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School-based Health Centers 2.0: Using social media to increase utilization of UMMA Wellness Center Services

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School-based Health Centers 2.0: Using social media to increase utilization of UMMA Wellness Center Services

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Content SCHOOL-BASED HEALTH CENTERS 2.0:

USING SOCIAL MEDIA TO INCREASE STUDENT UTILIZATION OF UMMA
WELLNESS CENTER SERVICES

by

Janeane Nicole Anderson

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY (COMMUNICATION)
ANNENBERG SCHOOL FOR COMMUNICATION & JOURNALISM

August 2017

Copyright 2017 Janeane Nicole Anderson

ACKNOWLEDGMENTS

My brethren, count it all joy when you fall into various trials,
3
knowing that the testing of your
faith produces patience.
4
But let patience have its perfect work, that you may be perfect and
complete, lacking nothing.
5
If any of you lacks wisdom, let him ask of God, who gives to all
liberally and without reproach, and it will be given to him. James 1:2-5

Although this piece of scholarship bears my name alone, I would not have been able to complete
this project—or my doctoral degree, for that matter—without the continual support and guidance
of my community of family members, friends, academic advisers, and research partners.

I give all praises to my Lord & Savior, my Comforter in the midnight hour, Jesus Christ. May the
meditations of my heart and the work of my hands edify Him and uplift His people.

I cannot offer enough words of gratitude for the sacrifices of my family, namely my parents,
Barry and Gina, and my younger brother, Anthony. The authenticity and fearlessness with which
I am able to move through life is due, in part, to your matchless love and encouragement.
Throughout another journey, you were constant sources of emotional, spiritual, and financial
support without complaint or hesitation. Every late-night call for comfort and advice was
answered; every victory, celebrated. I love you.

I am lucky to have a sisterhood network and inner circle of friends who champion me at every
turn. Your prayers, phone calls just to “check in,” and positive words of affirmation kept me
going when the process seemed just beyond my capacity. Thank you for reminding me that I had
more than enough to get this job done.

I also extend my sincerest gratitude to my dissertation committee: Dr. Lynn Carol Miller, Dr.
Margaret McLaughlin, Dr. Tess Boley Cruz, and Dr. Leslie Clark. Thank you for challenging my
thinking, pushing me to produce my best work, and affirming the importance of the kind of
scholarship I seek to produce. I am especially humbled by the devotion of my chair, Dr. Miller,
to my professional and scholarly pursuits. Thank you for scaffolding my growth and
development as a woman and scholar while nurturing my independent spirit. I am proud to be
mentored by you.

I also acknowledge my collaborative research partners at the UMMA Fremont Wellness Center
Ms. Rosario Rico, Ms. Jackie Provost, and Mr. William Retz as well as each of the Student
Health Leaders who were so integral to this project. I also acknowledge behind-the-scenes efforts
of John C. Fremont Principal Pedro Avalos, Mervyn M. Dymally High School Principal Simone
Charles, and other Los Angeles Unified School District staff for ensuring the success of this
project.

This work is a testament to the unwavering dedication of my Given and Chosen family. Thank
you for pouring in to me so that I may, through my research and outreach efforts, pour into
others. I count it nothing short of a blessing to have such an extensive support system that is
dedicated to my personal and professional success. I share this victory with each of you. Quite
frankly, it could not have been accomplished without you.
iii
TABLE OF CONTENTS
Acknowledgments ii
List of Tables vi
List of Figures vii
Abstract viii
Chapter One: Introduction and Overview of the Study 1
Background 1
Problem Statement 3
Purpose of the Study 5
Description of the Intervention 6
Theoretical Perspectives and Conceptual Framework 8
Research Questions and Hypotheses 10
Significance of the Study 13
Summary of Methodology 15
Assumptions 19
Restrictions (i.e., school sampling and construct measurement) 20
Limitations 22

Chapter Two: Review of Literature 24
Adolescent health and wellness in the United States 24
Adolescent health disparities 27
Key adolescent risk behaviors 32
Adolescent engagement with the healthcare industry 45
School-based health centers: Pathway to health equity among adolescents? 51
U.S. teens’ use of new media technologies 56
Adolescent health information-seeking behaviors 57
eHealth literacy 59
Adolescents’ social media use 61
Negative impacts of social media use 62
Adolescents’ social media privacy concerns 63
Social media for health-related engagement 65
Social media-based health interventions 68
Summary 70

Chapter Three: Theoretical Perspectives and Conceptual Framework 72
Introduction 72
Description of conceptual model 73
Key constructs 76
Intermediate behavior change 81
Long-term behavior change 82

iv
Chapter Four: Methods 83
Study Context 83
Research Collaborators 84
Purpose of the Study 87
Research Design 89
Target Population and Participant Selection 90
Procedures 90
Recruitment 92
Study Administration 93
Instruments 98
Analysis of the Data 108
Ethical procedures and protection of participants’ rights 111
Chapter Five: Study Results 112
Introduction 112
Baseline assessments 113
Research questions and hypotheses 114
Data collection 116
Description of study-related data 118
Results 122
Social media-based intervention results 122
UMMA Fremont Wellness Center encounter results 126
UMMA social media activity/presence 129
UMMA Student Health Leader exit interview results 132
Implications 139
Summary 140

Chapter Six: Discussion 142
Introduction 142
Interpretation of study findings 144
Student utilization of school-based health center services 144
Study participants’ engagement in health risk behaviors 145
Study participants’ digital health advocacy behaviors 147
Study participants’ online health information seeking 149
Evaluation of youth-created and youth-curated social media content 150
Theoretical framework revisited 153
Limitations of the study 157
Sample size 157
Potential threats to validity 158
Measures 160
Participant inattention to intervention messages 161
Implications 162
Youth leadership development 162
Lessons Learned 164
Recommendations 168
Future research 171
v
Conclusion 173

References 174

Appendices

Appendix A: UMMA Student Health Leaders Mini Public Health School
Social Media Training Agenda 213

Appendix B: University of Southern California Institutional Review 216
Board Approval Letter

Appendix C: University of Southern California Institutional Review Board 217
Renewal Letter

Appendix D: Los Angeles Unified School District Committee for 218
External Research Review Approval Letter

Appendix E: UMMA Student Health Leaders Social Media Strategy 219
Pre-planning Worksheet

Appendix F: UMMA Student Health Leaders Digital Health Content Worksheet 222

Appendix G: Web Links to UMMA Fremont Wellness Center Digital Health
Content 223

Appendix H: Behavioral Assessment for Study Participant s 224

Appendix I: Safety Plan for Minor Study Participants 246

Appendix J: Description of Thematic Analysis Process for UMMA 248
Student Health Leader In-depth Interviews

Appendix K: UMMA Student Health Leaders Exit Interview Guide 249

Appendix L: Legend: UMMA Fremont Wellness Center visit codes 251

vi
LIST OF TABLES

Table 1: Key concepts and definitions of the Health Belief Model 74

Table 2: Demographics of study sample 120

Table 3: Participants’ social networking site preferences 121

Table 4: UMMA Fremont Wellness Center student service provision 128
Table 5: Description of digital health content for intervention condition 130
Table 6: Description of social media platform activity 131
Table 7: Type of digital health content by social media engagement 131
Table 8: Social media platform by social media engagement 132

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LIST OF FIGURES

Figure 1: Analytic Framework: School-based health centers to promote health
equity 52

Figure 2: Conceptual model for adolescent behavior change using social
media 77

Figure 3: Sexual/reproductive health content: Instagram photo 99

Figure 4: Alcohol, Tobacco, & Other Drug (ATOD) prevention content:
Facebook novella 100

Figure 5: Alcohol, Tobacco, & Other Drug (ATOD) prevention content:
Instagram video 100

Figure 6: Teen dating violence awareness content: Facebook video 101

Figure 7: General Fremont Wellness Center information content: Instagram
photo 101

viii
ABSTRACT

Adolescents of color receive less access to preventive health measures (e.g., health screenings)
and medical care than other youth. School-based health centers (SBHCs) provide an entry point
to address primary care health disparities, but even when SBHCs are available, their services are
often underutilized. The communication strategy to increase SBHC utilization is unclear. The
goal of the current work is to test a theory-based, peer-to-peer social media-based health
intervention’s promise in addressing this need. Thus, this quasi-experimental study tested the
efficacy of a 15-week, youth-led social media-based health intervention in South Los Angeles at
increasing use of school-based health center. Potential for increasing preventive (e.g., HIV/STI
testing, alcohol use reduction) and digital behavior (e.g., online information seeking, digital
health advocacy) was also explored. Participants (N=98) were African-American and Latino high
school students attending one of two campuses served by the UMMA Fremont Wellness Center
(FWC). Participants in the treatment condition were exposed to youth friendly digital health
content developed by trained peer health advocates, and those in the control condition received
standard care (e.g., pamphlets and health fairs). All study participants completed a questionnaire
at baseline and immediately post the 15-week intervention. Participants in the treatment
condition, compared to those in the control condition, used more UMMA FWC healthcare
services, reduced alcohol consumption, and increased online information seeking (via social
media-based health resources); no other effects were significant. A social media-based health
intervention that features youth friendly digital health content created by peer health advocates
shows promise for increasing student utilization of a school-based health center, peer-to-peer
health communication, and social media for health information seeking among youth while
reducing alcohol consumption.
CHAPTER ONE

INTRODUCTION AND OVERVIEW OF THE STUDY

Background
Most youth in the U.S. do not receive health screenings or preventive counseling at rates
consistent with clinical guidelines (Irwin, Adams, Park, & Newacheck, 2009). Despite coverage
expansions due to the Patient Protection and Affordable Care Act (PPACA), persistent
disparities among Blacks and Latinos (compared to whites) result in less access to and utilization
of preventive health measures and needed medical care (Artiga, Young, Garfield, & Majerol,
2015). School-based health centers (SBHCs) can help ameliorate persistent health disparities
among children and adolescents. SBHCs, including school-linked health centers and mobile
units, are designed to provide comprehensive health education as well as primary physical,
sexual/reproductive, and mental health services to enrolled students. They provide quality care
for uninsured/underinsured low-income young people, helping them achieve greater numbers of
quality-of-care markers (Allison et al., 2007). SBHCs provide an entry point to primary care,
with ongoing connections to a medical home, for youth who do not have access to consistent
care (Brindis & Sanghvi, 1997). SBHCs are found primarily in urban areas (57%), but there are
also significant numbers in rural (27%) and suburban (16%) locations (Gustafson, 2005; Keeton,
Soleimanpour, & Brindis, 2012). SBHCs provide a safety net for children and their parents.
These organizations also positively impact student academic achievement by addressing health-
related concerns in a timely fashion (e.g., during the school day) with reduced interruptions to
the learning process (often because of campus co-location).
2
A challenge, however, is that even where SBHCs exist, there is a lack of full uptake of
services by students to whom care is made available (Community Preventive Services Task
Force, 2016). The Internet may provide part of the solution for increasing young people’s use of
targeted health services. The Internet is valuable in satisfying adolescents’ information-seeking
needs because the anonymity of web-based searches, compared to in-person queries of health
professionals, allows young people to ask health questions they would not normally ask because
of embarrassment (Bleakley, Hennessy, Fishbein, & Jordan, 2008; Ralph, Berglas, Schwartz, &
Brindis, 2011). Computer-mediated health communication via digital media technologies,
including mobile technologies and social media, may prove to be a promising method for
increasing students’ use of SBHC services. What is unknown is whether health-related
information disseminated to adolescent online audiences via social networking sites (SNS) can
activate theoretical behavior change concepts (e.g., self-efficacy, perceived susceptibility,
perceived risk, cues to action), resulting in accessing SBHC services, and alone or in
combination, reducing risky behaviors and increasing prosocial, protective behaviors.
The overall aim of this research study is to identify an innovative method for increasing
student utilization of SBHC services through the implementation of a peer-to-peer social media-
based health intervention. Specifically, this research study will utilize a mixed-methods approach
to begin to understand if youth-curated, social media-delivered health content could positively
impacts adolescent health-related decision-making and behavior (and if so, how). A quasi-
experimental study will be conducted to compare the efficacy of a social media-based health
intervention to traditional SBHC outreach at achieving the following behavioral outcomes
among male and female high school students: increased utilization of SBHC services, increased
HIV/STI-related testing, increasing online information-seeking, increased peer-to-peer health
3
communication (i.e., digital health advocacy), and reduced risky behaviors. Thus, this study
seeks to begin the development of a theoretical model of adolescent health-related behavior
change.

Problem Statement
Health disparities in Los Angeles County persist. South Los Angeles has been identified
as a “health hot spot,” meaning a significant percent of residents live well below the poverty line
and are at disproportionately high risk for obesity, diabetes and sexually transmitted infections
(C. Barba, personal communication, March 25, 2016). More than any other region in Los
Angeles County, South Los Angeles residents are disproportionately harmed by inequities in
healthcare resources and physical environment constraints. Specifically, South LA has 43%
fewer healthcare resources (e.g., healthcare coverage, healthcare facilities, access to primary and
preventive care) and 43% fewer environmental resources (e.g., schools, housing, public safety,
physical activity options) than Los Angeles County in general (Park, Watson, & Galloway-
Gilliam, 2008). In South Los Angeles, more people die of lung cancer, stroke, diabetes and heart
disease than in any other place in Los Angeles County. African-American babies born in the area
have a 13.5% higher death rate within their first year than white infants in the area. Additionally,
Hispanic children in the area are nearly three times as likely as white children to have no usual
source of health care (UMMA, 2016). Considering the persistent health disparities that exist
within South Los Angeles—that are mainly concentrated among disadvantaged, underserved
Blacks and Latinos—provision and utilization of low-cost or free medical care services to city
residents is a public health priority.
4
Considering risky behaviors among adolescents are leading causes of their premature
mortality and morbidity, providing access to medical care services for young people is an
important public health issue. Whereas risk behaviors developed in childhood and adolescence
may continue throughout adulthood if not addressed, SBHCs fulfill an important health
promotion role. SBHCs help youth develop self-efficacy skills for avoiding high-risk situations,
and they can encourage behavior change because of the relationships that can be developed
between students and healthcare providers (Ralph & Brindis, 2010). Moreover, these healthcare
centers increase the likelihood that students will access reproductive healthcare services and are
correlated with increased contraceptive use and STD screening (Ethier et al., 2011). Likewise,
schools with SBHCs have demonstrated a greater decline in teen pregnancy rates (Ricketts &
Guernsey, 2006). SBHC-based health interventions also produce intermediate outcomes (e.g.,
improved health status, resiliency, school climate) that positively impact student academic
performance (Geierstanger, Amaral, Mansour, & Walters, 2004). However, disconnect between
the availability of healthcare and youths’ use of health services and resources (Community
Preventive Services Task Force, 2016) poses a challenge to efforts to reduce health disparities.
Thus, SBHCs must improve the design and delivery of health and wellness services that promote
youth health promotion and education. Specifically, SBHCs must employ innovative methods to
develop more effective programming for its youth clients. This research study seeks to examine
one promising method: peer-to-peer digital health advocacy
1
using social media.

1
Digital health advocacy is a term developed by the researcher that refers to youths’ use of new
media technologies, specifically social media platforms and social networking sites, to create and
share youth-friendly, relevant health content to network peers. This form of online peer-to-peer
content sharing is theorized to influence youth attitudes, norms and behaviors about health-
related topics, such as sexual/reproductive health, mental health, healthy eating and exercise, and
substance use avoidance.
5
Purpose of the Study
School-based health centers meet the healthcare needs of disadvantaged populations, with
particular attention to the preventive and primary care needs of adolescents. By addressing
barriers to medical care access, SBHCs have the potential to improve health equity (Knopf et al.,
2016). By averting healthcare costs (e.g., emergency department visits, hospitalizations,
unintended pregnancy) and productivity losses (e.g., school absences, missed employment
hours), SBHCs also demonstrate economic benefits that exceed operating costs (Ran,
Chattopadhyay, Hahn, & Community Preventive Services Task Force, 2016). However, lack of
full uptake of SBHC services by students to whom these services are available has been cited as
a key challenge of SBHC implementation (Community Preventive Services Task Force, 2016).
Specifically, in high-need communities—characterized by urban locales with low-income,
underserved residents—the proportion of students who enroll and use SBHC services is often
less than those who are in need of these services. Addressing existent medical care needs will
increase student health and reduce absences based on illness. Knopf and colleagues (2016)
identify several areas for further research that remain regarding evidence gaps in SBHC
effectiveness, namely identifying strategies to increase youths’ use of SBHC services and
resources.
The Internet has become a preferred delivery method for health interventions because of
the nature of the Web 2.0 technologies, specifically the potential to reach large audiences with a
single posting, easy storage of information, ability to provide personalized feedback, and
information transmission that goes beyond text-based messages. In addition, growing numbers of
healthcare organizations employ the Internet as a health intervention delivery method because of
its ubiquity, and computer-mediated communication is a primary form of communication for
6
youths (Griffiths, Lindenmeyer, Powell, Lowe, & Thorogood, 2006). Today’s youth are
entrenched in social media; their online and offline lives are often inextricably linked. The next
generation of youth-targeted interventions must address the unique risk ecologies of urban
adolescents in new ways; social media (i.e., social networking sites) are promising methods.
Digital health advocacy is a way in which teens can engage in the peer-to-peer
learning/educating process. By capitalizing on youths’ existing social networks, which are
influential in healthy decision-making, peer-to-peer communication about health topics
facilitated by social networking sites may also promote social norms around developing and
maintaining positive lifestyle choices.
With this in mind, the purpose of this study is to systematically compare the efficacy of a
youth-based social media intervention to standard SBHC outreach at achieving increased SBHC
service utilization as well as increased online information seeking behaviors, peer-to-peer health
communication and HIV/STI testing and decreased risk behaviors (e.g., alcohol and substance
use, unprotected sex).

Description of the Intervention
Digital healthy advocacy is the concept that distinguishes the social media-based, youth-
led health behavior intervention employed in this current work. Digital health advocacy is a term
developed by the researcher that refers to youths’ use of new media technologies, specifically
social media platforms and social networking sites, to create and share youth-friendly, relevant
health content to network peers. This form of online peer-to-peer content sharing is theorized to
influence youth attitudes, norms and behaviors about health-related topics, such as
sexual/reproductive health, mental health, healthy eating and exercise, and substance use
7
avoidance. The youth-created digital health content in this pilot will be primarily designed to
increase student use of a SBHC. This potentially innovative intervention employs theories
common among successful behavioral health interventions (i.e., Health Belief Model, Social
Cognitive Theory) and incorporates a combination of theoretical components (e.g., perceived
threat, self-efficacy, and empowerment) and methods (e.g., digital health advocacy and peer
learning) that may represent a new generation of “hybrid intervention” that meets the multiple
health needs of youth of color in the U.S. (Whaley, 1999). Trained UMMA Student Health
Leaders—peer health advocates who attend Fremont High School and serve as on-campus health
resources and Center liaisons—will create content for the Fremont Wellness Center’s official
social media accounts. Content for these profiles will correspond to topics related to healthy
eating and active lifestyles, mental health, sexual health (e.g., healthy relationships,
communication about sexual history, safer-sex negotiations, contraceptives, and STI testing), and
substance abuse avoidance. Student Health Leaders will populate the social media accounts with
health-related content (e.g., facts, trend data, quizzes, “Question of the Day,” photographs, and
videos) informed by Health Belief Model constructs (e.g., perceived risk, susceptibility, self-
efficacy). UMMA Student Health Leaders are integral to this social-media based intervention,
for they independently create the intervention stimuli for their peer audiences (as opposed to
adults developing health content for youths). To the researcher’s best knowledge, there are no
social media-based health interventions that encourage adolescent behavior change through
digital health content created by trained peer health educators.
Per the tenets of digital health advocacy, intervention stimuli (i.e., digital health content
developed by SHLs) will be designed to be both informative and entertaining such that youths
will be encouraged to share content with their online friends and followers. Thus, peer-to-peer
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information-sharing behaviors among social media users, including viewers and followers of
UMMA’s social networking site accounts, are conceptualized to be a part of the overall
intervention. Lastly, youth who share the digital health content posted on UMMA’s social media
profiles are believed to engender peer-to-peer learning through their online and offline
discussions of the content, which may spark further health-related information-seeking
behaviors, engagement with a SBHC, and/or risk-reduction behavioral changes.

Theoretical Perspectives and Conceptual Framework
School-based health centers seek to increase student utilization of healthcare services,
and digital technologies may be a way to encourage more youth engagement with medical
organizations. Whereas social media-based health interventions have been identified as effective
means for behavior change, youth-created, social media-delivered health content is offered as an
innovative method for improving Internet-based interventions, in general, and addressing
deficiencies in teens’ use of SBHCs, specifically. The conceptual framework devised for this
research study is reflective of the following value-expectancy theories:

Health Belief Model
The Health Belief Model (HBM) provides the theoretical foundation for the conceptual
model proposed in this research study. One of the most widely used behavior change theories,
the HBM emerged in the 1950s as an explanation for why people did not use preventive
healthcare services (i.e., immunizations). Development of the model led to its ability to predict
why people will take action to prevent, screen for, or control health-related illness (Champion &
Sugg Skinner, 2008). As such, this model has tremendous applicability to the current research
9
study that seeks to explore new methods for increasing adolescent use of healthcare services.
HBM key constructs related to this study include perceived susceptibility, perceived risk,
perceived benefits, and cue to action.

Social Cognitive Theory
Social cognitive theory (SCT) explores the individual in relation to the environment and
focuses on the mechanisms by which individuals learn to create environments that meet their
needs. Psychological principles that address human information processing based on learning
through observation, experience, and communication are central to this theory. SCT key
concepts can be grouped into five categories: a) psychological determinants of behavior; b)
observational learning; c) environmental determinants of behavior; d) self-regulation; and e)
moral disengagement (McAlister, Perry, & Parcel, 2008). The use of SCT components in online
environments is hypothesized to combat risky behaviors among youth; therefore, self-efficacy
and observational learning are SCT concepts examined in this research study. Self-efficacy,
perhaps the most widely known SCT construct, addresses an individual’s beliefs about his or her
perceived ability or capacity to influence events and/or achieve a set goal. In this research study,
self-efficacy perceptions are believed to be bolstered by social media-based health content
designed for teens by teens—content that specifically addresses teens’ internal locus of control
and seeks to encourage behavior change. Observational learning can be achieved through peer
models, especially those who are perceived as “coping” models—individuals who are struggling
with the same obstacles.

