Capella University Health Care Utilization in Homeless Youth Discussion

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ORIGINAL PAPER
Health Care Utilization in Homeless Youth
Yolanda N. Evans • Sara M. Handschin •
Ann E. Giesel
Published online: 19 November 2013
Springer Science+Business Media New York 2013
Abstract To examine common reasons for utilization of
health care services at a free homeless youth clinic. This is
a retrospective chart review for visits over a 1 year period.
Data on age, gender, and up to 3 chief complaints per visit
were collected from the electronic medical record. Of the
744 clinical encounters, the mean age of youth was
18.8 years and 53.2 % involved female patients. The most
common reasons for utilizing services include screening
and treatment of sexually transmitted infections (STI)
14.3 %, physical exam for housing 13.7 %, dermatologic
complaints 13.5 %. Chief complaints were different for
males and females (p B 0.001). Females were more likely
to receive laboratory testing for STI than males
(p B 0.001). Females were most likely to seek care for
sexual and reproductive health needs and males were more
likely to come for acute concerns. These differences can
inform providers working with this vulnerable population.
Keywords Homeless youth Adolescent
Reproductive health Health care utilization
Introduction
It is estimated that between 1.6 and 2.8 million youth in the
USA runaway or are thrown away each year and youth
ages 12–17 are at higher risk for homelessness than adults
[1]. In Washington State, the 2010 Annual One Night
Count of people who are homeless in King County found
that of the 6,236 people staying in emergency shelters or
transitional housing on the night of the count, 1,009 (16 %)
were between the ages of 13–25 years [2].
Homeless youth acknowledge the need for help in
maintaining their physical well-being. They are more likely
to report poorer overall health, more emotional disturbances, and have higher rates of traumatic stress than nonhomeless children from middle income families. In order to
survive on the streets, they may resort to dangerous
behaviors, such as drug use and sex industry work. Even if
not permanently homeless, chronic periods of homelessness have been associated with survival sex, increased HIV
rates, and sexual victimization [3].
Homeless youth identify access to reproductive health
services as a fundamental need [4, 5] and value being
offered allopathic and complementary medicine services
[6, 7]. Youth have reported that peers provide anecdotal
remedies for ailments and may discourage seeking help
from medical professionals [5]. Those who do attempt to
access mainstream healthcare may be without health
insurance. If they have insurance, they may refuse to make
use of it for reasons such as not wanting to provide a real
name or contact information. They may also be ineligible
for services as a minor who is unaccompanied by a consenting adult. Therefore, medical drop-in services that are
based on a sliding scale fee for income or free of charge are
invaluable and depended upon by this population [8].
The purpose of this study is to describe service utilization at a free clinic for homeless youth in Seattle, Washington. Specific aims include: determining the common
reasons for seeking services and a comparison of patterns
of use by males and females. This drop in clinic provides
acute care, preventive care, reproductive health care, and
Y. N. Evans A. E. Giesel
Department of Pediatrics, University of Washington, Seattle,
WA, USA
Y. N. Evans (&) S. M. Handschin A. E. Giesel
Division of Adolescent Medicine, Seattle Children’s Hospital,
4540 Sand Point Way NE, Suite 200, Seattle, WA 98105, USA
e-mail: [email protected]
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J Community Health (2014) 39:521–523
DOI 10.1007/s10900-013-9789-3
limited medications for homeless youth between the ages
of 12–23 years free of charge. In addition, youth are often
referred for temporary housing, meals, clothing, alternative
drop-in school, case management, employment training,
and mental health and substance use counseling. Alongside
allopathic medical services, complimentary medicine in the
form of acupuncture and/or massage is available. There are
two paid staff members, the clinic manager and an
attending physician. The remainder of the staff are volunteers or trainees (medical students, Pediatric and Family
Medicine residents, and fellows in Adolescent Medicine).
Methods
A retrospective chart review of electronic medical records
(EMR) at the Country Doctor Free Teen Clinic was performed by the two co-investigators, Y. Evans and S.
Handschin. Permission to access the electronic medical
records was granted by the Director of Operations at the
Country Doctor Community Health Center, the facility
where the Country Doctor Free Clinic operates. The entire
study was approved by the University of Washington
Human Subjects Division. The medical records were
reviewed to gather eleven different items for each patient
encounter: patient stated age, stated gender, up to three
chief complaints (or reasons for visiting the clinic that
evening), whether or not a urine HCG was obtained (if
female), sexually transmitted infection (STI) laboratory
studies [including gonorrhea, chlamydia, HIV, or rapid
plasma reagin (RPR)], contraception dispensed including
oral contraceptive pills, NuvaRing, Ortho Evra Patch, Depo
Provera injections, or Plan B emergency contraception (if
female), the use of complimentary and alternative medicine
(CAM), discharge diagnosis, and medications dispensed.
For the purposes of this study we focused our descriptive
analysis on the following variables: stated age, stated
gender, chief complaints, urine HCG, STI laboratory
studies, contraception dispensed.
The Country Doctor Free Teen Clinic previously used
hand written notes to document patient encounters without
a standardized template. In February 2010, the clinic converted to the use of electronic medical records. Review of
the EMR for this study included reading hand written paper
notes that had been scanned into the EMR. Information
from the patient encounter notes was entered into Excel
spreadsheets. To confirm that the two co-investigators
recorded the same variables after reading the scanned hand
written documents, 10 patient encounters were separately
reviewed by each co-investigators, with agreement on 106
out of 110 variables recorded (96.4 %).
