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Youngpeoplessexualhealthliteracy_seekingunderstandingandevaluatingonlinesexualhealthinformation.pdf
Martin, Susan P. (2017) Young people's sexual health literacy: seeking, understanding, and evaluating online sexual health information. PhD thesis.
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Enlighten:Theses
http://theses.gla.ac.uk/
Young people’s sexual health literacy: seeking,
understanding, and evaluating online sexual health
information
Susan P Martin, MA, MRes
Submitted in fulfilment of the requirements for the
Degree of Doctor of Philosophy
MRC/CSO Social and Public Health Sciences Unit
College of Social Science
University of Glasgow
2017
1
Abstract
Background: Improving the sexual health of young people is a key policy focus in Scotland.
As the influence of the internet has grown within a rapidly changing health information
landscape, so have opportunities for both sexual health promotion, and concerns about the
challenges faced by young people in navigating this online environment. This study explores
young people’s sexual health literacy (SHL), primarily within this online context.
Methods: Paired interviews with friendship groups and observational online activities were
used to explore young people’s experiences of finding, understanding and evaluating online
sexual health information. A purposive sample of 49 participants (aged 16-19), diverse in
terms of gender, sexuality and religion, were recruited from across Scotland from areas that
varied in terms of deprivation and urban/rural classification.
Findings: Participants varied in their confidence and ability to find and identify reliable
information, and typically regarded identifying and filtering reliable sources as challenging.
Barriers to accessing information on websites included: inaccessible language; inappropriate
or non-relatable information; and websites that were difficult to navigate or did not function
correctly. Concerns about stigma and ‘being seen’ seeking sexual health information was a
key barrier. Stark differences, often mediated by gender, sexuality and educational
circumstances, emerged in perspectives towards accessing sexual health information and
support online. Findings suggest that different social media platforms present different
opportunities and challenges; for example, social content sharing services such as YouTube
may be useful venues for developing critical SHL, while social networking sites such as
Facebook, may be less suitable to user’s active engagement in identity construction.
Dissatisfaction with school-based sexual health education appears to be a catalyst for online
information-seeking, but school-based sexual health education did little to equip young
people to use the online environment effectively.
Conclusions: Gender, sexual identity, stigma, structural factors and social support converge
and intersect around young people’s SHL. A broad range of targeted interventions are
needed to improve SHL, focusing on overcoming stigma, presenting positive messages and
developing interactive and critical skills. Schools could do more to develop SHL skills,
including teaching the digital and critical skills to seek and appraise online information.
Expanding online sexual health services may effectively complement traditional services
and encourage uptake, but it is essential that research establishes a robust, comprehensive
conceptualisation of SHL, and develops measurement tools specific to SHL such that
interventions can be evaluated and refined.
2
Table of Contents Abstract .................................................................................................................................. 1
List of tables and figures ........................................................................................................ 8
Acknowledgements ................................................................................................................ 9
Author’s Declaration ............................................................................................................ 10
1 Introduction .................................................................................................................. 11
1.1 Study aims and research questions ........................................................................ 14
1.2 Overview of thesis structure .................................................................................. 15
2 Literature review .......................................................................................................... 16
2.1 Overview of the literature review .......................................................................... 16
2.2 Description of literature review search strategy .................................................... 16
2.3 Section One: conceptualising ‘health literacy’, ‘sexual health literacy’ and ‘digital
health literacy’ .................................................................................................................. 17
2.3.1 Health literacy: theory and conceptualisations .............................................. 17
2.3.2 Conceptualising and measuring sexual health literacy .................................. 28
2.3.3 Towards a working conceptualisation of sexual health literacy .................... 31
2.3.4 Digital literacy and digital health literacy ...................................................... 33
2.3.5 Tripartite information access model .............................................................. 36
2.4 Section Two: Young people, online sexual health information and the ‘digital
divide’ .............................................................................................................................. 38
2.4.1 Young people, the internet and sexual health ................................................ 38
2.4.2 The internet, social media, connectedness and empowerment ...................... 40
2.4.3 Concerns about online sexual health: risks of online information and
interactions ................................................................................................................... 41
2.4.4 Promoting young people’s sexual health with digital services and interventions
44
2.4.5 Digital divide? ................................................................................................ 48
2.4.6 Perceptions of young people as ‘digital natives’............................................ 49
2.4.7 Researching young people’s skills in seeking online health information ...... 51
3
2.5 How can this study contribute to existing literature .............................................. 52
3 Methods ........................................................................................................................ 55
3.1 Overview of chapter .............................................................................................. 55
3.2 Aims and scope of the study .................................................................................. 55
3.2.1 Aims of the study ........................................................................................... 55
3.2.2 Identifying the population of interest ............................................................. 55
3.3 Epistemological and methodological rationales .................................................... 56
3.3.1 Why a qualitative perspective? ...................................................................... 56
3.3.2 Data collection methodology ......................................................................... 58
3.3.3 Analytical approach ....................................................................................... 63
3.4 Data collection methods ........................................................................................ 65
3.4.1 Ethics .............................................................................................................. 65
3.4.2 Overview of paired interview design and facilitation .................................... 66
3.4.3 Piloting the methods: reflections and learning ............................................... 69
3.4.4 The main study ............................................................................................... 73
3.5 Data management and analysis ............................................................................. 82
3.5.1 Transcription and data management .............................................................. 82
3.5.2 Three stages of analysis ................................................................................. 83
3.5.3 Reporting the data .......................................................................................... 90
3.6 Reflexivity ............................................................................................................. 91
3.6.1 Reflexivity in research ................................................................................... 91
3.6.2 Issues of power and the influence of the researcher ...................................... 93
3.7 Summary ............................................................................................................... 95
4 Sexual health information sources: school, peers and the internet .............................. 96
4.1 Overview of chapter .............................................................................................. 96
4.2 Learning in school ................................................................................................. 96
4.2.1 Focus on risk and sexual ill health (It’s risky!) .............................................. 98
4.2.2 Abstinence based messages (It’s risky, so don’t do it!) ............................... 100
4
4.2.3 Prevention messages and practical information (It’s risky, so use protection!)
102
4.2.4 Incomprehensive content (It’s all about heterosexual sex!) ......................... 104
4.2.5 The learning environment: teaching quality, delivery mode and awkwardness
of learning environment ............................................................................................. 106
4.3 The peer and friendship context .......................................................................... 111
4.3.1 Exchanging knowledge and sharing experiences ......................................... 111
4.3.2 Gendered perspectives on seeking and providing support ........................... 114
4.3.3 The role of embarrassment and stigma in peer support ............................... 117
4.4 Using the internet to learn about sexual health ................................................... 118
4.4.1 What sexual health needs did participants use the internet to address? ....... 119
4.4.2 Perceptions of the internet as convenient and accessible ............................. 122
4.4.3 Support and individual nuance in online information .................................. 123
4.4.4 The anonymous nature of the internet .......................................................... 125
4.4.5 Issues of trust and reliability ........................................................................ 126
4.5 Summary of findings ........................................................................................... 128
5 The online context: locating, understanding and evaluating sexual health information
131
5.1 General internet access and use ........................................................................... 132
5.2 Preferences for different types of online content ................................................ 133
5.2.1 Attitudes to social media and user-generated content .................................. 133
5.2.2 Perspectives on presentation style and tone of information delivery ........... 139
5.2.3 Attitudes to interactive and visual content ................................................... 144
5.3 Strategies for finding relevant and reliable sexual health information................ 149
5.3.1 Reliance on, and trust in, Google Search ..................................................... 149
5.3.2 Formulating search strings ........................................................................... 153
5.3.3 Rapid information seeking ........................................................................... 157
5.3.4 Trust in familiar and reputable sources ........................................................ 159
5.3.5 Evaluating websites based on initial perceptions ......................................... 161
5
5.3.6 Beyond first impressions: more nuanced markers of reliability .................. 162
5.4 Encountering and overcoming obstacles ............................................................. 166
5.4.1 Overabundance of content and lack of guidance ......................................... 167
5.4.2 Difficulty in sourcing locally-relevant content and navigating complex
websites 170
5.4.3 Obstacles to finding individually-relevant content ...................................... 172
5.4.4 Barriers to reading and understanding content............................................. 173
5.4.5 Censoring searches and concerns about sexually-explicit content .............. 175
5.4.6 Emotions experienced during online sexual health information seeking..... 177
5.5 Summary of findings ........................................................................................... 178
6 Applying sexual health information in sexual and healthcare contexts ..................... 181
6.1 Overview of chapter ............................................................................................ 181
6.2 Communication skills in managing and applying sexual health information ..... 181
6.2.1 General perceptions of communicating about sexual health........................ 182
6.2.2 Participants’ perceptions of their communication strengths and weaknesses
183
6.3 Communicating with sexual partners and negotiating sexual contexts ............... 185
6.4 Negotiating sexual health information and services within formal healthcare
settings ........................................................................................................................... 190
6.4.1 Attitudes towards attending and interacting in formal healthcare settings .. 190
6.4.2 Communicating and interacting with healthcare providers ......................... 192
6.4.3 ‘Being seen’ seeking sexual health information and services ...................... 199
6.5 Overcoming and circumventing formal sexual healthcare barriers ..................... 203
6.5.1 Seeking alternatives to traditional sexual health services: online STI testing
and advice................................................................................................................... 203
6.5.2 Sexual health apps: useful or embarrassing? ............................................... 209
6.6 Summary ............................................................................................................. 212
7 Discussion .................................................................................................................. 215
7.1 Overview of chapter ............................................................................................ 215
6
7.2 The school context: hindering or facilitating sexual health literacy? .................. 217
7.2.1 Why is school important to sexual health literacy? ..................................... 217
7.2.2 What hinders sexual health literacy within the school context? .................. 217
7.2.3 What facilitates sexual health literacy within the school context? .............. 220
7.2.4 School-based sex education and the online context .................................... 222
7.3 Young people’s sexual health literacy within the online context ........................ 223
7.3.1 Young people’s motivations and drivers for seeking sexual health information
online 223
7.3.2 Young people’s access to the internet: digital divide? ................................. 225
7.3.3 Sexual health literacy: skills and challenges in online information seeking 227
7.3.4 What are the specific challenges relating to sexual health literacy within the
online context? ........................................................................................................... 232
7.4 The role of friends and peers in optimising sexual health literacy in online and
offline contexts ............................................................................................................... 237
7.4.1 Why are friends and peers important to sexual health literacy? .................. 237
7.4.2 Friends as a source of informational, emotional and practical support........ 238
7.4.3 Peers in the online context ........................................................................... 241
7.5 Formal healthcare context: traditional and online ............................................... 244
7.5.1 Traditional healthcare system: facilitating or hindering young people’s sexual
health literacy ............................................................................................................. 244
7.5.2 Integrating the traditional offline healthcare system with the online context
248
7.6 Summary ............................................................................................................. 252
8 Conclusion and recommendations ............................................................................. 253
8.1 Overview of chapter ............................................................................................ 253
8.2 Study aims ........................................................................................................... 253
8.3 Main conclusions ................................................................................................. 253
8.3.1 What is the role of the internet within the broader landscape of young people’s
sexual health information and support? ..................................................................... 253
7
8.3.2 How do young people describe and experience seeking, understanding,
evaluating and using online sexual health information and support? ........................ 255
8.3.3 What are the individual, social and environmental factors relevant to young
people’s experience and use of online sexual health information and support? ........ 258
8.4 Policy implications and recommendations .......................................................... 259
8.4.1 Implications for schools: optimising sexual health literacy through school-
based sexual health education .................................................................................... 259
8.4.2 Implications for policy makers..................................................................... 261
8.4.3 Implications for information and service providers ..................................... 263
8.4.4 Implications for intervention development .................................................. 264
8.5 Strengths and limitations of the study ................................................................. 265
8.6 Recommendations for future research ................................................................. 268
References .......................................................................................................................... 271
Appendix 1 – Participant information sheet ...................................................................... 308
Appendix 2 - Participant consent form .............................................................................. 310
Appendix 3 – Basic questionnaires .................................................................................... 311
Appendix 4 – Interview topic guide ................................................................................... 313
Appendix 5 – Online activity scenarios ............................................................................. 315
Appendix 6 – PhD study timetable .................................................................................... 317
Appendix 7 – Gatekeeper letter.......................................................................................... 318
Appendix 8 – Recruitment poster (online and offline) ...................................................... 319
Appendix 9 – Participant demographics and recruitment details ..................................... 320
Appendix 10 – Thematic framework ................................................................................. 323
Appendix 11 – Example of a pairs ‘biography’ ................................................................. 325
Appendix 12 – Data integration table ................................................................................ 329
8
List of tables and figures
Figure 2-1 Dynamic sexual health literacy model 33
Figure 3-1 Paired interview stages and data produced 66
Figure 3-2 Analysis and synthesis processes 83
Figure 3-3 Extract from Framework matrix 86
Figure 3-4 Extract from website coding 88
Figure 5-1 Example of preferred website layout 141
Figure 5-2 Example of an interactive tool used by participants 145
Figure 5-3 Example of an interactive tool used by participants (2) 146
Figure 5-4 Example of pictorial information diagram 148
Figure 5-5 Ranking/type of link selected by participants 150
Figure 5-6 Example of Google ‘featured snippet’ 153
Figure 5-7 Categories of search string (Scenario one) 156
Figure 5-8 Categories of search string (Scenario two) 157
Figure 5-9 Example of website providing author details 165
Figure 5-10 Example of difficult to navigate websites 172
Figure 7-1 Dynamic sexual health literacy model 215
Table 2-1 Chronological definitions of health literacy 19
Table 2-2 Characteristics of health literacy measurements 26
Table 2-3 Characteristics of broader health literacy measurements 27
Table 2-4 Illustrative forms of health literacy 35
Table 3-1 Website categories and sub-categories 89
9
Acknowledgements
I am incredibly thankful and grateful for the time, guidance, and support I have been lucky
to have over the course of my PhD. There are so many people to thank.
Firstly, I would like to sincerely give my thanks to all of the young people who kindly agreed
to share their experiences with me. This study would never have happened without their
willingness to take part.
I would like to thank my supervisors, Dr Lisa McDaid, Dr Shona Hilton and Professor Paul
Flowers, for their encouragement and guidance throughout the project. I have benefited so
much from their expertise, pragmatism and continual support. Particular thanks goes to Dr
Gillian Fergie, for reading and commenting on a draft of this thesis, and for her
immeasurable support, as both a colleague and a friend.
I am grateful to the MRC for funding this studentship, and to all of the research and support
staff at the Social and Public Health Sciences Unit for their support and encouragement
throughout my time as a student.
My PhD experience would have been rubbish without all the amazing students I was lucky
enough to have around me. I wouldn’t have got through this without all the chats, hugs, and
cups of earl grey. Special thanks go to Rosie, Karen, Oonagh, Nicola, Lauren, Megan, Jo,
and Matt.
I would like to thank my family and friends for supporting me and understanding when I
couldn’t always be there. To my mum, thank you for all the bowls of homemade soup and
for being there for me every step of the way. Lastly, I would like to thank Chris, for being
there for me always, for encouraging me, for loving and supporting me – you got me through
this.
This thesis is dedicated to my Dad, Jim, who would have been so proud of me for writing
all these words!
10
Author’s Declaration
11
1 Introduction
Improving sexual health and blood borne virus (BBV) outcomes continues to be a high
priority for the UK and Scottish Governments, with sexual ill-health remaining an important
area for policy development (Department of Health, 2013; Scottish Government, 2011).
While there have been positive downward trends in unplanned teenage pregnancy rates in
Scotland and England, figures remain higher than many other western European countries
(Association for Young People’s Health, 2017; Office for National Statistics, 2016;
Information Services Division, 2017). Similarly, although, there were small reductions in
overall rates of new sexually transmitted infections (STIs) in 2016, transmission rates remain
high, particularly amongst young people (Public Health England, 2017; Health Protection
Scotland, 2016; Health Protection Scotland, 2015). In Scotland, research suggests that STIs
amongst young people remain an issue, particularly for young women aged under 25. Young
people in Scotland are unduly affected by chlamydia, with 68% of diagnoses in 2015 being
amongst young people under 25, and for young women, this was 75% (Health Protection
Scotland, 2016). Thus, sexual ill-health among young people is a particular public health
issue, with young people in Scotland remaining at-risk for adverse sexual health, with
research suggesting that this is due to relatively high numbers of sexual partners, relatively
low age of first sex, and increasing sexual coercion (Kirby et al, 2010; Mercer et al, 2013).
A school-based survey of 3465 young people aged 14-17 in five European countries found
that the highest rates of sexual coercion were reported by young women in the UK, with
44% reporting some form of pressure to engage in sex or other sexual activity, both face-to-
face and online (Barter et al, 2015).
While concerns about young people’s sexual practices and relationships are not new, the
rapidly changing health information landscape has altered the nature of these concerns, and
worries have grown steadily about the influence of the online environment on young
people’s safety, sexual behaviours and practices (Livingstone et al, 2014; Parker et al, 2014).
Public debates have arisen over the accessibility of sexually explicit content and the growth
of practices such as ‘sexting’ and online bullying, and the influence these phenomena may
have on young peoples’ practices and wellbeing (Horvath et al, 2013; Tanton et al, 2015). A
European Union survey of young people’s internet use found that one fifth of young people
(aged 9-16) had viewed a sexual image online (Mascheroni and Olafsson, 2014), and more
recent research into young people’s experiences with online pornography in the UK found
that 47% of young people had encountered online pornography by the age of 16 (Martellozzo
12
et al, 2017).
In addition to public apprehension in relation to online content, there has been recognition
of the potential of online technologies to support young people’s negotiation of their sexual
health. Whilst information about sexual health can be gathered from a broad range of
sources, new digital media and information technology have altered the sexual health
information and care delivery landscape, and have an important role to play in how young
people understand and interact with sexual health information. The internet is a major source
of sexual health information, and research has found that young people use the internet to
access such information (Borzekowsi and Rickert, 2001; Hansen et al, 2003; Kanuga et al,
2004; Levine et al, 2008). The internet is considered to have potential for alleviating worries
about confidentiality and embarrassment associated with accessing health information and
care from more traditional sources (Barman-Adhikari et al, 2011; Klein et al, 1999). Thus,
digital technologies present new opportunities to improve access to, provision of, and
engagement with sexual health information. For this reason, the online context may be a key
area of opportunity for sexual health interventions, including reaching young people with
sexual health promotion and providing access to services such as online testing and treatment
(Bailey et al, 2015).
The opportunities and challenges related to the role of digital technologies within young
people’s sexual health should be considered in the context of the Scottish and UK
government’s move towards services becoming ‘digital by default’, and ever-growing self-
care and management expectations (Cabinet Office, 2014; Scottish Government, 2011a).
The ‘digital health’ landscape has embraced the use of wireless devices, the internet, social
networking and mobile networks to address health challenges.
Whilst digital technologies do represent new opportunities to improve provision of, and
engagement with, information and services, and ultimately reduce health inequalities, there
are growing concerns that transferring services and information sources to online spaces
could instead fuel health inequalities. Aicken et al (2016) warn that “health inequalities
might increase, especially if expansion of online sexual health care was coupled with
reduced provision of conventional sexual health care” (p.13). Digital health inequalities
comprise concerns over access, affordability, usability and appropriateness of technology,
as well as individuals’ varying capacities to make effective use of digital technologies. Such
inequalities are multifaceted and complex, with individual, institutional and political
13
dimensions (eHealth Stakeholders Group, 2014). While concerns around a ‘digital divide’
in terms of fundamental access to the internet is considered to have become ‘redundant’ due
to physical access within high-income countries been shown to be approaching universality
(Office for National Statistics (ONS), 2016), worries persist about inequalities in how people
use the internet (Boonaert and Vettenburg, 2011; Elwick et al, 2013).
Concerns about the ‘digital divide’ have tended to focus on older people, with young people
typically perceived as ‘digital natives’, fully embedded and competent within the online
context (Prensky, 2001). However, researchers have increasingly been recognising the
difficulties that young people might face in negotiating their sexual health within the
demanding and constantly changing online context. With the introduction of digital
technologies, the sexual health information and support landscape is dynamic, presenting
young people with challenges in effectively finding information and applying that
information in decision-making. There is a huge quantity of sexual health content online,
and due to the decentralised nature of the internet, regulating and negotiating the quality and
accuracy of that information is challenging. With sexual health information increasingly
being presented in digital format, and a growth in individuals seeking information online, it
is important to explore the opportunities and challenges for the groups at which such
resources are targeted, and those that inhabit these spaces. For research to shed light on the
complex role of the online environment within young people’s wider sexual health
information and support, it is necessary to conceptualise sophisticated working definitions
and models that relate to young people’s abilities and experiences in engaging with online
sexual health information.
The concept of health literacy has been influential in research and policy, and concerns how
individuals access, evaluate, understand and use health information and services, dependent
on individual, system and broader factors. Earlier definitions of health literacy tended to be
narrow in scope, deriving from a functionalist perspective, referring to the function of basic
skills in reading and writing that enable individuals to understand factual information on
health risks and access health systems (AMA, 1999). However, understandings have evolved
beyond narrow functionalist perspectives over time, towards broader definitions,
recognising the range of personal, social and cognitive skills necessary to access, understand
and use information to support and maintain health within healthcare, community and
broader social realms (Nutbeam, 2000; Nutbeam, 2008; Peerson and Saunders, 2009; Ratzan
and Parker, 2000). Nutbeam’s (2000) three-part model of health literacy has been
14
particularly influential, differentiating between three different key components of health
literacy: functional literacy, which refers to basic reading and writing skills to help use and
understand health information; interactive literacy, encompassing cognitive and literacy
skills to interpret and use information in changing circumstances and to interact and
communicate with others; and critical literacy, which is the possession of advanced
cognitive skills to analyse and question information critically and the ability to exercise more
control over health decisions and behaviours.
Despite developments in the concept of general health literacy, conceptualisations of health
literacy specific to sexual health remain underdeveloped. As such, relatively little progress
has been made on establishing a concept of sexual health literacy, which must necessarily
take into account the specific concerns associated with sexual health and the complexities of
sexual health practices within a range of different contexts. Therefore, in carrying out this
research it was necessary to synthesise a working definition of sexual health literacy with
which to better understand young people’s experiences, perspectives and practices. Further,
it was crucial that the working definition of sexual health literacy acknowledge that sexual
health is increasingly enacted online, such that it could facilitate examination of how the
digital health landscape relates to young people’s sexual health literacy.
1.1 Study aims and research questions
The broad aim of this study was to examine key information contexts within which sexual
health literacy is developed and shaped, with a particular focus on the online context. Thus
a key purpose was to explore how participants described and experienced locating,
accessing, understanding, evaluating and applying sexual health information within sexual,
social and formal healthcare contexts. The research questions were as follows:
1. What is the role of the internet within the broader landscape of participants’
sexual health information and support?
2. How do participants describe and experience seeking, understanding,
evaluating and using online sexual health information?
3. What are the individual, social and environmental factors relevant to young
people’s experience and use of online sexual health information and support?
While the focus of the research was on the online context, it was also important to consider
‘offline’ information and support, and, more importantly the interrelations between online
and offline contexts, recognising how these environments interact.
15
1.2 Overview of thesis structure
The thesis begins with a review of literature relevant to young people’s sexual health literacy
within online and offline contexts (Chapter Two). This review is presented in two sections:
firstly, an overview of theoretical literature on existing conceptualisations and
understandings of ‘health literacy’, ‘sexual health literacy’ and ‘digital literacy’, followed
by a review of the theoretical and empirical literature concerning young people’s experiences
of seeking sexual health information online, and the development of digital sexual health
promotion and care interventions. Chapter Three describes and discusses the research
methods, specifically: the broad approach and philosophic underpinnings; the specific
research design; description and reflections on implementation and data management and
analyses processes. The findings are reported in Chapters Four, Five and Six. Chapter Four
situates the role of the internet within the broader arena of participants’ sexual health support
and information sources, describing the ways participants described learning about sexual
health, and their perceptions of different information sources. Chapter Five focuses
specifically on the online context, reporting how participants described and experienced
seeking, understanding and evaluating sexual health information online. Chapter Six
examines how participants described applying sexual health information within a range of
contexts, including social and healthcare settings, and their perceptions of ways to
circumvent formal sexual healthcare barriers, within both the peer and online context.
Findings are integrated, synthesised and related to the existing literature in Chapter Seven,
and conclusions and recommendations are presented in Chapter Eight.
16
2 Literature review
2.1 Overview of the literature review
The literature review is presented in two main sections. In Section One (2.3), I set out
existing conceptualisations and understandings of ‘health literacy’, ‘sexual health literacy’
and ‘digital health literacy’, and propose a working definition of ‘sexual health literacy’.
This is followed by an examination of the tripartite information access model, which, along
with the different definitions of health, sexual health and digital health literacy, is
instrumental in establishing the conceptual foundations of this research. This is followed by
Section Two (2.4), which focuses on literature about young people’s use of the internet for
sexual health and the challenges and potential for sexual health promotion and care within
the online context. This chapter concludes by discussing how this study can contribute to
existing literature (2.5).
2.2 Description of literature review search strategy
Given the breadth and depth of literature relating to online information seeking within
different disciplines, this review should be considered as selective. While a systematic
review would have been a more rigorous and comprehensive approach, it was unsuitable for
this project, which was exploratory in nature, and subject to time and resource constraints.
The aim of the literature review was to attain a broad understanding of the topic and provide
an overview of the theoretical and empirical literature in order to identify important gaps in
the literature and thus inform development of research aims. A traditional narrative review
was suited to these aims of qualitatively summarising evidence to achieve a broad
perspective, rather than addressing a clearly defined, focused and answerable question. A
range of search strategies were employed to identify literature, allowing a sufficiently wide-
ranging selection of relevant literature to be reviewed.
To identify relevant literature, including research articles, reviews, commentaries, and
published abstracts, searches were conducted in the following electronic databases: ASSIA;
CINAHL; Embase; IBSS; MEDLINE; PsychINFO; PubMed; and Web of Science.
Keywords searches were used to identify relevant literature exploring ‘health literacy’,
‘digital/ehealth literacy’ and ‘sexual health literacy’. Searches were limited to papers
published in English post-1974, the date of the first mention of ‘health literacy’ at a health
education conference (Simonds, 1974). As well as explicit searches for literature focused
17
around ‘health literacy’, searches were conducted for literature on young people’s sources
of sexual health information, digital health and digital sexual health interventions. The
keyword searches were restricted to articles that explicitly mentioned the search terms within
the title or abstract.
Ovid Medline and Embase automatically match search terms with controlled vocabulary, or
Medical Subject Headings (MeSH). Thus, in addition to using the search terms, a separate
search was conducted for the MeSH term ‘health literacy’. This function was also used to
choose subheadings associated with ‘health literacy’: health knowledge, attitudes and
practice; and interpersonal communication.
Further literature was identified within reference sections of relevant papers and by
searching for articles citing particularly relevant papers. Reference manager software
(Endnote) was used to collate, summarise, categorise, store and retrieve the search results.
The initial search was carried out in 2013-14, and updated in 2016-17.
2.3 Section One: conceptualising ‘health literacy’, ‘sexual health
literacy’ and ‘digital health literacy’
As this research aims to understand how young people seek, understand, evaluate and use
online sexual health information, it was deemed essential to establish conceptual
understandings of ‘health literacy’, ‘sexual health literacy’, and ‘digital health literacy’ as
starting points. The development of these concepts are explored within this section.
2.3.1 Health literacy: theory and conceptualisations
Interest in the concept of ‘health literacy’ has grown since its first mention at an education
conference in the 1970s and has since been increasingly acknowledged as a priority for
health policy (Simonds, 1974). Entering the term ‘health literacy’ into PubMed using the
topic-specific query tool highlights the growth in interest, from 11 search results between
1974 and 1990 to 2511 between 2000 and 2017. As the field of health literacy has gained
importance, the term itself has been subject to debate (Baker, 2006). Sorenson and
colleagues’ (2012) systematic review highlighted the absence of consensus about the
definition of health literacy or its conceptual dimensions, such that it has different meanings
within different disciplines.
18
In scoping the literature on health literacy from 1974 to 2013, nineteen different definitions
were identified. These are presented in Table 2-1, which expands on the table of definitions
presented by Sorenson and colleagues (2012). Earlier definitions of health literacy tended to
be narrow in scope, deriving from a functionalist perspective, referring to the function of
basic skills in reading, writing and oral communication that enable individuals to understand
factual information on health risks and access health systems. This view is exemplified by
the American Medical Association’s (AMA, 1999) definition of health literacy as “the ability
to read and comprehend prescription bottles, appointment slips, and the other essential
health-related materials” (p.522). This perspective emphasises health literacy as an
individual construct, beginning and ending with the patient, primarily taking place within
healthcare settings and with a focus on specific information provision products.
Over time understandings have evolved beyond narrow functionalist perspectives towards
broader definitions, recognising the range of personal, social and cognitive skills necessary
to access, understand and use information to support and maintain health within healthcare,
community and broader social realms (Nutbeam, 2000; Nutbeam, 2008; Peerson and
Saunders, 2009; Ratzan and Parker, 2000). Nutbeam’s (2000) three-part model of health
literacy has been particularly influential, differentiating between three key components of
health literacy: functional literacy, which comprises basic reading and writing skills to use
and understand health information; interactive literacy, encompassing cognitive and literacy
skills to interpret and use information in changing circumstances and to interact and
communicate with others; and critical literacy, which is the possession of advanced
cognitive skills to analyse and question information critically, and the ability to exercise
more control over health decisions and behaviours. Thus, whilst Nutbeam (2000) recognised
the importance of functional literacy skills in enabling individuals to participate in society,
he argued that definitions focusing on functional literacy miss “much of the deeper meaning
and purpose of literacy for people” (p.263). From Nutbeam’s (2000) perspective, it is crucial
to focus on what literacy enables individuals to do.
19
20
21
The concept of critical health literacy has been particularly influential. Critical health literacy
focuses on the capacity to critically question and analyse information, and the ability to use
(or reject) such information to “exert greater control over life events and situations”, aligning
health literacy with notions of empowerment (Nutbeam 2000, p.264). Within the health
context, Nutbeam (2000) indicated that such skills could be used to support political action
to encourage community development and address social, environmental and economic
determinants of health. Chinn (2011) suggested dividing Nutbeam’s (2000) concept of
critical health literacy into three further components: critical analysis of information;
understanding social determinants of health; and engaging in collective action (Chinn, 2011).
There is a body of literature focused on the social determinants of health, with many
expanded definitions placing structural factors as a significant component, particularly
within critical health literacy (Kawachi and Berkman, 2003; Krieger, 1994; Nutbeam, 2000).
This perspective aligns with those interested in the emancipatory and empowering aspects
of health literacy, with critical societal awareness considered necessary in community
empowerment (Caplan, 1993).
Thus, within Nutbeam’s model (2000), improving health literacy has both personal and
social benefits. On an individual level, these may include: improved knowledge of health
risks; adherence to prescribed actions; acting independently on knowledge; increased
motivation and self-confidence; and improved individual resilience in relation to economic
and social diversity. On a social and community level, benefits may include: participation in
population health programmes; improved capacity to influence social norms and interact
with social groups; and improved ability to act on determinants of health to improve
community empowerment and development of social capital (Nutbeam, 2000). Thus,
increasing health literacy skills may result in greater autonomy and personal empowerment,
and, on a broader level, greater equity in public health. From this perspective, routes to
address health literacy include both increasing personal health literacy through education
and making systems less demanding and easier to navigate.
There are many barriers to health literacy, and broader definitions of health literacy
recognise this, acknowledging that the multidimensional and dynamic nature of health
literacy extends beyond the individual to the healthcare system and broader society, and is
shaped by changing individual-level, societal and contextual influences (Nutbeam, 2000;
Nutbeam, 2008; Paasche-Orlow & Wolf, 2007; Pleasant et al, 2016; Rootman and Ronson,
2003; Sorenson et al, 2012; Zarcadoolas et al, 2005). From a public health perspective, this
22
moves the focus beyond individual actors to consider wider structural issues (e.g. education,
social norms and possibilities of ‘behaviour’ change (in response to existing or new risks))
(Pleasant et al, 2016). It is also important to note that, in these broader conceptualisations,
‘individual actors’ include health care providers as well as patients, family members and
friends.
Approaches to health literacy must recognise the myriad of social factors present in
populations with widespread low health literacy, and the impact of socioeconomic disparities
and unequal access to good quality education (Goldberg, 2007). Literature has highlighted
demographic and social factors that impact health literacy, including: socioeconomic status;
employment; culture and language; education; age; race/ethnicity; environmental and
political forces; and media use (Manganello 2008; Paashe-Orlow and Wolf 2007; Sorenson
et al, 2012). Much of individuals’ health literacy depends on factors beyond their control,
such as: the quality and completeness of information communicated to them (in school, in
healthcare contexts, online); opportunities to develop skills within supportive environments;
provision of information on social and economic determinants of health; and opportunities
to achieve policy change (Nutbeam, 2000). Considering health literacy as a broader and
social construct is crucial, as too much focus on individuals results in responsibility, and
consequently solutions, being placed out with the healthcare system and broader society (as
highlighted by Freedman, 2009).
It is crucial to acknowledge that health is increasingly negotiated online. Berkman and
colleagues (2010) highlight the importance of changing contexts, particularly health
information technology, to health literacy, as technology is an increasingly important
medium for communicating health information. Such changing circumstances can influence
the extent and development of literacy skills, as well as their application in particular settings
(Pleasant and Kuruvilla, 2008). Online sexual health information is the key focus of this
thesis, and the online context is explored in greater detail in Section 2.4.
Pleasant and colleagues (2016) highlight the importance of definitions of health literacy, as
they influence the focus of concern, variables for analysis, parameters for inquiry and
measurement tools developed in practice and policy. With the growth of health literacy
theory, there has been rising demand for tools to measure health literacy to inform improved
education (Abel, 2008; Pleasant et al, 2011). However, while conceptualisations of health
literacy have become more sophisticated, reflecting its multidimensional nature,
23
measurement has not, continuing to focus primarily on individual-level functional literacy
(Jordan et al, 2011; Sorenson et al, 2012). Table 2-2 details examples of measurement
approaches. Jordan and colleagues (2011) found that none of the indices they evaluated
comprehensively measured health literacy and the ability to seek, understand and use health
information. Pleasant and colleagues (2011) criticised existing measurement tools for not
being informed by health literacy theory, and for being limited because of: a reliance on
direct reading tests, a focus on word recognition over comprehension; a lack of cultural
sensitivity; bias towards particular population groups; a failure to evaluate oral
communication skills; and insufficient consideration of health literacy as a public health
issue.
Some emerging tools aim for more in-depth assessment of dimensions of health literacy
beyond the individual, as well as investigating relationships between social determinants,
health status and service use (Sorensen et al, 2013) (see Table 2-3 for full descriptions). A
number of studies have attempted to comprehensively measure health literacy with a
combination of methods. For example, Yee and Simon (2013), in their study of health
literacy and contraceptive decision-making, used REALM-7, the Schwartz numeracy test as
well as in-depth qualitative interviews. Similarly, Needham and colleagues (2010) used a
22-item demographic and reproductive health questionnaire (race/ethnic background;
education; sexual behaviours), REALM and a review of a Chlamydia patient education
brochure and comprehension test to examine health literacy and STI risk in young women.
Such methods, particularly the inclusion of qualitative methods, demonstrate potential for
understanding into the dynamic and multidimensional components that make up health
literacy.
In addition to definitions being important in developing measurements, governmental
definitions of health literacy have policy implications. Government organisations,
particularly in the USA, have most commonly cited narrow, individual-focused definitions
such as Ratzan and Parker’s (2000) (see Table 2-1). This definition has been widely cited,
and used in both an Institute of Medicine report entitled ‘Health Literacy: A Prescription to
End Confusion’ (2004) and the Department of Health and Human Services’ (HHS) ‘Healthy
People’ report (2010). This approach, developed mainly in the USA, to help health
professionals communicate and help patients understand, characterises health literacy as “a
problem that patients have and physicians need to overcome” (Pleasant and Kuruvilla, 2008,
p.152). However, in a commentary piece on defining health literacy, Pleasant and colleagues
24
(2016) highlight that some, particularly out with the USA, are beginning to recognise the
“two-sided nature of health literacy” (p.2). In the Scottish Government’s (2014) policy
document, ‘Making it Easy: A health literacy action plan for Scotland’, the then MSP
Cabinet Secretary for Health and Wellbeing, Alex Neil, stated “health literacy is about
people having enough knowledge, understanding, skills and confidence to use health
information, to be active partners in their care, and to navigate health and social care
systems” (p.3). While this statement reflects an individual-level focus, the policy document
refers to system barriers and the role of healthcare workers in addressing their own, as well
as patients’, health literacy. Actions recommended include raising awareness and
capabilities of professionals and promoting development, access and use of health literacy
tools. However, that report tends to focus on healthcare contexts, not considering broader
contexts within which health literacy is shaped and applied.
Peerson and Saunders (2009) observe that medical literacy definitions of health literacy
exclude those who are neither patients nor part of health-care settings, and fail to
acknowledge health-related decision-making in everyday contexts. Numerous health
theorists have advocated moving away from solely medical contexts to include community
or broader social realms (Nutbeam, 2008; Peerson and Saunders, 2009). As Peerson and
Saunders (2009) state:
“Our concept of health literacy includes information and decision-making skills
occurring in the workplace, in the supermarket, in social and recreational settings,
within families and neighbourhoods, and in relation to the various information
opportunities and decisions that impact upon health every day” (p.289).
In this respect, Public Health England (2015) seem to acknowledge health literacy out with
healthcare settings in their policy document entitled “Improving health literacy to reduce
health inequalities”. This document included Nutbeam’s (2000) broad conceptualisation of
health literacy, incorporating functional, interactive and critical literacy skills, as well as
recommending targeted action to improve health literacy of low-literacy populations, broad
actions to make health and social care systems more health literate, and improving conditions
within which individuals are born, live, work and age.
25
26
27
28
Reviewing published definitions and dimensions of ‘health literacy’ enhanced my
appreciation of the complexity of the concept. Research in this field has progressed greatly,
and conceptual models of health literacy contain a broad range of factors, components and
dimensions, having progressively broadened in focus from purely functional, individual-
level aspects of health literacy (Chinn, 2011) to embracing an ecologically-framed
conceptual model, identifying health literacy as diffused in the realms of culture, context and
language (Baker, 2006; Nutbeam, 2008; Zarcadoolas et al, 2006). Sorenson and colleagues
(2012) propose an “all inclusive”, flexible definition of health literacy, accommodating the
roles of social, environmental and cultural factors and integrating diverging definitions,
conceptual frameworks and models of health literacy (p.3).
Having reviewed existing definitions of health literacy, Nutbeam’s (2000) three-part model
and Sorenson and colleagues’ (2012) conceptual understanding have been particularly
influential in guiding my research. Sorenson and colleagues’ (2012) conceptual framework
recognises: the dynamic nature of health literacy; the dependency of health literacy on
relationships between individual capacities, the healthcare system and broader society; and
numerous health-related decisions made in the context of everyday life. As they explain,
“Health literacy is linked to literacy and entails people’s knowledge, motivation and
competences to access, understand, appraise, and apply health information in order to make
judgments and take decisions in everyday life concerning healthcare, disease prevention and
health promotion to maintain or improve quality of life during the life course” (Sorenson et
al, 2012; p.3). It is evident that a broad focus, incorporating individual, contextual and
societal transformations as well as economic, socio-cultural and political changes, is
essential.
2.3.2 Conceptualising and measuring sexual health literacy
The complexity of conceptualisations of health literacy is illustrated by the development of
sub-concepts such as ‘oral health literacy’ and ‘environmental health literacy’ (Pleasant and
colleagues, 2016). Helitzer and colleagues (2012) state that “being health literate assumes
not just that generic literacy skills are applied in a health setting, but that individuals must
often have multiple health condition-specific literacy competency” (p.2). Despite the rise in
such specialities, conceptualisations of ‘sexual literacy’ or ‘sexual health literacy’ appear
largely undeveloped, although, a number of studies have explicitly focused on exploring or
measuring sexual health literacy within different populations (Graf and Patrick, 2015; Guzzo
et al, 2012; Jones and Norton, 2007; McMichael and Gifford, 2009; McMichael and Gifford,
29
2010; Reinisch and Beasley, 1990). Reviews of these studies revealed a variety of definitions
and approaches to ‘sexual health literacy’.
‘Sexual literacy’ was first mentioned in a Kinsey Institute Report based on a survey revealing
the alarming “sexual illiteracy” within the USA (Reinisch and Beasley 1990). Within this
study, ‘sexual literacy’ was measured using the Kinsey Institute/Roper Organisation
National Sex Knowledge Test, which tested the basic sexual knowledge of a statistically
representative group of adults in America, and concluded that “unfortunately, Americans
failed the test” (Reinisch and Beasley 1990, p.1). While providing no explicit definition of
‘sexual literacy’, Reinisch and Beasley (1990) measured sexual literacy in terms of
knowledge. In some respects, this knowledge-focused understanding remains, with Guzzo
and colleagues (2012), more than two decades later, referring to Reinisch and Beasley’s
(1990) study as influencing their research into race-ethnic differences in sexual health
knowledge. Within this survey-based study, Guzzo and colleages (2012) examined what they
defined as three components of sexual literacy: accurate knowledge about pregnancy risk,
pregnancy fatalism, and perceptions of contraceptive side effects. More recently, Graf and
Patrick (2015) published a paper titled ‘Foundations of life-long sexual health literacy’,
examining the influence of different sexual health information sources on current safe sex
knowledge and risky sexual behaviours amongst middle-aged and older adults in the USA.
Again, sexual health literacy was measured with a focus on knowledge, but Graf and Patrick
(2015) also explored participants’ sources of sexual health information, using a quantitative
survey method to investigate how timing and sources of sexual information relate to sexual
risk knowledge and behaviours. However, they did not examine the content and quality of
participants’ experiences in relation to their sexual health information sources.
Accurate knowledge is essential, but not enough on its own. Measuring ‘sexual health
literacy’ by surveying sexual health knowledge fails to acknowledge the importance of
having skills and opportunities to apply knowledge. Simply measuring knowledge cannot
give a comprehensive picture of an individual’s sexual health literacy, and attempts to
measure sexual health literacy have been characterised by inadequate consideration of
individual skills and the contexts within which sexual decision-making occurs.
While there has been little focus on broad conceptualisations of sexual health literacy in the
literature, three studies have explored the importance of knowledge and access to
information, the development of skills to enhance abilities to take control of sexual health
30
and wellbeing, and the need to focus on structural and contextual influences (Gilbert et al,
2014; Jones and Norton, 2007; McMichael and Gifford, 2010). Two of these studies used
qualitative methods to explore access, interpretation and implementation of sexual health
information with young people from refugee backgrounds in Australia (McMichael and
Gifford, 2010) and young women in rural Uganda (Jones and Norton, 2007). Each study
identified various structural and contextual barriers for their participants, including social
risks and lack of access to sexual health information (Jones and Norton, 2007; McMichael
and Gifford, 2010). McMichael and Gifford (2010) stress the importance of providing access
to clear, factual information on pregnancy, contraception and STIs, as well as developing
skills in “managing sexual relationships, negotiating sexual pressures, and the potentially
positive and emotional aspects of sex” (p.230).
Jones and Norton (2007) highlight the need to focus on the contexts within which sexual
health decision-making occurs and to consider the information accessed, the
conceptualisations and processing of such information, general sexual health awareness and
“the nature of the ‘ecologies’ in which their sexual health knowledge intersects with human
agency and proactive decision making” (p.289). Notably, Jones and Norton (2007) apply
Nutbeam’s (1998) empowering definition of health literacy to sexual health: “sexual health
literacy references the ability not only to understand sexual health information, but also to
act on the information available” (p.286). They argue that, while definitions focusing on
possessing sexual health knowledge may be more applicable in a wide range of contexts,
they have little applicability in developing countries, and do not account for the complex
challenges faced in the developing world: chronic poverty, gender imbalances, unfavourable
health conditions and poor infrastructure.
More recently, Gilbert and colleagues (2014) published a report from a meeting of
researchers, policy-makers, service providers and community members funded by the
Canadian Institutes of Health Research, focusing on health literacy and its relevance to gay
men’s sexual health and HIV prevention. The report embraces a broad conceptualisation of
sexual health literacy, describing an emerging framework for sexual health literacy for gay
men that recognises the importance of focusing on information providers as well as
individuals as users of information, and the structural and systemic factors that impact these
relationships (Gilbert et al, 2014). These three studies, in different countries and amongst
different populations, go beyond knowledge-based sexual health literacy, highlighting the
need for skills and the range of structural and contextual barriers to sexual health literacy,
31
including socioeconomic circumstances, gender oppression, cultural norms, community and
family pressures, all of which can influence sexual practices (Gilbert et al, 2014; Jones and
Norton, 2007; McMichael and Gifford, 2009; McMichael and Gifford ,2010;).
2.3.3 Towards a working conceptualisation of sexual health literacy
Sexual health is an integral part of overall health, but, as established in Section 2.3.2,
conceptualisations of health literacy have typically neglected to incorporate the specific
needs and concerns of sexual health. Beyond basic knowledge of facts, being sexually
healthy involves managing sexual relationships and healthcare, negotiating sexual pressures,
executing protective strategies and managing the moral stigma of STIs, sexual identities and
social norms of acceptable sexual behaviour. Sexual learning operates within complex,
dynamic contexts, and faces a range of barriers related to the changing landscape of
information sources and provision, knowledge and understanding, and concerns over
confidentiality, embarrassment and shame (McMichael and Gifford, 2010). Sexual
encounters comprise multiple interacting contextual and interpersonal elements, such that
applying learned information to healthy decision-making in sexual scenarios entails
employing interpersonal skills to negotiate and communicate with sexual partners about
complex risk information in dynamic and changing circumstances (‘in the heat of the sexual
moment’) (Gilbert et al, 2014). Thus, the broader issues that influence individuals’ ability to
manage sexual wellbeing may be different or more pronounced than for other general health
issues due to the particularly social and interactive nature of sexual health, and the
heightened significance of issues of taboos, stigma, sexual violence and sexual rights. As
such, conceptualisations of sexual health literacy must incorporate critical and interactive
aspects, even more so than conceptualisations of general health literacy.
The cultural and social contexts in which individuals are located, and the demands placed
on individuals, each of which shape accessibility and experience, are crucial. Sexual health
literacy must include critical awareness and analysis of socio-cultural beliefs, attitudes and
practices that may undermine individual autonomy and decision-making, and stem
opportunities to exercise agency in expressing sexuality and making safe, healthy decisions
(Jones and Norton, 2007). Going beyond the absence of disease, a broad definition of sexual
health literacy should incorporate physical, emotional, mental and social wellbeing, and
facilitate pleasure, intimacy and safe sexual experience (WHO, 2010).
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A definition of sexual health literacy should incorporate the level of sexual health
knowledge, the capacity and motivations to employ it, and the contextual influences to
finding, interpreting and using information and support. Thus, a foundation of sexual health
knowledge should be supported by the functional, interactive and critical skills necessary to
understand, evaluate and use it in everyday sexual and social contexts. Sexual health literacy
should empower individuals in decision making and in exercising their sexual health rights
(free from coercion, discrimination and violence), and must acknowledge the role that
contextual, social, cultural and economic factors have on these freedoms. Critical
understandings of socio-cultural beliefs, attitudes and practices that may undermine
autonomy and decision-making are essential to this empowerment. The importance of
context should be central to a comprehensive conceptualisation of sexual health literacy, as
contextual factors can complicate processes of making healthy sex choices, potentially
exerting greater influence than a lack of knowledge or motivation.
It was necessary to form a working definition of ‘sexual health literacy’ with which to guide
the design of this research. To this end, I propose an inclusive, holistic definition of sexual
health literacy influenced by broad understandings of ‘health literacy’, particularly
Nutbeam’s (2000) three-part model and Sorenson and colleagues’ (2012) ‘inclusive’
conceptualisation, as well as Jones and Norton (2007) and McMichael and Gifford (2009)
broad understandings of ‘sexual health literacy’. Synthesising these perspectives, I define
sexual health literacy as referring to an individual’s knowledge, beliefs, attitudes,
motivations and skills in accessing, understanding, evaluating and applying sexual health
information in social, sexual, online and healthcare contexts, to negotiate and make
judgements and decisions concerning sexual healthcare, health promotion, relationships and
wellbeing. Sexual health literacy is dynamic in nature, developed and applied in complex
ecologies and influenced by individual, healthcare system, contextual and societal factors.
In addition to synthesising this working definition, I produced a model (Figure 2-1)
visualising the relationships between the individual, information sources and the broader
context within sexual health literacy. The model illustrates how sexual health literacy
enables individuals to understand, interpret and evaluate information and apply that
information within a variety of contexts.
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Figure 2-1. Dynamic sexual health literacy model
2.3.4 Digital literacy and digital health literacy
Digital literacy is an expansive field of study, spread across many disciplines, including
computing, public policy, library science, education and political science (Thomson et al,
2014). As such, it cannot be explored at length here. However, given the increasing
importance of sexual health literacy within the online context, it is important to establish
what digital literacy is, and to understand why interactions between digital literacy and
sexual health literacy are increasingly important. As such, this section provides a brief
overview of digital literacy and digital health literacy literature.
Like health literacy, digital literacy has traditionally been defined narrowly, focusing on
technical skill and functional competence in basic information retrieval in relation to
information and communications technology (ICT) (Goodson and Mangan, 1996). However,
broader understandings have emerged, and the consensus appears to be that digital literacy
concerns more than a capacity to use computers and access information (Buckingham, 2006;
Jones-Kavalier et al, 2006), and is instead a dynamic, process-oriented skill that develops
and adapts over time as personal, technological, environmental and social contexts change.
Martin (2005) broadly defines digital literacy as:
“the awareness, attitude and ability of individuals to appropriately use digital tools
and facilities to identify, access, manage, integrate, evaluate, analyse and synthesise
digital resources, construct new knowledge, create media expressions, and
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communicate with others, in the context of specific life situations, in order to enable
constructive social action, and to reflect upon this process” (p.135)
This definition stresses the importance of communication and creating meanings as well as
searching, assessing and synthesising abilities.
More recently, Ng (2012) developed a digital literacy framework model drawing broader
definitions, incorporating three intersecting dimensions of digital literacy: technical,
cognitive and social-emotional. The technical dimension comprises the functional,
operational and technical skills to use ICT in learning and day-to-day activities; the cognitive
dimension comprises the ability to critically search, evaluate and create within the digital
context; and lastly, the social-emotional dimension comprises the capacity to responsibly
use the internet to communicate, socialise and learn. This framework has similarities with
Nutbeam’s (2000) health literacy model of functional, interactive and critical literacy skills.
Critical literacy is particularly central to digital literacy, and within all three dimensions of
Ng’s (2012) model: “understanding that people behind the scene writing the information
have their own motivations and being able to critically evaluate whose voice is being heard
and whose is not is important for learning as neutrally as possible” (p.1068). These demands
for critical literacy have grown commensurately with the importance of the online context.
As health information and communication is increasingly digitised, the need to focus on the
digital context grows (Madden et al, 2006; Norman and Skinner, 2006). Whilst traditional
conceptualisations of health literacy largely neglect the growing role of digital technology
and media, there has been a recent growth in literature on ‘digital health literacy’ and
‘eHealth literacy’ (Mein et al, 2012; Norman and Skinner, 2006). Digital health literacy has
been defined by Chan and Kaufman (2011) as “a set of skills and knowledge that are essential
for productive interactions with technology-based health tools” (p.1), and by Norman and
Skinner (2006) as “the ability to seek, find, understand, and appraise health information from
electronic sources and apply the knowledge gained to addressing or solving a health
problem” (p.3). Accessing, retrieving and appraising digital information occurs within
unregulated and dynamic environments, presenting different challenges to health promotion
in other forms of media. As Norman and Skinner (2006) state, “being health literate in an
electronic world requires a different or at least expanded set of skills to engage in health care
and promotion, or eHealth literacy” (p.4). Their conceptual model situates digital health
literacy within the wider literacy environment encompassing traditional, information, media,
health and scientific literacies (see Table 2-4), each of which is essential to “empower
35
individuals and enable them to fully participate in health decisions informed by eHealth
resources”.
Table 2-4: (Norman and Skinner, 2006)
36
Effective use of digital health information requires both digital literacy and health literacy,
each of which intersect with other forms of literacy, including basic literacy, information
literacy, media literacy, scientific literacy, cultural literacy and computer literacy (Norman
and Skinner, 2006). As such, using digital technologies for health requires individuals to
read, use computers, and search for, understand and contextualise health information. This
involves working with technology, thinking critically about issues of science and media, and
navigating a wide range of information tools and sources to locate the information needed
to make health decisions (Neter and Brainin, 2012; Norman and Skinner, 2006).
As when conceptualising health and sexual health literacy, a broad perspective is necessary
in defining eHealth or digital literacy, recognising the influence of many individual, societal
and environmental factors, including: the presenting health issue; health status; educational
background; socioeconomic status; motivation for information seeking; and the technologies
used (eHealth Stakeholder Group, 2014). Inherent in recognising the role of these contextual
factors in digital literacy is recognising the roles of policy and interventions in mitigating
potential barriers, empowering individuals across society to make better-informed sexual
health choices through improved digital health literacy. These issues are touched upon again
in Section 2.4, in reference to digital literacy inequalities.
2.3.5 Tripartite information access model
In addition to understanding different conceptualisations of health, sexual health and digital
literacy, Burnett and colleagues (2008) tripartite information access model also provided a
useful foundation for this research. This model recognises that issues of access and inclusion
are not simply about ownership and availability (Barzilai-Nahon, 2006), and distinguishes
between different types of access, which Burnett and colleagues (2008) argue are each
essential: physical, intellectual, and social access.
Physical access is the interpretation of ‘access’ most commonly focused on, and typically
refers to access to documents containing information, whether electronic, verbal or other
(Svenoius, 2000). Physical access to information is mainly an institutional issue, but, as
Thomson and colleagues (2014) observe, at the individual level users must know that
information exists, know where to find it and be able to find it, and these capacities can be
influenced by a range of factors including economics, geography, disability and technology.
Physical access is crucial, but not sufficient alone. In this respect, physical access in the
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tripartite information access model occupies a similar status to functional health literacy in
Nutbeam’s (2000) three-part model of health literacy.
To go beyond physical access and understand and employ information, individuals require
intellectual access. Intellectual access is influenced by the way in which information is
presented, and the way that presentation affects the individual accessing the information
(Pitts and Stripling, 1990). Thomson and colleagues (2014) list potential factors affecting
intellectual access as: “information-seeking behaviour, language, dialect, education, literacy,
technological skill, cognitive ability, disability, vocabulary, and social elements, like norms
and values” (p.5-6). For content to be equally accessible by all users, and therefore
considered intellectually accessible (Jaeger and Bowman, 2005), the outcomes that that
content produces must be similar in between users regardless of individual differences in
capacity (Thomson et al, 2014).
In addition to the physical and intellectual layers of access, the tripartite information access
model includes a third, often overlooked, layer: social information access. This layer
concerns the context of information, and information seeking, within the norms and attitudes
of social groups (Burnett et al, 2008). Jaeger and Burnett (2010) describe how ‘small worlds’
are created in which individuals share norms, values and behaviours, and these constructions
influence the value and acceptability of different types of information, and the
appropriateness of different information-seeking behaviours. The social information access
concept has been acknowledged in various types of research, including research into the
influences of social trust, social motivation, and social inclusion on information behaviour
(Chatman, 1987; Thomson et al, 2014).
The three layers of the tripartite information access model must be seen as inter-reliant to
the extent that information provision must allow all three to exist to be meaningfully
considered accessible; physical access to information is of little use if the individual cannot
understand or share it (Thomson et al., 2014). From this perspective, information sources,
such as sexual health websites, must ensure physical access to content through technical
aspects of their design, and that content must be intellectually and socially accessible by
being presented and written in ways that audiences can understand, and being relevant and
acceptable within the norms and values of audience members’ social contexts. The tripartite
information access model is relevant and valuable to this research both as a way to
understand the sophistication required for information sources to be truly ‘accessible’, and
38
as a perspective from which to critically address conceptualisations of ‘access’ to both the
online environment as a whole and individual information sources within that environment.
2.4 Section Two: Young people, online sexual health information and
the ‘digital divide’
Digital technologies have changed, and continue to change, the sexual health information
landscape, presenting dynamic opportunities and challenges to young people as they seek
sexual health information. As Tanton (2015) explained, young people’s sex information
landscapes have changed, and continue to change, in terms of the variety of different sources
available and the relative importance of those different sources.
The digital context may represent fertile ground for interventions, including sexual health
literacy interventions, but the fast-changing, relatively unregulated nature of the internet
makes it a challenging context to work within. Rather than a medium of one-way, one-to-
many knowledge transfer, the internet is intrinsically interactive and collaborative, and, with
the explosion of social media and user-generated content, the internet represents an
increasingly core part of people’s lived experiences. As well as knowledge exchange, the
internet is increasingly a site of service provision, as health services move to a digital-first
paradigm.
Given the growing importance of the internet in young people’s lives, and the dynamic
opportunities and challenges presented, studying the role of the digital context in young
people’s sexual health literacy is crucial. This section: introduces young people’s use of the
internet for sexual health information; outlines potential advantages of connectedness and
empowerment; discusses potential risks to sexual health in the online context; presents
literature on various types of online interventions targeting young people’s sexual health;
questions the effects of online sexual health information on inequalities; and examines
literature on young people’s online health information seeking skills.
2.4.1 Young people, the internet and sexual health
The internet is a key sexual health information source for young people (Richardson et al,
2002; Smith et al, 2000), and research indicates that they use it to seek sexual health
information, discuss personal issues and access peer advice (Borzekowski and Rickert, 2001;
Buhi et al, 2009; Hansen et al, 2003; Kanuga et al, 2004; Ralph et al, 2011). One of the key
39
types of sexual health content that young people seek online is information and reassurance
about norms of sexual behaviour (Harvey et al, 2007), and user-generated content in the
relatively anonymous online environment provides opportunity to find such content (Suzuki
and Calzo, 2004).
There is some evidence that the internet reduces barriers to accessing information and
support for some young people (Barman-Adhikari et al, 2011; Klein et al, 1999), and
searching for anonymous reassurance online may be particularly relevant to LGBTQ young
people, whose needs may not be met by traditional mainstream sexual health information
provision, and who may value anonymity particularly highly (Bond et al, 2009; Mustanski
et al, 2011; Ross and Kauth, 2002). Research has shown that young people use the internet
to learn about sexual positions, behaviours and pleasure-based aspects of sex (Buhi et al,
2009; Gilbert et al, 2005; Hooper et al, 2008).
Recent findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-
3) in Britain found that use of the internet for ‘key sexual health reasons’ was relatively rare
among people aged 16-44, particularly in relation to accessing online STI services or
protective and contraceptive supplies (Aicken et al, 2016). However, using the internet for
general help and advice about sex lives was more common, particularly amongst young
people and those who reported higher sexual risk behaviours, including men who have sex
with men (MSM) (Aicken et al, 2016). These findings highlight the importance of nuanced
understandings of the role of the internet within young people’s information and support
landscape, acknowledging the different types of content that young people may, or may not,
seek online, and acknowledging how different groups of young people may use the internet.
Aicken and colleagues (2016) described the finding that young people seek sex advice online
as “unsurprising” due to the confluence of young people’s higher internet and smartphone
use and greater need for sexual health information and care (p.12).
The internet and social media hold great promise for geographically unbounded
dissemination of sexual health promotion harnessing the social connectedness created by
social media. As Guse and colleagues (2012) state: “the Internet and other forms of digital
media have afforded opportunities for the breakdown of geographic boundaries in sexuality
education” (p.535). The next section explores how the increasingly social nature of the
internet may empower young people to improve their sexual health literacy.
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2.4.2 The internet, social media, connectedness and empowerment
Technologies referred to variously as social media, web 2.0 and new media have increased
in prominence, embedding interactivity within online experiences and expanding users’
production and consumption of content. In 2007, Beer and Burrows (2007) stated that, as
new social media technologies become ingrained within society, they are “reworking
hierarchies, changing social divisions, creating possibilities and opportunities, informing us
and reconfiguring our relations with objects, space and each other” (para 1.2). Now, ten years
later, social media is an even more prominent aspect of people’s lives, and continues to
reshape social life.
Social media has continued to infiltrate contemporary culture, integrating itself within young
people’s lives, particularly, to the extent that digital social networks are key aspects of young
people’s broader communities (Boyd, 2014; Evers et al, 2013; Marwick and Boyd, 2014).
Delineations between online and offline life have become blurred as mobile internet
technologies have progressed (Boyd, 2014; Pascoe, 2011), such that ‘using the internet’ is
no longer a distinct activity from being engaged in social situations, and technologies such
as dating apps bridge the physical and online social worlds.
As well as arguably enhancing social connectedness, digital technologies promise greater
access to information (Niland et al, 2015), including experiential knowledge (Pascoe, 2011)
and information about niche topics (Suzuki and Calzo, 2004). Suzuki and Calzo (2004) and
Bay-Cheng (2005) attributed young people’s use of online bulletin boards – the precursors
to today’s social media – to their facilitation of open sharing of information and experiences.
More recently, Simon and colleagues’ (2013) qualitative study of young people’s
motivations for, and experiences of, using online sexual health education, found that
participants were motivated to seek sex information from anonymous and social websites,
learning about sex from a wide variety of online sources including Twitter, YouTube,
pornography, Tumblr and podcasts. They concluded that young people find new digital
media extremely valuable for sex education (Simon et al, 2013).
From the perspective that the online context can increase both social connectedness and
access to relatable, experiential information, the internet can be seen as facilitating the
‘empowering’ aspect of health literacy described by Nutbeam (2008); the internet can
empower young people to socialise with others, find peers, and access a wide array of
information about their health, independently from parents, adults or healthcare providers.
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Parker and colleagues (2014) state this is particularly relevant to learning about sex and
relationships, where awkwardness may prevent young people from accessing that
information through ‘traditional’ means.
While exploring the opportunities presented by social media, it is crucial to consider the
challenges that must be overcome. The social and democratic characteristics of social media
that make it a powerful tool are the same characteristics that create challenges for safe,
reliable and effective sexual health promotion. Research suggests social media can be a
problematic environment for engagement with health content, due to its role as a site of
presentation and management of identity (Fergie et al, 2016; Marwick and Boyd, 2011;
Papacharissi, 2010). Fergie and colleagues’ (2016) qualitative study with young adults with
experiences of diabetes or a common mental health disorder found that participants,
regardless of their level of engagement with social media, described “how considerations of
their identity and presumed audience of social media impact their online practices” (p.51).
This evidence highlights the importance of understanding, and being aware of, the social
processes being carried out in these potential venues for sexual health promotion, and how
they might interact with effective promotion. The key concerns related to sexual health in
the online context are examined in the following section.
2.4.3 Concerns about online sexual health: risks of online information and
interactions
Contrary to perceptions of online sexual health information as a key aspect of ‘empowering’
sexual health literacy, contrasting perspectives highlight potential risks and disadvantages
of providing sexual health information online. These perspectives do not necessarily negate
the benefits, but highlight potential challenges to young people’s sexual health and wellbeing
that should be addressed (Tanton et al, 2015). This section outlines concerns related to:
privacy and safety; the decentralised, unregulated nature of the internet; the accessibility of
pornography; pressures to conform to unhealthy digital norms; and dangers of forming
unhealthy social connections online.
Public concerns about young people’s online safety are well established, particularly in
relation to ‘grooming’ and exposure to, and creation of, sexually explicit content
(Livingstone et al, 2014). These concerns are symptomatic of the decentralised and largely
unregulated nature of the internet, raising issues about both safety and finding reliable
information online. One often-cited risk of the open and unregulated internet is the
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availability and accessibility of pornography (Horvath et al, 2013; Parker et al, 2014). Parker
and colleagues (2014) state that, in comparison to offline contexts, “access to adult or
extreme material is fundamentally different and much easier” (p.3). Research indicates that
young people do access pornography using digital media, sometimes intentionally and
sometimes not (Livingstone and Helsper, 2007; Scarcelli, 2015). Some, particularly males,
view pornography as a source of sex education (Allen, 2006; Scarcelli, 2015). Gender
differences in young people’s attitudes to pornography are likely symptomatic of wider,
ingrained gendered perceptions of pornography, with cultural norms presenting pornography
as more acceptable for men than women (McKee et al, 2008, Scarcelli, 2015).
The accessibility of sexually explicit material online has raised concerns about young people
developing unrealistic, and potentially harmful, expectations of sex and relationships
(Horvath et al, 2013; Parker et al, 2014; Tanton et al, 2015) since the early 1990s, with
pornography viewed as a risk to young people’s sexual health practices and wellbeing
(Albury, 2014; Crabbe and Corlett, 2011; Flood, 2009; McKee, 2010). Sexual learning
through pornography may influence sexual attitudes and behaviours, including safer sex
practices, as well as perceived emotional and physical boundaries, raising concerns about
consent, pressure, coercion and gender roles (McKee et al, 2008). From a more optimistic
perspective, some argue that young people can develop skills to think critically about explicit
material (Albury, 2014; Allen, 2006). For example, teaching young people ‘porn literacy’
may empower them to be critical about gender roles, and portrayals of normative practices
(Albury, 2014).
Another aspect of explicit content in digital communication that has caused concern is
‘sexting’, the process of exchanging self-taken, sexually-explicit images via mobile or online
technologies. Research amongst young people has highlighted peer and partner pressure,
particularly for young women, to send self-taken sexual images, which may result in
negative experiences (Drouin and Tovin, 2014; Henderson, 2011; Renfrow and Rolla, 2014).
Some literature presents sexting as an indicator of further risk, creating vulnerabilities to
online bullying, victimisation and engagement in early or risky sexual practices (Houck et
al, 2013; Temple et al, 2012).
There has been some criticism of the focus on negative outcomes of sexting, with research
suggesting that sexting behaviours are less problematic than societal fears may suggest
(Cooper et al, 2016; Hasinoff, 2013), and that young people are careful and selective in their
43
their sexting behaviours (Albury et al, 2015). In reviewing the literature on sexting, Cooper
and colleagues (2016) characterised the behaviour as predominantly occurring in positive
forms, “within either a romantic relationship or as a means of adolescent explorations of
sexuality and identity creation” (p.12). Albury and colleagues (2015) carried out interviews
with three mixed-sex groups of 16-17 year olds in Australia, who they found to be “highly
conscious of privacy and that not all selfies were made to be shared” (p.1735), suggesting
that some young people can negotiate privacy in the online environment in relation to sexual
relationships, in a manner that epitomises context-specific definitions of sexual health
literacy.
An increased focus on sexting is part of a larger focus in literature on the changing nature of
social and visual media cultures, and online safety in general, and the extent that young
people’s social lives are played out in semi-private online spaces has raised concerns
(Ringrose et al, 2012). Some concerns relate to young people’s online relationships
unfolding outside of the protective oversight of adults; as Parker and colleagues (2014)
explain, “relationships can be more intensive, with more opportunities for contact and less
visibility or moderation by adults, and relationships and friendships often create permanent
digital content” (p.3). Here, a paradox is identified, in which online relationship formation
is both more private, in its lack of parental moderation, and less private, due to the permanent
records of social interactions that young people may leave online. Moreover, through being
recorded online, negative social and relationship events such as break-ups and bullying can
be “magnified” (Parker et al, 2014, p. 3).
In addition to concerns related to activities performed within online environments, it is
important to acknowledge concerns related to media in which online and offline
environments overlap, such as dating and matchmaking websites and apps, which,
particularly for MSM, may be associated with risky sexual activities (Elford et al, 2004).
There are a range of concerns, both in academic literature and public debates, about risks
young people can face in the online context and where online and offline contexts intersect.
While these risks garner considerable public attention, other potential barriers to young
people’s use of the internet as a source of sexual health literacy, such as challenges in
identifying reliable content, receive relatively little attention in public discourse and
academia. Despite widespread recognition of risks posed to young people within the digital
context, many sexual health stakeholders have identified the internet as an appropriate
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environment for sexual health literacy interventions. Some of these interventions are
discussed in the following section.