10
Empowerment Theory
Personal empowerment (Zimmerman, Israel, Schulz, & Checkoway, 1992) suggests that
a young person’s involvement with activities or organizations that provide opportunity for civic
and/or community engagement is key to personal development and skills building. For
adolescents, participation in positive roles, like academic, extracurricular, and community
leadership activities, followed by recognition is a key part of the empowerment process. The
theoretical model proposed in this research study offers that youths’ online activities, especially
those involving peer-to-peer communication, create opportunities for health leader roles that may
lead to empowerment. For instance, positive roles (e.g., health risk avoider, medically adherent,
peer health advocate, online information sharer) followed by health-related recognition (e.g.,
good report from a physician) may lead to personal and group empowerment.

Research Questions and Hypotheses
Digital technologies, including social networking sites, have shown promise as effective
health intervention delivery methods. What is not known is how social media platforms might be
leveraged to increase the effectiveness of school-based health center outreach efforts to achieve
greater student use of SBHC services. Additionally, there is no existing literature about how
social media-based health content that is developed and disseminated by trained youths (i.e., peer
health advocates) can be used to achieved SBHC health-related goals, namely increased student
utilization and reduced adolescent risk behaviors. Thus, this project seeks to address the
following research questions:
Is a youth-led digital health advocacy program more effective than traditional SBHC outreach
(e.g., pamphlets, health fairs) at achieving behavior change (e.g., increased student utilization of
11
SBHC services, increased STI-related testing, increased peer-to-peer health communication, and
reduced risky behaviors) among participants in a treatment group compared to participants in a
control group?
Based on current literature, the following hypotheses will be tested:
H1: Participants in the treatment condition will self-report more SBHC service use in a 90-day
period than participants in the control condition.

H2: Participants’ self-report of risk behaviors is associated with intervention condition.
H2a: Participants in the treatment condition will self-report less unprotected sexual
intercourse (i.e., condomless, no use of hormonal contraceptives) than participants in the control
condition from baseline to immediate post.
H2b: Participants in the treatment condition will self-report fewer sexual debuts than
participants in the control condition from baseline to immediate post.
H2c: Participants in the treatment condition will self-report less substance use, including
alcohol, tobacco, marijuana, and illicit substances, than participants in the control condition from
baseline to immediate post.
H2d: Participants in the treatment condition will self-report fewer instances of riding in a
motor vehicle with a driver who has consumed alcohol or other licit/illicit substances.

H3. Participants’ self-report of HIV/STI testing behaviors in the past 6 months is associated with
the intervention condition.

12
H4: Participants in the treatment condition will self-report greater digital health advocacy
behaviors than participants in the control condition.
H4a: Participants’ self-report of past direct messaging (DM) or re-tweeting of health-
related online content is associated with the intervention condition.
H4b: Participants in the treatment condition will report greater willingness to disseminate
health information to their social media contacts (i.e., “friends”, “followers”) than participants in
the control condition.
H4c: Participants in the treatment condition will self-report greater willingness to
intervene in potentially risky behavior among peers via social media platforms than participants
in the control condition.

H5: Participants in the treatment condition will self-report more online health information-
seeking behaviors than participants in the control condition.
H5a: Participants in the treatment condition will use the Internet for health-related
information more often than participants in the control condition.
H5b: Participants in the treatment condition will use social media sites for health-related
information more often than participants in the control condition.

Additionally, this pilot project will also address the following research question: What kind of
digital health content and social media platforms are more likely to encourage higher levels of
social media engagement among users?

13
Significance of the Study
This study is significant because of its innovative potential within the domain of social
media-based health interventions. Although the Internet, and more specifically social media, has
been identified as a vehicle for effective health information dissemination, there are a limited
number of health interventions for adolescents that use social media as the primary intervention
vehicle. Shaw and colleagues (2015) suggest that social media as a health intervention
mechanism is a novel idea that needs more research to improve methodological rigor and
theoretical soundness.
The study is predicated on the notion that popular social networking sites, like Instagram,
Snapchat, Twitter and Facebook, can be used to disseminate targeted, youth-friendly health
messages developed by trained peer health advocates to achieve improved teen health and
wellness outcomes. Findings from this research study may improve the design and delivery of
SBHC-provided health services that promote student health. Whereas this research project is
designed to compare the effectiveness of traditional outreach efforts against an innovative
method, findings from the study may be instructive for healthcare practitioners, SBHC staff, and
public health scholars, as they explore new methods to develop, implement, and evaluate youth-
centered programming using new media technologies. Moreover, this research study is expected
to have direct benefit on a local level to various stakeholder organizations (e.g., UMMA
Community Clinic, Los Angeles Unified School District) in terms of increasing the number of
students who are a) communicating about teens’ health and wellness needs; b) aware of the
primary and preventive healthcare services offered by the UMMA Fremont Wellness Center; and
c) attending to their healthcare needs.
14
This research project will contribute to existing intervention scholarship, particularly
interventions conducted in collaboration with school-based health centers and with youth as
collaborators. Several elements of this study are particularly noteworthy:
• Digital health advocacy. This concept has theoretical, cultural and practical significance.
“Digital native” is a commonly used term to describe today’s youth; the term signifies
young people’s familiarity and seemingly intrinsic ability to navigate new media
technologies as they emerge. Digital health advocacy refers to youths’ use of social
media platforms to disseminate health-related messages to peers and can influence
youths’ attitudes, norms and behaviors about health and wellness. Peer-to-peer online
communication about health topics can create social norms around healthy lifestyles and
influence youths’ perceptions about negative health outcomes associated with risk
behaviors. Digital health advocacy is an avenue in which young people can engage in the
peer-to-peer learning/educating process. Digital health advocacy capitalizes on teens’
existing social networks, which play influential roles in their attitudes and behaviors and
may inspire young people to become active participants in their health and healthcare.
Moreover, SBHC budget constraints and reductions in human capital resources to
conduct face-to-face outreach mean that digital outreach has positive cost-benefit.
• Moving beyond Facebook and Twitter. To the researcher’s knowledge, there are no health
interventions that feature youth-curated and created online health content using primarily
Instagram as the platform for message dissemination. Instagram now boasts more users
than Twitter, with 300 million users as of December 2014. Snapchat is another platform
used for message sharing. This platform is relatively new (launched in September 2011)
and has not been used in any adolescent health interventions. However, with more than
15
100 million active users who send snaps at a rate of more than 400 million per day, this
social media platform has untapped potential for health interventions. Notably, this
intervention is sustainable because the project is not platform specific. Social networking
sites grow and wane in popularity rapidly; what may be popular one day may be nearly
obsolete within a matter of months. Whereas teens use social media platforms that are
popular at a given time, the digital health content is formatted to maximize platform
characteristics. When new social media platforms become popular or add new features,
the intervention model remains the same. It allows for flexibility. Platform-specific health
content is both innovative and potentially effective because it may activate theoretical
constructs for behavior change.
• “Just-in-time” content. This research study explores teens’ development of social media-
delivered messages that reflect multiple message formats, including statistics, narratives,
real-time video, and videotaped role play. Message language is crafted in a way that is
authentic to youth culture and able to address contextual moments. Social media posts are
made at peak use times (e.g., before school, during lunch hour, evening hours, and
weekend nights) and times in which behavioral temptations are heightened (e.g., posts
about healthy food options at lunchtime or safer-sex reminders after school, late at night,
and weekends), thus capitalizing on the just-in-time potential of digital health
communication.

Summary of Methodology
The aim of this research study is to evaluate the use of social media (i.e., social
networking sites) as effective peer-to-peer, health content delivery methods that have the
16
potential to increase youths’ use of SBHC care services and resources (including HIV/STI
testing) and reduce risk behaviors.

Research design
The proposed study employs a quasi-experimental method with behavioral assessments
given at two time points during the study period to volunteer participants in each of two groups.
It was not possible to conduct a true experiment (randomly assigning participants to condition)
since there was the threat (within school) of diffusion (Cook & Campbell, 1979), namely
treatment effects spreading to control group participants. This threat is reduced by comparing
two schools, one with the proposed treatment (John C. Fremont High School) and a control site
(Mervyn M. Dymally High School). John C. Fremont High School is the treatment condition site
because of its co-location with the UMMA Community Clinic’s Fremont Wellness Center and
established Student Health Leader program; study participants from this campus will be enrolled
in the treatment group. Mervyn M. Dymally High School is the control condition site;
participants from this campus will be enrolled in the control group. This control site was selected
since students from this control school also have access to the UMMA Community Clinic’s
Fremont Wellness Center.
The 15-week study will compare standard SBHC outreach (e.g., pamphlets and on-
campus health fairs) to a social media-delivered health intervention. Study participants in both
the treatment and control conditions will complete baseline and immediate-post behavioral
assessments. Baseline measures are especially important in this quasi-experimental study to
assess any initial differences between the two sites prior to treatment (or not). The assessment is
a 91-item questionnaire using closed-ended, Likert-scale items that takes approximately 20
17
minutes to complete. All study participants (treatment and control condition) will complete the
assessments in person in a quiet, semi-private location (e.g., campus library or computer lab).
Participants will be compensated with a $10 merchant gift card for each completed assessment.

Materials
Peer-to-peer digital health advocacy intervention (treatment condition). Per study
requirements for students in the treatment condition, participants must “like” or “follow” the
UMMA Wellness Center’s official social media accounts, thus providing them with direct
exposure to youth-curated and youth-created digital health content (e.g., news articles, videos,
memes) that comprise the social media-based health intervention. A person who “likes” a group
on Facebook or “follows” an account on Twitter/Instagram/Snapchat or other social networking
sites becomes linked automatically to that group’s account, and all posted content is broadcast to
every network member’s page in the form of an RSS feed. Because participants “like” or
“follow” Fremont Wellness Center social networking site profiles as part of the study, they will
be exposed to youth-friendly health messages daily.
Participation in the digital health advocacy intervention arm is based on participant
discretion. Participants will not be required to meet any social media use requirements (e.g.,
number of total hours) as part of the study. Instead, they will be instructed to engage in social
media per their usual routine. In addition, participants will be reminded to adhere to all school
policies regarding use of electronics and websites. Students will be encouraged to share content
they find interesting from UMMA’s social media accounts to members of their online social
networks, using “share” functions within each social media platform (e.g., reposts on Instagram,
retweets in Twitter, and various “share & post” functions in Facebook). Whereas social media
18
users, including youths, frequently share online content as part of their engagement with
platforms of their choice, participants in this study will be asked to continue that same behavior
with content posted by Student Health Leaders on behalf of the Fremont Wellness Center.
Standard SBHC outreach (control condition). Study participants in the control
condition will be provided UMMA Fremont Wellness Center resource materials. Additionally,
two UMMA-sponsored, on-campus health fairs will be held during the study period (one prior to
the baseline assessment and one during the 15-week intervention period). These lunchtime health
fairs will be open to all Dymally High School students, regardless of study enrollment. Students
in the control condition will not have to meet any social media activity requirements, as they will
not be exposed to the social media intervention.

Procedure
Recruitment. For the treatment condition, all ninth grade students enrolled in a Physical
Education (PE) course will complete a health screening survey. The health screener is 22-item
questionnaire that assesses adolescent health risk factors within the domains of general wellness,
medical care access, overweight/obesity, chronic conditions (e.g., asthma, hypertension,
hyperlipidemia, and cardiovascular disease), substance use, unprotected sexual behavior, school
violence, and mental/emotional disorders. The health screener is employed by UMMA Fremont
Wellness Center staff to increase the percentage of students receiving services and identify high-
risk students who may be in need of timely medical care
2
. All of these students will be invited to
participate in the research study. In addition to recruitment of PE students, the researcher will
recruit students enrolled in a history course (9
th
-11
th
grade) and elective courses (e.g.,

2
The researcher developed the tool for the UMMA Community Clinic for purposes independent
of this research study.
19
Leadership, Media Production) (10
th
-12
th
grade). Interested students will be provided with an
age-appropriate assent/parent permission or consent form. Upon return of the signed assent or
consent form, a student will be enrolled in the study.
For the control condition, all students enrolled in a science course (9
th
-12
th
grade) will be
invited to participate in the research study. Interested students will be provided with an age-
appropriate assent or consent form. Upon return of the signed form, a student will be enrolled in
the study.
Recruitment differences are attributable to campus principal constraints. Mr. Pedro
Avalos, principal at the treatment site, prohibited study recruitment activities in required courses
(e.g., English, mathematics, science, health). Instead, he stipulated that all study-related activities
be conducted through the PE department or elective courses. Conversely, Ms. Simone Charles,
principal at the control site, identified the science department as most appropriate for recruitment
activities because of the study’s health-related focus. Plus, according to Principal Charles, most
students on the campus take three or more years of science courses, which would increase the
likelihood that recruitment efforts would reach the majority of potential participants.

Assumptions
This research study is predicated on the assumption that all participants enroll and
participate in the study with full knowledge and understanding of eligibility criteria, research
protocols, and participation requirements. Specifically, participants read and understand the
assent document (consent for those 18 years and over) prior to giving their informed
assent/consent. Parents read and understand the assent/parental permission document prior to
giving consent for their child to participate. Additionally, students understand that their
20
participation is voluntary and will have no impact on their academic standing in school, and they
can withdraw their participation at any time without penalty. Another assumption is that student
participants read and understand the items in the behavioral assessments and answer those
questions accurately and honestly. Further, students in the treatment condition adhere to
requirements for participation, namely following the social media accounts necessary for
exposure to the intervention. Lastly, it is assumed that student participants in the treatment and
control conditions are essentially similar on key independent variables, and any inaccuracies in
the data are not due to systemic bias but are randomly distributed.
These assumptions are critical to allow for proper data analysis. The assent/consent
process is important for ensuring youths who participate in the study are doing so with full
knowledge of research-related activities, and their continued participation for the duration of the
study period is completely voluntary. Likewise, parental permission is fundamental to research
with minors, for it serves as a safeguard against activities the parent/guardian may deem harmful
to their child. Youth participants need to understand that their answers to survey items are
confidential for privacy protection and to encourage truthful responses.

Restrictions (i.e., school sampling and construct measurement)
This research study will explore the role of peer-to-peer health advocacy using digital
media technologies to increase adolescent use of school-based health center primary and
preventative healthcare services. A host of community-based organizations work in partnership
with Los Angeles Unified School District (LAUSD) to sponsor school-based health centers.
There are more than 35 SBHCs operating on LAUSD campuses, of which 27 operate on high
school campuses. Local District South (South LA area) has four SBHCs located on high school
21
campuses (Carson High School Wellness Center, Fremont Wellness Center, Gardena High
School SBHC, and Jordan High School Wellness Center). These SBHCs comprise the study
sample pool. However, the environmental and organizational contexts vary at these centers.
Specifically, all do not have trained peer health advocates as part of the organizational staff.
Since replication of the study protocol in the absence of this key component is not feasible, the
study is restricted to the Fremont Wellness Center and high schools in the LAUSD Fremont
Zone of Choice (John C. Fremont High School, Mervyn M. Dymally High School, and Diego
Rivera Learning Complex). Access to the UMMA Fremont Wellness Center and study sites (i.e.,
Fremont and Dymally High Schools) was based on the researcher’s previously established
professional relationships and collaborative research partnerships. Thus, study-related activities
are limited to two of the three high school campuses within the SBHC service area.
Although the Health Belief Model, Social Cognitive Theory, Empowerment Theory, and
Health Behavior Framework guided choice of theoretical constructs for the current work, the
specific concepts chosen from these models were those identified by the researcher and youth
collaborators (i.e., UMMA Student Health Leaders) as most relevant to the target audience of
youth users of the SBHC. This is consistent with prior meta-analytic work examining the utility
of various theoretical constructs across models (Webb, Joseph, Yardley, & Michie, 2010), which
suggests the following constructs are most promising at achieving behavior change: Theory of
Reasoned Action/Planned Behavior (TPB), Transtheoretical Model (TTM), and Social Cognitive
Theory (SCT).

22
Limitations
This proposed research project has several limitations that must be acknowledged.
Potential selection bias poses the most significant threat to study internal and external validity.
As discussed in the restrictions section, study-related activities are limited to one SBHC and two
LAUSD high schools. These sites were not chosen at random; instead they were selected based
on researcher access and familiarity with organization staff and structure. Similarly, since John
C. Fremont and Mervyn M. Dymally High Schools have been a priori identified as treatment and
control sites, respectively, participant assignment to either condition is dependent upon
enrollment in a particular campus and does not involve random assignment. Participants self
select into this research study (i.e., participation is strictly voluntary). Since the research design
is not a randomized controlled trial and there is a potential selection bias among study sites and
participants, results cannot be generalized beyond a specific subset of adolescents. Non-
randomness at multiple levels of the research design may also result in interaction effects of
selection biases and the quasi-experimental treatment. It is possible that the effects of the social
media intervention will not generalize to students within the sample pool or larger study
population because of uncharacteristically high or low social media use among study
participants. Likewise, there is a potential for the Hawthorne effect. Per conditions of study
enrollment, participants in the treatment condition will be required to “like” and “follow” all
UMMA Fremont Wellness Center social media accounts. Students will also provide a moniker
for at least one of their social media accounts for study monitoring purposes. It is possible that
participants will increase their social media use because they perceive their online activity is
being monitored.
23
Another noteworthy limitation is the sample size. Although the treatment campus is a
large urban high school (student body population: 1,994), the school principal approved study-
related recruitment efforts for a limited number of courses (e.g., electives) and teachers (7 of
211). Therefore, only a limited number of eligible students were exposed to the recruitment
materials. At the control campus, the researcher was given similar constraints to recruit eligible
students (e.g., the science department), and with a student body population of approximately 648,
the control campus is smaller than the treatment condition site. Similar to the treatment site, a
limited number of students were exposed to the recruitment materials and enrolled in the study.
Therefore, the sample size for this current project is expected to be significantly smaller than the
pool from which eligible participants could be drawn, which is expected to impact the statistical
power.
Lastly, since this research project explores a relatively new area of digital media
scholarship, the possibility exists that extraneous variables might compete with independent
variables to account for changes in the outcome variables. Current literature in this domain is in a
relatively nascent stage, and recent meta-analyses do not identify confounding variables.

24
CHAPTER TWO

REVIEW OF LITERATURE

Adolescent health and wellness in the United States
Adolescent health and wellness is a proxy for the overall health of a nation. Youth who
develop behavioral habits that increase their risk for premature mortality and morbidity or who
lack consistent access to medical care signal differential qualities of health based on social
determinants. Healthy People 2020, the 10-year agenda for improving U.S. health outcomes,
provides a set of standards for adolescent health and wellness. Some of these standards include
an increase in adolescents who have had a wellness check-up in the past 12 months, who use
contraceptives (including condoms), who are in receipt of reproductive health services, who have
taken an HIV test in the past 12 months, and who delay their sexual debut or remain abstinent.
Additionally, a decrease in the number of adolescents who ride with drivers who have been
drinking alcohol, engage in substance abuse behaviors (e.g., marijuana use, illicit drugs, and
binge alcohol drinking), and use tobacco products are also among HP 2020 goals for U.S. youth
(Healthy People 2020, 2015). Since lifestyle choices are habitual and often reflect individual
decision-making, environmental influences, and constraints of systemic or structural boundaries,
improvements in adolescent health outcomes, especially for high-risk, vulnerable youth, require
collective efforts from a myriad of stakeholders including researchers, public health
practitioners, medical care providers, health organization leaders, and government officials.
Adolescence, the period in which a young person transitions from childhood to
adulthood, brings with it a unique set of opportunities and challenges. The onset of puberty often
25
signals the beginning of this developmental stage. At the same time teens are experiencing
significant physical and emotional changes, they must also navigate new intrapersonal and
interpersonal tasks such as developing their personal identities, fostering independence within
the context and constraints of their sociocultural environment, and learning to engage in intimate
sexual relationships with appropriate peers (Christie & Viner, 2005). The high-risk, potentially
harmful behaviors that characterize adolescence were once thought to be indicative of poor
logical reasoning skills (Steinberg, 2007). However, recent developments in neuroscience
suggest that adolescent behaviors can be attributed to stage-specific brain and affect changes as
well as heightened emotional sensitivity. An adolescent’s tendency toward risky behaviors is
often the result of slow maturation of the cognitive-control system (which regulates functions
like planning, thinking ahead, and self-regulation) and increased sensitivity of the
socioemotional network (which responds to social stimuli). Although logical reasoning abilities
become fully developed at approximately age 15, psychosocial maturity continues to develop
into full adulthood (Steinberg, 2005, 2007). For instance, Sales and colleagues (2012a) found
that sensation seeking and impulsivity are related to adolescent young women’s sexual
behaviors; however, impulsivity was a significant predictor of sexually transmitted disease
(STD) acquisition for older adolescent young women only. Despite their age, highly impulsive
adolescents may not have developed the self-regulatory skills associated with maturity to avoid
sexual risk behaviors that may lead to STD/STI contraction.
Peer networks become significant influences during adolescence. During this life stage,
acceptance and social support from friends and in-group members becomes keenly important to a
youth’s self-concept development. However, the presence of peers, especially during decision-
making, increases the likelihood of adolescent risk-taking; the socioemotional network often
26
becomes sufficiently aroused to block out the self-regulatory effects of the cognitive-control
network (Steinberg, 2007). Therefore, youths during this life stage are more vulnerable to peer-
influenced risky decisions than when alone or during later life periods (e.g., emerging adulthood,
full adulthood).
Despite youths’ tendency toward peer-influenced risk behaviors, adolescence is also a
time of budding independence. A young person’s developmental tasks increase. Specifically,
adolescents develop new cognitive skills, have a more defined sense of their personal and sexual
selves, and gain emotional, personal, and financial independence from their parent or guardian(s)
(Christie & Viner, 2005). Adolescence is characterized by a young person’s growing capacity for
abstract thinking and planning, which facilitates his or her greater autonomy, coupled with an
increased need for privacy and confidentiality (Tylee, Haller, Graham, Churchill, & Sanci,
2007). Autonomy development is fostered when an individual—in this case, a teenager—
perceives the external environment to be supportive of his or her budding independence (Pardeck
& Pardeck, 1990). Adolescents’ autonomy development not only impacts their decision-making
in social contexts and interpersonal relationships but also their ability to make sound judgments
regarding their own health and healthcare. In an environment in which a teen’s autonomy
development is supported, he or she may be less likely to engage in poor, risky decisions (e.g.,
alcohol initiation, tobacco and substance use, unprotected sex, and violent acts) (Spear &
Kulbok, 2004).
Adolescents’ desire for more autonomy coupled with the increased likelihood of risky
decision-making makes this period especially important for developing health awareness and
health literacy (Manganello, 2008). Young people should be encouraged to take their health
needs into their own hands, and this includes making health decisions independent of their
27
parent/guardian(s) and developing relationships with healthcare professionals who can provide
effective decision-making scaffolding and intervention. Unfortunately, many doctors are
uncomfortable and unskilled in physician-patient communication with adolescents. Since
adolescent patients have personalities, social norms, and cognitive abilities that differ from
adults, doctors may find that communicating with teen patients is more arduous (Christie &
Viner, 2005; Jacobson, Richardson, Parry-Langdon, & Donovan, 2001). Research indicates that
teenagers receive shorter average consultation times with their family doctor than children or
adults (Jacobson, Wilkinson, & Owen, 1994). In addition, younger adolescents may find
discussing risky behaviors or sensitive topics embarrassing, causing reticence during physician
visits (Ackard & Neumark-Sztainer, 2001). Litt and Cuskey (1984) found that how well (or not)
a physician explained medical problems and laboratory tests was related to adolescent patient
satisfaction, a key indicator of appointment noncompliance. Therefore, poor physician-patient
communication can contribute to gaps in healthcare use among youths. Adolescents who report
no healthcare at all or report not seeking healthcare services within the past two years are less
knowledgeable of services available to them, have less positive attitudes about healthcare in
general, and may be less likely to seek care in the future (Aten, Siegel, & Roghmann, 1996 as
cited in Zimmer-Gemback, Alexander & Nystrom, 1997). Moreover, lapses in adolescent
healthcare, especially among vulnerable youth subgroups, contribute to persistent health
disparities.

