Time to Reboot: Engaging Youth in Preventive Behavior Change
By Marguerita Lightfoot
As I watched the vice-presidential debates from a hotel room, I was amused by the steady stream of commentary I received via text message from my twenty-something brother. Then it occurred to me that if I were home, my friends and I would have chosen to watch the debate together in someone’s home. It would have been a social event. However, it is clear that young people of my brother’s generation, adolescents to twenty-something, connect with each other in a very different way.
Young people are much more likely to jointly experience events, not in someone’s living room, but rather via text messages, My Space, Twitter, blogs, or instant messaging. In fact, recent marketing research indicates that 80% of youth own three or more personal media devices, 96% go online daily, and for 78% of youth, cell phones are the most popular method of remote communication (Event Marketing Institute, 2008). According to the Pew Internet & American Life Project (2008), 91% of persons aged 18 – 29 years use the internet at least occasionally, most parents (59%) of 12 – 17 year olds believe the internet is beneficial in the lives of their children, and 64% of online adolescents aged 12 to 17 years create online content (e.g., blog, post online photos; Lenhart and Madden, 2007). Only 7% of these parents believe the internet is a “bad thing.” If young people connect with each other, connect with the outside world, and obtain information via the internet, psychologists must consider how these emerging vehicles for interpersonal and social interaction can be utilized to promote the psychological well-being of youth. We can not limit our discussions to simply documenting the “risks” associated with these mediums; rather we must also consider how these mediums can be used to advance psychology, both scientifically and therapeutically.
Advances in computer technology and its increasing availability provide a rich learning and therapeutic aid for adolescents (Skinner, Biscope, Poland & Goldberg , 2003; Smith, Gertz, Alvarez & Lurie, 2000; Dede, 1986). Computer-assisted instruction has been used therapeutically with
Phobic patients (Marks, Mataix-Cols, Kenwright, Cameron, Hirsch, & Gega, 2004; Newman, Consoli & Taylor, 1997; Bornas, Tortella-Feliu, Llabres & Fullana, 2001)
Depressed patients (Osgood-Hynes, Greist, Marks, Baer, Heneman, Wenzel, Manzo, Parkin, Spierings, Dottl & Titse, 1998; Marks et al., 2003; Christensen, Griffiths, & Korten, 2002; Selmi, Klein, Griest, & Erdman, 1990)
Overweight patients (Williamson, Martin, White, Newton, Walden, York-Crowe, Alfonso, Gordon & Ryan, 2005; Turnin, Bourgeois, Cathelineau, Leguerrier, Halimi, & Sandre-Banon, 2001; Rothert, Strecher, Doyle, Caplan, Joyce, Jimison, Karm, Mims, & Roth, 2006)
Persons with obsessive-compulsive disorder (Greist et al., 2002)
Patients with eating disorders (Bara-Carril, Williams, Pombo-Carril, Murray, Aubin, Harkin, Treasure, & Schmidt, 2004; Taylor, Winzelberg, & Celio, 2001; Andrewes, O’Connor, Mulder, McLennan, Weigall, & Sy, 1996)
and has increased patient's behavior management of diabetes (King, Estabrooks, Strycker, Toobert, Bull, & Glasgow, 2006; Glasgow, Toobert, Hampson, & Noell, 1997), and reduced adolescent substance use and violence (Schinke, Di Noia, & Glassman, 2004). As a result of these successes, computer-based interventions have been widely advocated in the fields of health education and prevention (Casazza & Ciccazzo, 2006; Goodman & Blake, 2005; Sampson & Kruboltz, 1991), yet there are few successful models of prevention of unhealthy behaviors for adolescents using computers and even fewer instances of evidenced-based programs being used in practice. The successful use of computers for treatment can be extended to use for prevention.
For youth who have been unsuccessful in mainstream programs, who respond poorly to didactic instruction, or experience difficulty in engaging or gaining insight in the therapeutic process, computers are a viable way to deliver prevention information and promote skill development. Because of the computer’s potential for enhancing intrinsic motivation, providing individualized feedback, and encouraging active engagement, computer-assisted instruction may offer certain advantages over traditional therapeutic strategies such as small groups. Further, in the settings in which youth are most exposed to psychosocial interventions—school-based settings—information is most commonly communicated by means of printed materials (e.g., books) and pamphlets. These materials are inexpensive and informative, but they lack intrinsic appeal and encourage passive learning; students often read these materials with a minimum of effort, involvement, and retention. Computer-based programs may enhance the attractiveness of such information, particularly for those youth who have not been successful in traditional educational settings.
In order to guide the development of such programs, principles of e-learning are useful. Gurak and Lannon (2003) argue that effective electronic communication is accessible (accurate, clear, complete, concrete, organized and visually effective), usable, and relevant. These e-learning principles are drawn from the disciplines of business/professional training, rhetoric, and educational psychology. As indicated in the final report from the Agency for Health Care Policy and Research (2003) on Consumer Health Informatics and Patient Decision Making, health informatics is defined as "the use of computers and telecommunications to help consumers obtain information, analyze their health care needs, and make decisions about their own health.” Consequently, relevant and salient computer programs have the potential to engage youth in therapeutic interventions, give youth the ability to guide their own process and progress, and provide tailored information and guidance.