2.4.4 Promoting young people’s sexual health with digital services and
interventions
Literature has explored the potential for sexual health promotion to engage young people
through the internet, leveraging an environment that they already use to provide access to
advice and testing, working to alleviate common barriers, such as embarrassment and stigma,
to potentially improve sexual health outcomes. This section outlines the literature on online
interventions designed to improve sexual health promotion, information and access to
services.
The deep integration of online technologies within young people’s lives, combined with the
interactive nature of social media, may represent a valuable opportunity for engaging young
people in sexual health promotion (Bailey et al, 2010; French et al, 2014; Gabarron et al,
2016; Guse et al, 2012). The World Health Organisation stresses the importance of choosing
the best medium for reaching the target population (WHO, 2015). A number of systematic
reviews have been published concerning the use of digital technologies and social media for
sexual health promotion, with differing foci (Bailey et al, 2010; Bailey et al, 2012; Gabarron
et al, 2016; Gold et al, 2011; Guse et al, 2012; Jones et al, 2014; Schnall et al, 2014; Yonker
et al, 2015).
From the early days of computer-mediated communication to the present day, digital
interventions have progressed from using computers to present one-way information in
schools and clinical settings (Kann et al, 1987), to taking advantage of the multimedia and
interactive nature of today’s online technologies (Bull et al, 2009; Tortolero et al, 2010). In
the emerging field of mobile health (mHealth), portable mobile technologies are used as
health research and care delivery platforms (mHealth for Development, United Nations
Foundation, 2009). Mobile health is increasingly seen as a valuable alternative to clinician-
delivered interventions, which may present barriers of time and cost (Ownby et al, 2013;
WHO, 2011). A WHO (2011) report stated that “the use of mobile and wireless technologies
to support the achievement of health objectives (mHealth) has the potential to transform the
face of health service delivery across the globe” (Kay et al, 2011, p.1).
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Digital interventions have been used for sexual health promotion, for example in
encouraging safer sex practices (Gold et al, 2012; Lim et al, 2012; Suffoletto et al, 2013) and
promoting STI testing (Downing et al, 2013). Some of these interventions were tailored and
targeted to specific populations (Jones et al, 2012). Gold et al (2011) conducted a systematic
review of 178 interventions using SNS for sexual health promotion, typically in the USA,
on Facebook, and run by not-for-profit groups or clinical service organisations. The review
found that most SNS platforms were not used to their broadest potential, and most
interventions simply comprised programme or organisation presences on SNS, many of
which had fallen inactive. Thus, Gold and colleagues (2011) concluded that, whilst SNS are
increasingly used for sexual health promotion, engagement with, and utilisation of, these
activities varies greatly.
Reviews by Guse and colleagues (2012), Jones and colleagues (2014) and Gabarron and
colleagues (2016) suggest that online interventions can, but do not always, positively impact
on knowledge and behaviours. In contrast to the lack of sophistication exhibited by the
interventions reviewed by Gold and colleagues (2011), Guse and colleagues (2012)
identified more variety in their systematic review of interventions published between 2000
and 2011 using digital media to improve adolescents’ (aged 13-24) sexual health knowledge,
attitudes and behaviours. Approaches used included: online quizzes about sexual health
knowledge and perceptions (Bull et al, 2009; Roberto et al, 2007); peer/expert videos
(Tortolero et al, 2010); role-model accounts (Bull et al, 2009; Marsch et al, 2011); moderated
online discussion forums (Tortolero et al, 2010); and self-assessment of skills and attitudes
(Roberto et al, 2007). The interventions reviewed various psychosocial outcomes (including
abstinence attitudes and condom self-efficacy), knowledge of HIV, STIs or pregnancy, and
delayed initiation of sex. Similarly, Gabarron and colleagues’ (2016) more recent review of
51 primarily USA-based studies of sexual health promotion interventions on online social
media found that approximately a quarter of these showed “promising” results in relation to
behaviour. However, Jones and colleagues’ (2014) review of 11 social media interventions
for young adults demonstrated increased knowledge, but produced less convincing evidence
of those interventions’ ability to generate behaviour change.
In addition to interventions designed to improve knowledge and behaviours, digital
interventions are also being used to deliver information about, and facilitate access to, sexual
health services. Bailey and colleagues (2015) stated that many such tools are already in use
within the UK, including search tools to assist with locating services, online symptom
46
checkers, online appointment booking, appointment text reminders, provision of condoms
and emergency contraception, and online testing services (Woodhall et al, 2012). There has
also been an increase in research exploring the feasibility of online STI testing services
(Lorimer and McDaid 2013; Owens et al, 2010; Peeling, 2006; Woodhall et al, 2012), as
well as research into integrated e-services for diagnosis, management and treatment
(Estcourt et al, 2017).
The evidence base for the acceptability and effectiveness of online sexual health services
seems to be growing (Bailey et al, 2012; Gold et al, 2011; Kang et al, 2010), and young
people seem largely well disposed towards such services due to their convenience and
privacy (Lorimer and McDaid, 2013; Novak and Karlsson, 2006; Shoveller et al, 2012).
Conversely, Aicken and colleagues (2016) found from NATSAL-3 survey data that few
participants reported a preference for using the internet to access STI testing, STI treatment
or contraception, although the authors suggested their finding might “underestimate the
proportions that might choose Internet-based services if they were well-regulated and based
in the NHS.” (p.7). From this perspective, the true public acceptability of internet-based
sexual health services might only be determined once widely available through respected
providers. Aicken and colleagues (2016) went on to call for qualitative research into
“awareness of, expectations and barriers to use of currently available online sexual health
services”, in the hopes of increasing access to services amongst populations at higher risk of
STI and who underutilise traditional services, such as young people, MSM, individuals who
report multiple sexual partners and those living in deprived areas (p.8).
Digital interventions have increasingly leveraged mobile smartphones for facilitating
tailored health messaging and outreach (Kay et al, 2011). Unlike websites, mobile
applications (apps) can be downloaded and used offline, allowing users to access the
information without an internet connection (Broderick et al, 2014). Thus researchers are
increasingly designing and developing smartphone-based apps to deliver tailored and
interactive services (Muessig et al, 2013). Whilst there has been a rapid increase in mHealth
interventions, particularly in relation to healthy eating, exercise and measuring blood
pressure, development has been slower in sexual health promotion (Muessig et al, 2013),
which could be attributed to perceptions of sexual health as private and potentially
embarrassing (Bailey et al, 2015).
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Muessig and colleagues (2013) conducted a review of 55 HIV/STD-related apps, exploring
uptake, acceptability and content and concluded that most of the apps had failed to engage
their target audiences, generally receiving low user reviews and being downloaded
infrequently. The authors called for health practitioners and app developers to include
evidence-based risk-reduction interventions within app design and to improve inclusiveness
and interactivity. Carvajal and colleagues (2013) reviewed 16 contraceptive reminder apps
designed to reduce teen pregnancy rates, which used a variety of methods of providing
assistance and information Carvajal and colleagues (2013) were more positive about these
apps than Muessig and colleagues (2013) were about HIV/STD apps, and argued that such
apps have great potential in improving contraceptive consistency and should be promoted
by care providers in counselling sessions. However, these findings were presented in a brief
commentary piece rather than a full-length research paper, so neither the research methods
nor findings were presented in detail.
Research exploring public acceptability of sexual-health-related mobile apps has
demonstrated willingness to use HIV prevention apps (Holloway and colleagues, 2014;
Muessig and colleagues, 2013). Muessig and colleagues (2013) explored user’s design
preferences for an HIV-related app, and found that participants requested an app with user-
friendly content about STDs, symptom evaluation, test site locations, alcohol and drug risk,
relationships, safe sex, and gay-friendly health providers, as well as facilitating
communication with gay, HIV-positive men. Similarly, Ramanathan and colleagues (2013)
studied user preferences concerning mobile health applications for self-monitoring and self-
management amongst HIV-positive individuals and young mothers, and found
individualisation and context-awareness to be the most important features influencing
attractiveness and acceptability.
Literature suggests that using apps on smart phones to provide HIV and STI prevention and
care has numerous benefits, including: convenience, flexibility, tailoring, accessibility,
anonymity, real-time feedback and interactivity. Well-designed mobile apps can facilitate
delivery of interventions in ways that are desirable for at-risk populations, including MSM
and racial and ethnic minorities (Muessig et al, 2013). However, Muessig et al (2013) and
Bailey et al (2015) both state that current sexual health prevention and care apps lack many
promising features, and call for developers to create appropriately tailored, interactive apps.
Specifically, Bailey and colleagues (2015a) suggest the NHS have been slow to embrace
digital interventions, and that, while numerous health apps are available, they are not
48
evidence-based, and the NHS has no system of formally approving apps as safe.
Development may be hindered by the resources necessary to develop, assess and promote
sophisticated and reliable mobile sexual health apps, particularly as they must compete with
popular commercial apps. As Gold and colleagues (2012) observed, keeping the content,
look and feel of apps up-to-date is a costly, ongoing process, and funding models that view
intervention development as a one-off cost may not foster effective online interventions,
which is in line with their finding that many interventions on social media have fallen
inactive (Gold et al, 2011). As a solution, Bailey and colleagues (2015) suggest cross-
sectoral collaboration and offering digital interventions “in conjunction with currently
existing digital health systems” to overcome barriers of sustainable funding and user uptake
(p.10).
Digital sexual health interventions have the potential to enhance access for vulnerable and
hard-to-reach groups, as well as making sexual health care easier for those who may be
reluctant to visit sexual health care settings. However, there is a need to consider the
possibility that increasing digitalisation might fuel, not reduce, inequalities. The following
section explores literature on the ‘digital divide’, considering how inequalities in internet
use might drive inequalities in young people’s sexual health.
2.4.5 Digital divide?
It is important to consider how the growing importance of the internet as a source of sexual
health information and support may unequally benefit different individuals and societal
groups. As services increasingly become ‘digital by default’, Thomson and colleagues
(2014) warn that “the lack of digital literacy and digital inclusion threatens democratic
processes” (p.1), while Neter and Brainin (2012) identify the risk of eHealth literacy creating
new divisions between health consumers.
Since the emergence of the computer economy over the last 25 years, researchers have
developed the concept of a ‘digital divide’, characterised by “unequal access to the internet
and its use” (Boonaert and Vettenburg, 2011, p55). The term describes divisions across and
within society in relation to age, gender and socio-economic status, and refers to differences
between those with the essential resources to participate in current society and those without
(Chen and Wellman, 2004). However, emerging research suggests that traditional
conceptualisations of the ‘digital divide’ focused on access, are now ‘redundant’, particularly
within middle-high income countries (Elwick et al, 2013; ONS, 2016). Elwick and
49
colleagues (2013) found internet access to be approaching universality, and recent ONS
(2016a) statistics indicate that, in the UK, 89% of all households, and 99% of households
with children, have access.
The tripartite information access model (Burnett et al. 2008) introduced in Section 2.3.5 is a
useful point of reference for considering ‘access’ to the internet and online content. While
physical access to the internet is approaching universality, intellectual and social access are
not necessarily as equally distributed; a digital divide may continue to exist in how
individuals use the internet (Boonaert and Vettenburg, 2011; Elwick et al, 2013; Eynon,
2009; Lichy, 2011). This is commonly referred to as the ‘second-level digital divide’ (Lichy,
2011; Zhao, 2009). Eynon (2009) defines this new digital divide, concerning digital literacy
skills rather than physical access, as a:
“multifaceted phenomenon, defined as a continuum of access and use where multiple
interrelating reasons such as attitudes, skills, quality of access and social support are
at work in explaining if, and how, people use new technologies” (p.278)
This conceptualisation of division recognises that connectivity and usage can be influenced
by a number of factors, including demographic, socio-economic and cultural variables, and
socio-technical factors that support or constrain access (Eynon, 2009; Lichy, 2011;
Livingstone and Helsper, 2007). Thus, research has begun to focus on comparisons across
socio-spatial perspectives and between ‘advantaged’ and ‘disadvantaged’ socio-economic
groups (Eynon, 2009; Lichy, 2011; Livingstone and Helsper, 2007). The concept of the
second-level digital divide will be deeply relevant to my research, helping to focus data
collection and analysis less on issues of physical access, and more on the socio-cultural
factors that may affect young people’s intellectual and social access to online sexual health
information and services.
2.4.6 Perceptions of young people as ‘digital natives’
Related to changing conceptualisations of the ‘digital divide’ are perceptions of young
people as ‘digital natives’. Young people of school, college or university age, who have
grown up with the internet, are assigned labels emphasizing the significance of digital
technologies within their lives, such as ‘digital natives’, ‘the net generation’ and
‘millennials’ (Helsper and Eynon, 2010; Prensky, 2001). As Parker and colleagues (2014)
explain: “Teenagers are the most technology-savvy group in the UK, with much of their
social lives conducted online, and it is clear that young people have access to a much less
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moderated world than previously existed. It no longer makes sense to separate online and
offline activities – digital activity is an integral part of young people’s relationships” (p.3).
Labelling young people as digitally adept implicitly marks older people as being otherwise
(Prensky, 2001; Underwood, 2007). In an extreme example of this distinction, Prensky
(2001) defined digital natives as “native speakers of the digital language of computers, video
games and the internet” (p.1), stating that their brains have adapted in structure to suit the
way they process information to the use of digital technologies. According to Prensky
(2001), digital natives process information quickly, often multi-task, prefer graphics to text,
function well when networked and prosper on quick gratification and rewards. In contrast,
‘digital immigrants’, born before 1980, are ill-adapted to digital technologies, and would not
turn to the internet as a first port of call for information Prensky (2001).
Perceptions of young people as ‘digital natives’ may partially explain why more literature
focuses on older people’s digital literacy. This focus may be warranted, as research suggests
that those who use health services the most and experience the greatest burden of ill health
are least likely to use online services or have basic digital literacy skills (eHealth
Stakeholders Group, 2014; The Royal Society of Edinburgh, 2013). However, a growing
body of literature is critical of perspectives that generalise the internet use of whole
generations. Boyd (2014) argue that the term ‘digital natives’ obstructs nuanced
understandings of the challenges that young people face online. Researchers have shown
that, while age may be related to internet use (Cheong, 2008; Dutton and Helsper, 2007;
Helsper and Eynon, 2010), young people do not use new technologies in the same ways, for
the same reasons, and with the same levels of effectiveness (DiMaggio and Hargittai, 2001;
Facer and Furlong 2001; Hargittai and Hinnart, 2008; Livingstone and Helsper, 2007).
Access to online health information, and the capacity to interpret and implement such
information, can be influenced by socioeconomic and cultural factors (Warschauer and
Matuchniak, 2010). For example, research suggests that students who experience greater
socio-economic deprivation access the internet as frequently as other socio-economic
groups, but are considerably less likely to use the internet in carrying out school work
(Elwick et al, 2013). Similarly, Lichy (2011) found that engagement in scholastic and
educational activities online is socioeconomically patterned in both France and the UK.
Research further suggests that young people’s digital literacy can be influenced by social
support from peers (Margolis et al, 2008) and family members (Barron et al, 2009).
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2.4.7 Researching young people’s skills in seeking online health information
While having access to the internet and capacity to use the internet are prerequisites for
effectively finding health information online, doing so requires skills that may not be shared
equally amongst young people. Twelve years ago, Gray and colleagues (2005) described
young people’s use of the internet to source general health information as a useful example
of the pressures placed upon individuals’ health literacy, with young people facing processes
of identifying useful websites and relevant content, evaluating information and determining
how to apply that information. They found that students were typically confident internet
users, but varied in their competence in locating, evaluating and using online health
information.
Since Gray and colleagues’ (2005) research was published, the role of the internet in young
people’s lives has changed and grown, with the online context taking a more central role in
health information and service provision, such that the pressures placed on individuals’
health literacy in the online context are likely even greater today. Developments in internet
technology have led to a greater role for social and multi-media content, such that the
demands of negotiating the online context are not just more intense, but also different from
what they were in the past.
Despite the increasing complexity of using online health information, some research into
young people’s capacity to evaluate online content has identified improvements. While
studies by Borzekowski and Rickert (2001a), and Hansen and colleagues (2003) found that
young people experience difficulties evaluating the reliability of general health information
online, later studies have suggested that young people are typically skilled in evaluating
sources (Buhi et al, 2009; Jones and Biddlecom, 2011). Research has progressed beyond
measuring effectiveness to exploring the strategies young people use to evaluate sources,
including: relying on reputable or well-known sources; avoiding certain types of sources;
and triangulating information (Buhi et al, 2009; Gray et al, 2005; Jones and Biddlecom,
2011).
While these few studies are instructive and of good quality, they primarily focus on college
students, and are based in the USA, and therefore may not be reflective of the experiences
of people of different age groups and in different locations. As such, from a UK perspective
it is important that research increases our understanding of young, Scottish people’s
behaviours and experiences in searching for sexual health information online. At the same
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time it is important that, in addition to studying young people’s online information-seeking
skills, research examines young people’s interactive sexual health literacy. Barriers such as
embarrassment and shame are considerable, and research has shown that young people
experience these in relation to talking about sex or sexual health with others (e.g. teachers;
friends; family) (McMichael and Gifford, 2010). Therefore, communication must be studied
as a core component of sexual health literacy alongside individual information-seeking, and
a broad conceptualisation of communication should be used that includes verbal, non-verbal
and online communication in various situations, including communicating with service
providers and within sexual interactions.
While understanding young people’s information-seeking skills is valuable, it must be
acknowledged that the presence of relevant, accessible and accurate information is a pre-
requisite for successful information-seeking. From the 1990’s to the present day, research
has consistently found sexual health information to be presented at too high a level for young
people (Charbonneau, 2013; Parker et al, 1996), variable in quality and narrow in scope
(Bay-Cheng, 2001), with topics including sexual identity/orientation, masturbation and
abortion under-represented (Isaacson, 2006; Keller et al, 2004; Simon and Daneback, 2013).
Moreover, the growth of user-generated content and social media may further exacerbate
concerns about the quality of information available online (Adams, 2010), and therefore
concerns about the demands placed on young people’s information appraisal skills. Within
social media, peers collaboratively generate their own understandings without input from
health professionals, but, as Fergie and colleagues (2015) note, this is not necessarily without
benefits, as social media can also present participants with “opportunities to contribute to
medical knowledge which circumvent established boundaries” (p26).
2.5 How can this study contribute to existing literature
Research around conceptualisations of health literacy, sexual health literacy and digital
health literacy has highlighted these concepts’ multidimensional and contested nature.
However, there has been a limited focus on health literacy specific to sexual health (or,
‘sexual health literacy’), and studies that have measured sexual health literacy have tended
to do so quantitatively, measuring knowledge and access to sources with little consideration
of broader aspects of health literacy. As such, there is potential for new research to usefully
focus on sexual health literacy in a way that recognises its functional, interactive and critical
aspects. Thus, it is crucial that this thesis approaches sexual health literacy in terms of skills,
not simply knowledge.
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Young people rely on more ‘traditional’ sources of sexual health information (Alldred and
David, 2007; Parker et al, 2014; Tanton et al, 2015). It is important to recognise this, and
consider the relationships between these traditionally ‘offline’ sources and the ‘online’
environment. Viewing the offline and online environments in isolation, as separate domains,
is likely counterproductive, and recognising the interactions between, for example, online
diagnostic information and interactions within ‘offline’ health care settings is part of
understanding interactive sexual health literacy. It is important to explore the broader context
of young people’s sexual health decision-making, including their sources of information,
such as school, peers, friends, and social media. Simon and Daneback (2013) identified gaps
in the literature around young people’s motivations for seeking sexual health information
online and understandings of how forces in the ‘offline’ domain may drive young people to
seek sexual health information online. When considering the broader sexual health
information landscape, the influence of school could be substantial, and another area of
investigation could be heterogeneity in experiences of school-based sexual health education.
For example, studying differences between denominational and secular schools, for which
the Scottish context would be well suited.
There is a need for up-to-date, qualitative research within the Scottish context that explores
the variety and importance of different information sources for young people, as well as the
extent to which those sources meet their information needs (Tanton et al, 2015). Given that
most research into sexual health literacy and online health information seeking has been in
the USA, more detailed understandings of young people in Scotland may be illuminating.
Similarly, literature has been dominated by studies of university-aged people, and studying
the experiences and behaviours of a greater range of ages and circumstances may be
constructive, particularly given the speed at which young people’s sexual activity can change
as they reach their late teenage years. Understandings of the experiences and behaviours of
a range of different age groups could be instructive for efforts to create online sexual health
information tailored to specific groups.
In addition to studying the role of school-based sexual health information, this thesis may
benefit from studying the role of friends and peers, another key source of predominantly
‘offline’ sexual health information and support. As established, it is crucial to acknowledge
the interactive aspects of sexual health literacy, and peer support represents a way in which
young people may both give and receive support. It also has clear overlap with the online
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environment, given the increased role of social media and user-generated online content in
young people’s lives.
As interest in digital technology in sexual health care and prevention grows, there is a need
for further quality research to understand the effect of new media use on adolescents’ sexual
health, and to identify the best ways to use new technologies to promote sexual health in the
short and long terms (Allison et al, 2012). Researchers have called for qualitative research
into the different kinds of services and information young people want, as well as into
awareness, expectations and barriers to online sexual health services (Aicken et al, 2016;
Livingstone and Mason, 2015).
In the rapidly-changing health information landscape of this digital age, it is increasingly
important to better understand people’s experiences of, and perspectives on, finding,
interpreting and applying online sexual health information. Although literature has studied
aspects of young people’s interactions with online sexual health information, few studies
have done so comprehensively, taking into account an expansive conceptualisation of sexual
health literacy.
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3 Methods
3.1 Overview of chapter
This chapter describes and discusses the research methods, beginning by describing the aims
and scope of the study (3.2), before discussing the epistemological and methodological
considerations informing research design decisions (3.3). This will be followed by a
description of the specific research design and data collection methods (3.4) and data
management and analysis processes (3.5). Finally, I discuss issues of reflexivity and the
influence of the researcher (3.6).
3.2 Aims and scope of the study
3.2.1 Aims of the study
The aims of this study were to examine young people’s sexual health literacy, particularly
within the online context, exploring how they describe and experience locating, accessing,
understanding, evaluating and applying sexual health information within sexual, social and
formal healthcare contexts. The research questions were as follows:
1. What is the role of the internet within the broader landscape of young
people’s sexual health information and support?
2. How do young people describe and experience seeking, understanding,
evaluating and using online sexual health information?
3. What are the individual, social and environmental contexts relevant to
young people’s experience and use of online sexual health information and
support?
3.2.2 Identifying the population of interest
This project began with an interest in young people’s sexual health. The age range of 16-19
years was chosen to enable exploration of abilities in seeking, understanding and evaluating
online sexual health information at ages when many young people in the UK become, or
consider becoming, sexually active. As Robinson and Rogstad (2002) state: “adolescence is
a time of risk taking as part of the process of growing up” (p. 314). Recent findings from
the National Surveys of Sexual Attitudes and Lifestyles (Natsal-3) found that the median
age of first heterosexual intercourse for both sexes was 17 years (Mercer et al, 2013). Young
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adolescents are also more likely to have short monogamous relationships, concurrent
relationships and more new partners, and be particularly vulnerable to poor sexual health
outcomes (Robinson and Rogstad, 2002; Slater and Robinson, 2014).
As detailed within the literature review (Section 2.4.5), research has highlighted potential
inequalities in how individuals use online technologies, in relation to a range of factors,
including demographic, socio-economic and cultural (Elwick et al, 2013; ONS, 2016).
Despite this, young people have traditionally been considered as ‘digital natives’, which
arguably hinders understandings and research into variety in young people’s negotiations of
the online environment (Boyd, 2014). My study aims to confront the potential variety of
young people’s experiences by representing a diverse range of young people. The sampling
approach is described in Section 3.3.2, and the final sample is detailed in Section 3.4.4.
3.3 Epistemological and methodological rationales
3.3.1 Why a qualitative perspective?
Depending on their chosen research questions, researchers should determine the most
appropriate approach, which then influences the study design, including data collection,
tools and analytical approaches. Many methodological approaches and tools are available to
researchers, with different strengths and weaknesses. Within the social sciences, there has
traditionally been a clear divide between quantitative and qualitative approaches.
Quantitative research tends to involve deductive and structured research techniques, and is
suited to collecting data that can be generalised to some larger populations (Cresswell, 2013).
Qualitative methodologies tend to offer greater flexibility, involving inductive research
techniques, which are valuable to researchers who aim to describe, explore or understand
phenomena, establishing the ‘what’, ‘why’ and ‘how’, rather than ‘how frequently’ or ‘how
many’ (Gantley et al, 1999). While qualitative methods are often criticised for lacking
scientific rigour, they allow researchers to acknowledge the social context of people’s
experiences and explore behaviour within specific settings rather than across broad
populations.
The research reported in this thesis comprised an exploratory research project grounded in
participants’ perceptions and experiences. Consequently, qualitative methods were chosen
for their focus on gaining insights into the wider contexts of experiences. In particular, a
qualitative descriptive approach was employed, allowing participants’ experiences to be
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comprehensively summarised whilst remaining close to the data and “to the surface of words
and events” (Sandelowski, 2000, p.334; Neergaard et al, 2009). Descriptive approaches
differ from more interpretive approaches, such as grounded theory or phenomenological
approaches, as researchers using descriptive approaches tend to stay closer to the data and
words or actions of the participants, rather than describing events through a conceptual or
abstract framework (Sandelowski, 2000; Neergaard et al, 2009). Such an approach is
particularly useful when seeking to shed light on a gap in knowledge, and particularly to
provide answers to questions of practitioner and policy relevance (Sandelowski, 2000;
p.336; Neergaard et al, 2009).
While descriptive approaches are considered to be less interpretive, it is important to
recognise that some degree of interpretation is intrinsic to the research process. Taking a hue
from an interpretivist perspective, researchers must be aware of their role in subjectively
interpreting participants’ accounts, which are themselves subjective representations of their
lived experiences (Cresswell, 2013). An interpretivist approach to research recognises that
human social action must be understood through interpretation of what actions mean to those
taking part, but also that interpretations are influenced by researchers’ backgrounds and
experiences (Crotty, 1998).
With this understood, qualitative methods can aid identification of meanings, patterns and
themes through considering and prioritising understandings and subjective experiences
(Broom and Willis, 2007). As detailed in Section 3.2.1, my study aimed to understand young
people’s online sexual health information practices. It is self-evident that seeking,
understanding and using health information are active processes, and each individual may
have unique approaches to finding and using sexual health information. Understanding such
nuances is a strength of qualitative research (links to research question 2: How do young
people describe and experience seeking, understanding, evaluating and using online sexual
health information?). People’s experiences are complex and context-sensitive, and my aim
was to choose a method that would best illuminate these complexities. Exploring how such
practices are shaped, and the impact of wider social and environmental contexts, were key
focuses (maps on to research question 1: What is the role of the internet within the broader
landscape of young people’s sexual health information and support?; and research question
3: What are the individual, social and environmental contexts relevant to young people’s
experience and use of online sexual health information and support?).
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3.3.2 Data collection methodology
The chosen study design integrated different qualitative research methods. After careful
consideration of the research aims and the strengths and limitations of various qualitative
methods, a paired interview method incorporating an observational analysis was deemed
best suited to exploring the role of the online context within young people’s wider sexual
health information landscapes (research question 1), their use of online sexual health
information (research question 2), and interactions between those online and offline contexts
(research question 3). Within this section, I will discuss the use of paired interview and
observational methodologies broadly, and the specific rationale for choosing these methods
for this study. I will then discuss formulating sampling and recruitment strategies, and
considerations about the interview setting.
3.3.2.1 Rationale for use of paired interview method
Paired interviewing first emerged as a qualitative methodology in the 1970s, and is typically
defined as one researcher interviewing two participants at the same time in the same place
(Arksey, 1996; Pahl and Pahl, 1971). Since its creation, paired interviewing has been used
in various qualitative studies to explore various topics amongst different groups, including
young people and within friendship groups (Highet, 2003; Houssart and Evens, 2011).
Despite this, Wilson and colleagues’ (2016) review of qualitative methodological literature
found paired interviews to be largely absent, deeming this to be surprising given the
method’s methodological potential, which offers “the unique advantage of allowing the
interviewer to observe interactions between pairs of interest” (p.1551).
Within qualitative methodology, paired interviews are typically seen as a middle ground
between individual interviews and focus groups, offering some valuable alternative strengths
(Morris, 2001). They share some of the benefits and strengths of focus groups, creating a
space within which participants can engage in discussions with each other, potentially
resulting in richer data on individual and group interactions, perceptions and experiences
(Kitzinger, 2004; Marshall and Rossman, 2014). While my research aims could have been
addressed using a focus group method, upon reflecting on the literature and considering the
potentially sensitive nature of the topic, I decided that paired interviews could encourage
engagement by providing each participant ample opportunity to contribute. By giving
individuals more scope to contribute, richer data about individuals may emerge, reducing
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the risk of ‘skimming of the surface’ of participants’ experiences and perspectives (Munday,
2006).
Paired interviews offer more space than focus groups “for frequent and sustained dialogue
between participants, a process possible in larger groups but likely to be much more
dispersed and fragmented” (Highet, 2003, p.114). Thus, conversations are less likely to
diverge in multiple directions, as they can in focus groups. Given that addressing my
research questions demanded examining various aspects of the sexual health literacy
landscape, not confined simply to the online context, I concluded that paired interviews
would allow effective moderation of interviews to remain on-topic throughout a dense
interview schedule, while still producing valuable group dynamics that are the key strength
of group research (Highet, 2003).
An aim of the paired interview method is to create research environments within which
researchers can observe interactions between pairs to gain insights into their perceptions,
understandings and experiences, and explore power dynamics, highlighting issues of tension
and conflict which may not emerge in individual interviews (Arksey, 1996; Houssart and
Evens, 2011). Wilson et al (2016) highlight the benefits of paired interviews in shedding
light on both similarities and differences in participants’ perceptions. They allow researchers
to observe how pairs make decisions and reach compromises together (Seale et al, 2008),
and how they engage in shared storytelling and the negotiation and co-construction of
knowledge (Highet, 2003). These observations can help researchers to understand the
implicit resources important in decision-making. Participants can encourage and prompt one
another, resulting in richer stories and more detailed accounts.
Paired interviews’ potential for capturing frequent and sustained dialogue between
participants may be enhanced when conducted with participants in established relationships
(such as family, friends or partners). Highet (2003) states that paired interviews with self-
selected friends offer spaces where young people’s understandings may be contextualised
within their social worlds, providing insights into their social relationships with each other.
As Highet (2003) details:
“Paired interviews offer a novel context within which young people can discuss,
debate and theorize about aspects of their social worlds, offering occasional glimpses
into more private territory”
(Highet, 2003, p.108)
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By creating this novel context, paired interviews allow nuanced insight into differing
relationships and social dynamics, and the influence of these on communication of
perceptions and experiences. They are more conducive to exploration of personal feelings
than larger groups, while retaining some valuable elements of group discussion, such as
spontaneity (Highet, 2003). Another advantage of conducting paired interviews with
participants with pre-existing relationships may be that participants can help fill gaps in each
other’s recollections, providing insights that may not be revealed in solo interviews
(Seymour et al, 1995).
Commensurate with indications from literature that paired interviews are well suited to
research with young people and participants from friendship groups, I chose to recruit young
people with existing friendships to take part. Encouraging participants to choose friends to
take part with may help “offset the inhibiting potential of the setting” and “create a
supportive social context” to facilitate engagement in conversation that may produce insights
into close friendship bonds by drawing on natural social networks (Highet, 2003, p 108).
Highet (2003) argues that interviewing friendship pairs may produce less inhibited
contributions due to pairs’ pre-existing trust, changing power dynamics to allow more
natural conversation and more genuine insights into social meanings. It was hoped that
interviewing self-selected friendship pairs would diminish both the discomfort inherent to
any interview situation, and discomfort associated with discussing sexual health issues,
particularly with an older researcher (the role of the researcher is discussed in Section 3.6.2).
By reducing these sources of discomfort and self-consciousness, the research design was
hoped to facilitate open reflection, expression and exploration of emotions and feelings.
As with any methodology, there are limitations to paired interviews. One participant may
dominate conversation and not allow the other equal opportunities of self-expression
(Arksey, 1996; Houssart and Evens, 2011). Similarly, power dynamics within pairs may
influence the reliability of individuals’ accounts (Sandelowski, 2008); participants may
influence one another, and feel unwilling or unable to answer questions freely, feeling
pressured to conform to a unified account (Wilson et al, 2016). However, concerns about
reliability of accounts are intrinsic to all qualitative research methodologies. Wilson and
colleagues (2016) state that the literature on this topic is conflicted, with no consensus about
the influence that one participant’s accounts may have their partner’s. However, they
conclude that:
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Paired depth interviews have logical appeal because they have the potential to lead
to the collection of data in a more cohesive way whenever the participants form
natural pairs in the context of the research question(s). Indeed, it can be argued that
in such situations, compared solely to conducting individual interviews of each
member of the pair, the use of paired depth interviews would lead to an interview
process that is more continuous, iterative, interactive, dynamic, holistic, and, above
all, synergistic (Wilson et al, 2016, p.1565)
Thus, after considering the strengths and limitations of this methodology, I concluded that
paired interviews would be an appropriate and valuable method for my research, allowing
participants to discuss their experiences of seeking, evaluating and using online sexual health
information, as well as questioning and critiquing their interview partners’ approaches and
understandings. The research aims demanded an in-depth data collection method that
supported dialogue and rich interactions. The literature illustrates how paired interviews can
give insights into the social context of participants’ experiences, and I therefore determined
that the method was appropriate to addressing my research questions, particularly research
question three, with its focus on contextual aspects of young people’s experience and use of
online sexual health information.
Paired interviews offer the potential to incorporate different data collection techniques to
generate richer data, such as activities to promote discussion and interaction (Wilson et al,
2016). The following section discusses the use of observational methodologies, and justifies
the inclusion of an observation aspect within the paired interviews.
3.3.2.2 Rationale for the use of observational methods
Clinicians and epidemiologists have consistently used observational methods within
healthcare settings to monitor patients or diseases (Mays and Pope, 1995). Qualitative
observational studies within the social sciences involve detailed and systematic observation
of behaviour and interactions, watching and recording what individuals do or say in specific
settings (Mays and Pope, 1995). Mays and Pope (1995) state “an important advantage of
observation is that it can help to overcome the discrepancy between what people say and
what they actually do” (p.183). In other words, observational analysis can help circumvent
biases within individuals’ accounts of their own actions and behaviour, such as selectivity
and differences in recall, as well as potentially revealing behaviours that participants may
not be conscious of. Real-time data collection of this type has been suggested to reflect
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individuals’ thinking processes in the moment more accurately than retrospective reflections
(Eysenbach and Kohler, 2002; Hansen et al. 2003).
Observational methods can be illuminating and insightful, but have certain limitations.
While proponents of observational methods believe them to be less reactive than other
common data collection techniques (Johnson, 1975), they nonetheless take place within
somewhat artificial environments, often under experimental conditions. Both participants’
awareness of being observed and artificial time pressures often necessitated by research
practicalities may produce observed behaviours that differ from how participants would
behave when not under observation.
Despite these limitations, the method’s transferability and value is increasingly recognised
within health behaviour and information research. Research into online health searching
behaviours has traditionally relied on surveys (Baker et al, 2003; Fox et al, 2006), which are
vulnerable to recall bias and, potentially, inability to capture particular search tactics, with
few studies actually observing, recording and analysing individuals engaged in search
processes (Buhi et al, 2009; Eysenbach and Kohler, 2002; Gray et al, 2005; Hanson et al,
2003; Smith et al, 2000). Hansen et al (2003) highlight the importance of such methods
within health information research: “analysing search behaviour through actual observation
should be a cornerstone in any effort to improve adolescents’ access to health information”
(p.18).
After reflecting on the methodological literature, I concluded that augmenting paired
interviews with observational research could produce insights beyond those attainable
through self-reported data, which could be particularly relevant for addressing research
question two. A key challenge of gathering data about internet use is that the resources drawn
upon and decisions made during search processes are often implicit; this challenge may be
circumvented by observing pairs’ use of resources in the co-creation of knowledge during
an activity. Observing participants engaged in an online activity enables examination how
they ‘actually’ experience searching for, and evaluating, sexual health information in real
time, albeit in artificial circumstances. Furthermore, incorporating an observational activity
further justified the use of the relatively manageable paired interview method, as opposed to
focus groups.
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The designs of the paired interviews and online activity are detailed in Section 3.4.2, and the
analytical considerations of synthesising data from the different stages of data collection are
described in Section 3.3.3.
3.3.2.3 Sampling and recruitment approach
Unlike quantitative research, sampling for qualitative studies is seldom statistically based.
Rather, participants tend to be sampled purposively to provide a range of contrasting
accounts and experiences from a population (Merriam, 2002; Polkinghorne, 2005). Mays
and Pope (1995) summarise this approach: “The idea of this type of sampling is not to
generalise to the whole population but to indicate common links or categories shared
between the setting observed and others like it” (p.4). Guided by these principles, my
research aimed to represent a diverse range of young people’s perspectives, exploring both
commonalities across the sample and variation within the sample. Thus, to explore the
diversity of how young people experience and describe seeking and using online sexual
health information, this study sought a heterogeneous and purposive sample driven by the
literature (detailed in Section 2.4.6).
The target population for this study was young men and women (aged 16-19), purposively
sampled to include individuals from diverse socioeconomic backgrounds and geographical
areas (the main study sample is detailed in Section 3.4.4). However, while sampling was
purposive, with the aim of recruiting a diverse sample, sampling was driven by participants
to an extent, as individuals were invited to recruit their friends to be interviewed with, so
ultimately I ceded some control over the makeup of the sample to create paired interview
situations that engendered comfort and openness.
To represent a diverse range of perspectives from the target population I used a broad range
of recruitment strategies, which will be detailed in Section 3.4.4.
3.3.3 Analytical approach
A range of approaches to qualitative analysis have emerged from specific epistemological
and methodological traditions (Frost et al, 2010). However, there has been little literature
related to analysis of paired interview data (Wilson et al, 2016). To address this, Wilson and
colleagues (2016) identified fifteen possible approaches, encouraging future researchers to
document their analysis to provide further shared insights. Their suggested approaches range
from more quantitative approaches such as word counting (Carley, 1986), to in-depth
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qualitative approaches such as discourse analysis (Gee, 2014) and narrative analysis
(Riessman, 1993).
3.3.3.1 The Framework method
The Framework Analysis approach was adopted to ensure systematic thematic analysis and
facilitate synthesis of key themes and interpretations across the dataset (Ritchie and Spencer,
2002). This approach to analysis involves five key stages: familiarisation; identification of a
thematic framework; indexing; charting; and mapping and interpretation. Systematic
analysis is enabled by the key feature of Framework analysis, which is the methodical
organisation of data within framework matrices, allowing comprehensive analysis both
across themes, and within cases. While cases are typically individual participants, a case can
also be other units of analysis; in my research it became necessary to treat both individuals
and pairs as units of analysis (described in Section 3.3.3.2). Thus, the Framework analysis
method was particularly valuable for my research, allowing perspectives on themes to be
compared across all participants, while also allowing individuals’ and pairs’ perspectives on
specific themes to be contextualised alongside other aspects of their accounts (Gale et al,
2013). Furthermore, Framework allows inclusion of non-interview data, such as field notes
and reflections, increasing the context-driven nature of the analysis (Gale et al, 2013).
Taking these strengths into account, the Framework method was deemed to be well-suited
to grounding analysis in participants’ accounts and being sensitive to context, which was
particularly relevant to my research questions, which concerned young people’s sexual
health literacy within the wider contexts of their experiences. In Section 3.5.2, I provide an
explanation of how I approached the five key steps of Framework Analysis.
3.3.3.2 Paired interview analytical considerations
An important consideration in analysing paired interviews is to maintain balance between
examining the pair ‘as a unit’ and identifying individual voices within. In relation to focus
groups, Kitzinger and Barbour (1999) state that analysis requires balance between
considering the overall picture of the group ‘as a unit’ and acknowledging the individuals
within it. I decided that my analysis would recognise both pairs and individuals as units of
analysis as appropriate, recognising that individuals might share experiences, but might
relate to those experiences differently. It is important to explore individual responses, as well
as looking at contrasts and comparisons between participants’ accounts. This is also true
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when analysing across the sample, as well as within pairs, as it is important to highlight and
code parts of discussions that exemplify both typical responses and minority viewpoints.
While it was necessary to explore individuals’ perspectives, it was equally necessary to
recognise the importance of dynamics within pairs. As detailed in Section 3.3.2, a key
strength of paired interviews is in generating rich insights into participants’ interactions and
dynamics. Therefore, to justify the data collection method, analysis must consider the effects
of participants on their co-interviewees, and how accounts may be changed, opposed or
censured within group interactions.
3.3.3.3 Synthesis of findings
Due to the relative complexity of the data collected, it was necessary to systematically
integrate conversational and observational data. The data integration approach used
facilitated synergistic interpretations, which considered the findings from all the data
collected across the different stages of the research. This approach was adapted from that
used by Flowers and colleagues (2016), who used this method to integrate findings from
quantitative and qualitative data within a single matrix. The researchers reflected that this
synergistic approach generated valuable knowledge by identifying complementary and
unique findings from different data sources.
3.4 Data collection methods
Within this section I begin by discussing ethical considerations (3.4.1), before presenting an
overview of the paired interview design and facilitation (3.4.2). I then discuss implementing
those methods within the pilot phase (3.4.3) and main study (3.4.4).
3.4.1 Ethics
Too often, ethical issues are treated as an afterthought, and not granted sufficient
consideration in research design. However, qualitative research must be considered in terms
of a relationship or collaboration with participants, and therefore ethical engagement should
feature throughout qualitative research, from beginning to end of data collection and within
the process of writing up the research. This engagement involves informal processes that
help build trust and rapport with participants, and formal ones, providing ethical guidance,
and protection for both researchers and participants.
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Consideration of both informal and formal ethical issues informed the design of the pilot and
main study. Key ethical issues related to the importance of informed consent, confidentiality
and the sensitivity of the issues covered within the research. It was vital to make clear to
participants what the research involve and make them aware of their rights within the
research process. Each participant was given a simple, comprehensive information sheet by
either a gate-keeper or myself approximately a week in advance of their interview, and were
made aware that they could refuse to answer any questions and withdraw their consent at
any time, for any reason (see Appendix 1). Informed consent to record audio throughout the
interview, and screenshots during the observational activity, was obtained, and participants
were made aware that they would remain anonymous, and the data would be stored and
destroyed in accordance with MRC guidelines on good practice (see Appendix 2).
Ethical approval for this research was obtained from the University of Glasgow College of
Social Sciences Research Ethics Committee. Ethical issues that arose will be discussed in
more detail in Section 3.4.3.
3.4.2 Overview of paired interview design and facilitation
Each paired interview comprised of three stages (illustrated in Figure 3-1): a ‘traditional’
interview stage, in which the participants were prompted to discuss sources of sexual health
information in general, and online sexual health information specifically; an interactive
online activity; and a post-activity discussion in which I asked questions to provoke
discussion of the information-seeking processes that played out in the online activity. The
three stages are described in more detail below.
Figure 3-1: Paired interview stages and data produced
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At the outset of the paired interview, I discussed the information on the information sheet
and the consent procedures with participants. Written consent was sought before
commencing, and participants were made aware that they could withdraw consent at any
stage without providing a reason. After consent forms were signed, participants were asked
to complete two short questionnaires to collect basic demographic information and
information on their internet access and use (see Appendix 3). The results of these were used
to contextualise participants’ contributions within interviews.
3.4.2.1 Stage one: ‘traditional’ exploratory interview
The first stage of the paired interview followed a traditional interview format, following a
semi-structured topic guide covering broad issues intended to explore how participants
experienced, used and described online technologies and sexual health information, as well
as exploring participants’ understandings of ‘sexual health’ and their experiences and
perceptions of other information sources.
A topic guide was created so that discussions could be steered to cover issues including:
understandings of sexual health issues; communication skills; awareness of, and engagement
with, different sources of sexual health information; access to, or engagement with, different
forms of media and technology; experiences of applying sexual health information within
social and healthcare contexts; and perceptions of barriers to doing so (see Appendix 4).
Throughout the interview I strove to ask questions to explore more contextual factors,
reflecting the importance of examining psycho-social, and environmental factors in online
sexual health literacy and decision-making. While the topic guide was consistent between
interviews, it was followed in a flexible, semi-structured manner such that participants had
freedom to introduce and discuss topics they saw as relevant. To ensure the topics to be
covered mapped back onto the overarching research aims, I carried out a mapping exercise
of the research questions and the questions within the topic guide, categorising each question
in the topic guide to ensure it contributed to the research aims.
3.4.2.2 Stage two: online observational activity
The second stage of the paired interview was an observational analysis comprising an
unsupervised online information-seeking activity designed to allow examination of
participants’ search strategies and abilities to locate, navigate, interpret and evaluate online
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sexual health information. Thus, after initial discussion about general experiences and
perceptions of digital technologies and sexual health information seeking in the exploratory
interview stage, participants were provided with a laptop with a blank web browser on-
screen, and asked to think about the techniques they would usually use to search for
information relevant to two predetermined sexual health scenarios (see Box 3-1 below). The
scenarios were presented in a relatively general manner, designed not to require specific
answers, but rather to prompt participants to consider how they would search for and
evaluate information they deemed relevant to addressing each scenario (see Appendix 5).
The first scenario was hypothetical situation a person might encounter following sexual risk-
taking: “You had unprotected sex and are worried that you might have an STI. Use the
laptop provided to find information that will be useful to you”. In contrast, the second
scenario was a hypothetical situation involving gathering information in anticipation of a
sexual encounter: “your friend is thinking about having sex for the first time and would like
some advice. Use the laptop provided to find information that will be useful to them.” The
two differing scenarios were purposefully chosen to allow assessment of a range of health
information needs: generic, specific, service related and location specific, and were
developed with reference to relevant literature on typifying realistic, common situations
(Forrest et al, 2011; Hansen et al, 2003).
Box 3-1. Online scenarios
After being provided with the scenarios and laptop, I left the participants for approximately
20 minutes for them to address the scenarios without being directly observed. Participants’
use of the internet and discussions with each other as they carried out the activity were
recoded using TechSmith Camtasia Studio screen capture software to document images and
audio of the activity, saving two screen captures per second and recording participants’
conversations to produce synchronised videos of the process. In addition, participants were
given pens and paper and asked to take notes for later discussion. Both before beginning the
overall interview process, and before beginning the online activity, participants were made
aware that they would be audio recorded during the online activity, and that I would listen
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back to the recordings and watch the search terms and websites they visited. I explained that
participants could call me back to the room for any reason.
Typically observational activities such as this involve asking individual participants to use a
‘think out loud’ approach (Hansen et al, 2003). In this study, the pairs were encouraged to
share their thought processes aloud with each other as they searched for answers. It was
hoped that working in pairs to find information would place less pressure individual
participants than in solo observational activities, and that natural interaction between friends
would provide greater insights into information search and evaluation processes. Ideally,
participants would discuss their search processes openly, free from direct supervision and
without feeling that their performance was being tested.
3.4.2.3 Stage three: post-activity discussion and finishing up
Following the online activity, I re-entered the room and began the third stage of data
collection, which was a discussion of more specific aspects of seeking and evaluating online
sexual health information. The notes taken by participants during the online activity were
used to reassemble their behaviours from the activity and inform discussion. The discussions
explored: decision-making processes, including criteria for selecting specific online sources;
facilitators and barriers encountered; and each participant’s perceptions of their friend’s
approaches to information-seeking.
As the paired interview ended, participants were invited to contribute further comments by
post, email or on a one-to-one basis if they wished to clarify certain points or had been
reluctant to say something in the presence of their friends.
3.4.3 Piloting the methods: reflections and learning
A pilot study was conducted in winter 2014 to test and help refine data collection methods
ahead of the main study (see PhD study timetable – Appendix 6). Two paired interviews
were conducted, one with male participants and another with female participants.
Conducting these pilot interviews allowed the methodological combination of paired
interviews and online activity, including the screen capture software, to be tested in practice,
providing opportunities to gather feedback on the topic schedule, the scenarios used in the
online activity, and the practicalities of using the hardware and software. The main insights
gained are described below.
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3.4.3.1 Recruitment and sampling
Participants for the pilot phase were recruited using convenience sampling through personal
and professional networks, facilitating relatively fast recruitment. However, as convenience
sampling would likely constrain the diversity of the sample, a more expansive sampling
strategy was developed for the main study (detailed in Section 3.4.4).
To gain insights into possible differences in accounts by gender, I purposively sought to
include both male and female participants. I recruited one pair of female participants (Jess
and Amelia, both aged 16), and one pair of male participants (Aaron and Michael, both aged
19). Participants were given pseudonyms to protect their anonymity.
3.4.3.2 Suitability of methods
In practice, the research design detailed in the preceding section appeared to have many
benefits in terms of producing valuable data that may not have been produced by
straightforward interviews. As detailed in Section 3.3.2, a key rationale for observational
methods is to create an environment much closer to ‘real-life’ than face-to-face interviews,
allowing observation of similar behaviours to those that might be exhibited in participants’
everyday lives. Certain behaviours, such as online information seeking, can be difficult to
access fully through research, and participants’ recall of their experiences may differ
substantially from their actual experiences and behaviours. During the initial stage of the
first paired interview, Jess and Amelia (aged 16) described having no problems searching
for sexual health information on the internet, perceiving the internet as a place to go for all
kinds of information. For example, Amelia said: “You can find anything on the internet, so
if you’re looking for something, you can just go there, you can fling anything in, you’ll get
something”, and Jess agreed: “I think you can just really search for anything”. However,
during the online activity, they became frustrated trying to source information, particularly
for Scenario Two, and were surprised by this, with Amelia stating “Like you expect loads to
turn up about that”. This example demonstrates how participants’ perceptions and
expectations of internet use may not match their practical experiences, and how my method
allowed this dissonance to be surfaced. In another incident, Jess initially stated that she knew
of no sexual health websites during the first stage of the interview, but, during the online
activity, she narrated the process of accessing a familiar website: “Just checking ‘Being
Girl’…that what I was talking about…it’s an online girl’s magazine…I remember going on
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it and thinking oh this is so cool...”. Again, this illustrates how participants’ practices in the
online activity provided insights that the face-to-face interviews may not have.
Whilst the online activity shed light on participants’ searching practices and relationship
dynamics, one limitation was that I was not present to prompt for explanations about certain
decisions. Consequentially, at times listening back to the data from the online activities I
would have liked to have been able to ask participants to explain their practices in more
depth. The opportunity to probe for greater depth is, ordinarily, a key advantage of
qualitative research, but it was not afforded to me during the online activity. However,
incorporating a post-activity interview, in which I asked for feedback on the activity,
mitigated this limitation somewhat. These reflections reinforced the need to explore and
probe their online activity practices in the third stage of the interview.
Similarly, another issue that was presumably related to the participants being left
unsupervised was that, at times, they became distracted and did not always focus on
addressing the scenarios, particularly towards the end of the online activity. This was
particularly the case for Aaron and Michael (aged 19), who, and as time progressed, used
less serious search terms. In an extreme case, Aaron entered the search term ‘ku klux klan’
seemingly to irritate and embarrass Michael. At another point, Aaron and Michael took
pictures of them carrying out the online activity and sent them to their friends using
SnapChat, suggesting that they were happy to share what they were doing on social media.
These examples illustrate that an unsupervised observational method demands relinquishing
some control as a necessary by-product of producing data that would be unlikely to arise
from supervised interviews alone.
Testing the software and hardware used to carry out and document the online task in a
practical research situation was a vital aspect of the pilot phase. Within the first pilot
interview, in a meeting room in the participant’s local library, I found that the library’s
wireless internet access was slow, impacting participants’ searches. Beyond this, the
software functioned correctly and the task was recorded properly. In reaction to encountering
poor wireless internet, and in recognition that some interview sites may have no internet
access, I sourced a mobile internet dongle to use in case of limited internet access at future
interview sites. As a further precaution, I created print-outs of example search results pages
and websites as a back-up discussion prompt to use in the case of technical problems.
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3.4.3.3 Ethical issues
On reflection, watching and listening back to the recording of the online activity from the
pilot interviews raised feelings of unease and ethical concern. While I had followed correct
ethical procedures by ensuring participants were made aware that their behaviours would be
recorded and watched back, it seemed at times that they had forgotten they were being
recorded; at one point, Michael reminded Aaron: “remember this is being recorded”. While
I had set out to capture natural conversations and behaviours that young people might engage
in outside of the research context, this phenomenon made me somewhat uneasy, as if I were
covertly observing private conversations. After reflecting on this phenomenon, I concluded
that such unease is inherent to producing useful, in-depth insights into ‘natural’ discussions
and behaviours. While participants’ apparent comfort within the research environment may
be indicative of a successful observational research design, it also highlights the importance
of being rigorously ethical when storing, analysing and writing-up the data emerging from
these naturalistic processes, and highlighted the importance of reaffirming and ensuring
informed consent at the outset and throughout.
An area of ethical consideration was highlighted in the pilot study, when Aaron expressed a
misconception about STI risk that I felt a natural desire to correct him. However, in advance
of the interviews, I had taken the decision that I would not intervene in participants’
understandings or practices, except for in cases where I believed their wellbeing to be at
serious risk. While it is open for debate whether interventions into minor misconceptions are
within the remit of the researcher, in the case of interviews with friendship pairings, and
particularly when discussing a topic as potentially sensitive as sexual health, it may be
appropriate to seek to avoid causing embarrassment, except when the understandings are
likely to be directly harmful.
Upon completing and reflecting on the pilot paired interviews, I concluded that the method
was useful and suitable to addressing my research aims, producing data that highlighted
personal reflections on online behaviours and provided insights into online behaviours. As
no substantial changes to the data collection methods were necessary, the data from the pilot
study were included within the main study.
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3.4.4 The main study
Fieldwork for the main study began in January 2015 (see PhD study timetable – Appendix
6). This section details sampling and recruitment strategies, characteristics of the sample,
issues of power and the influence of the researcher, and general reflections on the methods
in practice.
3.4.4.1 Recruitment
Recruiting young people for this kind of study can be complex and time-consuming, and
arranging interviews with participants can involve negotiating with gatekeepers to co-
ordinate time schedules and interview locations. To recruit a diverse range of young people
of varying socioeconomic status and geographical origin I used a range of recruitment
strategies, including both working with gatekeepers and directly contacting young people
within a range of settings across Scotland.
One strategy chosen was recruiting via gatekeepers working within organisations that young
people frequent, including youth clubs, community centres and charity organisations. Such
settings provide access to young people within more informal environments than the school
setting, the formality of which may have negatively influenced comfort in agreeing to take
part in research about sexual health. I carried out a scoping review to systematically identify
appropriate organisations within Scotland.
Given the need to recruit a sample diverse in socio-economic status (SES) and geographical
location, I approached organisations within areas of high deprivation (measured by area
deprivation: SIMD). While area deprivation does not necessarily match the material well-
being or disadvantage of individuals within those areas, categorising participants by other
measures of SES (e.g. defined by level of education, occupation/income and type of housing
tenure) was regarded as unsuitable due to participants’ ages. Upon reflection, I decided that
focusing on geographical localities with the highest and lowest area deprivation scores
would increase the likelihood of recruiting young people from diverse socioeconomic
backgrounds. However, the heterogeneity of deprivation within areas must be
acknowledged, with participants’ area-based SES being a potential indicator, not a firm
determinant, of their individual circumstances. The need to recruit participants from varied
geographical locations was addressed by approaching organisations and young people within
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a variety of urban, semi-urban and rural areas across Scotland, as defined by the Scottish
Government (SG) urban/rural classification (Scottish Government, 2014a).
Having identified organisations that might provide access to suitable participants, I contacted
the identified organisations initially by email to introduce myself and describe my research,
before contacting them by telephone to ask if they would be interested in helping to recruit
for the study (see Appendix 7). They were sent recruitment information concerning: the
focus of the project; participants’ roles in the research; the number of participants required;
the expected format and content of the paired interview; details of how participants would
be compensated for their time (with shopping vouchers worth £20 each); contact information
for myself and supervisors; and clear information about anonymity, confidentiality and use
of data. Where possible, I met gatekeepers in person to give them information sheets, answer
their questions and organise times and locations for paired interviews. Once individuals
agreed to take part, contact was maintained by telephone, email and text to encourage
attendance and respond to queries. During the recruitment process, I maintained a detailed
database of each organisation, with notes of contacts made and responses received, to keep
track of communications and maintained effective, respectful, and professional
relationships.
A potential risk of relying on gatekeepers to recruit participants is that they may screen
potential participants, consciously or otherwise (Kitzinger and Barbour, 1999). To reduce
selection bias, I asked gatekeepers to pass information sheets on to all the young people that
used their facility, or, better still, I offered to attend to talk to the young people directly,
allowing them to have time to think about whether they would like to take part and ask
questions about the research. One youth group gatekeeper provided guidance, introducing
me to a group of young people with minor support needs (typically troubles with
concentration), identifying them as a key group whose perspectives should be represented in
my research. In addition to highlighting, and providing access to, specific groups, some
gatekeepers assisted in recruitment by providing me with contact details of gatekeepers
within other organisations.
Despite the potential limitations of using gatekeepers, I found it to be a successful way to
recruit participants, with eighteen interviews being arranged in this way. In addition to
assisting with recruitment, some gatekeepers provided added insight and more contextual
data. For example, after an interview within which the participants, Josh and Christina (aged
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16), were quiet and difficult to engage in conversation, the gatekeeper asked if I had managed
to ‘get a word in edgeways’, implied that this was out of character. Such added insights were
noted in my field notes and considered during analysis (detailed in Section 3.5.2).
In addition to working with gatekeepers, I directly contacted young people, primarily
through posters, word of mouth and online posts (see recruitment online/offline poster in
Appendix 8). More passive methods, like putting posters with study details in community
centres and college and university student unions, were less successful than more direct
contact with gatekeepers and young people, with only one paired interview being recruited
in this way. This could be attributed to visibility of the posters, but also to reluctance to
initiate contact with a stranger about a potentially sensitive topic. The study was also
advertised online, through personal and professional contacts on Facebook and Twitter.
Participants recruited in this way tended to have been referred by contacts who had told them
about the posts, rather than seeing the posts themselves. By not relying on online recruitment
methods I avoided excluding participants who either do not have internet access or are not
regular internet or social media users.
Once fieldwork had commenced, I recruited new participants through snowball sampling.
This strategy is particularly useful in accessing participants for research in sensitive topic
areas, for which advertisements such as posters may not be as persuasive or reassuring as a
personal recommendation (Ritchie et al, 2003). After each interview I thanked the
participants for their participation and asked them if they could pass on an information leaflet
with contact details to any friends that might want to take part (aiding snowball sampling).
Participants for two paired interviews were recruited in this way. In one interview, this
process helped shed light on barriers to recruitment and issues in relation to gender norms;
at the end of the interview with Amelia and Jess (aged 16), I asked them if they thought any
of their friends might like to take part, and they thought their female friends might, but not
their male friends. Amelia explained “oh no they are too masculine for this kind of thing”.
This was an interesting insight, alluding to norms around participation in research, possibly
in relation to sexual health specifically. Some of these gender issues are explored within the
findings chapters.
When young people contacted me for more information or to take part (either by telephone,
email or text), I provided them with more information and invited them to participate at
locations and times that suited them. While participants were invited to bring friends, they
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were given the option of being interviewed individually if they prefer, or could not arrange
for a friend to join them. This allowance was afforded to participants due to the sensitivity
of the subject matter, but also due to a practical desire to reduce barriers to recruitment.
Despite some initial concerns about recruiting young people, recruitment was relatively
straightforward. This may have been aided by young people feeling more confident to come
forward and take part with a friend. Similarly, the interviews were relatively easy to
schedule, which may also be attributed to the pairs’ established relationships, rather than
trying coordinate groups of strangers. Similarly, Highet (2003) found paired interviews
relatively simple to recruit and facilitate, attributing this to the established relationships
between the participants.
3.4.4.2 Characteristics of the sample
Between January and August 2015, 49 participants (aged 16-19) from across Scotland
participated in 25 interviews (23 paired interviews; two individual interviews and one triad
interview). The triad interview and individual interviews were necessitated by circumstances
rather than participants’ preferences. In terms of their relationships with one another,
participants tended to bring along a ‘best friend’, or childhood or school friend. Two pairs
were related and two pairs were acquaintances, with implications for interview comfort and
openness, as will be discussed in more detail in Section 3.4.4.4. This section details the
makeup of the sample by: geographical location; gender and sexuality; education and
occupational status; age; socio-economic status; nationality and ethnicity; religious
affiliation; and support needs. Finally, this section highlights some limitations of the sample.
Participants were recruited from, and interviews took place within, locations across
Scotland, including: South Lanarkshire; Glasgow; Edinburgh; Dundee; Aberdeenshire;
North Lanarkshire; East Ayrshire; Fife; Perth and Kinross; Angus; and Inverclyde.
Participants were predominantly recruited within large and small urban areas (18
interviews); followed by accessible small towns (4 interviews) and accessible rural areas (3
interviews). I was unable to recruit any participants from organisations within remote rural
areas (those with populations less than 3,000 and a drive time of over 30 minutes from the
nearest settlement (Scottish Government, 2014a)). Despite this, the sample represented a
satisfactory mixture of urban and rural localities across Scotland.
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I aimed to recruit equal numbers of young men and women to facilitate exploration of
relationships between gender and perspectives. The final sample comprised 30 female
participants (61%) and 19 male participants (39%). This imbalance may be related to females
being more comfortable talking about sexual health with friends. Most participants identified
as heterosexual (n=36), five identified as gay or lesbian, three as bisexual, and five either
left this question blank or indicted that they preferred not to answer.
Participants varied in their circumstances regarding education and work: most were still at,
or had recently left, school (n=22), followed by attending college or university (n=14), being
employed (n=5) and looking for work (n=3), while six did not provide this information.
Participants were predominantly younger; 31 (63%) were aged between 16-17 and 18 were
aged 18-19 (37%). Eleven interviews comprised participants recruited from within the 15%
most deprived areas (SIMD) and one pair was recruited from a charity that works with young
people vulnerable to homelessness.
All participants classed themselves as white Scottish, except one who identified as white
Polish. Most participants reported having no religious background (n=36), but 13 described
themselves as having a religious background: 10 Roman Catholic, two Church of Scotland
the one other Christian. Two of the interviews (n=3) were with individuals with minor
support needs.
Overall, the sample was heterogeneous in terms of the characteristics targeted, representing
young people from a broad range of backgrounds. The diversity of ages and educational
backgrounds represented in the sample was particularly valuable, as previous studies
exploring online information-seeking amongst young people tend to focus on university
students. Each participant and pair’s characteristics are detailed in Appendix 9. It is
important to consider the limitations of the research sample. While the sample was diverse,
some groups that were not represented, including participants with no access to the internet,
participants from ethnic minorities and participants from remote rural locations. These
limitations could mean that the full range of perspectives was not represented in the data.
More specifically, as all participants had daily access to online technologies at home, and
primarily on mobile phones, this sample cannot address questions about the ‘digital divide’
in traditional access terms, but, as highlighted in the literature review, use, not access, is now
the more relevant digital divide, and the recruited sample did allow use to be explored.
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Another key concern is that, as many participants were recruited from youth organisations,
they were already somewhat engaged in their communities, within these organisations and
with other young people. Therefore, those who do not have such social support, who may be
more likely to instead seek support online, may have been underrepresented. Additionally,
given that participants were necessarily aware that they were agreeing to participate, with a
friend, in an interview about sexual health, individuals who struggle the most to
communicate about sexual health were likely underrepresented. However, despite this
concern, not all participants appeared comfortable in talking about sexual health, indeed
some acted as if they had not been enthusiastic to participate, perhaps having been persuaded
by their friends.
3.4.4.3 Interview setting
Paired interviews primarily took place within places that participants frequented, or could
easily access, including: local youth clubs/organisations (n=12); local library or community
centres (n=8); private meeting rooms within my workplace (MRC/CSO Social and Public
Health Sciences Unit, University of Glasgow) (n=2); and within participants’ homes (n=3).
I was enthusiastic for interviews to take place where participants felt comfortable, and felt
that an academic office environment may exacerbate participants’ perceptions of me as a
professional, increasing barriers between us (power dynamics are discussed in more detail
in Section 3.6.2). Participants who were interviewed within their own homes appeared to be
particularly at ease; Kara, who was paired with her friend Amy, tried to make me feel at
ease, encouraging me to make myself at home and help myself to food.
While I strove to conduct interviews within enclosed, private spaces to encourage comfort
and openness, this was not always possible. Participants’ chosen interview settings raised
issues of noise and privacy, with participants at times distracted by activities elsewhere
within the environment, particularly within youth club settings. On two occasions other
members of a youth club entered the room during the interview, interrupting the flow of the
conversation and potentially increasing participants’ anxieties about the subject matter and
privacy. In one such incident, Cleo lowered her voice when a fellow member of the youth
club’s staff walked past, explaining to Alice that she did not “want to talk too loud in case
people are pure listening”. This contextual insight highlights concerns about being overheard
discussing sexual health. Beyond this, noisy environments caused technical challenges, as
participants’ words were not always clear on interview recordings.
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3.4.4.4 Further reflections on data collection
This section further details my reflections on both the opportunities and challenges presented
by applying these methods in practice, drawing on interview transcripts for illustrative
examples.
As reflected on in Section 3.4.3, incorporating the online observational activity within the
pilot study demonstrated online practices that could not have been accessed directly through
interviewing alone. For example, in the first stage of the interview, participants at times had
difficulty answering questions about searching practices, explaining that they did without
conscious consideration. These barriers were partially overcome through the observational
online activity, which allowed me to observe search practices that participants may have
been unlikely to recall or report in an interview, for example: strategies for locating relevant
information; rationales for choosing specific links; difficulties with certain information and
language; and their general skills in navigating the online environment (these will be
described in Chapter 5). This produced rich data, which questions alone may not have
captured, about participants’ experiences if searching for, and evaluating, online sexual
health information in real time, albeit within an artificial environment. Furthermore, the
online task appeared to improve participants’ recall and sharing of opinions in the post-
activity stage of the interview.
Because the activity was done in pairs, and participants talked to each other while negotiating
their search strategies, the activity produced insights into both shared norms and experiences.
For example, whilst deciding which search result to follow after entering search terms,
Sophie said “Usually I’d just click on the top ones”, to which Keira agreed: “Yeah I always
click them because I feel the top ones are most reliable and I feel like the more you go down
its more weird things you get”. This illustrates how the paired activity provided insights into
shared practices that a solo activity may not. As well as consensuses between participants,
the activity also highlighted differences in opinion, both within and between pairs. For
example, Lucy and Reece disagreed over the reliability of a WikiHow article, which Reece
wanted to use:
Reece: Okay. Actually, WikiHow is really good. I like WikiHow.
Lucy: No.
Reece: Go on WikiHow.
Lucy: No, we'll go on Better Health.
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Reece: No, go on WikiHow.
Lucy: Let's not go on WikiHow!
Reece: But WikiHow's good.
Lucy: Yeah, and it could also be written by anyone.
Reece: So can pretty much anything on the internet
(Lucy and Reece, aged 17)
Thus, this method revealed disagreements between participants in terms of their search
strategies and perceptions of different sources, insights which would have been difficult to
gain from a solo activity.
The ways that differences played out within the interview also provided insights into the
dynamics of pairs’ social relationships, which apparent within the face-to-face interview,
and, particularly, during the online activity. While most selected close friends to accompany
them, dynamics and power relationships within pairs varied. Generally, participants worked
well together, with decision-making, formulating of search terms, suggestions and feedback
being mutual, collaborative processes, but in some pairs one participant dominated,
particularly in initial stages of searching. This initial inequity generally reduced as the
searching process unfolded, but for three pairs imbalances were evident for the duration.