Data was transferred directly from Excel into STATA
version 10. Analyses included descriptive summaries of
stated age, stated gender, chief complaints, urine HCG, STI
laboratory studies, contraception dispensed. Patient
encounters were stratified by gender and Chi2 analysis was
used to compare the reasons for clinic visits and STI
screening tests performed between males and females.
Results
All patient encounters that occurred between January 5,
2009 and January 5, 2010 were included in the chart review.
Patients who left without being seen or charts with missing
information on the items of interest were excluded from the
study. A total of 31 encounters were excluded. A total of 744
patient encounters met inclusion criteria with 371 individual
patients utilizing the clinic during this time frame.
Study results are summarized in Table 1. The average
number of visits per patient over the study period was two.
The mean age of patients served was 18.8 years with 53 %
reporting female gender and 47 % reporting male gender.
Among the overall sample, the most common reasons for
visiting the clinic were for STI testing (14.3 %), the need
for physical exam to obtain housing (13.7 %), and a dermatologic complaint (13.5 %). The chief complaints were
different for males and females (p B 0.001).
For females, the most common reasons for visiting the
clinic included STI testing (18.2 %), contraception
(17.5 %), and a physical exam for housing (12.4 %). There
were a total of 222 screening STI tests performed among
females. Females were more likely to receive laboratory
testing for STI than males (p B 0.001) For males, the most
common reason for visiting the clinic was a dermatologic
complaint (16.4 %), a physical exam for housing (15.2 %),
and upper respiratory infection symptoms (12.2 %). There
were 122 STI screening tests performed among males.
Discussion
Screening and treatment of STIs was the most common
reason for homeless youth to access health services in our
study. There were differences by gender. Young women
were most likely to seek care for sexual and reproductive
health needs and had a higher proportion of visits for these
concerns. Young men had higher proportions of visits for
acute concerns including URI symptoms, dermatologic and
musculoskeletal complaints. Our findings are consistent
with previously documented health needs in this population, where homeless youth requested reproductive health
and STI screening [9, 10].
One reason for the gender difference could be the
requirement of many shelters in the Seattle metro to require
a physical examination prior to admission. This requirement
522 J Community Health (2014) 39:521–523
123
may increase the number of teens, especially males, seeking
care. Males are less likely to seek health services overall
[11], yet our study found nearly equal numbers of males and
females utilizing the homeless teen clinic. Another explanation for the gender difference could involve the provision
of reproductive health (contraception) and STI screening
offered at our site. Homeless females have been found to
request and seek out services for contraception and STI
screening and treatment [10]. Because our clinic is known
by local youth to offer these services, it is not unexpected
that a high proportion of homeless females would request
them.
Our findings indicate that homeless youth will seek
contraception and commonly prescribed methods include
combination birth control pills and Depo Provera. However, long acting reversible contraception, such as the
implantable rod or intra-uterine device, were not available.
Condoms were offered, but provision to patients was not
routinely documented in the EMR and was therefore
excluded from analyses.
The findings of this study are unique to this particular
clinic and can not be generalized to other populations. Our
results do not reflect services that were declined or patients
who did not receive services because they were recently
conducted elsewhere, such as through another clinic,
shelter or the juvenile justice system. Nor do they reflect
the number of patients who received health education
regarding STIs or contraceptive counseling, but declined
any of the options.
This study provides further evidence that homeless
youth do seek health care and will utilize vital services,
such as acute care and reproductive health care, when
offered. Though males and females may seek care for
different reasons, these clinic visits provide the opportunity
for important screening and preventive care. Care providers
should be educated and competent in sexual and reproductive and be prepared to provide such services to this
vulnerable population.
Acknowledgments The authors would like to acknowledge Mavis
Bonnar and the staff at the Country Doctor Community Clinic for
their support on this project.
Conflict of interest The authors have no conflicts of interest to
disclose.
References
1. Youth noise (Internet): YouthNoise Homelessness Archive.
(2010). cited 10/20/2010. Available from: http://www.youthnoise.
com/page.php?page_id=6144.
2. Seattle king County Coalition on Homelessness. (2012). 2012
annual one night count of people who are homeless in king
county, Seattle, WA. http://www.homelessinfo.org/what_we_do/
one_night_count/2012_results.php.
3. Marshall, B. D. L. (2008). The contextual determinants of sexually transmissible infections among street-involved youth in
North America. Culture, Health & Sexuality, 10(8), 787–799.
4. Ensign, B. J. (2006). Perspectives and experiences of homeless
young people. Journal of Advanced Nursing, 54(6), 647–652.
5. Ensign, J., & Panke, A. (2002). Barriers and bridges to care:
Voices of homeless female adolescent youth in Seattle, WA,
USA. Journal of Advanced Nursing, 37(2), 166–172.
6. Ensign, J. (2004). Quality and improvement. Quality of health
care: The views of homeless youth. Health Services Research,
39(4), 695–707.
7. Breuner, C., Barry, P., & Kemper, K. (1998). Alternative medicine use by homeless youth. Archives of Pediatric Medicine,
152(11), 1071–1075.
8. De Rosa, C., Montgomery, S., Kipke, M. D., Iverson, E., Ma, J.,
& Unger, J. (1999). Service utilization among homeless and
runaway youth in Los Angeles. Journal of Adolescent Health,
24(3), 190–200.