Adolescent health disparities
Levels of healthiness vary among individuals based on a number of factors, many being
biological and genetic. However, health differences based on social determinants (e.g., economic
28
stability, education, healthcare access, and neighborhood environment and resources) often lead
to health disparities. Health disparities are systematic, avoidable health differences based on
personal characteristics associated with marginalization or discrimination, including (but
definitely not limited to) age, gender, race/ethnicity, sexual orientation, geography, or
socioeconomic status (Braveman et al., 2011). Within an international context, health disparities
or inequalities are based on socioeconomic differences; domestically, disparities more often
correspond to race or ethnicity distinctions. However, in the U.S. there is a correlation between
race/ethnicity and socioeconomic status, such that individuals of color (e.g., African Americans
and Latinos) often have lower SES. Large, persistent black-white differences in health co-occur
with similarly large, persistent differences in SES (Williams & Collins, 2001). Social hierarchies
are predicated on constructed categories, which result in social disadvantage and poorer
outcomes—health and otherwise.
Social disadvantage is a root cause of health disparities (Airhihenbuwa & Liburd, 2006).
Unable to fully participate in civic life based on their unfavorable social positions and the
conditions that follow, members of disadvantaged groups often have their needs and concerns
overlooked or ignored. Members of disadvantaged groups have inequitable access to social,
economic, cultural, and political resources, which almost guarantees their lower relative
positions. The accumulation of social disadvantage leads to chronic stress, which adversely
impacts personal health. Allostatic load, the physiological cost of chronic exposure to stressful
environmental challenges (i.e., wear and tear on the body) (Taylor, Repetti, & Seeman, 1997),
reduces immune system efficacy in combating external pollutants and increases the likelihood of
illness (Gee & Payne-Sturges, 2004). Additional stress as a result of discrimination or
marginalization may serve as a catalyst for participation in unhealthy behaviors (e.g., smoking,
29
alcohol/substance use, risky sexual behaviors, and violence). “The implication, when applied to
the health domain, is that dealing with experiences of discrimination may leave individuals with
less energy or resources for making healthy behavior choices” (Pascoe & Richman, 2009, p. 2).
Schnittker and McLeod (2005) identify both upstream (i.e., fundamental social causes of
disease) and downstream (i.e., things that get under the skin) causes of health disparities. Minkler
(2004) identifies powerlessness as the primary risk factor for poor health outcomes. Using
ecosocial theory, Krieger (1999) argues that the impact of discrimination is "embodied" in the
individual. In other words the social and biological intersect, such that one's lived experiences
with discrimination, racism, classism, sexism, or other “isms” manifests in the way one lives,
ails, and dies. The persistence of health inequalities in the U.S. moves beyond a public health
concern to a moral problem. Health inequalities are concentrated among disadvantaged groups
(e.g., communities of color) whose lack of social, cultural, and economic resources puts them at
further disadvantage. Braveman and colleagues (2011) call this phenomenon the “reinforcement
or compounding of social disadvantage,” making reductions in health disparities relevant social
justice work (p. S151).
More often than not, discussions of social disadvantage and health disparities center on
issues related to race/ethnicity and class; however, age is also a salient factor. U.S. teens are
often at a social disadvantage because their age and relative political invisibility precludes them
from participating in civic life. Policies are made without their input, and they have few outlets
to exercise their voices. In addition, young people are adversely impacted by the same indicators
of discrimination and marginalization as adults (e.g., residential segregation, poor education, lack
of economic opportunities, reduced access to healthcare). Cumulative stress impacts youths in
similar ways as adults and serves as a catalyst for negative coping behaviors like unprotected
30
sex, substance use, and school truancy. For youth of color, particularly Latino and African-
American adolescents, the negative outcomes of marginalization and disadvantage on their
health outcomes are acute.
Neighborhood effects on health. Environments are important contexts for learned and
practiced health-related behaviors among adolescents. Thus, neighborhood characteristics can
greatly influence an individual’s health status. The built environment
3
is characterized by the
presence and availability of municipal services, recreational activities, and any other man-made
infrastructure (Burns & Snow, 2012). Hospitals, schools, recreation centers, and shelters are
some of the institutional assets found in neighborhoods. An abundance of resources within the
built environment is associated with prosocial behavior (e.g., exercise, healthy food
consumption, and healthcare utilization). Research suggests that residents of neighborhoods with
institutional resources are more likely to experience improved health and social outcomes.
Neighborhoods characterized by larger acreage of green space, lower exposure to chronic noise
from vehicles, and overall safety and security have lower rates of depression among residents
and aid in mental health recovery (Satcher, Okafor, & Dill, 2012). Infrastructure and
relationships (namely community-level institutions and social support/social network provisions
available to parents for adolescent monitoring) are key mechanisms through which
neighborhoods influence youth-specific behaviors—and ultimately health outcomes (Levanthal
& Brooks-Gunn, 2000).

3
The built environment is all buildings, spaces, and products that are created and modified by
humans. It includes homes, schools, workplaces, parks/recreation areas, businesses, and roads. It
can be divided into six core areas (e.g., land use, zoning, buildings, transportation systems,
services, and public resources). Services and public resources are the core areas of the built
environment that are most applicable to adolescent risk.

31
Conversely, a built environment that is characterized by degradation or deficiencies does
not facilitate healthy living. Neighborhoods characterized by poverty, blight, crime or violence,
and lack of environmental outlets (e.g., parks, recreational facilities) communicate a social norm
that prosocial behavior may not be worth the cost of forgoing temporary pleasure (e.g., sex,
substance use). In fact, these neighborhoods may encourage risky behaviors, especially among
adolescents whose limited mobility prevents them from accessing resources outside a confined
geographic space.
Environmental riskscapes. If an environmental or psychosocial stressor is not modifiable
but an individual has the resources to manage the threat, then the resulting stress is negative but
not necessarily damaging. However, toxic stress results when an individual is chronically
exposed to environmental stressors outside of his or her control, in the absence of financial,
emotional or social resources with which to handle the threat. As such, tolerable stress may
morph into toxic, damaging stress when an individual’s encounters with unmanageable stressors
become more frequent and/or of greater intensity (Adler & Stewart, 2010). This context
characterizes urban riskscapes that contribute to persistent health inequities, particularly among
teens and young adults. The term “riskscapes” has been applied to high-risk, low-income
geographic settings that have a disproportionate burden of inequitable planning and zoning,
neighborhood stressors, unhealthy land uses, and limited access to health-promoting resources,
such as medical facilities, grocery stores, parks, open spaces, and healthy schools (Satcher et al.,
2012). Distressed neighborhoods (usually characterized by residents who are low-income, of
color, or both) are disproportionately affected by predatory zoning regulations and reductions in
built environment infrastructure that facilitate healthy behavior (Morello-Frosch, Pastor, & Sadd,
2001).
32
As these environments begin to degrade, they are often taken over by criminal elements,
which beget more high-risk activity until a social norm that accepts risky or unhealthy behavior
is established (Lang et al., 2010). Individuals living in riskscapes will be more likely to manifest
higher rates of problem behaviors than counterparts living in more advantaged neighborhoods
(Bauermeister, Zimmerman, & Caldwell, 2010). For instance, lack of recreational spaces limit
young people’s opportunities to socialize in non-sexual environments (Akers, Muhammad, &
Corbie-Smith, 2011). Interview data from this study indicated that young adult males perceived
their female counterparts as their recreation—their playground, so to speak—in the absence of
neighborhood facilities. Young people engaged in sex-related behaviors as a result of boredom
and lack of options for appropriate, low arousal male-female socializing. As a consequence,
youth living in riskscapes have higher rates of a) early sexual debut, b) multiple sex partners, c)
sexually transmitted infections, d) unintended pregnancies, e) sexual assault, and f) lower rates of
contraceptive use (Akers et al., 2011; Browning, Leventhal, & Brooks-Gunn, 2004; Cubbin,
Santelli, Brindis, & Braveman, 2005). Built environments can also hinder youths’ access to
resources that can be used to minimize or avoid the consequences of risky sexual behavior
(Burns & Snow, 2012). This kind of neighborhood disadvantage shapes localized norms
regarding adolescent sexuality and childbearing, including acceptance of earlier sexual debut,
greater sexual activity, and lower rates of consistent condom use (Burns & Snow, 2012; Lang et
al., 2010).

Key adolescent risk behaviors
Results from the 2014 National Health Interview Survey are heartening: 82.7% of U.S.
children under the age of 18 years old reported an “excellent” or “very good” health status. Yet,
33
there is room for improvement. For instance, less than half (48.9%) of poor youths report
excellent health, and children under 18 years old with Medicaid or another form of public health
insurance are the least likely to report their health status as “excellent”—even less likely than
those youths who are uninsured (CDC, 2014). In 2013, the leading causes of death for youths
(persons aged 10-24 years) were accidents (unintentional injuries), suicide, and homicide (Heron,
2016). This statistic corresponds to the 4.8% of poor adolescents aged 12-17 years who missed
11 or more school days in the past 12 months due to illness or injury (CDC, 2014). Low-income
adolescents are four times more likely to be without a consistent source of healthcare than youths
from middle- and higher-income families. Adolescents from poor families are also more likely
than their peers from wealthier families to forgo healthcare within the past 12 months, forgo an
annual check up, and be prohibited from receiving medical care because of the associated costs
(Newacheck, Hung, Park, Brindis, & Irwin, 2003). In addition, there is an association between
socioeconomic status and adolescent risk behaviors, such that low SES is associated with poor
diet, less physical exercise, and more cigarette smoking (Hansen & Chen, 2007). The impact of
adolescent risk behaviors may be felt more acutely among low-income youths because lack of
financial resources may prevent these young people and their families from accessing medical
care services when needed.
Extant literature within the domains of adolescent sexual health and sexual risk, alcohol,
tobacco and other drugs (ATOD), and mental health is extensive, and a complete review is
beyond the scope of this chapter. What follows is a concise explication of key concepts and
factors relevant to this research project.
Sexual health and sex-related risk behaviors. Sexual development is part of the larger
human developmental process; therefore, it is critical to help adolescents achieve and maintain
34
sexual health and avoid sexual risks. The most recent World Health Organization (WHO) (2006)
definition
4
of sexual health extends beyond the mere absence of disease to encompass a more
holistic view of healthy sex. Sexual development is a key task in an adolescent’s growth and
development. Establishing sexual relationships and engaging in sexual behaviors provides youths
with opportunities for developing self-identity (including sexual orientation and/or identity),
learning how to socialize with others, creating emotional connections, and navigating sexual
intimacy with maturity (Diamond, Savin-Williams, & Dube, 1999). However, much of the
empirical research on adolescent sex and sexuality takes a negative position or problem-oriented
perspective. Lefkowitz and Vasilenko (2014) suggest that examinations of adolescent sexual
health that go beyond the adverse effects of youth sex-related behaviors are necessary. The
authors make the claim that adolescents’ engagement in sexual behaviors has positive effects on
their physical, mental, and social health.
Relationship context changes throughout adolescence; what younger teens mean by
“relationship” differs from older ones. Younger youths’ romantic relationships are characterized
by their short-lived duration, lack of physical contact and emotional investment, and occurrence
primarily at school, on the telephone, or in social groups. However, older youths’ romantic
relationships have an increased likelihood for emotional closeness and engagement in sexual
activity (e.g., oral, vaginal and/or anal intercourse) (Ott, 2010). According to results from a study
conducted by Guzman and Stritto (2012), parental influence plays a stronger role prior to youth

4
WHO defines sexual health as “a state of physical, emotional, mental and social well-
being in relation to sexuality; it is not merely the absence of disease, dysfunction or
infirmity. Sexual health requires a positive and respectful approach to sexuality and
sexual relationships, as well as the possibility of having pleasurable and safe sexual
experiences, free of coercion, discrimination and violence. For sexual health to be
attained and maintained, the sexual rights of all persons must be respected, protected and
fulfilled.”
35
engagement in sexual behaviors; however, once sexual activities have been initiated, peers play a
more central role in youth decision-making. Although younger adolescents may engage in more
frequent parent-child sexual communication, youths in this age category have less partner
communication, partner refusal self-efficacy, condom self-efficacy, and STI knowledge than
older adolescents—factors that are associated with younger adolescents’ increased likelihood of
contracting HIV/STIs (Sales, DiClemente, Davis, & Sullivan, 2012b). African-American and
Hispanic teens experience sexual debut at an earlier age than their white and Asian counterparts.
By age 17, 82% of African-American males, 74% of African-American females, and 69% of
Hispanic males had engaged in sexual activity (Cavazos-Rehg et al., 2009).
Romantically partnered adolescents who engage in sexual behaviors are at increased risk
for adverse health outcomes (e.g., unplanned pregnancy, HIV/STI exposure) as well as negative
emotional effects (e.g., relational power imbalances, intimate partner violence). Teen boys’
romantic partners are usually the same age or close to the same age (e.g., mean difference of
approximately two months); however, teen girls are more likely to have older romantic partners.
Additionally, the age difference between a female and her male partner increases with the
female’s age (Ott, 2010). Significant age discordance between male-female romantic partners
corresponds to sexual risk. Younger adolescent females with substantially older male romantic
partners are not only more likely to engage in sexual intercourse (Kaestle, Morisky, & Wiley,
2002) but also more likely to engage in unprotected sexual intercourse (Volpe, Hardie, Cerulli,
Sommers, & Morrison-Beedy, 2013), which increases their risk of unplanned pregnancy and
HIV/STI acquisition.
Despite extant sexual risks among partnered adolescents, current trends in unplanned
births among female adolescents are heartening. National rates of teen pregnancies, births, and
36
abortions have been on the steady decline. In 2010, teen pregnancies reached their lowest levels
in 40 years, with 6% of teens becoming pregnant
5
. Increased access to and use of contraceptive
methods (e.g., birth control, condoms, and IUD) as well as decreased rates of sexual intercourse
have been identified as key factors that contribute to the significant declines in rates of teen
pregnancy (e.g., 55% reduction among youths age 15-17 and 27% reduction among youths age
18-19). In addition to a 22% decline in 15- to 17-year olds who had ever engaged in sexual
intercourse, adolescents are more likely to use two or more contraceptive methods when
engaging in sexual activity, with simultaneous use of birth control pills and condoms most
popular (Santelli, Lindberg, Finer, & Singh, 2007).
However, adolescents still frequently engage in risky sexual activity. According to the
2015 National Youth Risk Behavior Survey (YRBS), 41.2% of high school students nationwide
had ever had sexual intercourse. Of those sexually active youth, risky behavior was significant
with 43.1% not using a condom during last sex, more than 80% not using birth control to prevent
pregnancy during last sex
6
, 11.5% having four or more lifetime sex partners, and 20.6%
consuming alcohol or using drugs prior to their last sexual encounter (Kann et al., 2016a). In
addition, sexual minority teens are more likely to engage in sexual risk behaviors (e.g., sexual
debut before age 13, four or more lifetime sex partners, no pregnancy prevention method during
last sex, and alcohol or substance use prior to sexual intercourse) than non-sexual minority teens
(Kann et al., 2016b). As a result of adolescent risky behaviors, high rates of STIs among
teenaged youth present a lingering public health problem. Nearly half of the 19 million new

5
In 2010, California recorded the highest number of pregnancies among young women (aged 15-
19) years of any state in the nation (Kost & Henshaw, 2014).
6
18.2% reported that either they or their partner used birth control pills; 3.3% used an IUD
(Mirena or ParaGard) or implant (Implanon or Nexplanon); and 5.3% reported use of injectable
birth control (Depo-Provera), patch (OrthoEvra), or birth control ring (NuvaRing).
37
STDs reported each year are among young people aged 15-24 years old (Weinstock, Berman, &
Cates, 2004). Nearly 1 in 4 new HIV infections is among young people ages 13-24, most of
whom are unaware of their infection (CDC, 2013), and nearly half (48%) of African-American
girls had at least one of the most common STIs (e.g., gonorrhea, chlamydia, HPV) (Sales et al.,
2012a). Whereas risky sexual behavior is often a precursor to HIV/STIs and HIV often remains
dormant and asymptomatic for years, rates of HIV among early adults (20-24 years old) may be
attributed to infection during adolescent and teen years (CDC, 2012). In addition, many
adolescents do not perceive themselves at risk for contracting HIV or other STIs; therefore, they
are less likely to attend to intervention messages that highlight their susceptibility and respond
with attitudinal and/or behavioral changes (Silverman, 2013).
Moreover, despite national declines in unplanned pregnancies among teens, disparities in
early motherhood based on race/ethnicity persist. Black and Hispanic teens are more than twice
as likely to give birth during their teenage years and more than twice as likely to undergo
abortion procedures compared to white teens in the same age group (Kost & Henshaw, 2014).
Adolescent males’ risk for early fatherhood and HIV/STI contraction is linked to both risky
sexual behaviors (i.e., condomless sex) as well as the emotional and sociocultural context in
which these behaviors occur (e.g., characteristics of sexual partner, relationship context, personal
and family values, and environmental cues) (Ott, 2010).
In the absence of relational role models, establishing healthy, non-platonic relationships
may be even more important to the social development and sexual health of adolescent sexual
minorities (Lefkowitz & Vasilenko, 2014). Sexual minority adolescents may engage in sexual
risk behaviors (e.g., infrequent condom use, multiple sexual partners) to hide their same-sex
attractions and/or prove their heterosexuality in an effort to hide a stigmatized self-identity
38
(Ybarra, Rosario, Saewyc, & Goodenow, 2016). The prevalence of female sexual minority
adolescents’ sexual risk behaviors differs from heterosexual girls. Lesbians are six times more
likely to report infrequent condom use during penile-vaginal sex and 80% less likely to engage in
safer-sex negotiations (i.e., conversations about the use of barrier methods) than heterosexual
female adolescents, which puts them at heightened risk for unplanned pregnancies or HIV/STI
contraction. Bisexual young women report higher lifetime prevalence of sexual behaviors as well
as more lifetime and past-year partners compared to heterosexual girls (Ybarra et al., 2016).
Bisexual female adolescents also report earliest sexual debut, greatest use of emergency
contraception, and highest frequency of pregnancy termination (compared to heterosexual and
lesbian adolescents) (Tornello, Riskind, & Patterson, 2013).
Alcohol, tobacco, and other drug (ATOD) use among U.S. teens. Consumption of
alcohol, tobacco, and marijuana as well as illicit drugs like cocaine, heroin, amphetamines, and
inhalants by adolescents is illegal and socially sanctioned; however, the ubiquity of these
substances in U.S. society makes youth drug use widespread. Alcohol consumption is a common
teenage health risk behavior. Alcohol consumption among teens leads to the increased likelihood
of sexual risk behaviors (e.g., sexual intercourse under the influence, non-contraceptive sex, and
multiple sex partners), unintended pregnancy, sexual assault, motor vehicle accidents, and high
school dropout. In addition, early alcohol involvement increases the risk for alcohol dependence
and/or abuse later on in life (Donovan, 2002). Adolescent alcohol initiation (i.e., the transition
from lifetime alcohol abstinence to any alcohol use, even a few sips) is greater among youths
whose parents drink or use illicit substances, who have peers who engage in alcohol
consumption or have favorable attitudes toward deviant behavior, and who experience negative
affect (e.g., anxiety, stress, and depression). Alcohol onset is also highly likely for alcohol-
39
abstinent yet “problem behavior prone” teens. These youths who have ready access to alcohol,
perceive their parents as unconcerned about their alcohol use, and have friends who are either
current alcohol users or are also unconcerned about alcohol use are more likely to initiate alcohol
use than other teens (Donovan, 2002).
The use of licit drugs is often (but not always) a pathway toward illicit drug use, which
could result in substance use disorder (Kirby & Barry, 2012). Kandel (1975) asserts that
adolescent substance users advance through four stages of use: 1) abstinence or nonuse to
beer/wine consumption; 2) from beer/wine consumption to cigarettes and hard liquor; 3) from
cigarettes and hard liquor use to marijuana use; and 4) from marijuana use to illicit drug use.
Using a Guttman scale analysis, Kirby and Barry (2012) identified alcohol as the first step or
“gateway drug” that leads to use of tobacco, marijuana, and other illicit substances. Specifically,
high school students who had ever consumed alcohol in their lifetime were 13 times more likely
to smoke cigarettes, 16 times more likely to use marijuana and other narcotics, and 13 times
more likely to use cocaine.
Teens who live in single-parent or non-traditional households and whose parent(s) earned
less than a high school education are more likely to engage in regular alcohol consumption and
smoking. In addition, rates of regular smoking and drinking are more common among
adolescents who report a history of abuse (physical and/or sexual) or family violence, negative
life events, and moderate to high depressive symptoms (Simantov, Schoen, & Klein, 2000).
Teens, regardless of gender, attribute their tobacco use to exposure and their alcohol
consumption to stress relief and recreation. However, male adolescents are more likely than their
female counterparts to credit smoking and drinking behaviors with desires for social acceptance
(e.g., looking “cool” or emulating what popular kids do). Girls are more likely to attribute these
40
behaviors to internal motivators (e.g., escape from personal problems, weight loss) (Simantov et
al., 2000).
In high school, teens spend more time in unsupervised, non-academic environments with
peers (e.g., after-school employment, recreational, or social activities) facilitated by increased
independence afforded those with access to a motor vehicle and money. Truancy, low grade
point average, and recent sexual activity (i.e., past 90 days) are strong predictors of youth
substance use (Hallfors et al., 2002). Current literature identifies school truancy as a reliable
indicator of adolescent risk behaviors; the concept is associated with low school involvement
and/or school connectedness
7
as well as peer bonding with behavioral deviants (e.g., other
students who ditch class, engage in substance use, or participate in other harmful behaviors). As
such, school truancy is linked to adolescent substance use (e.g., alcohol, tobacco, marijuana,
inhalants, and illicit drugs).
ATOD use and sexual activity cluster and co-vary among adolescents. Youth who engage
in substance use are more likely to have a greater number of intercourse occasions and sexual
partners. Whereas sexual activity is often linked to licit substance use (e.g., alcohol, tobacco, and
marijuana) that serves as a gateway to illicit substance use, youth who engage in recent and/or
frequent sexual intercourse are more prone to substance use than youth who are ATOD
abstainers or practice sexual abstinence (Hallfors et al., 2002). Another salient characteristic of
adolescent ATOD use is maturation of physical characteristics, which may serve as a proxy for
social desirability or “adultness.” Specifically, female youths whose bodies developed early (e.g.,
breasts, hips and thighs, or other sexualized physical features) are often courted by older males