Samantha (aged 17) and Martha’s (aged 16) relationship was one of short-term
acquaintanceship rather than long-term friendship. When their online activity began, Martha
entered search terms without consulting Samantha, and was reluctant to listen to Samantha’s
suggestions, who wanted to think carefully about search terms. This power imbalance was
matched by an imbalance in confidence evident during the interview stages, in which
Samantha appeared more nervous, exhibiting greater difficulty in expressing her ideas. In
another pair, their familiarity with one another resulted in Josie (aged 19) taking charge of
the decision-making, while Kyle (aged 19) contributed little, seeming content to note the
information that Josie found. During the the online activity, Josie’s influence on Kyle was
highlighted while discussing their findings about HIV:
Kyle: ‘It can lead to AIDS if left untreated’.
Josie: It cannae be treated. That's the point.
Kyle: Aye, but if you leave it and you don't know you've got it it can go intae AIDS.
Josie: It goes tae AIDS no matter what…
Kyle: But HIV is manageable but, isn't it?
Josie: No. There's nae tablets, there's nae cure, there's nothing for it.
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Kyle: Really?
Josie: Mmm hmm. Did you no' know this?
Kyle: Naw, man. I can’t believe that
(Kyle and Josie, aged 19)
In this example, participants took different roles in an apparently functional partnership. In
a minority of cases, pair dynamics prevented insights into searching practices. For example,
Christina and Josh, whose relationship seemed to have a competitive dynamic, stopped the
activity after five minutes in reaction to differences of opinion, instead of working to reach
a compromise, illustrating how the unsupervised nature of the online task could hinder data
collection with some pairs of participants.
Throughout the research process I was conscious of the need for flexibility in implementing
the research method. The pilot phase (as described in Section 3.4.3) was beneficial in
determining the methods to be sufficient and motivating me to source additional IT
equipment and develop alternative materials in anticipation of technical problems. Despite
this, I embarked on the main study with some concerns about the online activity, including
the risk of technical problems, but, thankfully no substantial problems arose. Aside from
technical challenges, another reason for flexibility when carrying out paired interviews is
that individuals may not attend at the arranged time, and an unplanned solo interview may
have to be carried out. Two participants stated that they would prefer to take part alone, and
one of them, Tina, later confided that she did not feel that she had many friends to turn to.
In this instance, I was glad to be able to include Tina, and not let her circumstances prevent
her participation, as her perspectives were particularly important to document given her lack
of a friend support network. However, these experiences highlighted how limited friendship
networks could prevent some young people from participating in this type of research.
Conversely, on one occasion a participant, Caleb, brought two friends with him, and, not
wishing to turn one away, I chose to be flexible and incorporate all three. The resulting
interview was less effective than the paired interviews, as it was more difficult to explore
three participants’ perspectives.
For some participants with minor additional support needs, it was appropriate to improvise
to adapt the research design. As the unsupervised online activity was not necessarily suitable
for these participants, I asked whether they preferred for me to stay in the room, which they
did. When participants in these improvised, supervised online activities were unsure about
web searches, I instead guided them through some websites and prompted them to discuss
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their reactions to them. In these instances, the data produced was not as rich as in the paired
interviews with unsupervised online activities, but it was important to be flexible and
inclusive to represent as much diversity as possible.
3.5 Data management and analysis
Working with the copious and complex data produced necessitated special consideration.
Data produced included: individual and group-level self-reported experiences and
perceptions; interactions between participants; participants’ descriptions of their actions
during the online task; and search behaviours exhibited during the online task. These data
needed to be synthesised to be analysed as one coherent body, which presented substantial
challenges. For example, within any given pair, there was the potential to compare their
stated perceptions in the initial interview with: their descriptions of their search behaviours
during the online task; their exhibited behaviours during the online task; and their reflections
on their behaviours following the online task. On top of this, it was necessary to consider
similarities and differences between participants both within and across pairs. This chapter
details how the copious, complex data were transcribed, managed, analysed and reported.
3.5.1 Transcription and data management
The three stages of the paired interview (before, during and after the online activity) were
audio-recorded, with informed consent, and transcribed verbatim. I transcribed the first four
paired interview and online activity transcripts, and the remainder were transcribed by a
professional transcription service adhering to MRC and University of Glasgow
confidentiality guidelines. I read each transcript while listening to the corresponding audio
recording to both correct errors and familiarise myself with the interviews, adding notes and
reflections and drawing on field notes. Kvale (2007) considers this an important means of
reawakening “social and emotional aspects of the interview situation” (p.95). Following
transcription each participant, along with any other individuals described in their accounts,
were assigned pseudonyms to maintain anonymity. Further, any identifying information
such as details of workplaces or youth organisations were removed or altered.
Transcripts were imported into NVivo 10 qualitative software, to facilitate capturing and
organise the extensive qualitative data. NVivo 10 was a useful way to manage the data,
allowing me to focus on brief excerpts of transcripts while retaining the ability to see
excerpts in their original context. As well as the written transcripts, the video files generated
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by TechSmith Camtasia Studio synchronising participants’ discussions during the online
task with the corresponding screen captures were imported into Nvivo10. However, NVivo
10 consistently crashed, seemingly prompted by the large quantity of data imported. As an
alternative coding strategy, I created a Microsoft Excel workbook containing a separate
worksheet for each pair in which I systematically recorded detailed information about their
search strategies, websites chosen and the discussions that accompanied these behaviours
(detailed in Section 3.5.2.2).
3.5.2 Three stages of analysis
This section will describe the process of analysing the data and synthesising the findings,
which comprised three stages: Framework analysis of conversational data; descriptive
quantitative analysis of observational data; and data integration (see Figure 3-2).
Figure 3-2. Analysis and synthesis processes
3.5.2.1 Framework analysis of conversational data
The Framework analysis approach was adopted to ensure a systematic approach to thematic
analysis and facilitate synthesis of key themes and interpretations across the dataset (Ritchie
and Spencer, 2002). This approach to data analysis involved five key stages: familiarisation;
identification of a thematic framework; indexing; charting; and mapping and interpretation.
The Framework analysis process began with familiarisation stage, involving reading and re-
reading transcripts, listening to recordings, reviewing field notes and taking notes to identify
themes and issues from the data. This early analysis stage was primarily carried out using
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paper and pen, recording analytical notes and emerging themes in the margin, ranging from
attitudes and values, practices and emotions to methodological considerations (for example,
relating to pair dynamics and the interview context).
This familiarisation informed the second stage of analysis, which was identification of a
thematic framework. Using the notes taken during the familiarisation stage and the key
themes, issues and concepts identified, I developed a broad thematic framework to shape
coding to enable further analysis and allow the research questions to be answered. These
codes were kept relatively broad so as not to miss any relevant data, with the intent of
becoming narrower as analysis progressed (Bloor et al, 2001). The thematic framework
encompassed six main areas:
Understandings of, and attitudes towards, sexual health
Sources of sexual health information and learning: school; internet; friends and
family; media; other
Locating, evaluating and understanding online sexual health information: strategies,
facilitators and barriers
Using and applying sexual health information: communicating and negotiating in
sexual, social and healthcare contexts
Perspectives on the use of online sexual health services and social media for sexual
health promotion
Pair dynamics and interactions
The final broad code was included to ensure that I remained conscious of the importance of
pair dynamics and the influence of relationships between friends on the data elicited. I
studied my observations of in-pair dynamics from my field notes, and coded interactions
between pairs, including agreements, disagreements, joking, and annoyance, and I recorded
how differences were managed. I also noted when one individual appeared to dominate an
interview, and considered how this might have influenced their friend’s contributions. The
content of individual participants’ contributions and the context in which they occurred were
not treated as separate units of analysis; my field notes and reflections on participants’
characteristics, interactions and paired dynamics were considered throughout analysis.
Once these broad theme codes were identified, I imported the transcripts to NVivo 10 and
provided each pair with a case node to allow exploration of patterns across the sample, whilst
including the context of data within each interview. As this point, I began stage three:
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indexing. The broad codes identified above were used as starting points for coding. For each
broad theme identified, I created a theme node within NVivo 10, and coded each interview
transcript systematically, assigning excerpts of transcripts to relevant theme nodes. As
described, to ensure that contextual dynamics within pairs were retained during coding and
analysis, I strove to code excerpts of conversations between participants, rather than coding
individual statements in isolation (Kidd and Parshall, 2000).
At this stage, coding within each of these themes became unwieldy in terms of the quantity
of data extracts being assigned to each broad theme node, and thus I created secondary and
tertiary nodes within the theme nodes to allow more in-depth coding of data (see Appendix
10 for a detailed thematic framework). For example, within the ‘Sources of sexual health
information and learning (SCHOOL)’ code, I created sub-codes for: ‘scope and content’;
‘frequency and timing’; ‘delivery mode and quality of teaching’ and ‘facilitators of and
barriers to learning’. The codes, sub-themes and broader themes were revised as the process
progressed. To ensure that I had not overlooked relevant data, I reviewed prior coding in an
iterative process.
After I had finished coding, I progressed to the fourth stage of the Framework approach,
charting, creating matrices around each key theme. Matrices for each of the five thematic
areas were created in Microsoft Excel with columns for each sub-themes rows for each
paired interview. Within each matrix, I summarised key points, made notes and included
illustrative quotes from participants relevant to each particular theme (see example extract
from a framework matrix, Figure 3-3). I also noted differences and similarities between
participants within pairs. Systematic coding and charting allowed comparison across the
sample, highlighting commonalities and differences within and across the paired interviews.
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Figure 3-3. Extract from Framework matrix
The final stage of framework analysis consists of mapping and interpretation. In this crucial
stage, the charted data is examined to establish key themes, typologies, associations and
theories around the research questions. This stage of moving between themes and participant
accounts helped in identifying patterns, similarities and differences across the data, allowing
interpretations and explanations to emerge. I created descriptive and interpretive summaries
of each of the broad themes using the matrices, and created ‘biographies’ of each pair in
relation to each theme to consider the whole context, allowing links to be drawn between the
paired interview and online activity stages of data collection. These summaries included
information about the pair dynamics and interactions during the interview, to aid in
contextualising participants’ contributions. An abridged example of such a ‘biography’ is
included in Appendix 11. These summaries were drawn on in comparing experiences
between pairs. Following this process, I systematically collated and made sense of all the
data. The codes and subthemes were collated with field notes to produce overall summaries
of each over-arching theme, which ultimately formed each of the three findings chapters.
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3.5.2.2 Online activity analysis
The observational activity generated both video (consisting of regular screen captures) and
audio data. Verbal interactions between participants were transcribed and analysed
qualitatively, as explained in the preceding section, while the videos necessitated a different
approach. A coding scheme was developed to record the content of the videos to
documenting the pairs’ online search processes. Specific codes included: the scenario being
addressed; the length of time spent on each scenario; the broad search strategy used (search
engine or direct URL); the search strings used; the number of search results pages viewed;
the search rankings of chosen links; the types of websites chosen; the number of pages
viewed within individual websites; time spent on each website; the use of menus;
engagement with advertisements; and engagement with visual content. A Microsoft Excel
workbook was created, containing separate worksheets for each pair, in which I
systematically recorded detailed information about search strategies, websites chosen and
the discussions that accompanied these behaviours (see example Excel extract, Figure 3-4).
By systematically analysing the videos using this coding scheme, information-searching
processes were documented methodically. The websites participants accessed during the
online activity were categorised by the operator/developer of the website (e.g. a Government
health organisation), and subcategories by the type of website (e.g. user generated/social
media websites). The categories and sub-categories of websites used displayed in Table 3-
1. Categorising websites allowed greater insight into the types of websites participants
selected, as well as the location and context of the information, and facilitated comparison
between the types of online sources used during the online activity and the types that
participants reported preferring during the interview stage. Having established this basic
information about the websites that participants accessed, I employed thematic analysis of
the videos to produce more detailed descriptive and interpretative summaries of pair’s search
processes and the discussions they had during the online activity.
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Figure 3-4. Extract from website coding
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Table 3-1: Website categories and sub-categories
3.5.2.3 Data integration
When analysing qualitative data, it is important to draw from experience and interpretation
of complete interviews to retain awareness of the original context of extracts. To facilitate
this, I wrote and compared interpretive and descriptive summaries of the data and entered
them into a data synthesis table. While the primary focus of analysis was participants’
individual feelings, perceptions and experiences of searching, evaluating and using online
sexual health information, and the context within which this occurs, it was important to also
incorporate insights from the search processes and negotiations exhibited during the online
activity. Considering one aspect of the research in isolation would be to undermine the value
of combining the two methods, so effective synthesis of paired interview and online activity
data was essential.
To facilitate high-level synthesis of findings from the different stages of data collection for
the Discussion Chapter (7), the key findings from the paired interviews were combined with
those from the online activity within an analytical findings integration table. The table was
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organised to allow consideration of the findings related to specific contexts (rows) across
each of the findings chapters (columns), thereby synthesising findings drawn both from
conversational and observational data. The first three columns represented the three findings
chapters, and each contained the key findings of that chapter. Those chapters concerned:
young people’s understandings of sexual health and experiences of different sexual health
information sources; perceptions and performances of locating, understanding and
evaluating online sexual health information; and using and applying sexual health
information within different contexts. The fourth column contained interpretation and
synthesis of key findings from each chapter relevant to different contextual aspects of
participants’ experiences. The key environments within which sexual health literacy is
developed and applied were represented in the rows of the table: the online context; school;
peers and the formal health context. The data integration table produced from my findings
is in Appendix 12.
3.5.3 Reporting the data
It is important to consider how the data are reported. To capture the context of data, I felt it
important to report interactions by quoting excerpts capturing exchanges between
participants, instead of quoting participants in isolation. However, in practice it was not
always appropriate to do this, with conversations between pairs often chaotic, such that the
discussions surrounding statements were not always relevant to those statements, and
reporting excerpts of conversations would obstruct rather than enhance clarity. Therefore, I
made the decision to quote discussions between pairs when the context genuinely
contributed to meaning, but not necessarily when the context did not add value to the
quotation. Alongside quotations encapsulating perspectives, I have reported participant
characteristics, such as age, where relevant. Quotes from data elicited during the online
activity is presented in coloured text to highlight differences and context.
I have not consistently used numerical data to report the numbers of participants presenting
specific opinions. I decided that, in many cases, using numbers to represent this complex
data would be only superficially meaningful, undermining the nuances of individuals’
perspectives. As such, while I report numerical data in some circumstances, I primarily use
terms such as ‘most’, ‘majority’, ‘many’, ‘some’ and ‘rarely’ to indicate how common
perspectives were within the sample. In doing this, I acknowledge that the strengths of
qualitative research lie in describing subjective experiences within specific contexts, rather
than measuring frequencies of discrete variables.
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Beyond reporting data within this thesis, an important additional consideration was how to
present data when communicating my research findings in presentations. Given the rich data
captured, it was desirable to present excerpts from videos, both to present the data and
illustrate the methods. However, reproducing recordings of participants’ voices in
presentation contexts raised ethical concerns. I adopted two strategies to address this issue:
in some presentations, I played videos with audio tracks redubbed by colleagues reading
transcripts, while in others I read the transcript aloud as the muted video played. I will
continue to use these approaches when presenting this data in future.
3.6 Reflexivity
This section contains discussion of the process of reflexivity in the research, and the
influence and power of myself within the research context, with illustrative examples.
3.6.1 Reflexivity in research
It is important to acknowledge that there are no perfect methodological tools, and that each
approach has strengths and weaknesses. Plummer (2001) advocates ‘a self-consciousness
about method’, while Brewer (2000) stresses the importance of ‘analytical reflexivity’.
Within qualitative research, a reflexive approach recognises the necessity of these
responsibilities from the beginning to the end of the research process, including data
collection, analysis and writing up. Reflexive approaches allow researchers to think critically
about the impact of their own values, characteristics, biases and preconceptions in shaping
the research and creation of knowledge (Bryman, 2015; Willig, 2013). Willig (2013)
described two types of reflexivity: personal, and epistemological. Personal reflexivity
concerns the influence of researchers’ values, interests, political leanings and social
identities on their research, while epistemological reflexivity concerns the the influence of
the construction of study design on the data and findings, and how these might have
influenced understandings of the data.
The concept of the neutral, absent and objective researcher, common in positivistic
methodological theory, has been critiqued by many (Harding, 1986; Mauthner and Doucet,
2003). While it is often assumed that the best approach to qualitative research is one of open-
mindedness, allowing theory to emerge from the data, O’Reilly (2005) stresses the need to
accept the impossibility of carrying out research without predetermined ideas or judgements.
From this perspective, the best approach is for researchers to be as aware of preconceptions
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as they are of the content of previous literature and the methodological strengths and
weaknesses of their chosen methods (O’Reilly, 2005). Thus, O’Reilly (2005) explains that,
before carrying out qualitative fieldwork, it is important to consider and record any
preconceived ideas or expectations:
“it is only when you face your preconceptions head on that you are able to put them
on one side when you actually go out and observe and talk to people. You can only
be open to surprise if you know what you expect to find”
(p.31-2).
While I am sceptical of being able to entirely put expectations or preconceptions to “one
side”, I believe the process of overtly identifying my personal preconceptions was useful.
My preconceived expectations included: participants would have broadly negative
perceptions of school-based sexual health education; participants’ understandings of sexual
health would be primarily negative and risk-focused; and participants would generally be
competent internet users. I recognised these as being partially derived from my own personal
experiences, as well as my knowledge of the relevant research literature. I remained
conscious of these preconceptions throughout data collection and analysis, to guard against
them biasing either my questions or my interpretations as best as possible.
As well as not being objective, most kinds of qualitative research cannot be unobtrusive, and
it is important to be aware of the effect of the researcher. When conducting research we
cannot help but interfere with phenomena we hope to research (Holstein and Gubrium,
2004). In data collection, factors such as the researcher’s gender, ethnicity, class and
educational level may influence interactions with participants and the data produced, so the
fieldwork context cannot disconnected from the researcher’s influence (Block, 2000;
Holstein and Gubrium, 2004). Therefore, it is important to consider the data generated from
fieldwork as not simply reflecting participants’ experience, but as a product of the interaction
between the researcher and participant (Block, 2000; Holstein and Gubrium, 2004). While
the data produced during stages one and three of the interviews were inevitably products of
interactions between me and my participants, I contend in the following section that, though
I was absent during the online activity (stage two), I nonetheless influenced the data
construction in that stage.
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3.6.2 Issues of power and the influence of the researcher
This section explores the role of power within the research context during my study. As
discussed in the preceding section, it is crucial to continually acknowledge the role of power
and perception within research settings (Matthews, 2001; Morrow and Richards, 1996). The
relationships developed are influenced and shaped by factors including perceptions of
authority, stereotypes, age, social class, and gender (Matthews 2001). Exploring such power
relationships is crucial, particularly in this research project, where I, the researcher, was not
physically present for part of the interview.
During the interactive online activity stage of the interview, I would leave the participants
unsupervised whilst they undertook the online activity. So, in a literal sense, I was an
“absent” researcher. While the participants were being recorded, which was made clear to
them prior to the activity, I was not physically present to observe in real time. By removing
themselves from data collection, researchers create a different environment from the
traditional interview, with their own opportunities and concerns. Gibson (2005) explains that
“the researcher, whether physically present or not, is inevitably part of the research world
being studied. Reflexive analysis of this relationship might be especially important in
situations in which the influence of the absent researcher is less transparent” (p.36).
As a researcher, it is important to consider how the participants may have perceived me and
how this might have influenced them; was I perceived as an older authority figure or as a
young woman with similar experiences? Just as I had expectations as I met participants to
begin the interview process, so would they of me. One pair explicitly said so: on arrival,
Emma said: “you’re just wee” and her sister, Mia explained “yeah we thought you’d be much
older”. However, my role as a university researcher likely caused me to be viewed as an
authoritative source, rather than a peer. I deliberately wore casual dress and engaged
participants in conversation to build rapport prior to interviews, trying to portray myself with
a certain naivety, as someone who was keen to learn from them, rather than an ‘expert’. To
try and put participants at ease, I explained that there were no right or wrong answers, and
that there was no pressure on them, but doubtless some did feel uneasy and pressured by the
research context.
The inherent unease engendered by the research context may have been exacerbated by the
subject matter being discussed. Despite me initially asking general questions around internet
use to ‘warm up’ participants, my presence as a researcher asking questions about sexual
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health undoubtedly influenced their willingness to openly share their perspectives. Many
seemed initially hesitant to share their thoughts and understandings of what ‘sexual health’
meant to them. At times, this appeared to be due to embarrassment at openly discussing
sexual health, exhibited through both frequent nervous laughter and silences. For most
participants, the initial embarrassment eventually subsided, with them becoming more open
to discussing their understandings relatively fully. However, others remained reticent
throughout, exhibiting their awkwardness through very brief answers and reluctance to
elaborate despite gentle prompting. This outcome should be considered, along with the fact
that participants were likely somewhat self-selecting for willingness to discuss sexual health,
suggesting that more reticence might be expected in a truly random sample.
The online activity assisted in highlighting issues of power and expectations within the
research, as well as the effect of my physical presence on participants’ openness. Once I left
the room and the activity began, participants generally seemed more at ease, showing greater
willingness to voice their frustrations, confusions, and feelings. In one case, as soon as I left
the room one participant whispered ‘I just don’t have a clue about sex’, to which the other
replied ‘I know, it really confuses me all this’, suggesting that they had been more guarded
with me. Differences between participants’ presentations of themselves and their knowledge
between the interview and activity stages of the research suggest that the research design
was somewhat successful in accessing both participants’ public and private accounts, the
latter of which, as Cornwell (1984) suggests, are usually only revealed upon repeat
interviews and increasing familiarity between interviewers and interviewees.
However, despite my absence, both me and the research environment still appeared to
influence participants’ actions. For example, some participants voiced concern about
sexually explicit content appearing on screen during the activity; Craig (aged 16) said
‘Should we be clicking on images do you think? Is that, like, can you do that?’, while some
male participants wondered whether I would reprimand them for searching for pornography,
even as a legitimate response to one of the scenarios presented to them. These insights
suggest that participants may have been self-censoring in other ways as well.
Despite me telling participants that there were no right or wrong answers, some participants
clearly felt pressured to perform well for my benefit. For example, Michael (aged 19) said
“do you think she printed these out of her own pocket? We need to give her good answers’,
and Matthew (aged 17) and Charlie (aged 18), who both had minor support needs,
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continually asked if they were giving me the ‘right answers’. Ruth (aged 16) worried about
what I would think “she must listen back to this and be like ‘what are they even talking
about?’. Through statements like this, it became evident that participants were concerned
about my reactions to them, and some seemed to provide answers that they thought I wanted
to hear. For example, when asked whether they might use sexual health apps, Darren (aged
17) stated he would, while his friend Craig (aged 16) said he wouldn’t, to which Darren told
Craig “you’re a miserable so-and-so, you…”. In this example, Darren appeared to feel that
I wanted them to say positive things about sexual health apps, and that Craig was letting me
down. In future it may be beneficial to consider ways of making clear to participants that
there are no right or wrong answers.
These examples illustrate the importance of recognising that, even without the researcher
being physically present, the fieldwork environment cannot be disconnected from the
researcher’s influence (Gibson et al, 2005). The online activity was effective, producing
valuable data that would not have been produced by traditional interviews alone, and ideally
going beyond participants’ verbal constructions of their own behaviours to access actual
behaviours (Silverman, 2001). However, it must be acknowledged that the activity did not
necessarily recreate real-life searching behaviours, as it was an inherently artificial
environment and the young people remained aware of their positions as research participants.
It was important to take these factors into account during data analysis and write-up.
3.7 Summary
Within this chapter, I detailed the methodological process of designing and conducting this
research. The multi-method approach to data collection (incorporating both ‘online’ and
‘offline’ aspects) and the interpretive approach to data analysis enabled exploration of young
people’s sexual health literacy, primarily in an online context, but taking other key influences
and contexts into consideration. The findings of this research are reported in the following
three chapters, drawing on what participants said in the paired interviews, and what they
both said and did during the online activity. Within the findings chapters, I have included
my own brief interpretive reflections on the potential meanings of findings where
appropriate. In the discussion chapter, I summarise the key findings from each findings
chapter, and expand upon my interpretations with reference to literature and theory.
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4 Sexual health information sources: school, peers and
the internet
4.1 Overview of chapter
This chapter will present participants’ descriptions of their motivations for, and experiences
of, using different sexual health information sources, addressing research question 1: What
is the role of the internet within the broader landscape of young peoples’ sexual health
information and support sources?
Participants varied in their past learning experiences, their approaches to learning and their
current preferences for seeking sexual health information. While this thesis focuses on the
online environment, this chapter begins by examining participants’ experiences of receiving
sexual health information and support at school (Section 4.2) and from friends and peers
(Section 4.3), before discussing their use of the internet (Section 4.4). While other sources
were mentioned, including family and other media, school, friends and the internet emerged
as the three key sources. As these findings will demonstrate, school and friends are
fundamental, interrelated, elements of the information and support landscape, and
understanding them is crucial to contextualise the role of the online environment. By
describing how participants discussed learning and seeking sexual health information,
Chapter 4 establishes the background to various aspects of participants’ sexual health
literacy, contextualising the analysis underpinning Chapter 5, with its focus on the online
context.
The data derive from participants’ direct conversations with me during the paired interviews
and from their discussions during the online activity, during which I was absent. Particular
attention has been paid to highlighting similarities and differences between participants,
alongside identifying common themes across the sample.
4.2 Learning in school
School-based sexual health education (which, in Scotland, has been named Relationships,
Sexual Health and Parenthood Education since 2014 (The Scottish Government, 2014a)),
emerged as a key source of learning, typically mentioned when asked ‘where do you think
you have learned about sexual health?’. All participants described having received some
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form of school-based sexual health education, with the exceptions of Ralph, who left school
aged 13, and Laura and Courtney, who attributed this to attending a denominational school1:
And where do you think you’ve learned?
Laura: Not at school
Courtney: Definitely not at school
Laura: Yeah, we go to Catholic schools and it’s no’ really a thing they teach you
Courtney: Like, never, you don’t…it just doesn’t come up
(Laura, aged 16 and Courtney, aged 17)
While most described receiving sexual health education at school, accounts of the extent and
nature of the education received varied in terms of the type of messages promoted, the topics
covered, and the individual relevance of the content. Participants typically perceived their
school-based sexual health education as infrequent and sporadic, typified by Claire and
Ashleigh:
And what was it like in school?
Claire: Can’t really remember…we did it, like, earlier on
Ashleigh: Eh, it was, yeah it was early and it was quite short
Claire: Yeah, we didn’t do that much of it
Ashleigh: Yeah we didn’t do it for very long
(Claire and Ashleigh, aged 17)
Like Claire and Ashleigh, many struggled to remember their school sexual health education,
often attributing this to having received it early (in the first two years of high school) or
having received too little for it to be memorable. Most participants stated they would have
liked to receive more.
This section describes participants’ reflections on school-based sexual health education,
including their perceptions of the sufficiency, consistency and applicability of content, as
well as the learning environment and delivery mode. Insights about aspects of school that
may facilitate, or obstruct, young people’s negotiations of their sexual health will be
highlighted throughout.
1 The Scottish educational system consists mainly of non-denominational schools, but also a small number of
denominational schools. The majority of denominational schools in Scotland are Roman Catholic. Fourteen
participants attended a denominational school, all of which were Roman Catholic.
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4.2.1 Focus on risk and sexual ill health (It’s risky!)
Participants’ accounts of their school-based sexual health education suggested that class
content tended to focus on specific topics and messages; most of participants recalled
learning primarily about outcomes of risky behaviours, such as unwanted pregnancy and
STIs. Connie and Jamie’s recollections typified this:
Do you remember what kind of topics were…?
Jamie: Yeah, aye S…
Connie: STIs and STDs
Jamie: HIV and Chlamydia really
Connie: Aye, that was the biggest things that they really focused on
(Connie, aged 18 and Jamie, aged 16)
Jacob and Connor, who attended a denominational school, directly associated ‘sexual health’
with ‘STDs’ and ‘dangers’ due to their school sexual health education:
When you think of sexual health, what does it mean to you?
Jacob: I think about the NHS, like we used to get talks in school and I just think of
that and it’s pretty much to do with all the dangers and stuff like that…that’s what it
reminds me of
Connor: Yeah, it just reminds me of like STDs
Jacob: That’s what it reminds me of too actually…yeah kinda being warned about
them and all that in school
(Jacob and Connor, aged 18)
Such responses were not unusual, with participants’ recollections of a focus on risk within
their school-based sexual health education often appearing to be reflected in the narrow, risk-
and-disease-focused articulations of ‘sexual health’. While participants typically described
a focus on physical aspects of sexual heath within school-based sexual health education, in
four interviews participants recalled learning about relational and emotional aspects. Two of
these pairs had been involved in school-based peer education initiatives at school, in which
third-year students delivered health education to younger students. Joe and Ruth discussed
both receiving and delivering this type of education:
Joe: It’s used in the schools and you go to, like, primary schools and, kind of, educate
them a bit more as well
Ruth: It’s mostly like alcohol an’ that
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Joe: And drugs and stuff, like, drug misuse and stuff yeah
Ruth: And friendship, yeah. And then health buddies was more about, like your
relationships at home, relationships with partners. Like, puberty and stuff. And then
what they done was you taught that to – was it third years?
Jo: No, second years
(Ruth and Joe, aged 16)
In this exchange, Joe and Ruth recalled that the content they covered included relationships.
Indeed, Ruth, was one of the only participants to mention emotional and relational aspects
within her reported understandings of ‘sexual health’:
So when you think about sexual health, what do you think about?
Joe: Just the risks an’ a’ that really, I think
Ruth: Yeah, definitely
Joe: Like, protection and just things like that
Ruth: It’s more like the relationship that I think about…
Yeah…
Ruth: Like, ‘cause obviously nowadays you either have, like, there’s obviously lots
of different kinds of relationships you can have with people, to do with sex an’ that.
So, I don’t know, I’m only thinking about that. Just about the actual, not so much the
health, but, like, the more involvement, I think, with each other.
(Joe and Ruth, aged 16)
Typically, however, participants rarely mentioned relationships, communication and broader
wellbeing within either their recollections of school or their understandings of ‘sexual
health’. In fact, within the other two interviews where participants described learning about
relationships, they drew distinctions between interpersonal content of sexual health
education classes and ‘sexual health’. Kara and Amy described the content of their school-
based sexual health education:
Kara: Now it’s mostly relationships they do. They try and avoid like, anything too
deep so they just do relationships and like, abusive relationships
Amy: Yeah, I think they do touch on, like diseases and infections, like actual sexual
health, but no’ very much, not enough to learn from
(Amy and Kara, aged 17)
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Here, Kara and Amy appear to consider relationships as not being a legitimate part of ‘actual
sexual health’, which Amy defined as concerning disease and infection, highlighting the
degree to which some associated sexual health with risk and physical ill health.
Few participants mentioned anything positive when defining ‘sexual health’ or describing
school-based sexual health education content. A small number of participants, such as Nicola
and Ralph, commented on the lack of teaching about broader and more pleasurable aspects
of sex:
Nicola: Well they’ve [schools] not been letting young people know, like, they should
talk to them like face to face tae show that like it’s okay if you have these questions,
it’s okay tae do this, it’s perfectly normal. But they don’t talk about like a lotta things
like masturbation or whatever, like they don’t talk about that because like… I don’t
know why because like a lotta kids do it and they feel like horrible for doing it…
Ralph: It should be talked about…
Nicola: You know ‘its fine, it’s okay. Don’t worry’…
(Nicola, aged 17 and Ralph, aged 19)
As well as highlighting the limited focus on pleasurable aspects of sexual health within
school, Nicola and Ralph identified how tacitly reproducing taboos could cause shame and
suppress communication. They had recently watched a television documentary called ‘Sex
in School’, in which a Belgian sexologist introduced a new kind of sex education covering
sexual pleasure within a Lancashire school. This documentary seemed to have influenced
their understandings, making them critical of the negative framing of sexual health within
their own schools, which highlights the potential role of the media in critical awareness.
Within this primarily risk-based teaching, participants described two main themes of
content: abstinence and using protection. Participants’ attitudes towards these teachings are
explored in the following two sections.
4.2.2 Abstinence based messages (It’s risky, so don’t do it!)
Abstinence-based education was primarily experienced by participants who attended
denominational schools. Jacob (aged 18) typified these experiences, stating: “it kinda made
it out as though you’ll have sex and you’ll get an STD”. Jacob and Connor indicated that
their school used fears about STD transmission to promote abstinence. Jess and Amelia
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highlighted similar teaching within their school and described their abstinence-based
education as excluding information about safe sex and contraception:
Amelia: I feel like with our school, cause the other schools are like obviously not
religious and stuff so they don’t care about like like…like our school doesn’t like,
they don’t do the whole contraception thing, they all do like the natural thing cause
it’s…
Jess: Yeah
Amelia:…like Catholic and stuff em…and then all the other schools obviously get
like… get taught how to have like safe sex and all that and we don’t like
Jess: Yeah you feel like…
Amelia:…you feel at a bit of a disadvantage
Jess: In RE like you kind of like touch on subjects but it doesn’t go into like detail
Amelia: Yeah it’s just like, it’s basically just like NO [laughing]
Jess: Yeah
Amelia: No, don’t
(Jess and Amelia, aged 16)
Amelia and Jess’s recollections emphasised their feelings of being disadvantaged by their
denominational education. They appeared concerned about their limited knowledge during
the online activity, with Amelia stating: “I don’t know, sex confuses me” and Jess replying:
“I know, I don’t really know anything”. Amelia’s understanding of ‘sexual health’ was
somewhat consistent with her school experiences, perceiving sexual health as being about
absence of disease, using the stigmatising, moralistic terminology of “if you’re clean or not”.
Lily and Skye did not attend a denominational school, but demonstrated awareness of the
influence of socio-cultural factors (specifically religion) on access to information, feeling
that those that do may be disadvantaged in terms of sexual health education:
Lily: I just think if a lotta younger people were taught a lot more about sexual health
‘cause like you get like, you get taught about sex an’ that but you don’t get taught
about sexual health properly. Like you don’t. An’ in like religious schools an’ all that
they won’t tell you about like contraception or anythin’ cause they’re against
contraception so they won’t know about that either. But you should be told about
that. I think anyway.
Skye: ‘Cause a lotta the schools that people go to are religious
Lily: Aye
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Skye: In like Glasgow and like around certain areas, they are all the religious schools
(Lily and Skye, aged 19)
In identifying Glasgow as an area with many denominational schools, Skye highlighted one
way that geographical location might drive inequalities in sexual health literacy.
4.2.3 Prevention messages and practical information (It’s risky, so use protection!)
While some participants described receiving abstinence-based sexual health education at
school, the majority described a focus on prevention messages, particularly on contraception
use. Martha and Samantha described a focus on ‘safe sex’ and contraception at the expense
of other topics:
Martha: It was always really contraception that was, like, what’s the word for it...like,
it was encouraged
Samantha: Yeah
Martha: But there was never really anything about anything else, or that, it was just
contraception, contraception, contraception
(Martha, aged 16 and Samantha, aged 17)
Despite focusing on risk and preventative measures, participants typically described class
content as lacking practical information about lowering risk within sexual and healthcare
contexts. For example, Alice and Cleo recalled learning about STDs, but receiving
insufficient information about the practicalities of using condoms:
Cleo: We learned about STDs which was good to be aware of…but other than that
you didn’t know like how to say use a condom and stuff like that
Alice: Mmhmm, they didn’t do…
Cleo: It got touched on once and that’s not gonna exactly be in your mind for when
you have first time sex
Alice: It wasn’t great
(Alice, aged 18 and Cleo, aged 19)
This experience was shared by many, and seemed to drive confusion, uncertainty and
misconceptions, with only a small minority feeling they had been adequately taught how to
use condoms. A lack of practical guidance was emphasised by participants who described
primarily learning about sexual health within science classes, such as Melissa:
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Well they do like, how the body changes and they do, like, I don’t know – they do,
like what age that’s gonna happen and they just tell you to use, like, contraception.
They don’t actually tell you anything about the different things you can do an’ that,
what contraception you could use an’, they just say what’s gonna happen to your
body
(Melissa, aged 16)
Melissa described biology classes’ failure to explain contraception in practical terms, instead
taking a biological, mechanical focus on procreation, sexual diseases and contraception. As
a result, Melissa felt insufficiently informed about different contraceptive options.
Beyond prevention, Lucy and Reece highlighted a ‘one-sided’ lack of guidance on managing
the results of risky behaviours:
Lucy: It was basically just 'wear protection'
Reece: Yeah, that was…
Lucy: kind of repeated again and again and again
Reece: There was nothing about, say, if you…
Lucy: And they kind of go on about, like, alcohol and, like…and all that sort of stuff
as well, like that kind of area, but…
Reece: It was more to do with preventing it rather than, like say, not saying we
do…but if we had, like, something like an STI or something, they didn't give us any
information on how we could deal with that. So it was more just informing us on
how to prevent it.
Lucy: Yeah.
Reece: So it was kind of like the one-sided kind of thing.
(Lucy and Reece, aged 17)
Similar issues were also raised by other participants who felt they were given general
messages about prevention, but insufficient practical information on where to access
contraception or testing services.
In addition to criticising school-based sexual health education for providing insufficient
practical information, participants did not recall being taught skills for safe and effective
information-seeking. Notably, no participants described receiving advice on seeking
information, support and services online. As discussed in the literature review, the internet
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is a potentially valuable information source laden with potential challenges and risks.
Participants’ perspectives on the internet are discussed in detail in Section 4.4.
4.2.4 Incomprehensive content (It’s all about heterosexual sex!)
Participants who identified as gay, lesbian or bisexual described the sexual health content
they received at school as irrelevant and insufficient, failing to account for the interface
between sexual identity and sexual health information needs. For example, Abbie said of
school that “they taught me nothing”, and eloquently critiqued insensitivities to gender and
sexuality:
And they didn’t talk about anything, like we didn’t talk about homosexual, they
didn’t talk about trans issues, they didn’t talk about any sexual health other than,
“This is how you not get pregnant.” This is how to not get pregnant, and that’s it,
that’s all you need to know, and you’re like, “Ok, cool””; It’s like… how do people
have sex? And it’s like, “Oh, like this…” And you’re like, “What about gay people?”
“Oh, eh, eh…” “What about trans people?” “What about non-binary people?” It’s
like, “Oh…” Like they totally skipped over everything.
(Abbie, aged 17, paired with Sinead)
Abbie found the information she received neither interesting nor relevant, and worried that
classmates may have had similar unmet needs, but been too embarrassed to ask. She
recounted an occasion when she requested that her teacher cover homosexual health issues,
and found herself being invited to talk in front of class:
And I was like, “What about page twenty-six? What about page twenty-six? The one
that’s actually really quite important.” She was like, and everyone looked at me, and
I wasn’t even out at the time, I was just like… Well I was out, but not to everyone,
and I’m just like… And they’re like, “Are you gay?” I’m like… just didn’t know
what to do, I was like…“no, I’m just quite interested in this.” Like—yeah I just went,
“Yeah, page twenty-six.” And she’s like, “Well, I don’t feel like I should be the
person to talk to you’s about it. Would you like to come up and talk, Abbie?
(Abbie, aged 16, paired with Sinead)
Abbie described a particularly insensitive reaction from her teacher, in which her desire to
learn about relevant sexual health issues resulted in her being ‘outed’, both as being gay and
as wanting to increase her knowledge. While Abbie generally described herself as being
comfortable talking about sexual health with others, she described being embarrassed in this
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situation, with her embarrassment stemming specifically from her teacher’s indiscrete
response to her attempts to steer the focus of the teaching towards issues relevant to her.
Liam, who identified as gay, recalled similarly unhelpful experiences with teachers, such as
a teacher approaching him to ask for both permission and advice for covering homosexual
sex:
My teacher actually came up to me once and asked, said, ‘we’re going to do one on,
like genders. Like, you know, like homosexual sex. Is it okay if I do that?’ It’s like
you want my permission?! Like, in case I got offended. And then she…was like ‘so
what exactly do you want me to cover?’ I was like ‘I’m the one who’s supposed to
be learning stuff here, not you. Where’s your teacher training?’
(Liam, aged 16, paired with Rowan)
Like Abbie, Liam described learning to ask “leading questions” to try to meet his information
needs without overtly singling himself out within class, but nonetheless described being
picked on by classmates. Both Abbie and Liam’s accounts demonstrated their confidence
and both critical and interactive literacy skills in identifying shortcomings of information
provided and trying to discretely request more relevant content. Unfortunately, in each of
these experiences, seeking more relevant teaching had unintended adverse consequences.
Participants’ concerns about abstinence-based teaching and risk-focused teaching,
mentioned in Section 4.2.2, seemed particularly acute for gay, lesbian or bisexual
participants. Denominational schools were identified as particularly heteronormative.
Rowan (aged 16), who identified as gay, was critical of the influence of religion on sexual
health education content, describing denominational schools as presenting heterosexual
relationships as the only legitimate relationships, pursuing “their own agenda to completely
tarnish all homosexual relationships”. Further, he recounted that: “the only teaching we ever
got on homosexual relationships was: ‘Yeah, there are homosexual relationships but we as
Christians believe that's morally wrong’”. Rowan’s friend Liam, who also identified as gay,
but did not attend a denominational school, observed that his school provided no positive,
practical information about anal sex:
I think it's quite ironic when we were doing STIs obviously one o' the big ones was
HIV/AIDS an' they were saying that that's more commonly transmitted, like, through
the likes of anal sex but you never actually taught us about anal sex. Like you know,
like the safety side, using lubricant, whatever. An' it's like if you're going to tell us
“Here's the dangers” at least tell us how to prevent it.
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(Liam, aged 16, paired with Rowan)
This again illustrates the finding, introduced in Section 4.2.3, that sexual health messages
are often not supported with adequate practical information.
The accounts of Abbie, Liam and Rowan illustrate how education can undermine non-
heterosexual relationships, both implicitly, by failing to provide relevant information, and,
potentially, in more explicit ways. Emma, who identified as heterosexual, described how
heteronormative teaching could impact attitudes:
And when you're in school, they dinnae really talk you through the difference on that.
Like some teachers are against it, some are like: “Go for it.” And it's quite like, when
you find oot somebody is, either gay or straight or whatever, you're kinda like, you
don't know how to take it anymore. Like, especially in the schools you're like: “Oh
that person's a lesbian, you dinnae want to get changed in front of her?” And it's all
these snide remarks, and it's like, you really need to learn aboot what's going on.
(Emma, aged 17, paired with Mia)
Emma highlighted how heteronormative teaching could have negative consequences,
beyond adequately preparing individuals, by fuelling confusion and stigma about sexuality.
These accounts demonstrated how teachers’ competence and willingness to engage with
non-heterosexual relationships might influence understandings, perceptions and outcomes.
The role of teachers and the learning environment more broadly are examined in the
following section.
4.2.5 The learning environment: teaching quality, delivery mode and
awkwardness of learning environment
As well as the content of their schools’ sexual health teaching, participants discussed the
environments in which teaching took place. Participants typically described receiving
school-based sexual health education through traditional didactic teaching methods within
personal, social and health education (PSHE) classes or religious education (RE) classes and,
for a small number of participants, science or biology classes. Accounts of learning
environments were predominantly negative, and teachers were typically perceived as
‘awkward’ and ‘unqualified’. Most teaching was led by ‘regular teachers’ (e.g. maths
teachers), which some identified as a major barrier to learning, highlighting shortcomings in
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non-specialist teachers’ knowledge, confidence and enthusiasm. Aaron and Michael
encapsulated such concerns:
Aaron: The teachers didn’t really care about it…nah…I mean we got classes but…
Michael: Like they done classes for it but they weren’t really…
Aaron: They weren’t like educated on it, it was just like teachers who like done
it…like maths teachers
Michael: And they just make it up
(Aaron and Michael, aged 19)
Michael demonstrated little confidence in his teacher’s competence in teaching sexual
health, suggesting that they neither followed a curriculum nor provided accurate information.
Within four interviews, participants described situations where teachers’ lack of enthusiasm
limited pupils’ education, for example by cancelling and neglecting to reschedule classes out
of a desire to avoid the awkward experience of delivering sexual health teaching.
Most participants felt that school-based sexual health education should be distinct from other
school subjects, and be delivered by external ‘experts’ or nurses. For example, Kara and
Amy, identified teachers’ existing professional relationships with students as barriers to
students’ willingness to engage:
Kara: if we were in SE I’m not gonnae be like “aww, Miss…” like and then say
something really embarrassing and then next week I’m going tae be like “Hi, can you
help me pick my course choices,” you know what I mean? Like…
Amy: Yeah it’s really awkward
Kara: Yeah
Amy: I think it is a bit awkward though ‘cause you them an like cause we have like
a professional relationship wi’ her rather than, like, one where you want tae talk about
that stuff with her, it’s a bit awkward
(Kara and Amy, aged 17)
This account implicitly identifies sexual health as an “embarrassing” topic that should be
distinct from other school subjects and regular teachers. Kara later described a one-off sexual
health conference conducted within their school and run by external staff as “the most useful
thing in school”, highlighting possible benefits of delivery within an ‘out of class’ context.
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As well as questioning the people delivering teaching, some participants identified barriers
created by group-learning environments and didactic teaching method. Nicola and Ralph felt
that shyness and embarrassment prevented some from asking questions in classes:
Nicola: like they ask dae you have any questions but some o’ them are too shy to say
so they don’t cover it, I think they should just tell them
Ralph: They should do more one-on-one because those things, it’s always one person
goes out and speaks to a whole class. “Do you have any questions?” And it’s about
you, just you. And there’s a whole class there of people you know and people you
don’t, you don’t want to embarrass yourself.
Nicola: Just like…‘cause obviously, could be like this question that people laugh
about. How can you not know this or why would you ask that? It’s just like it makes
them a lot more nervous
(Nicola, aged 17, and Ralph, aged 19)
Here, Nicola and Ralph identified how embarrassment could prevent individual’s needs from
being met within the class context, and suggested that teachers could avoid this by providing
comprehensive information without being prompted by students.
While most participants agreed that sex education should be delivered by external ‘experts’
or ‘nurses’, some described experiences of such alternative education being provided at
school. Another alternative way of delivering teaching is peer education, in which students
receive teaching from older students, which was described by participants in two interviews,
including Ben, Caleb and Dylan:
Caleb: we get, like, sex ed from the teacher but it’s not the same, ‘cause it’s kind of
boring, ‘cause you switch off
Dylan: ‘Cause it’s the teachers
Caleb: But when someone’s only a couple of years older than you, you’re kind of
like yeah…
Ben: More your age group
Dylan: So you’re a wee bit more comfortable about it
(Ben, Caleb and Dylan, aged 17)
Dylan, Caleb and Ben seemed relatively relaxed discussing sexual health within school,
which they attributed to peer education, which they valued for it being relatable. Dylan
reflected that “it wasn’t as awkward as you thought [laughing]”.
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While participants were typically critical of their experiences at school, some, primarily
heterosexual males, recalled school-based sexual health education favourably, as a
comfortable, and sometimes fun, learning experience. Craig and Darren credited their
teachers with pitching lessons at a good level, combining seriousness with humour, and
highlighted how preferences about learning environments might vary between genders:
Darren: I think they did take it seriously, but they kinda, conveyed the, sort of, laughy
sort of thing so that they could get rid of the awkwardness but I think everyone did
learn, yeah…the teachers, they made, kind of, like, jokes round about, like, things
an’ that and it really helped as well.
Craig: Yeah
Darren: Like, it helped get rid of the awkwardness especially because there were girls
an’ that in the class so I think that really helped
Craig: Yeah I think the girls were more awkward ‘cause the boys were all pretty
boisterous about it [laughing]
Darren: Yeah [laughing]
Craig: Pretty happy to do everything [laughing]
(Craig, aged 16 and Darren, aged 17)
For Darren and Craig, a balance of seriousness and humour mitigated “awkwardness”, which
they considered particularly valuable in a mixed-sex class. This account highlights the
importance of skilled educators, as well as implicitly suggesting that mixed-gender classes
may not benefit males and females equally. This perspective was supported by the accounts
of some female participants, who tended to focus on embarrassment within classes and
characterise the class context as unconducive to learning about sexual health, which they
often attributed to the presence of boys. For example, Kara (aged 17) described “very
immature boys” undermining classes by not taking them seriously, and Alice (aged 18)
explained that the presence of boys hindered her ability to ask questions, as she: “would have
had a bit more confidence to actually ask questions without being embarrassed about it”.
Lily and Skye echoed these sentiments, and advocated separating girls and boys to foster
comfort and confidence:
What do you think sexual health education in school should be like?
Lily: They should put it intae PSE, but I think they should like, they’d have to
separate boys from girls I think. I think they’d need tae
Skye: ‘Cause I think you feel more comfortable talking aboot it…with other girls
(Lily and Skye, aged 19)
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This account underlines the importance of the learning environment and highlights a
potential driver of gender inequality in sexual health literacy.
As well as feeling less comfortable within sexual health class environments, female
participants appeared to exhibit less confidence in their sexual health knowledge. When
asked where she and Sophie (aged 18) had learned about sexual health, Keira (aged 18)
paused before saying “to be honest with you…it’s not something that I really know a lot
about”, and the two girls attributed this to poor learning experiences at school. Participants
who reported particularly negative school learning experiences typically: expressed
dissatisfaction with their levels of knowledge; voiced frustration, confusion and anxiety; and
were less confident in their abilities to seek sources to improve their own knowledge.
Typifying this, Amy, who described negative experiences of learning about sexual health at
school, seemed particularly unsure and often unnerved, especially during the online activity:
Kara: Right. Amy, put yourself in this scenario
Amy: I wouldnae have clue, like, if you go an’ get tested
Kara: Right, no, Amy, you had unprotected sex last night and you’re worried and
that about STIs. What are you gonnae dae?
Amy: Cry, probs I dunno
Kara: Right
Amy: I dinnae ken!
(Amy and Kara, aged 17)
Such uncertainty appeared to be more common amongst female participants, while most
male participants tended to exhibit more confidence in both their sexual health knowledge
and their ability to increase their knowledge through other sources outwith school. However,
it should be noted these are self-reported data, which might reflect desires to be seen as
sexually knowledgeable, particularly in front of peers (explored in Section 4.3).
As illustrated in the preceding sections, participants typically had negative experiences of
school-based sexual health education, although experiences tended to vary by gender, sexual
orientation and the type of school attended. Participants recounted varying levels of
confidence in their own sexual health knowledge, which again varied by individual
characteristics. Participants’ responses to dissatisfaction with this traditional sex education
varied. Some associated negative school experiences with motivation to seek information
elsewhere, particularly online (this will be described in Section 4.4).
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4.3 The peer and friendship context
The role of friends and other peers in providing peer support regarding sexual health
emerged as a key aspect of participants’ sexual health literacy environment. It should be
noted that, as the sample primarily comprised participants who had agreed to take part in
paired interviews with friends, the sampling strategy may have been biased towards young
people who were positively disposed to discussing sexual health with friends.
It should also be noted that an intrinsic prerequisite of peer support is access to peers, and
some participants indicated that they did not use friends for information because they did
not have close friends. Three such participants described family members as their primary
sources of sexual health information. Each of these participants (Tina, aged 18; Matthew, 17
and Charlie, 18) had additional support needs, and stated they would actively avoid using
the internet to seek sexual health information. Tina, described approaching her mother and
her mother’s friend for any health information, primarily because they were trustworthy and
well-intentioned: “cause you know, cause like, they’ll probably want tae like look out for
me and try and keep me safe”. In contrast, many participants perceived family members, and
particularly parents, as a ‘last resort’ in worrisome situations. However, Tina, Matthew and
Charlie’s accounts demonstrate that participants’ without peer support networks valued
informal social support.
Participants’ discussions and behaviours shed light upon the various benefits of, drivers of,
and barriers to friend and peer support in relation to sexual health, and these are examined
in this section.
4.3.1 Exchanging knowledge and sharing experiences
Participants described learning about sexual health from friends, and some predicted that
they would continue to do so in future. Participants typically identified specific individuals
that they felt comfortable with and were helpful, knowledgeable or experienced. Kyle
described Josie as “his Google”, whom he consulted regularly if worried or seeking advice:
So what would you do if you were looking for information about sexual health?
Josie: Google it, probably
Kyle: Aye, Google. Or ask her probably
Josie: Or ask me
Kyle: Aye she’s the expert
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(Kyle and Josie, aged 19)
Similarly, Martha (aged 16) explained that she had learned mostly from her friends,
particularly from those with specific experience of relevant issues who could provide
experience-based advice, which she valued above information learned online or in school.
Similarly, Lily (aged 19) identified the value of ‘personal’ support: “I’d give friends my
personal opinion rather than them going online. And I’d speak from like my experience and
stuff…rather than going online and finding stuff that isnae personal tae you”.
While some valued friends as sources of information, others perceived their friends as being
equally inexperienced, and therefore not helpful. For example, Jess and Amelia, appeared to
value the perceived authority of online information over the limited knowledge of their
friends:
Amelia: It’s quite trusting because it’s like some, it’s got like some experts on it and
like you can’t ask your friend everything…cause they’d be like ‘I don’t know’ like….
Jess: Yeah I know
Amelia: They’d be like ‘look it up!’
Jess: Yeah
Amelia: There’d always be that usual like ‘look it up’
(Jess and Amelia, aged 16)
Here, Amelia indicats that, not only would a friend likely be unable to answer her questions,
but they would likely suggest she searches the internet instead. This sharing of
incompleteness of knowledge demonstrates a degree of trust, as well as shared learning and
reassurance. This account also illustrated how different sources of sexual health information
interact and overlap, with the online context being an ever-present part of the landscape of
sexual health support.
Some participants described occasions when they used their knowledge to inform or correct
friends, and some demonstrated such behaviour within the online activity. For example,
whilst seeking information about safe sex during the online activity, Reece was concerned
at Lucy’s unawareness of risks related to anal sex:
Lucy: …I suppose you could just tell your friend to have anal sex.
Reece: Wow. Wow.
Lucy: Can you still get an STI from anal sex?
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Reece: Yeah, of course you can.
Lucy: [laughing] Oh. Was that a really silly question?
Reece: Yes.
Lucy: Okay. [laughing]
Reece: That's actually worse, there's a higher chance.
Lucy: Sorry. Really? Why?
Reece: Think about it.
Lucy: Because your bum's dirty?
Reece: Not only that, you usually, like, cut… like, imagine like a small hole.
Lucy: No, I don't want to. [laughing]
Reece: No, no, no, no, no. This is serious. Imagine a small hole and you put
something big and the hole's going to, like, rip.
Lucy: Yes.
Reece: Open wounds. I'm guessing it hurts.
Lucy: Me too. [laughing]
Reece: [laughing] But yeah, that's actually worse.
Lucy: Okay, that makes sense.
(Lucy and Reece, aged 17)
In this excerpt, Reece demonstrates both his own knowledge on the topic and his ability to
provide his friend with a relatively detailed, easily understood explanation, while Lucy
exhibits trust in her friend’s information. On another occasion, whilst looking up information
about protective strategies, Darren (aged 17) also seemed surprised that condoms were
necessary for anal sex and his friend Craig (aged 16) emphasised this to him: “Now you’ve
tae use a condom no matter what you’re doing, right end of.”
For some participants, possessing sexual health knowledge seemed to make them feel
protective of their peers, and responsible for dispelling myths. For example, Ruth and Joe,
who had both taken part in peer education projects through their local youth organisation’s
involvement in their school, discussed sharing their knowledge with other young people to
dispel myths:
I find it funny. There’s, like, so many people that, like, like they’ve – like, if they’re
talking about sex and, like, they speak about like the pull-out technique and they
aren’t, like, (Oh, yeah) – honestly, the amount of times I turn round to them like
“You’re saying this to somebody who volunteers at the C-Centre [local youth
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organisation].” I was like “That does not work.” Then go on a big massive lecture,
so, yeah, it’s like – it’s something that, yeah, obviously gives you more knowledge
but gets you dead protective about other people with it as well.
(Ruth, aged 16, paired with Joe)
Ruth’s account suggests that her knowledge made her protective of others, highlighting how
improving one individual’s knowledge can benefit others within their peer network, as well
as alluding to performative aspects and kudos associated with having better knowledge.
While being empowered to dispel misunderstandings in others can exemplify the power of
peer support, this impulse could also propagate myths. Michael and Aaron were particularly
reluctant to admit to uncertainty about sexual health, and Aaron repeatedly espoused the
importance of being aware of myths, but at one point he revealed his own incomplete
understandings while attempting to demonstrate his awareness:
Aaron: But if something’s silly but like like say you received a blow job and you
think you had an STD out it
Michael: Yeah yeah right
Aaron: It would be such a waste of time booking an appointment and that
appointment could be done and you know young kids still think they can get it that
way and they’d waste time...it’s about getting the information
(Aaron and Michael, aged 19)
Here, Aaron communicates a misconception that could conceivably lead to the avoidable
transmission of an STI and failure to seek medical help, and highlights how peer support is
only as good as the information being exchanged.
4.3.2 Gendered perspectives on seeking and providing support
Sometimes participants’ motivations for seeking support from friends appeared to be based
on an expectation of comfort and supportiveness, rather than the value of knowledge or
experience. Seeking and providing personal and emotional advice and support was
particularly valued by female participants, who typically conveyed a sense of mutual
supportiveness, as exemplified by Laura and Courtney:
Laura: we talk about everything
Courtney: yeah we do
Laura: If we don’t know something we’ll help each other out
Courtney: Try and figure it out
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(Laura, aged 16 and Courtney, aged 17)
Generally, female participants seemed more disposed to discussing relational and emotional
aspects of sexual health, and valued their friends as sources of reassurance and support to
ease anxieties and decision-making. Due to this, friends were often considered as first points
of contact when worried about sexual health. Keira and Sophie typified this:
Keira: I’d probably just talk to one of my friends first
Sophie: Yeah friends
Keira: ‘Cause I probably wouldn’t go straight to like…
Sophie: the doctors
Keira: …my doctors or clinic, I wouldn’t…it would need to be something
serious…I’d talk to my friends first and if they thought I should then I would go
see…I would eventually go…I think
Sophie: Yeah, probably the same
(Keira and Sophie, aged 18)
They suggested that friends could give them confidence and help them to determine whether
they needed to seek further help. A small number of female participants described
experiences of providing practical support to friends to overcome barriers within sexual
healthcare contexts. Abbie and Sinead both described experiences of accompanying friends
to doctors and clinics. For example, Sinead described a situation in which she supported a
friend:
Sinead: Yeah. One of my old friends she came like crying to me one day saying, “My
boyfriend’s just telt me he’s got chlamydia, I’m scared to get tested” and all this. And
I was like, “Calm down.” I was like, “I don’t even know about any sexual health
clinics.” And I was like, “Just go to your doctors.” “I’m too scared. I’m too scared.”
So I phoned the doctors and asked if they could get like a different doctor from her
own doctor. And I went with her and they just gave her tablets and she was fine after
a couple of weeks. Yeah. And I was just like, “Calm doon.” She was on the phone in
tears like, “What if I cannae have weans.” And I says like, “Calm doon, like…
Abbie followed Sinead’s story with an account of consulting with a doctor on behalf of an
anxious friend. These experiences highlight the fear and anxiety associated with visiting
doctors and communicating about sexual health, and the role that friend support can play in
overcoming such barriers.
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In contrast to many of the female participants, male participants were typically
unenthusiastic about earnestly discussing sexual health with friends. When they did describe
discussing sexual issues with friends, they typically described playful, flippant
conversations. Jacob and Connor typified this:
Connor: you’d talk to your friends about it but you’d never, it would never really be
serious…it would be more joking about it
Jacob: I wouldn’t ask him or my other pals
Connor: Don’t think I ever have naw
(Connor and Jacob, aged 18)
This playfulness was particularly apparent in heterosexual males, who typically joked
throughout the interviews. Darren (aged 17) was particularly playful during the interview,
laughing often, but also seemed uneasy with some topics discussed; at one point he described
that he would be “too ashamed” to admit to a friend that he did not know about sex (before
clarifying that he did), and seemed embarrassed when his friend Craig (aged 16) described
the pair’s lack of knowledge about STIs, explaining: “makes it sound wrong but he didn’t
know what herpes was and I didn’t know the effects of syphilis, so, we just look at images”.
Thus, some of the playfulness may reflect reluctance to make the limitations of sexual
knowledge and experience known. As noted in Section 4.2.5, most male participants
described themselves as relatively confident in their sexual health knowledge, in comparison
to female participants.
At times, male participants appeared keen to display their sexual experience and awareness,
consistent with a normative masculine identity of sexual confidence and competence. Emma
(aged 17) and Mia (aged 18) discussed boys and girls having different approaches to talking
about sex, characterising boys as boastful about sexual activity, and more likely than girls to
use slang terminology, such as ‘shag’, ‘slag’ or ‘slut’. Aaron (aged 19) used such language
on multiple occasions, and highlighted his sexual experience to his friend Michael, stating
he was “doing three birds [females] a month”. Aaron and Michael also shed light on different
gendered expectations in relation to having sex, with later initiation of first-time sex being
more accepted for young women. Aaron stated: “It’s awright for girls to do that, it’s quite
hot...not for guys though...”. This draws attention to the possible influences of performative
masculinity and gendered expectations of sexual activity as barriers to openly
communicating about sex and sexual health with friends. Such exhibitions of knowledge and
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experience appeared to be more about status and identity construction than knowledge
transfer as a practical or emotional solution to sexual health information and support needs.
4.3.3 The role of embarrassment and stigma in peer support
Despite participants primarily taking part in the interviews with friends, which suggests
some level of comfort with discussing sexual health with friends, some participants raised
concerns about, and identified barriers to such support. Amy, who described talking about
sexual health as “really embarrassing”, preferred less personal information-seeking:
And what do you think you’d do?
Amy: I’d probably just Google it, find oot for myself
Kara: No’ even speak tae me, no?
Amy: Eh yeah…maybe
Kara: I doubt that [laughing]
(Amy and Kara, aged 17)
This exchange provided some insight into their friendship, with Kara exhibiting awareness
that Amy would not approach her about sexual health issues, and gently teasing her for it.
Amy described being very reluctant to use sources that necessitated talking to anyone about
sexual health, and careful use of the internet was a tactic for avoiding this (discussed in
Section 4.4).
Certain topics seemed to cause participants to be hesitant to seek support from friends due
to stigma, particularly sexually transmitted infections, perhaps influenced by moral
perceptions. Thus, while many participants described being comfortable discussing sexual
health or exchanging knowledge with friends, some appeared guarded while doing so,
appearing to distance themselves from personally needing sexual health support or services.
On some occasions, participants, such as Ralph and Nicola, mentioned local sexual health
services, but ensured that their friends knew that they had not personally needed those
services:
Ralph: Clinics in South Lanarkshire... That’s literally a five minute walk from here.
Nicola: So you just…
Ralph: Oh yeah, I know where it is. I’ve not been, I’m just saying.
Nicola: I went to a clinic once… Wasn’t for me… it was one of my pals to get the
implant.
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(Nicola, aged 17 and Ralph, aged 19)
Within this example of Nicola providing support to a friend, both Nicola and Ralph were
quick to make clear to each other that they had not needed to use sexual health services,
which may highlight the role of stigma in stifling communication about seeking sexual health
services. Barriers to accessing sexual health services will be discussed in greater detail in
Chapter 6.
4.4 Using the internet to learn about sexual health
In addition to school and friends, the internet emerged as a key source of sexual health
information. Most participants cited the internet as their current main source of sexual health
information. Typical responses to the question ‘what would you do if you were looking for
information or advice about sexual health?’ included “yeah I always go to the internet”
(Claire, aged 17) and “just Google it usually” (Connor, aged 18). The internet was
characterised “natural”, “obvious” or “automatic” first port of call, particularly for teenagers:
So what would you do if you were looking for information or advice to do with sexual
health?
Amelia: I’d go to the internet
Jess: I think that for like anyone of our age, it would be like natural instinct to like
check the internet first
Amelia: Yeah you would just look it up
(Amelia and Jess, aged 16)
Some participants alluded to the internet being intertwined with young people’s identities,
with “like ninety-nine percent of like teenagers now like using the internet” (Courtney, aged
17). However, some stated they actively avoided using the internet for sexual health
information. These differing experiences and attitudes towards the internet as a source of
sexual health information will be drawn out within this section.
This section will firstly describe participants’ motivations for seeking sexual health
information online, and examine what types of sexual health needs the internet was
perceived as suited to addressing. The section will go on to describe what participants valued
about using the internet for sexual health information and support, and which aspects they
were wary of. These descriptions will illuminate both the drivers of sexual health
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information-seeking online, and factors that may facilitate and obstruct effective use of the
internet for sexual health information.
4.4.1 What sexual health needs did participants use the internet to address?
Most participants described previous experiences of seeking sexual health information
online, with varying motivations. Participants primarily described experience of using the
internet to seek specific sexual health information in response to significant concerns, for
example about contraceptive use or STI symptoms. Alice and Cleo typified this approach:
Have you ever used the internet to learn about sexual health?
Cleo: The only thing I could really say is ‘cause like I’ve got the coil so I would look
up stuff to do wi’ that. Before I wouldn’t really have done that I don’t think. I think
only really if you’ve got a scare you do something like that
Alice: Yeah, symptoms, you look up
Cleo: Yeah
(Alice, aged 18 and Cleo, aged 19)
While many participants, like Cleo and Alice, viewed online sexual health information as a
resource to be used in reaction to a specific concern, other drivers were discussed. Some
described using the internet to ‘self-teach’, to confirm or expand general sexual health
knowledge due to their needs not being satisfied in school. As described within Section 4.2,
these negative experiences were particularly prominent for participants who attended
denominational schools and those who identified as gay, lesbian or bisexual. Indeed, these
participants tended to describe turning to the internet to learn. Liam typified this approach:
So I find that, you know, my knowledge is like reading online like going on to likes
you know Pasante's or Durex, whatever their websites. That's mainly how I've got
my knowledge…more just self-taught myself 'cause the school couldn't do that
apparently...
(Liam, aged 16)
Liam’s friend Rowan, who also identified as gay, went on to provide a similar account:
Rowan: Yeah I’ve learned almost everything I know from online or here [LGBT
youth group] But, I mean, we did cover, you know, STIs an’ all that in my school,
you know. But not on a sexual basis though, just ‘this is what it is, this is what it
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does’. But that’s all…Everything else I've ever learned was either through my own
curiosity thinking 'Right, I haven't been taught. I need to self-teach now’.
(Rowan, aged 16)
Thus, Liam and Rowan identified their negative experiences of learning in school, which
failed to meet their information needs with uncomprehensive, heteronormative content, as a
driver to self-teach. Both participants described using the internet (as well as their local
LGBT youth group) to do this, with Rowan in particular valuing the private nature of the
online environment.
Some participants described using the internet to supplement information learned elsewhere,
or to satisfy curiosity. Connor (aged 18), who attended a denominational school which he
deemed to have provided ‘one-sided’ information about sexual health, recalled accessing
Wikipedia to supplement sexual health classes: “sometimes when you’d read about it in there
and I didn’t think I’d been given enough information about it, I’d go what is that and I’d go
check out about it myself, just cause I’m curious”. Such accounts were not unusual,
highlighting the possible role of negative or incomprehensive experiences of traditional sex
education as drivers for seeking sex education online.
Participants described using the internet to seek assurance about sexual practices, behaviours
and norms. For example, Maeve and Leah, during the online activity, recalled having used
the internet to look up information about having sex for the first time:
Leah: …oh my goodness, I’ve literally searched…
Maeve: What did you search?
Leah: I was like searching about sexual diseases and stuff. I feel like that’s what
people are nervous about when they…
Maeve: Yeah for like the first time, they’re nervous of what’s gonna happen
(Leah and Maeve, aged 16)
Some participants, particularly males, described accessing online pornogrhapy as a way to
seek assurance about sexual norms and to learn about having sex in ‘real life’. Participants
across the sample tended to perceive pornography as a learning resource for males, but not
females. Keira and Sophie typified this view:
Keira: Guys probably use porn
Sophie: Yeah guys do
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Keira: Yeah they probably look up that more than girls do…cause I think girls would
just kind of like…worry more and just like look up specific things whereas guys
would just kind of go to that
(Keira and Sophie, aged 18)
Here, Keira suggests that girls have specific concerns and information needs, while boys’
more general information needs can be satisfied by pornography. Indeed, some male
participants presented pornography as an information source. During the online activity,
Aaron and Michael recommended watching pornography to learn about first-time sex:
Aaron: I’d tell him to watch porn
Michael: You can’t search for that…
Aaron: I’m not saying that
Michael: I’m sure they’ll already have that
Aaron: Watch porn, get tips, do it…Do you think she’ll give me into trouble for that?