9. Ensign, J., & Santelli, J. (1998). Health status and service use.
Comparison of adolescents at a school-based health clinic with
homeless adolescents. Archives of Pediatrics Adolescent Medicine, 152(1), 20–24.
10. Ensign, J. (2000). Reproductive health of homeless adolescent
women in Seattle, WA, USA. Women & Health, 31(2–3),
133–151.
11. Marcell, A. V., Klein, J. D., Fischer, I., Allan, M. J., & Kokotailo,
P. K. (2002). Male adolescent use of health care services: Where
are the boys? Journal of Adolescent Health, 30(1), 35–43.
Table 1 Summary of demographics and chief complaints
Male Female Sample total
Total encounters (N) 348 (46.8 %) 396 (53.2 %) 744 (100 %)
Mean age in years (SD) 19.2 (2.3) 18.4 (2.5) 18.8 (2.4)
Chief complaint (%) Dermatologic 16.4 STI testing 18.2 STI testing 14.3
Physical exam for housing 15.2 Contraception 17.5 Physical exam for housing 13.7
Respiratory/URI symptoms 12.2 Physical exam for housing 12.4 Dermatologic 13.5
Musculoskeletal 11.4 Dermatologic 11.0 Respiratory/URI symptoms 10.7
Other 11.0 Respiratory/URI symptoms 9.5 Other 9.8
STI testing 9.8 Other 8.8 Contraception 9.5
Test results 5.8 Test results 6.1 Musculoskeletal 7.7
STI sexually transmitted infection, URI upper respiratory infection
J Community Health (2014) 39:521–523 523
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ORIGINAL PAPER
Cell Phone Utilization Among Foreign-Born Latinos: A Promising
Tool for Dissemination of Health and HIV Information
Lorena Leite • Megan Buresh • Naomi Rios •
Anna Conley • Tamara Flys • Kathleen R. Page
Published online: 26 February 2013
Springer Science+Business Media New York 2013
Abstract Latinos in the US are disproportionately affected
by HIV and are at risk for late presentation to care. Between
June 2011 and January 2012, we conducted a cross-sectional
survey of 209 Baltimore Latinos at community-based venues
to evaluate the feasibility of using information communication technology-based interventions to improve access to
HIV testing and education within the Spanish-speaking
community in Baltimore. Participants had a median age of
33 years interquartile range (IQR) (IQR 28–42), 51.7 %
were male, and 95.7 % were foreign-born. Approximately
two-thirds (63.2 %) had been in the US less than 10 years
and 70.1 % had been previously tested for HIV. Cell phone
(92.3 %) and text messaging (74.2 %) was used more than
Internet (52.2 %) or e-mail (42.8 %) (p\0.01). In multivariate analysis, older age and lower education were associated with less utilization of Internet, e-mail and text
messaging, but not cell phones. Interest was high for
receiving health education (73.1 %), HIV education
(70.2 %), and test results (68.8 %) via text messaging.
Innovative cell phone-based communication interventions
have the potential to link Latino migrants to HIV prevention,
testing and treatment services.
Keywords HIV Cellular phone Technology
Latino health Migrants
Introduction
Latinos are the largest and fastest growing ethnic minority
in the United States, with a total population of 50.5 million
in 2010 [1]. During the last decade, the Latino population
of Baltimore City increased by 135 %, primarily due to
recent migration of individuals born in Central America
and Mexico [2, 3]. As in other rapid-growth regions, such
as the southeastern US, Latinos living in Baltimore are
more likely to be young, male, foreign-born and in the US
for less than 15 years, compared to those from states with
well-established Latino communities such as New York,
Florida, and California [4]. Demographic changes have
resulted in high demand for culturally competent services,
which may not be readily available in rapid growth states.
Lack of services sensitive to the needs of migrants can
exacerbate disparities in quality and access to health care.
Latinos living in the US are disproportionately affected
by HIV, and have an estimated lifetime risk (ELR) of
infection 3.2 times higher than for Whites [5]. From 1997
to 2006, rates of AIDS cases in Baltimore City decreased
40 % among non-Hispanic Blacks and 23 % among nonHispanic Whites, but nearly doubled among Latinos (from
40.8 to 80.0 cases/100,000 people), and mortality due to
AIDS among Latinos was twice that of non-Latino Whites
[6]. Furthermore, Latinos are often diagnosed in the later
stages of disease [7–11]. Late diagnosis is associated with
high mortality, and unrecognized infection increases HIV
transmission in the community [12].
Foreign-born Latinos are at particularly high risk for late
presentation, with a shorter interval from HIV diagnosis to
AIDS when compared with US-born Latinos [9]. CDC data
shows that Latinos born in Mexico or Central America are
more than twice as likely to be diagnosed late with HIV
than Latinos born in the US [11]. Non-English speaking
Lorena Leite and Megan Buresh contributed equally to this
manuscript.
L. Leite M. Buresh N. Rios T. Flys K. R. Page (&)
Johns Hopkins University School of Medicine, 600 N. Wolfe St.
Phipps 524, Baltimore, MD 21287, USA
e-mail: [email protected]
A. Conley
Washington University, St. Louis, MO, USA
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DOI 10.1007/s10903-013-9792-x
Latinos in Los Angeles county are almost three times more
likely to present late to care than English-speaking Latinos
[13]. In North Carolina, a state that has experienced a rapid
increase in the Latino foreign-born population, Latinos
present to HIV care with a lower CD4 count than African
Americans (186 vs. 302 cells/mm3
) and account for a
majority of serious opportunistic infections in the clinic,
including tuberculosis and histoplasmosis which are likely
acquired in their country of origin [10, 14]. Therefore,
immigrants have a particular need for targeted interventions to provide earlier access to HIV testing.