7
Similarly, grade point average is an indicator of adolescent use of ATOD. Researchers have
identified an inverse relationship between grade point average (GPA) and substance use, such
that youth with higher GPAs are less likely to engage in ATOD use.
41
who may introduce them to adult-like behaviors, including drinking, smoking, and sexual
intercourse
8
(Tarter, 2002).
The adverse health effects of adolescent tobacco use are well documented. Nicotine,
tobacco’s most addictive chemical, causes neurological changes in developing adolescent brains
(Grana, Benowitz, & Glantz, 2014). Even intermittent smoking can result in tobacco dependence
and/or addiction. Biologically, adolescents are more susceptible to the reinforcing effects of
nicotine and more sensitive to the combination of nicotine and other chemicals found in
cigarettes (National Institute on Drug Abuse, 2012). Research suggests adolescents who begin
tobacco use are more likely to become addicted to nicotine than adults. In addition, cigarette
smoking leads to serious health problems, including respiratory problems, risk for other drug use,
and increased risk for a host of cancers (e.g., lung, pharynx, esophagus, and bladder), and
cardiovascular disease (CDC, 2015).
According to 2015 results from the Centers for Disease Control and Prevention Youth
Risk Behavior Survey (YRBS), 32.3% of high school students nationally have ever tried a
cigarette (i.e., traditional, combustible version), and 10.8% of high school students are current
cigarette smokers (Kann et al., 2016a). Peer smoking is the strongest predictor of adolescent
smoking debut and current smoking behaviors (Hu, Davies, & Kandel, 2006). Adolescents of
color are less likely to initiate smoking behaviors, become daily smokers, or become dependent
upon nicotine once becoming daily smokers than whites. Latinos are the least likely to be current
smokers or meet thresholds for dependence. However, African Americans and Native Americans
have the highest rates of dependence (Hu et al., 2006). There is a negative relationship between

8
Physical characteristics are included in this description of potential risk factors because of the
concomitance with biological external factors that may increase a young women’s likelihood of
ATOD exposure and subsequent use. However, adolescent females should not be shamed or
pathologized for their naturally occurring physical features.
42
SES and smoking, such that adolescents from low SES backgrounds are more likely to smoke
than their more affluent counterparts (Hanson & Chen, 2007).
Although rates of cigarette smoking among adolescents have decreased, use of e-
cigarettes has increased significantly. According to the CDC’s National Youth Tobacco Survey,
from 2011-2015, e-cigarette and hookah use increased among high school students from 1.5% to
16.0% and 4.1% to 7.2%, respectively. E-cigarette use now surpasses other forms of tobacco
consumption, including combustible cigarettes (9.2%) (Singh et al., 2016). Electronic nicotine
delivery systems (ENDS) is a class of products that includes e-cigarettes, personal vaporizers,
vape pens, e-cigars, e-hookahs, and vaping devices that produce an aerosol mix of flavored
liquid, nicotine, and other chemical compounds that are inhaled by the user when heated. E-
cigarettes are compact and easily concealed, and ENDS refill liquids (i.e., “juice”) come in
youth-friendly flavors like black cherry, marshmallow, and bubble gum (Hildick-Smith et al.,
2015). Thus, adolescents perceive ENDS to be a healthy alternative to traditional cigarettes. Only
15% of students perceive ENDS use to a pose a great risk to their health, yet 62% believe that
smoking a pack of conventional cigarettes pose a great risk to their health (Hildick-Smith et al.,
2015). However, vapor from e-cigarettes is sufficient to cause cell damage, including nicotine-
free versions
9
.
Adolescent use of ENDS devices could lead to a renormalization of smoking culture and
acceptance in the U.S., thereby undoing decades of public health education and promotion work
(Marynak et al., 2014). Findings from a study by Primack and colleagues (2015) indicate that

7
Vapor-exposed cells are more likely to show DNA damage, a potential precursor for cancer, or
progress to apoptosis and necrosis and die (Yu et al., 2016). Formaldehyde, a known carcinogen,
propylene glycol, a humectant that creates visible vapors is a known respiratory irritant, and
diacetyl, a flavoring agent linked to lung disease, are often found in ENDS refill liquids.

43
youth who use e-cigarettes at baseline were more likely to progress to either susceptible non-
smoking status or cigarette smoking than youth who did not use e-cigarettes as baseline.
Additionally, adolescents who used e-cigarettes at baseline had greater point estimates of moving
from non-susceptible non-smoker to susceptible non-smoker status or from non-susceptible non-
smoker to cigarette smoking. These results suggest young people who use e-cigarettes are at
significantly higher risk of later use of e-cigarettes and potentially other tobacco-related
products—even if they do not intend to use cigarettes in the future.
Tobacco consumption is not the only way youth are using ENDS. Some adolescents,
particularly current e-cigarette users, are using these electronic devices for cannabis
consumption. ENDS devices can be modified to vaporize cannabis in highly concentrated forms
(e.g., liquid hash oil, THC wax, or dried cannabis buds or leaves). Vaporizing cannabis is less
conspicuous than combustible methods (i.e., smoking) because vaporizing produces a less
pungent, recognizable odor. A study by Morean and colleagues (2015) found that use of e-
cigarettes for vaporizing cannabis was a relatively common behavior among high school
students, especially those who report lifetime dual use of tobacco and marijuana (26.5%). E-
cigarette users were five times more likely to engage in marijuana vaporization via an e-cigarette
than those who had never used an e-cigarette. Male students and younger students were also
more likely to engage in cannabis consumption via e-cigarette vaporization than female or older
high school students. What may be most important—and cause for concern—is that among all
students in the sample who had ever tried an e-cigarette (N=3847), more than 5% of them had
used the device to vaporize marijuana. This reifies public health concerns that e-cigarettes may
not only serve as a gateway to increased tobacco consumption but also marijuana use. Whereas
marijuana is often considered a gateway to more potent illicit drugs (e.g., cocaine,
44
methamphetamines) (Kandel, 1975), e-cigarette use among adolescences has potential for serious
adverse health outcomes.
Adolescent mental health. In developed countries, mental health issues and illnesses are
at the forefront of disease burden for young people. Approximately 1 out of every 4-5
adolescents in the U.S. meets the Diagnostic and Statistical Manual (DSM-IV) criteria for a
mental health disorder, and nearly one-third of adolescents in the nation meet criteria for an
anxiety disorder (Merikangas et al., 2010). The emergence of mental health disorders in
adolescence is most likely due to aberrations in typical biophysiological maturation processes
(i.e., hormonal changes, cognition, and affect) in concert with psychosocial changes (e.g.,
familial and school relationships) and/or environmental factors. In other words, the relationship
between adolescent brain development and the stage-specific onset of mental health disorders is
akin to “moving parts getting broken” (Paus, Keshavan, & Giedd, 2008). Mood and behavioral
disorders often emerge in early adolescence while the onset of substance use disorders increase
after age 15 (Merikangas et al., 2010). Mood and anxiety disorders are more prevalent in female
adolescents, while male teens and more likely to meet criteria for behavioral and substance use
disorders. Differences in the onset of affective disorders during adolescence between male and
female youths can be attributed in part to pubescent, sex-specific hormonal changes—thus
explaining the 2:1 female-male affective disorder ratio that occurs after (but not prior to) puberty
(Paus et al., 2008).
Risk factors cluster together, which explains the concomitance of ATOD use, sexual
activity engagement, intentional and unintentional injuries, and mental health problems (Tylee et
al, 2007). High levels of novelty seeking and harm avoidance are risk factors for adolescent
substance use, a precursor for substance abuse disorder (Paus et al., 2008). Engagement in
45
health-compromising behaviors, specifically ATOD use or unprotected sexual activity, greatly
increases a teen’s odds for depression, suicide ideation, and suicide attempts (Hallfors et al.,
2004). Violence has an adverse effect on adolescent mental health, such that youth who witness
violent acts have a two- and three-fold increase in self-reporting suicide ideation and suicide
attempts as well as alcohol use (Pastore, Fisher, & Friedman, 1996).
Flourishing adolescents (i.e., youth who exhibit psychosocial functioning and
emotional/social well-being) exhibit increased mental health and decreased health-risk behaviors
(e.g., ATOD use, truancy) associated with depressive symptoms (Keyes, 2006). Social support is
a protective factor against adolescent substance use. Teens who report strong parental
connectedness are less likely to engage in health-compromising behaviors (Simantov et al.,
2000). Likewise, social and school connectedness decrease the likelihood of adolescent ATOD
use and negative affect disorders, like depression. However, social connectedness but not school
connectedness elevates risk for regular cigarette smoking and marijuana use; thus, those youth
who have good social relationships but poor connection to school (as manifested in low
academic achievement, truancy, or on-campus behavioral problems) are at increased risk for
negative health-related behaviors (Bond et al., 2007).

Adolescent engagement with the healthcare industry
A host of factors contribute to the increased likelihood for adolescents to engage in high-
risk behavior; thus, this life stage is a prime time for the locus of control regarding health-related
matters to transition from parent/guardian to teenager. However, adolescents’ engagement with
the healthcare industry varies, depending on factors such as prior healthcare experiences (Jones,
DeMore, Cohen, O’Connell, & Jones, 2008), gender and race/ethnicity of youth patients (Perry,
46
Chien, Walker, Fisher, & Johnson, 2010), youth-physician concordance on race/ethnicity and/or
gender (Laveist & Nuru-Jeter, 2002), parental involvement (Tebb, Hernandez, Shafer, Chang, &
Otero-Sabogal, 2012), perceptions of physician trustworthiness (Klostermann, Slap, Nebrig,
Tivorsak, & Britto, 2005), and presence of a stigmatized condition (Corrigan, 2004; Heflinger &
Hinshaw, 2010). It is critical for youths to have access to comprehensive, confidential healthcare
to develop healthy lifestyle habits and prevent health consequences during adolescence from
developing into more acute problems. In the absence of primary and secondary prevention,
health disparities persist. Unfortunately, utilization of healthcare services significantly drops
after childhood (Marcell, Klein, Fischer, & Allan, 2002). This reduction is especially pronounced
for males (Aten et al., 1996) and adolescents of color (Tebb et al., 2012). Considering risky
behaviors among adolescents are leading causes of their mortality and morbidity, providing
access to medical care services for young people is an important public health issue.
Often adults—not the youth patient—decide whether or not medical care services are
necessary and, if so, when and where healthcare is accessed (Tylee et al., 2007). Involving
adolescents in medical decisions requires effective doctor-patient-parent communication as well
as an accurate assessment of the clinical issues (e.g. situational, familial and youth factors) that
impact healthcare decision-making (McCabe, 1996). Additionally, a patient’s self-determination
or autonomy and his or her cognitive and emotional capacity for medical involvement must be
considered by the physician-parent dyad. Youth-friendly healthcare is important for increasing
adolescent engagement with medical care facilities and practitioners (Tylee et al., 2007). In a
systematic review, Ambresin and colleagues (2013) found that eight indicators are central to
young people’s assessment of youth-friendly healthcare: accessibility of services, staff attitude,
communication, medical competency, guideline-driven care, age-appropriate environment, youth
47
involvement in healthcare, and health outcomes. Youth-friendly healthcare provision has been
shown to improve adolescent health outcomes (e.g., reduced sexual risk behaviors, depression
management) (Tylee et al., 2007) and treatment adherence (Taddeo, Egedy, & Frappier, 2008).
Confidentiality is another aspect that increases the likelihood that adolescents will engage
in medical care services. Although it varies by state, most youths are afforded confidential
healthcare, particularly for sensitive services
10
, at age 12. Confidential health visits provide an
important opportunity for young people to gain access to health information, support, and
services from trained healthcare providers—medical help that may not be accessed if visits were
not confidential. In fact, some adolescents will forgo care if they have to visit the family
physician. In a statewide survey of sexually active female adolescents, more than half of
respondents indicated they would stop using services if their parents were notified they were
seeking reproductive or contraceptive medical services. Of those young women, nearly 30%
indicated they would practice the unreliable withdrawal method or engage in unprotected sexual
intercourse. Female study participants also indicated they would discontinue HIV/STI testing,
yet less than 1% said they would stop engaging in sexual intercourse (Reddy, Fleming & Swain,
2007).
Although some parents may be uneasy about being excluded from confidential health
consultations because it means relinquishing parental control, these visits create important
opportunities for adolescents to take control of their own health outcomes (Tebb et al., 2012).
Minor consent laws vary by state; the Health Insurance Portability and Accountability Act

10
“Sensitive services” refers to services such as abortion, drug treatment, mental health care,
pregnancy-related services and STD-related services.
48
(HIPAA) privacy rule defers to those laws
11
. Requiring parents to sign written consent forms for
their children to receive the full scope of services provided is a common characteristic of school-
based health centers in the U.S., with the exception of states that allow youth to consent
themselves to certain or all medical services. A parent/guardian’s right to access their child’s
medical records depends upon the services rendered, and in most cases, the patient’s consent is
required prior to the release of these medical records (NCYL, 2006). Leading medical
associations
12
conclude that the health risks associated with STIs and other reproductive health
issues is so great that “legal barriers in deference to parental involvement should not stand in the
way of needed care” (Reddy et al., 2002, p. 711). If a health provider believes that disclosing a
minor’s protected health information to a parent may results in threat or harm, the provider may
deny the parent’s request for disclosure (English & Ford, 2004).
Adolescents are the least likely group to seek medical care in a health provider’s office.
During these office visits, when they do occur, health education and candid discussions of risky
behaviors, including unprotected sex, ATOD use/abuse, and violence, are often absent (Akard &
Neumark-Sztainer, 2001; Ethier et al., 2011)—even though adolescents report wanting to talk
about these specific concerns. In fact, among youths who report at least one of eight risk factors,
63% had not spoken to their clinician about any of those risks (Klein & Wilson, 2002). Many
prefer their physician to broach the topic of sex and sexuality first (Burstein, Lowry, Klein, &
Santelli, 2003; Same, Bell, Rosenthal, & Marcell, 2014). When discussions of sex and sexuality

11
Any information that is governed by the Family Educational Rights and Privacy Act (FERPA)
is exempt from the HIPAA privacy rule concerning protected health information, except
information that is in the record of a school-based health center. However, in every state, minors
can consent (without parental consent) to STD testing and family planning (English & Ford,
2004).

12
American Medical Association, American College of Obstetrics, American Academy of
Pediatrics, American Academy of Family Physicians and National Medical Association.
49
do occur between physicians and youth patients, the duration is brief. Alexander et al. (2014)
found that sexuality talk occurred in 65% of visits but only for an average of 36 seconds.
For teen patients, limited talk time with their healthcare provider reduces their overall
quality of care, which contributes to this age group being among the most medically underserved
(Aten et al., 1996). In a study by Adams, Husting, Zahnd, and Ozer (2009), low rates of
preventive discussions with healthcare providers were found. More than two-thirds of youth in
the study did not discuss substance use or sexually transmitted diseases, and one quarter did not
discuss nutrition or physical activity. Overall, adolescents were most likely to talk with their
healthcare provider about nutrition and exercise but least likely to discuss violence prevention. In
addition, discussions of health topics are often lower than recommended clinical guidelines.
Current literature suggests adolescents of color are engaging in health-related discussions
with medical care providers at rates similar to white youth. Moreover, uninsured and lower-
income youths engaged in more health discussions than youths with insurance or from more
affluent backgrounds, regardless of race/ethnicity or gender (Adams et al., 2009). Hispanic
adolescents are more likely than African-American and white youths to have their risks
discussed with a physician (Klein & Wilson, 2002); however, they are less likely to have alone
time with a physician when these issues can be addressed (Tebb et al., 2012). Hispanic
adolescents were also more likely than their white counterparts to discuss vehicle safety (e.g.,
seatbelt and helmet use), violence, nutrition, and STD screening (Irwin et al., 2009).
Additionally, Black adolescents had discussion rates that were either not statistically different or
higher than white adolescents in eight of nine discussion areas (Tebb et al., 2012). Nevertheless,
the overall lack of discussion among youth about age-specific topics (e.g., sexually transmitted
diseases, alcohol/drug/tobacco use, vehicle safety, or violence) deserves attention. Additionally,
50
persistent health disparities among minority youths despite similar amounts of patient-provider
talk time highlight discrepancies in actual provider care. This can be attributed to provider bias
based on automatic, unconscious cognitive processes (i.e., stereotyping) (Burgess, Stevens, &
van Ryn, 2004) as well as stereotype threat that may result in teens’ healthcare avoidance,
ineffective communication (e.g., less participation, inaccurate self-descriptions), and poor
adherence to medical treatment plans (Aronson, Burgess, Phelan, & Juarez, 2013).
Gender-based disparities in youth engagement with medical care providers in the clinical
setting also exist. Female adolescents who have trusting, more-than-just-information
relationships with medical care providers are less likely to report having unmet health needs.
However, those who do not have these kinds of relationships (and are sexually active) are more
likely to report having unmet health needs, specifically lack of information about unwanted
pregnancy prevention, HIV/STIs, birth control, and other contraceptives (McKee, Karasz, &
Weber, 2004). The authors of this article make the recommendation that clinicians should go
beyond pathologizing Black and Latina sexuality (citing Fine, 1988). Instead of simply
highlighting the dangers of sexual initiation and engagement, medical care providers should do a
better job of providing comprehensive sexual health education, which includes aiding young
women in developing healthy sexual selves. Additionally, younger and male teens are less likely
to be under care (Aten et al., 1996). Younger male adolescents (age 11-15) use healthcare
services (e.g., school-based health centers, community clinics, and hospitals) with the same
frequency as younger female adolescents; however, as male adolescents grow older (age 16-20),
their healthcare engagement is significantly reduced—and mirrors the imbalances between male
and female adults (Marcell, Klein, Fischer, & Allan, 2002). Specifically, male adolescents (age
13-19) frequent school-based health clinics with 20% less frequency than females. Although the
51
proportion of male visits to school-based health centers is highest compared to other healthcare
facilities, males do not attend to adolescent-specific programs with the same frequency as their
female counterparts—in some cases, male attendance is half that of females (Marcell et al.,
2002).
There are a host of reasons why male adolescents do not engage with the healthcare
system, namely school-based health centers designed to provide medical care specifically to
youth. Young men often perceive themselves as invincible, have reluctance to engage in health-
related discussions (e.g., mental health, sexuality, risk behaviors, and environmental stressors),
and believe acknowledgement of ailments or illness may be perceived as a sign of general
physical weakness or lack of manhood. In fact, male adolescents who ascribe to more traditional
masculine beliefs are less likely to get healthcare (Marcell, Ford, Pleck, & Sonenstein, 2007).
Moreover, parents may not actively encourage health maintenance visits for their male children,
and fathers’ neglect of their own health and self-care may send the message to their sons that
physician visits are unimportant or not necessary (Westwood & Pinzon, 2008).

School-based health centers: Pathway to health equity among adolescents?
Most teens spend a considerable amount of time at school; therefore, schools are ideal
locations for secondary prevention efforts. When youth share a connection to a place or space, it
is easier to develop health promotion programs, educational campaigns, and group interventions
that may lead to environmental and social change (Clayton, Chin, Blackburn, & Echeverria,
2010). School-based health centers (SBHCs) have been touted as potential remedies for
adolescent underutilization of healthcare services and can fill medical care gaps for youths from
low-income, underserved communities (see Figure 1). They often provide an entry point to
52
primary care, with ongoing connections to a medical home, for youths who do not have access to
consistent care (Brindis & Sanghvi, 1997; Clayton et al., 2010). SBHC-provided healthcare also
helps adolescents achieve greater numbers of quality-of-care markers (Allison et al., 2007).
SBHCs, including school-linked health centers and mobile units, are designed to provide
comprehensive health education as well as primary physical, reproductive and mental health
services to enrolled students. SBHCs help youth develop self-efficacy skills for avoiding high-
risk situations, and they can facilitate behavior change through relationships that develop
between students and medical care providers (Ralph & Brindis, 2010).

