Editor’s Note: This article, which is adapted from the research paper “Using a Web Site to Enhance Adolescent Health Promotion in an Inner-City High School,” was written by a group of culturally and ethnically diverse student nurses at the University of Washington School of Nursing in Seattle, in collaboration with the nurse practitioner and two health educators from the high school where the “Teen Smart” Web site project was implemented. The nursing students’ project was supervised by University of Washington Associate Professor Cathy Strachan Lindenberg, RN, DrPN, a Hispanic nurse of Costa Rican descent.
Today, at the dawn of the 21st century, the Internet is a major presence in our world and in our personal lives. It has already transformed the way we perform such day-to-day activities as buying books and CDs, checking the weather and chatting with friends. In the near future, the Internet will become an even more integral part of the way our society gathers information and communicates, with computer terminals available on airplanes, in every library and in every classroom.
The advent of the Internet as a daily presence in our lives has created unprecedented opportunities to transmit and share critical information, especially in the domain of health education. Physicians, nurses, corporations and health care agencies alike are now equipped with a powerful new tool for reaching large sectors of the population quickly and simultaneously.
Teenagers are one special population who are taking full advantage of the benefits the Internet has to offer. Adolescence is a crucial time in a person’s life when we first begin to develop a strong sense of individuality as we transition from childhood to adulthood. During this often turbulent and confusing period, lifelong patterns of problem solving and health habits are developed.
According to the Centers for Disease Control and Prevention, six common risk behaviors contribute to 75% of morbidity and mortality in the United States: tobacco use, alcohol and drug use, risky sexual behaviors, lack of physical exercise, poor nutritional habits and intentional and unintentional injuries. Many of these behaviors are established during adolescence and persist into adulthood. Because teenagers’ problem-solving abilities are not fully developed, they are at higher risk than adults for such serious health problems as substance abuse, sexually transmitted diseases, unwanted pregnancies and poor nutrition. Racial and ethnic minority teens growing up in disadvantaged or medically underserved communities are often at especially high risk, because of their unequal access to health care services and education about health issues.
Because most of these risky health behaviors are preventable, providing high-risk teens with information on health promotion is crucial. Today’s teenagers’ medium of choice, the Internet, with all its interactive possibilities, is the ideal vehicle for getting the word out in a format that is irresistible to young people.
In a recent article in the journal Adolescent Medicine, D.N. Paperny noted that “Adolescent health education, both problem-based and preventive care, in the new millennium will likely be predominately multimedia-based, making it accessible … to adolescents for use in their home computer. . .The computer can act as a mediator to facilitate mature, informed decision-making for adolescents without [their] suffering the embarrassment or actual consequences of poor health choices.”
These were the factors that prompted a group of University of Washington nursing students to explore the feasibility of developing a health promotion Internet site for at-risk teens that could be used to enhance health education in the high school classroom and also provide a source of confidential information for students who are hesitant to identify and discuss personal health problems, particularly those related to sex and drug use. The result was the “Teen Smart” Web site project, a community partnership with the faculty and students of Cleveland High School in Seattle’s Inner City.
Collaboratively developed and designed by a racially and culturally diverse group of students, faculty and staff from the nursing school and the high school, the bilingual (English/Spanish) Teen Smart site is located at www.son.washington.edu/teensmart. Minority Nurse readers can access the site for demonstration purposes only by logging on with the user name “chaz” and the password “chaz.”
Cleveland High School serves a student body of 750 ethnically diverse and economically disadvantaged teens in grades 9 through 12. Forty-six percent of the students are Asian Americans, 31% African Americans, 12% Caucasians, 9% Latinos and 2% American Indians. Many of the students identify themselves as multiracial; many come from first- and second-generation immigrant families. With such a culturally diverse mix of students, one of the biggest challenges we faced in developing the health promotion Web site was to provide information that would be of interest to all students in a manner that all could easily access and use.
While the project’s primary purpose was health education, it was also designed to address another identified need: to enhance educational technology in a school where reading, writing and math scores fell below the state average. At the time, Cleveland High was one of only two schools in the district that did not have a Web site. Therefore, the creation of Teen Smart was envisioned as a catalyst to improve students’ computer literacy while simultaneously promoting adolescent health.
In the spring quarter of 2000, as part of a course in community health, the nursing students participated in a 10-week clinical rotation at the high school, where they interacted primarily with two health teachers and approximately 40 ninth grade students enrolled in two health class sections. Health education is a required curriculum element for all students and is taught in an interactive format that includes units on stress reduction, self-esteem, nutrition, fitness, smoking, alcohol, drugs and sex education.
The student nurses also collaborated with the nurse practitioner from the high school’s on-site Teen Health Center. This clinic, which is open year round, provides the students with primary health services as well as mental health, reproductive health, drug and alcohol counseling.