Foreign-born Latinos are also vulnerable to factors that
have been shown to impact access to HIV services, such as
self-awareness of risk, immigration status, cultural background, isolation, and disruptions of social and family relationships [15–17]. Stigma is also a major barrier to accessing
HIV services among foreign-born Latinos [18, 19]. In 2008,
the Baltimore City Health Department (BCHD) established a
Latino Outreach Program to provide culturally-sensitive,
Spanish-language HIV education, testing, and linkage to
care services for Latino migrants. Program evaluation has
shown over 95 % of clients served by the Latino Outreach
program are foreign-born Latinos and that HIV testing rates
in this population have increased from 37 to 62 % in the
2 years since the program was established [20, 21]. While
traditional community-based outreach has improved access
to testing for Latinos in Baltimore, novel approaches should
be evaluated to complement these services and further
improve HIV testing rates.
Over the past decade, information and communication
technology (ICT), such as text messaging and Internet, have
been utilized to improve health care and education in various
settings. For example, interventions using cell phones and
text messaging have been used to increase HIV testing rates
[22], enhance medication adherence among HIV-positive
individuals [23–28] and access of minority youth to information about HIV/AIDS and referral to STD care [29, 30].
Text-messaging interventions have also been used to reduce
high-risk sexual behaviors and methamphetamine use
among men who have sex with men (MSM) [31] and instant
messaging has been used to counsel MSM about HIV in realtime. [32] When patients have been surveyed on their attitudes toward use of cell phones, text messaging and Internet
for HIV interventions, their response has been positive [33].
Cell phone-based interventions may therefore be an effective
means to disseminate health information to Latinos. While
there are disparities in technology use between native and
foreign-born Latinos, the digital divide is smaller for cellular
phones, with 72 % of foreign-born compared to 80 % of
native-born Latinos utilizing a cell phone [34]. According to
the Pew Internet and American Life project, African
Americans and Latinos are more likely than Whites to use
cell phones and mobile devices to access the Internet, use
instant messaging, visit social networking sites, look up
health information, and track or manage their health [35].
We conducted a cross-sectional survey study of Latinos
living in Baltimore to evaluate the feasibility of using communication technology-based interventions to improve
access to HIV testing and education within the Spanishspeaking community in Baltimore. We evaluated the relationship between age, gender, and education and ICT use.
We also assessed migrant-associated factors, such as country
of origin and time in the US, because differences in socioeconomic and educational attainment between migrants
from different countries could impact utilization of ICT [34,
36]. Identifying factors associated with communication
technology use and acceptability is important to understand
who may be reached by using technology-based interventions and what population may be missed due to the lack of
technology use, particularly among individuals who have
never been tested for HIV.
Methods
This was a cross-sectional survey of 209 Baltimore Latinos
conducted between June 2011 and January 2012.
Study Setting and Participants
The survey was conducted in selected street and community-based venues in Baltimore City. Several methods were
used to identify venues frequented by Latinos living in
Baltimore. We interviewed 10 key informants, including
outreach workers from the BCHD Latino outreach program, bar owners, bar clients, staff at community based
organizations, and social workers familiar with the Latino
community in Baltimore. Interview guides were developed
in collaboration with the BCHD Latino Outreach program
and included questions about barriers to HIV testing among
Latinos, appropriate incentives for participation, identification of local events for Latinos, and places with high
Latino presence. Once a list of venues was generated, we
observed locations at various time intervals to to evaluate
whether the target population could be assessed in sufficient numbers at each site. Eligibility for participation
included self-identification as Latino, age C18 years old,
ability to communicate in Spanish or English, and ability to
give oral consent.
The institutional review board of the Johns Hopkins
University School of Medicine approved this study.
Measures
We developed a 21-item survey querying: (1) demographics including age, gender, race, sex, education, years
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in the US, primary language and country of origin, (2)
frequency of technology use, including cellular phone, text
messaging, email and Internet, and (3) interest in receiving
health information, HIV education and HIV testing results
by each of the three modalities.
Technology use was assessed using the following
questions: (1) Do you use a cell phone? (2) If so, how often
do you use it? (3) Is your cell phone a smartphone? (4) Do
you use short message service (SMS)/text messaging with
your cell phone? (5) If so, how often do you use it? (6) Do
you use the Internet? (6) If so, how often do you use it? (7)
Do you use e-mail? (8) If so, how often to you use it?
Frequency of use was assessed as ‘‘daily,’’ ‘‘weekly,’’ ‘‘less
than once per week,’’ or ‘‘never.’’
Interest in receiving health information by each of the
different technologies was assessed using the following
questions: (1) Would you be interested in receiving health
information by (text message/SMS, Internet or e-mail)? (2)
Would you be interested in receiving education about HIV by
(text message/SMS, Internet or e-mail)? (3) Would you be
interested in receiving HIV test results by (text message/SMS,
Internet or e-mail)? The items selected for inclusion in the
questionnaire were chosen based on review of the literature,
and consultation with focus groups and key informants.