Figure 1
Analytic Framework: School-based health centers to promote health equity

Source: Knopf et al., 2016

increasedaccesstoandsatisfactionwithhealth-relatedservicesare
expected to increase receipt of recommended services
a
that lead to
early detection and treatment or prevention of disease. Increases
areexpectedinschoolachievementandtheproportionofstudents
with a usual place of care, along with reductions in illness, injury,
and healthcare overuse (e.g., use of emergency departments [EDs]
for non-urgent care). When SBHCs offer health education and
counseling, reductions in risk behavior are also expected. Overall,
SBHCs are expected to improve the health prospects of low-
income and racial and ethnic minority students.
Search for Evidence
Eight databases were searched from first available dates to July
2014. Full details of the search strategy are in Appendix B
(available online).
Inclusion Criteria
To qualify for inclusion in this review, a study had to
! evaluate the relative effectiveness of exposure to (or use of) the
servicesofanSBHCversusacomparisonconditionthatdidnot
include exposure to (or use of) such services;
! report at least one school achievement or health-related outcome;
! evaluate an SBHC that served school-aged children (pre-
Kindergarten through Grade 12);
! be published in English; and
! be conducted in a high-income nation.
43
Fouroutcomeswereexcludedbecausetheylackedaplausibleor
clear mechanism of impact:
! asthma prevalence;
! utilization of services not recommended by an authoritative
agency such as the U.S. Preventive Services Task Force;
! non-urgent ED utilization; and
! school attendance.
Although asthmatic events among asthma patients would be
subjecttoreductionbyaccesstoSBHCs,theunderlyingprevalence
of asthma would unlikely be affected by SBHCs. Although school
attendancewouldbeexpectedtoincreasebecauseofSBHC-related
reductions in illness, parents sometimes send sick children to
school because of treatments available in SBHCs—thus increasing
attendance because of sickness; further, sick children may be sent
home because of increased SBHC-associated diagnoses, thus
decreasing attendance.
The improvement of health equity would have been reported if
assessed in included studies. In addition, it is assumed that if
SBHCsareeffectiveinimprovinghealthoutcomesandaretargeted
Figure 1. Analytic framework: school-based health centers to promote health equity.
a
Recommended services are services recommended by an authoritative
body such as the U.S. Preventive Services Task Force, the Community
Preventive Services Task Force, or the Advisory Committee on Immuniza-
tion Practices.
Knopf et al / Am J Prev Med 2016;51(1):114–126 116
www.ajpmonline.org
53
The majority of SBHCs are built on the primary care model with variations based on mental
health and other expanded service offerings (e.g., dental care, health education, case
management) (Federico, Marshall & Melinkovich, 2011). SBHC provisions can vary
substantially with some facilities fully equipped and permanently staffed with fully licensed
medical care professionals (e.g., physicians and nurses) and auxiliary staff to centers offering
nursing services for only a few hours per week (Mason-Jones et al., 2012).
The Patient Protection and Affordable Care Act recognized SBHCs as federally
authorized medical programs
13
. Section 399Z-1 states that school-based health centers must
provide, at minimum, “comprehensive primary health services during school hours to children
and adolescents by health professionals in accordance with established standards, community
practice, reporting laws, and other State laws, including parental consent and notification laws
that are not inconsistent with Federal law” (PPACA, 2010). These youth-centric health facilities
provide a safety net for youth and their parents. (For a discussion of the healthcare safety net, see
Institute of Medicine, 2000 and Summer, 2011).
Confidentiality and privacy are critical components of SBHC healthcare (Ralph &
Brindis, 2010). These organizations increase the likelihood that students will access reproductive
health services and are correlated with increased contraceptive use and STI screening (Ethier et
al., 2011). Reproductive services are often offered in SBHCs serving middle school and high
school populations; however, the range of allowable services varies. Most available reproductive
services include abstinence counseling (84%), pregnancy testing (81%), and birth control
counseling (70%); 60% are prohibited from dispensing contraceptives (Ethier et al. 2011).
Schools with SBHCs have demonstrated a greater decline in teen pregnancy rates (Ricketts &

13
Title 42 Chapter 6A Subchapter II Part Q 280h-5.
54
Guernsey, 2006). Female students with access to SBHC services are more likely than those
without access to report sexual health and disease prevention care, use of hormonal
contraceptives at last sex, and STI screening (Ethier et al. 2011).
School-based health centers are part of a varied healthcare environment for adolescents
and fulfill an important role toward teen health promotion. SBHCs have the potential to fulfill a
health education gap created by decreasing school resources devoted to comprehensive, in-
school health education. Since 2000, the percentage of schools in the nation whose students are
required to receive instruction on health-related topics, such as alcohol, tobacco and other drug
(ATOD) use prevention, HIV/STI prevention, and nutrition and dietary behavior has steadily
declined. Similarly, since 2000, the percentage of schools in the U.S. with faculty or staff to
oversee or coordinate mental health and social services has declined, from 77.8% of schools in
2000 to 67.3% of schools in 2014. Of those schools with a mental health and social services
coordinator, a significant majority of these staff members do not receive professional
development training on topics related to adolescent health and well-being (e.g., ATOD
prevention, HIV prevention). In fact, less than a quarter receive HIV-prevention education, and
only 30% are trained in adolescent tobacco use prevention. Only training for injury
prevention/safety counseling and LGBTQ services has increased (from 27.7% to 47.8% and from
20.2 to 39.4%, respectively) (School Health Policies and Practices Study [SHPPS], 2014).
In addition, SBHCs provide important healthcare functions and medical interventions for
those who are at risk for mental health problems. Mason-Jones and colleagues (2012) found that
students with mental health concerns (e.g., suicide ideation, sleep disturbances, and depression)
were more likely to use services than those who did not report those problems, and adolescents
received more mental health services if their school had a SBHC than those students who didn’t
55
have access to an on-site SBHC. Similarly, SBHC users were 74% more likely to receive mental
health services when they were needed than nonusers. Students who frequently had experienced
emotionally stressful events (e.g., parental divorce, loss of a friend or family member, and/or
dissolution of a romantic partnership), used cigarettes, marijuana or alcohol, and self-reported
mental health problems were also more likely to use SBHC services than students who
experienced these events with less frequency (Amaral, Geirstanger, Soleimanpour, & Brindis,
2011). SBHCs provide a safe environment where adolescents can promptly address mental
health issues that may lead to negative disruptions in their academic and personal lives. For
Black and Latino adolescent males, these healthcare centers are valued, trusted spaces that allow
them to explore unresolved anger issues with trained professionals who “get them,” which often
leads toward resolutions with family and friends as well as academic gains (Bains, Franzen, &
White-Frese, 2014).
SBHC-based health interventions also produce intermediate outcomes (e.g., improved
student health status, improved school climate) that positively impact student academic
performance (Geierstanger, Amaral, Mansour, & Walters, 2004). Whereas negative health
conditions can have adverse impacts on student learning and attendance, medical care provided
in a youth-friendly, convenient location can positively impact student academic achievement.
Low (0.125 to 0.5 average visits per semester) and moderate (0.51 to 2.5 average visits per
semester) use is associated with a dropout reduction of 33% and 32%, respectively (Kerns et al.,
2011). For high-risk SBHC users (defined as African-American or Latino students with school
attendance less than 90%, a grade point average of less than 2.5, and free or reduced lunch
eligibility), there is an even stronger inverse relationship between SBHC use and dropping out of
high school. Results suggest that for high-risk students, use of SBHC care services decreases the
56
likelihood of high school dropout. Furthermore, findings from Kerns and colleagues (2011)
suggest that for high-risk students access to on-campus healthcare is important for reducing race-
and class-based health disparities as well as staving off premature morbidity and mortality.
Some teens frequently encounter barriers to accessing healthcare services, including
inconvenient hours of operation, long distances from where they live or go to school, and
financial costs due to lack of health insurance. Despite the convenience of an on-site SBHC,
youths still do not use services on par with identified health needs, and a significant portion of at-
risk students with access to SBHC-provided care still remains underserved (Ethier et al., 2011).
Health communication messages disseminated via web-based technologies have been identified
as effective means for increasing audience engagement with medical care providers. Thus, new
media technologies may be an unexplored method to increase student utilization of SBHC
services.

U.S. teens’ use of new media technologies
According to a recent study conducted by the Pew Research Center about teens’ use of
social media and other digital technologies, 92% of U.S. teens report going online daily, which
includes 24% who self-report going online “almost constantly.” Youth of color, particularly
African-American and Latino youths, report more frequent Internet use than white teens; 32%
and 34%, respectively, are almost constant online users versus only 19% of white teens (Lenhart,
2015).

57
Adolescent health information-seeking behaviors
Some of the time adolescents spend online is used obtaining health information. Users of
web-based resources report that the Internet is a fast, efficient way to gather health-related
information, compare content on various websites, and search for health information on
potentially sensitive topics with relative confidentiality (Renahy & Chavin, 2006). The multiple
ways in which adolescents obtain health-related information (e.g., family, friends, peers, and
online technologies) reflects the diversity of youth information-seeking strategies. Depending on
the type of health information being sought, adolescents have varying preferences on who they
would like to deliver the information and how it is delivered (Smart, Parker, Lampert, & Sulo,
2012). In fact, adolescents’ use of web-based sources to meet their health information-seeking
needs exceeds traditional media (e.g., print media, radio, and television). According to results
from the national survey “Teens, Health and Technology,” 84% of teens have gotten health
information online, with a quarter saying “a lot” of health information has been obtained from
web-based sources. Consistent with their greater daily Internet usage, African-American and
Latino teens are more likely to get health information online (40% and 31%, respectively) than
whites (18%) (Wartella, Rideout, Zupancic, Beaudoin-Ryan, & Lauricella, 2015).
Online health information-seeking activities are particularly common when adolescents
have general health questions or minor ailments (Gray, Klein, Noyce, Sesselberg, & Cantrill,
2005) or specific health concerns that may be difficult for them to ask in face-to-face settings.
The Internet is valuable in satisfying youths’ information needs because the anonymity of web-
based searches, compared to in-person queries of health professionals, allows youths to ask
health questions they would not normally ask because of embarrassment (Bleakley, Hennessy,
Fishbein, & Jordan, 2008; Ralph et al., 2011; Skinner, Biscope, Poland, & Goldberg, 2003). For
58
instance, online searches for sexual health information, namely HIV/STI-related content, are
common among LGBTQ youth. Their information-seeking behaviors are often motivated by
personal relevance (e.g., having symptoms of an STI or a pressing need to know information for
future benefit) (Magee, Bigelow, DeHaan, & Mustanski, 2011). As such, sexual health websites
serve a valuable function in improving youths’ abilities to make informed decisions.
Bandura (2001) suggests that actions initiated by empowered people are based on their
intentions, forethought, self-reflectiveness and self-reactiveness. Thus, youths’ engagement in
online health information-seeking behavior can result in empowered, more effective patient-
physician communication. Some adolescents use the Internet to get health-related information for
self-care and medical guidance, so they do not have to make an appointment with a physician
(Gray et al., 2005). However, Hu, Bell, Kravitz, and Orrange (2012) found that online
information seeking can complement rather than replace offline information sources prior to a
doctor’s appointment, and these health resources are often used to prepare a patient for a visit
with his or her physician. Patients who bring health information gathered from web-based
sources may have enhanced physician-patient communication because they are empowered to
make requests of their doctor based on the information gathered online during the pre-visit stage.
Whereas research indicates that conversations between adolescents and their medical care
providers often lack candor (Akard & Neumark-Sztainer, 2001), a teen’s health information-
seeking behaviors prior to a physician visit may increase the likelihood that important, age-
specific health concerns (e.g., sexual and reproductive health, substance misuse, weight
concerns, bullying, and violence) are addressed. Additionally, the Internet can act as a bridge,
connecting youth to offline health resources and services that would otherwise be unknown to
them (Magee et al., 2011). This is important because online information and tools also have the
59
ability to change teens’ behaviors. Twenty-eight percent of young people say they have changed
their behavior based on digital health information, and this percentage increases to nearly 1 in 3
(32%) if digital tools (e.g., mobile apps, wearable tracking devices) are included (Wartella et al.,
2015).

eHealth literacy
Among teen online health information seekers, the vast majority (72%) uses a search
engine to find health-related information, with 58% often beginning their search by Googling a
general search term. Half of teens (50%) surveyed in the “Teens, Health and Technology” study
say they click on the first website that comes up in their search, rarely going further unless they
have additional questions (Wartella et al., 2015). In their observational study of adolescents’
online health information searches, Hansen and colleagues (2003) found that youths had trial-
and-error approaches to search terms with significant backtracking. Participants often had
difficulty finding specific answers to health-related questions because of unnoticed or
uncorrected misspellings, vague search strings, and an inability to sift through website content in
a systematic way. Many times adolescents would fail to locate answers to their questions because
they scanned through pages too quickly, missing important content. Also, youth are often
overwhelmed by the volume of information they receive online, which hinders their ability to
find personally relevant answers to their questions (Skinner et al., 2003). As a result, 29% of
teens say they are dissatisfied with online health information because the content is too long to
sort through (Wartella et al., 2015). Youth also complain that the health information they find
online is not directly applicable to their health concerns (or at least those in their age range)
(Lenhart, 2015).
60
Since most adolescents lack health literacy skills, they are using general search engines
instead of specialized portals for their health information searches. Specifically, younger students
(i.e., 9
th
and 10
th
graders) and youth of color (i.e., Latino teens) have lower levels of health
literary than older students or non-Latino teens (Ghaddar, Valerio, Garcia, & Hansen, 2012).
They may be unsure about trusted, non-commercial websites to use as resources when health-
related questions arise. In addition to search engines like Google and Yahoo, youth use
Wikipedia for quick health information. Twenty-two percent of 13-18 year olds have used
Wikipedia, an open-access, crowd-sourced online encyclopedia for health information. This is
not surprising considering Wikipedia pages are among the first ten listed web sites in general
search engine results in more than 70% of cases (Laurent & Vickers, 2009). Most wikis,
particularly Wikipedia, make no claims about the veracity of site content, and users should be
skeptical about content accuracy. Yet, this fact may be forgotten or obscured because of
entrenched web use practices (e.g., most users do not check sources or overall page quality),
especially among audience members who have limited media and/or health literacy (i.e., youth)
(Eysenbach, 2008).
Internet users often triangulate among online and offline resources, so the effects of
breaches in online health information reliability may be lessened. Nevertheless, the potential for
physical or emotional/mental harm caused by teens applying spurious, low-quality, or
untrustworthy health information highlights the importance of youth obtaining credible health
information online. Young people may also have difficulty discerning the trustworthiness and
credibility of health-related websites because of a deficit of context. For instance, it is often
difficult to distinguish websites created by individuals versus professional organizations, and
search engines direct users to webpages within a site, bypassing the homepage, making it
61
difficult to assess the content as a whole (Eysenbach, 2008). In addition, youths report that it is
often difficult for them to find accurate, comprehensive sexual health information that is relevant
to their needs and written in language they can understand—sans sexually explicit/ pornographic
material or pop-up advertisements (Jones & Biddlecom, 2011).

Adolescents’ social media use
Although the majority of adolescents’ online health content comes from traditional
platforms like search engines or (to a lesser extent) websites from professional organizations
(e.g., government or higher education institutions), new media technologies have been identified
as a potential method for satisfying youths’ health information needs. New media technologies—
social media, specifically—provide new opportunities to provide on-demand health information
for adolescent populations. Social media is “a group of Internet-based applications that build on
the ideological and technological foundations of Web 2.0
14
and that allow the creation and
exchange of user generated content” (Kaplan & Haenlein, 2010 as cited in Moorhead et al.,
2013). A critical component of Web 2.0 is the move away from the desktop computer to portable
devices, namely mobile phones, and other media outlets (Adams, 2010).
Teens are often early adopters of technology and enthusiastic users of social media
platforms, specifically social networking sites (SNS). The vast majority of teens (89%) use at
least one of the most popular sites (Facebook, Twitter, Instagram, Snapchat, Tumblr, Google+,
and Vine); 71% use two or more (Lenhart, 2015). Video sharing is another popular digital media
activity. Making, sharing, and viewing online videos offer opportunities for media creation,

14
Web 2.0 is a term used to distinguish the current iteration of the Internet from the previous
one. The Internet of today is shaped by user-generated, user-controlled content that is far more
interactive than the static original version (Korda & Itani, 2013).
62
participation, and exposure—and teens are active participants. Fifty-seven percent report
watching online videos, and 14% report posting videos (Collins, Martino, & Shaw, 2011). Fifty-
nine percent of teens video chat with friends; 7% of them do so daily (Lenhart et al., 2015b).
Female teens are more likely to use social media platforms that are oriented to photo- and video-
sharing features (i.e., SNS) while male teens prefer video games or gaming consoles. Female
teens are more active on Instagram and Twitter (e.g., tagging and posting photos/videos and
updates) (Lenhart, 2015). Females are also more likely to log into their social networking
accounts daily than males (Landry et al., 2015). Sex differences were also found in a longitudinal
study of Latino adolescents’ social media use. Researchers discovered Latina adolescents were
more likely than their male counterparts to be active social media users (Vyas, Landry, Schnider,
Rojas, & Wood, 2012).

Negative impacts of social media use
The development of one’s sexuality and self-concept as a sexual being is an important
part of adolescence. Social norms about sex and sexuality as well as about appropriate,
normative behaviors are developed and maintained in youth-populated online spaces. Social
networking sites create an online environment in which youth are able to create and try on
identities for themselves; however, teens may use these online spaces to explore their sexuality
in unhealthy ways. A study conducted by Williams and Merten (2008) found that 17% of photos
on SNS were inappropriate, and 16% contained sexual activity references. These are relatively
small amounts, especially considering the thousands of photos that are posted online by young
people daily; however, these percentages mean that for some teens, SNS may provide an
entrance into sexual activity. Youths who self-present in a sexually explicit manner are more
63
likely to have peers in their social networks who do the same (Guse et al., 2012). SNS pages with
sexually explicit photographs, language filled with sexual innuendos, or posts that allude to
actual sexual behavior create an environment among networked peers that sexual behavior is
normal and appropriate. This increases the likelihood that others in the network will behave
according to the norm created (i.e., sexually active) and create additional materials (e.g., posts,
photos, and videos) that highlight sexual activity in the network. Moreover, there may be
inconsistencies between what teens post online and their actual sexual intentions or experiences.
However, online feedback that supports the teen’s new, sexualized presentation of self may
encourage additional sexualized postings that coincide with the teen’s perception of himself or
herself as a mature sexual being or appropriate object of sexual desire. As such, sexualized
behavior in online spaces may translate into sexual engagement in physical spaces (Collins,
Martino, & Shaw, 2011). Whereas adolescent sexual initiation and activity often leads to sexual
risk behaviors, which co-occur with alcohol, tobacco, marijuana and other drug use, youths’
exploration of their sexual selves and image development via SNS may provide entrée into
negative behaviors. In addition, Richards, Caldwell, and Go (2015) identified several other
negative impacts of social media use on children and teenagers, including reduced self-esteem
and body image (especially among female youths), Facebook depression, cyberbullying, and
online risky behaviors. Therefore, youths’ frequent social media use creates potential pitfalls that
may have adverse impacts on their health and wellness.

Adolescents’ social media privacy concerns
Most teens are avid social media users, sometimes engaging in less-than-prosocial
behaviors online, yet it is neither fair nor accurate to suggest that youth, in general, are not at all
64
concerned about privacy protections. Rather, teens’ and young adults’ navigation of the public-
private continuum, made more salient by SNS architecture and affordances, must be understood
within a context of their attempts to exert agency and control. The situation becomes more
complex in light of teens’ nascent understandings of necessary privacy concessions in favor of
increased health-related autonomy and online health information retrieval. Privacy and
confidentiality issues are of concern for adolescents when discussing sensitive, potentially
stigmatizing health content in online public forums. For instance, some young people manage
their online privacy needs by avoiding searches for sexual health information on shared or
publicly accessible computers (e.g., home computers in shared spaces). Adolescents and young
adults have mixed reactions to sharing and receiving sexual health information from an
organization, but these patterns differ by race/ethnicity (Divecha, Divney, Ickovics, & Kershaw,
2012). Many teenagers are reluctant to “like” a page because of privacy concerns and
presentation-of-self issues, resulting in little social media traction for many sexual health-related
organizations’ websites (Whiteley, Mello, Hunt, & Brown, 2012). Young people’s concerns with
online presentations of their self-images mean they are cautious about the kinds of content they
view and share. For instance, peers may perceive someone who actively shares sexual health or
STI-related information online as a disease carrier. Thus, young people often avoid online
behaviors that might invite unwanted stigma or probes into their personal lives in an effort to
maintain control over their images and reputations. Although Ralph and colleagues (2011) found
that youths’ willingness to “friend” or “like” a healthcare organization’s website varied, multiple
studies indicate that teens are skeptical about the appropriateness of sexual health promotion on
SNS like Facebook (Byron, Albury, & Evers, 2013; Whiteley et al., 2012).

