Date of Award

May 2024

Degree Type

Dissertation

Degree Name

Doctor of Philosophy

Department

Public Health

First Advisor

Lance Weinhardt

Committee Members

Young Cho, Amy Harley, Noelle Chesley, Cheng Zheng

Keywords

e-STI, eHealth, Internet-Accessed Testing for Sexually Transmitted Infections, MTurk, Sexually Transmitted Infections, Technology Acceptance Model

Abstract

Sexually Transmitted Infections (STIs) continue to be a global public health concern, with an estimated 357 million new infections of curable STIs each year. As of 2018, there were more than 2.4 million cases of STIs in the United States (US) with youth being affected disproportionately. Whereas STIs generally affect youth disproportionately compared to other age groups, young adults (18-24) have a heightened risk for STIs.There is a plethora of research on access to STI testing using conventional modes, but less research exists on access to testing services via the Internet (e-STI services). With only conventional modes of testing, national data shows that testing for STIs remains suboptimal, especially among young adults. Yet testing is a major component of the STI prevention strategies. The substandard utilization of testing services is due to existing multiple-level barriers highly characterized by the need for in-person interaction/contact. Public health STI prevention efforts may therefore miss the ‘core’ transmitters of STIs if it is assumed that young adults will utilize the existing STI clinics. Thus, there is a need to explore the possibility of e-STI as a mode of service delivery among young adults. As the COVID-19 pandemic exacerbated the use of in-person sexual health services, there was a dire need to maximize virtual service delivery. e-STI has the potential to minimize in-person interactions that remain a key challenge to conventional modes of access to STI testing. To this end, this study examined e-STI utilization and the predictors of e-STI service utilization as an alternative mode of service delivery among young adults. The purpose of this study was to understand how theoretical factors from the technology acceptance model (TAM) are associated with behavioral intention to use e-STI services among young adults, and the mediation mechanisms through which these factors influence intentions. The study pursued three central research goals: 1) to understand e-STI utilization and how users compare to non-users, and 2) test the TAM framework in understanding intentions to use e-STI services and 3) to identify the technology factors that predict intention to use of e-STI services among young adults. These goals were achieved by answering the following research questions: The questions on e-STI utilization were: 1) What are the characteristics of e-STI users and how do they compare to non-users? And 2) How widely has e-STI been used among young adults? Regarding the theoretical determinants of e-STIs, we asked. 1) Do factors from the technology acceptance model such as Perceived Usefulness (PU), attitude towards e-STI (ATT), and Perceived Ease of Use (PEOU), predict Behavioral Intention (BI) to use e-STI among young adults in the US? And 2) Does Attitude (ATT) mediate the relationship between Perceived Usefulness (PU) and Behavioral Intention (BI) and between Perceived Ease of Use (PEOU) and Behavioral Intention (BI)? Finally, we asked an open-text response question on the suggestions to improve e-STI testing that read: According to the young adults, what should be done to improve or modify e-STI testing services to increase usability and acceptance? The conceptual framework for the study applied two theories; the Technology Acceptance Model (TAM) and the Andersen and Newman Health Services Utilization Model to conceptualize e-STI from both the technological perspective, and the health service use perspective. The study was of a cross-sectional design that used a survey to collect original data online. Data was collected on the factors theorized to predict using the internet to access STI testing services in a sample of young adults recruited online from the Amazon Mechanical Turk, MTurk. Descriptive analysis in SPSS and Structural Equation Modelling (SEM) analyses in AMOS were conducted to assess the characteristics and mechanisms of the associations in data. The TAM assessed the influence of perceived usefulness, and perceived ease of use as independent variables on behavioral intention to use e-STI services as the dependent variable, and attitude as the mediating variable. The associations were found to be positive, indicating that the TAM is a good fit for evaluating e-STI services. Perceived usefulness and perceived ease of use were both significant predictors of attitude. Attitude mediated the relationships between Perceived usefulness, perceived ease of use and behavioral intention. Suggestions to improve e-STI services were related to system design features, privacy concerns, suggestions on creating more awareness, and cost and improving confidentiality of e-STI platforms. The current rise in STIs and the need to increase services with online and hybrid delivery calls for additional strategies, like e-STI to increase access to STI testing to more people who would otherwise not seek help in-clinic. Given the low utilization and experience of e-STI services in the US, knowledge of the predictors of intention to use e-STI is necessary to design interventions that maximize participation. It is imperative to understand the extent to which modifiable factors such as those from the conceptual framework, like Attitude towards e-STI utilization, predict intention to use e-STI is important.

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