Michael: No...it’s an honest opinion int it
Aaron: I’d tell them to go and watch porn
Michael: Probably better cause you can’t exactly demonstrate it for them...they need
to watch...
(Aaron and Michael, aged 19)
This exchange raises the idea that pornography’s visual nature makes it useful in preparing
for real-life sexual encounters. Furthermore, Michael’s hesitance at searching for
pornography during the online task highlights the inherent conflict of pornography being
both a potential information source and an illicit material. When providing feedback on the
online activity, Aaron said: “we weren’t taking the piss or anything but we’d tell them to
watch porn to get tips and to see how it’s actually done live”. Similarly, Connor and Jacob
(aged 18) both thought porn would be useful, with Jacob stating “it’s a much better indication
of what it’s actually like”, although Conner later mentioned that “porn’s kinda not realistic”.
Thus there was some recognition of differences between pornography and ‘real-life’ sexual
encounters, although they identified pornography as the best way for young people to learn
about sexual encounters, regardless of realism.
A number of participants exhibited their critical health literacy skills in critiquing the
influence of pornography on young peoples’ understandings and attitudes. Sisters Emma and
Mia discussed their perceptions of the influence pornography exerts on boys:
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Emma: Quite a lot of the influence on the internet, I think. Like, internet and…
Mia: Boys and pictures, and porn for boys
Emma: I think that's a big thing in boys though. 'Cause like, I dinnae really ken much
lassies that are intae like porn and stuff like that but like, pretty much every boy that
I ken is at least watched it once, and like, they all hey like photies of women w’ their
boobs out and stuff, like, so I think that's a big influence for males specifically.
Mia: Quite a lot of the pictures as well, and like, a lot of it is your ideal skinny
supermodel, dolled-up lassie, and I feel like in the real world there's only maybe
aboot a thirty percent that actually look like that. And probably none of them want to
be wi' you.
Emma: And lassies that are insecure aboot that, that's what makes lassies really
insecure. Like the images that boys find
(Emma, aged 17 and Mia, aged 18)
As well as negatively potentially creating unrealistic expectations for boys, this exchange
illustrates Emma and Mia’s critical understandings of how, as well as creating unrealistic
expectations for boys, pornography can also be harmful to girls. Emma also indicated that
young people misunderstand the artificiality of pornography, stating that “they don’t realise
that the man and the women are both porn stars”. Mia worried that pornography could
pressure young people into unwanted sexual activities, leading boys to “expect much mair
fae lassies”, and that “they always expect lassies to dae stuff like, anal and that, and like,
some lassies are like…because they've seen it filmed and that and they think that's supposed
to happen”. Perspectives like these demonstrated participants’ critical sexual health literacy
in considering how pornography may influence expectations.
4.4.2 Perceptions of the internet as convenient and accessible
One of the primary advantages of seeking sexual health information online mentioned by
participants was convenience of access, with most participants describing the internet as the
most convenient and easily-accessible source of sexual health information. Lucy (aged 17)
typified this, highlighting the omnipresent, instant availability of internet access on mobile
devices: “yeah, uh, I think it’s just because it’s like so easily accessible. I mean it’s just like
there. I mean you can use it on your phone”. No participants described experiencing barriers
to accessing the internet, and they typically perceived the internet as accessible to all.
Just two participants expressed concern about others having limited internet access.
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Samantha (aged 17) downplayed risks of people having no internet access at home by
highlighting the free internet access in public libraries and the range of other information
sources available. However, Joe (aged 16) expressed more concern about access inequalities,
suggesting that, if the internet is not universally accessible, then schools remain the most
important source of sexual health information as they are “somewhere, like, you can
guarantee everyone’s gonna get the information that – so, if you put it on, like, Facebook,
you know, online stuff, not everyone, like, might not have access to it.”. Aside from
Samantha and Joe, participants either overtly or tacitly indicated the belief that all young
people have access to the internet. However, this assumed universality of access, did not
necessarily extend to being happy or confident in using that internet access for sexual health
information and support. Participants’ attitudes towards using the internet for such
information and support will be examined in Chapter 5.
4.4.3 Support and individual nuance in online information
Many participants felt that online sexual health information tended to exacerbate worries
and instil fear. Whilst Martha and Samantha reported regularly seeking information about
both general and sexual health, they highlighted risks of online information causing distress
and uncertainty:
So do you ever use the internet to look up information about your health?
Martha: Oh, all the time
Samantha: Mm-hm. Yeah
Martha: I’m like the worst for that. Like, I self-diagnose myself with everything
[laughing]…it’s really bad, like so bad […]
Samantha: Sometimes when I look up something…to see if I’ve something wrong
with me. But they seem…it sounds…they make it sound a lot more threatening than
it actually is
Martha: It makes me feel so much more paranoid though. Really like, really bad. I
Google something about my sexual health, and it was coming up with stuff like
‘you’re allergic to semen’…just mental stuff. And I’m like ‘Wow! Are you sure?’
(Martha, 16 and Samantha, 17)
Others described similar situations in which seeking sexual health information online
heightened anxiety by causing misdiagnoses. Combined with this was a perception that,
while the internet can provide factual information, it does not provide the necessary support
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to ease the anxieties that that information might create. Jess and Amelia encapsulated this
perspective, suggesting that personal support is more effective:
Jess: I think it’s more of like a support thing as well…yeah it doesn’t really give you
like any support, because it’s not a person
Amelia: Yeah and it’s just kind of like fact fact fact…I suppose it’s meant to be like
that
(Jess and Amelia, aged 16)
For some, the internet’s potential to exacerbate anxiety and lack of personalised and specific
advice led them to favour face-to-face information seeking. Melissa typified the view that
there are limits to what the internet can provide:
I guess, like, if you’re Googling something, like, if you were, like, maybe if you were
wondering, like, what contraception would be good for you or something like that.
You can’t get that off the Internet. Like, you wouldn’t really be able to figure that
out, you would need to actually go into your doctor’s and find out about that, like.
So, yeah, I think that, like, the Internet doesn’t have everything that you need to
know. It’s like if you’re already using a contraceptive or if you’re, whatever, like,
then that’ll be fine or, like, with STIs, like, people, like, try and Google whether
they’ve got them or not and you can’t ‘cause Google can’t tell you if you have it or
not. Like, sometimes like that you have to, obviously you go to the doctor’s, but I
think that it does have some answers that you need
(Melissa, aged 16)
From Melissa’s perspective, the internet provided useful, but non-comprehensive,
information, with the implication that online information is best used in conjunction with,
not as a replacement to, traditional health services, particularly regarding complex issues
such as diagnosing STIs. This sentiment was shared by others, such as Aaron, who
specifically identified the internet’s shortcomings in providing personalised advice and in
diagnosing and solving problems:
I hate the internet, it’s crap…it’s so bad, I’ve used the internet so many times and
I’ve just patched it…I was just like... every time I’ve got a problem I just go straight
to my doctor”, explaining that, on the internet, “there’s so many different things, you
could type only one thing in and then like ten different things’ll come up and it’s
just so bad and you’d rather just go to someone that’s like specific and will just tell
you exactly what’s wrong with you and like you can get a test done.
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(Aaron, paired with Michael, aged 19)
Here, Aaron typifies the perspective of some participants that a single authoritative
information source is preferable to the internet, highlighting the difficulty of appraising a
range of different online sources and identifying the best information to follow. While some
participants valued the vast quantity of sexual health information available online, others
perceived it as a barrier to finding useful information.
4.4.4 The anonymous nature of the internet
Many participants valued the relative anonymity provided by the internet, describing online
information seeking as a means of avoiding embarrassing face-to-face discussions, and
feeling comfortable saying things that they would hesitate to say to doctors or friends in
person. Illustrating this, Amelia (aged 17) described saving “weird” topics for the internet,
while Rowan valued the freedom of being able to receive anonymous advice online:
So, I’ll just put in a question, they’ll answer it, they’re actually willing to help but
I’m probably never gonnae see them again. That puts that complete safety barrier on
me an’ I’m free to let loose any problems I have
(Rowan, paired with Liam, aged 16)
Here, Rowan expressed a typical perception of the online context as safe from judgement,
unlike face-to-face encounters. Some did not find discussing sexual health with other to be
problematic (which may be partially due to the sampling strategy, as discussed in Section
4.3), but recognised this as a common barrier for other young people, and one that the online
environment could alleviate. Melissa (aged 16) explained: “But I guess….because I feel
comfortable speaking to people. Like some people wouldn’t so I think they would prefer to
message someone online ‘cause again, like, they don’t see you, so it’s more private”.
While some participants regarded anonymity and privacy as benefits of seeking information
online, some expressed concern about privacy online. Amy explained such concerns to Kara:
Amy: I think it's quite risky looking it up online though 'cause I don't really want that
in my history either, like people seeing what I've... but then it's also that you have to
watch how you word it 'cause anything could pop up. It's a bit...
Kara: I think it's quite funny actually. Sometimes when you hit Yahoo some o' the
things it's just funny… [overtalk] it’s hilarious. [laughing]
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Amy: Like, if I have a problem and I, like, Google it I don't want my network provider
knowing what I'm Googling or anything. Like, that worries me a wee bit but...
(Amy and Kara, aged 17)
Amy worried that web searches could return ‘anything’, alluding to concerns about risqué
or explicit online content, and had previously also described being embarrassed about talking
about sexual health. While she described the internet as her primary source of information
due to anxieties about discussing sexual health, she still harboured concerns about the online
environment. Whilst Kara did not seem to share Amy’s concerns, others did; Charlie, who
actively avoided using the internet, explained:
I’ve never seen like look up the… like they kinda things. I’ve always been too like
nervous and embarrassed about it. I’ve never looked. I’d rather ask like a parent or
like no’ like, no’ a clinic, it’s…I think it’s, for me it’s security. Not secu-, you’re,
not security, it’s… I don’t know, it’s just I don’t, I do trust the internet it’s just in
case…privacy I suppose.
(Charlie, aged 18, paired with Matthew)
Charlie, who attended a group for young people with minor additional support needs,
explained that he had never sought sexual health information online due to nervousness,
embarrassment and worries about security and privacy; he preferred face-to-face interaction
with trusted people, like his parents.
Overall, participants tended to perceive the internet as broadly advantageous due to the
anonymity it provides, but at the same time, bringing with it several unique privacy concerns.
In Chapter 5, I expand upon this by exploring participants’ experience of negotiating the
advantages and disadvantages of the internet as a sexual health information source.
4.4.5 Issues of trust and reliability
In addition to concerns about the potentially unsupportive and insecure nature of the online
context, participants discussed considerations about the reliability and trustworthiness of
online sexual health content. A number of participants described having little concern about
reliability, as typified by Kyle (aged 19), who stated “I don’t really think about it”. However,
most conveyed some doubts. Some described being constantly wary of the untrustworthy
nature of the internet, and prioritised reliability in information-seeking. As Ruth (aged 16)
asked: “But you never do know on the internet do you?” to which Joe (aged 16) replied:
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“You just never do”. Nicola (aged 17), paired with Ralph, described reliability as having
become a greater priority for her over time: “when I was younger like I never really used to
like consider like different websites. I would just like see something and then probably laugh
childishly, which I still do now, but I’m a lot more, you know, aware of what I’m going on
and like okay this’ll probably be the most accurate thing about it. So… [laughing]”.
Participants’ perceptions of the reliability of online sexual health content varied, with some
preferring to avoid online sexual health information altogether, whilst others adopted
strategies to help find reliable content (described in Section 5.3). Despite being active
internet users, Mia (aged 18) and Emma (aged 17) exemplified the former preference,
reporting frequently using the internet for social networking and searching for general
information, but avoiding online sexual health information. Emma stated: “Google is my
best pal for everythin’…even if I want to find a spelling of something I use Google”, but she
said neither of them would use Google Search for anything ‘too deep’. Emma and Mia
preferred talking to someone they trusted because the internet might confuse them:
And so have you, do you ever use the internet to learn about sexual health?
Emma: No' really.
Mia: No.
Emma: I feel if we were to use the internet I think it would just puzzle you even more.
Right.
Emma: Because it's so upside down, like one minute it's right and then the next
minute it's wrong. So it's like..
Mia: Like basically Wikipedia. [laughing]
Emma: It's, it's lying to you basically [laughing]
(Emma, aged 17 and Mia, aged 18)
This exchange highlights issues about the trustworthiness of specific online sources and
online content in general. Similar concerns were echoed by other participants, who also
described experiencing difficulties finding reliable information and expressed concerns
about encountering information that is false, misleading, risky or explicit (explored in more
detail in Chapter 5). The three participants with additional support needs all described
worrying about finding accurate information online. Tina said:
Because like, you never know, I mean, there’s like – if there was like so many
websites about sexual health then basically it’d be hard to find what one that, to like,
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actually was the truth. So so, you’re just better just to, just look and maybe just
basically go, tell you, just go to your GP or something
(Tina, aged 19)
Tina also described preferring to go to her mum if she needed any advice, and perceived this
as safer than going online.
Conversely, Courtney and Laura distrusted the online environment in general, but
nonetheless described the internet as their preferred source of sexual health information.
Courtney described often looking up symptoms, but expressed misgivings about the
information she found:
Courtney: I just don’t believe it
Laura: Yeah
Courtney: I don’t believe it, I just like checking. But it’s not, nothing’s right on that
Laura: No no
Courtney: So I’d never go to the doctor after I check it just because I don’t believe
what it says
(Courtney and Laura, both aged 17)
Both Courtney and Laura described particularly negative experiences with healthcare
professionals, and seemed to feel that they had no choice but to seek information online (the
role of the healthcare context will be explored in Chapter 6).
4.5 Summary of findings
Participants varied in their learning experiences, their approaches to learning and their
preferences for seeking sexual health information. Participants described learning from a
diverse range of sources, of which the main three were school, friends and the internet.
School-based sexual health education was a primary site of learning that had been
experienced by almost every participant. Some described schools delivering relatable and
relevant content within comfortable and supportive learning environments. However,
participants more typically recalled negative experiences, characterised by insufficient and
infrequent teaching of narrow content focused on risk and abstinence. Teaching was
described as being generally didactic and information-based, promoting messages without
providing the skills-based teaching to enable students to act on those messages or to
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negotiate sexual health either online or offline. Participants who identified as gay, bisexual
or lesbian and those who attended denominational schools seemed particularly
disadvantaged, with information needs not fulfilled. Heterosexual male participants typically
had more positive experiences than female participants, who, irrespective of sexuality, were
more typically troubled by the awkwardness of the school learning environment.
Participants’ negative experiences of school were often reflected in both their low
confidence in their own sexual health literacy and their stated understandings of ‘sexual
health’, which were predominantly narrow in nature, with few participants acknowledging
the positive and relational aspects of sexual health.
Participants discussed learning with and from friends, often mentioning specific individuals
who they identified as helpful, knowledgeable or experienced. Female participants described
relying on friends for informational, emotional and practical support, both offline and online,
while male participants generally did not seriously discuss sexual health with friends. Self-
reported experiences of friend support were corroborated by demonstrations of such support
during the interviews and online activity. For some, possessing sexual health knowledge
made them protective, compelled to dispel myths amongst their peers, although the
information they offered was not always accurate. Support from friends was valued for
reliability, trustworthiness, supportiveness, relevance and relatability, but participants
identified disadvantages including friends’ limited experience and knowledge;
embarrassment; and difficulties in maintaining serious conversations about sexual health.
Beyond peer support, three participants, all with additional support needs, described specific
family members as primary sources of sexual health information.
Analysis identified the internet as most participants’ current primary source of sexual health
information, using it for general information, addressing specific concerns and learning
about sexual norms or behaviours. Some, particularly those who identified as gay, lesbian
or bisexual, appeared to be driven to use the internet in response to dissatisfaction with their
school-based sexual health education. For some male participants, pornography appeared to
play a role in learning about sexual encounters, and some participants highlighted their
critical health literacy skills in critiquing the influence of pornography on young peoples’
understandings of, and attitudes to, sex.
Participants shed light on various of facilitators of, and barriers to, using the internet for
sexual health information. Advantages included familiarity, convenience and anonymity;
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while potential disadvantages related to privacy, reliability and supportiveness. A minority
of participants, including those with additional support needs, actively avoided using the
internet for sexual health information, preferring other sources such as friends, family and
community organisations.
By describing how participants discussed learning and seeking sexual health information, as
well as their understandings of ‘sexual health’ as a concept and their confidence in their
sexual health knowledge, this chapter provides contextual background to various aspects of
participants’ sexual health literacy. The online environment, which is ingrained within young
people’s day-to-day lives, emerged as the main current information source for most
participants, albeit not relied upon in isolation. However, online sexual health information
and support are not without challenges, and, therefore, it is valuable to explore in more detail:
participant’s attitudes to different types of online content; their approaches to finding useful
information online; the obstacles they encounter in the information-seeking process; and the
techniques they use to overcome those obstacles.
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5 The online context: locating, understanding and
evaluating sexual health information
In Chapter 4, I examined how participants described learning about sexual health, and their
preferences for different information sources. This chapter focuses more specifically on
interpreting and evaluating sexual health information within the online context, aiming to
address research question 2: How do young people describe and experience seeking,
understanding, evaluating and using online sexual health information?
This chapter has two inter-related foci, drawing on data from the different stages of data
collection: i) how participants described seeking, interpreting and evaluating online sexual
health information in their discussions during the ‘traditional’ interview stage of the
research?; and ii) how participants experienced and negotiated online information searching
during the online activity? Thus, while a major focus of this analysis was participants’
individual feelings, perceptions and experiences of searching, evaluating and using online
sexual health information, the software also enabled insights into different processes and
searching practices involved. This section takes an individual-level perspective, focusing
particularly on the young people’s sexual health literacy, but also the broader factors
influencing these processes.
Chapter 5 begins by describing participants’ general internet use patterns, before going on
to examine: their preferences for different types of online content; the strategies they used
to locate relevant and reliable content in the online activity; and the problems they faced,
and sometimes overcame, during information-seeking. Data from participants’ descriptions
and experiences of negotiating sexual health content online will be drawn on throughout
each section. Data drawn from the online activity are identified as such when they are
reported, in addition to being highlighted in purple text.
As described in Chapter 3, participants took part in an online activity within the paired
interview. Participants were provided with two scenarios (detailed in Box 5-1) and asked to
use a laptop with internet access to seek relevant information. This chapter examines
participants’ reactions to each scenario, including their perceptions of the suitability of the
internet to address them.
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Box 5-1. Online scenarios
5.1 General internet access and use
A short survey of participants’ use of, and access to, the internet indicated that they all had
access to the internet and used the internet, often through multiple platform and in various
locations. During the paired interviews and online activities participants reiterated these
findings, conveying nuanced conceptions of internet use. Participants’ frequent use of, and
even reliance on, the internet was encapsulated in this exchange:
Do you use the internet?
Liam: Oh yeah. Every single day
Rowan: Every five minutes [laughing]
Liam: The internet is part of us. I think it’s just like an extension of us at this point.
YouTube is like our brain, basically [laughing]
Rowan: No, seriously. I spend ten hours on YouTube a day
Liam: Yeah
(Liam and Rowan, aged 16)
Here, Liam and Rowan uses humour to emphasise the role of the internet in their lives. A
similar tone was used by Charlie (aged 18), who described struggling to reduce his internet
use: “I’ve tried but it’s not happening. I’m trying no’ tae use it as much and get back out tae
reality [laughing] talk tae people on the phone. It’s no happening though”.
Most participants described primarily accessing the internet on smartphones, and Courtney
(aged 17) highlighted the importance of mobile internet access: “it’s really bad ‘cause my
phone just broke, so I’m like, without internet and I don’t [laughing] know what to do with
myself”. Participants also described accessing the internet on personal laptops (n=23);
tablets (n=11); family laptop or desktop computers (n=8); games consoles (n=2); and school
computers (n=1). Rather than devices being equivalent means of accessing the same online
content, participants’ device preferences appeared to depend on the context, purpose and
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topic of their internet use. Many participants conveyed the idea of there being two distinct
types of internet use: casual, everyday social media use; and serious, intentional information
seeking activities. While distinctions were often drawn between use of social media and use
of ‘the internet’, delineations were not necessarily strict, as typified in Melissa’s reflections:
Yeah. Well, I don’t always use Google an’ that but I’m always on, like, social
networking. I like to go on Twitter and stuff and see what’s happening, so, yeah. But
I do it – I guess, like, if you think aboot it, like, if you went and looked on, like, your
search history on your phone, like, you do actually Google a lot of stuff. Like,
whenever you’ve got a question you just Google it. Like, just about anything, you
just, like, Google it
(Melissa, aged 16)
Thus, Melissa, initially identified Google as part of the internet distinct from everyday social
media use, but then reflected that she accessed Google Search with a frequency comparable
with her use of social media.
The perspectives described in this section indicate that the participants perceived internet
use as a universal, everyday activity, but drew distinctions between different types of internet
use, and between different aspects of the internet. Understanding these delineations may be
important to understanding and improving online sexual health information provision.
5.2 Preferences for different types of online content
In the interviews and online activities participants discussed and exhibited preferences for
specific types of content when seeking sexual health information and support online. These
perspectives highlighted the variety of ways in which information can be presented online,
and the heterogeneity of young peoples’ attitudes towards those types of content. This
section introduces participants’ attitudes to specific content types, including the broad range
of social media and user-generated content, in addition to interactive features, videos and
images. Participants’ preferences regarding the formality of information are also examined.
5.2.1 Attitudes to social media and user-generated content
Some participants identified advantages of user-generated content, such as blogs or chat
forums, comparing them favourably to more conventionally ‘authoritative’ information.
Online content contributed by users was seen by many as a source of individually-relevant
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and relatable information. Joe and Ruth expressed comfort in being able to access such
content:
Joe: I Google – if something goes wrong, I Google it. Like, ‘what does this mean?
Ruth: Yeah, or you’ll, like, Google a scenario and you’ll be like “Okay. Somebody
else has had this, alright.
Joe: Yeah. It’s not just me this has happened to.
(Joe and Ruth, aged 16)
Here, Joe and Ruth identify deriving reassurance from knowing that others experience
similar sexual health issues to them. Similarly, Amy explained how such content could ease
teenagers’ anxieties about the ‘normality’ of sexual health concerns:
I think also there’s a lot o’ problems you get, like, teenagers or with anything to do
wi’ sex that you think ‘Oh my God, I’m the only person that’s got this, it’s so
embarrassing’ whereas if you go on there you can see other people have got the exact
same thing so, like, it’s normal and, like, it makes it easier to talk to people about it
‘cause you don’t think you’re weird or anything
(Amy, paired with Kara, aged 17)
Amy, seemed particularly concerned about sexual norms, and expressed anxiety in relation
to Scenario Two as she had not had sex and had worries about expectations. These accounts
illustrated how user-contributed content online could alleviate fears and reduce feelings of
being alone in worrisome situations, potentially in preparation for seeking face-to-face
support about an issue. Melissa (aged 16) specifically expressed a preference for the
‘personal touch’ of blogs, which she compared favourably to the formality of NHS websites:
“The blogs are quite good because, like, the NHS is just basically facts. Like, just
tells you this is this, this is that, this is how you treat this, this is how you treat that.
Like, you can get pregnant, know what I mean? So, like that, but then, like, blogs
actually have from people’s point of views, like, how they feel about it, how they
know other people have felt about it and that. So, I think the blogs are good ‘cause
you get a more personal touch, you get how people are feeling rather than just facts
‘cause that’s all the NHS really provided. They don’t actually, any comfort or
anything, it’s just, like, it’s just information. But then, like, the blogs tell you how
people are feeling and stuff, so, it’s a bit better ‘cause you, kind of, feel like they
understand you a bit more” (Melissa, aged 19)
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Melissa (aged 16) described these blogs as “kind of like speaking to someone else”, and
helpful in making decisions due to the relatable advice they present. She also highlighted the
value of emotional advice, rather than purely factual information. Melissa’s enthusiasm for
blogs was not shared by all participants. During the online activity, Connor and Jacob (aged
18) typified this by rejecting a blog on first impressions, deciding instead to read a non-profit
website, of which Connor remarked “it just looks kinda more plausible”. Generally,
different attitudes towards user-generated content emerged across the sample, with female
participants in particular valuing relatable, personal content.
A minority of participants valued YouTube specifically for its entertaining and relatable
user-generated sexual health content. During the online activity, both Kara (paired with
Amy, aged 17) and Abbie (aged 16, paired with Sinead) deliberately sought YouTube
channels that they liked. Abbie valued YouTube channels that provide information in a fun
way:
When I watch like videos on it, the ones from YouTube and stuff, most of the
information is given to you in a very light-hearted way. It’s mostly through jokes and
like, like short cut scenes between the person talking, like the person’ll be—explain
something quite seriously then show you a really funny clip of like them talking to
themselves or whatever. “Is it supposed to look like that?” [laughing] It’s like…
funny ways that’s like very relatable and… and you come back and they end it on a
serious note. Like, “But, seriously…”
(Abbie, aged 16, paired with Sinead, aged 19)
While Abbie valued the entertaining nature of such videos, she was also aware of their
serious messages, and went on to express admiration at some YouTube channels’
sophisticated techniques to engage viewers before delivering valuable, serious messages:
I think my favourite thing when they do it, is when they click-bait it, so that more
people will see it because there’s a YouTuber I watch called Elspeth and Elspeth is
a lesbian YouTuber. And a few, like a year ago or two years ago, she put a video of
her like biting her lip, was like the… the thumbnail is like a picture of her biting her
lip and it was like, “What I find really sexy?” And they clicked, and when you click
on it, she goes, “Do you know what I find really sexy?” And then she goes,
“Consent!” And you just hear a big talk on consent. I was like, “Yes!” ‘Cause there
will just be so many people that click on that, and be like, “Oh my God! Oh… oh,
right listen that’s actually…”
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(Abbie, aged 16, paired with Sinead, aged 19)
Abbie valued these YouTube channels for their socially- and culturally-critical content,
rather than simply informational or instructive information. She seemed particularly engaged
with this type of content, and had previously described her information needs, as a lesbian,
not being met in school. In describing a lesbian YouTube blogger, Abbie demonstrated
confidence in identifying both the flaws of traditional school-based information and the
benefits of alternative online sources that better addressed her needs. This demonstrates how
young people, particularly those who find school-based sexual health content less relevant
to their personal circumstances, may access alternative user-generated content online to find
relevant sexual health information. However, participants described barriers to using
multimedia content generally, which will be detailed in Section 5.2.3.
Participants described encountering sexual health promotion on social networking sites,
primarily Facebook, and some described engaging with such content if it looked interesting
(typically information presented in numbered formats such as ‘top ten facts’ or in a quiz
format). Emma explained:
When you’re like scrolling through Facebook now, there’s lots of things that pop up.
And it’s like: “Oh, when you’re having sex, you should maybe do this, or – ‘thirteen
things you should know about sex’, or…like, you get all they different factoid things
that pop up and you’re reading half of them and you’re like: ‘I would never do
that…so why does it say that on a page?’
(Emma, aged 17 paired with Mia)
Both Emma and her sister Mia worried about the influence of such readily accessible content
on expectations about sex, particularly as they struggled to relate to much of the content they
had encountered. Liam and Rowan described a post they had encountered that highlighted
the heteronormativity of mainstream media:
Rowan: In most Disn-, in fact in Disney and Pixar movies, Dreamworks an’ all that
exclusively, I’ve seen them have a woman fall in love with a bee yet…
Liam: I’ve seen that post too and I know when…
Rowan: Yeah, yet they’re not allowed to show a homosexual relationship for more
than five seconds per movie
(Liam and Rowan, aged 16)
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Here, Liam and Rowan demonstrated both their critical literacy in identifying problems with
the banal sexual health imagery in mainstream media and the influence that shared social
media messaging can have in developing critical sexual health literacy. However, few
participants mentioned the role of social media in increasing social awareness and
deconstructing sexual health myths. These accounts of participants engaging with content
about sex and sexual health on social networking services highlight both the potential and
the challenges of delivering sexual health promotions on such sites; while Rowan and Liam
exhibited heightened social awareness, Emma and Mia’s perspectives demonstrated how
Facebook content can increase the pressures that young people experience in relation to
perceived expectations of sexual behaviours.
Participants’ tended to value user-generated content in a one-way format, typically
describing consuming, rather than sharing or producing, such content. The use of interactive
elements for sexual health promotion on social networking sites, like Facebook, was opposed
by most participants, and engaging with sexual health content in a visible way was deemed
unacceptable. Even participants who described being very open to communicating about
sexual health opposed sharing of such content on social networking sites. For example, Kara,
who appeared to have no hesitation about discussing sexual health with others, stated:
I mean, my family’s on Facebook so I’m no’ gonna, like, I’ll just share this blog post
about, like, sex on my Facebook [laughing]. Like I’m no’ gonna do that. Like, my
uncle is going tae be, like, liking it an’ that an’ it’s just a bit weird. So, nah, I
wouldnae’, an’, like the same wi’ like Twitter, like, I don’t think I’d use it for that.
(Kara, paired with Amy, aged 17)
Kara’s friend Amy (aged 17), who struggled to communicate about sexual health, agreed:
“No, I wouldn’t want anything on Facebook”. Participants’ also worried about reactions
from friends. On Facebook, simply ‘Liking’ sexual health content was deemed sufficient to
attract judgement from peers, as Josie and Kyle explained:
Josie: On Facebook you need tae like the pages to…
Kyle: Aye, you need tae…suppose they come on your newsfeed. I don’t think I
would like anything like that
Josie: Naw, I wouldnae like it ‘cause then people, like, obviously it comes up as liked
Kyle: Like you’ve liked it an’ then everybody’s like ‘Oh, why?’
Josie: Like, ‘What’s he dae’in that for?!’ [laughing]
Kyle: Yeah, ‘What are you dae’in that for, you dirty?!’ [laughing]
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(Kyle and Josie, aged 19)
Here, Kyle’s use of language highlights the influence of moral attitudes and stigma on sexual
health information-seeking, particularly within a context within which identity construction
is typically performed. Aaron (aged 19), who appeared comfortable discussing sex and
sexual health, characterised seeking sexual health information on social media as highly
undesirable, stating that young people would receive “dog’s abuse” if seen interacting with
sexual health organisations on Facebook. He later expanded on this:
Aaron: not Facebook, they’d just get abused on there…nobody would ever tweet
saying oh I think I’ve got this symptom…you’d get absolutely slaughtered […]
Michael: If anything was to be put properly on walls and stuff it would be sarcastic
and jokey
(Michael and Aaron, aged 19)
Here, Michael suggests that the only acceptable interactions would be flippant in nature,
possibly as a protective measure. This is consistent with the finding, discussed in Section
4.3.2, that male participants appeared less willing to earnestly discuss sexual health, and
more likely to present themselves as sexually confident and competent. From this
perspective, the acceptability of humorous content may present potential solutions to barriers
to engagement, particularly with young men.
Analysis highlighted a broad range of attitudes towards the distinct, but overlapping, spheres
of social media and user-generated content, and those attitudes were influenced by a variety
of factors, including gender, sexuality and platform preferences. It is insufficient to consider
all social media and user-generated content as one homogenous category, as different
platforms and content types fill different roles for individual users. Some participants,
particularly young women and those who identified as gay, lesbian or bisexual, described
some user-generated content (blogs, YouTube) as providing relatable, individually-relevant,
supportive, entertaining, and socio-culturally critical content. Conversely, participants were
less positive about engaging with sexual health information on social networking services
such as Facebook and Twitter, despite such services being the primary focus of participants’
general internet use. Engaging with sexual health content on social networking services was
typically deemed unacceptable due to concerns about stigma and embarrassment associated
with being seen seeking sexual health information by friends and family. Some participants
identified potential for sexual health promotion on social networking services, describing
engaging with interesting content (albeit of variable quality), but this perspective was
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atypical. A key distinction between social networking services and other sources of user-
generated content may be that the former are sites of active identity construction, while
services such as YouTube, despite being social platforms, are perceived as more anonymous
sites of passive consumption.
5.2.2 Perspectives on presentation style and tone of information delivery
Participants’ often evaluated websites based on the style of their language and content, and
sometimes rejected websites they deemed to contain too much text. Emma and Mia typified
this perspective:
Emma: There’s quite a lot of information
Mia: I think, like in a way they've got lots of information but for a, a teenager or even
maybe younger, they would get in and be like: “Aw, I'm not looking at that” - and
just come back off it. Like…Like, if I go onto this one and it's, this one and there's
like quite a lot of this, and then like, it all, it just continues the - whole way down the
page of different things, I'd get bored wi’ reading that
Emma: It's just too much
Mia: Like Wikipedia is the worst, like. What is that, what even is that?
(Emma, aged 17 and Mia, aged 18)
In this exchange, Mia considers other young people’s likely reactions to information-heavy
sources, and illustrates the view expressed by many that too much content on one page can
prevent engagement. In addition to being ‘boring’, participants perceived text-heavy
websites as difficult to locate required information on, slowing down information-seeking.
Participants identified a variety of preferable ways in which websites could present
information, including: brief, concise text with links to further information; definitions of
terms; bulleted lists; step-by-step information; question and answer formats; and images.
Charlie (aged 18, paired with Matthew), who had mild additional support needs and
expressed distaste for excessive text, praised the Family Planning Association (FPA)
website, where discrete sections were accessed by clicking links, instead of being presented
on one long page (see Figure 5-1). Charlie commented: “Ahh, You can click on each o’
them. HIV. Just gives you information on it and what it means…Information on what it
means in case somebody doesn’t know what it means. For people who know and people
who don’t know it’ll be good for as well. ‘What causes…’ It’s good for information this
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one actually”. Similarly, Courtney and Laura liked an NHS website that supported basic
initial information with links to further information:
Laura: I think it was quite basic at the start
Courtney: Yeah
Laura: But there was like further links for more information so they didn’t put all the
things at one bit
Courtney: Yeah, so people don’t get confused, everything’s structured
(Courtney, aged 17 and Laura, aged 16)
This exchange highlights the appeal of presenting information at different levels, offering
both concise, focused information with further depth as required. Similarly, participants
valued links to definitions of technical terms, as expressed by Claire and Ashleigh in their
discussion of the Young Scot (national youth information charity) website:
Claire: Young Scot was really good
Ashleigh: Yeah, it was good, ‘cause it, like, has a question. And then, like, the
answer, kind of thing. So, like, that was always a good way to do it, really
Claire: Yeah. And then it had, like, links at the bottom (Yeah.) for other stuff that
you’d want to read
Ashleigh: And it, like, links to, like, to the word, like, the words. And then, like, it
was a link. All coloured like red. And it takes you on to, like, a different, whole
different, like, thing that you can read… that’s also important.
(Claire and Ashleigh, aged 17)
A preference for bulleted lists over dense text was typified by Maeve and Leah:
Maeve: Yeah, I feel like, like say we like Googled the symptoms, when it said it in
bullet points rather than like a big paragraph…
Leah: Yeah, when you have to like a big paragraph it was just like hard trying to find
the bit you were looking for
(Maeve and Leah, both aged 16)
During the online activity, Maeve and Leah liked a website called ‘Think Contraception’,
which Maeve described as “appealing”, and Leah agreed was “well set out” because of the
use of bullet points. Keira and Sophie (both aged 18), who also valued bullet points, liked
the step-by-step format of the website WikiHow:
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Keira: I liked the steps one…like step one it’d tell you what to do and then it would
explain it so then
Sophie: It was quite clear
Keira: And it had like pictures and stuff so it was like easier to understand than a big
paragraph and then you’re just like woah don’t know where to look
Sophie: Cause especially…like I couldn’t be bothered reading a huge paragraph like
and I think like young people couldn’t either
Keira: But if there’s just like steps that just kind of shows you like then and then right
and if you want to read more then it’s there but if you want to just know the basics
it’s there as well
Sophie: Yeah
Keira: Cause I don’t like reading big paragraphs…I just like something like quite
bullet pointed like then and then sorta thing
(Keira and Sophie, both aged 18)
Keira and Sophie had read a WikiHow page entitled ‘How to Overcome a Fear of Sex: 14
Steps (with pictures)’, and appeared to digest the content in a linear, comprehensive way.
Sophie commented “That’s quite a good website”, to which Keira agreed: “yeah, I like this
website…I like the ten steps it gives you”.
Figure 5-1: Example of preferred website layout
Participants’ varied in their preferences for different tones , with some preferring a serious,
straightforward tone, others preferring more informal, casual content, and valuing a balance
between the two. Michael and Aaron described preferring factual information that delivered
information efficiently without attempting to reassure:
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What was the information you looked at like?
Aaron: Formal… formal and blunt...20% of folk have this...it’s not like pure...but I
actually prefer it that way
Michael: Yeah that’s better
Aaron: Cause there’s no point trying to be nice about it cause you need to
know...probably not facts like that probably don’t need facts like that...they should
just tell you straight to the point
Michael: It’s probably useful telling you that but
Aaron: yeah I suppose
Michael: It’s not reassuring but
Aaron: it’s useful
(Aaron and Michael, aged 19)
Some felt that less direct, more sympathetic or “jokey” content could cause readers to take
topics insufficiently seriously, which Aaron suggested could have negative health impacts:
“it’s jokey and you could just think aw that’s fine then obviously it doesn’t matter and
then…7 months down the line and you’re screwed”. Similarly, Liam and Rowan were averse
to condescending or patronising information:
Liam: We’re here… Like I said, we're here to be... we're talking about adult issues,
you know, with our bodies. We're not here to watch like a Thomas the Tank Engine
explain it or anything like that so [laughing]... 'cause wouldn't that be fuckin’ freaky?
I don't know about you. You know Thomas the Tank Engine say “Me and Gordon
had fun last night. However, we did not use protection. Now we've got greasy
downstairs.” [laughing]
Rowan: Oh my God!.I prefer it to just be like completely plain. Like, okay, what's
your problem? This, this, that or this an' then we click it an' then it brings you a list
of 'Okay, these are the possibilities. This, this, that or this.' Okay, there you go. Okay,
yeah, yeah, I've got my answer. Yay! [laughing]
Liam: Yeah, I'd probably go that's easiest. With things like this you don't want them
to be fancy and like, you know, 'Oh, you poor wee thing. You think you've got
chlamydia. Aww. Here, here's a hug.' [laughing] […] You don't want, like I said, to
be all huggley and just 'Oh, you poor thing. Like how are you feeling?'”
(Liam and Rowan, aged 16)
Despite Liam and Rowan’s stated preference for ‘plain’, serious information, during the
online activity they reflected on how an amusing website could be helpful:
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Rowan: 'Women's top ten sex worries.' Well, that's probably not...
Liam: That duck face though. [laughing] Can we just take a minute to appreciate that
duck face?
Rowan: No, this isn't her face, she's just going... oh, okay. ‘Oh, no, this isn't her sex
face’. [laughing]
Liam: [laughing] See, that's probably good 'cause it relaxes you, you know, you could
be quite nervous and quite stressed out.
(Liam and Rowan, aged 16)
A preference for serious, direct content was primarily exhibited by male participants. In
contrast, eight participants, all young women, preferred more relaxed and reassuring content.
Jess and Amelia regarded online content as too fact-based and unsupportive:
Jess: I think it’s more of like a support thing as well…yeah it doesn’t really give you
like any support, because it’s not a person
Amelia: yeah and it’s just kind of like fact fact fact…I suppose it’s meant to be like
that [laughing]
Jess: I think it it’s like us, because we’re like teens, we’ll like want to be comforted,
like we won’t want to be told ‘right, go to your clinic like right away!’”
Amelia: You want it to be like right, we can sort it, we can deal with this yeah
(Jess and Amelia, aged 16)
Female participants’ stated preferences for reassuring, relatable content were exhibited in
the online activity. Keira (aged 18) described preferring “realistic stories” to factual
information, and she and Sophie (aged 18) primarily accessed user-generated and
commercial magazine sources in addressing Scenario Two. Similarly, Alice (aged 18) and
Cleo (aged 19) liked ‘Her Campus’ (an online magazine), which Cleo compared favourably
to the ‘scary’ content of an NHS website: “I think this one might be better because it’s saying
like it’s normal tae do this, like it’s normal tae do that and stuff…”. For some, relatable,
narrative information was reassuring. Many participants who preferred a more relatable tone
turned to user-generated content ahead of more conventionally authoritative sources, as
detailed in Section 5.2.1 and 5.2.2.
While participants exhibited starkly different tonal preferences, some communicated a need
for content that balances entertainment, reassurance, relatability and seriousness. Charlie
(aged 18, paired with Matthew, aged 17) explained that “I don’t want it being, like too
serious but at the same time be jokey, so that people don’t worry about it too much like don’t
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get their self stressed or overly concerned I suppose over it”. Abbie explained that making a
serious subject light-hearted can be helpful:
Just when it’s light-hearted and it doesn’t take it too seriously, it’s like, I don’t want
to be reading something and feeling like I’m in an exam. I want to be reading
something and be like, “Oh right, there’s all the information I need” and it’s not
making me go... [gasp]
(Abbie, aged 16, paired with Sinead)
Abbie’s friend Sinead (aged 19) agreed that this kind of content was “interesting” and
“funny”. From this perspective, information must be relevant and reliable, but it can also be
beneficial for it to be reassuring and engaging.
While participants generally preferred brevity, links to further information and step-by-step
layouts, participants varied in their preferences for serious, humorous or relatable tones, and
tonal preferences may be patterned by gender. Moreover, participants’ reactions to different
tones indicated that tone can be an important driver, or inhibitor, of engagement with
information sources. Together, these findings suggest that, to effectively engage young
people in online sexual health promotion, information should be presented in a range of
different tones.
5.2.3 Attitudes to interactive and visual content
Some participants described encountering few visual or interactive features during the online
activity and most described encountering predominantly written content. Reece and Lucy
agreed that they had encountered only one page containing images:
And did you find that any of the websites you looked at had images or…?
Reece: Not a lot, actually. The only one that's actually used images was the example
of wikiHow right there. It was usually more like listing things
Lucy: Yeah yeah
Reece: That was usually the layout
Lucy: Yeah your different STIs and your side effects and how long they take to kick
in. It’s just kind of very listy and wordy
(Lucy and Reece, aged 17).
Reviewing their online activity data confirmed that most websites they visited, which were
primarily government and not-for-profit health websites, mainly relied on text, and some of
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the websites quickly rejected had contained visible images or videos. Despite the widespread
perception that information was mainly textual, images, videos and interactive features were
relatively commonplace on the websites participants accessed during the online activity.
Some participants actively chose to avoid engaging with interactive content, or appeared not
to notice videos and interactive features.
Participants used interactive features within four interviews. Both Christina and Josh (aged
16) and Charlie (aged 18) and Matthew (aged 17) selected the interactive risk assessment
tool on the Sexual Health Scotland website (see Figure 5-2), but neither pair engaged with it
deeply. Christina and Josh briefly read out the information on-screen, and Charlie and
Matthew did not interact at all. Charlie, who had minor support needs and tended to be wary
of online information, wondered whether the tool might induce anxiety in users: “Would that
be quite worrying for some people d’you think? Some people reading that like what is high
risk?”.
Figure 5-2. Example of an interactive tool used by participants
Both Joe and Ruth (aged 16) and Lily and Skye (aged 19) deliberately accessed interactive
tools they had prior experience of. Joe had described an NHS symptom checker during the
initial interview, and Ruth asked him to find it during the online activity. However, upon
beginning the tool, Ruth expressed concern that it might be “a long one”, potentially too
time-consuming for their needs. Similarly, while seeking information about contraception,
Lily, who seemed to favour visual and interactive content, recalled a contraception quiz on
an NHS website: “D’you know you can do like a wee quiz thing I think on this and it finds
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oot whether like… (mumble) ‘My contraception tool’, look! You put it, like you put all the
information in”. When prompted to select the long or short version of the tool, Lily selected
the short version (see Figure 5-3), exhibiting a desire to source information quickly. On a
different website Lily noticed a video about genital warts on an NHS website and was keen
to watch, but Skye expressed reluctance:
Lily: Lovely, let’s watch a video!
Skye: Don’t! That’s about genital warts man [laughing]
Lily: So?
(Lily and Skye, both aged 19)
Lily continued despite Skye’s protest, but the video failed to load, highlighting a potential
technical limitation of multimedia content.
Figure 5-3. Example of an interactive tool used by Lily and Skye
Despite some participants’ enthusiasm, many avoided videos. Some, particularly those who
favoured direct, straightforward information, perceived videos as useless and time-
consuming. Jacob and Connor explained that, while videos might be useful for younger
people, the passive process of watching a video is less efficient than actively seeking
information within text:
Connor: If you were young and you wanted to find out about things then aye
Jacob: You’d need to have time as well, because sometimes when you’re watching a
video and you can’t…it’s like not the same as a website where you can just look up
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and down sorta…like it can take time to load whereas with this you can just go up
and down, see aw that’s the main section I want to look at there pretty much and you
can also do the control method and search for key words so…
(Connor and Jacob, aged 18)
Conversely, many participants perceived images as useful tools for helping to identify
relevant content, in addition to being more engaging and entertaining than uninterrupted text.
Courtney (aged 17) and Laura (aged 16) encountered images of different STIs on the Boots
WebMD website, and scrutinised each image without reading the surrounding text. Courtney
later recalled those images, but could not identify the infections they illustrated: “On the
Boots website there’s like pictures of like how to tell if you’ve got an STD, like pictures of
like the symptoms and stuff…So—like I don’t know which one it was but it was like ulcers
inside your mouth and…Puss-y spots and stuff like that. So… so that like if you do have
symptoms you can compare like them to what you have”. During the online activity Laura
suggested they select the Boots website, saying “I like the Boots one, I think the pharmacists
at Boots are more nicer than my doctor”, suggesting that familiarity and favourable
experiences ‘offline’ influenced her searching practices.
Whilst seeking information relevant to Scenario Two, Claire and Ashleigh (aged 17),
particularly liked a diagram on the Young Scot website illustrating different forms of
contraception (see Figure 5-4), and felt that visual familiarity with contraception could
prepare people for practical application. A small number of participants described visual
information as easier to recall than text; Reece (paired with Lucy, both aged 17) explained
that “pictures are better because it gives you something to visualise as well, whereas with
words you kind of have to imagine everything, but a picture you have to visualise and it stays
in your mind for longer”. Lucy disagreed, stating “I’d rather just, if I was looking for
something quickly, I just read it there an then”.
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Figure 5-4. Example of pictorial information diagram
Few participants specifically searched for images during the online activity. Within five
interviews, participants searched for images, predominantly of specific STIs, using Google
Images. Darren (aged 17, paired with Craig, aged 16) assumed Google Images would be
popular amongst boys: “I bet all the boys who’ve done this test went on Google images
[laughing]”. Craig laughed and agreed, possibly hinting to norms around young men’s use
of sexually explicit imagery. Indeed, Melissa (aged 16) was the only female participant to
use Google Images, searching for ‘chlamidia [sic]’ before quickly closing the results page,
perhaps out of concern or regret at the search. Some males exhibited wariness about image
searches; when Aaron (aged 19) searched for ‘first time having sex’ on Google Images,
Michael (aged 19) insisted “don’t click on that”. Participants’ reactions conveyed a sense
that images, like pornography, can occupy conflicting perceived positions as simultaneously
useful and illicit.
While many participants found images useful, almost as many expressed concern about the
indiscreet and potentially embarrassing nature of visual content, with text seen as easier to
conceal from onlookers. Charlie (aged 18, paired with Matthew, aged 17) explained that
“It’d make me embarrassed like looking at pictures, like it’d make me worry a wee bit, you
know, what can happen etc”. Josh (aged 16, paired with Christina) highlighted the risk of
being heard watching videos, explaining: “Naw! In case my mum and dad heard me
[laughing]”. Again, participants’ reactions hinted to stigma associated with viewing material
about sexual health, and self-censoring searching practices (discussed in Section 5.4.5).
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Perspectives on visual and interactive content varied across the sample. Participants typically
valued images and diagrams for both their efficiency in communicating information and
their eye-catching, engaging nature. However, participants exhibited less agreement about
the value of videos and interactive features, which some perceived as too time-consuming,
although this may have been partially a product of the time-constrained nature of the online
activity. The eye-catching nature of images, videos and interactive features may not
necessarily be advantageous, as participants expressed concern about their visibility making
them difficult to conceal from onlookers.
5.3 Strategies for finding relevant and reliable sexual health
information
Through their reflections in the paired interviews and in undertaking the online activity,
participants conveyed their strategies for finding relevant and reliable sexual health
information. Those strategies are described in this section, including: attitudes towards, and
the use of, Google Search; making fast judgements based on aesthetic impressions of
websites; familiarity as an indicator of reliability; and various other strategies.
5.3.1 Reliance on, and trust in, Google Search
All participants used Google Search during the online activity, with few navigating directly
to specific websites of which they had pre-existing knowledge. Ashleigh and Claire typified
the approach of open-ended searching through Google Search:
Ashleigh: I don’t really know of any [websites]
Claire: I’d probably just look it up on Google if I want to know, just like, just hope
for the best
Ashleigh: Yeah me too
(Ashleigh and Claire, aged 17)
During the online activity, participants never navigated beyond the first page of search
results, with the exception of Emma (aged 17) and Mia (aged 18), who navigated to the tenth
page specifically to demonstrate the low value of lower-ranked results. Participants
unsatisfied by search results were more likely to revise their search strings than to work their
way through those initial results. Of the 158 search results followed during the online
activity, 74.1% (n=117) occupied the first three positions of the first page of search results,
17.7% (n=28) occupied positions four to nine, and 8.2% (n=6) were sponsored
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websites/advertisements or links from Google ‘featured snippets’ (extracts from one of the
search results automatically displayed above the search results) (see Figure 5-5).
Figure 5-5: Ranking/type of link selected by participants
Many participants perceived the position of search results as a marker of relevance and
reliability. Some described not knowing why they chose the top results (perhaps simply out
of habit or convenience), while others described the top results as the most accurate and
reliable, and lower-ranked results as less reliable. Josie and Kyle typified the view, common
among participants, that choosing top results is a norm:
And how did you decide where to look for it?
Josie: I just clicked on the first one that came up
Kyle: Which people tend tae do
Josie: Aye
Kyle: They don’t usually go looking for a specific website
Josie: But sometimes if the NHS still isnae the first one I’ll go doon an’ look for the
NHS
(Josie and Kyle, aged 19)
Notably, Josie indicated that she sometimes prioritises NHS sources over higher-ranked
results, suggesting that search ranking was not necessarily the primary selection criterion.
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28
67
Ranking/type of links selected from Google Search results
Link 1-3
Link 4-9
Advertised website
Google 'featured snippet'
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Some, such as Jacob and Connor, assumed that top results were ranked by their past
popularity:
Jacob: Usually I’d go on the internet and I’d just Google it
Connor: Yeah and the most reliable pages are the ones that come up first because
they’ve been Googled so many times…so that’s probably my best way of doing it
Jacob: Yeah I’m the same pretty much, it would just be through Google
(Jacob and Connor, aged 18)
Similarly, Aaron (aged 19) described the first search result as “the most respected one”,
reasoning that “that’s the one most folk go on anyway so...most people can’t be wrong”.
However, not all participants put faith in result rankings; during the online activity, Aaron’s
friend Michael (aged 19) complained at Aaron’s immediate selection of top results,
interjecting “don’t just go for the first…you just went for the very first one”. Later, Michael
indicated that he preferred a more thorough approach, explaining that “if I’m doing work I’d
normally scroll through it, I’d look first to find the best one but that’s just me”. Michael went
on to elaborate that he would “just Google it and then filter it down mysel’…like if they end
with things like gov or go on the website, visually, to see what it’s like...but he’d just go for
the first one...”. Michael and Aaron’s disagreement illustrates the range of approaches to
using search engines, and suggests that Michael felt confident in his ability to evaluate search
results.
Most results pages (particularly for Scenario One) included sponsored advertisements for
websites within the top three results. Participants exhibited distrust in sponsored results, even
when they linked to reputable health organisations, such as Brook or the Terence Higgins
Trust. Sponsored links were excluded when coding the positions of participants’ selected
results, because they were so often intentionally ignored, and were selected on only six
occasions. During the online activity Darren warned Craig against clicking a sponsored link:
Craig: ‘How can I have safe sex’ [reading out link name], Young Scot, that’s what I
want.
Darren: No, that’s an advert.
Craig: It’s Young Scot. Oh, right, okay. ‘Stopping STIs’…use condoms for anal and
oral…
(Darren, aged 17 and Craig, aged 16)
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In this exchange, Darren expressed wariness about the link’s sponsored nature, but Craig’s
prior knowledge of the source legitimised it. However, participants’ perceptions of
sponsored links as untrustworthy generally led them to overlook them.
In addition to presenting ranked search results, results were often preceded by a box
containing an excerpt from one of the search results, described by Google as a ‘featured
snippet block’. Of the 16 times that these boxes appeared, participants selected them six. At
times participants read information directly from these boxes without following the link to
the source. Whilst looking up information about ‘sti symptoms’, Jess (aged 16) seemed
surprised to see the answers provided in the summary box (see Figure 5-6), stating: “oh look,
Google is giving us the answers!”. Reflecting on the online activity, Jess and Amelia seemed
to have found summary boxes useful:
Jess: I think when we searched STI symptoms, Google gave you it straight away
from like like yeah like obviously the addresses come up and it gave you like
symptoms straight away, like an extract from a website
Amelia: Yeah, if you’re looking up like a word, it’ll give you it like straight away,
it’ll give you the definition so if you’re looking up...
Jess: If it’s like symptoms from there like, you’d be able to kind of like trust the
websites know what I mean like, if Google can obviously trust it. I dunno, maybe
they’ve like paid, they’re probably like paid to do that and then...
(Jess and Amelia, aged 16)
Here, both Jess and Amelia seem satisfied with information being presented in summary
boxes. However, Darren (aged 17) and Craig (aged 16) decided to ignore such a box, instead
following a link to an NHS website, with Craig suggesting “maybe not look at Google’s
translation, we’ll go to the NHS”. As in the example above, Craig demonstrated his searching
preferences, going to sources that he considered reliable and had previous experience of.
This further illustrates the variety of approaches to using search engines exhibited within my
participants.
Participants’ widespread use of, and trust in, Google Search also influenced how they
formulated search strings. Participants’ choices of search terms and strings are discussed in
Section 5.3.2.
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Figure 5-6: Example of Google ‘featured snippet’
5.3.2 Formulating search strings
As all pairs used Google Search during the online activity, they all had to construct search
strings to find information relevant to the scenarios. Participants predominantly chose and
entered strings quickly, with little pause for thought or discussion. Participants’ readiness to
revise search strings when unsatisfied with initial results demonstrated a ‘trial and error’
approach to using search engines, in which they moved progressively closer to the required
results by iterating on search strings in response to results. For example, Rowan (aged 16),
curious whether there are any non-sexually-transmitted genital infections, initially searched
for ‘non sexuallt [sic] transmited [sic] male genital infections’, then, being dissatisfied with
the initial results, added the term ‘sti’. This process relies on rapidly evaluating the relevance
of search results, which is examined in Section 5.4. On average, pairs entered seven search
strings during the online activity, but that number varied substantially between pairs. Kara
and Amy (both aged 17), who performed 15 searches, frequently had new ideas and moved
through search results and web pages quickly, while three pairs performed only one search,
seemingly content to browse one or two websites from search results in relative detail.
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Participants’ chosen search strings varied between the two scenarios, and therefore the type
of information being sought (Figure 5-7 and Figure 5-8). In relation to Scenario One,
participants predominantly formulated search strings to find information about STI
symptoms, transmission, timing and prevalence (n=40), or about testing, treatment and
specific sexual health services (n=30). The remaining search strings were more general,
seeking generic information and advice (n=13), such as ‘I think I have an STI what do I do’,
and ‘I may have an sti’. In relation to Scenario Two, 26 search strings targeted general
information and advice about first-time sex, such as ‘how to have sex’, ‘sex for the first time
advice’ and ‘planning for first time with girlfriend’. Twenty-one strings targeted information
about safe sex, risk and protection, such as ‘how to have safe sex’, ‘condoms’ and ‘most
reliable forms of contraception’. The remaining five targeted known organisations or
websites such as ‘the corner Dundee’ or ‘gurl.com’.
Two broad styles of search string emerged: general, conversational, natural language strings
(n=46, 33.1%) and focused, specific, keyword-based strings (n=93, 66.9%). In most cases,
participants used both, but some seemed to favour one over the other. For example, fourteen
participants (within 7 interviews) predominantly used direct key words, while four
participants (within two interviews) only used conversational or informal general queries.
The conversational search strings tended to be relatively informal, often personal, and posed
as questions, such as ‘I think I have an sti what do I do’.
A small number of participants explicitly discussed the importance of using effective search
strings. Reflecting on the online activity, Courtney and Laura described how different search
strings could affect finding relevant information:
Courtney: I think sometimes like, it depends on how well you word it…The Google
search words…‘Cause sometimes it comes up and it’s like really, really broad and
you just don’t know what you’re really looking for
Laura: Sometimes there’s too much detail and sometimes it’s not enough
Courtney: Yeah, like you’ll start off knowing what you want to find and then you’ll
look at all the information and think, ‘What was I even looking for?
Laura: Because there’s just so much
(Laura, aged 16 and Courtney, aged 17)
This exchange highlights an appreciation of the depth of information available online, and
the need to balance breadth and specificity in search strings. Jess exhibited awareness of
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advanced search options available within Google Search, and how these options can
empower users:
Yeah I suppose you can find the more kinda like general stuff, like, just be browsing,
like even if there’s related links and stuff, em, but also if you put in certain like key
words like, like even on Google and stuff you have all these like filters and it’s like,
where it’s from, enter key words, like order of importance that your results come up
in, like. I think you can just really search for anything
(Jess, paired with Amelia, aged 16)
However, despite Jess’ admiration of the flexibility of Google Search, she and Amelia
became frustrated with unsatisfactory search results during the online activity:
Jess: It’s like what…don’t type in ‘first time sex’… because it comes up with ‘Bill
Cosby to perform live for the first time since November’ [laughs]…ad campaign
features the first-time same sex couple…em…I’m thinking about other key words
Amelia: I mean there’s not really much information
Jess: yeah I don’t think there’s enough about…
Amelia: like you expect loads to turn up about that one
(Jess and Amelia, aged 16)
Both were surprised by the lack of relevant information produced by their search string,
deeming there to be insufficient relevant content available. This may highlight problematic
issues relating to misalignments between medical and lay terminology inhibiting effective
searching.
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Figure 5-7: Categories of search string (Scenario one)
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Figure 5-8: Categories of search string (Scenario two)
5.3.3 Rapid information seeking
Participants’ use of websites was often haphazard potentially due to a drive to find
information quickly. When presented with large passages of text, some participants used
search functions to find key words, but most scrolled through pages quickly, visually
scanning for relevant content, often in headings or bold type. Sometimes this approach was
successful; for example, Lily and Skye (both aged 19) scrolled through an NHS webpage
and quickly found information relevant to the scenario. However, others using this approach
unintentionally scrolled past relevant information.
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While tables and bulleted lists were often seen as beneficial, they could cause participants to
misunderstand the context of information. Connor and Jacob quickly judged the Male Health
Centre website to be useful, with a clear layout and a table listing chances of contracting
STIs:
Jacob: aw see that’s quite good
Connor: That’s quite scary...there’s just so few that I know about
Jacob: So if you have a 30% chance...
Connor: That’s quite high
Jacob: ...of having genital herpes from having unprotected sex with some random,
anyone
Connor: Woah
Jacob: Put that one down that’s actually a really good one
Connor: I’m telling everyone that...20% for syphilis, fuck that!
Jacob: Is syphilis not the one that kills you?
Connor: Aw well my lifes over
Jacob: Aye well, so we’ve seen...the chances of getting it from having sex
(Jacob and Connor, aged 18)
The information in the table shocked Jacob and Connor, but their interpretation was flawed;
not having read the surrounding text, they assumed the table listed chances of contracting
STIs from any unprotected encounters, while it actually listed risks associated with
unprotected encounters with individuals who have already contracted the relevant STI. This
example illustrates how hasty information-seeking can misinform, and, in Connor’s case,
how that information might be reproduced among friends. In another example, Laura (aged
16) and Courtney (aged 17), quickly scrolled through a website called ‘POZ.com’ to a
section on risk, not realising that the website provided information specific to people living
with HIV.
Participants were typically hasty in their searching behaviours and, while some exhibited
competence in finding relevant information quickly, others were less successful, either
missing relevant information or misinterpreting information in ways that could conceivably
impact negatively on sexual health understandings. It must be acknowledged that
participants’ searches may have been artificially hastened by the time constraints of the
online activity, however, participants generally expressed preferences for finding
information quickly, so those observed practices may be reflective of real-life practices.
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5.3.4 Trust in familiar and reputable sources
Throughout the online activity, participants tended to exhibit a preference for sources they
had existing knowledge of and perceived as reputable. Familiarity alone was not necessarily
sufficient if sources were not seen as authoritative, as illustrated by Jacob and Connor
following the activity:
So how did you identify whether it was one you wanted to go on?
Jacob: So I’m trying to think what we done…I suppose under the Google thing
there’s descriptions that kinda says words that has that in it, so there’s certain in the
context of your key word…so we looked at that a lot and were like oh that doesn’t
look as if it’s credible or we looked at the actual titles as well cause the Male Health
Centre looks better than other places and stuff like that
Connor: Yeah if they’re a more official thing
Jacob: Yeah Men’s Health came up and we were like naw we’re not gonna look at
that because it’s a magazine you know what I mean
Connor: Yeah more professional
Jacob: And Cosmopolitan came up and I was like I’m definitely not going to look at
that…Just that, the stories and entertainment things, magazines things like that I
don’t think are very helpful...that’s about it...if you know your way around it’s pretty
easy to know what’s good to look at and what’s not so...
(Jacob and Connor, aged 18)
Here, Jacob and Connor describe choosing sources based on existing knowledge of them,
and a preference for ‘professional’ websites to entertainment sources. When unfamiliar with
sources, some participants made assumptions about reliability based on titles; Rowan
worried about selecting a particular website, although Liam reassured him that it was not
what he thought:
Rowan: I don’t feel really good about what ‘Her Campus would bring up. That
sounds…
Liam: I’ve heard o’ Her Campus…That’s fine
Rowan: Oh thank God ‘cause I was thinking it was some kind of, I don’t know,
college porn website
(Rowan and Liam, aged 16)
Similarly, Mia (aged 18) described not trusting sources with unusual names, suggesting that
unfamiliar sources were fabricated by Google: “If it's got a funny name then it's Google and
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it probably mair likely made up”. Her sister Emma (aged 17) stated that “you can kinda trust
the NHS. Like that they're no' gonna gie you false information”. They were both particularly
mistrustful of the internet in general, but specifically sought out NHS sources, perceiving
the NHS as the only trustworthy source. Abbie and Sinead described similar perceptions of
the NHS:
Abbie: I think I would just look it up, like search it and then look for a reliable source
Sinead: I’d just look through Google and then look at eh…look at like things that
you’ve heard o’ before. But I wouldnae go like search for a specific site, ‘cause you
know…
Abbie: I’ll usually go for anything NHS if it comes up, just because of it’s a reliable
site…
(Abbie, aged 16 and Sinead, aged 19)
Many participants described specifically choosing NHS website links due to familiarity with,
and trust in, their reputation. Liam and Rowan (both aged 16) described often seeking NHS
websites, and at one point during the online activity they selected an NHS website link from
the top of a search results page, and Rowan commented: “well, directly to the NHS, always”.
Within another interview, Charlie (aged 18, paired with Matthew, aged 17) described
choosing a NHS website: “because like I know like they’re proper if you know what I mean”.
Familiarity and reputation appeared to be valued highly. This was evident in the online
activity, with familiarity or previous (positive) experience of websites representing a
seemingly important in assessing reliability and usefulness. Nicola (aged 17) explained this
approach: “Mainly just look at the like link to it, like if it’s something that I know of and
that I know is kinda popular then I’ll give it a look. If I don’t really know what it is then I
don’t fully trust it. And I keep on looking”. Equally, participants described not choosing
websites with which they had bad experiences. Nicola’s friend Ralph (aged 19) actively
avoided links to WebMD during the online activity, describing negative prior experiences
of it.
These findings illustrate the power of familiar and reliable ‘brands’ in generating
engagement with young people. This may have important ramifications for online sexual
health promotion, as first impressions appear to be essential, and reliable, authoritative and
carefully-tailored information may simply be bypassed if it carries branding that is
unfamiliar or perceived as untrustworthy. As such, online sexual health promotion efforts
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may benefit from being hosted by, or overtly associated with, familiar, trusted sources, such
as NHS websites.
5.3.5 Evaluating websites based on initial perceptions
Participants typically assessed websites’ relevance and reliability quickly, substantially
based on aesthetic appearances. For example, upon one website loading, Martha (aged 16,
paired with Samantha) almost instantly remarked “this looks good, this is legit’. Conversely,
Nicola (aged 17, paired with Ralph, aged 19) quickly dismissed a website by declaring: “this
is a very shitty website”. Kara (paired with Amy, both aged 17) explained that she would
visually seek sources that looked “the most un-dodgy”, based on layout and graphics.
Participants described sites that are visually unappealing and difficult to understand and
navigate as uninviting.
In some cases, hasty appraisals of sources caused participants to dismiss websites
erroneously. As Connie (aged 18) and Jamie (aged 16) searched for information about local
STI clinics, they formed positive initial impressions of a private healthcare company
website, Better2Know, with Connie stating: “Alright, oh right, this website then actually
does sounds like a good one…”. However, Connie soon dismissed the website upon seeing
information about STI-STD testing clinics in London, reasoning that they were insufficiently
local to be useful, but missing more locally-relevant information provided elsewhere on the
page.
When reflecting on the aesthetic evaluation process, some participants found the relevant
aesthetic criteria difficult to identify. Kara explained that “you can tell a dodgy website when
you click on it…like, the fonts are no’ great and it’s just like…you can just tell it’s no’ a
good website. It’s hard to explain but you just know when a website’s legit and when it’s
not! (Kara, paired with Amy, both aged 17). Here, Kara identifies font as one indicator of
legitimacy, but conveys a sense that her evaluation processes are largely intuitive. Initial
aesthetic dislike of websites often led participants to quickly dismiss them and return to their
search results.
Participants described specifically seeking websites that appeared “professional”, and
equated this with reliability. However, prior knowledge of an organisation, as described in
Section 5.3.4, could outweigh aesthetic judgements. Illustrating this, Emma (aged 17, paired
with Mia, aged 18) initially reacted negatively to the aesthetics of a website, proclaiming
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“What’s this, I can totally tell when it's a fake”, but quickly changed her mind upon noticing
that it was an NHS website, concluding: “Oh no it’s NHS, it's no’ a fake”.
As detailed in Section 5.2, while participants predominantly valued ‘professional’ websites,
some preferred fun, visually-engaging content that organisations such as the NHS may not
provide. Cleo (aged 19, paired with Alice, aged 18) explained that “The NHS, I think silly
things like it could be a wee bit more fun rather than serious like the colours. It’s… all like
colour schemes like, you know, this page is gonna be boring like the Her Campus one it was
colourful, the same wi’ Cosmopolitan, it’s gonna be fun tae read”. Cleo’s aversion to
‘boring’ websites, which she identified through aesthetic features, was common amongst
participants.
5.3.6 Beyond first impressions: more nuanced markers of reliability
Beyond the primary strategies outlined in preceding sections, participants described and
exhibited a range of more nuanced strategies to identify relevant and reliable information.
Ten participants, within six interviews, described looking for particular markers of reliability
when appraising online sources, including: top-level domains websites; authorship of
content; recentness of content; whether content is biased or judgemental; and the country
from which content originates. Following the activity, Kara described judging a website to
be unreliable for a combination of these reasons:
“And there was... at one point I went on a website and it was like... it didn't look very
professional so I just came off. It was... it's one o' the last ones I go on actually. And
it was... went on it and it was... it was black and white, there was no colour, and it
was like there wasnae any - who wrote the article, like, what date it was published,
there wasnae any o' that an' there wasn't... there was like a title and there was adverts,
like, all about it. It just didnae seem very reliable”
(Kara, aged 17, paired with Amy)
Kara appeared to supplement an initial aesthetic sense that the website was not ‘professional’
by seeking information about authorship and publication date, and rejecting the website
when those details were not clear. Kara’s hesitance about advertisements was echoed by
others, such as Aaron (paired with Michael, both aged 19), who remarked: “if it’s like a
dodgy website where there’s like promotions coming up then you know it’s a dodgy
website...”.