65
Social media for health-related engagement
Despite some young people’s reluctance to use social media platforms for health-related
activities, SNS are burgeoning health resources: 20% of teens have used YouTube as a health
resource, 9% have used Facebook, and 4% have used Twitter. Six percent of teens say they
“often” find health information through links on social networking sites; 22% of teens said
“sometimes” (Wartella et al., 2015). “Social networking, which includes peer-to-peer
information sharing and moving beyond text-based information to symbolic information, images,
and interactive information, is considered to enhance lay understandings of health, patient
communication, and individual decision-making processes” (Adams, 2010, p. 394). Some
benefits of social media for health communication are an increase in available, sharable, tailored
health information, increased accessibility, and peer/social/emotional support (Moorhead et al.,
2013). Non-textual information presentations can enhance user understanding of health-related
topics, especially for individuals with special needs or low literacy (Adams, 2010). There is a
positive relationship between social media use and online health information-seeking behaviors,
such that the more a person uses social media the more likely he or she will access health
information online (Mano, 2014). Fitness and exercise, diet and nutrition, STI/STDs, depression
or other mental health issues, and drug or alcohol abuse are some of the topics for which teens
most frequently search via social media. Social media may be particularly relevant in the sexual
health domain for online health seekers, considering more than half of 13- to 18-year olds say
STDs, pregnancy, birth control, and puberty are topics “very important” to peers their age
(Wartella et al., 2015).
Considerable variability exists among U.S. teens’ health information-seeking and
engagement behaviors via social media platforms. Girls, African Americans, low-income youths,
66
and those who have engaged in risky behaviors are more likely to have used social media,
particularly Facebook or links on other social networking sites, for health information (Wartella
et al., 2015). Latina adolescents are also active social networking site users, which suggests
social media platforms may prove to be effective methods to reach this population subgroup with
relevant health information (e.g., reproductive health, unplanned pregnancy prevention, STI
prevention, health relationship, and intimate partner violence prevention) (Landry, Vyas, Turner,
Glick, & Wood, 2015). Although teens self-report social media use for information about health
topics of interest or concern to them
15
, only one in ten (10%) are “somewhat likely” to post a
query on a social networking site if they have a question or are looking for health advice, with
Black and lower-income teens more likely to post a question on a SNS (Wartella et al., 2015).
Due to the asynchronous nature of computer-mediated communication on some SNS
platforms, which lessens the risk of immediate negative feedback and loss of face (Suler, 2004),
users may engage in candid conversations with other web users. This may include engaging in
talk about health-related topics that could cause discomfort in face-to-face or in-person group
contexts. Anonymous mobile apps, like Whisper, Yik Yak and Ask.FM, afford teens the
opportunity to ask questions or post confessional messages without disclosing their identities.
Only 11% of teens report using anonymous sharing apps; however, race and gender differences
do exist. Female and Latino teens are more likely to use these platforms than males or youths of
other race/ethnicities. In fact, Latino teens are nearly twice as likely as white teens (16% versus
9%, respectively) to be users (Lenhart, 2015). Interactivity afforded by social media platforms,
anonymous or otherwise, may be well suited for adolescents whose risky behaviors necessitate
health information. Specifically, teens who engage in risky behaviors (e.g., past 30-day cigarette

15
1 in 10 teens (10%) self-report receiving “a lot” of health information from social networking
sites, and 23% say they get at least “some” of their health information from these platforms.
67
smoking, unprotected sexual intercourse, drug use, alcohol intoxication, or disordered eating) are
more likely than their non-risky peers to get health information from social networking sites.
These peers are also more likely to post a query on a social networking site, asking for
information or advice (Wartella et al., 2015). From a health promotion perspective, web-based
dialogue catalyzed by the affordances of social media can increase adolescents’ engagement with
health-related content. SNS provide an opportunity for health service organizations to present
information to youth audiences that goes beyond text-only formats.
In addition, online spaces, particularly those within networked publics, are characterized
by their scalability (i.e., content is easily seen by large audiences). SNS also create an
opportunity for healthcare providers to engage with adolescents and young adults outside of the
traditional office setting, which may prove effective at increasing actual SBHC use. SNS may be
one method to maintain adolescent patients (some of whom receive inconsistent care) and re-
engage those who have fallen out of the healthcare system. Moreover, integrating health-related
content within popular social networking sites like Facebook, Instagram, Twitter, or Snapchat
may prove effective in combating some teens’ lack of interest in health information while
increasing exposure to similar online resources (Magee et al., 2011). Neiger, Thackeray, Burton,
Giraud-Carrier, and Fagen (2013) suggest that social media use for health promotion must
increase engagement between healthcare organizations and its audience members to achieve
greater audience participation with the organization (e.g., receipt of program services). And
despite the ubiquitous nature of new media technologies, it is important to note that all online
platforms, including social media sites, are not equally effective in getting users to access online
health services. Consulting groups, like forums and online communities, are more effective than
more generalized sites (Mano, 2014).
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Social media-based health interventions
Health promotion interventions that are most successful at achieving desired outcomes
are ones that contain attitudinal components, education information, and behavioral skills
training (Albarracin et al., 2005). Traditional mass media (e.g., radio, television) have been
effective delivery methods for these health promotion campaigns and interventions for decades
(Grilli, Ramsay, & Minozzi, 2012; Wakefield, Loken, & Hornik, 2010). However, the one-way
flow of information, from the content producer to the message recipient, results in a lack of
feedback among traditional mass media (Thompson, 1992, as cited in Gray et al., 2005). The
interactivity and portabiity of Web 2.0 presents new opportunities for communication and
information exchange, which have given rise to Internet-based interventions that have proven to
be effective at achieving behavioral change (e.g., nutritional status improvement, weight loss
maintenance, tobacco cessation, and safer-sex behaviors). In a systematic review, web-based
interventions demonstrated greater efficacy at achieving knowledge gains and/or behavioral
change for managing chronic illness than non-web-based interventions (Wantland, Portillo,
Holzemer, Slaughter, & McGhee, 2004). A recent meta-analysis by Webb, Joseph, Yardley, and
Michie (2010) indicated that Internet-based interventions had a small but statistically significant
impact on health behaviors, and those interventions that targeted multiple behaviors had smaller
average effects than interventions that addressed a single behavior change.
Yet, current literature is inconclusive about the effectiveness of social media-based health
interventions at achieving improved health outcomes. Laranjo et al. (2014) conducted a meta-
analysis of social networking site interventions and found a slight yet positive effect of SNS
interventions on health-related behavior change. Swanton, Allom and Mullan (2014) conducted a
meta-analysis of the effect of new media interventions on STI testing and condom use. Findings
69
indicated participants in the intervention groups had greater STI testing and condom use
behaviors than participants in the control group
16
. Social media-based interventions also
produced gender-specific effects: teenage women exposed to new media sexual health
interventions were twice as likely to use condoms as participants in the control group (Swanton
et al., 2014). To the contrary, Shaw and colleagues (2015) conducted a qualitative meta-analysis
of three social media health interventions and found that behavior change outcomes were not
sustained. Guse et al. (2012) conducted a systematic review of risk-reduction interventions for
youth (age 13-24) that incorporated new media technologies (e.g. mobile technology, gaming,
social networking sites, Internet and text messaging). Findings indicated interventions were
successful at increasing HIV/STI risk knowledge but did not change behaviors.
Social media-based intervention effects are most often achieved in knowledge-based
outcomes, with statistically significant results for behavioral outcomes achieved less frequently.
Since knowledge gains may not translate to reductions in youth behaviors, the practical efficacy
of web-based interventions, including social media-based interventions, has not yet been
ascertained. The methodological soundness and rigor of study protocols and evaluation processes
have been cited as potential reasons for the lack of evidence for social media-based intervention
effectiveness. However, recent reviews acknowledge the potential of this delivery method,
particularly for youth audiences (Yonker, Zan, Scirica, Jethwani, & Kinane, 2015). In a
systematic qualitative review of social media-based health interventions, Househ, Borycki and
Kuskniruk (2014) suggest that social media have a “promising future” in healthcare management
because new media platforms can be used for a litany of patient engagement factors including
health information provision, data collection, appointment setting, prescription notification,

16
No small study bias was found; however, once potentially missing studies were accounted for
the effect on condom use was no longer statistically significant.
70
motivation, trust, and self-efficacy. Despite finding no effect in their review article, Shaw and
colleagues (2015) acknowledge that the use of social media as a health intervention mechanism
is a novel idea that needs more research to improve methodological rigor and theoretical
soundness. Guse et al. (2012) suggest that new media/digital technology should be used in the
new generation of youth-targeting, risk-reduction interventions, but further research is needed to
improve both short-term and long-term efficacy.

Summary
Adolescents are the least likely group to seek medical care in a health provider’s office.
During these office visits, health education and candid discussions of risky behaviors are often
absent. Considering risky behaviors among adolescents are leading causes of their mortality and
morbidity, providing access to medical care services for young people is an important public
health issue. School-based health centers are designed to provide education and primary
physical, reproductive and mental health services. They provide better care for
uninsured/underinsured low-income young people, helping them achieve greater numbers of
quality-of-care markers (Allison et al., 2007). These organizations positively impact student
academic achievement by addressing health-related concerns with reduced interruption to the
learning process (e.g., during the school day, on-campus location). SBHCs provide an entry point
to primary care for youth who do not have access to consistent care. Whereas risk behaviors
developed in adolescence may continue throughout adulthood if not addressed, SBHCs fulfill an
important health promotion role. SBHCs help youth develop self-efficacy skills for avoiding
high-risk situations. SBHCs can encourage behavior change because of the relationship that can
be developed between students and providers (Ralph & Brindis, 2010). Moreover, SBHCs
71
increase the likelihood that students will access reproductive health care services and are
correlated with increased contraceptive use and STD screening (Ethier et al., 2011). The Internet
is valuable in satisfying youths’ information-seeking because the anonymity of web-based
searches, compared to in-person queries of health professionals, allows youths to ask health
questions they would not normally ask because of embarrassment (Bleakley et al., 2008; Ralph et
al., 2011). Online health content from reputable health organizations serves a valuable function
in improving youths’ abilities to make informed decisions. Thus, computer-mediated health
communication via social media platforms, specifically social networking sites, may prove to be
a promising method for increasing use of SBHC services.

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CHAPTER THREE

THEORETICAL PERSPECTIVES AND CONCEPTUAL FRAMEWORK

Introduction
As described in detail in Chapter Two, school-based health centers mitigate many of the
physical, mental, and sexual/reproductive health issues that contribute to persistent health
disparities among youths of color by providing free or low-cost healthcare to adolescents, many
of whom live in urban, medically underserved environments. However, many school-based
health centers report that teens do not access health education and medical care services on par
with estimated need. This discrepancy between service need and utilization highlights
opportunities for healthcare organizations to develop innovative outreach efforts. Social media
platforms serve as youth-friendly, health communication delivery methods that provide
healthcare providers with opportunities to engage adolescents and young adults outside of the
traditional office setting. Social media create opportunities for information presentation that go
beyond text-only formats. Integrating health-related content within popular social networking
sites like Facebook, Instagram, Twitter, and Snapchat may prove effective in combating teens’
disinterest in health information while increasing exposure to similar online resources. In
addition to satisfying health information needs, social media platforms afford youths the
opportunity to create their own content, share with peers, and engage in peer-to-peer learning.
Thus, the interactive nature of social media platforms is hypothesized to increase teen
engagement with digital health content and school-based health center services (e.g., routine
screenings, physician visits, and counseling).
73
Achieving health behavior change is a complex, often difficult process. Theory-based
interventions have been proven to be more effective at helping participants achieve positive
health outcomes than those not based on proven change theories. The aim of this research study
is to evaluate youth-created, digital health content delivered via social media as a new,
potentially effective method for achieving adolescent behavior change (compared to standard
outreach); therefore, a conceptual model was developed to guide that evaluation. The conceptual
framework developed for this study incorporates key constructs (e.g., self-efficacy, perceived
threat, and cues to action) from popular behavior change theories (e.g., Health Belief Model,
Social Cognitive Theory). In this study, the researcher hypothesizes that activating theoretical
constructs in adolescents in a social media-based intervention will encourage health-related
behavior change. Specifically, social networking sites are information delivery methods by
which youth-created health content and peer-to-peer health communication leads to increased
health knowledge, accurate assessment of health threats, greater self-efficacy and empowerment,
reductions in risk behaviors, and increases in SBHC-related health promotion activities.

Description of the conceptual model
The primary purpose of the conceptual model developed for this research study is to
identify intervention core components that explain the process by which teens engage with
online health content and in online peer-to-peer learning to develop healthy lifestyle habits and
reduce risk behaviors. Key constructs of this model that are believed to activate immediate
desired change include: perceived susceptibility, perceived benefit, perceived risk, cue to action,
self-efficacy, and personal empowerment. Table 1 summarizes constructs, definitions, and
74
application examples of the Health Belief Model, the theory from which most of the conceptual
framework is adapted. Figure 2 illustrates the relationships among framework concepts.

Table 1

Key concepts and definitions of the Health Belief Model
Concept Definition Application
Perceived susceptibility Belief about the chances of
experiencing a risk or getting
a condition or disease
Define population(s) at risk,
risk levels
Personalize risk based on a
person’s characteristics or
behavior
Make perceived susceptibility
more consistent with
individual’s actual risk
Perceived severity Belief about how serious a
condition and its sequelae are
Specify consequences of risk
and conditions
Perceived benefit Belief in efficacy of the
advised action to reduce risk
or seriousness of impact
Define action to take: how,
where, when, clarify the
positive effects to be effected
Cues to action Strategies to activate
“readiness”
Provide how-to information,
promote awareness, use
appropriate reminder systems
Self-efficacy Confidence in one’s ability to
take action
Provide training and guidance
in performing recommended
action
Give verbal reinforcement
Demonstrate desired behavior
Reduce anxiety
Source: Champion & Skinner, 2008

Intervention components. The social media-based intervention used in this study aims
to influence participants’ knowledge and beliefs about their health status and risk behaviors as
well as perceptions of personal empowerment and self-efficacy for positive behavior change.
Knowledge of health risks is a key component of the social media intervention because healthy
decision-making and behavior change is predicated on accurate knowledge (Bandura, 2004). In
75
order to affect participants’ knowledge, peer health advocates—high school students employed
and trained by a local school-based health center—develop health messages for teen audiences
17
.
Frequent training in issues related to adolescent health (e.g., sexually transmitted disease
prevention, tobacco cessation, substance abuse prevention, healthy eating, and exercise) and
digital content creation (e.g., message development, key words, photography/imaging, and
memes) is necessary to ensure peer health advocates develop youth-friendly content that reflects
theoretical constructs.
Health communication content can itself inform, model, motivate, and guide audience
members to more healthful behavior. As the conceptual model suggests, youth-created health
content may be especially effective at the modeling aspect necessary for behavior change
because targeted audience members can see themselves in content creators; they are peers,
classmates, friends, and online social network members. Additionally, digital health
communication in this intervention can link targeted audience members to a school-based health
center that can directly facilitate their behavior change via healthcare resources and services. In
this study, youth-targeted health messages are either original content or based on curated
information from reputable sources (e.g., Centers for Disease Control and Prevention, American
Heart Association, Planned Parenthood, and UMMA Clinic proprietary resources). Messages are
repackaged to be accessible to youth audiences and appropriate for the school-based health
center’s existing social media accounts (e.g., 140 characters for Twitter, 1-minute videos, or
memes for Instagram). Social networking sites are identified as prime delivery vehicles for

17
Peer health advocates (i.e., UMMA Student Health Leaders) completed two weeks of public
health training, including an all-day session about developing health content for online media
platforms. These health leaders also participated in additional “booster” sessions during the study
period.
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intervention content because of their popularity as health communication channels among teen
audiences (see review of literature in Chapter Two).
Integral to the intervention is computer-mediated, peer-to-peer education. Youth-targeted
health messages are not only designed to activate theoretical constructs related to health beliefs,
self-efficacy, and empowerment but they are also designed to increase social media engagement
and digital health advocacy.
18
Information sharing between peers or social media “friends” and
followers is believed to encourage the kind of online dialogue that may lead to health-related
learning between those who share similar characteristics (e.g., age, social network membership).
To summarize, digital health content delivered via social media is theorized to encourage
behavior change by activating Health Belief Model, Social Cognitive Theory, and Empowerment
Theory constructs via interpersonal micronetworks (e.g., friends/peers at school), motivate
behavior change by displaying benefits via personal stories, and use social influences and peer-
to-peer health advocacy to change attitudes and perceptions. Social networking sites provide
both a direct pathway (e.g., information, modeling, and motivation) and a socially mediated
pathway (i.e., link individuals to social networks and community settings) for behavior change.

Key constructs
Perceived susceptibility. Individuals vary widely in their feelings of perceived
vulnerability to a health condition. Youths are least likely to perceive their own susceptibilities
because of life stage-specific characteristics (e.g., perceived invulnerability to harm, poor risk

18
As defined in Chapter One, digital health advocacy refers to youths’ use of new media
technologies, specifically social media platforms and social networking sites, to create and share
youth-friendly, relevant health content to network peers. This form of online peer-to-peer content
sharing is theorized to influence youth attitudes, norms and behaviors about health-related topics,
such as sexual/reproductive health, mental health, healthy eating and exercise, and substance use
avoidance.
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assessment skills). Teens are also more likely than adults to incorrectly assess the likelihood of
consequences associated with risk behaviors. Thus, intervention health content is designed to
make teens aware of their vulnerabilities to adverse outcomes if they engage in risk activities or
problem behaviors. By dispelling myths, the intervention content seeks to help participants make
more accurate assessments of their personal risks based on their actual behaviors. Whenever
possible, incidence and prevalence data for conditions or diseases is presented, so as to alert
teens in the study to their relative risks.

Figure 2

Conceptual model for adolescent behavior change using social media

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Perceived severity. Just as youth may not accurately assess their susceptibility to certain
health conditions, they might also incorrectly assess the health impacts or consequences. Some
young people know they are at risk for negative health outcomes based on their behaviors, but
they do not judge the potential consequences as severe enough to curtail or stop those behaviors.
Digital health content at the core of this intervention is designed to accurately relay information
about health consequences for young people from physiological, sociocultural, and economic
perspectives.
Perceived benefit. Intervention core components, namely targeted health content and
peer-to-peer health communication with trained peer health advocates, are believed to influence
participants’ perceptions of the usefulness of a school-based health center as a youth-friendly
health education and healthcare resource. Health messages, particularly video skits, provide
information about how to take steps toward achieving a healthier lifestyle and why a school-
based health center’s medical care professionals are useful aids.
Perceived barriers. Formative research with UMMA Fremont Wellness Center medical
care providers and Student Health Leaders revealed that stigma about the school-based heath
center was the main barrier to student utilization of its services. Students erroneously believed
that the FWC was primarily an STD clinic; therefore, going to the center was tantamount to
admission of an STD/STI diagnosis. Fear of being seen at the FWC was a salient deterrent, even
for those teens who could have benefitted from care. Additional barriers were lack of general
health knowledge among students and unfamiliarity with FWC providers, staff, and services
offered. To combat these potential barriers, Student Health Leaders actively tried to dispel the
myth of the Fremont Wellness Center-STD link by highlighting the range of services offered in
digital content and peer-to-peer health communications via official UMMA SNS accounts.
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Cues to action. Cues to action is a Health Belief Model construct often given cursory
attention; however, greater attention is warranted because of the interpersonal nature of health
beliefs, specifically, “individual beliefs and perceptions about health and illness are socially
constructed and contingent upon social interaction” (Mattson, 1999, p. 243). Two types of online
communication are core components of this intervention: health content targeted to teen
audiences and online peer-to-peer communication. Communication cues are conceptualized to
trigger interpersonal actions that may catalyze behavior changes (i.e., digital health advocacy).
Whereas many SBHCs are located on school campuses, including the SBHC in this study,
geographic co-location is another cue to action. Brick-and-mortar buildings on campus may
serve as visual reminders to engage in healthy behaviors. Plus, proximity provides teens with
access to health services and resources that may help combat barriers to behavior change. In the
case of this research study, on-campus peer health advocates also serve as cues to action; study
participants as well as enrolled students may be encouraged to begin or sustain healthy lifestyle
changes because of the peer encouragement and guidance Student Health Leaders provide.
Self-efficacy. Self-efficacy is an individual’s perceived (or actual) ability to complete a
task. Perceived self-efficacy is impacted by positive capacity changes. Success enhances self-
efficacy beliefs when performance is perceived to be based on skill rather than luck or external
forces (Bandura, 1977). However, even unsuccessful attempts, viewed through a growth-oriented
lens (Dweck, 2006), can increase a person’s perceived ability to achieve a task. Successful self-
changers combine efficacy beliefs with positive outcome expectations such that benefits
outweigh challenges to lifestyle change. Social Cognitive Theory posits that self-efficacy is
gained via modeling coping strategies. In this study, participants’ change capacities are reified by
online health content that features peer actors who are actual school classmates of target
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audience members, namely Student Health Leaders and Fremont High School campus leaders.
Health messages demonstrate prosocial behavior while direct messaging affordances via social
media apps allow for “verbal” instructions and reinforcements.
Personal empowerment. Empowerment links the individual and his or her well-being to
the wider sociocultural and political environment in which he or she functions (Amichai-
Hamburger et al., 2008). Empowered people are characterized by their motivation, positive self-
esteem, and perceived (and actual) self-efficacy. They gain mastery and control over their lives
and a critical understanding of their environment (Zimmerman et al., 1992). Empowerment is
included in the conceptual framework because of its emphasis on asset-based characteristics like
autonomy and self-efficacy. Autonomy and competence function similarly to perceived control
and self-efficacy, underlying components of Empowerment Theory and SCT. Whereas
adolescence is also characterized by these traits, inclusion of empowerment as a way to explain
teens’ knowledge gains and behavior changes toward more risk-averse lifestyles is justifiable.
Peer health advocates develop health content for social media platforms according to an
empowering approach. The online content is designed to highlight the target audience’s ability to
make healthful decisions once given resources; change is theorized to occur based on
participants’ personal desire and fortitude. Videos depict peers encountering adverse situations
(e.g., intimate partner violence, substance use, bullying, sexual pressure, and driving under the
influence) and choosing the healthier, less risky decision. Videos demonstrate to targeted youth
that a) the temptations and problems they encounter are typical of teens their age and do not
signal their psychosocial or moral deficit; and b) they have what it takes to tackle these
challenges successfully. In this way, the online health content aims to activate teens’ feelings of
personal empowerment. In addition, health content attempts to counteract any negative
81
empowerment that may have developed from a teen’s participation in problem behavior (e.g.,
substance use, risky sex).

Intermediate behavior change
Intervention core components (e.g., youth-targeted health messages developed by trained
peer health advocates and delivered via social networking apps, peer-to-peer information
sharing) are conceptualized to activate self-efficacy and personal empowerment as well as
influence health beliefs through Health Belief Model constructs (e.g., perceived susceptibility,
perceived severity, perceived benefit, perceived barriers, and cues to action). These relatively
immediate, intrapsychic changes are believed to manifest in intermediate, outward changes in
teens’ behaviors, namely online activity and SBHC use. Teens whose beliefs about their own
health-related habits and risk behaviors have been challenged by intervention content are
believed to spend more time online seeking health-related information, exposing themselves to
organizations or lay users who post similar content, communicating with social network
members and peer leaders about health-related topics, and sharing health content with friends
and followers. This results in an increase in the number of active online hours, the number of
social media followers, and social media engagement (which is operationalized in terms of likes,
tweets/retweets, comments, and shares). Immediate change (i.e., activation of theory concepts) is
theorized to directly increase participants’ use of the school-based health center. Whereas health
content is designed to be an explicit, salient cue to visit the Fremont Wellness Center, the
researcher also hypothesizes that this intervention component will lead to an increase in student
utilization of the SBHC. Per the conceptual model guiding this study, teens’ increased exposure
to and engagement with computer-mediated health content will also lead to increased SBHC use.
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Long-term behavior change
Increase in social media engagement, number of hours spent online, and number of
followers is theorized to increase school-based health center use. SBHC student utilization is the
conceptual link to desired long-term behavior change: increase in HIVSTI testing behaviors and
decrease in risky behaviors. The SBHC in this study provides a range of health education and
medical care services to adolescent patients, including (but not limited to) sexual/reproductive
health counseling, safer-sex and teen pregnancy prevention education, smoking cessation
programs, and substance abuse prevention. Use of this healthcare organization is conceptualized
to influence long-term behavior change by supporting participants’ change in health beliefs and
buoyed perceptions of personal empowerment and self-efficacy.