Data Collection
We used a stratified sampling scheme based on gender and
venue to reach a representative population. Data from
previous surveys were reviewed to assess the representation of specific subgroups (by gender, age, and country of
origin) in the local Latino population [37–39]. Formative
research including focus groups and key informant interviews was used to determine venues and times frequented
by Latinos in the Baltimore community. Once sampling
venues were defined through our formative research, we
used a random number generator to select venues and times
for sampling on specific dates to reach a representative
sample of Latinos in Baltimore. Stratified sampling was not
performed in health fair settings due to lack of feasibility.
Because certain venues were gender-biased (e.g. male
predominance in locations where day laborers congregate
and in bars), we monitored data for gender balance and if
either gender was grossly overrepresented, a sampling
venue frequented by the opposite gender was chosen.
During each sampling period, interviewers selected every
third unit (i.e. family, single person, couple) who walked
by to screen for eligibility and recruit to participate in the
survey. Oral informed consent was obtained and participants received a $5 gift card for their participation. Consent
and surveys were administered in Spanish or English,
depending on each participant’s preference. The maximum
number of participants for each venue was capped at
twenty people with an aim to survey five people per 2-h
sampling period. Each survey took approximately 15 min
to complete (range 10–30 min). Individuals who refused
participation were asked their age and a tally was maintained recording age, gender, and survey site for individuals who did not participate.
Data Analysis
Study data was collected and managed using REDCap electronic data capture tools hosted at Johns Hopkins University
School of Medicine [40]. Survey responses were reviewed to
examine the frequency of distributions and identify outliers,
non-normality, and other data irregularities. Descriptive
characteristics (mean, median, range and SD) were used to
summarize responses. We compared participant characteristics and technology use between individuals previously tested
for HIV versus those never tested using Pearson’s Chi square
test for categorical variables and Wilcoxon-Mann–Whitney
test for continuous variables. We used multivariable logistic
regression to identify factors associated with previous HIV
test, communication technology use, and interest in receiving
health information via text messaging. Statistical analysis was
performed using Stata version 10.0 for windows (Stata-Corp,
College Station, Texas, USA).
Results
Baseline Characteristics
Over an 8 month period, we offered participation to 674
eligible individuals and interviewed 209 (response rate
31 %). There was no difference by age or gender between
responders and non-responders. The majority (54.1 %) of
surveys were done on the street, 27.8 % at health fairs, and
18.2 % at community-based organizations (Table 1). The
median age of study participants was 33 years (IQR
28–42), 51.7 % were male, and the majority were foreignborn (95.7 %) and spoke Spanish (98.6 %) as their primary
language. Educational level was relatively low, with
32.1 % of the sample completing less than 6th grade and
only 23.9 % completing more than 12th grade. Countries
of birth included Mexico (31.3 %), El Salvador (22.6 %),
Honduras (14.9 %), Guatemala (13 %), US (4.3 %), and
others (13.9 %). Approximately two-thirds (63.2 %) of
participants had been in the US less than 10 years (median
time in the US = 7 years, IQR 4–12).
ICT Use and Previous HIV Testing
The majority of our sample reported using cell phones
(92.3 %) and text messaging (74.2 %). Internet use and
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e-mail were less common (52.2 and 42.8 %, respectively).
The majority (91.5 %) of respondents had exclusive ownership of their cell phone, and 59.6 % owned a smartphone.
Cell phone turnover was variable, with approximately half
(53.1 %) of the cell phone numbers in use for less than
2 years. In univariate analysis, individuals who did not use
Internet, e-mail or text messaging were less likely to have
been tested previously for HIV. Women were twice as likely
as men to have been previously tested for HIV and Guatemalans were the least likely to have had an HIV test in the
past. Overall, the majority (70.1 %) had been previously
tested for HIV. In multivariate analysis adjusting for demographic characteristics (gender, age, country of origin, and
educational status), women were twice as likely to have been
tested for HIV than men. Older individuals and those from
Guatemala were less likely to report a previous HIV test.
Factors Associated with ICT Utilization
and Acceptability for Dissemination of Health
Information
In order to identify which Latino subgroups may not be
reached effectively through communication technology
interventions, we evaluated factors associated with its use. In
multivariate analysis, older age and lower education were
associated with less Internet, e-mail and text messaging
utilization, but there was no association with cell phone use
(Table 2). The only characteristic associated with cell phone
use was gender, with less utilization among men.
We assessed three categories of acceptability for receiving health information of increasing sensitivity including
health education, HIV education, and HIV test results by text
messaging (Table 3). Acceptability was high for health
education (73.1 %), HIV education (70.2 %), and even HIV
test results (68.8 %). The common factor associated with
interest in receiving health and HIV information or HIV test
results via text messaging was exclusive cell phone ownership. Age and gender did not significantly impact the interest
in receiving information via text message. Interest in
receiving HIV education and test results was also associated
with higher education. Compared to individuals who reported a previous HIV test, respondents who had never been
tested for HIV were less interested in receiving general
health education, but equally interested in receiving HIV
information by text messaging. Respondents from El Salvador and Guatemala were less interested in receiving HIV
test results by text messaging than individuals from Mexico.
Discussion
The rapid growth of Latino migrant populations in some
regions of the US has increased the need for culturally-sensitive
health interventions. Foreign-born Latinos are at high risk
for late HIV diagnosis and worse HIV outcomes [9–11,
13]. Therefore, evaluating interest in new HIV interventions and promoting active community engagement is
crucial to successfully reach vulnerable populations. In our
study, respondents were as interested in receiving HIV
education and HIV test results by text messaging as in
receiving general health information. High interest in
receiving HIV information via text messaging is consistent
with findings from diverse resource-limited settings
[24, 41].