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While including authorship information was a positive sign in terms of the accountability of
sources, it was not simply the case that sources that provided authorship information were
preferred to those that did not. Rather, authorship information was a positive resource as it
allowed participants to make decisions about the legitimacy of a source. For example, Abbie
(aged 16) and Sinead (aged 19) decided to reject a post on the blog website ‘Jezebel’ upon
seeing that it was authored by a user named ‘slutmachine’, and Abbie commented: “It’s
taken us onto like pure…oh right, this is written by ‘slutmachine’ oh my God!...I don’t trust
this website”. Conversely, Liam and Rowan were pleased to find authorship details clearly
provided in an article, and reassured by the ‘professional’ description of him (see Figure 5-
9):
Rowan: [reading] ‘Expert chat. Let’s talk about sex…sex/relationships educator’…
Liam: It’s good to see he talks about himself and why he’s a professional
Rowan: [reading] Yeah…‘Justin has worked as a sex/relationships educator for over
fifteen years. He answers questions about sex and love and help…You can find his
website at blablabla.com
(Liam and Rowan, aged 16)
Rowan and Liam were also sensitive to biased information, as illustrated in their reactions
to advice provided by a doctor in reply to a user’s concerns about first-time sex on the
question and answer website ‘NetDoctor’:
Rowan: [reading the Doctor’s response]…’if you’re not sure about going ahead then
I urge you not to have sex for the first time’…Wow, that’s…
Liam: ‘I want advice on having sex’ and the doctor says ‘don’t have sex’
Rowan: That is like a major Christian answer [laughing]
(Liam and Rowan, aged 16)
On the same website, they read information about a Brook Advisory Centre stating:
‘Alternatively, go to the family planning clinic in your home town. Female doctors there will
be pleased to see you’, which they perceived to be sexist and biased. As well as criticising
perceived gender bias, Liam identifies the source as having an American bias, despite its
.co.uk suffix. Liam expanded on this during the post-activity feedback: “An' it sounded very,
like, American, if that makes sense? Like, just like the language it's using. You know, it's
like...” and Rowan added: “Well, 'cause America's always crazy. [laughing]”, conveying
reservations about American content, and preferences for UK content. Similarly, Ashleigh
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and Claire twice noticed that websites they had accessed were American. Ashleigh seemed
particularly conscious of this:
Ashleigh: Is this a… Is this… UK?
Claire: Don’t know
Ashleigh: Oh, it’s US. So it’s gonna be different
Claire: No, it’ll be… It’ll be like…
Ashleigh: It’ll be different. It won’t have the NHS and all that
Claire: True
Ashleigh: We’re gonna have to get the UK…
(Ashleigh and Claire, aged 17)
While Ashleigh and Claire rejected an American website when addressing Scenario One,
they later deemed the nation of origin of information less relevant to Scenario Two:
Ashleigh: This is…this looks American. This looks very American [laughing]
Claire: Aye, ‘cause all American sites say ‘In Spanish’ at the top
Ashleigh: Oh yeah, I mean it’s fine, but sometimes UK ones are a bit better
(Ashleigh and Claire, aged 17)
This exchange illustrates how familiarity with different styles of website allowed some to
quickly categorise websites based on ‘clues’ such as language options. Later, in post-activity
feedback, Ashleigh declared she would avoid “anything that wasn’t from the UK, just
because it’s like different”.
Courtney and Laura highlighted up-to-date content as an important concern:
Laura: And if like a doctor writes it, ‘cause you look who writes it, and who it’s by,
and who posted it. And also the like year. It’s like the more recent ones are more
updated and there’s more information in them.
Courtney: Uh huh, like I wouldnae, I wouldnae read an article fae like nineteen
nineties like if I was looking up sex for like tomorrow. Like, because chances are the
statistics are probably out of date, there’s probably more contraception out there than
what this article fae like ten years ago is saying. So I think I’d trust more up to date
like websites than I would websites fae years and years and years ago
(Laura, aged 16 and Courtney, aged 17)
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Specifically, Courtney implied that sexual health content is vulnerable to losing value with
age due to advances in medical knowledge. Excluding these few examples, most participants
did not appear to investigate authorship or publication dates during the online activity, and
no participants visited the ‘about’ section of any website.
Figure 5-9: Example of website providing author details
A minority of participants, particularly those identifying as gay, lesbian or bisexual,
identified biases and judgmental views within online content. Abbie (aged 16, paired with
Sinead, aged 19) was particularly critical of both style and content. In response to reading
the sentence “After the jump the five things about sex most other women are too prudish or
ashamed to share” on a user-generated website, Abbie objected: “Don’t call people a prude
just because they don’t want to talk about sex”. Similarly, she took issue with misogynistic
content: “[reading from screen] ‘Location, location, location, your pussy is prime real estate
if your body was a monopoly board’…Prime real estate! Makes it seem like you can be
owned”. Abbie often identified information as being heteronormative, misogynistic, or false;
in reaction to the sentence ‘it feels better without a condom’ she exclaimed “don’t tell people
that! That’s not helpful!”. Sinead tended to agree with Abbie, but was less vociferous in her
criticisms.
Most participants discussed performing some form of triangulation of information by
consulting multiple sources, often comparing online information with other sources such as
friends, family or health professionals. Some explicitly stated that the more sources contain
the same piece of information, the more likely that information is to be trustworthy. Lucy
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(paired with Reece, aged 17) typified this perspective: “If you read a few and they’ve all got
the same kind of information you know you're not going to go entirely wrong sort of thing.
Like, as long as it's not just like ones telling you to, like, ‘not use a condom and you'll be
safe, and the rest are telling you to use it’. Go with, like, the majority sort of thing”.
While participants described a broad range of sophisticated strategies for assessing
reliability, they did not necessarily exercise those strategies during the online activity.
Despite widespread recognition of the value of triangulating information from multiple
sources, participants rarely demonstrated this within the online activity. Instead, they
typically moved on to the next topic after finding the first relevant piece of information. To
some extent, this could be explained by the influence of the research context; the online
activity imposed artificial time pressures, and participants did not have access to offline
information sources with which to triangulate online information. However, it is reasonable
to assume that participants’ self-reported strategies would diverge somewhat from the
strategies they enact in real-life information-seeking, just as they did in the observational
activity. Nonetheless, participants’ ability to consider and describe nuanced strategies for
appraising information demonstrates the capacity for sophisticated information-seeking
skills that could perhaps be nurtured through skills-focused training.
5.4 Encountering and overcoming obstacles
While participants described and exhibited various strategies for locating and identifying
reliable and relevant information, they encountered various obstacles to doing so. In some
cases during the online activity, these obstacles were not overcome, leading to pairs cutting
their searches short. Participants’ perceptions of their performance in the online activity
varied. Some, like Jacob and Connor were satisfied with how they had addressed each
scenario:
Connor: so we’ve seen your chances of getting it
Jacob: And how long it takes
Connor: And what you might have so I think that’s it […]
Jacob: We’ve totally bossed that
Connor: We did actually
Jacob: Google helped us
Connor: Google is the boy
(Jacob and Connor, aged 18)
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Here, Jacob and Connor declare both their own success and highlight the utility of Google
Search. Some participants, like Cleo (aged 19) and Alice (aged 18) and Keira and Sophie
found Scenario Two easier to address:
So if you just go through each of the scenarios and talk a bit about how you got on?
Sophie: That was quite hard actually to type in what to find…like we weren’t sure
Keira: Yeah to find like after the unprotected sex was quite hard to find. It gave you
loads of information like about all the different STIs and the symptoms to look for
and everything but nothing really what to kinda do…as much…like once you’ve had
unprotected sex…Yeah so it’s quite hard […]
Sophie: Yeah and then this one [Scenario two was easier]. You just typed in ‘sex for
the first time’ and what to do
Keira: And yeah loadsa things came up and em
(Keira and Sophie, aged 18)
The first scenario also proved challenging for both Lucy and Reece (both aged 17) and
Christina and Josh (both aged 17). Lucy and Reece (both aged 17) struggled to find
information and became frustrated, with Lucy remarking that “It doesn’t seem like there’s
anything”, before deciding to progress to Scenario Two. Similarly, when Christina and Josh
(both aged 16), encountered challenges in addressing Scenario One, Christina said “I don’t
know”, seeming defeated, to which Josh reacted by moving on, with the apparent intent of
comforting his friend: “Right. Well, we’ve got that one. So we can try the next one. Right
so scenario two”.
While participants were typically satisfied with their performances in the online activity,
these accounts illustrate the difficulties they encountered. This section explores some of the
key barriers participants encountered and identified, including: difficulties identifying
situationally- and individually-relevant information; websites that malfunctioned or were
otherwise difficult to navigate; inaccessible language; and facing an overwhelming quantity
of content.
5.4.1 Overabundance of content and lack of guidance
Many participants identified the sheer quantity of content available as a barrier to effectively
seeking sexual health information online. For example, when discussing how to address
Scenario Two, Ruth and Joe felt that seeking information online could be counterproductive:
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Ruth: Yeah. Like, that’s more something that I would then say to them, like, “Well,
if you’re feeling unsure then maybe it’s not the right time.” Like, I would give them
advice more than tell them to go on the laptop.
Joe: Exactly.
Ruth: ‘Cause you’re gonna get far too many answers on the laptop.
Joe: And they’re just going to bury them aren’t they?
Ruth: […] Or freak them out more. Well, we’ll just tell her, eh? Tell, like, you would
speak to them about if they’re wanting a contraception and stuff, like, if it was a
female.
(Ruth and Joe, aged 16)
This exchange highlights how the quantity of information available can be perceived as a
barrier to informed choices, and why advice from friends may be a preferable, less
overwhelming, alternative. Ashleigh (paired with Claire, aged 17) echoed these concerns
when Claire suggested searching for ‘sex for the first time’: “no, ‘cause then that’s… People
just shove loads of… Like, that’s all, like, opinions. And it’s all gets scrambled in your
head”. Ashleigh indicated that the process of managing the wide range of perspectives
offered online could exacerbate confusion.
Some participants indicated that they would value knowing “firm websites” where they
could find trustworthy information. Notably, few participants appeared to know of any
specific sexual health websites to visit during the online activity. When faced with lots of
information Courtney said “yeah, I think like most teenagers would look at some of they
websites and just be like, “no” and just close it and deal wi’ it themselves” and Laura replied
“but if they knew there was like a specific website that gave them all the information then I
think they’d use that”. Laura and Courtney also thought young people should receive more
guidance, and worried about Google Search:
How do you feel about Googling it?
Laura: Mm hmm. But I think we should be taught in school.
Courtney: Uh huh
Laura: And get more lessons on it
Courtney: Mm hmm yeah ‘cause Google just covers the basics
Laura: And it’s complicated, there’s so many of them and no, I get confused
(Laura and Courtney, aged 17)
Several other participants identified school as a potential place to learn about reliable
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resources. Kara and Amy (aged 17) discussed the value of teenagers knowing specific
websites, and Kara suggested that school-based sexual health classes could refer pupils to
online sources relevant to class content: “It'd even be good, like, talking about the internet,
like, no' necessarily schools but maybe, like, you done things in school that were then, like,
linked to websites. So, like, you do, like, something in class about, like, the pill or something
and then the teacher was like ‘What we've covered today is on this website’”. As established
in Chapter 4, school remains a key, albeit imperfect, source of sexual health guidance and
information alongside the internet. Kara’s suggestion that relevant websites be highlighted
at school is an illustration of how school-based sexual health education might make more
effective use of the internet, both adding value to information provided in school and
enhancing young people’s online sexual health information seeking by recommending
specific relevant, accessible and authoritative websites.
There was also discussion of promotion of online sources beyond school. Ashleigh and
Claire identified that an absence of advertising for online sexual health information sources
may lead to low awareness of those sources:
Claire: Because, like, you don’t really hear about any sites like that. Like, (Yeah.)
you’d have to, like, look it up yourself and…
Ashleigh: Yeah. It’s never, like, it’s never really…
Claire: You wouldn’t really know where… I feel like you wouldn’t really know
where to start.
Ashleigh: Yeah. It’s never really presented to us. Like (overtalk)
Claire: Yeah. If, like, you saw an advert for one.
Ashleigh: You have to be, like, looking for it.
Claire: Yeah. But like, even in, like, if there was an advert for it, it would seem, like,
better as well
(Ashleigh and Claire, aged 17)
This exchange illustrated how a lack of guidance about specific sources can present a barrier
to using the internet. It is clear that perceptions of the quantity of sexual health information
available online, and the challenges of negotiating that information, represent barriers to
effective information-seeking. This may represent an opportunity for other sources to help
ease online information-seeking processes; specifically, there may be an opportunity for
school-based sexual health education to provide young people with specific
recommendations of online sources, and practical advice about engaging with them.
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5.4.2 Difficulty in sourcing locally-relevant content and navigating complex
websites
As identified in Section 5.3.2, many participants considered locally-relevant information
about services to be relevant to Scenario One, and some found success by including location-
specific terms in search strings. However, others encountered barriers to finding locally-
relevant information. Cleo and Alice searched specifically for STI clinics within their local
area (‘tests for sti in inverclyde area’) and selected the Sandyford website, which was the
first search result. When the website failed to load, the pair tried to locate the Sandyford
website more directly by searching for ‘sandyford’ and ‘sandyford Greenock’:
Cleo: I’ll type in ‘Sandyford’ to see if that helps
Alice: Don’t think it’s gonna work
Cleo: Not working at all the Sandyford website
Alice: They have a Facebook [laughing]
(Cleo, aged 19 and Alice, aged 18)
While the website still did not load, during the search process Alice noticed the
organisation’s Facebook page, which surprised them both. They accessed the Sandyford
Facebook page, but quickly left without vocalising why. Cleo expressed frustration at this
process: “Right, so in other words Google’s just scaring you wi’ like, telling you all these
STIs that you could have from… and not telling you where you could go and the Sandyford
website’s not working”. Here, Cleo suggests that Google provokes anxiety by providing
information about STIs without providing information about sexual health services.
Five pairs encountered barriers to locating information about local services on the NHS
Choices website. Claire and Ashleigh (both aged 17) followed a link to ‘find sexual health
services near you’, but upon entering her postcode, received a message explaining that the
website only covered services in England, and suggesting that they access NHS24 for
information on Scottish services. The pair seemed unsurprised by this, with Claire describing
it as “classic” and Ashleigh remarking “always left out, Scotland”. They followed the link
to NHS24, where, following a series of unwieldy steps, they ultimately located information
about local services.
Other pairs encountered the same initial problem with NHS Choices, with different
outcomes. Kara and Amy (both aged 17) ultimately found locally-relevant information by
returning to Google Search and entering a new search string. Liam and Rowan (both aged
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16) followed the link to NHS24, but struggled to make sense of the website, with Rowan
declaring “we’re all doomed”. Abbie and Sinead remained on the NHS Choices, but found
the content frustratingly dense (see Figure 5-10):
Abbie: What is this telling me at all?
Sinead: I don’t know
Abbie: This is not telling me anything. Oh, God.
Sinead: Right, we need to find somewhere like in South Lanarkshire. Under S
maybe? Whit?
Abbie: Scottish Health Service Centre.
Sinead: Hmm, right…
Abbie: Ok. [laughing]
Sinead: We’re so bad at this
Abbie: We’re not good at this at all
(Abbie, aged 16 and Sinead, aged 19)
Abbie and Sinead eventually abandoned their search, blaming themselves. These
experiences illustrate how some who encounter barriers adapt their strategies to overcome
them, while others do not overcome them.
The examples in Figure 5-10 illustrate how the complex nature of the websites of large
organisations can present barriers to finding information to the point that users may abandon
their information-seeking attempts. This underlines the need for information providers to
produce and maintain websites that are accessible, effective and fully-functional, particularly
when they are intended to be gateways to health services.
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Figure 5-10: Example of difficult to navigate websites
5.4.3 Obstacles to finding individually-relevant content
One obstacle that participants encountered to finding satisfactory information was in finding
information tailored to their genders and sexualities. During the online activity, often in
relation to Scenario Two, male participants often rejected websites they thought were
targeted at women. Typifying this, Ben, Caleb and Dylan dismissed the online magazine
‘Her Campus’, concluding that much of the information relevant to first-time sex online was
aimed at women:
Caleb: Her Campus!
Dylan: There’s a lot of stuff aimed at women [...] there seems to be a lot aimed at
women. Know what I mean? There’s no’ really… there’s not really any tips for men.
Ben: What sort of tips would you give a man?
Caleb: Yeah Dylan!
Dylan: I don’t know…
(Ben, Caleb and Dylan, all aged 17)
Caleb and Dylan bemoaned the perceived absence of information tailored for men on ‘Her
Campus’, and their experience may be indicative of a need for online information on this
topic tailored for male perspectives. This perspective was not only expressed by male
participants, however; Cleo and Alice felt that ‘Her Campus’ provided insufficient
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information on first-time sex for men, and suggested that a male-oriented equivalent could
be useful:
Cleo: But then maybe they should do like guys pages as well ‘cause I don’t think all
guys wantae go ontae Her Campus and read stuff like that so maybe like, I don’t
know if there is a His Campus, I don’t really…
Alice: There’s really not a lotta information for guys. We were looking at was all
really more information for girls in’t it? [laughing]
Cleo: Yeah, like if it’s sore for the girls
(Cleo, aged 19 and Alice, aged 18)
On one occasion, Keira and Sophie rejected a source that they deemed to be relevant to
lesbian, not heterosexual, first time sex. The pair valued ‘Cosmopolitan’ (a magazine) as an
information source, and initially liked the content in an article entitled ‘10 sex tips for your
first time with a woman’, but then rejected it for a perceived focused on lesbian sex:
Keira: [reading from the website]’girls have the same bits…yah!’
Sophie: Wait, is this for lesbians?
Keira: I don’t know
Sophie: I don’t like this website
Keira: I think this is for lesbians
(Sophie and Keira, aged 18)
The examples in this section illustrate the importance that young people can place on
information being tailored to their identities, and how encountering information that is not
perceived to be individually-relevant can cause disengagement. The apparent gender
imbalance of information about first sexual encounters, which was found to be more readily
available from sources tailored to female audiences, suggests that, not only might young men
be underserved by a lack of relevant information, but that the gendered nature of the
information available could reproduce the norm that concern about emotional aspects of sex
is a female trait.
5.4.4 Barriers to reading and understanding content
When reflecting on the online activity, participants typically indicated that they could easily
comprehend most of the written information they encountered. However, some encountered
challenges, particularly with medical terminology. Martha and Samantha struggled with
some terms on an NHS website:
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Samantha: Eh?
Martha: ‘Immun-o-die-fien-cien’?
Samantha: Eh…Immuno-deficiency
Martha: Oh, right wow [laughing] Really I don’t know that…these are random.
What’s that? How do you pronounce that?
Samantha: Eh it looks like ‘papilloma’ or something
(Martha, aged 16 and Samantha, aged 17)
Shortly after this exchange, Samantha and Martha left the website, with Martha declaring it
“rubbish”. Similarly, Charlie (aged 18, paired with Matthew, aged 17), who had additional
support needs, described avoiding websites with “overcomplicated” and “big words”. These
accounts illustrate how inaccessible language can reduce engagement. Further, a
misunderstanding of the term ‘spermicide’ on the NHS Choices website demonstrated how
an unknown technical term could undermine the surrounding information:
Skye: Spermicide, what’s spermicide.
Lily: Sperm
Skye: Oh sperm, just sperm. Why is it a ‘-cide’?
Lily: I pure don’t understand why you put it, put sperm in it before you use it.
Skye: I know what’s the point in that?
Lily: ‘Depending on the type of cap you may need to add extra spermicide after you
put it in.’ [laughing] Whit! But that does not make any sense to me.
Skye: Think that’s tae help people get pregnant.
Lily: No, it’s sayin’…. Is it?
Skye: It sounds like it.
Lily: ‘to prevent sperm from passing into the womb’?…
(Lily and Skye, aged 19)
This example indicated that substantial misunderstandings might be avoided through more
accessible terminology or readily available definitions. Jess described valuing websites that
provide definitions, indicating that they negate vocabulary problems, but also indicated
confidence in searching for definitions:
Like there’s not too much tricky language or anything and if you didn’t understand
anything you could always search it up or like, it just kind of gives you the meaning
anyway…I mean especially like on like the NHS websites and stuff, it’ll say like, if
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it has a really complicated word on it, it’ll just like give you the meaning for it
anyway. (Jess, aged 16, paired with Amelia)
Although most participants were confident in their own ability to comprehend challenging
language, some expressed concern that others might struggle. For example, Caleb (aged 17)
described most of the information encountered as “pretty easy to understand”, yet felt that
some would be confused by medical jargon: “ones without slang, what if you don’t know
what you’re looking for? Like, words like that, ‘cause you might not have heard, like, a
proper medical name for it. So they’d be like, wouldn’t have like any idea what they’re
looking for then”. Laura (aged 16, paired with Courtney) suggested that websites could
mitigate this risk through more ‘basic’ language: “some of them were more detailed and
more medical words…some people don’t do biology and they don’t know like the big long
words and all the enzymes and whatever. So I think the basic is easier for everyone. ‘Cause
everyone will understand it”.
As well as influencing accessibility, language may also be an indicator of relevance; Amy
(paired with Kara, aged 17) suggested that young people are more likely to perceive simple,
informal language as relevant: “Like, normally on most websites you can tell the age gap
that the information's aimed at and I think if it's using all these big words an' it's not really
aimed at our age I'd probably find something that's aimed at younger people I think”. From
this perspective, formal and technical language is not simply a functional barrier to
comprehension, but can signify that content is not designed for them.
5.4.5 Censoring searches and concerns about sexually-explicit content
Some participants, particularly female, seemed concerned about inadvertently encountering
explicit material online. During the online activity, Sophie and Keira (aged 18) exhibited an
aversion to explicit material; while viewing a web page, Sophie said “that’s quite a dirty
page, I think”, and Keira whispered “come off that”. Similarly, as touched on in Chapter 4,
gender differences in attitudes towards accessing pornography, or being seen accessing
pornography, were apparent. Cleo (aged 19, paired with Alice) suggested that women would
be less likely to want to access sexual information videos or watch pornography: “But
females probably don’t wantae watch like porn to find out about it so they might want tae
see a diagram on a website or something, just in case…” and Alice agreed. This was apparent
within the sample when discussing sources of sexual health information and pornography in
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particular (see Chapter 4). Cleo and Alice agreed that they would not watch an online video
in case it was sexually explicit:
Cleo: I think I’d rather just read it. I’d be dead embarrassed. I’m a pure good girl
[laughing]
Alice: Yeah. [laughing] I would be too scared tae like look at the video in case it is
gonnae come up kinda porn-ish
Cleo: yeah
(Cleo, aged 19 and Alice, aged 18)
These perspectives highlight issues around gender and the acceptability of sexually explicit
content, with boys expected to access pornography, but not girls. Some participants implied
that there is stigma associated with women seeking either sexually explicit content or sexual
health information. Enthusiasm to avoid explicit content could be seen as part of building a
normative feminine identity, or what Cleo described as being a ‘good girl’, avoiding stigma
associated with appearing too interested in sex or sexual health.
Similarly, participants expressed concern about using search strings that might produce
sexually explicit content, and appeared wary about searching for particular words or phrases,
particularly when seeking information about first-time sex in relation to the second scenario.
For example, Aaron and Michael (aged 19) felt that the initial search results they received
were aimed at women, so decided to search specifically for information focused on men, but
worried about which terms to use, apparently concerned about encountering content aimed
at gay audiences. Michael said: “but if I put guy it’ll bring up hingwy gay shit won’t it” and
Aaron replied: “Yeah, don’t put guy! [laughing]”. This highlights concerns about
formulating precisely-worded search strings to avoid unwelcome search results. Participants
worried that their search strings might lead them to sexually explicit content; Kara and Amy
were trying to choose a search term for Scenario Two, and Amy expressed concern about
the ‘risk’ of explicit content:
Kara: Right, I say we just go em [starts typing ‘first time…’ into search engine]
Amy: Oh no don’t Google it it’s too risky!
Kara: Ken what? I ken what I’d hit up
Amy: Dinnae type in ‘how tae have sex’. Please dinnae
Kara: I’m no going to type it intae YouTube…YouTube is dodgy like
(Kara and Amy, aged 17)
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Amy exhibited nervousness about online information throughout the activity, and was
hesitant to select links that she felt might lead to risqué content. While Amy described
primarily relying on online content due to embarrassment about talking about sexual health
face-to-face, within school, amongst friends and with healthcare providers, her self-directed
online information-seeking appeared to be marred by similar issues of fear and
embarrassment as in ‘offline’ contexts.
Some male participants also seemed to censor their searches. For example Jacob (aged 18)
said he would tell his friend to seek pornography, and Connor (aged 18) agreed: “that’s what
I was gonna say as well…but you can’t really do it on this laptop [laughing]”. In this
example, the censorship appeared to be related to the non-private context of the online
activity, rather than any personal aversion to sexually explicit content. Liam and Rowan
exhibited sophisticated reflections on the importance of context and intent to whether content
is categorised as explicit or educational. Liam explained: “It's amazing that, you know, just
'cause they say like 'This is not a porn site' or whatever, it's like... but technically you're
showing nudity an', like, you're showing... people probably still see that as porn” and Rowan
added: “But it is for educational purposes. Well, at least most of the time. [laughing]”.
As discussed, within the previous section, some participants highlighted worries around
visual content. When discussing the use of images or videos in sexual health promotion,
participants generally thought of sexually explicit content, and some exhibited concern about
accidentally accessing such images through ‘innocent’ searches. Some participants, such as
Mia (aged 18, paired with Emma, aged 17), were particularly wary of sexually explicit
content on YouTube: “Aye but they dinnae like, you can just get like, porn on YouTube…It's
mair like in case a bairn clicks on it, then it's no’ like showing you two folk gie'n it yaldy it's
like. Probably, yeah”. Rowan (paired with Liam, aged 16) described an occasion when he
had accidentally encountered explicit material when searching for information: ‘I mean, I've
had surprise problems like that before. I looked up sex advice. “Okay, now note the
discolouration here” an' then the music starts coming in an' then it turned intae a porn video
an' I'm like “No, not what I'm looking for! Not what I am looking for!” (shouting)
[laughing]’.
5.4.6 Emotions experienced during online sexual health information seeking
One barrier to applying critical health literacy may be emotions experienced during online
sexual health information seeking. Participants described predominantly seeking online
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sexual health information in response to specific information needs and concerns, which
suggests that information seeking is often done in a heightened emotional state. Furthermore,
some stated that online sexual health information often exacerbates fears, while some were
even panicked by the hypothetical scenarios outlined in the online activity. For example,
Jamie (aged 16) seemed to be anxious reading about STI’s, stating: “that’d be frightening
having one o’ them would it no?”. For Jamie, being more knowledgeable and aware of
symptoms and treatment seemed to increase his anxieties: “that’d be scary but, even just
knowing the fact…just knowing the fact is they’re out there, it is scary”. Connie (aged 18)
repeatedly tried to comfort Jamie by highlighting accessibility of treatment: “they’re more
treatable now though, that’s what they’re like trying to tell you”.
It is important to keep in mind how heightened emotional states may negatively influence
young peoples’ search strategies and assessment of information, affecting their sexual health
literacy. Only one participant, Reece considered the importance of contextual factors when
seeking information online, recognizing that assessing reliability while seeking information
eased concerns:
In this scenario it's easy to just look up something and know what's trustworthy. If
you're panicking about something you don't really take that into account, you just go
for what… yeah, so you just go for it, you find usually if it's something like that that
it's not really reliable (Reece, paired with Lucy, aged 17)
Reece highlights that when feeling relatively relaxed, employing strategies to assess
reliability were more straightforward, in comparison to looking for reliable information in a
‘real-life’ situation where panic is more likely to impair judgement.
5.5 Summary of findings
This chapter reported findings from analysis of data from the paired interviews and online
activity, focusing on how participants described and exhibited seeking, understanding and
evaluating sexual health information online. The participants all had internet access, and all
used the internet, but substantial heterogeneity was identified in their approaches to online
sexual health information, including: their attitudes to, and preferences for, different types
of content; the practical strategies they reported and exhibited in seeking relevant and
reliable information; and the barriers they encountered, and sometimes overcame, while
doing so.
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While all participants described being regular, comfortable internet users, they voiced
concerns about finding relevant and reliable sexual health information online. Participants
varied in the difficulty they associated with assessing reliability of online sexual health
information. Some described difficulties, stating that they might benefit from training (from
school or other authoritative sources) on critically assessing sources, while others exhibited
skilled critical appraisal of online content, identifying limitations of search strategies, types
of information, and specific content, and demonstrating awareness of social determinants of
health.
Most participants employed a fast, trial-and-error approach to searching for and assessing
sexual health content. Participants typically trusted and relied on Google. A small number
accessed known websites directly, which were typically websites of services with which the
participants had had prior contact, illustrating the impact that offline experience can have on
online behaviours. Participants described their main aim in information seeking to be to find
information as quickly as possible, fuelled by time-pressures and worries about ‘being seen’,
and chose search results and appraised sources and content quickly. While some participants
found success with fast visual scanning, at times hasty information-seeking resulted in
haphazard searching, with participants sometimes bypassing or misunderstanding relevant
information.
During the online activity, participants sourced information or ‘facts’ about STIs and
symptoms relatively easily, but encountered some difficulties in locating locally-relevant
information and resources and more general information about first-time sex. At times
participants exhibited lower functional literacy, experiencing challenges in reading and
understanding text, particularly medical jargon, but the majority demonstrated relatively
high functional literacy, with comprehension problems being primarily perceived as
something affecting others. Barriers to accessing information on websites included:
inaccessible language; inappropriate or non-relatable information; non-user-friendly
websites; and non-functioning websites, which at times caused participants to abort their
information-seeking attempts.
Participants perceived online information as potentially unreliable, exhibited varying ability
to identify reliable information, and reported uncertainty about evaluating information.
Common strategies described to locate reliable content were choosing ‘professional’ and
reputable sources, identified by prior knowledge or initial aesthetic impressions, and cross-
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checking information with other sources on and offline. More nuanced strategies mentioned
by small numbers of participants included checking top-level domains, authorship
transparency, geographical location and publication dates. However, despite describing
these strategies, participants rarely demonstrated them in the online activity. While some
demonstrated critical evaluation of search strategies and content, many were unsure and
stated they would benefit from receiving training on critically assessing sources.
Gender differences emerged in relation to information-seeking behaviours. Boys rejected
information perceived as being ‘for girls’ and there was variation in attitudes to sexual
health, and attitudes to pornography and explicit material. Sex and sexual health were
typically portrayed as topics that females are more worried about. Participants tended to
perceive pornography as a source of learning and guidance for males, but not females.
Worries about encountering sexually explicit material seemed to influence search strategies,
with female participants in particular demonstrating risk-averse strategies, sometimes
‘censoring’ their searched to avoid explicit content, and being image search services and
websites containing visual material. Male participants also censored searches, but tended to
attribute this to the interview environment, implying that they would not be so cautious
outside of the research context. A number of participants highlighted their critical health
literacy skills in evaluating the influence of pornography on young peoples’ understandings
and attitudes to sex.
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6 Applying sexual health information in sexual and
healthcare contexts
6.1 Overview of chapter
In Chapter 5, participants’ descriptions and experiences of negotiating sexual health content
online were explored. This chapter moves on to explore how participants described their
perceptions and experiences of using and applying sexual health information within a variety
of different contexts.
Individuals may apply understandings acquired online in a wide range of contexts. It is
important to consider how different contexts and networks influence how sexual health
information is experienced, used and applied to make decisions and negotiate sexual health.
This chapter will examine how information learned online (and offline) is applied within a
variety of different contexts (sexual, social, healthcare) and the kind of facilitators and
barriers that exist in relation to this. This will be drawn from both participants’ discussions
with me during the ‘traditional’ interview stage and their discussions with each other during
the interactive stage (online activity).
This chapter will begin by broadly looking at managing and applying sexual health
information, describing participants’ general perceptions as well as their own self-perceived
strengths and weakness in relation to communicating about sexual health (Section 6.2),
before focusing specifically on negotiating sexual health within sexual contexts (Section 6.3)
and healthcare settings (Section 6.4). Lastly, this chapter will focus on possible ways to
overcome and circumvent formal sexual healthcare barriers, within the online context
(Section 6.5).
6.2 Communication skills in managing and applying sexual health
information
Communication skills play a key role in seeking and using sexual health information,
influencing how information is found, managed, employed and negotiated across different
sexual health contexts. When people access sexual health information online, they must
process that information and apply it within a range of predominantly offline contexts.
Negotiating such contexts, whether traditional healthcare contexts or sexual contexts,
demands many skills, particularly communication skills. Within interviews, participants
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discussed their perceptions and experiences of barriers to applying information within
different contexts. Within this section, participants’ reflections on communicating about
sexual health in general will be discussed, before going on to specifically focus on
communicating in sexual contexts (Section 6.3) and formal healthcare settings (Section 6.4).
6.2.1 General perceptions of communicating about sexual health
Participants considered sexual health communication not just in relation to themselves, but
in terms of what other young people might experience. Some participants, like Courtney and
Laura, perceived those younger than them as more open and less embarrassed about
discussing sex:
Courtney: Like I think older people like nineteen, twenty, or maybe even older than
that, like wouldnae talk about it so much. But see like now like people younger than
us they just tell everybody. Like they don’t care like
Laura: Like I heard twelve or thirteen year olds at the bus stop talking when they had
sex at the car park in some caravan. And how many boys they’ve kissed. Speaking
about things they’ve been doing and they’re like twelve, thirteen. So like they were
telling everything
Courtney: At that age they just tell everybody
Laura: Like I don’t mind talking about it, but…I wouldn’t tell everyone just like my
friends and if they ask me I’ll tell them ‘cause it’s not a big deal
(Courtney, aged 17 and Laura, aged 16)
Ruth and Joe (aged 16) shared this perception, with Ruth adding that she felt that openly
discussing sex has become “a bit of a competition to them nowadays”. Perceptions of
younger people as engaged in a competition to appear more sexually experienced illustrates
how some young people could feel pressured to be sexually active.
While some participants perceived younger people as more open to discussing sex, they did
not necessarily see this openness extending to effective communication about reproductive
and sexual health. Some pairs attributed high rates of teenage pregnancy to a lack of
communication. Alice explained that:
I just think they find it more embarrassing, but I personally think like just look at all
the young mums. I just don’t think they actually talk aboot it instead the just dive in
and just getting on with it. I just don’t think it’s like a lot younger people are aware
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of the kinda contraception and stuff you can get ‘cause I really wasn’t that aware
until I’d went tae a clinic. So…
(Alice, aged 18, paired with Cleo)
Some participants attributed discomfort with communicating about sexual health to a lack
of practice, suggesting that, in addition to failing to provide sufficient information (as
detailed in Chapter 4), school-based sexual health education does not present young people
adequate opportunities to practice communicating about sexual health. While school may
not have developed young people’s communicativeness, some participants, like Keira,
suggested that online content could engender openness and confidence in communicating
with friends about sexual health:
“Yeah I think so say one of your friends was worried about something but like you’d
read up on it and knew something about it you’d feel more confident in telling them
like don’t worry it’s nothing you’ll be fine or if it’s bad, I’d go get that checked out”
(Keira, aged 18, paired with Sophie)
Aaron and Michael associated access to sexual health information online with building
confidence in accessing formal healthcare services:
Aaron: yeah, the fact that it’s everywhere, everyone talks about it…it’s all over the
internet, it’s everywhere, so it makes you feel like when you go to the doctors that
it’s just a normal thing, talking about it or looking for it on the internet, it’s not just
weird, you don’t feel like a pure weirdo, because it’s everywhere, that’s all everyone
talks about now
Michael: aye, you feel like you know what you’re talking about, you’ve got a bit of
knowledge about it so you’re not just going in confused
(Michael and Aaron, aged 19)
Applying information within the healthcare context is discussed in more detail in Section
6.4.
6.2.2 Participants’ perceptions of their communication strengths and weaknesses
Participants displayed variation in their comfort in discussing sexual health topics, which
was communicated both verbally and non-verbally. However, it is important to consider that
participants were aware of the research topic when they had agreed to take part, and can
therefore be assumed to have some degree of comfort in discussing sexual health.
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Nonetheless, some participants, like Amy were outspoken about their difficulties with
discussing sexual health:
And what about talking to other people about sex and sexual health?
Amy: I find it quite embarrassing, like. I find it difficult tae talk about that stuff.
Kara: I dinnae actually care
Amy: I do
Kara: Maybe I think I've got this thing where I overshare. It's like a trait problem,
eh? It's really bad
Amy: Yeah, you share too much [laughing]
Kara: I overshare too much. Some things are supposed to be kept to yourself so I
don't find it…
Amy: But I'm the opposite, like
Kara: I talk to my mum an' that, like
Amy: Well, I can't talk to, I don't talk to anyone about it. I find it really embarrassing.
I don't know why, no, I wouldn't talk to anyone about that, like. I don't know, I just
find that really embarrassing
(Kara and Amy, aged 17)
In this quote, Amy and Kara reveal starkly contrasting attitudes to discussing sexual health.
Amy described using the internet for information seeking to avoid face-to-face
communication, but still expressed anxieties about being seen to be seeking information
about sexual health.
Around a fifth of participants shared Amy’s discomfort, while a similar portion shared
Kara’s approach. About half of the participants who reported being comfortable
communicating about sexual health identified as gay, lesbian or bisexual, and most had
participated in sexual health workshops or local youth groups. As described in Chapter 4,
participants who identified as gay, lesbian or bisexual tended to have experienced poor
sexual health based school education, prompting them to learn in other ways, primarily
online but also from others, which could account for increased confidence and comfort in
communicating about sexual health. In turn, this might highlight the importance of
workshops and similar activities to improving skills and confidence in communication.
Many participants expressed anxieties around communicating about sexual health regarding
specific topics or contexts. Confidence tended to vary by situation and person. As Lily and
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Skye (aged 19) explained, comfort “depends what the issue is”, “what age they are” and
“what their situation is”. Discussing sexual health with friends was generally seen as more
agreeable than talking to parents, particularly amongst female participants, and trust was an
important factor (as indicated in Chapter 4). In relation to applying and using sexual health
information, two key contexts arose within which participants described having problems
communicating and negotiating sexual health: sexual and formal healthcare environments.
These will be explored in the following sections (6.3 and 6.4).
6.3 Communicating with sexual partners and negotiating sexual
contexts
Participants generally indicated experiencing anxiety about communicating with partners
and within sexual contexts. When asked about discussing sex or sexual health with partners,
participants often became quiet and appeared uncomfortable. For example, when asked
about communicating with partners, Laura (aged 16) quietly said “mm hmm yeah I suppose”
and her friend Courtney (aged 17) said “mm hmm” and did not expand further. Some
described being comfortable communicating with sexual partners. For example, Melissa
(aged 16), who was generally very comfortable discussing sexual health, said she would
often talk to her boyfriend, as did Lily (aged 19, paired with Skye) who described her
boyfriend as someone she would go to with sexual health issues: “I’d probably speak to my
friends first and then see what they think and then…oh and my boyfriend as well, I’d say tae
him and then go if anything was wrong”. During the online activity, Lily again demonstrated
the importance she placed on communication by responding to a website that asked ‘Can
you discuss sex with your partner?’, by remarking “yeah if you can’t you shouldn’t be in the
relationship”.
Some participants, like Liam and Rowan, who both identified as gay, had no sexual
experience but assumed they would be fine discussing sexual health within sexual situations
as they were generally confident and happy discussing sexual health:
And what about partners?
Rowan: I guess I would be, yeah
Liam: Probably. I mean, I think it's hard to tell 'cause I don't know about you but I've
not really had a proper partner in proper relationships as such so I think it's a bit hard
wi' that sort of thing, it's like you don't know really. But I would've thought so
Rowan: I feel like, you know, I mean, not that I've ever been with someone but if I
was with someone I feel like the pers- like, of course you're gonnae be okay, like, to
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at least some degree talking to someone about a sexual issue or something sexual
when that's actually the person you have sex with
Liam: Yeah
Rowan: Like, that's the person that you go all out with so of course that's the type o'
thing you can talk about. [laughing]
Liam: Yeah. Well, if you say, like, you know, “Look, honey, I've got chlamydia. I
think you should...” an' then you say “By the way, I think you should get checked,
just in case.” I mean, you wouldn't say “I've got chlamydia. Now, you just relax an'
go have sex wi' everybody else.” It's like...
(Liam and Rowan, aged 16)
Here, Rowan anticipated that communicating about sexual health issues with a partner
should be a prerequisite for having sex. However, this perspective represented his perception
of a hypothetical, future situation, not a lived experience, and may also be an example of
participants trying to provide ‘correct’ answers to interview questions, regardless of the
plausibility of applying his answer in reality.
Some participants described communication within sexual contexts as becoming easier over
time. For example, Ruth and Joe felt that communication becomes easier with age and
experience:
Ruth: I think it gets better the older you get
Joe: It does, yeah, because it’s down to experience again, like, you kind of know
more what you’re talking about kind of things
Ruth: I think when it’s younger because when you’re younger it’s like you don’t
know, like, if something happened you wouldn’t know if that’s normal…
(Ruth and Joe, aged 16)
Ruth and Joe were both sexually experienced and were involved in peer education within
their school, which helped them develop communication skills and become less awkward
discussing sexual health. Conversely, Emma described how she had been in a relationship
for two years and had not yet had a ‘proper’ conversation about sexual health with her
partner:
“I mean I've been in a relationship for two years and I still dinnae think we've had a
proper conversation aboot it, so… Like, no' really. Just, I think because I would say
I'm still really young, 'cause we are – we're only teenagers, we're only in our teens.
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And even trying to talk to a boy about what you feel and what you don't feel is right,
and stuff like that, I think it's really hard because they have their mind-set and you
have yours. And trying to share that's a lot harder than just being like: “Right, this is
what's happening and this isn't what's happening.” It's not that simple”
(Emma, aged 17, paired with Mia)
Emma seemed happy to talk about sexual health with her sister (Mia) and within her local
community hub, but less confident within the sexual context, attributing age and gender as
factors. Indeed, female and male heterosexual participants at times exhibited different
attitudes to sex and feelings about communication. Connor and Jacob suggested that
communicating about sex and sexual health was something that females would do more
readily than males:
What about talking to a partner or someone…?
Connor: I think…well are you talking about first time? You’d maybe kinda speak…
Jacob: It depends who you are
Connor: Aye
Jacob: Some people are really worried about it…like girls seem more worried about
it than guys I think…they would talk to their partner but I think a lot of people
wouldn’t
Connor: I think if it was a girl they would probably speak to their pal before speaking
to their partner
(Connor and Jacob, aged 18)
Females generally seemed more concerned about emotional and communicative elements of
sex, particularly first time sex, than males, most of whom described not talking to partners,
not necessarily due to communication challenges, rather due to deeming that communication
unnecessary. Aaron (aged 19, paired with Michael) was very open about discussing sex and
sexual health, but regarded it as unnecessary within a relationship. When asked about talking
to sexual partners he said: “nah, nah I wouldn’t do that…anytime I’ve had a girlfriend I
wouldn’t talk about that…if I thought I had an STD as well I’d keep that to myself”.
Worryingly, Aaron indicated that he would not communicate to a sexual partner that he had
an STD, and he seemed to hold misconceptions about STI transmission and have relatively
little knowledge of sexual health in general.
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As described in Chapter 5, female participants more frequently mentioned being anxious
about first time sex in relation to Scenario Two. Maeve and Leah discussed how their
hypothetical friend would feel in anticipation of a first sexual experience:
Maeve: Yeah, for like their first they’re nervous of what’s gonna happen…Like
‘cause if she’s having it for the first time that means like she’ll be like…
Leah: Nervous
Maeve: Yeah, I know
Leah: But like apart from the like the emotional stuff to it, like the physical stuff, like
the pregnancy, the STDs, STIs, whatever. Or like them like pressuring you into it or
something
(Leah and Maeve, aged 16)
Here, Leah and Maeve identify both emotional concerns about sex and negotiating pressure
from partners. Keira and Sophie found online advice about preparing for first time sex, but
felt that the information would be too difficult to introduce in the moment in a real-life sexual
encounter, exhibiting limited confidence in their communication skills:
Keira: If sex does not feel pleasurable…(whispers)…ease into a comfortable sexual
session…find a comfortable setting…this is like quite staged…like you couldn’t
really…like if you were actually in the situation like you couldn’t
Sophie: Yeah you’d have to actually be going out with them for like ages
Keira: See I couldn’t do that
Sophie: Naw I couldn’t do that either
Keira: Like I’d just feel too uncomfortable
Sophie: I’d be like ‘be quiet’
Keira: It says like tell your partner but I don’t know…I think you’d have to be really
comfortable with them like see if you
Sophie: Like going out for ages
Keira: Yeah see if you just had sex randomly like you couldn’t do all this because it
would be quite
Sophie: Like weird
Keira: Yeah…’communicate with your partner’ [reading from website]..eh.
(Keira and Sophie, aged 18).
Following the online activity, Keira described how negotiating sexual situations could be
even more difficult in “casual” encounters:
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“like if someone was just having like just sex like if they didn’t know them that well
doing all that would be quite…you wouldn’t be comfortable doing that so I think
most of the things we found were mostly like people in like relationships who have
been together for quite a long time cause you need to be comfortable in saying that
to them” (Keira, aged 18, paired with Sophie)
Here, Keira identifies the need for specific advice for negotiating different types of sexual
situations.
One style of advice that Sinead and Abbie liked was a more light-hearted approach, which
they encountered on a website that they thought provided useful information to help people
communicate with their partners about sex:
Abbie: Well I think you could learn quite a lot from these websites as bad as they
are.
Sinead: Yeah
Abbie: Like it’s telling you what you need to know. The basics of what you need to
know
Sinead: Yeah, but it’s making it funny as well, like the way it’s worded and stuff like
that
Abbie: Yeah, it’s all…“Size is very much to do with your ability as a lover”
Sinead: See how if the couple like read these together, they’ll have a laugh, and they
might feel like mair comfortable with each other [overtalk]..Do you know what I
mean? Like, “Shit, will you get hard for me, big boy?”
Abbie: Will we come at the same time…Oh, I think you’ll be a good lover…Oh, this
is good
Sinead: I’m just writing this website, ‘cause it’s quite a funny website, health,
twenty-four. Sex, great, top tips
(Sinead, aged 19 and Abbie, aged 16)
In discussing this humorous website, Sinead identifies the possibility that reading online
advice as a couple could be an effective way to build a comfortable, communicative sexual
relationship.
In general, the heterogeneity of participants’ reactions illustrates the range of different
relationship types, the diversity of types of online content and the variety in individuals’
confidence and comfort in applying advice in sexual contexts. This variety highlights the
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diversity of barriers to communication that young people may encounter, and the challenges
faced by organisations seeking to create online content that is useful to a wide range of young
people.
6.4 Negotiating sexual health information and services within formal
healthcare settings
Formal healthcare settings are key environments within which sexual health information
may be sought, used and applied to make decisions and negotiate sexual health. Most
participants described some experience within such settings, although not always related to
sexual health, and expressed general perceptions of what formal healthcare encounters were
likely to be like. Most often, participants presented consulting healthcare providers (typically
General Practitioners (GPs)) as a secondary or tertiary step to potentially take after initial
information-seeking. Thus, GP surgeries and sexual health clinics tended to be viewed as
places for diagnosis and testing facilities rather than providing information. During the
online activity, particularly in relation to Scenario One, participants generally concluded that
they would need to visit a formal healthcare location after seeking information on the
internet.
6.4.1 Attitudes towards attending and interacting in formal healthcare settings
Participants’ perceptions of negotiating sexual health (and illness) within formal healthcare
settings varied. Some participants described ease in interacting within such contexts. These
participants tended to have had previous positive experiences of healthcare, and were
comfortable communicating about sexual health in general. However, most participants
expressed anxiety about addressing sexual health within formal healthcare settings, and
some stated that they would avoid such settings. These participants expressed concerns about
both interacting with healthcare providers and being witnessed seeking sexual health
information.
Participants varied in their confidence about making initial contact with a doctors or clinics.
Some participants did not perceive it to be a challenge, indicating that familiarity and
positive relationships with healthcare services may engender comfort. For example, Josie
(aged 19, paired with Kyle) liked her GP and felt comfortable going to her for help in relation
to her sexual health, explaining “I’d go to my doctor, she’s heavy cool”. She also described
encouraging her friends to visit formal healthcare settings, stating that “I need tae force
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everybody tae go tae the doctors”. Illustrating how an individual’s comfort in accessing
services can potentially benefit their friends.
For sisters Emma and Mia, who had moved home frequently, building trust and familiarity
with healthcare providers was crucial, and they describes a sexual health nurse in their local
community hub, with whom they had built trusting relationships. Emma perceived the
organisational configurations of health centres as barriers to building trusting relationships,
making her reluctant to seek help in this way:
See I wouldn’t even know where to start like. If you went to your doctor and you
were like: “Mm, can I have some contraception?” They'd probably, I think they'd
look at you weird, like, especially when you're going to your doctor now, 'cause like
you phone up and you make an appointment and you don't know who you're getting
til you get there. And it's, oh, a new system that they've started and they're just down
and your like. This is awkward if you're coming down here every time and you're
meeting someone different and you have to explain what's going on.
(Emma, aged 17, paired with Mia).
Many participants exhibited limited awareness of sexual health services, and uncertainty and
unfamiliarity fuelled anxiety. For example, Kyle (aged 19, paired with Josie), upon reading
information about local sexual health testing services during the online activity exclaimed:
“Wait, so you can get tested for that, for STIs at your GP’s surgery! I never knew that!”.
Sinead criticised inadequate promotion of, and information about, sexual health clinics:
I don’t think so, like, well, my friend the other day there was looking for a health
clinic, like to get checked for something [laughing]. And she was like, “I don’t know
where to go.” And I was like, “There’s no’ really that much information on places to
go.” And if there is it’s no’ advertised as well as what it should be […] Because
there’s quite a few like young people that might need it but cannae like don’t know,
and they don’t want tae, they’re too embarrassed to go to their doctors or—.’
Sinead (aged 19, paired with Abbie)
Sinead identified how limited knowledge about services, a lack of promotion of services and
embarrassment about consulting GPs can combine to create significant barriers to using
health services. The perspective that sourcing information about available services is
challenging echoes findings detailed in Chapter 5, in which some participants encountered
barriers to locating local sexual health services during the online activity.
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Many participants expressed worries and anxieties about local GPs or sexual health clinics.
Amy (aged 17) expressed anxiety about consulting a GP to address Scenario One, saying
“Oh nah, that would gi’ me the fear”. Lucy and Reece highlighted the confidence required
to ask a GP for an STI test:
Lucy: And then you'd be going to the doctor and be like “I had unprotected sex. Can
you take my blood and see if I have HIV?
Reece: Well, you kind of need to have a lot of confidence but if you did have it. It's
better to catch this kind of thing, like, sooner […]
Lucy: So you basically have to go to the doctor to find out if you had an STI?
Reece: Yeah. Yeah, you would have to go to the doctors
Lucy: I’d rather not [mumbling]
(Lucy and Reece, aged 17)
Here, Lucy may implies that the admission of risky sexual behaviour implicit in requesting
an STI test may fuel anxiety. Despite Lucy’s stated reluctance to visit her GP for an STI test,
she later explained that: “I think it’d be very awkward and embarrassing but if it was like a
call that needed to be made I’d probably make it”. Most participants were reluctant to visit
formal healthcare settings, but recognised that certain situations were, as Maeve (aged 16,
paired with Leah) put it, “definitely a go to the doctor situation”. The reasons behind many
participants’ reluctance to access healthcare services are expanded upon in the following
sections.
6.4.2 Communicating and interacting with healthcare providers
Participants raised a range of issues related to interacting and communicating with health
providers. A minority of participants appeared comfortable interacting with health providers
about sexual health. For example, Aaron, was generally at ease discussing sexual health, had
previous experience being treated for an STI and preferred the direct and quick nature of
such help-seeking, in contrast to his friend Michael:
Aaron: The internet is so bad…I’ve used the internet so many times and I’ve just
patched it, I was just like…every time I’ve got a problem I just go straight to my
doctor…It’s just there’s so many different things, you could type only one thing in
and then like tend different things’ll come up and it’s just so bad and you’d rather
just go to someone that’s like specific and will just tell you exactly what’s wrong
with you and like you can get a test done
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Michael: I wouldn’t want to go to the doctor…I’ve never went to the doctor to talk
about anything…like I’ve never had a problem so I’ve been fine…I wouldn’t, unless
I had to…I wouldn’t…unless I got into a big problem like Aaron [laughing]…I’d be
embarrassed to talk about it
(Aaron and Michael, aged 19)
Here Aaron explains that he prefers to have his concerns quickly answered by a doctor than
adding to his uncertainty by seeking information online. However, Aaron’s friend Michael
was much more reticent to consult with a doctor about sexual health issues due to feelings
of embarrassment. Michael’s experience typified most participants’ descriptions of seeking
information or help within healthcare organisation contexts.
A small number of participants expressed reluctance to use formal healthcare due to worries
about being examined. Josh and Christina (aged 16) described actively avoiding formal
healthcare settings for this reason, while Cleo (aged 19, paired with Alice) described a
“mortifying” experience at her local sexual health clinic in which she “hated every single
moment of it”, explaining that online testing and self-testing would be more comfortable..
Her friend Alice (aged 18) appeared much more at ease within the clinical context, but
understood others’ anxieties, explaining: “I think some people feel comfortable but some
other people like like Cleo, I’m not bothered about a woman being down and being able tae
look at it, but she’s like pure squeamish wi’ it [laughing]”. Cleo’s perceptions of clinical
settings and online and self-testing illustrate how anxieties about accessing formal healthcare
settings can result in preferences for alternative options that offer greater anonymity and
privacy. Participants’ views on online testing will be described in more detail in Section
6.5.1.
Reluctance to consult healthcare providers often appeared to be related to embarrassment at
discussing sexual health matters face-to-face. For example, Darren and Craig described
being comfortable consulting their GP about non-stigmatised health issues such as broken
bones, but not sexual health:
Darren: Nah, I wouldn’t do that and plus it’s a bit, it’s not too formal but it’s like
your doctor’s, like, your doctor, you don’t really want to – it’s like telling your uncle
about it or something, it’s just weird. So, I think I’d rather use self-diagnosis of some
kind, yeah [laughing]
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Craig: Yeah you walk in and they’re like “Oh, hi” and shake your hand an’ that and
then you have to just sit down and talk to them about your problems, it’s a bit too
close. [laughing]
(Darren, aged 17 and Craig, aged 16)
Here, Darren expresses a preference for self-diagnosis over the formal, embarrassing context
of consultation with a familiar GP. The barrier presented by familiarity with their GP was
potentially exacerbated by Darren and Craig living in a rural area, where a GP might be a
more integral to the local community than in urban areas.
Melissa highlighted the role of individuals’ confidence in successfully communicating with
healthcare providers:
“I’ve got some friends that are in the year below me and I think they feel quite scared
to start contraceptions and stuff like that and they don’t feel very comfortable
speaking to people. And I know, like, quite a lot of people, like, get embarrassed
when they have to come here [local youth information and sexual health
organisation] to get contraception an’ that ‘cause they don’t wanna go to the doctors
and that but”.
(Melissa, aged 16)
She explained how different personalities may have different approaches to seeking sexual
health services: “So, I think some people are – don’t like speaking about it and just like to
keep it to their self but some people do just – don’t mind speaking about it, just speak to
people. So, I think it depends on the person”.
While some participants, such as Melissa, considered how differences in individuals’
confidence and personalities may determine their comfort with face-to-face sexual health
services, many described negative perceptions and experience of healthcare professionals.
Laura and Courtney both felt like they were “judged” by their GPs:
Courtney: I hate going to the doctor
Laura: Yeah, I feel like I’m judged, so I don’t really like going
Courtney: Yeah, that’s the same as me yeah
Laura: Yeah I just say to my friends…and if I need to go I’ll take my friend with me
‘cause I don’t like…I won’t go myself…I just feel like they judge me and like I don’t
feel comfortable by myself
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Courtney: […] ‘cause, like, ‘cause they sit there and they type while you’re there and
you don’t know what they’re typing and it freaks me out [laughing]
(Laura, aged 16 and Courtney, aged 17)
In this exchange, both Laura and Courtney relate experiences of feeling judged by healthcare
professionals, and Laura identifies the value of bringing a friend for support. Laura and
Courtney both described relying on the internet for health information , despite worries about
reliability, primarily due to negative experiences with doctors. Ruth described a more
specific experience of a sexual health nurse:
I don’t really like – but I’ve got, like, personal experience wi’ a doctor to like why I
don’t like it. But it’s more of, like, ‘cause what it was is I went to go on the rod and
the girl had turned around, the nurse said, like, said like “Oh, so how many people
have you slept with?” And I told her and I was like fourteen at the time and she went
“And you’re fourteen?” And I was like, yeah, so I was sitting there but my pal was
sitting there at the time and she just, like, started giggling, like, that was dead snidey
and I was like – but ever since then I’ve, like, hardly ever been to a doctor.
(Ruth, paired with Joe, aged 16)
Ruth’s experiences highlighted how influential one bad experience can be, as it led to her
actively avoiding going to a doctor. In contrast, her friend Joe had positive perceptions of
sexual health clinics, which he described as “all just down to experience”.
Some participants drew meaningful distinctions between specialist sexual health clinics and
GP surgeries. Keira and Sophie suggested that GPs might judge young people discussing
sexual health, while sexual health clinic staff would not:
Keira: Cause like they also like see so many people like with obviously like the same
kinda thing whereas when it’s just your normal kind of doctor you’d be a bit like
Sophie: Yeah if you had to walk in you’d usually be like ‘oh I’ve got a cough’ but
you’d have to walk in and be like ‘I think I’ve got a sexually transmitted disease
Keira: If you were in the clinic they’d expect that or something so you wouldn’t be
as embarrassed to say something like that
(Keira and Sophie, aged 18)
Thus, participants raised a range of potential barriers to confidently and effectively engaging
with healthcare providers, including embarrassment and worry about being judged.
However, it may be important to recognise differences between different types of health
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services, and how they may vary in the extent and nature of the barriers obstructing their
use; perhaps focusing on sexual-health-specific services may help young people to
circumvent the embarrassment and stigma they might associate with seeking sexual health
support in general health service contexts.
Participants also described difficulties in understanding information provided by healthcare
professionals. During the online activity, Claire and Ashleigh encountered information about
smear testing, and Claire recalled being asked about smear testing by her GP and being
unsure of what it meant:
Ashleigh: ‘Pap test’? [reading from webpage]
Claire: My doctor asked me if I wanted to do a smear test, but I didn’t know what it
was. I was just like no…
Ashleigh: What is it?
Claire: I don’t know.
Ashleigh: Slow down [in response to Claire scrolling quickly down the webpage]
Claire: I think he said I didn’t have to start ‘til next year anyway, so… that’d be good
to know.
Ashleigh: See, that’s the kind of thing you’d want to know
(Ashleigh and Claire, aged 17)
Despite not knowing what a smear test was, Claire preferred to decline the test rather than
ask her GP to explain. She had earlier described discomfort at discussing sexual health with
her GP, which possibly influenced her response to that specific situation. This indicates
potential limitations of communication skills on both Claire and her doctor’s behalf, as
providing a brief explanation could have helped Claire to make an informed decision. Sinead
and Abbie also highlighted poor doctor-patient communication in a consultation with GPs:
Sinead: Oh, I was at the doctors last week, I was just like, “What does that mean?”
And he was just like, “Just go and take the tablet one day, like one time—one—once
a day.” And I was just like, “Oh, right.” I was like, “What’s it for?” And he’s just
like, “Just take the tablet.” And I was like, “Ok.” [laughing]… Uh huh, ‘cause I was
like, “What?” Like such a numpty, like I didn’t even know what he was talking aboot.
[laughing]
Abbie: Yeah, when I was in the hospital I asked them to tell me what they did during
my operation. They were like, “Oh, well…” (makes noise). They told me all this
kinda thing and I was like, “In English please.” And they were like, “Oh, right, we
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cut a bit off your kidney. We cut a bit off your bladder.” I was like, “Oh, right, ok.
That’s easier. But please don’t tell me you did a cross sectional surgery on the lower
abdomen followed by…” Like, I don’t want to know. “Just tell me why I’ve got a
scar please.” [laughing]
(Abbie, aged 16 and Sinead, aged 19)
Unlike in Claire’s case, Abbie and Sinead both responded to unclear information by
requesting, and receiving, clearer explanations. Abbie seemed to prefer information in non-
medical formats, preferring to talk to friends and access user-generated online content rather
than engage with face-to-face formal healthcare: “It’s like, it’s so much easier ‘cause it’s
like an actual person [referring to user-generated content], and it’s not someone going, “well,
in medical terms, let me just give you all these words you don’t even understand, so that you
leave here even more confused than before”. As well as exhibiting confidence in requesting
clarity from healthcare professionals and in discussing sexual health, Abbie had developed
a critical approach to assessing health information, perhaps due to poor information
provision in school. In this respect, Abbie and Claire illustrate two different reactions to
being provided with unclear information within a formal healthcare setting, and highlight
how limited communication skills and confidence can act as barriers to using services
effectively.
Some participants described a lack of trust in health professionals and low confidence in
their abilities. These participants typically had particularly negative experiences with
healthcare professionals and applying information within healthcare contexts, and therefore
preferred to avoid formal healthcare settings. This was typified by Laura and Courtney, who
each described particularly negative experiences of healthcare. Laura described her GP as
“useless” based on multiple incidents where they did not take her concerns seriously and
misdiagnosed her:
Some doctors are not as educated as they should be and you tell them what’s wrong
with you and like you know what’s wrong with you ‘cause someone else told you
and then you go up to them, “oh, it’s just a cold”…and like, or “you’re just not well,
you’ve got the flu”, when I came out to be anaemic and like really ill
(Laura, aged 16, paired with Courtney)
Experiences like the one described led Laura to avoid consulting with healthcare
professionals in favour of self-diagnosis and online information: “I don’t like going to them
now. I would rather check the symptoms myself and if I’m kinda sure I’ll get my own
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medicine or like phone up and ask and then do it myself…cause I don’t like doctors”. Laura’s
friend Courtney had very similar experiences, feeling that doctors tend to “brush you off”
and not take concerns seriously enough, resulting in misdiagnosis and erosion of trust: “I
just don’t feel like my doctor knows what they’re doing”. Due to such experiences,
participants like Laura and Courtney felt like they had to find information in other ways, or
felt helpless:
Can you think of other ways you might try and find out about sexual health?
Courtney: Not really no
Laura: No, just Google it
Courtney: Yeah
Laura: cause the doctors don’t really help you, or, if you like ask them for help…like
I asked for, what vaccination for Malawi, he was like, “just Google it”…so…so I
don’t think doctors are much help and no one can really tell you about this. You just
have to Google it yourself
(Laura, aged 16 and Courtney, aged 17)
In this exchange, Laura, who had previously described encountering difficulties finding
information online, describes her GP recommending that she use the internet to search for
information on travel vaccinations.
While many participants described various barriers to accessing healthcare, Ruth described
some measures in place at her local health centre designed to reduce embarrassment for
young people accessing services:
Ruth: So, that gives you, like, a bit more information and then we just checked the
Google website – the [local youth organisation] website and just seen, like, what they
actually have and I don’t know if you’ve seen it but downstairs in the drop-in they’ve
got, like, a tick sheet. So, like, when you go in you don’t have to be like “Oh, I’m
here for a pregnancy test.” Like, they give you, like, a laminated card and you’ll just
tick it
Joe: Once… so it’s very confidential so you can see someone in that they won’t
actually know what they’re in for
Ruth: So, they’ve, like, what you do is, like, you’ll just click, like, they’ve got the,
like, a wee cartoon sheet of it and you’ll just click on pregnancy test and it comes up
like a wee cartoon picture and then it’s got, like, information there about what they
can do to help and stuff. So, that would probably be the best one, like, even just
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saying to a pal, like, “If you go to the [local youth organisation]” and they’re like
“Well, I’m not sure” it’s like “Well, go and see what they can actually do for you
first ‘cause they’re not gonna be biased.” Like, I wouldn’t – like, I would support it
completely. But obviously from their point of view they would be like “Oh, I don’t
know.”
(Ruth and Joe, aged 16)
The measures described by Joe and Ruth are perhaps examples of how relatively simple
changes can substantially mitigate concerns about embarrassment and privacy. Ruth’s
account also highlights the risk of stigma in being witnessed by others accessing sexual
health services, which is an issue discussed in more detail in Section 6.4.3.
While Joe and Ruth identified a system designed to engender confidence, more participants
described systems that exacerbated concerns. Some, like Emma and Mia, perceived the
organisational configurations of health centres as barriers to building trust, preferring to talk
to a local sexual health community nurse who knew their personal situations. Sinead
described feeling awkward about the number of personal and potentially unnecessary
questions asked of her during a visit to the pharmacy to receive emergency contraception:
“I think like see how when you go in for the morning after pill into like the chemist
or whatever. It is the only awkward thing about it is that, when they take you into the
room and they ask you all these questions…Like they come in wi’ sheets of paper
and I’m just like, “So why do you need to know this? Like why do you need to know
like how many times I’ve had sex?; Why do you need to know like, when the last,
what time the last time I had sex was at?” And I was just like, “Why do you need to
know if I’m with the guy?” Like it’s pure awkward questions like, I don’t really want
to answer these like…And then, if you don’t then she willnae gi’ you it.”
(Sinead, aged 19, paired with Abbie)
This highlights how routine systems can alienate young people seeking sexual health
services, and also points to Sinead’s critical awareness of barriers and stigma around sexual
health.
6.4.3 ‘Being seen’ seeking sexual health information and services
When discussing potential concerns about accessing formal healthcare settings, participants
identified a range of issues related to interacting with staff and understanding information,
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but most also expressed concern about ‘being seen’. Participants described concerns about
being observed seeking help or information related to sexual health in various contexts,
including both healthcare services and the online environment, and being seen to be seeking
help, even by friends or family, was described as a source of embarrassment and stigma.
Even participants who described being happy to communicate about sex and sexual health
within healthcare contexts exhibited concern about friends seeing them visiting a doctor for
sexual health reasons. For example, Aaron, who described being happy to communicate
about sexual health (which was corroborated by his friend Michael) had concerns about
confidentiality:
Aaron: like if you go to your local doctor…because that was one of the things the
first time I went…I didn’t want to go into the room and see one of my mates and then
I’d sit down and they’d be like ‘what are you in for?’ and then I’d have to explain it
[laughing]…and they’d be sitting tweeting at the same time…that sort of thing…so
it’s like your local place and where we’re from everyone knows everyone as well…
Michael: yeah it’s a small place
Aaron: …you go in there and you see somebody and then you see them at the pub
the next night and they’re just thinking what were you in the doctors for and you’d
just be so embarrassed”
(Aaron and Michael, aged 19)
So Aaron did not seem to mind discussing sexual health with his family or his friends, but
was worried about his reputation in his small town. This was an issue for many participants,
but particularly those from rural areas and smaller towns, for whom their GP was typically
‘the family doctor’. Kyle preferred going to the sexual health clinic for sexual health issues
instead of using his family doctor to ensure confidentiality and to reduce the likelihood of
encountering someone he knew:
I think if I was tae go tae anywhere if it was aboot sexual health I’d go tae like the
clinic, I wouldnae go tae my doctor… Aye, I don't think it's... I don't know 'cause like
I've got the same doctor as my family an' a' that but I just... Just in case they slip up.
Aye. Like “Aww, Kyle was in here getting condoms the other day.
(Kyle, aged 19, paired with Josie)
This typified many participants concerns about parents and acquaintances finding out.