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CHAPTER FOUR

METHODS

Study Context
This research study was conducted in the South Los Angeles area of Los Angeles County
in collaboration with Los Angeles Unified School District (LAUSD) and the UMMA
Community Clinic. South Los Angeles has the highest rate of overall poverty in Los Angeles
County: 31% of the estimated 1.03 million residents live below the federal poverty line. The
average annual household income in South Los Angeles is less than $22,050 for a family of four.
Health disparities combine with limited income to create an environment of increased health-
related vulnerabilities for area residents. South Los Angeles has been identified as a “health hot
spot” because of persistent health disparities among youths and adults (e.g., infant mortality,
chronic conditions, and sexually transmitted infections). For instance, 51 out of 1,000 15-19 year
olds will give birth—signaling the highest teen pregnancy rate in Los Angeles. About 1 in 100
residents will become infected with chlamydia each year, which is nearly twice the LA County
average and more than double the national average (UMMA, 2016).
Disparities in health access also exist. South LA has 0.11 school-based health centers per
1,000 uninsured children, or 35% less than the LA County baseline. In comparison, West LA, a
more resource-plentiful area of the county, has 0.50 SBHCs per 1,000 uninsured children or
201% more than the county baseline. There are approximately 10 pediatricians for every 100,000
children in South Los Angeles, less than five times the county average and only 1.6
specialist/physicians per 100,000 patients, less than three times the county average (Park,
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Watson, & Galloway-Gilliam, 2008). Although South LA residents are disproportionately
impacted by health conditions, many that require hospitalization (if untreated or poorly
managed), there is only one hospital bed per 1,000 South LA residents (UMMA, 2016).
Of any LA County Service Planning Area (SPA), South LA (SPA 6) has the largest
percentage of Black and Latino residents. Research study sites, John C. Fremont High School,
Mervyn M. Dymally High School and the UMMA Fremont Wellness Center, are all located in
the South LA neighborhood of Florence. This area is not racially diverse, with 69.8% of the
population Latino and 28.1% Black. 41.3% of residents are foreign born, and nearly 30% of
families are led by single parents/guardians. Only 2.8% of neighborhood residents have a 4-year
degree (Mapping L.A., 2008). Health concerns of the majority residents of color in this
neighborhood reflect health-related problems that disproportionately impact South Los Angeles
as a whole. Since race/ethnicity, socioeconomic status, and age are factors in predicting health
status, the need for comprehensive quality healthcare services is great. The medical care services
and health promotion education provided by school-based health centers have been cited as
effectives ways to ameliorate health disparities among low-income, underserved urban residents,
many of whom are youths of color.

Research Collaborators
UMMA Community Clinic: Fremont Wellness Center. The University Muslim
Medical Association (UMMA) Community Clinic is the first Muslim American-founded,
community-based health organization in the nation
19
. Founded in 1992 by Muslim American

19
In 2008, UMMA was designated a Federally Qualified Health Center (FQHC) by the U.S.
government, the first Muslim American organization to be granted this status.

85
medical students at University of California Los Angeles and Charles Drew University, the
UMMA Community Clinic operates two facilities in South Los Angeles to address the health
concerns of its diverse, under-resourced client population. In June 2013, UMMA opened a
school-based health center in partnership with LA Land Trust and LAUSD on the campus of
John C. Fremont High School. The Fremont Wellness Center and Community Garden (FWC) is
a full-service facility for students and residents. Its services include pediatrics, confidential teen
healthcare, adult medicine, mental/behavioral health, family planning, confidential HIV/STI
testing, and high school sports physicals. The FWC also provides health insurance enrollment
assistance to those who are uninsured. Although the FWC is located on the campus of John C.
Fremont High School, it services students at Bethune Middle School, Thomas Alva Edison
Middle School, and Charles R. Drew Middle School as well as students at Fremont High School,
Dymally High School, and the Diego Rivera Learning Center. The Fremont Wellness Center is
staffed by one licensed physician (Dr. Cesar Barba), one nurse practitioner (Ms. Glenda Leflore-
Jacobs), and three medical assistants. The Center is open from 8 a.m. to 5 p.m. Monday through
Friday. Walk-in appointments are available for all patients, and two time slots (10:30 a.m. and
1:30 p.m.) are set aside each day for Fremont High School students only. As in most community-
based clinics, the FWC has health-related educational pamphlets available for student patients to
read while in the waiting room.
UMMA Student Health Leaders. The UMMA Fremont Wellness Center employs a
cohort of John C. Fremont High School students who serve as campus and community health
resources advocates, particularly for teens and young adults living in or near South Los Angeles.
Student Health Leaders (SHLs) receive ongoing training in several key aspects of public health,
including health disparities, reproductive/sexual health, alcohol and substance use prevention,
86
tobacco prevention and/or cessation, healthy eating, and mental/emotional health. Student Health
Leaders conduct on-campus student health advocacy through lunchtime tabling events in the
Fremont High School campus courtyard, after-school events, and community volunteerism. The
FWC has a goal of 40% of its client base coming from Fremont High School; therefore, the role
of SHLs as peer liaisons between the campus and clinic is critical to educating and encouraging
student use of FWC services. To be considered for employment, interested Fremont High School
students (9
th
-12
th
grade) submit an application and participate in an interview with UMMA staff
and current SHLs.
During the 2015-2016 academic year, a cohort of 15 Student Health Leaders were
selected. Five were exclusively selected to comprise a social media team that would focus
primarily on developing original content for the Fremont Wellness Center’s social media
accounts in order to increase the organization’s online presence and increase student use of
healthcare services.
John C. Fremont High School. Founded in 1924, John C. Fremont High School is a
Title 1 co-educational public high school (grades 9-12) in Los Angeles Unified School District 7.
The school services residents of several South Los Angeles neighborhoods, including the
unincorporated Florence-Graham community. The Avalon Gardens housing project is zoned to
Fremont High School. During the 2015-2016 academic year, the student enrollment was 1,994.
The student population is 7.7% African American/Black and 90.1% Hispanic/Latino. The school
houses four learning communities designed to provide focused, personalized instruction: the
School of Global Media Arts (SGMA), Medical, Environmental Science & Agriculture (MESA),
the School of Environmental and Social Justice (ESJ), and Math, Science, Technology Magnet.
Fremont High School has existing partnerships with several community-based organizations,
87
including Community Coalition, Gear Up, Integrated School Health Center pilot, Los Angeles
Education Partnership, Los Angeles Neighborhood Land Trust, UMMA Community Clinic, and
Weber Community Clinic.
Mervyn M. Dymally High School. The Academy for Multilingual Arts & Sciences
opened in 2012 as part of Los Angeles Unified School District’s $19.5 billion New School
Construction and Modernization Program. The school also services South Los Angeles residents,
including those in the communities of Broadway-Manchester, Florence, Florence-Firestone,
Watts, and Willowbrook. During its first year, student enrollment was 328, with 26.5% African
American/Black and 72.9% Hispanic/Latino; 66.8% of students qualified for free and reduced-
price meals. At the end of the 2015-2016 academic year, Dymally High School had a student
enrollment of 624; the population demographics were 24% African American/Black and 76%
Latino/Hispanic
20
.

Purpose of the Study
Among students in the Los Angeles Unified School District, the need for quality,
comprehensive healthcare access is apparent. There are 72 school-based health centers in Los
Angeles County, and the majority of SBHCs in the county service elementary and high schools
(40% and 39%, respectively). Thirty-five SBHCs operate in collaboration with LAUSD. In 2011,
$36 million was appropriated to build state-of-the-art, full-service community clinics, called
Wellness Centers, on 14 of LAUSD’s highest-need campuses. These healthcare facilities are
operated by community clinic providers and open to LAUSD students, their family members,
and community residents. In fact, from January 2013 - July 2014, LAUSD Wellness Centers

20
Percentages are based on data from academic year 2014-2015 for which the most recent
race/ethnicity data was available.
88
provided healthcare services in 16,022 patient encounters. Similar to SBHCs across the nation,
Wellness Centers operating in LAUSD improve attendance, improve behavior and school
climate, reduce dropout out, and support academic achievement (LAUSD, 2016).
Healthcare services provided by the UMMA Community Clinic are available, oftentimes
free of cost, to all LAUSD students. However, student utilization of FWC services is less than
optimal among Fremont HS students despite the on-campus location, and few, if any, Dymally
HS students visit the Center. Organization leadership attributes the underutilization to several
factors, one of which is difficulty effectively marketing youth-centered services to their target
demographic. The researcher and UMMA leadership established a collaborative research
partnership with the expressed purpose to identify innovative strategies for improving adolescent
health in the LAUSD Fremont Zone of Choice via increased youth healthcare engagement.
Based on the research team’s formative research and practical experiences, a focus on social
media was selected as the strategy with the most change potential.
Adolescents are often early adopters of new technologies. Social norms of today’s youth
culture seem to require active social media participation. Popular social media platforms,
including Facebook, Instagram, Twitter, and Snapchat, moderate youths’ peer-to-peer
interpersonal communications in both online and offline contexts. To the researcher’s best
knowledge, there are no social media-based health interventions that encourage adolescent
behavior change through digital health content created by trained peer health advocates. Whereas
adolescence is characterized by the transition from parental dependence to independence and
peers become strong behavioral influencers, social media can facilitate youths’ learning about
health and wellness from in-group members, especially those young people who are popular
(e.g., “IG famous” or “Twitter famous”) or knowledgeable (e.g., UMMA Student Health
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Leaders). Thus, the purpose of this research study is to examine how youth-centric health content
disseminated via social media can reduce risky, health-related behaviors (e.g., ATOD use,
unprotected sex) and increase a) teens’ use of SBHC services, b) HIV/STI testing, c) online
information seeking, and d) digital health advocacy by encouraging peer-to-peer health
communication, which is can improve top-of-the-mind awareness of SBHC services and change
adolescent health norms and behaviors.

Research Design
An experimental design with baseline and immediate post behavioral assessments was
employed. Male and female students enrolled in grades 9-12 at John C. Fremont High School
and Meryvn M. Dymally High School who met study eligibility requirements and expressed
interest in participation (i.e., submission of a signed assent or consent form) were assigned to the
treatment and control groups, respectively. Participants in the treatment condition received a 15-
week social media-based intervention, which consisted of youth-friendly health content created
by UMMA’s Student Health Leaders and delivered daily via popular social networking site
accounts, like Facebook, Twitter, Instagram, and Snapchat. Participants in the control condition
received standard care, which consisted of health pamphlets and two, on-campus student health
fairs, sponsored by the UMMA Fremont Wellness Center. Students in the control condition
completed the same baseline and immediate post behavioral assessments as students in the
treatment condition. Participation in this study was completely voluntary. Participants in both
conditions were compensated with $10 merchant gift cards for each completed behavioral
assessment.

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Target Population and Participant Selection
The target population included high school-aged adolescents enrolled in 9
th
- 12
th
grade at
a high school serviced by a school-based health center (SBHC). The sample population for the
treatment condition included 9
th
- 12
th
grade students enrolled in a history course or elective
course (e.g., Leadership, Media & Production). The sample population for the control condition
included 9
th
- 12
th
grade students enrolled in a science course. Potential participants must have
met the following eligibility requirements for the treatment condition: a) 13-19 years of age, b)
current school enrollment for the duration of the study period, c) owner of a personal Facebook
page, d) owner of at least one (1) other social media account (e.g., Twitter, Instagram, or
Snapchat); e) willingness to “like” the UMMA Wellness Center Facebook page and “follow”
Twitter, Instagram, or Snapchat accounts, f) willingness to complete behavioral assessment at
baseline and immediate post intervention at 15 weeks, and g) ability to read and write in English.
Potential participants in the control condition must have met the same eligibility requirements
(e.g., age, willingness to complete behavioral assessment, school enrollment, and English
language proficiency) except those regarding their social media activity. There were no
demographic characteristics that excluded enrolled students who met eligibility requirements
from participating in the study. There was a language-based exclusion criterion; however,
educational instruction at both John C. Fremont High School and Mervyn M. Dymally High
School is in English, so this eligibility requirement was not expected to create a recruitment bias.

Procedures
Formative research. In order to develop the social media arm of the intervention and
guide the Student Health Leaders’ creation of relevant online health content, the researcher
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engaged in one-on-one and small-group conversations with Black and Latino male and female
teens living in South LA and East LA to assess their health concerns. An understanding of
youths’ knowledge- and skills-based needs was ascertained according to Health Belief Model
concepts, including perceived vulnerability to negative health outcomes from risk behaviors as
well as perceived benefits and impediments to behavioral changes. Student Health Leaders
engaged in conversations with their classmates about a range of health topics of interest or
concern to them and ranked them in order of importance. Members of the target audience
expressed most interest in sexual/reproductive health, substance use, mental health (e.g., stress,
anxiety, and depression) and healthy eating. These subject areas provided a guide for SHLs’
creation of teen-friendly online health content.
Student Health Leader training. UMMA Student Health Leaders participated in a two-
week Mini Public Health School leadership and training program from August 3-14, 2015 from
8:30 a.m. to 3 p.m. This program was designed to expose youths to public health principles and
train them to become peer health educators and advocates at Fremont High School and in the
South Los Angeles community. During the Mini Public Health School, the researcher conducted
a 2.5-hour session about communicating health messages through social media. During this
session, Student Health Leaders were exposed to the fundamentals of journalism and
photojournalism, identity development and branding, audience analysis, and methods for
effective communication via social media platforms (see Appendix A for the session outline).
Additionally, Student Health Leaders on the social media team received guidance and
mentorship during their digital content creation processes prior to and during the intervention
period to ensure high quality, accurate health content and meaningful youth development.
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In line with recommendations from Neiger et al. (2013), the researcher and SHLs on the
social media team engaged in numerous conversations about research study goals, organizational
goals and objectives, overlap between the two, and how potential conflicts between goals would
be reconciled if they arose; how success would be quantified; key characteristics of the Fremont
High School student body (target audience), including those beyond the demographic student
profile; and what the research team wanted target audience members to do (i.e., engage with
Fremont Wellness Center online health content, share health messages with peers, and utilize the
FWC for healthcare services). Student Health Leaders and the researcher participated in a co-
learning partnership whereby the resources and expertise of both were valued. This co-learning
relationship created the space for brainstorming, critical dialogue and skills building that
benefitted the entire research process—and ultimately the target audience.

Recruitment
This study was approved by the University of Southern California University Park
Institutional Review Board and the Los Angeles Unified School District Committee for External
Research Review (see Appendices B-D). From mid-September until early October (September
14 – October 2), ninth and tenth grade Physical Education (PE) students (estimated N based on
class rosters=595) were exposed to the researcher’s oral recruitment. In addition to recruitment
activities in PE classes, attempts were also made to recruit students in a Media & Production
course. At the conclusion of the Fall 2015 semester, no students from the treatment campus had
been successfully recruited into the treatment condition. Due to low recruitment numbers at the
treatment site, no recruitment activities were conducted at the control condition site during that
semester.
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Due to failed recruitment during the Fall 2015 semester, the researcher renewed efforts at
the beginning of the Spring 2016 academic semester, specifically the third week of January 2016
(January 19-22). During this recruitment wave at the treatment condition site, students in history
courses or an upper-level elective (i.e., Leadership) were recruited. At the control condition site,
students in sciences course were recruited during the second week of February (February 9-12).
The researcher delivered a 5-7 minute recruitment speech to students present on recruitment
days. Interested students were given assent/parental permission forms; consent forms were given
to potential participants aged 18 years or older. Students were instructed to return the signed
assent/consent forms by the end of the recruitment period. The researcher returned to the
recruitment classrooms on both campuses each day to pick up forms and answer any questions
about study participation. Teachers were given $15 gift cards to the merchant of their choice as a
token thank you.
Once the recruitment phase at both the treatment and control condition sites ended,
interactions between the researcher and study participants were limited to emails, phone calls,
and text messages for the remainder of the study period. Researcher-participant contact was for
study-related purposes only, specifically notifications about date/time/location for baseline and
immediate post behavioral assessments. Reminders to follow the UMMA social media accounts
were sent via text message and email to participants in the treatment condition at the third and
fifth week of the intervention.

Study Administration
This research study was conducted from January to June 2016. Per eligibility
requirements, participants were required to have a personal Facebook page and an account on
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Twitter, Instagram, or Snapchat. All participants self-reported ownership of a personal Facebook
page; however, some expressed not having an account on one of the other platforms. Those
students were instructed to create an account prior to participation. Personal accounts on all of
the social networking sites used in the intervention are free to establish, and all study participants
met platform age requirements (i.e., 13 years old or older). Upon submission of signed
consent/assent forms and establishment of required social media accounts, enrolled participants
were notified to complete a baseline behavioral assessments immediately after school in one of
four campus computer labs (treatment condition). These assessments were developed using the
web-based survey program Qualtrics (www.qualitrics.com). The survey took students
approximately 20-25 minutes to complete. Participants in this condition were exposed to a social
media-based health intervention for 15 weeks (February – May 2016), and per the consent/assent
agreement, participants agreed to engage with UMMA social media accounts according to their
usual social media use routines. At the end of the intervention period, participants completed
immediate post behavioral assessments in a campus computer lab. For the control condition,
enrolled participants completed baseline and immediate post behavioral assessments in the
campus library during the pre-lunchtime Advisory period.
Digital health content development and management. Student Health Leaders met
each Tuesday after school for 90 minutes (3.5 hours on Fremont High School professional
development/student early release days). These meetings provided SHLs the opportunity to plan
on-campus outreach activities, coordinate off-campus volunteer efforts, participant in teen health
training sessions, and develop health content for the Fremont Wellness Center’s social media
accounts. Student Health Leaders were given complete autonomy in developing digital health
content. Jackie Provost, Chief Operation Officer of the UMMA organization at the time of the
95
study, provided loose guidelines that the content should contain no profanity. The researcher
developed a social media strategy and coordinating documents (e.g., monthly assignment
calendars) to help guide SHLs’ development of health content for the organization’s various
digital platforms and make sure the health topics (e.g., sexual health, mental/emotional health,
tobacco and substance use, healthy eating, and exercise) that emerged during formative research
were addressed (see Appendix E and F). These categories reflected health topics of which
Student Health Leaders said they and their peers had the least knowledge and/or the most
concern. The relevance of these topics (e.g., sexually transmitted diseases, teen pregnancy,
mental health, substance abuse, exercise, and nutrition) to youths’ own perceptions of their
health information needs is corroborated in extant literature (e.g., Smart et al., 2012). These
health topics served as content parameters for media production.
Study personnel decided that daily postings would be ideal and no more than 72 hours
between posts on any platform. This required SHLs to create digital content outside of meeting
times. These teens independently developed scripts for skits, recorded and edited all content
using online apps, and added stylistic features (e.g., graphs, music, and animation) to enhance
content quality. Student Health Leaders were able to devise scenarios and language that were
authentic to the target audience and addressed health beliefs, which allowed for more effective
social media-based outreach. Youth-created digital content was designed to engage followers and
educate them about health-related topics in an innovative yet comfortable environment. In
addition to content that addressed relevant health topics and/or concerns, online followers were
given information in each posting about how to contact the FWC for medical care services and
resources.
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All of the UMMA Fremont Wellness Center social media accounts are public accounts;
therefore, anyone can view the posted content, including comments from “friends”, followers, or
visitors to the page. Automated follow-up messages were not part of the study. SHLs and study
personnel decided to respond to any feedback from followers with personalized messages,
depending on the unique content or questions posed. The only automated message that was
consistently presented was instructions to visit the FWC if the follower/viewer had questions or
was in need of services. Additionally, an Ask.FM account was established so that followers of
the FWC social media accounts could ask questions of Student Health Leaders anonymously.
The researcher monitored all peer-to-peer communication to ensure followers received accurate
information and SHLs’ responses were appropriate. The researcher also created a safety plan (see
ethical procedures section in this chapter for a more detailed explanation) that was established
and implemented for the study period in order to ensure minor participants’ online safety while
engaged with intervention content. UMMA leadership reviewed the safety plan to make sure it
aligned with Fremont Wellness Center clinical procedures.
Follow-for-follow is a common convention for gaining new social networking site
followers and increasing popularity rank. Formative research revealed that some adolescents are
concerned about their follower-followee ratio, such that they are reluctant to follow social media
accounts that do not or will not follow the personal pages of its followers. Student Health
Leaders and study personnel decided that the UMMA Fremont Wellness Center SNS accounts
would not adhere to follow-for-a-follow convention. During the study period, the FWC did not
follow adolescent accounts (i.e., SHLs and other high school students) to maintain fairness and
professionalism of the newsfeed. Additionally, only health-related Instagram accounts were
added, specifically those that represented vetted organizations (e.g., Planned Parenthood) or
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youth-friendly accounts that provided relevant information to FWC student clientele. Prior to
following any Instagram account, study personnel reviewed the potential new contact for
appropriateness, relevance, and accuracy of content.
Student Health Leaders’ on-campus outreach. Student Health Leaders’ social media-
based health content complemented their on-campus and community outreach work. During the
study period, SHLs continued to set up tables during designated lunch periods, distribute flyers,
host events, and volunteer in the community to publicize FWC resources. On-campus outreach
activities were held monthly in the campus courtyard. Sample outreach activities include fruits
and vegetables and anti-stress lunchtime tablings, free breakfast during finals week, anti-bullying
flash mobs, STI/HIV haunted house, anti-tobacco door decoration contest, anti-tobacco lunch
fair, and after-school World AIDS Day fair.
SHLs’ on-campus tabling events were ongoing outreach efforts that predated the social
media-based intervention. Prior to the implementation of the current work, SHLs’ primary peer
advocacy efforts occurred during lunchtime events in which Fremont students could engage in
face-to-face interactions with SHLs and get health-related resources, materials, and information
about scheduling FWC appointments. The current research study was initially viewed as an
innovative, online addendum to in-person contact. Social media-based outreach was not designed
to replace SHLs’ on-campus student outreach efforts; therefore, on-campus activities and the
social media strategy for the health intervention were implemented concurrently. Because
UMMA Student Health Leaders were current Fremont students, there were no tabling events at
Dymally High School (control condition site) during the intervention period. Fremont High
School’s 35-minute lunch period from 11:13 - 11:48 a.m. did not correspond with Dymally High
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School’s lunch period from 1:09 - 1:44 p.m.; therefore, SHLs were unable to conduct lunchtime
table events at the control site because of classroom attendance expectations.
UMMA part-time paraprofessional staffing at control condition site. As part of
standard care that was made available to study participants in the control condition, an UMMA
Fremont Wellness Center paraprofessional staff member, Ms. Fatima Valdez, provided on-site
adolescent health resources to Mervyn M. Dymally High School students. Valdez, a former
UMMA Student Health Leader for five years, was assigned to make FWC appointments as well
as provide family planning counseling and student-friendly resources (e.g., pamphlets, referrals).
Small group or one-on-one, walk-in appointments were available each week during Ms. Valdez’s
on-campus clinic hours (e.g., Fridays from 9 a.m. to 12 p.m.); 30-minute appointments were
primarily conducted during the Advisory period or lunchtime.