Patient-centered issues such as privacy and literacy are
important to consider prior to implementing ICT-based
HIV interventions. The importance of privacy is evident in
our study results, where exclusive cell phone ownership
was strongly associated with interest in receiving health
information via text messaging. Educational attainment
was not associated with cell phone use, but did influence
internet and e-mail utilization. Even though national data
shows that foreign-born Latinos have lower ICT utilization
than US-born Latinos [34], we did not find differences in
ICT utilization by country of origin in our sample of primarily Spanish-speaking foreign-born Latinos. Country of
origin was only associated with previous HIV testing
(lower rates among Guatemalans) and lower interest in
receiving HIV test results by text among individuals from
Guatemala and El Salvador.
One factor that may explain the interest for text-based
interventions is a relative shortage of culturally-appropriate
health and HIV-related services for Latinos. US Latinos
consider HIV/AIDS the second most concerning health issue
in the US and are more likely than whites to be personally
concerned about contracting HIV [42]. Baltimore Latinos
also face significant structural barriers to accessing healthcare and are therefore more likely to seek care from public
and community health initiatives. Approximately threequarters of Baltimore Latinos do not have health insurance
[43] compared to one-third of US Latinos, and 15 % of the
general US population [44]. Cultural factors may also contribute to the interest in receiving HIV education by text
messaging. For example, receptivity to provider initiated
health information may be influenced by the cultural belief in
medical authority [45].
An important consideration in developing technologybased interventions is ensuring that the technology is
accessible to the target population. The lack of association
between cell phone utilization and previous HIV testing is
encouraging and suggests that text messaging can be used
to reach individuals who have not been previously tested.
We found that male gender was associated with lower cell
phone utilization and a lower likelihood of previous HIV
testing. Higher testing rates among women are consistent
with both national [46] and local data [21], and may be
664 J Immigrant Minority Health (2014) 16:661–669
123
Table 1 Baseline characteristics of participants, overall and by HIV testing status
Total
N = 209
Previous HIV test p value* AOR**
Yes
N = 148 (70.1 %)
No
N = 61 (29.2 %)
Age (median ? IQR), years 33 (28–42) 33 (27–41) 33 (29–47) 0.22
Age (categorical), n (%)
\35 122 (58.4) 90 (73.9) 32 (26.2) 0.10 Ref.
35–50 59 (28.2) 43 (72.9) 16 (27.1) 0.83 (0.39–1.77)
50? 28 (13.4) 15 (53.6) 13 (46.4) 0.33 (0.22–0.86)
Sex
Male 108 (51.7) 68 (63.0) 40 (37.0) 0.01 Ref.
Female 101 (48.3) 80 (79.2) 21 (20.8) 2.3 (1.17–4.56)
Primary language spoken
English 3 (1.4) 2 (66.7) 1 (33.3) 0.87 –
Spanish 206 (98.6) 146 (70.9) 60 (29.1)
Survey location
Health fair 58 (27.8) 43 (74.1) 15 (25.9) 0.78 –
CBO 38 (18.2) 27 (71.1) 11 (28.90)
Street 113 (54.1) 78 (69.0) 35 (31.0)
Country of birth
Mexico 65 (31.3) 52 (80.0) 13 (20.0) 0.01 Ref.
El Salvador 47 (22.6) 30 (63.8) 17 (36.2) 0.49 (0.20–1.21)
Honduras 31 (14.9) 21 (67.7) 10 (32.3) 0.64 (0.23–1.75)
Guatemala 27 (13.0) 12 (44.4) 15 (55.6) 0.21 (0.08–0.59)
US 9 (4.3) 8 (88.9) 1 (11.1) 1.84 (0.20–16.77)
Other 29 (13.9) 24 (82.8) 5 (17.2) 1.72 (0.48–6.15)
Years in United States (median ? IQR), years 7 (4–12) 8 (4–12) 7 (5–12) 0.76
Years in United States
0–10 132 (63.2) 93 (70.4) 39 (29.6) 0.88 –
11? 77 (36.8) 55 (71.4) 22 (28.6)
Highest level of education
\6th grade 67 (32.1) 41 (61.1) 26 (38.8) 0.06 Ref.