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Within two interviews, whilst looking up sexual health services during the online activity,
participants specifically searched for information about confidentiality. Martha and
Samantha discussed the importance of finding a clinic that was confidential:
Martha: ‘What we offer in our clinics.’ [reading from webpage] Oh, shall we type in
if they’re confidential? ‘Cause if it…
Samantha: I think it would all be confidential
Martha: Yeah, probably. But…but I… like, that’s what I would be worried about.
Samantha: Yeah
(Samantha, aged 17 and Martha, aged 16)
Kara and Amy (aged 17) were unsure of if they could get the pill without their parents’
consent. Amy said “but can ye go on the pill withoot your parents knowing?, to which Kara
replied: “Yeah think so... Go tae GP. Emma told me that…”. This extract also highlights
peer sharing of knowledge, as discussed in Chapter 4.
Some participants discussed specific concerns related to obtaining condoms, which were
typically mentioned in relation to Scenario two. Male participants tended to seem more
comfortable obtaining condoms, with some mentioning using the C:card scheme2. Liam
explained:
“'Cause like I've been getting free condoms in Glasgow. Like, you obviously get,
like, the wee C:cards. You can just take that in, so that's obviously quite easy for me
just to go, like, Boots, whatever, an' just pick them up for free. But, I mean, apart
from that, I mean, that's all I really do”
(Liam, aged 16, paired with Rowan)
In this account, Liam depicted obtaining condoms as a very straightforward process. Emma
and Mia described how boys in their school would often talk about getting free condoms
from their local community centre:
Mia:…there's loads of like club posters and that, in the school that we used to go to
and that, they had quite a few posters. Like when you come down here there's posters
aboot the Hub and that. So like there's a lot o’ like posters and like, people speaking
2 C:Card is a condom distribution scheme where young people are given a plastic cart which they can use to
discreetly collect free condoms (http://www.ccard.org.uk/about-us/)
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aboot it, and then. You've got a’ the boys and they're like: “Hey I got condoms for
free.” And you’re like, stuff like that gets aboot tae
Emma: The boys, the boys just kinda show it up a bit I think but
(Emma, aged 17 and Mia, aged 18)
In this exchange, Emma and Mia suggested that males are open, and perhaps boastful, about
obtaining condoms. Condoms appear to be less straightforward for females; some female
participants, like Maeve and Leah, were unsure of where to get condoms and anxious about
the thought of picking them up:
Maeve: Where would you even buy a condom from? If you were like needing one
Leah: There’s places to buy a condom....like…
Maeve: Like do you get them in the doctors?
Leah: Yeah. You can…
Maeve: I just feel like I’d be really nervous
Leah: Yeah me too, like I thought you’d get them for free at the doctors but then I’m
not sure
Maeve: Don’t know
Leah: I feel like if they were free why do you…
Maeve: I know, I would feel too nervous to take one
Leah: I know, like but then they have places like in bathrooms in like where you can
buy them without having to have like have deal with people…
(Maeve and Leah, both aged 16)
Here Maeve and Leah highlight how condoms can be seen as taboo for young people, and
young women in particular, and how concerns about stigma, embarrassment and
confidentiality might prevent safe sex behaviours. Potentially, this discomfort with condoms
could also obstruct communication about safe sex in sexual situations, leading to unsafe
behaviours.
Acquiring condoms was one of a variety of aspects of sexual health that participants
associated with a risk of ‘being seen’ by friends or family. However, while concerns about
‘being seen’ were common among participants, and applied to a diverse range of contexts,
it is important to note that those concerns were not experienced equitably, with female
participants experiencing greater concern when acquiring condoms, and young people in
small towns and rural areas experiencing the risks of being witnessed accessing sexual health
services more keenly than those in the relative anonymity of urban settings.
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6.5 Overcoming and circumventing formal sexual healthcare barriers
Most participants identified barriers to attending and using traditional formal sexual health
services. As well as identifying ways to overcome those barriers such as using peer support
(discussed in Chapter 4), participants’ identified ways to circumvent them such as online
STI testing and contraception services and online professional advice services. Some
participants mentioned these services without prompting while others responded to questions
about them. In this section, participants’ perceptions of alternative sexual health services are
explored.
6.5.1 Seeking alternatives to traditional sexual health services: online STI testing
and advice
Some participants suggested alternatives to traditional sexual health services, such as online
STI testing and advice services, in order to circumvent the need to attend formal settings.
While addressing Scenario one, particularly when seeking information about STI testing, a
small number of participants either specifically searched for or otherwise came across
information about home testing kits. For example, Amelia described encountering
information about home testing kits:
Jess: [the website] also says like, it gives you good information like about what to do
if you think you have an STI…and like on the website there it says ‘find your nearest
clinic’…
Amelia: … plus there was things that came up like ‘at home clinic’ so you would get
a wee bag you know to test...then you don’t have to face the clinic, where your mum’s
friend might work or something d’ya know what I mean
(Jess and Amelia, aged 16)
Here, Amelia highlights the benefits of home testing in terms of protecting confidentiality.
Similarly, Amy identified home testing as an alternative to the anxiety of visiting a clinic:
Amy: Can you no’ get that personal STI kit?
Kara: A personal…?! [laughing]
Amy: I’m being serious!
Kara: Has it got your name on it? [laughing]
Amy: Nah, but, like, can you no’ but it at like Tesco or that?
Kara: I dinnae think so, no
Amy: I’m pretty sure you can like
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(Amy and Kara, aged 17)
As Kara was sceptical of the existence of home testing services, Amy searched the internet
for further details:
Amy: I’m pretty sure you can buy an STI testing kit
Kara: Amy, I’m no’ going tae test mysel’. Like, come on!
Amy: See you can buy them online
Kara: Aye, but I dinnae trust myself tae dae that
Amy: ‘Homehealth.uk’, ‘Superdrug’, there you go
Kara: Amy, eight test sticks for a tenner. Four tae me, four tae you [laughing]…nah,
I’d just go to the doctor [overtalk]
(Kara and Amy, aged 17)
Amy, who had described preferring to seek sexual health information online, seemed
enthusiastic about the idea of home testing, while Kara, who preferred formal healthcare
settings to online services, was not enthusiastic. Indeed, participants’ reactions to online
testing services were divided, with participants who found the healthcare context daunting
tending to favour alternative testing services. Courtney (aged 17, paired with Laura) felt that
online testing would risk less “judgement” and “embarrassment”. She also felt that, with GP
clinics, “all your information gets stored, so that can get passed to any doctor, any health
professional”, and indicated that she would prefer that her GP not be made aware that she
had taken an STI test.
Participants identified that home testing services could reduce geographical barriers, as well
as emotional ones, by improving access for people in remote areas, but also felt that people
might abuse testing kits “for a joke” (Connie, aged 18, paired with Jamie), wasting resources
and disrupting services for those in genuine need. Some participants reacted positively to the
concept of home testing, but stressed the importance of accuracy and legitimacy; Lucy (aged
17, paired with Reece) noted that the idea could be helpful “if they were like scientifically
proven to work”, while Claire (aged 17, paired with Ashleigh) stated that “As long as it’s,
like, legit then I think it’s pretty good”.
Almost half of participants stated that they would avoid home testing services due to
concerns about trustworthiness, validity and confidentiality. Emma recalled encountering
online testing:
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There's quite a lot of they things like when we go on Facebook and that, no' even
Facebook, like you're gonna be on the internet and you're like: 'Oh, I've got, I don't
know if I've got an STI.' Like, an STI test for thirty pound, basically, [laughing] like,
why would you trust a computer? Like are you gonna take the swab, send it away,
and let it come back and it possibly be dodgy? Why not just go down to your doctor?
(Emma, aged 17, paired with Mia)
Here, the obfuscated identify of the online testing service appeared to be the foundation of
Emma’s lack of trust. Emma was generally very reluctant to use the internet for sexual health
information due to concerns about trustworthiness, so this was not unexpected. Also, Emma
was familiar with her local community centre and the sexual health nurse who worked there
and therefore perceived no barriers to go in person to be tested. Similarly, Josie (aged 19)
said “I’d just be worrying that it’s some weirdo”, to which her friend Kyle (aged 17)
responded by highlighting worries around confidentiality: “I think it'd need tae be, like,
really discreet packaging an' a' that as well”. Martha (aged 16, paired with Samantha)
expressed concern about an STI test being sent to her house when her father was in, and for
that reason would prefer to access a formal healthcare setting, of which she had previous
experience. Darren and Craig echoed these concerns:
Darren: Imagine your mum opened it [laughing] and saw, like, “Oh, I dunno, it must
have been dad. It wasn’t me.” Yeah. [laughing]
Craig: No, I don’t think I’d use it
Darren: If they e-mailed you, perhaps. Oh, you’d have to send it back ‘cause it’s a
test, eh?
Craig: Yeah…yeah, I think I would avoid that;
Darren: I’d prefer to go to the doctor I think. ‘Cause you think if your granny was
over and she went and got the mail and it’s like this thing. “Oh, this is addressed to
you, I’ll just open it for you.” “No, Granny, it’s alright.” [laughing]
Craig: “Here’s your STI test.” [laughing]
(Darren, aged 17 and Craig, aged 16)
Notably, Darren and Craig had expressed concern about being witnessed at their local health
clinic, but nonetheless preferred the clinical context to a home testing service.
Nicola (aged 17) and Ralph (aged 19) mentioned many of the same concerns as others, but
added that receiving test results by email could be more difficult than the more supportive
situation of receiving results in person; Ralph explained that “an email’s very
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unsympathetic…and professional”, and Nicola added that “And I think if you can like know
the person like if you know them physically, if you see them and stuff that’s a lot more easier
to talk about it”. However, Nicola did identify that some would value anonymity over face-
to-face discussion of test results.
In discussing online testing services, Joe and Ruth also discussed online services that
distribute free condoms by post. As with online testing services, they identified this as
potentially useful, but with some concerns about trustworthiness:
Joe: there’s, like, sites where you can get, like, free condoms in the post and things
like that, I think they’re quite handy…but, yeah, just – I wouldn’t really like to have
a test online because, say it came, like, a positive reaction then you start to panic
thinking it was, like, a dodgy test you got or something, do you know what I mean?
I’d rather go somewhere it’s, like, more clinical and things like that. And, like, you
know for sure if they’re right or wrong, do you know what I mean?
Ruth: I think I would find all of it dodgy, like, even getting condoms online, like, like
I would still find that dodgy. But then again, that’s another thing that you don’t know-
Joe: Don’t know where it’s coming from either do you?
Ruth: Where it’s coming from. Yeah, like, a lot of the stuff, like, it comes from, like,
how many times have you bought something off of, like, Ebay and stuff and it’s, like,
turned out to be, like, the cheapy version of what you wanted. So, it’s like you’re
wanting to get Durex and it’s coming back some weird foreign thing. [laughing] So,
you’re just, like, it’s just something you’ve got to watch out – like, again, I would go
to the [local youth/sexual health service organisation]
(Ruth and Joe, both aged 16)
In this exchange, Ruth identified the value of trusted brands and scepticism about cheap,
foreign products, and, notably, perceived free condoms collected from a clinic to be more
reliable than free condoms distributed by post. Ruth perceived no problem with going to her
local sexual health centre for condoms in person, in contrast to other female participants
referred to above, who described anxieties around being seen picking up condoms.
Participants discussed ways to break down barriers for people within the formal sexual
healthcare context, particularly for those who struggled to communicate face-to-face and
were in need of general advice. During the online activity, Maeve and Leah whilst looking
up information about STIs came across a phone number for a helpline which popped up as
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an advert on the screen. This was from an American website and was dismissed because of
this, but Maeve thought a UK version would be useful, but also suggested an online chat to
help with people who would not want to phone:
Maeve: Oh there’s a number […] I mean if that was in the UK and it was like a
number I would possibly call it…but then I feel like it would be like a number that
charges you
Leah: I feel like they should have like, ‘cause I feel like I would be okay with going
to the doctor but I feel like there’d be lots of people that don’t want to so like…and
lots of people wouldn’t want to phone either
Maeve: Yeah, I feel like there should be like an online like chat thing
Leah: Yeah…like even if they don’t want to phone yeah
(Maeve and Leah, aged 16)
An online sexual health messenger service was proposed by three sets of participants quite
early on in the research, consisting of online sexual health advisors that could be messaged
privately through social networking sites, such as Facebook, in order to receive advice. Amy
(aged 17, paired with Kara) raised this as an idea, as she herself was extremely reluctant to
interact within formal healthcare contexts and liked that this could offer an alternative private
setting where her worries could be settled, rather than manifest: “'Cause you can worry about
a problem for ages and not… be too embarrassed to do anything about it, but if you just do
that, like, just gonnae be a random online just having a quick chat with and then that's it over.
That would be so good, yeah”. Thus, despite general scepticism across the sample
concerning the use of social media for sexual health promotion (described in Section 5.2.1),
participants were generally keen for such services to be available in more private ways to
provide reassuring and personalised support within a confidential environment. The
discrepancy between participants’ general distaste for sexual health content on social media,
and some participants’ specific interest in sexual health messaging services might be
explained by the more confidential, less public nature of the private message functions of
social networks, which, to a large extent, are not relevant to concerns about ‘being seen’
interacting with sexual health content in the public aspects of social networking sites.
For some participants, however, their wariness of social networking sites like Facebook
being used for sexual health promotion, and general concerns around the unreliable nature
of online identities extended to these potential online professional support messenger
services. For example, Kyle (aged 19) explained that “you don’t know who’s sitting at the
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other side o’ that profile”, to which his friend Josie (aged 19) agreed: “aye, you don’t know
who you’re talking to”. Martha (aged 16, paired with Samantha) was also unsure about
messengers on Facebook as she would be unsure if she could trust them: “I think it could be
good if it wasn’t, like, I don’t know, Facebook and stuff, like, you don’t know, like, how
you were saying about the trust thing, like, how you would trust it. So…”. Conversely, some
participants, such as Jacob, indicated that young people’s concerns about anonymity might
be assuaged if such services were overtly presented as impersonal and authoritative:
I dunno it might be good in a way but I think I think you need to make it sorta like
not be them that are on it but the organisation because I think people asking sorta like
organisations a question via messaging, but if you put a face to it, it kinda makes you
think, I know you would never meet them but you think oh there’s a person behind
that and you start getting a bit more anxious towards it...even if they are really nice I
think
(Jacob, paired with Connor, aged 18)
Thus, Jacob explained that by presenting sexual health messaging services as faceless,
impersonal organisations, young people may feel reassured that they anonymity will be
protected. Generally, professionalism and legitimacy were important for participants. Craig
(aged 17, paired with Darren) liked that such services could potentially provide the kind of
support a chatroom provides, without worries about trustworthiness: “that’s like a chatroom
but with reliable sources”.
Participants’ attitudes to online sexual health services varied both between participants and
between types of services. While some did not favour online testing, others perceived it as a
potentially valuable alternative to the emotional and geographical barriers preventing
effective use of traditional services, although there was a general acknowledgement that
online services should, at best, complement, not replace traditional services. Participants
were typically positive about the concept of online sexual health support services using the
private messaging features of social networking services, despite widespread aversion to
engaging with sexual health support in the more public areas of social networking services.
Participants’ differing attitudes towards sexual health promotion on different parts of social
media illustrate the necessity for service-providers to have a nuanced, up-to-date
understanding of the different aspects of social media services, and the different ways that
young people use and perceive those aspects. Facebook, in its ubiquity, represents both a
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large opportunity for sexual health promotion, and a complicated, ever-changing set of
challenges for effective engagement.
6.5.2 Sexual health apps: useful or embarrassing?
Participants had very diverse views in relation to acceptability and usefulness of sexual
health specific apps. While participants often described having fitness and general health
apps on their smartphones, they reaction to being asked about a sexual app tended to one of
worry and quick rejection. This was typified by Christina and Josh, who initially both
described using a health symptom checker app:
What about health apps on your phone?
Josh: I do, I have…
Christina: Well, does, like, exercise count? [laughing]
Josh: Mine is kind of a doctor thing. You just type in your symptoms and it’ll tell
you, it’ll give you a list of things it could be
Christina: Oh yeah I’ve got that on my phone…
And what do you think of it? Do you remember what it’s called?
Josh: I think it’s DNS Doctor or something. It’s like kind of a silly name. But every
time I’ve been not well I’ll use that
Christina: I’ve never used it [laughing]
Josh: Then I’d go to the doctor and they’d tell me what’s what
(Josh and Christina, aged 16)
Thus Josh seemed to have integrated this health symptom checker app into his information
seeking practices when worried about his health. However, later on within the interview,
when asked about a sexual health app, Josh and Christina quickly rejected the idea, primarily
due to it being visible to friends:
What about having a sexual health app?
Christina: No! What if your pals got your phone, they’d be like “what’s this on your
phone?”
Josh: Aye I wouldnae
So do you think you…
Josh: Just go online aye
Christina: Yeah
Josh: ‘Cause you can always, like delete your search history
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(Josh and Christina, aged 16)
This highlights stigma around being seen to be concerned about your sexual health, and
benefits of being able to use the internet for a one-off search that can be quickly deleted, in
contrast to having for a period of time, a visible application on a smartphone that would risk
others seeing it. This was the main reason that most of the participants provided when asked
about sexual health apps. Visibility was a key concern, and most felt that accessing
information on the internet was more ‘discreet’. Aaron and Michael highlighted that while
there have been advances in relation to more open communication about sexual health, that
on a personal level most young people would not want to be seen with a sexual health app:
And what about an app?
Michael: Ah I don’t know I could see if folk saw that on your phone they might be a
bit
Aaron: Yeah, if you saw that on someone’s phone you’d be like, aw what’s that mad
creep doing [laughing]
Yeah?
Michael: Yeah, even though it is something more and more people talk about you
still don’t want someone seeing you’ve got that on your phone
Aaron: You’d get so much abuse
Michael: That just seems to be the way it is
(Aaron and Michael, aged 19)
In imagining a hypothetical scenario where himself or a friend had an app, Aaron suggested
he would either be the perpetrator or victim of ‘abuse’, while Michael’s last comment
highlights an awareness and in a sense, a hopelessness around the ingrained stigma and taboo
surrounding sexual health. Thus, while smartphones might be generally perceived as
personal technologies, such accounts suggest that they function as social devices and are
thus likely to be seen and used by others.
However, in contrast, some participants saw more potential in the idea of health apps as a
means of accessing sexual health information and resources. Cleo and Alice both described
regularly using exercise and fitness apps on their phone, and seemed favourable towards
sexual health apps, and their potential for circumventing barriers to access such as
embarrassment:
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Cleo: I’ve never thought of using it but is there not like iCondom or something that
you can download? I know there is that but I’ve never sort of…
Alice: I think that would probably be useful for people who are choosing tae use like
condoms instead of like the rod or like coil or something. So that they know exactly
where they can go tae get them ‘cause obviously some people are too embarrassed
to go and buy them
Cleo: Yeah
Alice: Like in case people see them buying them
(Alice, aged 18 and Cleo, aged 19)
Alice went on to say that “people might be embarrassed” about having the app, but Cleo
dismissed this saying: “well they shouldn’t because they’ve got a password, the majority of
people have got passwords on their phone so could get but I don’t have a password on my
phone right enough but… people can go on my phone and see stuff I don’t care
[laughing]…so I wouldn’t be embarrassed, it’s just being safe”. Thus, Cleo highlights that
doing something to benefit your sexual health should not be embarrassing (there was a sense
that some felt like this should be the case, but they could not help it). Kyle and his friend
Josie, were both particularly keen on sexual health apps being developed to assess
symptoms, to reduce having to go to a clinic and be seen by friends:
Josie: If you're sitting in the clinic and one o' your pals turns up you're like “Oh, hi.
Just tae get information, honestly.” [laughing]
Kyle: I've bumped intae a few people that I know an' I've only been the once an' I
met like three people. It was so embarrassing[laughing]
Josie: Aye
Kyle: I think if there’s no’ an app they should make an app [laughing] That’s a pure
good idea
Josie: You just want an app. How can you no’ make it for?
Kyle: I’ve no got a clue how tae time my shoes, never mind make an app [laughing]
An’ I think wae an app it’s mair private tae you. You don’t need tae, like, ask people
awkward questions if you feel awkward aboot it. You can just go in an’ see what’s
what
(Josie and Kyle, aged 19)
They both concluded by saying they thought an app would be popular and be used by lots of
young people.
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Participants seemed to particularly value apps, like the iCondom one mentioned by Cleo,
that were practical in nature, concerned with helping an individual get access to
contraception or find their nearest clinic. A few participants, like Connie (aged 18),
specifically mentioned an app to help with locating services: “yeah, like, sexual health apps
with where you closest clinic and that is…I think that would be a really, really good point”.
Her friend Jamie agreed. During the online activity, Connie and Jamie, like many other
participants struggled to find information about local testing services. Thus, participants
seemed to be favourable towards apps that would help them overcome barriers faced within
the online context already or within school (where practical information was generally
absent).
Two pairs of participants were favourable towards apps that would allow quick and relevant
information to be accessed without having to navigate through a sometimes overwhelming
amount of content on the internet. Amy and Kara (aged 17) both already had period tracker
apps on their phones which they found useful and described as being ‘discreet’. Kara was
less keen on having a more general sexual health information app, as she was happy to
explore content online, particularly user-generated content, but Amy, in contrast, liked that
she would not have to search through lots of content: “I think if there was an app o' like all
different answers stored in it aboot sexual health, I think that'd be quite good 'cause you're
not sort o' searching the whole o' the internet, it's just all locked down in one place. That'd
be good”.
Across the sample, participants presented varied attitudes towards the acceptability and
usefulness of providing sexual health support and information through mobile apps. While
many participants regarded general health apps to be acceptable, everyday software,
adoption of sexual health apps was limited by stigma. The risk of ‘being seen’ was, again, a
key concern; one-off web searches were deemed to be more discreet than installing and using
mobile apps. However, participants did identify some positive aspects of sexual health apps,
particularly as sources of practical information about online services.
6.6 Summary
Evidently, communication skills play a central role in managing and applying sexual health
information and negotiating sexual health within different contexts. Some participants
attributed poor sexual health outcomes and high rates of teenage pregnancy to limited sexual
health awareness and poor communication skills, which could be related to insufficient
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knowledge transfer and limited opportunities to improve sexual health communication
within school-based sexual health education. However, others perceived younger people as
generally more open to discussing sex and sexual health, which has been normalised by the
vast quantity of sexual health content available online. This was viewed in a positive light
to an extent, having led to increased confidence in providing advice to friends or applying
information within formal healthcare contexts. However, some worried about the increased
pressures on young people face in relation to sexual activity.
Participants who identified as gay, lesbian or bisexual, or had previously taken part in sexual
health workshops (within and outwith school), tended to be more comfortable discussing
sexual health within most contexts, highlighting the benefits of having opportunities to
improve skills and confidence in communication. However, most participants expressed
anxieties around communicating about sexual health within specific contexts, such as sexual
contexts and formal healthcare contexts, and some preferred to avoid face-to-face
communication on the topic of sexual health.
Most participants described being broadly comfortable discussing sex and sexual health with
friends, but less comfortable communicating with sexual partners and within sexual
contexts. Age and gender both seemed to influence low confidence communicating within
sexual contexts. Gender differences in attitudes to sex and feelings about communication in
sexual situations supporting perceptions that females worry more about, and want to talk
about, sex and sexual health while males are less concerned about communicative and
emotional aspects of sexual relationships. The internet appeared to both facilitate and
obstruct management and application of sexual health information within sexual contexts.
On the one hand, unrealistic online advice was criticised as being difficult to apply within
dynamic real-life sexual encounters, and on the other hand, relatable and light-hearted
content was seen as a potential way to encourage communication about sex with partners.
Generally, however, participants seemed to struggle within the sexual context, with various
barriers obstructing the building of comfortable, communicative sexual relationships.
Participants varied in their perceptions of negotiating their sexual health (and illness) within
formal healthcare settings. A minority, who typically had prior positive experiences and
were generally happy communicating about sexual health, were comfortable interacting
within formal sexual healthcare settings. However, most participants had anxieties about
negotiating sexual health within traditional healthcare contexts, based on either prior
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negative experiences of fear of the unknown, including worries about communicating and
interacting with healthcare providers, to broader concerns around being seen or found out
seeking information or help for sexual health. These worries caused some to be reluctant to
access services, and some to completely avoid services. Lack of awareness of services and
embarrassment about consultations interacted to create major barriers within the formal
healthcare context, but participants highlighted ways that formal healthcare systems can
work to engender confidence by reduce embarrassment and alienation for those accessing
services.
Interviews explored the potential of overcoming barriers to traditional sexual health services
through alternative services. Some participants suggested that online STI testing and advice
services could allow young people to circumvent anxieties and embarrassment associated
with formal sexual health settings, as well as geographical barriers faced by residents of
remote areas, in which concerns of ‘being seen’ may be more acute. However, participants
raised concerns trustworthiness, validity, confidentiality and lack of support with online
services. These concerns perhaps illustrate why online services may not fully replace
traditional services, but participants’ general positivity towards online services suggest that
they may complement traditional services effectively. Participants had contrasting views
about the acceptability of sexual health apps, with some viewing them as discreet ways to
overcome barriers of traditional healthcare and online contexts by, and others focusing on
concerns about ‘being seen’ engaging with such apps, highlighting the real impact that
stigma can have on communication and engagement with services.
This chapter has considered the influence of different contexts and networks on how sexual
health information is experienced, used and applied to make decisions and negotiate sexual
health and illness. Participants described personal, practical, institutional and emotional
barriers to applying information within sexual, social and healthcare contexts. Problems and
barriers that young people face have been identified, as have potential solutions, which will
be revisited in the conclusions and recommendations chapter (Chapter 8).
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7 Discussion
7.1 Overview of chapter
This chapter presents a summary and discussion of the findings presented in the previous
three chapters (4, 5 and 6), considering how those findings relate to existing literature and
the research questions:
1. What is the role of the internet within the broader landscape of young
people’s sexual health information and support?
2. How do young people describe and experience seeking, understanding,
evaluating and using online sexual health information and support?
3. What are the individual, social and environmental contexts relevant to
young people’s experience and use of online sexual health information and
support?
Sexual health literacy refers to an individual’s knowledge, beliefs, attitudes, motivations and
skills in accessing, understanding, evaluating and applying sexual health information in
social, sexual, online and healthcare contexts to negotiate and make judgements and
decisions concerning sexual healthcare, health promotion, relationships and wellbeing. It is
dynamic in nature, developed and applied in complex ecologies, influenced by individual,
system, interpersonal, contextual and societal factors. The model developed (Figure 7-1)
illustrates how sexual health literacy enables the individual to both understand, interpret and
evaluate information and apply that information within a variety of contexts.
Figure 7-1. Dynamic sexual health literacy model
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The findings from each chapter were integrated and assessed for synergies, as described in
Chapter 3. The data integration process involved integrating findings from the ‘traditional’
part of the paired interviews with those from the online activity within a data integration
table to allow for synergistic interpretations taking into account findings from the data
collected across different stages of the research (see Data integration table in Appendix 12).
The first part of the discussion will explore young people’s sexual health literacy within the
school context (7.2). The school context is an essential starting point as school-based sexual
health education is a near-universal influence on young people’s sexual health literacy that
informs how they engage with sexual health and support in other contexts, including the
internet. Section 7.3 comprises an examination of young people’s sexual health literacy
within the online context, both on an individual level, examining Nutbeam’s (2000) model
of health literacy, and on a broader level, considering influences on sexual health literacy
within the online context, with particular attention paid to socio-cultural and demographic
factors. The final two sections of the discussion will focus on other key information
provision contexts within which sexual health literacy is shaped and applied: amongst
friends peers (7.4) and within the healthcare system (7.5).
In practice, most participants drew from multiple information sources, and their accounts
highlight the need to manage a range of different sources with different strengths and
weaknesses. It is insufficient to view online information in a vacuum because it influences
interacts with other sources of sexual health information and support. As Ringrose and
Barajas (2011, p.126) explain, “drawing a binary between online and offline or virtual and
face-to-face experiences has been a weakness in prior research on teens and gendered
identity on line”, going on to argue that “digital interactions mediate everyday activity”.
With this interrelation between online and online contexts, this discussion will consider how
school, peer and formal healthcare contexts contribute to young people’s sexual health
literacy, and the extent to which they are influenced by, and integrated within, the online
context. Throughout, reference will be made to the literature, highlighting similarities and
differences to my findings.
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7.2 The school context: hindering or facilitating sexual health
literacy?
7.2.1 Why is school important to sexual health literacy?
Due to advances in digital technologies and availability of online material, young people
now inhabit a fundamentally different, and more dynamic, social and sexual information
landscape. Despite this, research has shown that young people still wish to be taught sex
education within school (Alldred and David, 2007; Parker, 2014). This was reflected
amongst my participants, who cited the internet as their current main source of sexual health
information, but school-based sexual health education as the key source of learning about
sexual health when ‘growing up’.
Health literacy theorists have highlighted the importance of societal and environmental
factors, such as the education system, in facilitating or hindering health literacy (Kickbusch,
2008; Mangello, 2008; von Wagner et al, 2009). School is a key sexual health information
learning context for young people, in which knowledge, skills, expectations and norms
around sexual health, gender and sexuality can be learned and shaped. Research within the
UK has hinted to the role of school-based sex education in positively influencing health
outcomes, demonstrating associations between receiving school-based sexual health
education and lower reporting of negative sexual health outcomes (MacDowall et al, 2015;
Wellings et al, 2013). As such, even within a rapidly evolving information landscape, school
remains an important influence on sexual health literacy.
7.2.2 What hinders sexual health literacy within the school context?
While research has suggested that population-level school-based sexual health education
may have reached its limits (Elliot et al, 2013), my participants’ experiences indicate that
there may be substantial variation in the scope and quality of the school-based sexual health
education that young people in Scotland receive, and this is supported by research in the
wider UK context (Bailey et al, 2015). Despite school being a key source of learning about
sexual health, my participants’ accounts predominantly characterised the school context as
hindering, rather than being conducive to, development of sexual health literacy. As
frequently reported elsewhere (Pound et al, 2016), participants typically described school-
based sexual health learning as a negative experience, reporting poor quality and infrequent
teaching, with narrow and negative content and a lack of skills-based teaching. My analysis
indicates that school-based sexual health promotion continues to fail to provide young
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people with comprehensive sexual health education, which would both disseminate
‘knowledge’ and equip pupils with practical information and skills to negotiate their sexual
health within sexual, social, and healthcare contexts.
The influence of socio-cultural and contextual factors on provision, access to and experience
of sexual health education within the school context can be profound (Bailey et al, 2015;
Livingstone and Mason, 2015). My findings suggest that young people attending
denominational schools tend to receive sexual health education that is less frequent and less
comprehensive than that received in non-denominational schools, highlighting the effects
that cultural, systemic and infrastructural factors can have on young people’s rights to
comprehensive sexual health education, and thus, on the development of their sexual health
literacy. Livingstone and Mason (2015), highlighted the influence of cultural and religious
diversity in sexual norms, which influence acceptability of how young people access sexual
information and experience. They highlight the complexity that this diversity adds to the
process of creating information and guidance about presenting sexual information in a
culturally-nuanced way.
Research has highlighted other contextual and socio-cultural factors influencing experience
of school-based sexual health education, such as gender and sexuality (Couch et al, 2007).
Young women’s worries about engaging with sex education in school in the presence of
young men has been a feature within the literature (Alldred and David, 2007; Measor et al,
2000). Within my study, female participants, in particular, characterised the school
environment as not conducive to learning, with immaturity (of ‘boys’) and embarrassment
identified as substantial barriers. In contrast, heterosexual male participants in this study
primarily recalled school-based sexual health education favourably, as an enjoyable, positive
learning experience. Literature has found that young men describe being disruptive within
school sex education to divert attention from their own possible ignorance and to conform
to male stereotypes of sexual knowledge and competence (Buston et al, 2002; Hilton, 2007;
Limmer, 2010; Measor et al, 2000). Such gender performances were evident in heterosexual
male participants’ conversations with their interview partners in this study (see Section
7.4.2).
Perhaps unsurprisingly, research has found that some young women’s concerns about
humiliation within mixed-sex learning environments leads them to express preferences for
the comfort and confidence that may be fostered by single-sex learning (Strange et al, 2003).
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Some female participants within this study offered similar perspectives, suggesting that
potentially disruptive male performances of heteronormative masculinities meant that
mixed-sex environments tended to favour young men, but not young women, and that young
men may be more likely to enjoy, and benefit from, mixed-sex delivery of sexual health
education in schools. This finding does not necessarily lead to recommendation of gender-
segregated sexual health teaching in schools, but might suggest that friendship groups of
young people who share similar outlooks might learn best together. From this perspective,
gender may be an appropriate line of division for some groups, but equally existing peer
groups might be effective learning groups regardless of gender composition. Indeed, my
reflections on using paired interviews in this research suggest that supportive peer groups
may be suitable for encouraging sexual health discussion; pairs and triads can perhaps act as
supportive peer-learning spaces, facilitating open discussion unencumbered by the social
dynamics of larger groups. The potential of the friendship and peer context as a site for
learning within school-based sexual health education will be discussed in Section 7.4.
Participants who identified as gay, lesbian or bisexual perceived their information needs as
not having been met in school, consistent with previous research findings that school-based
sex education tends to be incomprehensive, providing insufficient teaching related to non-
heterosexual experiences (Formby, 2011; Kubicek et al, 2011). Participants who identified
as gay, lesbian or bisexual described shortcomings in teachers’ knowledge and training. Due
to their schools’ failure to provide non-heteronormative content, two participants described
subtly trying to ask questions of their teachers, and, in response, their teachers suggesting
that they teach the class. Both described embarrassment at being ‘outed’ as wanting to
increase knowledge of homosexual issues, and worry about classmates’ reactions. This
mirrors research that has highlighted that the ingrained heteronormative narrative within
school-based sexual education signifies an unacknowledged dialogue within the school
context that does not prepare young people for sexual relationships and may contribute to
experiences of prejudice and stigma (Allen, 2008; Fornby, 2011; Kubicek, 2010).
What participants were taught in school seemed to reflect on their understandings of ‘sexual
health’, with the majority of participants presenting negative understandings focusing on
risk, danger and spread and risk of infection, and little consideration of pleasure. Sexual
health literacy may be hindered by negative attitudes to sexuality and a failure to consider
the potentially positive and emotional aspects of sex (McMichael and Gifford, 2009), and a
focus on risk may influence perceptions of morality, blame and responsibility (Gaspar et al,
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2014). Fostering moral judgements about sexual behaviours and circumstances could lead
individuals to seek to distance themselves from those engaged in negatively-constructed
behaviours, or inhabiting negatively-constructed circumstances, with negative consequences
for public health (Wellings et al, 2012). Research has highlighted how infrequent, negative,
moralistic teaching that fails to confront sexual issues openly can contribute to anxiety and
stigma, reproducing perceptions of sex as a ‘taboo’ that should not be talked about or
prepared for (McKee et al, 2014; Woodcock et al, 1992). This has further implications for
young people’s interactive literacy skills and openness to communicating about sex and
sexual health. A small number of participants in this study directly associated school-based
sex education with young people’s general reluctance and confidence to openly
communicate about sex and sexual health, and many participants expressed anxieties about
communicating about sexual health within certain contexts, such as sexual and formal
healthcare environments.
7.2.3 What facilitates sexual health literacy within the school context?
While participants’ accounts of the school environment were primarily negative, particularly
in relation to teachers, who were generally regarded as unqualified and awkward, some
participants described ways in which schools facilitated better learning by creating
comfortable environments, incorporating community organisations and outside experts.
Such views are well established within the literature (Langille et al, 2001; Lester and Allan,
2006). Research has reported that young people want educators, particularly in sexual health
education, to be trustworthy, knowledgeable and non-judgemental (Alldred and David,
2007; Kimmel et al, 2013; MacDonald et al, 2011). The small number of my participants
who had received teaching from outside ‘experts’ valued those experiences, with one
describing it as the ‘best thing in school’, valuing the anonymity and the comfortable, safe
environment that it fostered.
In addition to ensuring that the staff delivering sexual health classes in school are as credible
and personable as possible, formal peer-education may represent another useful route of
sexual health learning in school. Participants who had been involved in school-based, peer-
led sexual health education initiatives, either as recipients or providers, valued the relatable
nature of this delivery mode. These participants seemed confident in their knowledge,
seemed more comfortable communicating about sexual health and typically described
feeling a responsibility to share their knowledge to dispel myths amongst peers. These
perspectives indicate the potential of peer education to develop sexual health literacy skills,
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particularly interactive and critical, through both practicing communicating about sexual
health and influencing the social norms of peers.
Research into the effects of peer-led interventions have typically highlighted improvements
in knowledge, but not in behaviours (Chandra-Mouli et al, 2015; Salam et al, 2016).
Chandra-Mouli and colleagues (2015) found that five meta-analyses of peer education
programmes in a range of different contexts demonstrate that, whilst peer education may
encourage knowledge exchange, it has little effect on promoting healthy behaviours (Kim
and Free, 2008; Medley et al, 2009; Tolli, 2012). Furthermore, these reviews highlighted
that peer education typically benefits peer-educators through the training provided to them,
rather than benefiting their peers, who are the intended beneficiaries of such programmes.
As such, despite the proven impact on knowledge, and the popularity of the method amongst
young people (Stephenson et al, 2008), some have called for the approach to be discontinued
due to ineffectiveness (Chandra-Mouli et al, 2015). While those conclusions are based on
strong evidence, from a sexual health literacy perspective, there may be grounds to consider
that, even in the absence of impacts on measurable sexual behaviours, positive impacts in
young people’s confidence in communicating about sexual health may reap benefits that are
less directly-measurable, but no less valuable. Peer support is not limited to formal, school-
based programmes; peer support in other contexts, particularly the online context, are
discussed in Section 7.4.
Beyond criticisms of the efficacy of peer support programmes within schools in changing
behaviours, researchers have suggested that school-based sexual health education at the
population level, may have reached its limits (Elliot et al, 2013). Elliot and colleagues (2013)
evaluated an intervention designed to augment existing school-based sex education in
Scotland, and found that the additional intervention had limited effectiveness in terms of
behavioural outcomes. The authors concluded that the intervention had been ineffective,
highlighting only minor improvements to participants’ behavioural outcomes, and suggested
that interventions targeted at groups with poor sexual health outcomes may be more
effective. While behavioural change is crucial, there may be a risk of focusing on behaviour
change at the expense of the other aspects of a broad conceptualisation of sexual health
literacy. For example, such an intervention, involving integrating access to sexual health
services within schools, may positively impact upon pupils’ critical and interactive sexual
health literacy, which might, in the long term, contribute to a culture that fosters healthy
choices and outcomes. While Elliot and colleagues’ (2013) evaluation was necessarily
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relatively brief, due to its focus on changes within school pupils, creating cultural change
within schools is likely to be a slow process, demanding long-term change on the parts of
institutions and staff. The school context may inherently be too complex for brief evaluations
to adequately measure changes. Couch and colleagues (2006) explain that social and
contextual interventions often have indirect effects which may be difficult to measure
directly, and conclude that: “to ask of social and contextual interventions immediate and
directly observable effects at the individual behavioural level is to misunderstand them
profoundly” (p.22).
7.2.4 School-based sex education and the online context
Qualitative understandings of young people’s experiences of receiving and seeking sexual
health information from different sources, including the internet, has been highlighted as a
gap within the literature (Simon and Daneback, 2013). Simon and Daneback’s (2013) review
hypothesised the possible influence of poor-quality school-based sex education on
“open[ing] the door for emerging technologies to serve as resources for sexual script
building” (p.305). While it is established that young people value the internet as an
information source due to its anonymous nature and convenient access (which was supported
in my participants’ accounts), less is known about how young people’s offline sexual
education may drive them to seek sex education online. My study sheds light on how
experiences of offline sex education may act as a catalyst for seeking sex education online.
For some of my participants, online information acted as a replacement for the inadequacy
of the traditional sex education described in Section 7.2.2, while for others who had not
received any school-based sex education, online information offered a means of filling that
void. Participants who identified as gay, lesbian and bisexual in particular described turning
to other sources (primarily the internet) to ‘self-teach’ due to their information needs not
being met in school. Indeed, research has shown that young people who identify as gay may
‘come out’ in the online world before doing so ‘offline’, indicating the potential importance
of online connections and communities (Bond et al, 2009; Mustanski et al, 2011; Ross and
Kauth, 2002).
Online information may also act as a solution to the narrow range of topics covered in
traditional sex education. Research has shown that young people use the internet to learn
about sexual norms, including sexual positions, behaviours and pleasure-based aspects of
sex (Buhi et al, 2009; Gilbert et al, 2005; Harvey et al, 2007; Hooper et al, 2008). Such use
of the internet may stem from the lack of coverage of these issues within traditional offline
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sex education. Within my sample, this was hinted to by male participants in particular, who
described using pornography as a way to learn how to have sex in ‘real life’, echoing the
findings of previous literature (Buston and Wight, 2006; Hilton, 2007; Limmer, 2010)
(pornography as a source of information will be discussed in Section 7.3.4.2).
Despite the important role of the internet in most young people’s lives, there appears to be
little recognition or integration of the online context within school-based sex education.
Pound and colleagues’ (2016) qualitative synthesis of young people’s views and experiences
of school-based sex and relationship education, primarily within the UK and US within the
last 25 years, identified that, while online safety and sexting are covered in some school-
based sexual health programmes, no literature examined young people’s experiences and
perceptions of that content. None of the participants within my study recalled learning about
sexual health in relation to the online context; no mention was made of being taught skills
to navigate the online environment to find sexual health information. Participants discussed
how evaluating online information could be made easier if schools taught online sexual
health information-seeking and assessment skills and promoted reliable websites. Elwick et
al (2013) state that using the internet in this way should be actively promoted, and that
‘digital literacy’ should be a teaching priority for children and young people from all
backgrounds.
7.3 Young people’s sexual health literacy within the online context
In this section, I will explore young people’s sexual health literacy within the online context.
This section will take an individual-level perspective, focusing particularly on young
people’s functional and critical literacy, as well as a broader perspective, taking into account
contextual and socio-cultural factors that influence experiences and shape how online sexual
health information is accessed, understood and appraised.
7.3.1 Young people’s motivations and drivers for seeking sexual health information
online
Research has shown that the internet is a key source of sexual health information for young
people (Benigeri and Pluye, 2003; Mitchell et al, 2014; Smith et al, 2000; Tanton et al, 2015).
Adopting online technologies is seen to be ingrained within young people’s lifestyles, and
research has found that young people use the internet to seek educational content about a
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wide range of sexual health issues (Borzekowski and Rickert, 2001a; Buhi et al, 2009;
Kanuga et al, 2004; Levine et al, 2008; Ralph et al, 2011).
As identified in Section 7.2.4 dissatisfaction with school-based sexual health education may
drive some young people to seek sexual health information online. In addition to offering an
alternative, and potentially more comprehensive, source of sexual health information, the
internet may provide additional advantages over traditional offline sources; young people’s
use of the internet as a source of sexual health information has been linked to its accessibility
and the unique social context provided by the online environment. The anonymity and
accessibility of the internet may help users to avoid some of the common barriers
experienced when talking about or seeking advice about sexual health in offline contexts
(Barak and Fischer, 2001; Simon and Daneback, 2013). My participants valued the internet
for its familiarity, speed, convenience and anonymity, and enjoyed the comfort of avoiding
face-to-face interactions. However, a minority avoided online sexual health information due
to anxieties in relation to privacy and navigating an overwhelming choice of sources. Thus,
the unique benefits for which the internet is often valued for are also seen as barriers by
some.
Both my participants and those of Magee and colleagues (2012) described seeking online
information in response to specific sexual health concerns. This typical motivation highlights
the possibility that sexual health information-seeking may often be carried out in, and
affected by, states of emotional distress. However, my participants also described
encountering online sexual health content unintentionally, during everyday web or social
media use. Literature has highlighted the role that such incidental health information can
have on individuals’ knowledge, understandings and practices (Tewksbury et al, 2001; Tian
and Robinson, 2009). In a study of adults diagnosed with cancer, Tian and Robinson (2009)
found encountering incidental health information in traditional media to be positively
associated with health knowledge. Similarly, spending time in the online environment,
potentially encountering more incidental health information, could possibly impact health
knowledge, attitudes and practices (Tian and Robinson, 2009). The growth of social sharing
of articles on social media could represent a new and developing route through which young
people encounter sexual health information, and how certain content becomes widely-
viewed (or ‘viral’), but, due to the nature of the topic, sharing and engaging with sexual
health content on social media is likely to be hampered by stigma, embarrassment and the
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threat it may be seen to pose to identity construction processes (this will be explored in more
detail in Section 7.3.4 and 7.5.3).
7.3.2 Young people’s access to the internet: digital divide?
Studies have suggested that the influence of poor health literacy on health outcomes and
behaviours begins at the stage of information-seeking, highlighting the importance of access
to reliable sources and content (Birru et al, 2004; Ishikawa and Yano, 2008). Literature
concerning online information seeking, has traditionally focused on access in practical and
physical terms, using the concept of a ‘digital divide’, characterised by unequal access to
online technologies (Chen and Wellman, 2004; Boonaert and Vettenburg, 2011). However,
this focus, particularly within high income countries such as the UK, has largely been
deemed redundant, with physical access to the internet having been shown to be approaching
universality (ONS, 2016). This was supported by my finding that my participants all
described themselves as active internet users with no problems accessing the internet, often
on multiple platforms and in multiple places. However, it is important to situate this within
my sampling strategy however, which aimed to sample for diversity, but was not necessarily
representative; some groups, including ethnic minorities and those from remote rural
locations, were not represented, and it is feasible that internet access varies by those
demographic characteristics.
While a substantial digital divide in terms of fundamental access to the internet may no
longer exist, theorists have argued that a divide continues to exist in terms of how individuals
use the internet, influenced by a number of factors, including socio-economic status
(Boonaert and Vettenburg, 2011; Elwick et al, 2013; Eynon, 2009; Lichy, 2011). Contrary
to the narrative of ‘digital natives’, research has suggested that there may be digital divides
between young people in relation to internet use (Gray et al, 2005; Lorimer and McDaid,
2013), and health literacy is key to understanding this. Gray and colleagues (2005) described
the use of the internet to source health information as a useful example of the pressures
placed upon individuals’ health literacy: incorporating useful websites, relevant content,
evaluating information and then contemplating how to incorporate or apply this information
within their lives. Gray et al (2005) found, based largely on self-reported data, that students
were relatively sophisticated internet users, but exhibited variety in their competence in
locating, evaluating and using online health information. This illustrates how general
internet competence does not necessarily correspond to digital health literacy and the ability
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to successfully navigate, comprehend, appraise and use information (Gray et al, 2005;
Skinner et al 2003).
Gray and colleagues’ (2005) research was published 12 years ago, and the role of the internet
in young people’s lives has changed dramatically in the intervening time. The online context
has taken a more central role in health information and service provision, such that the
pressures placed on individuals’ health literacy are likely greater today. While the internet
has always been an interactive medium, developments in internet technology have led to a
greater focus on social and multi-media content, meaning that the demands of negotiating
the online context are not just more intense, but also different in nature. Boyd (2014)
highlights the complexity of negotiating the online context:
“familiarity with the latest gadgets or services is often less important than possessing
the critical knowledge to engage productively with networked situations, including
the ability to control how personal information flows and how to look for and
interpret accessible information ” (p.180)
However, despite this complex and changing environment, within my study, where
participants were purposively sampled from areas with different SIMD scores, there
appeared to be no stark differences in participants’ use of the internet for sexual health
seeking by socioeconomic status. This could be considered surprising, as socioeconomic
status is considered a key factor in the ‘second-level digital divide’ and digital literacy
inequalities (Eynon, 2009; Lichy, 2011; Livingstone and Helsper, 2007). If no substantial
relationship between socioeconomic status and young people’s use of the internet for sexual
health information seeking were to be found within the wider population, this would call
into question any conceptualisation of a ‘digital divide’. However, my qualitative research
design, in which I purposively sampled participants who varied by multiple criteria, was not
suited to making any such definitive statements. Nonetheless, this topic may warrant further
research.
It is important to recognise distinctions between physical and intellectual conceptualisations
of a digital divide. It is possible that a socioeconomic divide in fundamental access to online
information has been replaced by digital inequalities, not necessarily socioeconomic, in
young people’s ability to effectively access information, fuelled by unsatisfactory teaching
and stigma. These inequalities may not be particular to sexual health, but could be enhanced
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by the sexual health context, particularly for certain groups. Some of these issues will be
discussed in the following sections.
7.3.3 Sexual health literacy: skills and challenges in online information seeking
7.3.3.1 Functional health literacy: locating and understanding information
Functional health literacy skills are key to locating and understanding health information
(Nutbeam, 2000). Research has suggested that young people most commonly approach
online information-seeking through search engines (primarily Google), entering key words
and trusting search result rankings to present accurate information (Buhi et al, 2009; Gray et
al, 2005; Mager, 2012). Similarly, my participants also exhibited reliance on, and faith in,
Google, typically selecting the highest-ranked results. In contrast to Buhi and colleagues’
(2009) findings, my participants largely avoided sponsored links, and at times voiced
suspicion of them, despite many of them leading to reputable health organisations. Some
participants did bypass Google to directly access known websites, typically of local sexual
health information and service providers with which they participants had had previous
experience, illustrating the interrelation between online and offline contexts, both for service
users and providers.
Generally, my participants indicated that filtering the information available online was
challenging, echoing findings of Jones and Biddlecom (2011), whose participants were
frustrated by the time involved in finding accurate information amongst the vast quantity of
less useful information. My participants indicated that they would value knowing “firm
websites” where they could find trustworthy information, and, as described in Section 7.3.3,
suggested that reliable websites could be recommended in school. Knowing that information
exists, and where to find it, is key to accessing information effectively, and, as such, a lack
of promotion of reliable information is a barrier to sexual health literacy (Burnett et al, 2008).
While my participants found information or ‘facts’ about STIs and symptoms relatively
easily, they encountered difficulties locating locally-relevant information during the online
activity, some of which corroborate the literature. Buhi and colleagues’ (2009) observational
study of American college students’ online sexual health information-seeking found that
most located correct answers to the sexual health questions asked of them, but a quarter
reported frustration in trying to source locally-relevant information. My participants
encountered barriers to locating information about local testing facilities, hindered by
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unfocused search strings and websites that were not user-friendly. Some overcame these
barriers by modifying their search strategies, while, as in Buhi and colleagues’ (2009)
research, others simply gave up. My qualitative interviews revealed that those who easily
found local testing information generally had prior awareness of local services, highlighting
once again how offline and online experiences influence each other.
In addition to struggling to find locally-relevant content, many of my participants
experienced difficulty navigating the internet for more general information about first-time
sex. Some felt that that the information provision on such topics was poor, particularly on
‘authoritative’ websites like the NHS, and they struggled to find relevant and credible
information on commercial and user-generated websites. Here, issues of ‘relevance’ and
‘reliability’ interact, which will be explored further in the following section. Some female
participants seemed to locate information about first time sex relatively easily, while some
males rejected much of the information they found as being ‘for girls’. This relates to notions
that sex is a topic about which females worry disproportionately; it may be that more female-
oriented information is produced in proportion with their heightened concern. In addition to
potential concerns about underrepresentation of male perspectives, there may also be
grounds for concern that the gender-imbalance of the information on first-time sex available
online might act to reproduce societal perceptions that concern about emotional aspects of
sex is a feminine trait. Gender norms will be explored in more detail in Section 7.3.4.
Research suggests that comprehending and spelling medical terms obstructs young people’s
use of the internet for general health information (Borzekowski et al, 2001; Hansen et al,
2003; Rideout, 2001; Skinner et al, 2003). Gray et al (2005) found that adolescents in both
the UK and USA struggled to spell general medical terms and construct questions describing
symptoms. While my participants expressed dislike of medical terminology, it rarely
prevented comprehension, and spelling errors were minimised by Google’s autocorrect
feature. A small number of participants experienced challenges in reading and understanding
text, particularly medical jargon, resulting in misunderstandings and abandoned searches.
Participants who exhibited lower functional literacy included those with dyslexia (and
reading difficulties) and those with additional support needs. Research suggests that most
digital health tools and information neglect the varying demands they exert on different
individuals’ skills and knowledge (eHealth Stakeholders Group, 2014). eAccessibility is a
crucial determinant of health inequalities that is often overlooked in the design of online
tools and content, particularly in commercial interventions (eHealth Stakeholders Group,
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2014). Such shortcomings fuel inequalities in intellectual access to health information
(Jaeger and Bowman, 2005). Researchers have called for health providers and organisations
to demonstrate greater awareness of the effects of varying reading ability on information
uptake (Cline and Haynes, 2001; McInnes, 2011), and have recommended simplifying
medical jargon and making information more accessible (Brodie et al, 2000; Borzekowski
et al, 2001a; Hansen et al, 2003; Rideout, 2001; Skinner et al, 2003).
Examining the difficulties encountered by participants in filtering online information raised
issues related to information provision, system demands and complexities that can represent
major barriers to young people’s sexual health literacy. Navigating less accessible websites
requires sophisticated digital literacy skills, and at times caused participants to abort their
information-seeking attempts. Some participants expressed surprise at the effort required to
find information, and felt that information should be more accessible, particularly practical
information about helplines and other services. This highlights the necessity for information
providers to provide content that is accessible, functional and easy to navigate.
7.3.3.2 Critical health literacy: critically questioning and appraising information
One component of critical health literacy is having the skills to critically question and
analyse information, and the ability to use or reject that information to exert more control
over health decisions (Nutbeam, 2000). Another component of critical health literacy is an
understanding of social, environmental and economic determinants of health, recognising
the influence of structural and system demands on decision-making (Chinn, 2011). Insights
into my participants’ critical health literacy skills suggest they varied considerably.
Evidence within the USA suggests that young people predominantly distrust online sexual
health information, regardless of gender, race or internet use habits (Simon and Daneback,
2013). However, it should be noted that the reality is likely more nuanced, with both my
findings and evidence from the literature (Fergie et al, 2015) indicating that, while online
information as a whole may be viewed as broadly unreliable, there are specific online sources
that young people do regard as highly reliable. My participants described general wariness
of online content, although there was variety between individuals in their degree of wariness,
and there was variety in the trust afforded to different sources. Two extremes emerged, with
some being highly conscious of reliability, and consequently either adopting strategies to
find reliable content, or avoiding using the internet altogether, while others exhibited little
concern for reliability. Participants who preferred to avoid seeking information online due
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to concerns about the reliability of available information, or low confidence in their own
ability to discern reliability, tended to prefer talking to friends, family or health
professionals.
Previous research on information seeking and appraisal has found that internet users often
make fast-paced judgements about sources, informed by heuristic approaches and initial
impressions (often based on context, consistency of information, recommendations and
personal tastes (Fergie et al, 2015; Metzger et al, 2010). My participants exhibited speed in
choosing search results and appraising and making decisions about sources. Appraisals were
often informed by aesthetic features, in addition to sources’ perceived relevance to the
individuals’ locations, sexualities and genders. Geographical location was notable because,
despite the supranational nature of the internet, locality did influence perceptions of
relevance and reliability of information, with participants rejecting non-UK, and particularly
American, websites. Participants were similarly rapid in seeking specific information within
websites, with fast visual scanning at times causing them to bypass relevant information. It
is important to situate these findings within the online activity context, where participants
may have felt pressure to find information quickly. However, participants also described
their ‘real-life’ search practices as also being focused on finding information quickly, for
reasons, including ‘laziness’ and worries about being seen seeking sexual health information.
Thus, in addition to information seeking being based on heuristic and initial impressions, as
described by Fergie and colleagues (2015) and Metzger and colleagues (2010), I found
evidence that searching can be influenced by socio-cultural factors, including the stigma
associated with seeking sexual health information.
Research has highlighted common strategies used to assess reliability, including relying on
reputable or well-known sources, being wary of particular types of sources and triangulating
information (Buhi et al, 2009; Gray et al, 2005; Jones and Biddlecom, 2011). Similar
approaches were demonstrated by my participants. Participants typically preferred websites
they deemed to be ‘professional’ and reputable, identified through aesthetic impressions or
prior knowledge. Similar to the findings of Gray and colleagues (2005) findings, my
participants relied on “trusted brands”, including Google and organisations such as the NHS.
Preferences for familiar, well-regarded sources may be key to effective online sexual health
promotion, as associating content with trusted brands, such as the NHS, could help drive
engagement, while high-quality content may be more might be bypassed if associated with
an unknown or untrusted organisation or source.
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At a higher level than considering the organisation operating an online source, participants
sometimes considered the type of source, with some expressing wariness of social media
and user-generated content in comparison to more ‘authoritative’ and ‘expert’ content.
However, this varied between individuals, and by the type of information being sought, for
example, when seeking relatable advice, user-generated content was deemed more suitable.
Participants were generally wary of editable sources such as Wikipedia, but many used
WikiHow, valuing the pictorial, stepwise information style. Distrust of editable sources,
particularly Wikipedia, is established in the literature, despite evidence that Wikipedia is
often more reliable than traditional reference material (Boyd, 2014). Underestimations of the
reliability of Wikipedia could have ramifications for teaching digital health literacy, as Boyd
(2014) argues that young people tend to be encouraged to simply avoid Wikipedia, rather
than developing the critical literacy skills necessary to critically evaluate the reliability of
information.
While Wikipedia is typically regarded with suspicion, young people broadly trust Google,
despite it providing no verification of the quality of search results, and being a for-profit
company monetised through advertising and reliant on algorithms that people and
organisations with vested corporate interests can actively manipulate (Boyd 2014). Boyd
(2014) suggests that “the notion of the algorithm is foreign to most people, including most
youth” (p.185), implying that users may not be sufficiently aware of the potential biases of
the search engine, although one pair of my participants did discuss algorithms and the
importance of carefully choosing search strings. The stark differences in both perceptions of
Wikipedia and Google and the nature of these two information sources highlight the
importance of considering different online information platforms as separate contexts, rather
than viewing the internet as a monolithic information source.
While the reliability of sources was typically evaluated rapidly based on first impressions or
prior knowledge of the source, some participants described more nuanced strategies,
including checking for reputable top level domains, transparent authorship information, up-
to-date content and an absence of advertising. Buhi et al (2009) and Jones and Biddlecom
(2011) also identified the use of such key indicators. Another technique that participants
described was to triangulate information through comparing online and offline sources.
Similarly, Jones and Biddlecom (2011) and Buhi et al (2009) found that participants self-
reported crosschecking information in this manner. However, while these strategies were
described by participants, they were rarely demonstrated within the online activity. These
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discrepancies illustrate the value of comparing self-reported and exhibited behaviours, as
perceived ideal practices may not actually be carried out in practice.
A minority of my participants exhibited more advanced critical health literacy skills, and
using Chinn’s (2011) conceptualisation, demonstrated both a critical analysis of information
and an understanding of the social determinants of health. These participants identified
problematic sexual content in mainstream media, and often favoured user-generated content
instead. As mentioned earlier, some participants, particularly those identifying as gay,
lesbian or bisexual, demonstrated critical literacy in relation to dominant hegemonic
practices and oppression within the school context, and its failure to prepare them to make
sexual decisions. Some further applied this critical literacy to the online context, being
critical of biased and judgemental sources, heteronormative and misogynistic content, and
the effects such content has social norms and attitudes. Research has shown that the quality
of online sex and sexual health information varies considerably, and can be negative in tone
and narrow in scope (Bay-Cheng, 2001), with certain topics often side-lined, including
sexual identity/orientation, masturbation and abortion (Simon and Daneback, 2013), as well
as a general lack of information about young people’s navigation of sexual health situations
and conflicts (Isaacson, 2006; Keller et al, 2004). Some preferred to use ‘unofficial’, non-
hegemonic, user-generated content for this reason. This can be seen as illustrative of the
power of sophisticated critical sexual health literacy skills in overcoming some of the most
commonly experienced challenges of seeing sexual health information online.
7.3.4 What are the specific challenges relating to sexual health literacy within the
online context?
While sexual health literacy is beset by similar challenges to general health literacy, it is
important to consider the challenges that may be specific to, or more acute in, sexual health
literacy. Given that broad conceptualisations of access include the effective use and
application of information in various contexts, free from worry about embarrassment and
stigma, it is important to consider how socio-cultural and contextual factors may be
particularly pronounced in the sphere of sexual health.
7.3.4.1 Social access and stigma
Young people face a range of barriers to effectively locating and applying sexual health
information, including the different contexts within which sexual health learning occurs,
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which can problematise sex and sexual health amongst young people (Kendall, 2013).
Research in Australia has shown that young people demonstrate reluctance to seek
information about sexual health due to stigma, as well as a perceived lack of services (Couch
et al, 2006). Worries around confidentiality and barriers such as embarrassment and shame
are considerable. Research has shown that young people have these worries in relation to
talking about sex or sexual health with others in offline contexts (e.g. teachers; friends;
family) (Harvey et al, 2008; McMichael and Gifford , 2009), and it seems these barriers can
also exist in the online context.
As discussed in Section 7.3.2, my participants did not experience any barriers to physically
accessing the internet, but did experience barriers in relation to what Burnett and colleagues
(2008) refer to as intellectual access, or the ability to effectively navigate the online
environment to access reliable and accurate sexual health information. Young people’s
concerns about the stigma of ‘being seen’ may contribute to hasty, flawed information-
seeking, causing potentially valuable content to be overlooked, restricting what Burnet and
colleagues (2008) refer to as social information access, concerning the sociocultural context
of information seeking. Social access appear so be another area in which sexual health
content presents barriers to access that may not exist for general health information.
Participants’ concerns about stigma highlight how even young people who demonstrate high
functional health literacy may encounter barriers to effectively finding and interpreting
sexual health information. Stigma may both drive young people’s use of the internet and
drive ineffective information-seeking strategies, and this illustrates the importance of taking
broader contexts into account when considering sexual health literacy.
7.3.4.2 Sexually explicit material and gender norms
Most young people with internet access have encountered sexually explicit material online,
intentionally or otherwise (Livingstone and Helsper, 2007; Mitchell et al, 2003; Owens et
al, 2012). My participants discussed encountering explicit material in response to relatively
innocuous searches, and worries about sexually explicit material seemed to influence my
participants’ search strategies, with some ‘censoring’ search strings or being wary of using
image search services and websites containing visual material. This was more evident in
female participants, whose embarrassment and concern about reputation manifesting in risk-
averse searching. Males also censored searches, but tended to attribute this to the interview
environment, implying that they would be less cautious outside of the research context.
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Male participants referred to pornography as an information source, corroborating literature
suggesting that young people use digital media to access pornography as a source of sex
education (Albury, 2015; Allen, 2006; McKee, 2008), potentially in response to
inadequacies of formal sexual health education (Kubicek et al, 2010). Allen (2011)
suggested that young people may demonstrate interest in pornography due to: curiosity about
specific practices, desires to demonstrate knowledge to peers and desires to follow normative
gender roles. Research has highlighted the culturally-ingrained gendered nature of
pornography, which is continually presented as more acceptable for men than women
(McKee et al, 2008, Scarcelli, 2015). Similarly to participants in my study, participants in
Scarcelli’s (2015) research into girls’ experiences with online pornography found that they
presented pornography as something they were familiar with, but did not access.
From the early 1990’s, sexually explicit material on the internet has generally been viewed
as presenting risks to young people’s sexual practices and well-being (Albury, 2014; Flood,
2009; McKee, 2010;), particularly young males (Crabbe and Corlett, 2010). Researchers
have highlighted how pornography may affect young people’s sexual practices and scripts,
with young men’s consumption of pornography associated with dominant attitudes and
behaviours towards young women (McKee et al, 2008). Pornography must been seen within
the wider context of media representations in their role in sexualising popular culture and
promoting or ‘eroticising’ gender inequality (Attwood, 2009; Crabbe and Corlett, 2010;
McNair, 2012). Some websites accessed during the online activity exemplified this, for
example with misogynistic content including a ‘men’s health page’ entitled ‘7 ways to give
it to her good’.
While pornography is a problematic information source, it is important to acknowledge that
it may provide benefits. Conversely, cautiously self-censoring searches to avoid explicit
content could lead young people to overlook potentially useful information. There is a need
to balance the potential benefits of accessing illuminating, realistic information with the
potential disadvantages of being influenced by unrealistic portrayals of sex and sexual
health. The key concern here is perhaps not the explicit media itself, but the critical health
literacy skills of individuals; for young people to make safe, effective use of such content, it
is necessary for them to extract useful information while remaining critical about the sexual
and gender norms being illustrated.
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Beyond pornography and explicit content, research highlights that new media contexts
reinforce gendered norms and ideals (de Ridder and van Bauwel, 2013; Livingstone et al,
2011; Livingstone and Mason, 2015; Ringrose and Barajas, 2011). Livingstone and Mason
(2015) highlight the challenges that girls and young women face online in “negotiating the
line between performing the hyper-feminine sexuality that is often seen in the media, and
stepping outside what is ‘proper’ behaviour for a girl” (which is policed through judgmental
language such as ‘slut’ or ‘slag’ (Ringrose and Barajas 2011)), while boys face different
pressures to performs “an emotionless, detached, and often aggressive masculinity”
(Livingstone and Mason, 2015, p.23). Renold (2013) found that even children as young as
10-12, and particularly girls, felt pressured to conform to such gender norms.
Just as pornography occupies a complex position of being both problematic and a potentially
useful information source, research has focused on how the online context presents both
risks and opportunities to young people, and how these vary by gender. Livingstone and
Haddon (2009) explain that boys are more likely to both encounter and generate risks in the
online environment, while girls are more likely to be victims of risk. However, it may be
necessary to use a broad conceptualisation of risk; Ringrose and Barajas (2011) called for
traditional notions of risk as a binary proposition, in which risk and opportunity are opposite
phenomena, to be expanded upon, recognising that practises can simultaneously present both
opportunities and risks. As Ringrose and Barajas (2011) put it, “Gender relations are more
messy and complex than rational agents doing risk aversion vis-à-vis risky or healthy
options” (p.123). As such, in the ‘messy’ world of gender and sexual health, dichotomies of
good and bad content may be unhelpful.
While the online context may often reinforce heteronormative and gendered ideals, some
discourses within social media may help young people to challenge gender norms (de Ridder
and van Bauwel (2013). As Ringrose and Barajas (2011, p.134) suggest, social media can
provide ‘opportunities for communication that opens up gender and sexual identity in new
ways’, enabling ‘cultural resistance’ of norms of gender and sexuality. This was found
amongst my participants, although, as will be discussed in Sections 7.3.4.3 and 7.5.3, the
extent to which social media develops critical perspectives appears to vary between different
social platforms. For young people to effectively negotiate the online environment, and
realise the opportunities presented by social media, it may be necessary for other sources of
education to develop young people’s critical and interactive skills (Albury, 2014; Allen,
2006). Within my study, participants highlighted different perspectives on, and reactions to,
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sexually explicit content, and the range of these perspectives, combined with the complexity
of the role of explicit content, suggest that media studies lessons might aid young people’s
negotiations of these issues (Bragg and Buckingham, 2009). Similarly, teaching ‘porn
literacy’ to young people may help them to view pornography through a critical lens (Albury,
2014).
A minority of my participants exhibited sophisticated critical health literacy in discussing
the potential influence of pornography on young people’s attitudes towards sex, and the
implications of using pornography to learn about sexual encounters, demonstrating
awareness of harmful, unequal and oppressive socio-cultural beliefs and practices that may
stem opportunities to exercise agency in making sexual health decisions, which Jones and
Norton (2007) state is necessary to be critically health literate.
7.3.4.3 Challenges for sexual health interventions on social media
Social media is another area in which the challenges of sexual health literacy are particularly
acute. Participants typically valued the internet as a private and anonymous means to avoid
the perceived embarrassment and stigma of discussing sexual health within potentially
embarrassing ‘offline’ contexts. However, the nature of the internet meant that ‘being seen’
was not restricted to offline contexts, as social media sites also present risks of being
observed engaging with sexual health content. In relation to sexual health, young people
tended to value aspects of the internet that provided privacy, rather than social interactivity.
This distinction could have implications for sexual health interventions increasingly moving
online (discussed in Section 7.5). However, it is important to note that, as will be discussed
in Section 7.4.3, participants’ distaste for engaging with sexual health content on social
media was not uniform across social media platforms, with social content sharing platforms
such as YouTube being less problematic than social networking platforms such as Facebook.