At the outset of the project, we determined that a vital requirement for the health promotion Web site’s success was gaining the teenagers’ trust. The student nurses spent a few weeks getting to know the high school students, both individually and as a group. We sat in on their health classes and engaged in activities designed to help us learn more about the teens’ health interests and needs. In addition, we familiarized ourselves with the school’s health education curriculum, teaching materials and methods through participative observation and meeting with the teachers weekly after each class session.
These activities allowed both the teachers and the students to get to know us better and increase the level of trust before we attempted to introduce the idea of the Teen Smart Web site to this group of students. Often, when individuals sense that someone is genuinely interested in their thoughts and behaviors, they are more likely to actively participate in the relationship. We felt that by gaining the students’ trust we could promote greater participation and openness to using the Teen Smart Web site to enhance their health knowledge and skills.
Once the basic framework for a trusting, open and mutually participatory relationship had been established, the next step was to determine which health topics the Cleveland High students were most interested in. We also wanted to find out where they obtained their information and what being healthy meant to them. To evaluate the needs and health concerns of students in the freshman health classes, we conducted focus groups using a semi-structured interview format.
The main areas of interest and concern the students expressed were issues related to weight, nutrition, drugs, sleep and sex (see “What Teens Want to Know About Health” sidebar). The recurring themes they cited as the meaning of good health were eating right, exercising and feeling good about oneself (good mental health). It is important to note that many of the students were reluctant to talk openly or expand upon sensitive areas of concern, such as sex and drug use, in a public focus group forum.
We then turned our attention to evaluating the high school students’ access to computers as well as the computer literacy of students in the health classes and the student body as a whole. We constructed a survey designed to elicit information on the students’ use of computers, knowledge of computers and frequency of use. This helped guide us in deciding what level of Internet instruction to provide to the students in their orientation to the Web site.
To further determine whether or not a Web site was an appropriate venue for distributing health education information to these particular students, we also gathered demographic information, such as ethnicity and gender. This allowed us to assess whether the students who would be participating in the project were representative of the overall school population, and whether some groups would need differential approaches to instruction.
All of these pieces of information were vitally important to assessing the feasibility of integrating a Web site into the existing health class curriculum and teen clinic services. We distributed the computer use survey to the health classes and then to the entire school during a lunch period. Over 300 students participated in this voluntary and anonymous survey.
The results revealed that most students had high levels of access to computers and the Internet. Of the students surveyed, 99% had used a computer and 75% said they used the computer at least every week. Students used the computer most often for schoolwork, games and job-related information. In addition, 67% said they used the Internet at least once a week.
We also learned that 72% of the respondents had access to a computer at home, and 83% of those computers had Internet access. This was surprising given the high proportion of low- income and immigrant students in the school. Both genders were well represented in the survey as were the different ethnic groups found at the school.
After weeks of preparatory work, we were finally ready to invite and orient students to the Teen Smart Web site. For those students who were less experienced with using a computer and accessing the Internet, we developed simple instruction sheets. To engage the students’ interest and introduce them to the Web site’s wide variety of information and interactive components, we created special games and assignments tied in with each week’s health education classroom content.
The weekly assignments, which required the students to utilize different aspects of the Web site, included such activities as taking a health quiz, finding information on a topic related to what had been discussed in health class, asking an online question to a nurse, and/or analyzing a problem-based case study and posting their responses on a message board. In turn, the students’ responses to the case studies generated new material and opportunities for class discussion. To further increase the students’ motivation to use the Web site, the health education teachers allocated grade points to some of these exercises. Similarly, an online “scavenger hunt” assignment allowed students to earn extra credit if they finished early.
We were pleasantly surprised with the lack of difficulty the students experienced when using this unfamiliar method of completing assignments. Although the skill level varied among students, almost all of them easily performed the basic tasks required, such as starting the Web browser, finding the Web site with the URL and using the mouse to navigate the site. Most students needed only minimal assistance locating the section of the Web site that would contain the information they sought. Nearly all of the students completed their assignments in the time allotted and many had time to complete the extra-credit scavenger hunt.
The computer-based exercises provided new avenues for student participation in class discussion as well as more opportunities for the teens to use their reading, writing and critical thinking skills. But the implementation of Teen Smart also focused on raising the students’ interest in health promotion.
For example, online self-assessment quizzes entitled “How Healthy Are You?” were linked to the topics covered in the weekly health education classes. The quizzes gave each student immediate individual feedback, scoring their health behaviors from low to high and providing them with links to other health-related Web sites relevant to their answers. This empowered the teens by providing them with information they could use to improve their health decision making.
Another Teen Smart feature, “Ask A Nurse,” was designed to give the students a private and confidential forum to discuss health questions with the Teen Health Center nurse practitioner. Individual students’ questions were published and answered anonymously in the Web site’s “Frequently Asked Questions” section so that all the students could benefit from the information.