6th–12th grade 92 (44.0) 72 (78.3) 20 (21.7) 1.66 (0.77–3.58)
[12th grade 50 (23.9) 35 (70.0) 15 (30.0) 0.88 (0.35–2.20)
Uses Internet
Yes 109 (52.2) 85 (78.0) 24 (22.0) 0.02 –
No 100 (47.9) 63 (63.0) 37 (37.0)
Uses e-mail
Yes 89 (42.8) 70 (78.7) 19 (21.4) 0.03 –
No 119 (57.2) 77 (64.7) 42 (35.3)
Cell phone use
Yes 193 (92.3) 139 (72.0) 54 (28.0) 0.18 –
No 16 (7.7) 9 (56.3) 7 (43.8)
Text messaging
Yes 155 (74.2) 117 (79.1) 38 (62.3) 0.01 –
No 54 (25.8) 31 (21.0) 23 (37.7)
Length of current cell phone number ownership
\2 years 111 (53.1) 81 (73.0) 30 (27.0) 0.47 –
2? years 98 (46.9) 67 (68.4) 31 (31.6)
J Immigrant Minority Health (2014) 16:661–669 665
123
Table 1 continued
Total
N = 209
Previous HIV test p value* AOR**
Yes
N = 148 (70.1 %)
No
N = 61 (29.2 %)
Number of cell phones owned in the past 2 years
1 89 (46.1) 66 (74.2) 23 (25.8) 0.70 –
2–4 91 (47.2) 63 (69.2) 38 (30.8)
5? 13 (6.7) 10 (79.9) 3 (23.1)
Ownership
Exclusive user 173 (91.5) 126 (72.8) 47 (27.2) 0.73 –
Shared 16 (8.5) 11 (68.8) 5 (31.3)
Smartphone ownership
Yes 115 (59.6) 85 (73.9) 30 (26.1) 0.48 –
No 78 (40.4) 54 (69.2) 24 (30.8)
CBO community-based organization
* p value corresponds to bivariate analysis
** Adjusted odds ratio (AOR) result from multivariate analysis, adjusted for demographic factors (age, gender, country of origin, and education
level) with a p value B0.10 in univariate analysis
Bold values are those which achieve statistical significance (95 % confidence intervals do not overlap 1)
Table 2 Multivariate analysis of factors associated with technology use
Internet e-mail Cell phone Text messaging
Age
\35 Ref. Ref. Ref. Ref.
35–50 0.44 (0.21–0.91) 0.31 (0.14–0.70) 0.76 (0.22–2.67) 0.61 (0.27–1.36)
50? 0.17 (0.06–0.55) 0.09 (0.02–0.38) 1.68 (0.22–33.26) 0.32 (0.12–0.87)
Sex
Male Ref. Ref. Ref. Ref.
Female 1.42 (0.74–2.71) 1.36 (0.69–2.70) 5.2 (1.07–25.46) 1.68 (0.82–3.43)
Country of birth
Mexico Ref. Ref. Ref. Ref.
El Salvador 0.65 (0.27–1.57) 0.68 (0.27–1.71) 4.86 (0.53–44.17) 0.55 (0.21–1.48)
Honduras 0.65 (0.23–1.78) 1.04 (0.35–3.07) 0.97 (0.23–4.01) 1.11 (0.34–3.63)
Guatemala 0.64 (0.22–1.85) 0.53 (0.16–1.76) 3.98 (0.31–38.53) 0.36 (0.12–1.07)
US 6.79 (0.70–65.9) 0.95 (0.17–5.23) – 1.37 (0.14–13.44)
Other 1.87 (0.59–5.90) 2.35 (0.69–8.00) 0.82 (0.13–2.87) 0.35 (0.11–1.10)
Years in United States
0–10 Ref. Ref. Ref. Ref.
11? 0.55 (0.25–1.20) 1.16 (0.50–2.70) 0.67 (0.16–2.87) 0.83 (0.36–1.91)
Highest level of education
\6th grade Ref. Ref. Ref. Ref.
6th–12th grade 3.46 (1.62–7.38) 2.75 (1.19–6.34) 2.39 (0.68–8.37) 1.61 (0.72–3.57)
[12th grade 5.20 (2.01–13.44) 8.51 (3.00–24.12) 5.67 (0.56–57.37) 2.99 (1.06–8.44)
Previous HIV test
No Ref. Ref. Ref. Ref.
Yes 1.32 (0.64–2.72) 1.79 (0.78–4.09) 1.82 (0.5–5.98) 1.73 (0.83–3.62)
AOR adjusted for age, gender, country of origin, time in the US, educational level, and previous HIV test
Bold values are those which achieve statistical significance (95 % confidence intervals do not overlap 1)
666 J Immigrant Minority Health (2014) 16:661–669
123
partly related to testing during prenatal care. Even though
cell phone utilization was more common among women
than males, 82 % of males surveyed owned a personal cell
phone, suggesting that cell phone ownership would not be a
major barrier to receiving text messages with health
information. It is also important to note that certain forms
of ICT such as Internet use and text messaging appear to be
less accessible to individuals of lower educational level,
who may be the most vulnerable to inequities in health care
access. Less education is associated with less HIV testing
among Latinos in Baltimore City [20, 21] and nationwide
[15], suggesting that less educated Baltimore City Latinos
are the most vulnerable to being missed by developing an
ICT intervention for HIV prevention. While cell phone use
was common (85 %) among Latinos with less than 6th
grade education, only 60 % were interested in receiving
HIV education by text message. The lower utilization of
text-based messaging among low education Latinos may be
due to literacy levels, which was not measured in this
study. However, an urban probability sampling study of
foreign born Latinos living in Baltimore conducted in the
same geographical location, showed [90 % basic Spanish
literacy rates despite low educational attainment [38]. Our
findings suggest that text messaging can be used to supplement, but not replace, other outreach activities.
Several limitations of this study should be considered.
