74.0%) and parents (n = 129, 69.7%) about the information that they found online. On average, the adolescent mothers visited 3.2 websites (±1.2 websites) in retrieving information. The adolescent mothers felt the Internet was a better source of health information than the newspaper/TV news (n = 113, 60.9% versus n = 72, 39.1%), magazines (n = 130, 70.2% 166
113 (60.9) 130 (70.2) 156 (84.4) 73 (39.4) 91 (49.1) 18 (9.8)
versus n = 55, 29.8%) and radio (n = 156, 84.4% versus n = 29, 15.6%). They believed that the Internet was a worse source of information than friends/family (n = 73, 39.4% versus n = 112, 60.6%), the library (n = 91, 49.1% versus n = 94, 50.9%), and the doctor’s office (n = 18, 9.8% versus n = 167, 90.2%; see Table 5).
N = 185 (%)
Variable Major health concerns
N = 185 (%)
RQ3: Preferred Health Resources and Use of Social Media in Adolescent Mothers Immediately After Birth (Academic Medical Center Cohort) and in the First Postpartum Year (Community Cohort) Responses of adolescent mothers to survey questions differed somewhat between the two groups (adolescent mothers surveyed immediately after birth from academic medical center and adolescent mothers surveyed in the first postpartum year in the community). For example, adolescent mothers who were surveyed in the first postpartum year (community) were more likely than adolescent mothers surveyed immediately after birth (academic medical center) to report weight loss/ eating disorders as a health issue of concern (n = 58, 64.0% versus n = 3, 2.8%, p < .001). They were more likely to use health class (n = 41, 44.9% versus n = 25, 27.8%, p = .002) and Twitter (n = 5, 5.6% versus n = 2, 2.8%, p = .012) as a source of health information. Adolescent mothers who were surveyed in the first postpartum year (community) trust the Internet more as a source of health information (n = 23, 24.7% versus n = 2, 2.8%, p = .001) than adolescent mothers surveyed immediately after birth (academic medical center). Adolescent mothers who were surveyed in the first postpartum year (community) were less likely than adolescent mothers surveyed immediately after birth (academic medical center) to view the Internet as a better source of health information than the library (n = 34, 37.1% versus n = 56, 61.1%, p = .018), magazines (n = 59, 65.2% versus n = 68, 75.0%, p = .022), and radio (n = 69, 76.4% versus n = 83, 91.7%, p = .010). They were less likely to have a social networking profile (n = 64, 70.8% versus n = 76, 83.3%, p = .011) and more likely to have a Twitter account (n = 13, 14.6% versus n = 5, 5.6%, p = .003) and to use Twitter to Journal of Child and Adolescent Psychiatric Nursing 27 (2014) 163–168 © 2014 Wiley Periodicals, Inc.
Preferred Health Resources and Use of Social Media to Obtain Health and Depression Information by Adolescent Mothers
communicate with friends (n = 10, 11.2% versus n = 3, 3.2%, p < .001). Adolescent mothers who were surveyed in the first postpartum year (community) were less likely than adolescent mothers surveyed immediately after birth (academic medical center) to use the computer/Internet/social media for coping than direct contact with the family and friends (n = 44, 48.9% versus n = 50, 54.4%, p = .046).
Discussion The study has several implications for healthcare providers. First, adolescent mothers spend significant time on the Internet both searching for health information and communicating with friends. Cell phones are their preferred methods for accessing the Internet. Thus, the Internet is potentially a feasible and acceptable vehicle to deliver health interventions to adolescent mothers (Park & Calamaro, 2013; Webb, Joseph, Yardley, & Michie, 2010). In developing health interventions on the Internet, consideration should be given to developing content that can be easily accessed with a variety of cell phone types. Our research and clinical experience has demonstrated that many adolescent mothers do not have more expensive smart phones. Adolescent mothers are likely to have a social networking profile (n = 154, 83.3%) and to send more than 50 texts a day (n = 128, 69.4%) and receive more than 50 texts a day (n = 125, 67.4%). Thus, social media and text are also potential vehicles for dissemination of health information and health interventions. In support of this recommendation, adolescent mothers were nearly as likely (n = 85, 46.1%) to use the computer/Internet/social media for coping as they were to use direct contact with the family and friends (n = 100, 53.9%) The biggest health issues the adolescent mothers reported were sexual health issues (n = 160, 86.3%), sexual assault (n = 155, 84.0%), violence (n = 151, 81.7%), and depression (n = 147, 79.2%). Nonpregnant adolescents report a need for online information about mental health problems (Havas, Nooijer, Crutzen, & Feron, 2011). Thus, the findings from this study provide the foundation for a future research study that includes testing of an Internet intervention for adolescent mothers with symptoms of depression. Confidentiality was very important to these adolescent mothers. Studies have demonstrated that it is possible to achieve confidentiality and active trust of adolescents by providing a health intervention through the Internet (Cugelman, Thelwall, & Dawes, 2011). Some health interventions on the Internet have also provided direct contact with healthcare providers (Crutzen et al., 2011). Responses of adolescent mothers to survey questions differed somewhat between the two groups (adolescent mothers surveyed immediately after birth from academic medical center and adolescent mothers surveyed in the first postparJournal of Child and Adolescent Psychiatric Nursing 27 (2014) 163–168 © 2014 Wiley Periodicals, Inc.
tum year in the community). Thus, it is clear that communication patterns and health concerns differ over the first postpartum year. Once again, this information can be used to tailor health interventions for this group. A strength of the study is that information was collected from one group of adolescent mothers immediately after delivery and from a second group of adolescent mothers across the first postpartum year. To our knowledge, these are the first data to be reported regarding use of the Internet by adolescent mothers at either time frame. In addition, a standard instrument developed by the Pew Corporation was used for data collection, allowing comparison of data. Limitations of the study include the cross-section design. In the community group, data were not collected on time since delivery. In the data analysis, the confidence intervals were wide, indicating small numbers of participants in each category and a potential limitation. Results of the study can only be generalized to similar populations.
Acknowledgments The project was supported by a research grant from the Improved Health Outcome Program, Passport Health Services. Preliminary findings from the study were presented at the Nurse Practitioner in Women’s Health Conference in Austin, Texas, October 2011.
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