Interestingly, the questions the students posed online were much more likely to address health concerns of a sensitive nature--i.e. sex and drugs--which they had been reluctant to volunteer in the focus group discussions. This suggests that an interactive Web site provides an excellent way for high-risk teens to get accurate information on topics they may not feel comfortable asking an adult in person. Teen Smart also provided a way for the teen clinic to reach students who were uninterested or unwilling to come in for face-to-face health services.
The Web site’s “Discussion Board” feature, which was supervised by the health education teachers, provided the students with opportunities to analyze common life situations where decision-making is crucial to their health and safety. Each week, the discussion board presented a problem-based scenario on topics such as drinking and driving, unprotected sex or using illicit drugs. Individual students could post a response describing what they would do in that situation and also view other students’ answers. The teachers were then able to use the posted responses for further class discussion.
The discussion board case scenarios were designed to help the teens build skills in anticipatory problem-solving by placing them in hypothetical yet realistic situations in which they were requested to share what they would do in such a situation and why. Like “Ask a Nurse,” this interactive feature also provided another confidential forum for students to share their own values, perspectives and behaviors while exercising reading, writing and critical thinking skills. Still another benefit was that it allowed them to practice psychosocial communication skills needed in risky social situations.
To measure Teen Smart’s effectiveness in serving the students, we included a “Feedback” section. By clicking onto a button, the teens were able to rate the Web site’s features and assignments in such areas as ease of use, fun, aesthetics, usefulness, appropriateness and relevance.
The feedback we received regarding the site’s content and the opportunity to ask confidential questions was quite positive. The majority of the students found Teen Smart to be interesting (78% of respondents), fairly easy to use (80%) and easy to understand (93%).Asked to identify the most useful aspect of the project, the majority responded that the Web site contained health information they were interested in knowing about.
In other areas, however, the students felt that improvements were needed. They recommended that the schools’ computers be upgraded to allow greater speed and that the login process be streamlined. Some students thought the Web site’s design and colors needed a makeover. While the teens reported enjoying the discussion board, they suggested that it could be improved by allowing simultaneous chat and including students from other schools.
What advice do we have for other nurses and health educators who may be interested in starting a similar program? From both the Cleveland High School students’ feedback and our own observations, we identified four key factors that we feel are essential to the successful implementation of a health promotion Web site for high-risk teens: simplicity, privacy, interactiveness and sustainability.
First, it is essential that teens are able to easily access the Web site. This means not only providing ready access to good-quality computers but also making sure the site has a simple Web address (URL). While computers were readily available at Cleveland High, they lacked the memory and speed which interactive Web-based learning requires. We also found that our URL, www.son.washington.edu/teensmart, was difficult for the students to remember and they would often mistype it.
We have already mentioned that the students we worked with appreciated the opportunity to ask questions and search for answers in a confidential, private environment. However, privacy not only has to be provided on the Web site but also in the students’ working space. We observed that students would often peek at each other’s computer monitors out of curiosity or for assistance, and that this would occur while students were taking personal health quizzes or looking up private information. We recommend that schools establish a designated computer area that will protect teens’ privacy when they are looking up sensitive information, and that computers in the classroom be distanced far enough apart to avoid exposing confidential material.
Thirdly, the Web site should make maximum use of interactive features. Not only did the students enjoy the interactive sections the most, but the teachers and nurse practitioner also found them to be the most useful teaching tools. Students showed the most enthusiasm about Teen Smart when they were accessing the discussion board, receiving instant feedback from the “How Healthy Are You?” quizzes and getting answers from “Ask a Nurse.” Because features like these involve more than just passively receiving information, they make learning active and fun for the students by involving them in the learning process.
Finally, sustainability and maintenance of the Web site is a very important issue. The site’s interactive components require human response, which involves both time and money. Maintaining the Web site—including updating the contents and adding new material to keep it fresh and interesting--requires the active participation of students, teachers and nurses.
Therefore, sustainability must involve incorporating teachers and students into the planning, management and continual evaluation of the site, which requires ongoing training for both teachers and students in Web site use and maintenance. This is a major factor in keeping the Web site viable and encouraging students to continue to use it as an independent learning tool.
These four lessons are crucial if the Web site is to become an active component of the school’s health education curriculum. By integrating Teen Smart into the existing coursework, the teachers at Cleveland High School are motivating their students to access the Web site for information relating directly to their everyday assignments. They are also providing them with a much-needed confidential health resource. Teen Smart not only provides at-risk minority teens with an invaluable and easily accessible source of information about healthy living and health risks, but also empowers them to assume responsibility for making the right health decisions.
These results from focus groups conducted with the high school students were instrumental in helping the team of nursing students and health educators develop the content and structure of the Teen Smart Web site. The teens’ answers are listed in descending order of frequency.
Q: What kinds of health issues do you and your friends think/talk about?
Q: If you have questions about health, do you ask someone? If so, who?
Q: Where else do you get health information?
Q: What does being healthy mean to you and your friends?