A valid concern in using computer programs for therapeutic purposes with adolescents is that once given control of the computer in an unsupervised setting, the youth will “goof-off” or abuse the opportunity. However, previous work in self-efficacy skills training using computer-assisted interventions for youth in group homes, residential facilities, detention, runaway shelters, correctional facilities, Job Corp sites, adolescent substance rehabilitation centers, and community-based organizations have found that youth stay on-task. Furthermore, the vast majority of the youth in field tests exhibited behavior that indicated they took the computer simulation seriously and took advantage of the opportunity to practice their skills (Paperny, 1997; Thomas, Cahill, & Santilli, 1997). The youth remained on-task and negotiated the program as instructed. Similar to adults who expressed a preference for interactive computer programs to human advice on sensitive topics, most adolescents also reported feeling comfortable with a computer and preferred talking about sex with a computer more than with a person (Evans, Edmundson-Drane, & Harris, 2000; Paperny, Aono, & Lehman, 1990). This also suggests that youth appreciate the computer as a reusable means of gaining health information rather than as a “game” to try. For example, in an evaluation of a drug- and alcohol-use computerized intervention, the computer program was equally as effective as traditional interventions in improving students’ attitudes toward drug and alcohol use, and was rated as being more interesting than traditional interventions (Marsch & Bickel, 2004; Meier & Sampson, 1988). Furthermore, interactive computer programs could help disenfranchised youth learn skills to improve health and instill in these youth the self-efficacy to apply these new skills. Among youth from disadvantaged backgrounds, interactive modes potentially can bring a sense of confidence because youth can control their progress and learning (Diem & Katims, 2002).
In one example of a computer-based prevention program, we developed an interactive computerized intervention to reduce high risk sexual behaviors to prevent acquisition of sexually transmitted infections in delinquent adolescents. We adapted an efficacious, small-group, cognitive behavioral intervention (Project Light; National Institute of Mental Health, 1998) into an interactive computer program. A total of 133 adolescents aged 14 to 18 years from three continuation schools were recruited into the study and received the small-group intervention, the adapted computerized program, or no intervention. Participants completed baseline and three-month assessments and reported their sexual behavior (i.e., whether they had sex, number of sexual partners, and frequency of condom use). Participants were a mean age of 16 years (S.D. = 1.3), mostly male (55%), and of African American and Latino race/ethnicity (95%). Youth received intervention in school classrooms. The intervention targeted self-efficacy, behavioral skills, and cognitions that support engagement in healthy behaviors. Each session included a goal review, introduction of new material and related attitudinal and behavioral skills, goal setting, and group reinforcement and encouragement. The program included knowledge, identifying and managing triggers for behavior, problem-solving, interpersonal assertiveness, and maintenance of new behavioral routines. Small groups were conducted weekly and were facilitated by experienced counselors trained in cognitive behavioral therapy. The use of an intervention manual ensured consistent delivery and fidelity of the intervention. The computer program was made available in one classroom on laptop computers for youth to access during the school day. The interactive computer program was designed to be responsive and engaging to adolescents (see Figure 1). The content and process of the computer program was parallel to the small group condition.
As shown in Table 1, the rates of attendance to the intervention suggest the utility of using computers to engage youth in preventive health behavior. Similar to many psychoeducational programs, only 7% of participants in the small group condition attended all of the sessions and 56% attended some of the sessions. Absence from school on the day a session was conducted was the most commonly cited reason participants missed a session. By contrast, 70% of participants who receive the computer program were able to complete all of the sessions and 21% completed some but not all of the sessions. Therefore, 91% of the participants received some or all of the computerized content while only 63% of those in the small group received the programmatic contact. Participants in the computer program condition were able to work at their own pace and access the program when convenient for them, significantly increasing their ability to complete the program. Further, as shown in Table 2, participants rated the computer program very highly. All participants who received the computer program indicated they found the program interesting and would recommend the program to a friend. Most participants also reported they liked completing the program (89%) and rated the program as better than other programs they had received (87%).
The findings from this study have been reported elsewhere (Lightfoot et al., 2007). The computer program was comparable and sometimes better at reducing the sexual risk behaviors of the adolescents when compared to the small group program. Adolescents who received the computer program were significantly less likely to engage in sexual activity and reported significantly fewer sexual partners when compared to the control condition. Therefore, the computer program was better able to engage participants, facilitated higher rates of completion, and successfully encouraged preventive behavior change.
We have extended this work and designed a website for runaway and homeless youth that aims to prevent relapse to unhealthy behavior. First, runaway and homeless youth participated in a ten session cognitive behavioral small-group program when they received services from homeless shelters and drop-in centers. The small groups targeted the substance use and sexual risk behaviors of these youth. Once participants had completed 70% of the sessions, they were given access to the website, which reinforced the skills they learned while they were in the small groups and peer norms for maintaining healthier behaviors. A website intervention is particularly appropriate for runaway and homeless youth because, given their transience, they can not be expected to participate in long-term therapeutic interventions. Further, although homeless, we found in a previous study that upwards of 75% of youth indicated they had an email address and accessed the internet regularly. Participants in this study were followed longitudinally for 24 months. We were able to locate and assess 76% of participants at 24 months, aided significantly by connecting with participants through social networking sites such as My Space. The impact of the website on preventing relapse is currently being evaluated.
The current literature and our current studies support the need for engaging adolescents in programs that develop decision making, goal setting, and coping. These types of programs can be invaluable in assisting adolescents in making healthy choices. However, engaging adolescents in therapeutic programs is challenging and providing them with a full dose of treatment is difficult. However, a still underutilized strategy for engaging youth is the utilization of the communication mediums that adolescents employ. Our work indicates that computers are a viable way to deliver prevention information and promote skill development. While psychological science has established the dangers of these new media (e.g., Internet, video games), such as increased violence and addiction, we must also consider the potential strengths of these strategies and employ them appropriately. Our data suggests that this is not only possible, but sometimes preferable to adolescents.
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