In discussing using social media for sexual health interventions, Fergie and colleagues
(2016, p.53) highlight the importance of ‘understanding common reservations about
engaging online’. It is vital to understand how the social media environment might inhibit
engagement, particularly in the area of sexual health, and how ‘even the seemingly
innocuous act of ‘liking’ pages (which initiates subscription to content on an ongoing basis)
is subject to considerations about identity-management’ (Fergie et al, 2016, p 53). While
some of my participants did see some potential for sexual health promotion on social media,
describing engaging with links to interesting content, these experiences were atypical. The
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processes of identity construction that are actively performed on many social media services
concerns must be a key consideration for sexual health interventions on such services (Evers
et al., 2013; Fergie et al., 2016), and are a clear means by which sexual health content may
face barriers to user uptake that do not necessarily apply to general health content.
7.4 The role of friends and peers in optimising sexual health literacy
in online and offline contexts
7.4.1 Why are friends and peers important to sexual health literacy?
Health literacy theorists have stressed the importance of studying health literacy within such
broader community and social realms, recognising the impact of situational determinants
such as peer influence and social support on health literacy and health (Mangello, 2008;
Nutbeam, 2008; Paasche-Orlow and Wolf, 2007; Sorenson et al, 2012). In their
conceptualisation of health literacy, Sorenson and colleagues (2012) state that health literacy
skills can be used to overcome personal, social, structural and economic barriers to health.
While low health literacy has traditionally been considered as an individual trait (AMA,
1999), it is evident that the support individuals receive from their social environments can
be key to shaping their health literacy. Buhi and Goodson’s (2007) systematic review of
literature on young people’s sexual behaviour and intentions found peer norms to be a key
influence on sexual behaviours.
Whilst my participants typically identified the internet as their current primary source of
sexual health information, most described using and managing multiple information sources,
and friends and peers emerged as a particularly important influence. The role of friends and
peers is particularly important when considering sexual health literacy in a modern,
connected information landscape, given that information and support are exchanged between
friends and peers in online and offline. Theorists have identified growing integration of
online and offline environments (e.g. dating apps), with the geographically-unbounded
nature of mobile technologies blurring the boundaries between the two (Boyd, 2014; Pascoe,
2011). As young people use mobile technologies to share information, socialise with friends,
and connect more broadly with communities (Boyd, 2014; Evers et al, 2013; Marwick and
Boyd, 2014), their online activities are intrinsically linked to their offline social worlds.
My participants described spending considerable time online, particularly with social media,
including social networking sites (SNS) (e.g. Facebook), messaging applications (e.g.
Snapchat and WhatsApp) and social photo and video-sharing sites (e.g. Instagram and
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YouTube). It is important to consider the role of friends and peers more widely in influencing
sexual health, which Byron (2017) highlights as “particularly pertinent given current
attempts to promote sexual health to young people via social media, where friendship and
practice is central” (p.487).
7.4.2 Friends as a source of informational, emotional and practical support
The literature has primarily discussed friends and peers as sources of sex and sexual health
information in relation to augmenting school-based sex education (Graf and Patrick, 2015;
Sprecher et al, 2008), as discussed in Section 7.3.1. However, a growing body of literature
examines the role of friends and peers in providing sexual health informational, supportive
and practical social support outwith the school context (Byron, 2017; Cheetham, 2014;
Mastro and Zimmer-Gembeck, 2015; McDavitt and Mutchler, 2014; Powell, 2008).
Research shows that young people cite friends as a source of information about sex and
sexual health, and value trusted peers for their experience-based knowledge and non-
judgemental advice (Byron, 2015; Byron, 2017; Powell, 2008). This was evident among my
participants, who described learning with friends and from friends, highlighting ways that
friends could provide informational, emotional and practical support in relation to sex and
sexual health, both off and online. Echoing Byron’s (2015) findings from research with
Australian adolescents (aged 18-25 years), my participants described drawing on trusted
friends, who were experienced and knowledgeable. However, pre-existing knowledge and
experience were not always considered essential, with female participants in particular
describing ‘working it out together’, alluding to the value of two-way communication in
problem solving, contrasting with the dynamics of more traditional, didactic information
provision.
The propensity to engage in friendship and peer-support was not universal within my study.
Gender appeared to be a factor in engagement, and my analysis suggests that young women
benefit particularly from friendship and peer support, both online and offline (discussed in
Section 7.4.3). Research has found that young women in particular are open to discussing
relationships and emotions (Allen, 2008; Day and Livingstone, 2003; Measor et al, 2000;
O’Higgins and Gabhainn, 2010; Teitelman et al, 2009), and my female participants were
more likely to discuss relational and emotional aspects of sexual health than male
participants, who tended to be dismissive of this. Male participants seemed less willing to
make the limitations of their sexual knowledge and experiences known, preferring to discuss
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sexual health in a playful, sometimes immature, manner. Research suggests that young men
are expected to be sexually knowledgeable (Buston and Wight, 2006; Hilton, 2007; Limmer,
2010; Measor et al, 2000). It is likely that, for males, maintaining a façade of jovial
indifference about sexual health is a performative means of protecting masculine social
status. This speaks to literature around performative masculinity as a potential barrier to
young men talking constructively about sexual health with their friends (as discussed in
Section 7.2.2). This evidence illustrates a mechanism by which inequalities in sexual health
literacy may be somewhat patterned by gender, highlighting the influence of socio-cultural
norms about masculinity and attitudes towards sex and communicating about sex.
Beyond friend and peer support being a means of gaining information, some of the
knowledge exchange exhibited within my study highlighted the role of peers in potentially
influencing norms within social groups. Participants in both Byron’s (2017) and my research
described sharing their knowledge and experience with their friends. Byron’s (2017)
participants described acting as educators to friends, sharing experiences and information to
promote sexual health practices, highlighting informal sexual health promotion within the
friendship context. My participants both described instances of promoting sexual health
directly to friends and demonstrated ad-hoc peer education during the interviews and online
activity. Possessing sexual health knowledge made some participants protective of others,
feeling compelled to dispel myths amongst their peers. Those who described sharing or
exchanging knowledge and support with friends were predominantly those with more
confidence in their knowledge, sexual health experience or familiarity with seeking
information, and there was some evidence that the desire to provide peer support and act as
a protector was related to positive past experiences of sexual health learning. These
participants demonstrated sophisticated sexual health literacy skills, illustrating their ability
to potentially influence norms within their social groups, and demonstrating how friends can
influence each other’s understandings. However, this influence is not necessarily positive,
as some participants shared misinformation and perpetuated myths, but nonetheless the
friend-support exhibited highlighted how health literacy can go beyond the individual and
influence wider community and society (Nutbeam, 2000).
The friendship context may also have a role to play in making health systems easier to
navigate (Cheetham, 2014; Sorenson et al, 2012). Forrest’s (2007) review of literature on
young men’s use of sexual health services found that supportive peer relationships were
important facilitators of access. My participants described drawing on friends for practical
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and emotional support to overcome barriers within healthcare contexts, and some provided
tangible examples of assisting friends in overcoming sexual health literacy barriers by
attending health services with them. Cheetham’s (2014) study of the role of peers in uptake
of a scheme designed to increase access to condoms found that individuals helped friends to
access the resource, alleviating embarrassment and stigma, which are commonly associated
with sexual health services (Stone and Ingham, 2003). However, Cheetham’s (2014) sample
comprised only people who had themselves registered for the C-Card scheme, and thus the
experiences of those potentially unable to negotiate the barriers to participation were not
captured. One of the aims of the C-Card scheme was to increase young men’s use of sexual
health services, and, notably, while addressing Scenario Two of the online activity, three
male participants within my sample stated that they would tell their friend about the C-Card
scheme, while, conversely, some female participants exhibited more wariness in relation to
accessing condoms. Cheetham (2014) identifies a “need to revisit the dynamics of young
people’s peer relationships and harness their potential to influence sexual attitudes and
behaviour in positive ways, rather than simply seeing these always as a source of negative
pressure” (p 1). My findings support this call by demonstrating how young people can act
help friends with low health literacy by sharing knowledge, and assisting them to overcome
barriers to accessing health services.
While acknowledging the potential benefits of peer support, it is vital to consider the
commensurate disadvantages faced by those who have limited friendship groups or find
face-to-face interaction challenging. On this issue, my sampling methods may have
generated a somewhat skewed sample in terms of comfort in discussing sexual health with
friends, but, nonetheless, some participants described embarrassment at discussing sexual
health with friends. Barriers such as embarrassment and shame are substantial, and research
has shown that young people experience these when talking about sex or sexual health,
including when talking with friends (Kendall, 2013; McMichael and Gifford, 2009). A small
number of participants who reported being particularly uncomfortable talking about sex and
sexual health (exhibited at times within the interview) preferred to seek information online
in relative privacy.
The relationship between offline support and online engagement has been highlighted within
the literature. Fergie and colleagues (2016), in their study exploring production and
consumption of user-generated content about diabetes and mental health, found offline
experience of support to be a key determinant of young adults’ engagement with online
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content. For example, ‘non-engagers’ typically had reliable offline support systems, which
seemed to negate the need for engagement with online content. This was also found within
my study, with some participants preferring to use a trusted personal support system than
engage with a potentially untrustworthy online source. Wyatt et al (2002) discussed how
non-use of technologies does not necessarily relate to inequality, typifying within policy and
academia, providing an alternative typology of types of users, including ‘resisters’ and
‘rejectors’, which recognises multiple reasons for non-use, including having adequate
alternative sources or a personal support system (p.76).
7.4.3 Peers in the online context
Friendship and peer support related to sexual health is an area in which the overlap and
interrelation between young people’s online and offline environments is particularly
relevant. The opportunities and challenges presented by the interrelation between the online
and offline spheres in peer and friend support are discussed in this section.
The social connectivity enabled by digital technologies can enhance access to information
(Evers et al, 2013; Niland et al, 2015), particularly experiential knowledge and information
about ‘taboo’ subjects (Suzuki and Calzo, 2004). Research shows that young people want
information about the normality of sexual practices and behaviours (Harvey et al, 2007),
and, for those reluctant to talk to friends in person, user-generated content online provides
non-judgemental, relatable information and peer advice (Hillier et al, 2012; Suzuki and
Calzo, 2004). Over a decade ago, both Suzuki and Calzo (2004) and Bay-Cheng (2005)
examined the popularity of online bulletin boards among young people, illustrating how
these communal online spaces, which preceded today’s social media, allowed young people
to openly share information and experiences without barriers encountered elsewhere. Some
of my participants (particularly female) sought such relatable content online (such as in blogs
or vlogs), seeking the comfort of knowing ‘it’s not just me’, and some specifically
complained about a lack of relatable content on government and health provider websites.
Some social media contexts can provide spaces for community empowerment and effective
venues for developing sexual health literacy, as clearly illustrated in some of my
participants’ positive experiences with YouTube content. Two of the YouTube bloggers
accessed by participants during the online activity demonstrated social awareness by
deconstructing myths and discussing consent, illustrating the influence that good user-
generated content might have on young people’s critical sexual health literacy.
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However, not all aspects of social media are popular venues for sexual health information
and support, and engaging with sexual health content on social networking services such as
Facebook and Twitter is fraught with concerns about ‘being seen’ seeking stigmatising
information. While privacy can be an appealing feature of using the internet to access sexual
health information, young people’s use of social media requires that privacy be continually
negotiated, as user interactions on social media can be visible to wider networks beyond
friendship circles (Boyd, 2008). Thus, while the internet is broadly seen as an anonymous
source of information that mitigates concerns about stigma and embarrassment, social
networking sites may represent a sphere of the internet in which young people are beholden
to similar expectations of propriety to those found in the offline environment. Contrary to
the strategies to control information shared on social media, as identified by Boyd and
Marwick (2011), my participants primarily described entirely avoiding social media in
relation to sexual health information. Similar preferences were identified in young
Australian people, due to concerns about privacy, stigma, and bullying (Byron, 2015; Evers
et al, 2013). This strict separation drawn by my participants between sexual health
information and social networks may be a result of the deliberate processes of identity
creation that take place on social media (as discussed in Section 7.3.4) and the heightened
awareness of the environment they occupy, as described by Byron (2015).
It is evident that while the strength of social media is in the provision of two-way
communication (Bruns, 2009) that dynamic complicates sexual health promotion. It may be
important to draw distinctions, as my participants did, between social networking services,
which present challenges for sexual health promotion, and other user-generated resources
such as blogs, video sharing sites and question and answer forums, which may deliver
appealing information without the risks to social status associated with social media.
However, this is not to say that sexual health promotion on social networking services is
impossible; content that is sufficiently engaging can be shared without fear of stigma, and
can still provoke serious discussion. Evers et al (2013) found that young Australian people
suggested that humour, particularly in YouTube videos, could overcome some challenges
related to bullying and stigma, as humour can distancing information creators’ personal
lives. Similarly, Byron (2013) identified a preference for sexual health information that can
be shared without reflecting negatively on the sharer. Participants in my study supported
these assertions, describing content that they had seen shared on social media, including
advertisements and quizzes. Perhaps, as Evers and colleagues (2013) suggest, “there is the
potential that after humorous content is shared, a discussion or debate among peers will
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emerge” (p.272). As such, humorous content may be a stigma-free way to ultimately provoke
serious consideration of sexual health issues.
As well as humour, more serious, socially-critical sexual health content may thrive on social
media. My participants typically viewed content focused on risk and ‘scare tactics’ as less
likely to be shared, but some accounts illustrated how serious shared content may be
particularly powerful is in exercising critical health literacy by challenging mainstream
media content. Two participants illustrated this in describing socially-shared content that
presented critical perspectives towards the banality and heteronormativity of mainstream
media. This demonstrates the potential for young people to access critical perspectives
through user-generated content and social sharing that they might have been unlikely to
encounter otherwise.
My findings illustrate how the online environment represents an important sphere of support
within which individuals can interact with their peers, with its own set of advantages and
concerns. These interactions may in influence individuals’ functional and critical literacy, as
they encounter new information and perspectives that might stimulate awareness and
analysis of socio-cultural beliefs, attitudes and practices that might undermine healthy
decision making, autonomy, individual agency and sexual self-expression. As with peer and
friend support offline, it is necessary to question how individuals without robust and broad
friendship groups may be disadvantaged, but the unbounded nature of social media platforms
may be such that barriers to building peer groups are less significant than in the ‘offline’
world.
It is clear from both the literature and my data that, both online and offline, friendship and
wider peer groups can play important roles in young people’s sexual health literacy. The
friendship context is often perceived as a risk to young people’s knowledge, and health
promotion rarely focuses on how support from friends can be an asset, and how young people
can make best use of it (Byron, 2017). Byron (2017) highlights how formal discourses of
young people’s sexual health typically present learning as an individual and private
responsibility, devaluing and discouraging drawing on friends and peers (instead
encouraging focusing seeking information from ‘legitimate’ sources like doctors and official
websites). A narrow perception of sexual health literacy in terms of individual knowledge
ignores the role of friends and social support more generally in aiding negotiations of sexual
health. Friends and peers can provide support that more formal resources cannot, and my
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findings support a shift in focus towards the socio-sexual contexts within which sex and
sexual health are negotiated.
7.5 Formal healthcare context: traditional and online
In addition to the friendship and peer context, health literacy is also relevant to the formal
healthcare contexts within which individuals interact. As Baker (2006) explains, “health
literacy is a dynamic state of an individual during a health care encounter. An individual’s
health literacy may vary depending upon the medical problem being treated, the healthcare
provider, and the system providing the care” (p.878). Therefore, in addition to functional
and critical health literacy, individuals require interactive health literacy, which comprises
the networking and social skills necessary to effectively apply knowledge in practice
(Nutbeam, 2000). In formal healthcare settings, sexual health information is sought, used
and applied in making decisions and negotiating sexual health. Here, I examine the role of
the formal healthcare context in both facilitating and hindering young people’s sexual health
literacy, and how this is integrated within the online context.
7.5.1 Traditional healthcare system: facilitating or hindering young people’s sexual
health literacy
While online sexual health information and offline healthcare services are distinct contexts,
it is useful to understand how they overlap and interact with each other. Researchers have
highlighted a gap in knowledge concerning how young people apply online information
offline, such in interactions with health services and health professionals (Gray et al, 2005;
Simon and Daneback, 2013). Thus, it is important to consider the relationship between
online information-seeking and accessing offline healthcare contexts. Buhi and colleagues’
(2009) self-reported survey found that a third of students described being eager to share
online health information and raise concerns with health providers, indicating that accessing
online health information can drive young people to seek offline healthcare services. Few of
my participants described being “eager” to share online health information in offline
contexts, but they tended to perceive the internet as a place to find initial sexual health
information before attending a consultation with a healthcare provider, if appropriate. From
this perspective, the internet can be seen as having taken over much of the information-
provision role of GP surgeries and sexual health clinics, but those formal healthcare contexts
remain important for their primary purpose of delivering diagnosis and testing facilities.
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Participants’ descriptions of negotiating sexual health (and illness) within formal healthcare
settings varied. Some described relative ease and comfort interacting within such contexts,
based on prior positive experiences. As with online information sources, familiarity seemed
to be a key driver of trust in health services, with positive experiences of services
engendering trust in those organisations both online and offline. Just as familiarity with
health services engendered confidence for some participants, uncertainty and unfamiliarity
fuelled anxiety in others. Many displayed limited awareness of both their local sexual health
services and sexual health services more generally (such as understandings of available
testing procedures and what they involve) and, as demonstrated in the online activity and
within literature, participants faced barriers to locating information about local services
(Section 7.3.2). Awareness of health services is identified by Nutbeam (2000) as an
individual benefit of functional health literacy, but it is evident that some of my participants
lacked such awareness, fuellings anxieties about seeking help within sexual health services.
Research with young people in Australia and Canada also found low awareness and
knowledge of sexual health services (DiCenso et al, 2001; Janssen and Davis, 2009). Gray
et al (2005) noted that lack of awareness and promotion was a significant barrier to health
literacy.
Research suggests that young people in the UK, North America, Australia and New Zealand
face a range of barriers to using formal healthcare systems (Booth et al, 2004; Lindberg et
al, 2006; Lorimer et al, 2009). Internal barriers included worries about stigma, shame and
embarrassment (Booth et al, 2004; Couch et al, 2006; Lindberg et al, 2006), while external
barriers included lack of confidentiality, disrespectful or unskilled health care providers and
challenges related to access (Booth et al, 2004; Lindberg et al, 2006; Thomas et al, 2006).
My participants alluded to similar barriers, predominantly related to embarrassment in
interacting with healthcare providers about sexual health issues, as well as concerns about
‘being seen’ accessing sexual health care. Even participants who described being
comfortable communicating about sex and sexual health within healthcare contexts
exhibited concern about friends or family witnessing them visiting doctors for sexual health
reasons. Research has suggested that young people associate talking to healthcare providers
about sexual health with embarrassment (Harvey et al, 2008; Klein et al, 1999) and that
concerns about stigma can discourage accessing services (Booth et al, 2004; Lindberg et al,
2006). Lorimer and colleagues (2009) found that both young males and females in Scotland
described embarrassment at being offered STI screening in front of others within a sexual
health setting, with female participants in particular describing worries about being seen as
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“that sort of person” (i.e., one seeking STI testing). This perhaps exemplifies what Wellings
and colleagues (2012, p.21) identify as ‘the tendency to distance oneself from people at risk
of STIs” based on moral judgements about the assumed actions or characteristics of such
people, which can negatively impact upon public health’.
My participants regarded confidentiality as essential, with some searching specifically for
information about confidentiality when researching local testing providers, and some female
participants worrying about having to inform their parents before using services. Existing
research supports the finding that confidentiality is a major concern for young people (Booth
et al, 2004; Lindberg et al, 2006). Thomas and colleagues’ (2006) survey of young people
in the UK found that confidentiality was considered the most important feature of sexual
health service provision, cautioning that, if confidentiality is not ensured, young people may
not attend services. Such barriers were potentially exacerbated for participants within my
study living in smaller towns or rural areas, where a GP may be a more integral part of the
local community than in urban areas. Indeed, Garside and colleagues’ (2002) mixed methods
research found that young people from rural and smaller communities in England were more
concerned with barriers to anonymity due to greater visibility and lower privacy in smaller
communities. They describe how, for those young people, “issues of confidentiality and
anonymity permeate every stage of the consultation – going into the doctors, in the waiting
room, going to the chemist, and future consultations.” (p.24)
Literature has focused on health providers’ attitudes and behaviours as being key to
facilitating or hindering access to services and information (Couch et al, 2006; Kwan et al,
2006; Pleasant, 2008). My participants raised issues related to interacting and
communicating with health providers, including worries about being examined, worries
about being judged and potential shortcomings of provider communication. Participants
described examples where doctors failed to clearly communicate with them, and they
described responding to these situations in a variety of ways. Some had the confidence and
health literacy skills to question doctors’ unsatisfying explanations, while others felt too
embarrassed to challenge doctors, and came away with unsatisfactory understandings as a
result, highlighting how limited interactive skills and confidence can restrict effective use of
services. Health literacy theorists have highlighted the importance of effective patient-
provider communication in relation to health literacy (Paasche-Orlow and Wolf, 2007; Rudd
et al, 2005). Paasche-Orlow and Wolf (2007) emphasise that the problem is not simply about
individuals’ low-health literacy, but about providers within the system and their
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responsibility to communicate effectively. Thus it is important to consider both individual
and system-based factors (Kwan et al, 2006; Pleasant, 2008).
Some participants spoke of the role of the internet in informing their interactions with
healthcare providers, describing how online information optimised their interactive health
literacy, building their confidence to use formal health services armed with information
acquired online. Similarly, Gray and colleagues (2005) found that participants would use
information found online to ‘stimulate’ discussion with healthcare providers, and the
researchers argue that health providers should be prepared to discuss information brought to
consultations by young people, and perhaps suggest ideas for further independent research.
Some of my participants related experiences of health service providers’ unwillingness to
engage with service users’ online-sourced information and understandings, illustrating why
young people might feel unsure about introducing online information in offline healthcare
contexts.
As well as describing doctor-patient level barriers, a minority of participants identified
further systemic facilitators and barriers. Participants who were comfortable and familiar
with services often recognised the barriers that existed for young people generally, and the
daunting nature of visiting a service for the first time. Participants’ discussions also
highlighted how formal healthcare systems could work to engender confidence by reducing
embarrassment for those accessing services, such as identifying systemic features (such as
asking non-essential personal questions) that might alienating young people. While health
literacy proponents highlight the importance of increasing personal health literacy through
education, it is also important that systems be made easier to navigate (Sorenson et al, 2012).
Lindberg and colleagues (2009) highlight the importance of healthcare providers working to
change procedures, policies and physical surroundings to make them more comfortable and
welcoming.
It is evident that young people experience a broad range of barriers to negotiating sexual
health within formal healthcare contexts, including low awareness, poor provider skills and
embarrassment, which combine to create challenges to interactive literacy and impose
barriers to using sexual health services. Such barriers affected participants differently.
Addressing sexual health within formal healthcare settings incited feelings ranging from
relatively mild reluctance to attend, to complete avoidance and preferences for self-
diagnosis, ignoring health issues, or seeking alternative means. Social and psychological
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research has shed insight on information-seeking and avoiding processes, highlighting that
individuals actively avoid information at times, particularly if they feel that it will result in
uneasiness or conflict, and particularly in relation to cancer information (Case et al, 2005).
Shoveller et al (2012) stress the importance of researching alternative settings within which
young people might go to seek help, particularly online, and they argue for the development
of training resources to help health practitioners redesign their practices to supplement online
services, and thus “respect contemporary youth culture” (p.17).
7.5.2 Integrating the traditional offline healthcare system with the online context
7.5.2.1 Circumventing barriers through online sexual health services
There is a growing body of evidence regarding the acceptability and effectiveness of online
sexual health services in overcoming practical and cultural barriers to use of traditional
offline services (Bailey et al, 2012; Estcourt et al, 2017; Gkatzidou et al, 2015; Gold et al,
2011; Kang et al, 2010). Research suggests that young people are generally open to such
services (including STI/HIV testing and online counselling services), valued for
convenience, privacy and immediate access (Lorimer and McDaid, 2013; Shoveller et al,
2012), and has suggested that young people want online technologies to be used to provide
convenient and confidential non-clinical testing services (Lorimer et al, 2009). Indeed, some
of my participants suggested alternatives to traditional sexual health services, such as online
STI testing and advice services, which might circumvent the need to attend formal settings
and thus reduce anxiety and embarrassment. Participants identified that such services could
reduce both geographical and emotional barriers by improving access for people in remote
areas and providing more conducive environments for frank discussion of concerns. These
participants were typically daunted by ‘offline’ services, and therefore stood to benefit from
alternative sources of sexual health services.
Despite the potential advantages of online services, both literature and my findings suggest
that their acceptability is commonly mitigated by concerns around trustworthiness, validity
and confidentiality, and almost half of my participants stated that they would avoid online
testing services because of these concerns (Bailey et al, 2015). The importance of privacy
has also been identified by other research, covering a range of contexts, illustrating the
importance of embedding confidentiality within online health services (Gkatzidou et al,
2015; Lindberg et al, 2006; Lorimer et al, 2009; Shoveller et al, 2012). Concerns about
legitimacy were particularly applicable to online testing due to perceptions that medical
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procedures should be entirely administrated by medical professionals. As such, online
services might foster confidence in potential users by raising awareness about their
legitimacy and associating themselves with established, trusted healthcare brands (Bailey et
al, 2015).
My findings illustrate that online services should at best complement, not replace, traditional
services. Estcourt and colleagues (2017), developed a complex intervention in the form of
an online eSexual Health Clinic to diagnose, manage and treat chlamydia, and found
preliminary evaluations to be effective, although they call for further research, stressing the
need for comprehensive services. Online services such as this may reduce barriers for those
who face them accessing traditional services, however they stress that, to reduce chlamydia
incidence at a population level, eHealth services should be one component within a wider
approach to sexual healthcare provision (Estcourt et al, 2017). Furthermore, Estcourt and
colleagues (2017) specifically highlight the need for digital infrastructures within the NHS
to be updated to support such interventions.
My participants’ attitudes to online sexual health services varied not only between
individuals, but between service types. My participants identified potential in sexual health
information through private messaging services, such as Facebook, which could provide
access to professional advice with some degree of privacy and anonymity, which both my
findings and the literature suggest are important to young people (Byron, 2013; Evers et al,
2013). It is noteworthy that participants were typically positive about the concept of
accessing online sexual health support via the private messaging features of SNS, despite
common aversion to engagement in more public areas of SNS (as detailed in Section 7.5.3).
The differences in participants’ attitudes towards different parts of SNS as venues for sexual
health support highlight the need for service-providers to have nuanced, up-to-date
understandings of different aspects of social media services and the varying ways that young
people use and perceive them, so that the potential of SNS for sexual health promotion can
be reached.
7.5.2.2 Complementing formal healthcare services with mobile apps
Mobile applications (apps) are increasingly viewed as a unique opportunity for tailored
health messaging and outreach, and valuable alternatives to clinician-delivered
interventions, the use of which may be obstructed by barriers of time and cost (Ownby et al,
2013). While most mobile-phone-based interventions thus far have been SMS-based (Lim
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et al, 2008; Swendeman et al, 2010; Ybarra et al, 2007), the growing popularity of
smartphones and apps have increased opportunities for interventions to use mobile apps to
deliver tailored and interactive services (Gibbs et al, 2016; Muessig et al, 2013). This has
been supported within policy strategies in the UK, which encourage digitalisation of health
services and a movement to self-management and care (National Information Board, 2014).
Despite growing emphasis on developing mobile health apps, awareness of available sexual
health apps was low amongst my participants. Indeed, while research has found that apps for
exercise and diet are commonplace, apps specific to sexual health are relatively rare (Bailey
et al, 2015; Gibbs et al, 2016). Those sexual health apps that are available (mainly HIV and
STI prevention apps) have been evaluated as being incomprehensive and inaccurate (Gibbs
et al, 2016). Gibbs and colleagues (2016) carried out a review of STI apps and found that
such apps were relatively sparse, challenging to identify, out-of-date, and “highly variable”
(p.6) in the comprehensiveness and accuracy of their content. They conclude that “there is
no easy way for the consumer to recognise apps that are likely to provide legitimate,
trustworthy content” (Gibbs et al, 2016, p.6) and recommend that, in addition to better apps
being developed, potential users should be provided with education in assessing reliability
and guidance on legitimate and accessible apps. One aim of the strategy to digitise the NHS
is to develop an endorsed app library to provide such guidance (National Information Board,
2014).
It is important to consider issues of accessibility, particularly in relation to varying health
literacy levels. Broderick and colleagues (2014) stress that the potential benefits of mobile
devices and apps are negated if they are not developed for varying health literacy levels, as
they may simply exacerbate the existing challenges faced by individuals with low health
literacy. To avoid this alienation, Broderick and colleagues (2014) call for developers to
build “health literacy apps”, defined as those whose development is informed by health
literacy and usability strategies, as outlined in ‘Health Literacy Online: Strategies for Writing
and Designing Easy-To-Use Health Web Sites’ (U.S Department of Health and Human
Services, 2010). The strategies include learning about targeted users, writing actionable
content, displaying content clearly, organising and simplifying information, engaging users
and revising content.
A review by Muessig and colleagues (2013) highlighted that most sexual health apps have
received very little engagement and have failed to draw user attention or positive user
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reviews. While this may be due to poor development and lack of trustworthiness,
comprehensiveness and accessibility as described above, it is also important to consider
wider factors relating to users perspectives on such technologies being used for this purpose.
This lack of engagement may be a due to issues of privacy, a lack of demand for such apps
or, a lack of awareness, and negative user reviews may reflect sexual health apps being
perceived as out of date, failing to keep pace with rapid developments in commercially
produced apps (Bailey et al, 2015).
Beyond considering the quality of apps themselves, it is important to think more widely
about how target audiences perceive mobile applications. There may be a tendency for
information and services providers to see mobile apps as a perfect platform for engaging
with young people in relation to sexual health promotion and services. Researchers may
assume that, because STIs are stigmatised, and young people are ‘digital natives’, apps are
a perfect solution. However, it is important to be sceptical, and first understand the role of
mobile apps in young people’s lives and consider the extent to which sexual health content
is likely to be welcome in the form of apps. While many of my participants regarded general
health apps to be acceptable, they were typically wary of sexual health apps, feeling that
stigma would prevent their widespread adoption. One-off web searches were seen as more
discreet and less risky in terms of ‘being seen’, as the on-screen icons of sexual health apps
might be observed by others.
Gkatzidou and colleagues (2015) carried out focus groups exploring young people’s
perspectives on design and acceptability, and found that privacy and visibility were their key
concerns. Beyond understanding how young people perceive mobile apps, Oudshoorn and
Pinch (2003) described how, unlike researchers and information providers, who may view
smartphones as inherently personal technologies, young people perceive them smartphones
as social devices that are likely to be seen by others. They describe technological
development as a “culturally contested zone”, and state the need to account for “the
multiplicity and diversity of users, spokespersons for users, and locations where the co-
construction of users and technologies takes place” (Oudshoorn and Pinch, 2003, p.24).
Kline (2000) and Laegran (2008) suggest that potential users may resist or reject
technologies when their developers construct them in ways that do not align with their values
or identities (Oudshoorn and Pinch, 2003), which may be an important consideration for
future development of interventions delivered through mobile apps. It is important to make
sure that apps are accessible, promoted, designed with potential users’ values, identities,
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skills and environments in mind, as well as taking into consideration users’ concerns about
privacy and anonymity, which might be mitigated through tailored privacy settings and
discreet designs (Gkatzidou et al, 2015; Oudshoorn and Pinch, 2003). Furthermore,
Gkatzidou and colleagues (2015) highlight that a ‘one size fits all’ approach to design may
be insufficient, given the range of different user preferences, and suggest that building
customisation options into apps may help to “encompass the four way fit between person,
technology, task and context” (p.10).
7.6 Summary
In this chapter I have examined young people’s sexual health literacy within four key
contexts (school; online; peers; formal health care), illustrating the complex interactions
between the individual and the ecologies within which sexual health literacy operates. I have
discussed and highlighted similarities and differences to the literature, with a focus on the
influence of and interactions between each context in optimising and hindering young
people’s sexual health literacy. Within the next chapter, I outline the conclusions that can be
drawn from this research, and the implications of those conclusions for policy and future
research.
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8 Conclusion and recommendations
8.1 Overview of chapter
This chapter will present the main conclusions drawn from this study, as well as the policy
implications and recommendations of these. This will be followed by a discussion of the
strengths and limitations of the study, and finally, recommendations for further research.
8.2 Study aims
The aim of this research was to explore the key information contexts within which young
people’s sexual health literacy is developed and shaped, with a specific focus on the online
context. The research questions were as follows:
1. What is the role of the internet within the broader landscape of young
peoples’ sexual health information and support?
2. How do young people describe and experience seeking, understanding,
evaluating and using online sexual health information?
3. What are the individual, social and environmental contexts relevant to
young people’s experience and use of online sexual health information and
support?
The main conclusions in relation to each of these research questions, will be detailed in the
following section.
8.3 Main conclusions
8.3.1 What is the role of the internet within the broader landscape of young
people’s sexual health information and support?
While every participant was an active internet user, using the internet for sexual health
information and support was not universal. Participants varied greatly in the extent to which
the internet played a role in seeking sexual health information and support; while some
favoured the internet above all other sources, others resolutely avoided online sexual health
information. More typically, participants described using a range of sources, including: the
internet, school-based sexual health education and friends, and their perspectives illustrated
the importance of understanding how online and offline sources interact as part of an
information and support landscape. Key findings related to the internet, school-based sexual
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health education, peer support, sexual health services and the ways that these contexts
overlap and interact are detailed below:
The online context:
All participants were self-described active internet users, often on multiple platforms
and in multiple places; my sample provided no evidence of a socioeconomic ‘digital
divide’ in terms of fundamental internet access.
The internet was most participants’ current primary source of sexual health
information, valued for its accessibility, convenience, familiarity and anonymity, but
a minority would avoid the internet due to concerns about reliability and preferences
for face-to-face support.
Online sexual health information can, for some, alleviate barriers to seeking
information in ‘offline’ contexts.
The school context:
Almost all participants described experiences of school-based sexual health
education, and their reflections were broadly critical, characterising such education
as insufficient in scope and quantity, typically focusing on a negative, narrow,
conceptualisation of sexual health.
Sexual health education at school may hinder sexual health literacy through a focus
on ‘knowledge’ and messages, rather than providing practical information and
building skills to negotiate sexual health; participants’ negative and risk-based
understandings of ‘sexual health’ appeared to mirror a focus on risk within school-
based sexual health education.
School-based sexual health education may be improved through the incorporation of
outside ‘experts’ and community and youth organisations.
Dissatisfaction with school-based sexual health education may be a catalyst for
seeking sexual health education online, but participants’ experiences suggest that
school-based sexual health education does little to equip young people for
negotiating and using the online environment effectively.
The friend and peer context:
Some preferred learning and talking to friends, particularly those who lacked trust in
the online context and felt like the internet would increase worries and provide little
reassurance.
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Participants, particularly females, described and demonstrated the potential for peers
to influence sexual health understandings and norms and reduce practical and
emotional barriers to accessing sexual health services.
Participants’ who described sharing or exchanging knowledge and support with
friends were predominantly those who were more confident in their sexual health
knowledge and communication, and had positive prior experiences of sexual health
learning or had experience seeking information or negotiating sexual health.
The formal healthcare context:
The varied barriers to negotiating sexual health within formal healthcare contexts
included: low awareness, difficulties locating relevant information online, poor
provider skills, and embarrassment. Participants expressed anxieties around
communicating with health professionals and identified shortcomings in patient-
provider communication.
Familiarity with organisations was a key driver of trust, with positive experiences
engendering trust in those organisations both online and offline. Just as familiarity
with health services engendered confidence for some participants, uncertainty and
unfamiliarity fuelled anxiety in others.
Online alternatives to traditional sexual health services may reduce geographical and
emotional barriers, circumvent the need to attend formal settings and thus reduce
anxiety and embarrassment. However, participants raised concerns about
trustworthiness, validity, confidentiality and a lack of support.
8.3.2 How do young people describe and experience seeking, understanding,
evaluating and using online sexual health information and support?
In the face-to-face and observational stages of the interviews, participants both described
and exhibited their approaches to seeking, understanding, evaluating and using online sexual
health information. Participants expressed nuanced perceptions of different types of online
sources, highlighting that ‘the internet’ is not a monolithic, homogenous information source,
but one that consists of different types of sources and media, which may be perceived
differently by different users and for different types of use. As well as presenting varied
perspectives on different types of online sources, participants exhibited varied approaches
to appraising specific sources, and preferences for modes of information presentation. In
carrying out, and reflecting upon, information searches, participants exhibited variety in their
experiences and perceptions of the challenges involved in finding reliable information
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online. While many participants found locating and evaluating reliable and relevant
information to be challenging, some exhibited sophisticated search strategies and critical
appraisal of source types, sources and content. Key findings in relation to platform and
information preferences; critical evaluation of sources and information; and challenges to
locating relevant and reliable content, are detailed below:
Platform and information preferences:
Preferences for different types of online content varied, including differing attitudes
towards: user-generated content; pornography; relatable content; light-hearted
content; visual and interactive content; commercial content; and government-
provided content.
Participants typically viewed familiar sources, and those they deemed as ‘official’
and authoritative’ and reputable (such as NHS websites) as the most reliable,
although not always useful in providing information.
Participants typically preferred websites with clear layouts; stepped information;
brief text; easy to understand language and realistic and practical content.
Pornography and sexually explicit content was typically viewed as a norm for
young men, rather than for young men, and gender differences were apparent in
participants’ embarrassment and concern about stigma associated with sexual
health information-seeking; many female participants adopted risk-averse search
strategies to avoid sexually explicit content; at times visual and interactive content
appeared to be dismissed because of this.
Participants drew important distinctions between social networking services (which
present problems for sexual health promotion related to stigma, status and ‘being
seen’) and other user-generated platforms, such as blogs, video sharing sites and
question and answer forums (which were typically regarded as appropriate settings
for sexual health information, albeit with some concerns about reliability). Most
participants rejected the former, while some participants, primarily females and
those who identified as gay or lesbian, tended to value the latter as a source of
relatable and relevant advice that was sometimes missing from more ‘authoritative’
sources.
Participants identified potential in sexual health information and service provision
through private messaging services, and mobile applications, however participants
also expressed concerns about privacy on each of these platform types.
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Critical evaluation of sources and information:
Finding information quickly was deemed important for most. Search processes
typically involved rapid searching for, and evaluation of, sources and content,
based on either recognition of known organisations or instinctive, initial aesthetic
perceptions of relevance and reliability. At times, such rapid evaluation led
participants to bypass relevant information or arrive at misinformation.
The minority of participants who engaged in deliberate, critical evaluation of
sources did so by considering: the top-level domains (and therefore geographical
provenance) of websites; the presence of authorship information; the creation date
of content; and the absence of advertising.
Participants who identified as gay, lesbian or bisexual highlighted heteronormative
content during the online activity, and sought out sources (particularly user-
generated content) that they felt might provide more relevant information.
Similarly, some participants identified misogynistic, homophobic or otherwise
problematic content, and reflected on how it might influence norms and attitudes.
These observations and behaviours highlight sophisticated critical sexual health
literacy skills within a minority of participants.
Social media may be an important context for exercising critical health literacy by
challenging mainstream sexual health content; social sharing enables young people
to access and share critical perspectives that they would be unlikely to encounter in
more traditional information contexts.
Challenges to locating relevant and reliable content:
Participants varied in their confidence and ability to find and identify reliable
information, there was little awareness of specific sexual health websites and many
regarded filtering the extensive information available to be challenging.
Some websites malfunctioned or were otherwise difficult to use (text-heavy;
unclear layout), and in some cases these websites led participants to abort searches,
highlighting the importance of both fostering digital literacy skills and developing
user-friendly websites. Complicated and non-user friendly websites acted as a
barrier to participants who appeared to generally be confident in navigating the
online environment.
While finding fact-based information (specifically about STIs) seemed to be
relatively straightforward, finding more general information and advice (about first-
time sex) was more challenging. Failing to provide relatable advice about realistic
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sexual health circumstances may be a shortcoming of ‘official’ and ‘authoritative’
sources, such as NHS websites, which may lead young people to seek information
on commercial and user-generated websites, as well as from peers.
8.3.3 What are the individual, social and environmental factors relevant to young
people’s experience and use of online sexual health information and support?
This study has shed light on the different circumstances and experiences that can influence
individuals’ sexual health literacy, highlighting the impact of individual, socio-cultural,
information provision and system factors. Several key individual and environmental factors
were highlighted, including: the failure of school-based sex education in preparing young
people to negotiate their sexual health; the role of peer support in developing and
overcoming sexual health literacy barriers; the influence of gendered norms on sexual health
information seeking practices and communication; and the impact of stigma in online and
offline contexts and in shaping searching practices. While a greater focus on critical and
interactive aspects is important in all forms of health literacy, it is particularly key in relation
to sexual health literacy, which is applied within fundamentally relational situations, which
are often intimate and emotionally-charged, complicated by social stigma and taboos. Many
factors converge and intersect around sexual health literacy, including gender, sexual
identity, stigma, system barriers, and social support, and all of these factors influence how
individuals negotiate their sexual health. These dynamic and ever-changing sexual health-
specific contextual concerns exacerbate health literacy challenges, and stigma and negativity
should be seen as key focuses for sexual health literacy promotion, which may benefit from
greater emphasis on interactive and critical skills in particular. Key findings are detailed
below:
Concerns about the stigma, embarrassment and shame of ‘being seen’ seeking
sexual health information, or support, presented barriers to finding and using
information in various contexts, both online and offline, from being seen attending
a sexual health clinic (particularly in rural areas) to being seen engaging with
sexual health promotion on social media. Embarrassment may also play a role in
limiting effective communication within intimate sexual scenarios.
Stigma may both drive young people’s use of the internet and, conversely, lead to
ineffective use of the internet; hasty information-seeking may lead to
misinformation, even among those who otherwise demonstrate high functional
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health literacy. Therefore, stigma may be a barrier that transcends traditional
epidemiological risk groups.
In addition to gender differences identified in sections 8.3.1 and 8.3.2, female
participants were more open to engaging in informal peer education and support,
while males’ reluctance may be due to masculine norms of projecting sexual
experience and competence. Similarly, females were more likely to identify
relational, emotional and interpersonal aspects of sexual health, which are all
crucial to negotiating healthy and happy relationships.
Females, those who attended denomination schools and participants who identified
as lesbian, gay or bisexual appeared to be disproportionately underserved by sexual
health education provision at school.
Critical health literacy is particularly important within the sexual health context,
due to the roles of social and cultural norms in fuelling stigma and risky,
problematic behaviours.
A minority of participants, particularly those who identified as gay and lesbian,
exhibited sophisticated critical engagement with socio-political aspects of sexual
health. As identified in Section 8.3.1, these participants critiqued aspects of school-
based sexual health education, including biased, moralising, heteronormative and
insufficiently practical content. These participants appeared less encumbered by
embarrassment and stigma, being more open to communicating about sexual health
than most participants.
8.4 Policy implications and recommendations
In this section, I offer recommendations emerging from the research findings with potential
implications for: schools; policy makers; information and service provision; and intervention
development.
8.4.1 Implications for schools: optimising sexual health literacy through school-
based sexual health education
It is evident that the school context is a key environment within which young people’s sexual
health literacy skills could be developed, yet both existing literature and my participants’
accounts suggest that schools instead hinder development of sexual health literacy. Young
people do look to school-based learning about sexual health, but the content and learning
environment are not conducive to developing practical health skills, and sexual minorities
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and those attending denominational schools are particularly poorly served. It seems that
curriculums may not be keeping pace with the information contexts relevant to young
people. My findings suggest that inadequate teaching in schools drives young people to seek
sexual health information online, but also that schools do not support development of young
people’s skills to effectively navigate the online environment. Given that most participants
identified school as their main source of early learning about sexual health, and the internet
as their current main source, school logically represents a valuable opportunity to develop
skills in navigating the online environment.
Broadly, school-based sexual health education may be improved on both delivering
information about sexual health, and on developing the necessary critical and interactive
literacy to independently find, appraise, understand and apply sexual health information.
Specific recommendations concerning content and information provision include:
Provision of comprehensive, sex-positive, inclusive, non-judgemental and practical
content that is relevant to all young people’s lives. Practical skills that should be
developed include navigating both online and offline environments to safely and
confidentially seek help and services.
Inclusion of activities to foster development of interactive and critical literacy to
empower young people to: negotiate sexual and healthcare contexts; engage in peer
support; appraise information; understand and challenge gender norms, expectations
and stereotyping (Banister et al, 2006); understand the roles of power and privilege;
be aware of the social, economic and environmental determinants of sexual health
(Nutbeam, 2000); and analyse beliefs, attitudes and practices that influence their
opportunities to exercise agency and make safe and healthy decisions (Jones and
Norton, 2007).
Schools provide training on critically assessing online search strategies and
information sources. My findings suggest that developing critical sexual health
literacy is related to overcoming barriers to effectively using online sexual health
information.
Specific recommendations to improve delivery modes and learning environments to foster
comfortable and effective learning include:
Giving young people opportunities to learn within single-sex classes and smaller
peer groups. Supportive peer groups, including small groups such as pairs and
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triads, appear to create positive conditions for sexual health discussion removed
from some of the disruptive social dynamics of larger groups.
Providing teachers with continuing training on delivering school-based sexual
health education (Kirby et al, 2007).
Collaborating with local youth, sexual health and charity organisations to run
workshops delivered by external specialist teachers.
Integrating digital technologies in sex education delivery (both in classes and
through companion mobile apps and websites) to maximise young people’s
engagement and prepare them for effective, adaptive online self-teaching.
Acknowledging within curricula that ‘online’ and ‘offline’ sources overlap as part
of one dynamic information landscape. Promoting reliable websites to ease the
burden of evaluating information sources. Further, sexual health promotion
messages could be embedded within school’s internal IT systems used for
accessing class resources (Bailey et al. 2015).
Introducing education about sexual health, sex and relationships earlier in the
curriculum.
8.4.2 Implications for policy makers
Access to effective sexual health education is crucial in reducing sexual health inequalities,
yet sexual health education provision in the UK is variable and inequitable (Bailey et al,
2015). Within Scotland, comprehensive sexual health education has yet to be made a
compulsory part of school curriculums. The Scottish Government’s most recent statutory
guidance on the conduct of Relationships, Sexual Health and Parenthood Education in
Schools was released in 2014 as an acknowledgement of the Marriage and Civil Partnership
(Scotland) Act 2014 (Scottish Government, 2014b). This guidance is presented from a
rights-based approach:
“The Scottish Government is committed to ensuring that all children and young
people receive high quality relationships, sexual health and parenthood education
(RSHP) in order to respect, protect and fulfil their human rights as they grow up”
(Scottish Government, 2014b, p.1)
The guidance also states their intention of such education to be “inclusive of, and responsive
to, all, regardless of their sexual orientation” (p.2). However, despite this pledge of
commitment to inclusivity, young people’s rights to such comprehensive sexual health
education are somewhat undermined. Schools and local authorities implement guidance
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inconsistently, resulting in substantial variety in the sexual health education that young
people across Scotland receive, potentially exacerbating inequalities in sexual health
literacy. My research highlights some of this variability in terms of the frequency of
education provision, the content provided, and the influence exerted by socio-cultural and
demographic factors. These findings draw attention to how cultural, systemic and
infrastructural factors can undermine the right of young people to comprehensive sexual
health education.
One area where cultural and institutional factors may exert a profound influence on young
people’s sexual health education is denominational education. The Scottish Government
upholds religious authorities’ power to determine the sexual health education provided
within corresponding denominational schools. Furthermore, that right is exercised: the
Scottish Catholic Education Service, which establishes and implements education policy on
behalf of the Roman Catholic Bishops of Scotland, states that “Catholic schools in Scotland
are enabled by the Scottish Government and required by the Church to follow Church
guidance, provided via the Scottish Catholic Education service, to give witness to the
Catholic faith and to uphold the tradition of Catholic education” (Scottish Catholic
Education Service, 2015). My findings suggest that young people who attend
denominational schools do tend to receive sexual health education that is less frequent and
less comprehensive than those in non-denominational schools.
Recommendations of areas of consideration for policy arising from my research
findings include:
Making high-quality, comprehensive and skills-based sexual health education
compulsory in all schools that recognises sexual diversity.
Monitoring and evaluating implementation of comprehensive school-based sexual
health education and training.
Recognising the increasing move towards digital services, and the corresponding
need to prepare all young people to engage with online information and support
safely and effectively.
Recognising the need to maintain both online and ‘offline’ services, and that moves to
replace existing services with online-only services might exacerbate inequalities.
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8.4.3 Implications for information and service providers
While supporting young people to critically engage with sexual health information and
services is crucial, the accessibility of the information and services available is of
fundamental importance. The onus cannot be on young people to increase their individual
health literacy, rather providers must seek ways to better communicate with young people,
promote available services, and reduce embarrassment and alienation.
A variety of recommendations for reducing barriers to making use of both online and offline
information and services emerged from my research findings. Recommendations relevant to
the traditional, offline information and services include:
Raise awareness of local sexual health services, potentially through collaboration
between schools and services.
Structure services in ways that best minimise service-users’ concerns about ‘being
seen’ seeking sexual health information or support.
Structure services and train healthcare providers in ways that engender confidence
and comfort and minimise embarrassment and alienation in young people accessing
those services.
Encourage the use of peer support in reducing barriers to accessing services, for
example by publicising the acceptability of service-users being accompanied by
friends.
Recommendations relevant to the online environment include:
Make young people aware of reliable, high-quality online sources by promoting
those sources in schools, in offline services and in broader publicity campaigns
Ensure that sexual health information and support websites are simple to navigate
and have complete content; invest in maintenance to ensure technical aspects of
websites remain functional.
Ensure that online resources use accessible language, appropriate to the functional
literacy levels of the groups likely to access them.
Be inclusive of a broad range of digital literacy levels when designing resources
Acknowledge that concerns about ‘being seen’ apply in the online environment, as
well as offline, and develop resources that will not overtly resemble “sexual health”
resources to onlookers.
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Acknowledge young people’s varied preferences for different styles of information
delivery, producing resources that offer prose, bulleted lists, images and videos, and
present both straightforward, authoritative information and more relatable, narrative
information grounded in real-world situations.
Harness many young people’s preferences for user-generated content, and that type
of content’s strengths in developing critical health literacy, by developing safe,
controlled, reliable online environments for moderated user-generated content.
8.4.4 Implications for intervention development
Many of the recommendations listed above highlight opportunities for interventions to
improve sexual health literacy in both online and traditional, offline education and service
contexts. Conversely, the findings of my research highlight various potential pitfalls of
interventions that embrace digital media. I found that young people were resistant to the
notion of engaging with sexual health information on social media platforms such as
Facebook or Twitter. As Fergie (2015) suggests, “it is important that health content delivered
online does not conflict with the everyday identity work that constitutes a large portion of
many young adults’ engagement with social media platforms such as Facebook and Twitter”
(p.235). While the ubiquity of some social media platforms in young people’s lives may
mark them as important targets for health promotion, the development of sexual health
promotion interventions in social media must take into account young people’s reluctance
to tar their constructed social media identities by ‘being seen’ engaging with sexual health
information. However, young people within my study tended to draw distinctions between
social media platforms (i.e. Facebook, Twitter), and other social content-sharing services
such as video sharing (i.e. YouTube) and blogging platforms, with participants exhibiting
much greater comfort in engaging with sexual health content in the latter. As such, social
media interventions would benefit from recognising the heterogeneity of social media and
considering high levels of specificity with regards to form of delivery.
The individual differences illustrated in this thesis suggest that a comprehensive range of
different interventions is necessary to ensure that every young person’s needs, capacities,
attitudes and preferences can be catered for, and thus it is fundamentally important to present
comprehensive sexual health information in a variety of formats and presentational styles to
accommodate different learning styles. However, beyond simply improving information
provision, it is crucial to acknowledge and develop critical and social aspects of sexual health
literacy, and to contextualise the role of the internet within the broader information
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landscape. Instead of considering the internet as a discrete, alternative source of sexual health
information and support, interventions should harness the potential benefits of embedding
the online environment within traditional sexual health education, building information-
seeking and appraisal skills to empower young people to safely and effectively use the
internet to develop their own sexual health literacy. In addition to embracing the online
information, sexual health education may also be usefully enhanced by integrating peer
education, and my findings highlight the value of informal support and advice, both online
and offline, as an alternative to more traditional, ‘authoritative’ sources. Beyond education,
sexual health service providers may harness the benefits of the internet by continuing to offer
online alternatives (but not necessarily replacements) to ‘offline’ sexual health services.
Such interventions could have a range of benefits, including saving costs and reducing
barriers to access, particularly those related to concerns about ‘being seen’. However, while
my participants identified potential advantages of such services, they also identified risks
around security and reliability, highlighting the need for such interventions to be safe and
robust, and for potential users to be reassured.
Finally, the development of sexual health interventions must be supported by the
development of dedicated tools for measuring sexual health literacy, for which this thesis’
contribution to establishing the fledgling concept of ‘sexual health literacy’ may prove
instructive.
8.5 Strengths and limitations of the study
This study has provided a range of insights into young people’s sexual health literacy,
enhancing understandings of young people’s experiences of, and perspectives on, finding,
interpreting and applying online sexual health information in a rapidly-changing health
information landscape. More specifically, it has provided exploration and analysis of young
people’s experiences with online sexual health information, using a broad and
comprehensive approach that embodies an expansive conceptualisation of sexual health
literacy. This study was novel in considering the relationship between traditional, ‘offline’
sources of sexual health information and the ‘online’ environment as a means of
understanding the interactive aspects of sexual health literacy. It was also crucial to explore
young people’s sexual health decision-making within various information and support
contexts, including school, peers and social media, and to consider what influences those
contexts might have on decision-making. A key strength of the research is that it provides
insights into a diverse range of experiences and practices of young people within the Scottish
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context, while previous research on this topic has primarily been conducted with
college/university-aged and educated groups in the USA. There was a need for up-to-date,
qualitative research within the Scottish context, exploring the variety, importance and
sufficiency of young people’s different information sources. Further, given the potential of
digital technology in sexual health care and prevention, there was a need for quality research
to examine young people’s perceptions and experiences of online sexual health information
and support, identifying ways in which new technologies might be used to promote young
peoples’ sexual health in both the short and long terms.
A specific strength of this study is that it enabled me to observe young people’s experiences
of negotiating sexual health information online, in addition to collecting their self-described
perceptions and practices. This was achieved through an innovative research design that
integrated interview and observational methods to allow for more complete understanding
of participants’ perspectives and practices. The observational online activity allowed
exploration of how participants actually experienced searching for and evaluating sexual
health information in real time, albeit under artificial conditions, which reduced the need to
rely on, and prompt participants for, self-reported descriptions of information-seeking
practices, which are often considered ‘natural’ and therefore difficult to recall. Thus, data
from each part of the interview could be used to compare findings from multiple research
studies, elaborate upon findings from each research stage in the other and discover
contradictions between multiple stages (Greene et al, 1989).
While this study has several substantial strengths, it is crucial to reflect on its limitations.
Regarding the sample, while the young people recruited were diverse, some groups were not
represented, including those who did not have access to the internet, young people from
ethnic minorities and young people from very remote, rural locations. Thus, it must be
recognised that the findings may not be directly transferable to groups not represented, such
as those without internet access or little social support. Another potential limitation of the
sample is that the perspectives of the young people who chose to take part in the research
may differ from those who did not, or would not, choose to participate. Further, while a
range of recruitment strategies were used in order to access a range of experiences, many
participants were recruited through gatekeepers within youth and community organisations,
and were therefore engaged within their communities to some extent. For these reasons,
participants may have been somewhat self-selecting for both a willingness to discuss sexual
health and for having a social support network to draw on, and the sample may have
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underrepresented those who do not have such social support, may struggle the most to
communicate about sexual health, and may be more likely to instead seek support online.
Another potential limitation of the sample is that, because asking participants’ about their
own sexual experience or behaviours was deemed to be beyond the scope of the research, it
is not clear whether the sample is representative of the population in terms of engagement in
risky sexual behaviours; while indications of participants’ behaviours emerged from many
of the interviews, I did not seek to comprehensively collect such data. While acknowledging
these important considerations about the potential limitations of the sample, it is appropriate
to note that truly randomly sampling is unlikely to be feasible for research of this type; those
young people most averse to discussing sex and sexual health are unlikely to participate in
research about those topics, and questioning participants about their own risky sexual
behaviours is unlikely to engender trust and openness.
It is important to properly situate the findings, which were based on both my interpretations
and on the participants’ own narratives and representations of their experiences. Further, it
is crucial to be consider to context of data collection when interpreting the findings; the
relatively artificial interview context in which participants made their contributions may
have influenced those responses. Within that context, participants’ responses were subject
to influence from both myself, as a researcher, and also by their friend. As with much
qualitative research, this research was highly reliant on each participant’s presentations of
self. While the online activity afforded more opportunities for participants’ self-
presentations to be compared against their practices than would be afforded solely by an
interview, the artificial nature of the online activity will have inevitably influenced the data
generated. Observational methods can be illuminating and insightful, but it is crucial that
researchers remain aware of their limitations, particularly in how their artificial parameters
and participants’ awareness of being observed may result in practices that differ from those
carried out in natural, unobserved circumstances.
In taking stock of limitations of research, it is important to identify areas where data
collection did not produce data relevant to specific topics of interest. Specifically, details of
how participants used and applied sexual health information found online proved
challenging to access. Participants struggled to recall specific examples of applying online
sexual health information, so I opted to approach the issue in more general terms, exploring
the general process of applying sexual health information within a range of different
contexts, and the barriers that might be encountered. Another opportunity to gather more
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comprehensive data might have been to perform detailed analysis of the specific websites
accessed during the online activity. This analysis was beyond the scope of this research, but
a greater understanding of the content and presentation of the online sources used might
provide further insights into participants’ experiences of negotiating sexual health
information online. Further research might build upon emerging understandings by
producing a scoping review of sexual health websites available for young people and their
health literacy requirements.
A limitation inherent to research into digital technologies relates to the rapidly-changing
nature of online technologies and the dynamic nature of online practices. While my research
generated broad data that captured the breadth of both participants’ self-reported
perspectives and experiences and their online information-seeking practices, it is important
to note that the relevance of those data may diminish more rapidly than the findings of
research concerned with less dynamic contexts. In addition to being limited by their
relevance to specific social groups in specific types of location within Scotland, my findings
are limited by their relevance to: contemporary digital technologies; the contemporary
information-seeking practices of young people; and the contemporary information available
on the internet. Conversely, the time-sensitive nature of my findings also highlights their
heightened value as a contribution to literature, as previous research into similar topics will
likely be of diminished relevance to current technologies, practices and information. The
nature of how online information-seeking experiences and practices evolve may be a useful
topic for further research.
8.6 Recommendations for future research
This study raises a number of issues that require further research. This is the first UK-based
study focusing on sexual health literacy amongst young people, and has provided a range of
insights into experiences of, and perspectives on, finding, evaluating and using online sexual
health information and support, identifying ways in which new technologies might be used
to promote young people’s sexual health in both the short and long terms. This work could
potentially be expanded using quantitative methods and through comparative work in other
global contexts. The findings could also be further explored with particular groups, including
further research into the experiences of young people with learning disabilities and young
people from ethnic minority backgrounds. Such research could contribute to a more
comprehensive understanding of the varied sexual health literacy experiences of specific
social groups, including the barriers to, and facilitators of, sexual health literacy encountered
269
by young people within those groups, particularly within the online context, which could
inform the development of better information sources and interventions.
Beyond considering the internet as a monolithic information source, this study provided
insights into how young people engage with different types of online content, and how
certain types of content, such as YouTube bloggers, might be particularly well suited to
supporting young people’s critical sexual health literacy. This analysis illustrated the impact
that good user-generated content can have on young people’s critical sexual health literacy
(both social sharing and action), and enhanced understandings of different forms of social
media as contexts for engagement with sexual health information and support, whilst
considering contextual issues related to the identity construction that takes place in such
spaces. This may be an important area for further research exploring the specific online
environment, and specific types of content, that best support young people’s engagement
and critical sexual health literacy.
As well as further research into young people’s perspectives and experiences, further
research may usefully contribute by further triangulating my findings through interviews
with healthcare providers and content creators. Similarly, it may also be useful to review the
quality of sexual health information currently provided online from the perspective of health
literacy demands, accessibility of websites, inclusivity of information, and applicability to
young people’s diverse skills, means and competencies. Such mapping of the content and
quality of information available to young people both online and offline could inform the
development of improved resources. Similarly, further research mapping out variations in
content, style and quality of school-based sexual health education across Scotland could
develop better understandings of how these variations may exacerbate inequalities in sexual
health literacy, and potentially how those inequalities may be addressed. In recognition of
the substantial role of informal peer support, in addition to the online and formal education
environments, further research might also seek to better understand the strength and
weaknesses of informal peer support, potentially understanding how the power of peer
support could be harnessed to encouraging the social reproduction of accurate information
and positive messages related to sexual health.
Finally, further exploration and development of sexual health literacy as a concept, and as a
measurement tool would be beneficial. Research has highlighted a relationship between
health literacy and health outcomes, with an updated systematic review from Berman et al
270
(2011) finding that low health literacy is associated with poorer health outcomes and less
health care service use. To be able to intervene to improve sexual health literacy, it is
necessary to first develop practical, reliable measures of sexual health literacy, so that better-
tailored sexual health education can be built upon empirical understandings of young
people’s existing sexual health literacy. As highlighted in my literature review, most health
literacy measurement tools have been one-dimensional, not recognising the
multidimensional nature of health literacy, and none have focused on sexual health literacy
(Jordan et al, 2011; Sorenson et al, 2012). Nutbeam (2009) calls for more work on
developing health literacy measurements that are specific to defined health content and
contexts. Due to sexual health literacy’s underdevelopment as a concept, no measurement
tools have been developed that are specific to sexual health literacy. This study has further
contributed to developing sexual health literacy as a concept, and could serve as a basis upon
which to create a sexual health literacy measurement tool.
In this thesis, I used a combination of paired interviews and observational activities to
analyse young people’s experiences of sexual health literacy, exploring the role played by
the internet within a wider landscape of information and support, and examining the
influences of various individual, socio-cultural, information provision and structural factors
on sexual health literacy. While similarities were identified between young people’s
perspectives, the findings revealed many stark contrasts in experiences, attitudes and
preferences, illustrating the complexity of improving young people’s sexual health literacy.
These observations suggest that, for interventions designed to improve young people’s
sexual health and sexual health literacy to be effective, they must be expansive in terms of
scope and flexible to individual differences. Seeking to replace an offline service with an
online one may be too simplistic, given both the interactions between the two environments,
and the variation in young people’s ability to effectively use online information and services.
Instead, effective interventions may be multi-faceted, seeking to provide information and
support through a range of different media and in a variety of different styles, to cater to the
breadth of young peoples’ preferences and needs. Thus, further research should develop and
evaluate tailored multimodal interventions that recognise three key needs: the need for a
broad conceptualisation of sexual health literacy; the need to recognise the individual, socio-
cultural, structural and environmental factors that shape sexual health literacy; and the need
to support development of sexual health literacy across key online and offline contexts,
including peers, school, formal healthcare and online.
271
References
Abel, T. (2008) 'Measuring health literacy: moving towards a health-promotion perspective',
International journal of public health, 53(4), pp. 169-70.
Adams, R. J., Stocks, N. P., Wilson, D. H., Hill, C. L., Gravier, S., Kickbusch, I. and Beilby,
J. J. (2009) 'Health literacy: a new concept for general practice?', Australian Family
Physician, 38(3), pp. 144.
Adams, S. A. (2010) 'Revisiting the online health information reliability debate in the wake
of “web 2.0”: an inter-disciplinary literature and website review', International journal of
medical informatics, 79(6), pp. 391-400.
Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs American
Medical Association (AMA) (1999) 'Health literacy: report of the Council on Scientific
Affairs', JAMA, 281, pp. 552-557.
Aicken, C., Estcourt, C. S., Johnson, A. M., Sonnenberg, P., Wellings, K. and Mercer, C. H.
(2016) 'Use of the internet for sexual health among sexually experienced persons aged 16 to
44 years: evidence from a nationally representative survey of the British population', Journal
of medical Internet research, 18(1).
Albury, K. (2014) 'Porn and sex education, porn as sex education', Porn Studies, 1(1-2), pp.
172-181.
Albury, K. (2015) 'Selfies, sexts, and sneaky hats: Young people’s understandings of
gendered practices of self-representation', International Journal of Communication, 9(2015),
pp. 1734-1745.
Alldred P and David, M. (2007) Get real about sex: The politics and practice of sex
education. Berkshire: McGraw-Hill Education (UK).
Allen, L. (2006) '“Looking at the Real Thing”: Young men, pornography, and sexuality
education', Discourse: studies in the cultural politics of education, 27(1), pp. 69-83.
272
Allen, L. (2008) ''They Think You Shouldn't be Having Sex Anyway': Young People's
Suggestions for Improving Sexuality Education Content', Sexualities, 11(5), pp. 573-594.
Allison, S., Bauermeister, J. A., Bull, S., Lightfoot, M., Mustanski, B., Shegog, R. and
Levine, D. (2012) 'The intersection of youth, technology, and new media with sexual health:
moving the research agenda forward', Journal of Adolescent Health, 51(3), pp. 207-212.
Arksey, H. (1996) 'Collecting data through joint interviews', Social Research Update.
Association for Young People’s Health (AYPH) (2017) Young People’s Health, where are
we up to? Update 2017. London: AYPH
Attwood, F. (2014) Mainstreaming sex: The sexualization of Western culture. New York:
IB Tauris.
Australian Bureau of Statistics (2008) Adult literacy and life skills survey. Summary results,
Australia, Canberra: Australian Bureau of Statistics.
Bailey, J. V., Murray, E., Rait, G., Mercer, C. H., Morris, R. W., Peacock, R., Cassell, J. and
Nazareth, I. (2010) 'Interactive computer‐ based interventions for sexual health promotion',
The Cochrane Library.
Bailey, J., Murray, E., Rait, G., Mercer, C., Morris, R., Peacock, R., Cassell, J. and Nazareth,
I. (2012) 'Computer-based interventions for sexual health promotion: systematic review and
meta-analyses', International journal of STD & AIDS, 23(6), pp. 408-413.
Bailey, J., Mann, S., Wayal, S., Hunter, R., Free, C., Abraham, C. and Murray, E. (2015)
'Sexual health promotion for young people delivered via digital media: a scoping review',
Public Health Research, 3(13).
Bailey, J., Mann, S., Wayal, S., Abraham, C. and Murray, E. (2015a) 'Digital media
interventions for sexual health promotion-opportunities and challenges', BMJ, 350, pp.
h1099.
273
Baker, D. W., Williams, M. V., Parker, R. M., Gazmararian, J. A. and Nurss, J. (1999)
'Development of a brief test to measure functional health literacy', Patient education and
counseling, 38(1), pp. 33-42.
Baker, L., Wagner, T. H., Singer, S. and Bundorf, M. K. (2003) 'Use of the Internet and e-
mail for health care information: results from a national survey', Jama, 289(18), pp. 2400-
2406.
Baker, D. W. (2006) 'The meaning and the measure of health literacy', Journal of general
internal medicine, 21(8), pp. 878-883.
Banister, E. M. and Begoray, D. L. (2006) 'Adolescent girls' sexual health education in an
indigenous context', Canadian Journal of Native Education, 29(1), pp. 75.
Barman-Adhikari, A. and Rice, E. (2011) 'Sexual health information seeking online among
runaway and homeless youth', Journal of the Society for Social Work and Research, 2(2),
pp. 89-103.
Barron, B., Martin, C. K., Takeuchi, L. and Fithian, R. (2009) 'Parents as learning partners
in the development of technological fluency'.