The cross-sectional design limits the ability to make causal
associations. To minimize sampling bias, we used a stratified
sampling scheme at venues identified during formative
research. Only 31 % of individuals approached agreed to
participate in the survey, but there was no difference in
gender or age distribution among responders and nonresponders. We did not collect data assessing the cause for
non-participation, but potential factors could include lack of
familiarity with research studies, mistrust of scientific
investigations, time-constraints, or concerns regarding confidentiality [47, 48]. We attempted to enhance participant
trust by ensuring that all study interviewers/recruiters were
Table 3 Multivariate analysis
of factors associated with
interest in receiving health
information via text message
AOR adjusted for age, gender,
country of origin, time in the
US, educational level, exclusive
cell phone ownership, and
previous HIV test
Bold values are those which
achieve statistical significance
(95 % confidence intervals do
not overlap 1)
Health education HIV education HIV test result
N (%)
Yes 152 (73.1) 146 (70.2) 143 (68.8)
No 56 (26.9) 62 (29.8) 65 (31.3)
Age
\35 Ref. Ref. Ref.
35–50 0.59 (0.27–1.28) 0.82 (0.38–1.78) 0.96 (0.44–2.10)
50? 0.45 (0.16–1.23) 0.59 (0.22–1.60) 0.67 (0.24–1.84)
Sex
Male Ref. Ref. Ref.
Female 1.42 (0.72–2.81) 1.00 (0.51–1.96) 1.56 (0.79–3.09)
Country of birth
Mexico Ref. Ref. Ref.
El Salvador 0.45 (0.17–1.14) 0.36 (0.14–0.94) 0.32 (0.11–0.89)
Honduras 1.11 (0.35–3.49) 0.99 (0.32–3.07) 0.43 (0.14–1.32)
Guatemala 0.76 (0.25–2.34) 0.81 (0.27–2.51) 0.26 (0.09–0.81)
US 0.42 (0.08–2.17) 0.31 (0.06–1.50) 0.46 (0.09–2.46)
Other 0.68 (0.21–2.15) 0.48 (0.16–1.50) 0.19 (0.06–0.62)
Years in United States
0–10 Ref Ref. Ref.
11? 0.84 (0.37–1.91) 0.54 (0.24–1.21) 0.45 (0.19–1.03)
Highest level of education
\6th grade Ref. Ref. Ref.
6th–12th grade 1.38 (0.63–3.02) 1.66 (1.22–5.81) 1.30 (0.59–2.83)
[12th grade 1.68 (0.63–4.46) 3.55 (1.31–9.65) 3.00 (1.08–8.36)
Owns exclusive cell phone
No Ref. Ref. Ref.
Yes 2.33 (1.02–5.28) 2.85 (1.28–6.36) 3.00 (1.31–6.88)
Previous HIV test
No Ref. Ref. Ref.
Yes 2.12 (1.03–4.36) 1.54 (0.75–3.19) 1.99 (0.96–4.12)
J Immigrant Minority Health (2014) 16:661–669 667
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members of the community fluent in Spanish. It is also
possible that hidden populations at particularly high risk for
HIV, such as men who have sex with men or intravenous
drug users, may not be represented in this sample. We found
that low educational attainment was associated with less
Internet, e-mail and text messaging utilization, but we did not
enquire about literacy level, which would have provided an
additional dimension to understanding the feasibility of textbased interventions. In addition, our ability to distinguish
differences between US-born and foreign-born Latinos was
limited because of the low numbers of US-born Latinos in
our sample. While the study was conducted in a predominantly foreign-born Latino community in Baltimore City and
results may not be generalizable to other Latino populations
in the US, our findings may be particularly relevant to outreach programs in areas experiencing a similar rapid growth
of foreign-born Latinos from Central America and Mexico.
Finally, we developed the questionnaire used to collect data
because there was no previously validated measure to assess
ICT use among Latinos. Evidence of the survey’s content
validity was conferred through review in focus groups and by
key informant feedback.
Past accomplishments in HIV prevention through ICT in
other populations have the potential to be used in Baltimore
with culturally appropriate adaptations. San Francisco’s
Department of Public Health developed a text message
STI/HIV information and referral service and successfully
reached low income adolescents in a relevant format [30].
A South African text message randomized controlled trial
to encourage the uptake of HIV counseling and testing was
able to determine the content, frequency and cost that led to
motivating patients to get tested [22]. Previous work in
Baltimore City showed that gaps in basic HIV knowledge,
such as modes of HIV transmission and knowing that a
person with HIV can look healthy, correlated with previous
HIV testing patterns. Simple text messages reinforcing
these concepts and directing people to free testing sites
could be one way to use ICT to enhance HIV awareness
and promote testing among Latinos.
In summary, the use of ICT, particularly cell phones, has
the potential to expand the reach of traditional HIV outreach
activities for foreign-born Latinos in Baltimore [21]. Novel
initiatives should actively engage the community to develop
focused and catchy messages that empower Baltimore Latinos
to get involved in HIV prevention and care. Evaluation of the
efficacy of such interventions on HIV awareness and health
seeking behavior will be essential to ultimately achieve
improvements in timely testing for HIV among Latinos.
New Contribution to the Literature
The expansion of culturally-sensitive outreach programs
for Latinos living in Baltimore has improved HIV testing
rates in this population over the past few years. However,
late presentation to HIV care is still common among
Latinos and novel interventions to improve HIV education
and access to testing are needed. Previous studies have
shown high cell phone use among native and foreign-born
Latinos living in the US [34] but to our knowledge, this is
the first study evaluating the interest in using ICT to disseminate HIV information among a primarily foreign-born
Latino population. We found that cell phone use is common among Latinos living in Baltimore, and interest in
receiving health and HIV information by text messaging is
high, even among individuals who have never been previously tested for HIV. These findings suggest that ICT
interventions could be used to bolster traditional outreach
efforts.
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