Barter, C., Wood, M., Aghtaie, N., Larkins, C., Stanley, N., Apostolov, G., Shahbazyan, L.,
Pavlou, S., Lesta, S., De Luca, N., Cappello, G., Overlien, C. and Hellevik, P. (2015).
Incidence Rates and Impact of Experiencing Interpersonal Violence and Abuse in Young
People’s Relationships. Briefing Paper 2, Safeguarding Teenage Intimate Relationships
(STIR); DAPHNE III European Commission. Available at: http://stiritup.eu/wp-
content/uploads/2015/06/STIR-Briefing-Paper-2-English-final.pdf (Accessed 6th July
2017)
Barzilai-Nahon, K. (2006) 'Gaps and bits: Conceptualizing measurements for digital
divide/s', The information society, 22(5), pp. 269-278.
Bass, P. F., Wilson, J. F. and Griffith, C. H. (2003) 'A shortened instrument for literacy
screening', Journal of general internal medicine, 18(12), pp. 1036-1038.
274
Bay‐ Cheng, L. Y. (2001) 'SexEd. com: Values and norms in web‐ based sexuality
education', Journal of Sex Research, 38(3), pp. 241-251.
Bay-Cheng, L. Y. (2005) 'Left to their own devices: Disciplining youth discourse on
sexuality education electronic bulletin boards', Sexuality Research and Social Policy, 2(1),
pp. 37-50.
Beer, D. and Burrows, R. (2007) 'Sociology and, of and in Web 2.0: Some initial
considerations', Sociological Research Online, 12(5), pp. 17.
Benigeri, M. and Pluye, P. (2003) 'Shortcomings of health information on the Internet',
Health promotion international, 18(4), pp. 381-386.
Berkman, N. D., Davis, T. C. and McCormack, L. (2010) 'Health literacy: what is it?',
Journal of health communication, 15(S2), pp. 9-19.
Birru, M. S., Monaco, V. M., Charles, L., Drew, H., Njie, V., Bierria, T., Detlefsen, E. and
Steinman, R. A. (2004) 'Internet usage by low-literacy adults seeking health information: an
observational analysis', Journal of Medical Internet Research, 6(3), pp. e25.
Block, D. (2000) 'Problematizing interview data: Voices in the mind's machine?', Tesol
Quarterly, 34(4), pp. 757-763.
Bloor, M. (2001) Focus groups in social research. London: Sage.
Bond, B. J., Hefner, V. and Drogos, K. L. (2009) 'Information-seeking practices during the
sexual development of lesbian, gay, and bisexual individuals: The influence and effects of
coming out in a mediated environment', Sexuality & Culture, 13(1), pp. 32-50.
Boonaert, T. and Vettenburg, N. (2011) 'Young people’s internet use: Divided or
diversified?', Childhood, 18(1), pp. 54-66.
Booth, M. L., Bernard, D., Quine, S., Kang, M. S., Usherwood, T., Alperstein, G. and
Bennett, D. L. (2004) 'Access to health care among Australian adolescents young people's
perspectives and their sociodemographic distribution', Journal of Adolescent Health, 34(1),
pp. 97-103.
275
Borzekowski, D. L. and Rickert, V. I. (2001) 'Adolescent cybersurfing for health
information: a new resource that crosses barriers', Archives of pediatrics & adolescent
medicine, 155(7), pp. 813-817.
Borzekowski, D. L. and Rickert, V. I. (2001a) 'Adolescents, the Internet, and health: Issues
of access and content', Journal of Applied Developmental Psychology, 22(1), pp. 49-59.
Boyd, D. (2008) 'Facebook's privacy trainwreck: Exposure, invasion, and social
convergence', Convergence, 14(1), pp. 13-20.
Boyd, D. (2014) It's Complicated: The Social Lives of Networked Teens. New Haven: Yale
University Press.
Boyd, D. and Marwick, A. (2011) 'Social steganography: Privacy in networked publics',
International Communication Association, Boston, MA, pp. 93.
Bragg, S. and Buckingham, D. (2009) 'Too much too young? Young people, sexual media
and learning', in Attwood, F. (ed.) Mainstreaming Sex: The Sexualization of Western
Culture. London: I.B. Tauris, pp. 129-146.
Brewer, J. (2000) Ethnography. McGraw-Hill Education (UK).
Broderick, J., Devine, T., Langhans, E., Lemerise, A. J., Lier, S. and Harris, L. (2014)
Designing health literate mobile apps. Institute of Medicine of the National Academies.
Brodie, M., Flournoy, R. E., Altman, D. E., Blendon, R. J., Benson, J. M. and Rosenbaum,
M. D. (2000) 'Health information, the Internet, and the digital divide', Health affairs, 19(6),
pp. 255-265.
Broom, A. and Willis, E. (2007) 'Competing paradigms and health research', in Saks, M. &
Allsop, J. (eds.) Researching health: qualitative, quantitative and mixed methods. London:
Sage, pp. 16-30.
Bruns, A. (2009) 'Social media: Tools for user-generated content: Social drivers behind
growing consumer participation in user-led content generation, Volume 2-User engagement
276
strategies', http://www. smartservicescrc. com. au/files/files/Social-Media-Volume2-User-
Engagement-Strategies. pdf, pp. 1-47.
Bryman, A. (2015) Social research methods. Oxford: Oxford university press.
Buckingham, D. and Buckingham, D. (2006) 'Is there a digital generation', in Buckingham
D and Willet R (ed.) Digital generations: Children, young people, and new media. Mahway,
NJ: Lawrence Erlbaum Associates, pp. 1-13.
Buhi, E. R., Daley, E. M., Fuhrmann, H. J. and Smith, S. A. (2009) 'An observational study
of how young people search for online sexual health information', Journal of American
college health, 58(2), pp. 101-111.
Buhi, E. R. and Goodson, P. (2007) 'Predictors of adolescent sexual behavior and intention:
A theory-guided systematic review', Journal of Adolescent Health, 40(1), pp. 4-21.
Bull, S., Pratte, K., Whitesell, N., Rietmeijer, C. and McFarlane, M. (2009) 'Effects of an
Internet-based intervention for HIV prevention: the Youthnet trials', AIDS and Behavior,
13(3), pp. 474-487.
Burnett, G., Jaeger, P. T. and Thompson, K. M. (2008) 'Normative behavior and information:
The social aspects of information access', Library & Information Science Research, 30(1),
pp. 56-66.
Buston, K. and Wight, D. (2006) 'The salience and utility of school sex education to young
men', Sex Education, 6(02), pp. 135-150.
Buston, K., Wight, D. and Hart, G. (2002) 'Inside the sex education classroom: the
importance of context in engaging pupils', Culture, Health & Sexuality, 4(3), pp. 317-335.
Byron, P., Albury, K. and Evers, C. (2013) '“It would be weird to have that on Facebook”:
young people's use of social media and the risk of sharing sexual health information',
Reproductive health matters, 21(41), pp. 35-44.
Byron, P. (2015) 'Troubling expertise: social media and young people’s sexual health',
Communication Research and Practice, 1(4), pp. 322-334.
277
Byron, P. (2017) 'Friendship, sexual intimacy and young people’s negotiations of sexual
health', Culture, Health & Sexuality, 19(4), pp. 486-500.
Cabinet Office (2014) Policy Paper: Government Digital Inclusion Strategy. Available at:
https://www.gov.uk/government/publications/government-digital-inclusion-
strategy/government-digital-inclusion-strategy (Accessed: 7th August 2014.
Caplan, R. (1993) 'The importance of social theory for health promotion: from description
to reflexivity', Health promotion international, 8(2), pp. 147-157.
Carley, K. (1986) 'An approach for relating social structure to cognitive structure', Journal
of Mathematical Sociology, 12(2), pp. 137-189.
Carvajal, D. N., Brittner, M. R. and Rubin, S. E. (2013) 'Can apps reduce rates of teen
pregnancy?', Journal of Family Practice, 62(10), pp. 538-540.
Case, D. O., Andrews, J. E., Johnson, J. D. and Allard, S. L. (2005) 'Avoiding versus seeking:
the relationship of information seeking to avoidance, blunting, coping, dissonance, and
related concepts', Journal of the Medical Library Association, 93(3), pp. 353.
Chan, C. V. and Kaufman, D. R. (2011) 'A framework for characterizing eHealth literacy
demands and barriers', Journal of medical Internet research, 13(4), pp. e94.
Chandra-Mouli, V., Lane, C. and Wong, S. (2015) 'What does not work in adolescent sexual
and reproductive health: a review of evidence on interventions commonly accepted as best
practices', Global Health: Science and Practice, 3(3), pp. 333-340.
Chatman, E. A. (1987) 'The Information World of Low-Skilled Workers', Library and
Information Science Research, 9(4), pp. 265-83.
Cheetham, M. (2014) 'The social meanings of the C-Card scheme: the importance of friends
and peers', Sex Education, 14(2), pp. 115-127.
Chen, W. and Wellman, B. (2004) 'The global digital divide–within and between countries',
IT & society, 1(7), pp. 39-45.
278
Chew, L. D., Griffin, J. M., Partin, M. R., Noorbaloochi, S., Grill, J. P., Snyder, A., Bradley,
K. A., Nugent, S. M., Baines, A. D. and VanRyn, M. (2008) 'Validation of screening
questions for limited health literacy in a large VA outpatient population', Journal of general
internal medicine, 23(5), pp. 561-566.
Chinn, D. (2011) 'Critical health literacy: A review and critical analysis', Social science &
medicine, 73(1), pp. 60-67.
Cline, R. J. and Haynes, K. M. (2001) 'Consumer health information seeking on the Internet:
the state of the art', Health education research, 16(6), pp. 671-692.
Cooper, K., Quayle, E., Jonsson, L. and Svedin, C. G. (2016) 'Adolescents and self-taken
sexual images: A review of the literature', Computers in human behavior, 55, pp. 706-716.
Cornwell, J. (1984) Hard-earned lives: accounts of health and illness from East London.
Abingdon: Routledge Kegan & Paul.
Couch, M., Dowsett, G. W., Dutertre, S., Keys, D. and Pitts, M. K. (2006) 'Looking for more:
A review of social and contextual factors affecting young people’s sexual health', The
Australian research centre in sex, health and society monograph series. Melbourne: La Trobe
University.
Crabbe, M. and Corlett, D. (2011) 'Eroticising inequality: Technology, pornography and
young people', Redress, 20(1), pp. 11.
Creswell, J. W. (2013) Research design: Qualitative, quantitative, and mixed methods
approaches. London: Sage publications.
Crotty, M. (1998) The foundations of social research: Meaning and perspective in the
research process. London: Sage.
Davis, T. C., Crouch, M., Long, S. W., Jackson, R. H., Bates, P., George, R. B. and
Bairnsfather, L. E. (1991) 'Rapid assessment of literacy levels of adult primary care patients',
Family medicine, 23(6), pp. 433-435.
279
Day, A. L. and Livingstone, H. A. (2003) 'Gender differences in perceptions of stressors and
utilization of social support among university students', Canadian Journal of Behavioural
Science, 35(2), pp. 73-83.
De Ridder, S. and Van Bauwel, S. (2013) 'Commenting on pictures: Teens negotiating
gender and sexualities on social networking sites', Sexualities, 16(5-6), pp. 565-586.
Department of Health (2013) A Framework for Sexual Health Improvement in England,
London: Department of Health.
Department of Health and Human Services (2000) Healthy people 2010. US Dept. of Health
and Human Services.
DiCenso, A., Borthwick, V. W. and Creatura, C. (2001) 'Completing the picture:
Adolescents talk about what's missing in sexual health services', Canadian journal of public
health, 92(1), pp. 35.
DiMaggio, P. and Hargittai, E. (2001) 'From the ‘digital divide’to ‘digital inequality’:
Studying Internet use as penetration increases', Princeton: Center for Arts and Cultural
Policy Studies, Woodrow Wilson School, Princeton University, 4(1), pp. 4-2.
Downing, S. G., Cashman, C., McNamee, H., Penney, D., Russell, D. B. and Hellard, M. E.
(2013) 'Increasing chlamydia test of re-infection rates using SMS reminders and incentives',
Sexually transmitted infections, 89(1), pp. 16-19.
Drouin, M. and Tobin, E. (2014) 'Unwanted but consensual sexting among young adults:
Relations with attachment and sexual motivations', Computers in Human Behavior, 31, pp.
412-418.
Dutton, W. H. and Helsper, E. J. (2007) Oxford internet survey 2007 report: The internet in
Britain, Oxford, UK: Oxford Internet Institute, University of Oxford.
eHealth Stakeholder Group (2014) Health inequalities and eHealth. European Commission.
Available at: http://ec.europa.eu/digital-agenda/en/news/commission-publishes-four-
reports-ehealth-stakeholder-group (Accessed: 2nd February 2015)
280
Elford, J., Bolding, G., Davis, M., Sherr, L. and Hart, G. (2004) 'Web-based behavioral
surveillance among men who have sex with men: a comparison of online and offline samples
in London, UK', JAIDS Journal of Acquired Immune Deficiency Syndromes, 35(4), pp. 421-
426.
Elliott, L., Henderson, M., Nixon, C. and Wight, D. (2013) 'Has untargeted sexual health
promotion for young people reached its limit? A quasi-experimental study', Journal of
epidemiology and community health, pp. jech-2012-201034.
Elwick, A., Liabo, K., Nutt, J. and Simon, A. (2013) 'Beyond the digital divide: young people
and ICT', Reading: CfBT Education Trust, SSRU Institute of Education.
Estcourt, C. S., Gibbs, J., Sutcliffe, L. J., Gkatzidou, V., Tickle, L., Hone, K., Aicken, C.,
Lowndes, C. M., Harding-Esch, E. M. and Eaton, S. (2017) 'The eSexual Health Clinic
system for management, prevention, and control of sexually transmitted infections:
exploratory studies in people testing for Chlamydia trachomatis', The Lancet Public Health,
2(4), pp. e182-e190.
European Commission 2007. Together for health: a strategic approach for the EU 2008-
2013. European Commission Brussels.
Evers, C. W., Albury, K., Byron, P. and Crawford, K. (2013) 'Young people, social media,
social network sites and sexual health communication in Australia:" This is funny, you
should watch it"', International Journal of Communication, 7, pp. 18.
Eynon, R. (2009) 'Mapping the digital divide in Britain: implications for learning and
education', Learning, Media and Technology, 34(4), pp. 277-290.
Eysenbach, G. and Köhler, C. (2002) 'How do consumers search for and appraise health
information on the world wide web? Qualitative study using focus groups, usability tests,
and in-depth interviews', Bmj, 324(7337), pp. 573-577.
Facer, K. and Furlong, R. (2001) 'Beyond the myth of the'cyberkid': Young people at the
margins of the information revolution', Journal of youth studies, 4(4), pp. 451-469.
281
Fergie, G. M. (2015) Understanding young adults’ online engagement and health
experiences in the age of social media: exploring diabetes and common mental health
disorders. PhD Thesis; University of Glasgow.
Fergie, G., Hunt, K. and Hilton, S. (2016) 'Social media as a space for support: Young adults'
perspectives on producing and consuming user-generated content about diabetes and mental
health', Social Science & Medicine, 170, pp. 46-54.
Flood, M. (2009) 'The harms of pornography exposure among children and young people',
Child abuse review, 18(6), pp. 384-400.
Flowers, P., Riddell, J., Park, C., Ahmed, B., Young, I., Frankis, J., Davis, M., Gilbert, M.,
Estcourt, C. and Wallace, L. (2016) 'Preparedness for use of the rapid result HIV self‐ test
by gay men and other men who have sex with men (MSM): a mixed methods exploratory
study among MSM and those involved in HIV prevention and care', HIV medicine, 18(4),
pp. 245-255.
Formby, E. (2011) 'Sex and relationships education, sexual health, and lesbian, gay and
bisexual sexual cultures: Views from young people', Sex education, 11(3), pp. 255-266.
Forrest, S. (2007) Boys, young men and sexual health services: The conditions and
circumstances under which boys and young men first use sexual health services, London
UK: Boys Development Project, Brook.
Forrest, S., Strange, V., Oakley, A. and The Ripple Study Team (2004) 'What do young
people want from sex education? The results of a needs assessment from a peer-led sex
education programme', Culture, health & sexuality, 6(4), pp. 337-354.
Fox, S., Rainie, L. and Horrigan, J. (2006) 'The Online Health Care Revolution: How the
Web Helps Americans Take Better Care of Themselves. Washington, DC: Pew Internet &
American Life Project
Freedman, D. A., Bess, K. D., Tucker, H. A., Boyd, D. L., Tuchman, A. M. and Wallston,
K. A. (2009) 'Public health literacy defined', American journal of preventive medicine, 36(5),
pp. 446-451.
282
French, R. S., Cowan, F. M., Wellings, K. and Dowie, J. (2013) 'The development of a multi-
criteria decision analysis aid to help with contraceptive choices: My Contraception Tool',
Journal of Family Planning and Reproductive Health Care, pp. jfprhc-2013-100699.
Frost, N., Nolas, S. M., Brooks-Gordon, B., Esin, C., Holt, A., Mehdizadeh, L. and
Shinebourne, P. (2010) 'Pluralism in qualitative research: The impact of different researchers
and qualitative approaches on the analysis of qualitative data', Qualitative research, 10(4),
pp. 441-460.
Gabarron, E. and Wynn, R. (2016) 'Use of social media for sexual health promotion: a
scoping review', Global Health Action, 9.
Gale, N. K., Heath, G., Cameron, E., Rashid, S. and Redwood, S. (2013) 'Using the
framework method for the analysis of qualitative data in multi-disciplinary health research',
BMC medical research methodology, 13(1), pp. 117.
Gantley M, Harding G, Kumar S and Tissier J (1999) An introduction to qualitative methods
for health professionals, London: Royal College of General Practitioners.
Garside, R., Ayres, R., Owen, M., Pearson, V. A. and Roizen, J. (2002) 'Anonymity and
confidentiality: Rural teenagers' concerns when accessing sexual health services', Journal of
Family Planning and Reproductive Health Care, 28(1), pp. 23-26.
Gee, J. P. (2014) An introduction to discourse analysis: Theory and method. New York:
Routledge.
Gibbs, J., Gkatzidou, V., Tickle, L., Manning, S. R., Tilakkumar, T., Hone, K., Ashcroft, R.
E., Sonnenberg, P., Sadiq, S. T. and Estcourt, C. S. (2016) '‘Can you recommend any good
STI apps?’A review of content, accuracy and comprehensiveness of current mobile medical
applications for STIs and related genital infections', Sexually Transmitted Infections, pp.
sextrans-2016-052690.
Gibson, B. E. (2005) 'Co-producing video diaries: The presence of the “absent” researcher',
International journal of qualitative methods, 4(4), pp. 34-43.
283
Gilbert, L. K., Temby, J. R. E. and Rogers, S. E. (2005) 'Evaluating a teen STD prevention
Web site', Journal of Adolescent Health, 37(3), pp. 236-242.
Gilbert, M., Dulai, J., Wexel, D. and Ferlatte, O. 2014. Health literacy, sexual health and gay
men: Current perspectives. Toronto, ON: Ontario HIV Treatment Network.
Gkatzidou, V., Hone, K., Sutcliffe, L., Gibbs, J., Sadiq, S. T., Szczepura, A., Sonnenberg, P.
and Estcourt, C. (2015) 'User interface design for mobile-based sexual health interventions
for young people: Design recommendations from a qualitative study on an online Chlamydia
clinical care pathway', BMC medical informatics and decision making, 15(1), pp. 72.
Gold, J., Pedrana, A. E., Sacks-Davis, R., Hellard, M. E., Chang, S., Howard, S., Keogh, L.,
Hocking, J. S. and Stoove, M. A. (2011) 'A systematic examination of the use of online
social networking sites for sexual health promotion', BMC public health, 11(1), pp. 583.
Gold, J., Pedrana, A. E., Stoove, M. A., Chang, S., Howard, S., Asselin, J., Ilic, O.,
Batrouney, C. and Hellard, M. E. (2012) 'Developing health promotion interventions on
social networking sites: recommendations from The FaceSpace Project', Journal of medical
Internet research, 14(1), pp. e30.
Goldberg, D. S. (2007) 'Justice, health literacy and social epidemiology', The American
Journal of Bioethics, 7(11), pp. 18-20.
Goodson, I. F. and Mangan, J. M. (1996) 'Computer literacy as ideology', British Journal of
Sociology of Education, 17(1), pp. 65-79.
Graf, A. S. and Patrick, J. H. (2015) 'Foundations of life-long sexual health literacy', Health
Education, 115(1), pp. 56-70.
Gray, N. J., Klein, J. D., Noyce, P. R., Sesselberg, T. S. and Cantrill, J. A. (2005) 'The
Internet: a window on adolescent health literacy', Journal of adolescent health, 37(3), pp.
243.
Greene, J. C., Caracelli, V. J. and Graham, W. F. (1989) 'Toward a conceptual framework
for mixed-method evaluation designs', Educational evaluation and policy analysis, 11(3),
pp. 255-274.
284
Guse, K., Levine, D., Martins, S., Lira, A., Gaarde, J., Westmorland, W. and Gilliam, M.
(2012) 'Interventions using new digital media to improve adolescent sexual health: a
systematic review', Journal of Adolescent Health, 51(6), pp. 535-543.
Guzzo, K. B. and Hayford, S. (2012) 'Race-ethnic differences in sexual health knowledge',
Race and social problems, 4(3-4), pp. 158-170.
Hansen, D. L., Derry, H. A., Resnick, P. J. and Richardson, C. R. (2003) 'Adolescents
searching for health information on the Internet: an observational study', Journal of medical
Internet research, 5(4), pp. e25.
Harding, S. G. (1986) The science question in feminism. Milton Keynes: Cornell University
Press.
Hargittai, E. and Hinnant, A. (2008) 'Digital inequality differences in young adults' use of
the Internet', Communication Research, 35(5), pp. 602-621.
Harvey, K. J., Brown, B., Crawford, P., Macfarlane, A. and McPherson, A. (2007) '‘Am I
normal?’Teenagers, sexual health and the internet', Social science & medicine, 65(4), pp.
771-781.
Hasinoff, A. A. (2013) 'Sexting as media production: Rethinking social media and sexuality',
New Media & Society, 15(4), pp. 449-465.
Health Protection Scotland (HPS) (2015) HPS Weekly Report – Genital herpes simplex,
genital chlamydia and gonorrhoea infection in Scotland: laboratory diagnoses 2005-2015.
Available at: http://www.hps.scot.nhs.uk/documents/ewr/pdf2015/1524.pdf (Accessed 6th
July 2017)
Health Protection Scotland (HPS) (2016) Chlamydia trachomatis and Neisseria
gonorrhoeae infection in Scotland: laboratory diagnoses 2006-2015. Available at:
http://www.hps.scot.nhs.uk/documents/ewr/pdf2016/1639.pdf (Accessed 6th July 2017)
Helitzer, D., Hollis, C., Sanders, M. and Roybal, S. (2012) 'Addressing the “other” health
literacy competencies—knowledge, dispositions, and oral/aural communication:
285
development of TALKDOC, an intervention assessment tool', Journal of health
communication, 17(sup3), pp. 160-175.
Helsper, E. J. and Eynon, R. (2010) 'Digital natives: where is the evidence?', British
educational research journal, 36(3), pp. 503-520.
Henderson, L. (2011) 'Sexting and sexual relationships among teens and young adults',
McNair Scholars Research Journal, 7(1), pp. 9.
Highet, G. (2003) 'Cannabis and smoking research: interviewing young people in self-
selected friendship pairs', Health Education Research, 18(1), pp. 108-118.
Hillier, L., Mitchell, K. J. and Ybarra, M. L. (2012) 'The Internet as a safety net: Findings
from a series of online focus groups with LGB and non-LGB young people in the United
States', Journal of LGBT Youth, 9(3), pp. 225-246.
Hilton, G. L. (2007) 'Listening to the boys again: An exploration of what boys want to learn
in sex education classes and how they want to be taught', Sex Education, 7(2), pp. 161-174.
Holloway, I. W., Rice, E., Gibbs, J., Winetrobe, H., Dunlap, S. and Rhoades, H. (2014)
'Acceptability of smartphone application-based HIV prevention among young men who have
sex with men', AIDS and Behavior, 18(2), pp. 285-296.
Holstein, J. A. and Gubrium, J. F. (2004) 'The active interview', in Silverman D (ed.)
Qualitative research: Theory, method and practice. London: Sage, pp. 140-161.
Hooper, S., Rosser, B. S., Horvath, K. J., Oakes, J. M. and Danilenko, G. (2008) 'An online
needs assessment of a virtual community: what men who use the internet to seek sex with
men want in Internet-based HIV prevention', AIDS and Behavior, 12(6), pp. 867-875.
Horvath, M. A., Alys, L., Massey, K., Pina, A., Scally, M. and Adler, J. R. (2013) Basically...
porn is everywhere: a rapid evidence assessment on the effects that access and exposure to
pornography has on children and young people. London, UK: Office of the Children’s
Commissioner for England.
286
Houck, C. (2013) 'Youth sexting: Balancing media representations and emerging data', The
Brown University Child and Adolescent Behavior Letter, 29, pp. 1-8.
Houssart, J. and Evens, H. (2011) 'Conducting task‐ based interviews with pairs of children:
consensus, conflict, knowledge construction and turn taking', International Journal of
Research & Method in Education, 34(1), pp. 63-79.
Information Services Division (2017) Teenage Pregnancy: Year of Conception ending 31
December 2015. Available at: http://www.isdscotland.org/Health-Topics/Sexual-
Health/Publications/2017-07-04/2017-07-04-TeenPreg-Summary.pdf? (Accessed 6th July
2017)
Institute of Medicine. 2004. Health literacy: a prescription to end confusion. National
Academies Press Washington, DC.
Isaacson, N. (2006) 'An overview of the role of sexual health organizations, corporations,
and government in determining content and access to online sexuality education for
adolescents', Sexuality Research & Social Policy, 3(2), pp. 24-36.
Ishikawa, H. and Yano, E. (2008) 'Patient health literacy and participation in the health‐
care process', Health Expectations, 11(2), pp. 113-122.
Jaeger, P. T. and Bowman, C. A. (2005) Understanding disability: Inclusion, access,
diversity, and civil rights. Westport, CT: Greenwood Publishing Group.
Jaeger, P. T. and Burnett, G. (2010) Information Worlds. UK: Taylor & Francis.
Janssen, M. and Davis, J. (2009) 'The Youth worker's role in young people's sexual health:
A practice framework', Youth Studies Australia, 28(4), pp. 19-28.
Johnson, S. M. and Bolstad, O. D. (1975) 'Reactivity to home observation: A comparison of
audio recorded behavior with observers present or absent', Journal of Applied Behavior
Analysis, 8(2), pp. 181-185.
287
Jones, K., Baldwin, K. A. and Lewis, P. R. (2012) 'The potential influence of a social media
intervention on risky sexual behavior and Chlamydia incidence', Journal of community
health nursing, 29(2), pp. 106-120.
Jones, K., Eathington, P., Baldwin, K. and Sipsma, H. (2014) 'The impact of health education
transmitted via social media or text messaging on adolescent and young adult risky sexual
behavior: a systematic review of the literature', Sexually transmitted diseases, 41(7), pp. 413-
419.
Jones, R. K. and Biddlecom, A. E. (2011) 'Is the internet filling the sexual health information
gap for teens? An exploratory study', Journal of health communication, 16(2), pp. 112-123.
Jones, S. and Norton, B. (2007) 'On the limits of sexual health literacy: Insights from
Ugandan schoolgirls', Diaspora, Indigenous, and Minority Education, 1(4), pp. 285-305.
Jones-Kavalier, B. R. and Flannigan, S. I. (2008) 'Connecting the digital dots: Literacy of
the 21st century', Teacher Librarian, 35(3), pp. 13.
Jordan, J. E., Osborne, R. H. and Buchbinder, R. (2011) 'Critical appraisal of health literacy
indices revealed variable underlying constructs, narrow content and psychometric
weaknesses', Journal of clinical epidemiology, 64(4), pp. 366-379.
Jordan, J. E., Buchbinder, R., Briggs, A. M., Elsworth, G. R., Busija, L., Batterham, R. and
Osborne, R. H. (2013) 'The Health Literacy Management Scale (HeLMS): A measure of an
individual's capacity to seek, understand and use health information within the healthcare
setting', Patient education and counseling, 91(2), pp. 228-235.
Kang, M., Skinner, R. and Usherwood, T. (2010) 'Interventions for young people in Australia
to reduce HIV and sexually transmissible infections: a systematic review', Sexual health,
7(2), pp. 107-128.
Kann, L. K. (1987) 'Effects of Computer‐ assisted Instruction on Selected Interaction Skills
Related to Responsible Sexuality', Journal of school health, 57(7), pp. 282-287.
Kanuga, M. and Rosenfeld, W. D. (2004) 'Adolescent sexuality and the internet: the good,
the bad, and the URL', Journal of pediatric and adolescent gynecology, 17(2), pp. 117-124.
288
Kawachi, I. and Berkman, L. F. (2003) Neighborhoods and health. New York: Oxford
University Press.
Kay, M., Santos, J. and Takane, M. (2011) 'mHealth: New horizons for health through
mobile technologies', World Health Organization, 3, pp. 66-71.
Keller, S., LaBelle, H., Karimi, N. and Gupta, S. (2004) 'Talking about STD/HIV prevention:
A look at communication online', AIDS care, 16(8), pp. 977-992.
Kendall, N. (2013) The sex education debates. Chicago: University of Chicago Press.
Kickbusch, I., Wait, S. and Maag, D. (2005) Navigating health: The role of health literacy.
Alliance for Health and the Future; International Longevity Centre-UK.
Kickbusch, I. (2008) 'Health literacy: an essential skill for the twenty-first century', Health
Education, 108(2), pp. 101-104.
Kidd, P. S. and Parshall, M. B. (2000) 'Getting the focus and the group: enhancing analytical
rigor in focus group research', Qualitative health research, 10(3), pp. 293-308.
Kim, C. R. and Free, C. (2008) 'Recent evaluations of the peer‐ led approach in adolescent
sexual health education: A systematic review', Perspectives on sexual and reproductive
health, 40(3), pp. 144-151.
Kimmel, A., Williams, T. T., Veinot, T. C., Campbell, B., Campbell, T. R., Valacak, M. and
Kruger, D. J. (2013) '‘I make sure I am safe and I make sure I have myself in every way
possible’: African-American youth perspectives on sexuality education', Sex education,
13(2), pp. 172-185.
Kirby, D. B., Laris, B. and Rolleri, L. A. (2007) 'Sex and HIV education programs: their
impact on sexual behaviors of young people throughout the world', Journal of Adolescent
Health, 40(3), pp. 206-217.
Kirby, J. L. M., van der Sluijs, W. and Currie, C. (2010) 'Sexual health among young people
in Scotland'. HBSC Briefing Paper 18. University of Edinburgh.
289
Kitzinger, J. (2004) 'The grit in the oyster: Analysing phrases, anecdotes, analogies,
associations and silences in focus groups', Bulletin de Psychologie, 57, pp. 299-308
Kitzinger, J. and Barbour, R. (1999) Developing focus group research: politics, theory and
practice. London: Sage.
Klein, J. D., Wilson, K. M., McNulty, M., Kapphahn, C. and Collins, K. S. (1999) 'Access
to medical care for adolescents: results from the 1997 Commonwealth Fund Survey of the
Health of Adolescent Girls', Journal of Adolescent Health, 25(2), pp. 120-130.
Kline, R. R. (2000) Consumers in the country: Technology and social change in rural
America. Baltimore: The Johns Hopkins University Press.
Krieger, N. (1994) 'Epidemiology and the web of causation: has anyone seen the spider?',
Social science & medicine, 39(7), pp. 887-903.
Kubicek, K., Beyer, W. J., Weiss, G., Iverson, E. and Kipke, M. D. (2010) 'In the dark:
Young men’s stories of sexual initiation in the absence of relevant sexual health information',
Health Education & Behavior, 37(2), pp. 243-263.
Kubicek, K., Carpineto, J., McDavitt, B., Weiss, G. and Kipke, M. D. (2011) 'Use and
perceptions of the internet for sexual information and partners: a study of young men who
have sex with men', Archives of sexual behavior, 40(4), pp. 803-816.
Kvale, S. (2008) Doing interviews. London: Sage.
Kwan, B., Frankish, J., Rootman, I., Zumbo, B., Kelly, K., Begoray, D., Kazanijan, A.,
Mullet, J. and Hayes, M. (2006) 'The development and validation of measures of “health
literacy” in different populations', UBC Institute of Health Promotion Research and
University of Victoria Community Health Promotion Research.
Laegran, A. (2008) 'Technosocial Space: Connecting People and Places', in Turner P, Turner
S & Davenport E (eds.) Exploration of Space, Technology, and Spatiality: Interdisciplinary
Perspectives. London: Information Science Reference.
290
Langille, D., MacKinnon, D., Marshall, E. and Graham, J. (2001) 'So many bricks in the
wall: young women in Nova Scotia speak about barriers to school-based sexual health
education', Sex Education: Sexuality, Society and Learning, 1(3), pp. 245-257.
Lester, C. and Allan, A. (2006) 'Teenage sexual health needs: asking the consumers', Health
Education, 106(4), pp. 315-328.
Levine, D., McCright, J., Dobkin, L., Woodruff, A. J. and Klausner, J. D. (2008) 'SEXINFO:
a sexual health text messaging service for San Francisco youth', American journal of public
health, 98(3), pp. 393-395.
Lichy, J. (2011) 'Internet user behaviour in France and Britain: exploring socio‐ spatial
disparity among adolescents', International journal of consumer studies, 35(4), pp. 470-475.
Lim, M. S., Hocking, J. S., Hellard, M. E. and Aitken, C. K. (2008) 'SMS STI: a review of
the uses of mobile phone text messaging in sexual health', International journal of STD &
AIDS, 19(5), pp. 287-290.
Lim, M. S., Hocking, J. S., Aitken, C. K., Fairley, C. K., Jordan, L., Lewis, J. A. and Hellard,
M. E. (2012) 'Impact of text and email messaging on the sexual health of young people: a
randomised controlled trial', Journal of epidemiology and community health, 66(1), pp. 69-
74.
Limmer, M. (2010) 'Young men, masculinities and sex education', Sex Education, 10(4), pp.
349-358.
Lindberg, C., Lewis-Spruill, C. and Crownover, R. (2006) 'Barriers to sexual and
reproductive health care: urban male adolescents speak out', Issues in comprehensive
pediatric nursing, 29(2), pp. 73-88.
Livingstone, S. and Haddon, L. (2009) 'EU Kids Online', Zeitschrift Für
Psychologie/Journal of Psychology, 217(4), pp. 236.
Livingstone, S., Haddon, L., Görzig, A. and Ólafsson, K. (2011) 'Risks and safety on the
internet', The perspective of European children. Full findings and policy implications from
the EU Kids Online survey of, pp. 9-16.
291
Livingstone, S., Haddon, L., Vincent, J., Mascheroni, G. and Ólafsson, K. (2014) Net
children go mobile: The UK report, London: London School of Economics and Political
Science.
Livingstone, S. and Helsper, E. (2007) 'Gradations in digital inclusion: children, young
people and the digital divide', New media & society, 9(4), pp. 671-696.
Livingstone, S. and Mason, J. (2015) Sexual rights and sexual risks among youth online,
London: The London School of Economics and Political Science.
Lorimer, K., Reid, M. E. and Hart, G. J. (2009) 'Willingness of young men and women to be
tested for Chlamydia trachomatis in three non-medical settings in Glasgow, UK', Journal of
Family Planning and Reproductive Health Care, 35(1), pp. 21-26.
Lorimer, K. and McDaid, L. (2013) 'Young men’s views toward the barriers and facilitators
of Internet-based Chlamydia trachomatis screening: qualitative study', Journal of medical
Internet research, 15(12), pp. e265.
MacDonald, J.-A., Gagnon, A. J., Mitchell, C., Di Meglio, G., Rennick, J. E. and Cox, J.
(2011) 'Asking to listen: towards a youth perspective on sexual health education and needs',
Sex Education, 11(4), pp. 443-457.
Macdowall, W., Jones, K. G., Tanton, C., Clifton, S., Copas, A. J., Mercer, C. H., Palmer,
M. J., Lewis, R., Datta, J. and Mitchell, K. R. (2015) 'Associations between source of
information about sex and sexual health outcomes in Britain: findings from the third National
Survey of Sexual Attitudes and Lifestyles (Natsal-3)', BMJ open, 5(3), pp. e007837.
Madden M and Fox S (2006) Finding answers online in sickness and in health. Washington,
DC: Pew Internet and American Life Project.
Magee, J. C., Bigelow, L., DeHaan, S. and Mustanski, B. S. (2012) 'Sexual health
information seeking online: a mixed-methods study among lesbian, gay, bisexual, and
transgender young people', Health Education & Behavior, 39(3), pp. 276-289.
Mager, A. (2012) 'Search engines matter: From educating users towards engaging with
online health information practices', Policy & Internet, 4(2), pp. 1-21.
292
Mancuso, J. M. (2008) 'Health literacy: a concept/dimensional analysis', Nursing & health
sciences, 10(3), pp. 248-255.
Manganello, J. A. (2008) 'Health literacy and adolescents: a framework and agenda for future
research', Health education research, 23(5), pp. 840-847.
Margolis, J., Estrella, R., Goode, J., Holme, J. J. and Nao, K. (2010) Stuck in the shallow
end: Education, race, and computing. Cambridge: MIT Press.
Marsch, L. A., Grabinski, M. J., Bickel, W. K., Desrosiers, A., Guarino, H., Muehlbach, B.,
Solhkhah, R., Taufique, S. and Acosta, M. (2011) 'Computer-assisted HIV prevention for
youth with substance use disorders', Substance use & misuse, 46(1), pp. 46-56.
Marshall, C. and Rossman, G. B. (2014) Designing qualitative research. London; Sage
publications.
Martellozzo, E., Monaghan, A., Adler, J.R., Davidson, J., Leyva, R. and Horvath, M.A.H.
(2017) ‘I wasn’t sure it was normal to watch it: A quantitative and qualitative examination
of the impact of online pornography on the values, attitudes, beliefs and behaviours of
children and young people’. London: NSPCC
Martin, A. (2005) 'DigEuLit–a European framework for digital literacy: a progress report',
Journal of eLiteracy, 2(2), pp. 130-136.
Marwick, A. E. and Boyd, D. (2014) 'Networked privacy: How teenagers negotiate context
in social media', New Media & Society, 16(7), pp. 1051-1067.
Mascheroni, G. and Olafsson, K. (2014) ‘Net Children Go Mobile: risks and opportunities’.
Second Edition. Milano: Educatt.
Mastro, S. and Zimmer-Gembeck, M. J. (2015) 'Let's talk openly about sex: Sexual
communication, self-esteem and efficacy as correlates of sexual well-being', European
Journal of Developmental Psychology, 12(5), pp. 579-598.
Matthews, H. (2001) 'Citizenship, youth councils and young people's participation', Journal
of youth studies, 4(3), pp. 299-318.
293
Mauthner, N. S. and Doucet, A. (2003) 'Reflexive accounts and accounts of reflexivity in
qualitative data analysis', Sociology, 37(3), pp. 413-431.
Mays, N. and Pope, C. (1995) 'Qualitative research: Observational methods in health care
settings', BMJ: British Medical Journal, 311(6998), pp. 182.
McDavitt, B. and Mutchler, M. G. (2014) '“Dude, You’re Such a Slut!” Barriers and
Facilitators of Sexual Communication Among Young Gay Men and Their Best Friends',
Journal of adolescent research, 29(4), pp. 464-498.
McInnes, N. and Haglund, B. J. (2011) 'Readability of online health information:
implications for health literacy', Informatics for health and social care, 36(4), pp. 173-189.
McKee, A., Albury, K. and Lumby, C. (2008) The porn report, Carlton: Melbourne
University Press.
McKee, A. (2010) 'Does pornography harm young people?', Australian Journal of
Communication, 37(1), pp. 17.
McKee, A., Watson, A.-F. and Dore, J. (2014) '‘It's all scientific to me’: focus group insights
into why young people do not apply safe-sex knowledge', Sex Education, 14(6), pp. 652-
665.
McMichael, C. and Gifford, S. (2009) '“It is good to know now… before it’s too late”:
Promoting sexual health literacy amongst resettled young people with refugee backgrounds',
Sexuality & culture, 13(4), pp. 218.
McMichael, C. and Gifford, S. (2010) 'Narratives of sexual health risk and protection
amongst young people from refugee backgrounds in Melbourne, Australia', Culture, health
& sexuality, 12(3), pp. 263-277.
McNair, B. (2013) Porno? Chic!: How pornography changed the world and made it a better
place. London: Routledge.
Measor, L., Tiffin, C. and Miller, K. (2000) Young People's Views on Sex Education:
Education, Attitudes, and Behaviour. London: Routledge.
294
Medley, A., Kennedy, C., O'Reilly, K. and Sweat, M. (2009) 'Effectiveness of peer education
interventions for HIV prevention in developing countries: a systematic review and meta-
analysis', AIDS Education and Prevention, 21(3), pp. 181-206.
Mein, E., Fuentes, B., Más, F. S. and Muro, A. (2012) 'Incorporating digital health literacy
into adult ESL education on the US-Mexico border', Rhetoric, professional communication,
and globalization, 3(1), pp. 162.
Mercer, C. H., Tanton, C., Prah, P., Erens, B., Sonnenberg, P., Clifton, S., Macdowall, W.,
Lewis, R., Field, N. and Datta, J. (2013) 'Changes in sexual attitudes and lifestyles in Britain
through the life course and over time: findings from the National Surveys of Sexual Attitudes
and Lifestyles (Natsal)', The Lancet, 382(9907), pp. 1781-1794.
Merriam, S. B. (2002) 'Introduction to qualitative research', in Merriam, S.B. (ed.)
Qualitative research in practice: Examples for discussion and analysis. San Francisco:
Jossey-Bass, pp. 1-17.
Metzger, M. J., Flanagin, A. J. and Medders, R. B. (2010) 'Social and heuristic approaches
to credibility evaluation online', Journal of communication, 60(3), pp. 413-439.
Mitchell, K. J., Ybarra, M. L., Korchmaros, J. D. and Kosciw, J. G. (2014) 'Accessing sexual
health information online: use, motivations and consequences for youth with different sexual
orientations', Health education research, 29(1), pp. 147-157.
Morris, N. S., MacLean, C. D., Chew, L. D. and Littenberg, B. (2006) 'The Single Item
Literacy Screener: evaluation of a brief instrument to identify limited reading ability', BMC
family practice, 7(1), pp. 21.
Morris, S. M. (2001) 'Joint and individual interviewing in the context of cancer', Qualitative
Health Research, 11(4), pp. 553-567.
Morrow, V. and Richards, M. (1996) 'The ethics of social research with children: an
overview', Children & society, 10(2), pp. 90-105.
295
Muessig, K. E., Pike, E. C., LeGrand, S. and Hightow-Weidman, L. B. (2013) 'Mobile phone
applications for the care and prevention of HIV and other sexually transmitted diseases: a
review', Journal of medical Internet research, 15(1), pp. e1.
Munday, J. (2006) 'Identity in focus the use of focus groups to study the construction of
collective identity', Sociology, 40(1), pp. 89-105.
Mustanski, B., Lyons, T. and Garcia, S. C. (2011) 'Internet use and sexual health of young
men who have sex with men: A mixed-methods study', Archives of sexual behavior, 40(2),
pp. 289-300.
National Information Board (2014) Personalised Health and Care 2020: Using Data and
Technology to Transform Outcomes for Patients and Citizens: HM Government. Available
at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/
384650/NIB_Report.pdf (Accessed: March 2017).
Needham, H. E., Wiemann, C. M., Tortolero, S. R. and Chacko, M. R. (2010) 'Relationship
between health literacy, reading comprehension, and risk for sexually transmitted infections
in young women', Journal of Adolescent Health, 46(5), pp. 506-508.
Neergaard, M.A., Olesen, F., Andersen, R.S., and Sondergaard, J. (2009) ‘Qualitative
description – the poor cousin of health research?’, BMC Medical Research Methodology,
9:52.
Neter, E. and Brainin, E. (2012) 'eHealth literacy: extending the digital divide to the realm
of health information', Journal of medical Internet research, 14(1), pp. e19.
Ng, W. (2012) 'Can we teach digital natives digital literacy?', Computers & Education, 59(3),
pp. 1065-1078.
Niland, P., Lyons, A. C., Goodwin, I. and Hutton, F. (2015) 'Friendship Work on Facebook:
Young Adults' Understandings and Practices of Friendship', Journal of Community &
Applied Social Psychology, 25(2), pp. 123-137.
Norman, C. D. and Skinner, H. A. (2006) 'eHealth literacy: essential skills for consumer
health in a networked world', J Med Internet Res, 8(2), pp. e9.
296
Novak, D. and Karlsson, R. (2006) 'Simplifying chlamydia testing: an innovative Chlamydia
trachomatis testing approach using the internet and a home sampling strategy: population
based study', Sexually transmitted infections, 82(2), pp. 142-147.
Nutbeam, D. (2000) 'Health literacy as a public health goal: a challenge for contemporary
health education and communication strategies into the 21st century', Health promotion
international, 15(3), pp. 259-267.
Nutbeam, D. (2008) 'The evolving concept of health literacy', Social science & medicine,
67(12), pp. 2072-2078.
Nutbeam, D. (2009) 'Defining and measuring health literacy: what can we learn from literacy
studies?', International Journal of Public Health, 54(5), pp. 303-5.
Nutbeam, D., Harris, E. and Wise, M. (1998) 'Health literacy', International Encyclopedia
of Public Health, 3, pp. 204-211.
Office for National Statistics (ONS) (2016) Conceptions in England and Wales: 2014.
Available at
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/concep
tionandfertilityrates/bulletins/conceptionstatistics/2014 (Accessed: 6th July 2017)
Office for National Statistics (ONS) (2016a) Internet access - households and individuals.
Available at:
https://www.ons.gov.uk/peoplepopulationandcommunity/householdcharacteristics/homeint
ernetandsocialmediausage/bulletins/internetaccesshouseholdsandindividuals/2016
(Accessed: 25th January 2017)
O'Higgins, S. and Gabhainn, S. N. (2010) 'Youth participation in setting the agenda: learning
outcomes for sex education in Ireland', Sex Education, 10(4), pp. 387-403.
O’Reilly, K. (2012) Ethnographic methods. London: Routledge.
Osborne, R. H., Batterham, R. W., Elsworth, G. R., Hawkins, M. and Buchbinder, R. (2013)
'The grounded psychometric development and initial validation of the Health Literacy
Questionnaire (HLQ)', BMC public health, 13(1), pp. 658.
297
Oudshoorn, N. E. J. and Pinch, T. J. (2003) 'How users and non-users matter', in Oudshoorn,
N.E.J. & Pinch, T.J. (eds.) How Users Matter. The Co-construction of Technologies and
Users. Cambridge, Massachusetts: MIT Press, pp. 4-22.
Owens, S. L., Arora, N., Quinn, N., Peeling, R. W., Holmes, K. K. and Gaydos, C. A. (2010)
'Utilising the internet to test for sexually transmitted infections: results of a survey and
accuracy testing', Sexually transmitted infections, 86(2), pp. 112-116.
Ownby, R. L., Waldrop-Valverde, D., Jacobs, R. J., Acevedo, A. and Caballero, J. (2013)
'Cost effectiveness of a computer-delivered intervention to improve HIV medication
adherence', BMC medical informatics and decision making, 13(1), pp. 29.
Paasche-Orlow, M. K. and Wolf, M. S. (2007) 'The causal pathways linking health literacy
to health outcomes', American journal of health behavior, 31(1), pp. S19-S26.
Pahl, J. M. and Pahl, R. E. (1972) Managers and their Wives. London: Penguin Books.
Papacharissi, Z. (2010) A private sphere: Democracy in a digital age. Cambridge: Polity
Press.
Parker, I. (2014) Young people, sex and relationships: The new norms, London: Institute for
Public Policy Research.
Parker, R. M., Baker, D. W., Williams, M. V. and Nurss, J. R. (1995) 'The test of functional
health literacy in adults', Journal of general internal medicine, 10(10), pp. 537-541.
Pascoe, C. (2011) 'Resource and risk: Youth sexuality and new media use', Sexuality
Research and Social Policy, 8(1), pp. 5-17.eeling, R. (2006) 'Testing for sexually transmitted
infections: a brave new world?', Sexually Transmitted Infections, 82, pp. 425-430.
Peerson, A. and Saunders, M. (2009) 'Health literacy revisited: what do we mean and why
does it matter?', Health promotion international, 24(3), pp. 285-296.
Pitts, J. and Stripling, B. (1990) 'Information power challenge: To provide intellectual and
physical access', School Library Media Quarterly, 18, pp. 133-134.
298
Pleasant, A. and Kuruvilla, S. (2008) 'A tale of two health literacies: public health and
clinical approaches to health literacy', Health Promotion International, 23(2), pp. 152-159.
Pleasant, A. and McKinney, J. (2011) 'Coming to consensus on health literacy measurement:
an online discussion and consensus-gauging process', Nursing outlook, 59(2), pp. 95-106.
e1.
Pleasant, A., Rudd, R. E., O'Leary, C., Paasche-Orlow, M. K., Allen, M. P., Alvarado-Little,
W., Myers, L., Parson, K. and Rosen, S. (2016) Considerations for a new definition of health
literacy. National Academy of Medicine.
Plummer, K. (2001) 'The call of life stories in ethnographic research', in Atkinson P, Coffey
S, Delamont J, Lofland J & L, L. (eds.) Handbook of ethnography. London: Sage, pp. 395-
406.
Polkinghorne, D. E. (2005) 'Language and meaning: Data collection in qualitative research',
Journal of counseling psychology, 52(2), pp. 137.
Pound, P., Langford, R. and Campbell, R. (2016) 'What do young people think about their
school-based sex and relationship education? A qualitative synthesis of young people's
views and experiences', BMJ open, 6(9), pp. e011329.
Powell, E. (2008) 'Young people's use of friends and family for sex and relationships
information and advice', Sex Education, 8(3), pp. 289-302.
Prensky, M. (2001) 'Digital natives, digital immigrants part 1', On the horizon, 9(5), pp. 1-
6.
Public Health England (2015) Local action on health inequalities: improving health literacy
to reduce health inequalities, London: UCL Institute of Health Equity.
Public Health England (2017) Sexually Transmitted Infections and Chlamydia Screening in
England, 2016. Health Protection Report. 11(20)
299
Ralph, L. J., Berglas, N. F., Schwartz, S. L. and Brindis, C. D. (2011) 'Finding teens in
TheirSpace: using social networking sites to connect youth to sexual health services',
Sexuality research and social policy, 8(1), pp. 38-49.
Ramanathan, N., Swendeman, D., Comulada, W. S., Estrin, D. and Rotheram-Borus, M. J.
(2013) 'Identifying preferences for mobile health applications for self-monitoring and self-
management: Focus group findings from HIV-positive persons and young mothers',
International journal of medical informatics, 82(4), pp. e38-e46.
Ratzan S.C and Parker R.M (2000) 'Introduction', in Selden C.R et al (ed.) National Library
of Medicine Current Bibliographices in Medicine: Health Literacy. Bethesda, MD: National
Institutes of Health, U.S. Department of Health and Human Services.
Reinisch, J. M. and Beasley, R. (1991) 'The Kinsey Institute New Report on Sex: what you
must know to be sexually literate', Journal of Social Work Practice, 5(2), pp. 213.
Renfrow, D. G. and Rollo, E. A. (2014) 'Sexting on campus: minimizing perceived risks and
neutralizing behaviors', Deviant Behavior, 35(11), pp. 903-920.
Renold, E. (2013) Boys and girls speak out: A qualitative study of children's gender and
sexual cultures (ages 10-12), Cardiff: Cardiff University.
Richardson, C. R., Resnick, P. J., Hansen, D. L., Derry, H. A. and Rideout, V. J. (2002)
'Does pornography-blocking software block access to health information on the Internet?',
JAMA, 288(22), pp. 2887-2894.
Rideout, V. (2001) Generation Rx. com: How young people use the Internet for health
information, Menlo Park, CA: Kaiser Family Foundation.
Riessman, C. K. (1993) Narrative analysis. Newbury Park, CA: Sage.
Ringrose, J. and Barajas, K. E. (2011) 'Gendered risks and opportunities? Exploring teen
girls' digitized sexual identities in postfeminist media contexts', International Journal of
Media & Cultural Politics, 7(2), pp. 121-138.
300
Ringrose, J., Gill, R., Livingstone, S. and Harvey, L. (2012) 'A qualitative study of children,
young people and'sexting': a report prepared for the NSPCC'.
Ringrose, J., Harvey, L., Gill, R. and Livingstone, S. (2013) 'Teen girls, sexual double
standards and ‘sexting’: Gendered value in digital image exchange', Feminist Theory, 14(3),
pp. 305-323.
Ritchie, J. and Spencer, L. (2002) 'Qualitative data analysis for applied policy research', in
Bryman, A. & Burgess, R. (eds.) The qualitative researcher’s companion: Vol. 2002.
Abingdon: Taylor and Francis, pp. 305-329.
Roberto, A. J., Zimmerman, R. S., Carlyle, K. E. and Abner, E. L. (2007) 'A computer-based
approach to preventing pregnancy, STD, and HIV in rural adolescents', Journal of health
communication, 12(1), pp. 53-76.
Robinson, A. and Rogstad, K. (2002) 'Adolescence: a time of risk taking', Sexually
transmitted infections, 78(5), pp. 314-315.
Rootman, I. and Gordon-El-Bihbety, D. (2008) 'A vision for a health literate Canada',
Ottawa, ON: Canadian Public Health Association.
Rootman, I. and Ronson, B. 2003. Literacy and Health in Canada: What We have learned
and What can helo in the future. Canadian Institutes of Health Research.
Ross, M. W. and Kauth, M. R. (2002) 'Men who have sex with men, and the Internet:
Emerging clinical issues and their management', in Cooper A (ed.) Sex and the Internet: A
guidebook for clinicians. New York: Brunner-Routledge, pp. 47-69.
Rudd, R. E., Renzulli, D., Pereira, A. and Daltroy, L. (2005) 'Literacy Demands in Health
Care Settings: The Patient Perspective', in Schwartzberg, J., VanGeest, J. & Wang, C. (eds.)
Understanding Health Literacy: Implications for Medicine and Public Health: American
Medical Association.
Salam, R. A., Faqqah, A., Sajjad, N., Lassi, Z. S., Das, J. K., Kaufman, M. and Bhutta, Z. A.
(2016) 'Improving adolescent sexual and reproductive health: A systematic review of
potential interventions', Journal of Adolescent Health, 59(4), pp. S11-S28.
301
Sandelowski, M. (2000) ‘Whatever happened to qualitative description?’, Research in
Nursing and Health, 23 (3): 334-40.
Sandelowski, M. (2008) 'Theoretical saturation', in LM, G. (ed.) The Sage encyclopedia of
qualitative methods. London: Sage Publications, pp. 875-876.
Scarcelli, C. M. (2015) '‘It is disgusting, but…’: adolescent girls’ relationship to internet
pornography as gender performance', Porn Studies, 2(2-3), pp. 237-249.
Schnall, R., Travers, J., Rojas, M. and Carballo-Diéguez, A. (2014) 'eHealth interventions
for HIV prevention in high-risk men who have sex with men: a systematic review', Journal
of medical Internet research, 16(5), pp. e134.
Scottish Catholic Education Service (2015) Conduct of Relationships, Sexual Health and
Parenthood Education in Schools: Advice for Catholic Schools. Available at:
http://www.rercglasgow.org/uploads/1/1/7/2/11725030/rshp_circular_advice_final.pdf
(Accessed: November 2015)
Scottish Government (2011) The Sexual Health and Blood-Borne Virus Framework 2011-
2015, Edinburgh: Scottish Government.
Scottish Government (2011a) Scotland's Digital Future: A Strategy for Scotland.
Edinburgh: Scottish Government.
Scottish Government (2014) Making it easy—A health literacy action plan for Scotland,
Edinburgh: The Scottish Government.
Scottish Government (2014a) Scottish Government Urban/Rural Classification 2013-14,
Edinburgh: The Scottish Government.
Scottish Government (2014b) Conduct of Relationships, Sexual Health and Parenthood
Education in Schools, Edinburgh: The Scottish Government.
Seale, C., Charteris-Black, J., Dumelow, C., Locock, L. and Ziebland, S. (2008) 'The effect
of joint interviewing on the performance of gender', Field Methods, 20(2), pp. 107-128.
302
Seymour, J., Dix, G. and Eardley, T. Joint accounts: methodology and practice in research
interviews with couples. 1995, York: University of York.
Shoveller, J., Knight, R., Davis, W., Gilbert, M. and Ogilvie, G. (2012) 'Online sexual health
services: examining youth's perspectives', Canadian Journal of Public Health/Revue
Canadienne de Sante'e Publique, pp. 14-18.
Sihota, S. and Lennard, L. (2004) Health literacy: being able to make the most of health.
London: National Consumer Council.
Silverman, D. (2001) 'Ethnography and observation', Interpreting Qualitative Data:
Methods for Analysing Text, Talk and Interaction. London: Sage.
Simon, L. and Daneback, K. (2013) 'Adolescents’ use of the internet for sex education: A
thematic and critical review of the literature', International Journal of Sexual Health, 25(4),
pp. 305-319.
Simonds, S. K. (1974) 'Health education as social policy', Health Education Monographs,
2(1_suppl), pp. 1-10.
Skinner, H., Biscope, S., Poland, B. and Goldberg, E. (2003) 'How adolescents use
technology for health information: implications for health professionals from focus group
studies', J Med Internet Res, 5(4), pp. e32.
Slater, C. and Robinson, A. J. (2014) 'Sexual health in adolescents', Clinics in dermatology,
32(2), pp. 189-195.
Smith, M., Gertz, E., Alvarez, S. and Lurie, P. (2000) 'The content and accessibility of sex
education information on the Internet', Health Education & Behavior, 27(6), pp. 684-694.
Sørensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z. and Brand,
H. (2012) 'Health literacy and public health: a systematic review and integration of
definitions and models', BMC public health, 12(1), pp. 80.
Sørensen, K., Van den Broucke, S., Pelikan, J. M., Fullam, J., Doyle, G., Slonska, Z.,
Kondilis, B., Stoffels, V., Osborne, R. H. and Brand, H. (2013) 'Measuring health literacy in
303
populations: illuminating the design and development process of the European Health
Literacy Survey Questionnaire (HLS-EU-Q)', BMC public health, 13(1), pp. 948.
Sprecher, S., Harris, G. and Meyers, A. (2008) 'Perceptions of sources of sex education and
targets of sex communication: sociodemographic and cohort effects', Journal of Sex
Research, 45(1), pp. 17-26.
Steckelberg, A., Hülfenhaus, C., Kasper, J., Rost, J. and Mühlhauser, I. (2009) 'How to
measure critical health competences: development and validation of the Critical Health
Competence Test (CHC Test)', Advances in health sciences education, 14(1), pp. 11.
Stephenson, J., Strange, V., Allen, E., Copas, A., Johnson, A., Bonell, C., Babiker, A.,
Oakley, A. and Team, R. S. (2008) 'The long-term effects of a peer-led sex education
programme (RIPPLE): a cluster randomised trial in schools in England', PLoS Med, 5(11),
pp. e224.
Stone, M., Jastak, S. and Wilkinson, G. 1995. Wide Range Achievement Test-3 (WRAT-3).
Wilmington, DE: Jastak Publishing Co.
Stone, N. and Ingham, R. (2003) 'When and why do young people in the United Kingdom
first use sexual health services?', Perspectives on sexual and reproductive health, 35(3), pp.
114-120.
Strange, V., Oakley, A., Forrest, S. and Team, R. S. (2003) 'Mixed-sex or single-sex sex
education: how would young people like their sex education and why?', Gender and
Education, 15(2), pp. 201-214.
Suffoletto, B., Akers, A., McGinnis, K. A., Calabria, J., Wiesenfeld, H. C. and Clark, D. B.
(2013) 'A sex risk reduction text-message program for young adult females discharged from
the emergency department', Journal of Adolescent Health, 53(3), pp. 387-393.
Suzuki, L. K. and Calzo, J. P. (2004) 'The search for peer advice in cyberspace: An
examination of online teen bulletin boards about health and sexuality', Journal of applied
developmental psychology, 25(6), pp. 685-698.
304
Svenonius, E. (2000) The intellectual foundation of information organization. Cambridge,
Massachusetts: MIT press.
Swendeman, D. and Rotheram-Borus, M. J. (2010) 'Innovation in sexually transmitted
disease and HIV prevention: Internet and mobile phone delivery vehicles for global
diffusion', Current opinion in psychiatry, 23(2), pp. 139.
Tanton, C., Jones, K. G., Macdowall, W., Clifton, S., Mitchell, K. R., Datta, J., Lewis, R.,
Field, N., Sonnenberg, P. and Stevens, A. (2015) 'Patterns and trends in sources of
information about sex among young people in Britain: evidence from three National Surveys
of Sexual Attitudes and Lifestyles', BMJ open, 5(3), pp. e007834.
Teitelman, A. M., Bohinski, J. M. and Boente, A. (2009) 'The social context of sexual health
and sexual risk for urban adolescent girls in the United States', Issues in mental health
nursing, 30(7), pp. 460-469.
Temple, J. R., Paul, J. A., van den Berg, P., Le, V. D., McElhany, A. and Temple, B. W.
(2012) 'Teen sexting and its association with sexual behaviors', Archives of Pediatrics &
Adolescent Medicine, 166(9), pp. 828-833.
Tewksbury, D., Weaver, A. J. and Maddex, B. D. (2001) 'Accidentally informed: Incidental
news exposure on the World Wide Web', Journalism & Mass Communication Quarterly,
78(3), pp. 533-554.
The Royal Society of Edinburgh (2013) Spreading the benefits of digital participation: An
interim report for consultation. Available at:
http://www.royalsoced.org.uk/cms/files/advicepapers/inquiry/RSE_DI_Inquiry_Interim.pd
f (Accessed: 6th June 2014)
Thomas, N., Murray, E. and Rogstad, K. (2006) 'Confidentiality is essential if young people
are to access sexual health services', International journal of STD & AIDS, 17(8), pp. 525-
529.
Thompson, K. M., Jaeger, P. T., Taylor, N. G., Subramaniam, M. and Bertot, J. C. (2014)
Digital literacy and digital inclusion: Information policy and the public library. London:
Rowman & Littlefield.
305
Tian, Y. and Robinson, J. D. (2009) 'Incidental health information use on the Internet',
Health communication, 24(1), pp. 41-49.
Tolli, M. (2012) 'Effectiveness of peer education interventions for HIV prevention,
adolescent pregnancy prevention and sexual health promotion for young people: a systematic
review of European studies', Health education research, 27(5), pp. 904-913.
Tortolero, S. R., Markham, C. M., Peskin, M. F., Shegog, R., Addy, R. C., Escobar-Chaves,
S. L. and Baumler, E. R. (2010) 'It's Your Game: Keep It Real: Delaying sexual behavior
with an effective middle school program', Journal of Adolescent Health, 46(2), pp. 169-179.
U.S. Department of Health and Human Services (2010) Health Literacy Online: A guide to
writing and designing easy-to-use health Web sites, Washington: Office of Disease
Prevention and Health Promotion.
Underwood, J. D. (2007) 'Rethinking the Digital Divide: impacts on student‐ tutor
relationships', European Journal of Education, 42(2), pp. 213-222.
Von Wagner, C., Steptoe, A., Wolf, M. S. and Wardle, J. (2009) 'Health literacy and health
actions: a review and a framework from health psychology', Health Education & Behavior,
36(5), pp. 860-877.
Walrave, M., Heirman, W. and Hallam, L. (2014) 'Under pressure to sext? Applying the
theory of planned behaviour to adolescent sexting', Behaviour & Information Technology,
33(1), pp. 86-98.
Warschauer, M. and Matuchniak, T. (2010) 'New technology and digital worlds: Analyzing
evidence of equity in access, use, and outcomes', Review of Research in Education, 34(1),
pp. 179-225.
Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A., Pignone, M. P.,
Mockbee, J. and Hale, F. A. (2005) 'Quick assessment of literacy in primary care: the newest
vital sign', The Annals of Family Medicine, 3(6), pp. 514-522.
306
Wellings, K., Aral, S., Leichliter, J. and Peterman, T. (2012) 'Sexually transmitted
infections', in Wellings, K., Mitchell, K. & Collumbien, M. (eds.) Sexual Health: A Public
Health Perspective. Berkshire: McGraw-Hill Open University Press.
Wellings, K., Jones, K. G., Mercer, C. H., Tanton, C., Clifton, S., Datta, J., Copas, A. J.,
Erens, B., Gibson, L. J. and Macdowall, W. (2013) 'The prevalence of unplanned pregnancy
and associated factors in Britain: findings from the third National Survey of Sexual Attitudes
and Lifestyles (Natsal-3)', The Lancet, 382(9907), pp. 1807-1816.
WHO (2010) Developing sexual health programmes: A framework for action. World Health
Organisation: Department of Reproductive Health Research.
WHO (2015) WHO recommendations on health promotion interventions for maternal and
newborn health. Geneva: World Health Organisation.
Willig, C. (2013) Introducing qualitative research in psychology. Berkshire, UK: McGraw-
Hill Education (UK).
Wilson, A. D., Onwuegbuzie, A. J. and Manning, L. P. (2016) 'Using Paired Depth
Interviews to Collect Qualitative Data', The Qualitative Report, 21(9), pp. 1549.
Woodcock, A., Stenner, K. and Ingham, R. (1992) '“All these contraceptives, videos and
that…”: young people talking about school sex education', Health Education Research, 7(4),
pp. 517-531.
Woodhall, S. C., Sile, B., Talebi, A., Nardone, A. and Baraitser, P. (2012) 'Internet testing
for Chlamydia trachomatis in England, 2006 to 2010', BMC Public Health, 12(1), pp. 1095.
Wyatt, S., Thomas, G. and Terranova, T. (2002) 'They Came, They Surfed, They Went Back
to the Beach: Conceptualizing', Virtual Society?: Technology, Cyberbole, Reality, pp. 23.
Ybarra, M. L. and Bull, S. S. (2007) 'Current trends in Internet-and cell phone-based HIV
prevention and intervention programs', Current HIV/AIDS Reports, 4(4), pp. 201-207.
307
Yee, L. M. and Simon, M. A. (2014) 'The role of health literacy and numeracy in
contraceptive decision-making for urban Chicago women', Journal of community health,
39(2), pp. 394.
Yonker, L. M., Zan, S., Scirica, C. V., Jethwani, K. and Kinane, T. B. (2015) '“Friending”
teens: systematic review of social media in adolescent and young adult health care', Journal
of medical Internet research, 17(1), pp. e4.
Yost, K. J., Webster, K., Baker, D. W., Choi, S. W., Bode, R. K. and Hahn, E. A. (2009)
'Bilingual health literacy assessment using the Talking Touchscreen/la Pantalla Parlanchina:
Development and pilot testing', Patient education and counseling, 75(3), pp. 295-301.
Zarcadoolas, C., Pleasant, A. and Greer, D. S. (2003) 'Elaborating a definition of health
literacy: a commentary', Journal of Health Communication, 8(S1), pp. 119-120.
Zarcadoolas, C., Pleasant, A. and Greer, D. S. (2005) 'Understanding health literacy: an
expanded model', Health promotion international, 20(2), pp. 195-203.
Zhao, S. (2009) 'Teen adoption of MySpace and IM: inner-city versus suburban differences',
CyberPsychology & Behavior, 12(1), pp. 55-58.
308
Appendix 1 – Participant information sheet
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310
Appendix 2 - Participant consent form
311
Appendix 3 – Basic questionnaires
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Appendix 4 – Interview topic guide
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315
Appendix 5 – Online activity scenarios
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317
Appendix 6 – PhD study timetable
318
Appendix 7 – Gatekeeper letter
319
Appendix 8 – Recruitment poster (online and offline)
320
Appendix 9 – Participant demographics and recruitment details
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Appendix 10 – Thematic framework
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325
Appendix 11 – Example of a pairs ‘biography’
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Appendix 12 – Data integration table
330