Instruments
Intervention content. Social media-based health content featured in this research study
was curated from websites of reputable health organizations (e.g., Centers for Disease Control
and Prevention, American Heart Association, and Planned Parenthood) as well as vetted youth-
friendly blogs and adolescent health websites and repackaged to be accessible for youth
audiences and appropriate for various social media platforms (e.g., 140 characters for Twitter,
vivid images or memes for Instagram). Original digital health content was developed by Fremont
Wellness Center Student Health Leaders (SHLs), trained peer advocates who work on behalf of
the Wellness Center to educate and empower South Los Angeles youth to avoid risky decisions
(e.g., unprotected sex, alcohol, drug and/or tobacco use). The PI trained SHLs in key aspects of
digital health advocacy (e.g., message development, key words, photography/imaging, and
99
memes) in order to create youth-friendly content for the FWC’s social media accounts. The
language was crafted in a way that reflected theoretical constructs and was authentic to South LA
youth culture. Figures 3-7 provide examples of health content developed for UMMA’s social
media accounts, and links to video content are provided in Appendix G.

Figure 3
Sexual/reproductive health content: Instagram photo

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Figure 4
ATOD prevention content: Facebook novela

Figure 5
ATOD prevention content: Instagram video

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Figure 6
Teen dating violence awareness content: Facebook video

Figure 7
General Fremont Wellness Center information content: Instagram photo

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In accordance with engagement evaluation standards proposed by the #SMMStandards
coalition in 2011(Marklein & Payne, 2012 as cited in Neiger et al., 2013), social media
engagement for this research study was measured on three levels: low, medium, and high. Low
engagement requires the least effort from users and was operationalized as views and “likes” by
viewers or followers. Medium engagement was defined as comments on any of the FWC
accounts; high engagement refers to content sharing behaviors, such as Facebook shares,
Instagram tags, and/or replies with original content. For healthcare organizations that want to
communicate health information to its audiences, one-way messaging via social media may be
appropriate, especially if an organization has a small social media presence and/or nascent social
media outreach strategy. Whereas one stage of engagement leads to the next, initial low
engagement (e.g., views, likes) is a prerequisite to higher levels of engagement (e.g., comments,
shares). Since the ultimate goal of the Fremont Wellness Center’s peer-led social media outreach
project was to increase student use of FWC services, SHLs endeavored to increase the FWC’s
social media presence on social networking platforms popular with youth and encourage all
levels of student engagement with the health messages.
Dependent measures. In order to test study-related hypotheses, participants in the
treatment and control conditions completed a questionnaire that contained an assessment of the
intermediate and long-term behavioral changes examined here for H
1
-H
5
at both baseline (start of
the study) and 15 weeks post intervention (immediately after the social media-based intervention
concluded) (see Appendix H). These dependent variables included self-reports of SBHC use,
digital health advocacy, Internet-based health information-seeking activity, social media-based
health information-seeking activity, HIV/STI testing, and measures of risky behavior (consistent
condom use, intent to delay sexual debut, alcohol use, tobacco use, and licit and illicit drug use).
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Additionally, the behavioral assessment included measures that correspond to participants’
general social media activity, social media integration, parent-child sexual communication,
social support, self-esteem, and collective efficacy.
UMMA Fremont Wellness Center (SBHC) use. Participants were asked if they had ever
received medical care services from the Fremont Wellness Center. Response choices include: 1=
“Yes”, 2= “No”, 3= “I don’t know.” A follow-up question was also asked: “In the past 3 months,
how many times have you visited the UMMA Fremont Wellness Center for any kind of health
care or medical services, including counseling or testing?” Response choices included: 1= “0
times”, 2= “1 time”, 3= “2 times”, 4= “3-6 times”, 5= “7-10 times”, 6= “10+ times.”
Digital health advocacy. Digital health advocacy refers to youths’ use of social media
platforms to disseminate health-related messages to peers that may influence youth attitudes,
norms and behaviors about sexual health, HIV/STI prevention, and substance use avoidance.
These platforms afford youth the ability to create user-centric experiences that increase
engagement with peers and may lead to increased interactions with medical care providers. Two
items assessed changes in a participant’s digital health advocacy: “Have you ever re-tweeted or
direct messaged (DM) a health-related message to one, more than one, or all of your Twitter
followers?” Response choices include: 1= “Yes”, 2= “No”, 3= “I don’t know.” The other item
asked, “How likely are you to get involved if one of your social media “friends” posted a
message about them engaging in risky behavior (e.g., alcohol or drug use, driving while under
the influence of drugs or alcohol, risky sexual behavior, violence, or criminal activity)?”
Response choices ranged from 1= “Very unlikely” to 5= “Very likely.” These items were not
correlated (r
s
=0.12, p=0.29).
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Health status. Participants were asked to rate their health and were provided five choices:
1= “Excellent”, 2= “Very good”, 3= “Good”, 4= “Fair”, and 5= “Poor.”
Neighborhood issues. Neighborhood issues were measured by ten items that asked
participants how much of a problem are the following issues in the urban area in which they live:
a) litter in the streets, b) smells and fumes, c) walking around after dark, d) problems with dogs,
e) noise from traffic or other homes, f) lack of entertainment for youth, g) traffic and road safety,
h) places to shop, i) vandalism, j) disturbances by neighbors (adult or youth). Response choices
include: 1= “Not a problem”, 2= “Some problem”, and 3= “Serious problem.” Cronbach’s alpha
for neighborhood issues items was 0.92.
Social media activity. Several items addressed participants’ social media use. Participants
were asked about their experience with popular social media platforms, like Facebook, Twitter,
Instagram, and Snapchat. Responses ranged from 1= “I have tons of experience” to 4= “I don’t
know anything about social media.” Participants were also asked about the average number of
hours per week they use social media; what sites they frequently use; how many times per day
they check their social networking site accounts; how many times they post to their own or
someone else’s SNS accounts; the number of followers and people they follow on both Twitter
and Instagram; and how many times per day they tweet (on Twitter). Closed-ended responses
were provided.
Social media integration. Participants’ emotional connection to social media platforms
as well as the integration of those platforms into their daily routines was measured with the 10-
item Social Media Integration Scale (Jenkins-Guarnieri, Wright, & Johnson, 2013). Sample
items were “I feel disconnected from friends when I have not logged into Instagram”, “I prefer to
communicate with others mainly through Instagram”, and “Instagram plays an important role in
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my social relationships.” A 5-point Likert scale (1= “Strongly disagree” to 5= “Strongly agree”)
was used for the response set. The scale was found to be highly reliable (α = 0.87).
Use of websites as health information resources. Two items addressed how often
participants use the Internet and social media platforms as health information resources,
specifically “How often do you use the Internet for health-related information for you or a
friend?” and “How often do you use social media sites for health-related information for you or a
friend?” A 5-point Likert scale (1= “Never” to 5= “Frequently”) was used for the response set,
and the items were highly correlated (r
s
= 0.61, p<0.01).
Online information sharing. Online information sharing was measured by nine items
that asked participants how likely they would be to share the following health-related
information via social media with their closest female and male friends: a) sexual/reproductive
health, b) unplanned pregnancy prevention, c) safer-sex behaviors, d) HIV/STD prevention, e)
healthy diet and nutrition, f) exercise, g) mental health, h) drugs and alcohol, and i) UMMA
Wellness Center resources. Response choices ranged from: 1= “Very unlikely” to 5= “Very
likely.” Cronbach’s alphas for online information sharing items among female and male friends
were 0.94 and 0.96, respectively.
Alcohol, Tobacco and Other Drug (ATOD) use. Substance use was measured using the
8-item CRAFFT behavioral screening tool (CRAFFT, 2009). The assessment was developed to
screen adolescents for high-risk alcohol and other drug disorders. Sample items were “During the
past 3 months, did you drink any alcohol (more than a few sips)?”, “During the past 3 months,
did you use any tobacco products?”, “Have you ever ridden in a car driven by someone
(including yourself) who was high or had been drinking alcohol?”, and “Have you ever gotten
into trouble while you were using alcohol or drugs?” Response choices for each item include: 1=
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“I have never used alcohol or drugs”, 2= “Yes”, and 3= “No.” The scale was not found to be
reliable for this sample (α = 0.28).
Sexual communication. Parental communication was measured by six items that asked
participants how often they and their parent(s) talked about the following health-related topics: a)
sex, b) how to use condoms, c) protecting yourself from HIV/STDs, d) protecting yourself from
becoming pregnant, e) postponing or not having sex, and f) peer/sexual pressure from a dating
partner. Responses ranged from 1= “Never” to 4= “Often,” and these items were found to be
highly reliable (α =0.93). Sexual communication was also measured by one item that asked
participants if they have been able to talk openly to a friend, family member or
boyfriend/girlfriend about sexuality. Response choices include: 1= “Yes”, 2= “No”, 3= “I don’t
know.”
Sexual self-efficacy. This concept was measured by one item that asked participants if
they have been able to say “no” to unsafe sexual behavior in the last month. Response choices
include: 1= “Yes”, 2= “No”, 3= “I don’t know.”
Sexual behaviors. Several items measured participants’ sexual behaviors, including
safer-sex practices. Participants were asked about their sexual debut intention. Response choices
for this item include: 1= “I have already begun having sexual intercourse”, 2= “Yes, I do intend
to begin sexual intercourse”, and 3= “No, I do not intend to begin sexual intercourse.”
Participants were also asked about their past 90-day sexual activity, past 30-day sexual activity,
contraceptive use at last sex, consistent (100%) condom use during sex in the past 90 days, and
consistent (100%) condom use during sex in the past 30 days. Response choices for these items
include: 1= “I have never had sex”, 2= “Yes, I have [engaged in behavior described in item
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stem]”, and 3= “No, I have not [engaged in behavior described in item stem].” Past sexual
activity items were found to be reliable (α =0.63).
HIV/STI testing behaviors. Three items measured participants’ HIV/STI testing history.
Participants were asked about their lifetime and past six months STI testing. Specific items were
“Have you ever (in your lifetime) been tested for a sexually transmitted infection?” and “Have
you been tested for an STI in the last six months?” These two items were highly correlated (r
s
=
0.80). The last item asked participants to select the reason(s) for not testing any STI-related
symptoms. Participants were provided with a list of 11 reasons (e.g., I do not have insurance, I
do not know where to get an STI test, I assumed the doctor or health care provider would test me
without me asking him/her, and I thought I had to get my parent’s permission since I’m under
18) and could select multiple responses.
Self-Esteem. Participants’ self-esteem was measured using the Rosenberg Self-Esteem
Scale (Rosenberg, 1965). The 10-item scale measures positive and negative feelings about the
self to create a composite of global self-worth. Sample items were “On the whole, I am satisfied
with myself”, “I am able to do things as well as most people”, “I feel that I’m a person of worth,
at least equal with my peers and friends”, and “I take a positive attitude toward myself.” A 5-
point Likert scale (1= “Strongly disagree” to 5= “Strongly agree”) was used for the response set,
and the scale was found to be highly reliable (α =0.87).
Social Support. Participants’ perceptions of the social support they receive from family
members, friends, and a significant other was measured using the Multidimensional Scale of
Perceived Social Support (MSPSS) (Canty-Mitchell & Zimet, 2000), a 12-item scale with a 7-
point Likert response set, ranging from strongly disagree to strongly agree. Sample items were
“There is a special person who is around when I am in need”, “I get the emotional help and
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support I need from my family”, and “I have friends with whom I can share my joys and
sadness.” For this study, a 5-point Likert scale (1= “Strongly disagree” to 5= “Strongly agree”)
was used for the response set, and the scale was found to be highly reliable (α =0.89).
Youth empowerment. Participants’ perception of their ability to work with others to
make a difference and achieve a goal was measured using five items of the youth assets subscale
of the Adolescent Health Attitude and Behavior Survey (AHABS) (Reininger et al., 2003).
Sample items were “I feel that I could work with other young people and adults in my
neighborhood to make it better”, “Young people my age are able to make a difference in my
neighborhood”, and “If I felt strongly about an issue, I would talk to people in power about my
opinion.” The Cronbach’s alpha for the 5-item subscale was 0.85. An additional item was added
to measure more directly participants’ perception of youth empowerment using social media.
The stem for this item read: “If I felt strongly about an issue in my school or neighborhood, I
would use social media to make my voice heard.” A 5-point Likert scale (1= “Strongly disagree”
to 5= “Strongly agree”) was used for this item’s response set. The entire scale was found to be
highly reliable (α =0.84).

Analysis of the Data
Power analyses. A priori power analyses were conducted in order to ascertain the
appropriate sample sizes for the treatment and control conditions in order to detect statistically
significant effects, if they existed. Based on a meta-synthesis by Johnson, Scott-Sheldon, and
Carey (2010), an effect size of 0.35 was used for the primary dependent variable: student use of
the UMMA Fremont Wellness Center. The researcher anticipated non-normality of study
outcome variables; therefore, the minimum number of participants necessary to detect an effect
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size was calculated using the Wilcoxon-Mann-Whitney test. According to G*Power estimates
(Faul, Erdfelder, Lang, & Buchner, 2007), 107 participants per condition (total sample size of
214) were needed to sufficiently power the study at the 80% level. Given recruitment constraints
at both the treatment and control sites, this pilot did not accrue the required number of study
participants and was underpowered, reducing the likelihood of detecting significant treatment
effects.
Data analyses plan. The overarching goal of this work is to determine if a youth-led
digital health advocacy program was more effective than traditional SBHC outreach (e.g.,
pamphlets, health fairs) at achieving behavior change (e.g., increased student utilization of
SBHC services, increased HIV/STI-related testing, increased peer-to-peer health communication,
and reduced risky behaviors) among participants in a treatment group compared to participants in
a control group. Five hypotheses (one for each dependent variable) were generated for
subsequent testing. In addition, the researcher posed the following research question related to
social media engagement: What kind of digital health content and social media platforms are
more likely to encourage higher levels of social media engagement among users?
Data analyses occurred between August and November 2016. Study participants’ survey
data from completed behavioral assessments included repeated measures from two time points:
(1) baseline at study enrollment and (2) immediately after the conclusion of the intervention. At
baseline, the two school groups (treatment and comparison) were evaluated for equivalency on
all study outcomes (i.e., H
1
-H
5
) and demographic characteristics, including age, gender,
racial/ethnic identity, year in school, school status (e.g., grade point average), home status (e.g.,
familial living arrangement), perceived health status, and most recent physician visit, using
independent samples t-test and Pearson’s chi-square comparisons. To assess differences in
110
outcomes across these two school groups, all outcomes were assessed in terms of the main effect
of change over time, the main effect of the intervention, and the interaction between treatment
and time. The interaction between treatment and time was considered an indication of
intervention efficacy. For example, the treatment and comparison groups were not expected to
differ in SBHC visits at baseline, but the treatment group was expected to show more visits at
post intervention than the comparison group. Differences in intervention effects between the two
conditions (i.e., hypothesis testing) was assessed using a repeated measures ANOVA and simple
effects probing for continuous dependent variables and Pearson’s chi-square tests for nominal
dependent variables. Changes in study outcomes for participants in the treatment condition only
were examined using paired t-tests (continuous DVs) and McNemar chi-square tests (nominal
DVs). Per the conceptual model developed for this study, the researcher intended to examine
age, gender, race/ethnicity, health status, social media use, and neighborhood issues (e.g.,
riskscape characteristics) as potential modifying factors on study outcomes. However, given the
small sample size and lack of sufficient power, the researcher did not conduct moderation
analyses.
Data on user/follower engagement with UMMA Fremont Wellness Center social media
accounts on Facebook and Instagram as well as the John C. Fremont Instagram account were
tracked for the entire study period. The effect of social media content type (e.g., photo, video,
news article, and novella/narrative) and platform on each of four levels of social media
engagement (e.g., views, likes, comments, and shares) was examined using the combination of
Kruskal-Wallis tests and Dunn-Bonferroni post hoc probing. Data from exit interviews with
Student Health Leaders on the social media team were explored using thematic analysis
techniques according to grounded theory.
111
Ethical procedures and protection of participants’ rights
Precautions were taken to ensure students did not feel coerced to participate in the study.
Researcher-initiated recruitment procedures were conducted in person by the researcher in a
semi-private setting (e.g., teacher classroom). Students were frequently reminded, verbally and in
written correspondence, that participation in the study was completely voluntary. Precautions
were also taken to protect student privacy. Data obtained from participants' social media activity
were anonymized prior to analysis. Additionally, data obtained from participants’ behavioral
assessments was not linked to social media data.
The researcher also devised a safety plan (see Appendix I) to ensure minor participants
were protected while engaging in study-related online activities. The plan was developed based
on a review of numerous guides and toolkits related to social media safety for teenagers. UMMA
leadership approved the safety plan based on its alignment with study-related objectives and
clinic procedures. Study participants’ access to the UMMA Clinic’s public social media pages
was not limited nor were participants’ comments or posts altered, for these actions could have
resulted in breaches of confidentiality or potentially “outing” students as being study
participants. Moreover, because Student Health Leaders posted content that was curated from
reputable health organizations and pre-approved by credentialed health professionals (i.e., study
personnel), safety of the online environment created within UMMA social media accounts for
the purpose of this study was enhanced because study personnel controlled the accuracy of health
messages and supervised Student Health Leader feedback (when possible).

112
CHAPTER FIVE

STUDY RESULTS

Introduction
The purpose of this quasi-experimental study was to identify an innovative, potentially
effective method for increasing student utilization of school-based health center (SBHC) services
by comparing standard SBHC outreach (e.g., pamphlets, school-wide health fairs) to a youth-led,
theory-based digital health advocacy program using popular social networking sites. Specifically,
participants in the treatment condition who received the social media-based intervention were
hypothesized to self-report greater adolescent behavioral change (e.g., increased student
utilization of SBHC services, increased STI-related testing, increased peer-to-peer health
information-seeking and communication, and reduced risky behaviors) than participants in the
control condition. Additionally, this study sought to identify the health content and social media
platform types that achieve varying levels of social media engagement. The researcher
performed repeated measures analysis of variance (ANOVA) with simple effects probing,
Pearson’s chi-square, and McNemar chi-square tests to analyze the effects of time (from baseline
to immediate-post intervention) and condition (treatment versus control) on dependent variables
related to study hypotheses using the Statistical Package for Social Science (SPSS) version 24
(IBM Corp., 2016). To substantiate findings from hypotheses testing, secondary data provided by
the UMMA organization was analyzed; percentage changes were used to indicate increases (or
decreases) in adolescent use of the Fremont Wellness Center (i.e., patient encounters). One-way
ANOVAs were used to determine whether levels of social media engagement (e.g., views, likes,
113
comments, and shares) differed based on the online content type and social media platform type.
In-depth exit interviews with members of the Student Health Leader social media team were
conducted to identify salient themes related to social media-based health message delivery and
peer-to-peer health advocacy among youth. These interviews were audio recorded (with
participants’ consent), transcribed, coded, and analyzed according to thematic analysis
conventions (Braun & Clarke, 2006; Denzin & Lincoln, 2000). Specifically, upon conclusion of
all in-depth interviews with SHLs who participated in developing digital health content for the
study intervention, the researcher conducted verbatim transcription on each audio recording. The
decision for the principle investigator—as opposed to another member of the research team or
third-party vendor—to transcribe the audio recordings was made to reduce the number of errors
that can occur due to lack of familiarity with the topic area (Poland, 1995). The researcher then
followed Braun and Clarke’s (2006) step-by-step process for thematic analysis (see Appendix J).
This chapter presents the results of statistical tests and qualitative analysis. A first step, however,
was to examine and ensure that the two groups did not differ at baseline on outcomes and other
measures.

Baseline assessments
At baseline, study condition was not associated with participants’ self-report of their
health status, ever having received healthcare services from the UMMA Fremont Wellness
Center, alcohol consumption, marijuana use, tobacco use, past 30- and 90-day sexual activity,
intention to become sexually active, lifetime HIV/STI testing, and characterization of their social
media activity. Age was associated with condition, such that participants in the treatment group
were more likely to be in the 10
th
grade; however, there was not a statistically significant
114
difference in age between the two conditions. Grade point average was marginally associated
with condition, such that a greater percentage of students in the control group reported mostly A
and mostly B averages than students in the treatment group. A greater percentage of students in
the treatment group report mostly C averages. Although study condition was not associated with
participants’ alcohol, tobacco, or marijuana use, study condition was associated with other
substance use, such that a smaller percentage of participants in the treatment versus control
group reported avoiding any licit or illicit substance to get high in the past 90-days (40.4% and
59.6%, respectively). Analyses at baseline indicated that the treatment and control group were
sufficiently similar to attribute differences at immediate-post to effects of the 15-week
intervention.

Research questions and hypotheses
The major goal of the current work was to test whether a youth-led digital health
advocacy program was more effective than traditional SBHC outreach (e.g., pamphlets, health
fairs) at achieving behavior change (e.g., increased student utilization of SBHC services,
increased STD-related testing, increased peer-to-peer health communication and reduced risky
behaviors) among participants in a treatment group compared to participants in a control group?
Thus, there was a series of hypotheses and exploratory research questions.
H1: Participants in the treatment condition will self-report more SBHC service use in a 90-day
period than participants in the control condition.
H2: Participants’ self-report of risk behaviors is associated with intervention condition.
115
H2a: Participants in the treatment condition will self-report less unprotected sexual
intercourse (i.e., condomless, no use of hormonal contraceptives) than participants in the control
condition from baseline to immediate post.
H2b: Participants in the treatment condition will self-report fewer sexual debuts than
participants in the control condition from baseline to immediate post.
H2c: Participants in the treatment condition will self-report less substance use, including
alcohol, tobacco, marijuana, and illicit substances, than participants in the control condition from
baseline to immediate post.
H2d: Participants in the treatment condition will self-report fewer instances of riding in a
motor vehicle with a driver who has consumed alcohol or other licit/illicit substances.
H3. Participants in the treatment condition will self-report more HIV/STI testing in the past 6
months than participants in the control condition.
H4: Participants in the treatment condition will self-report greater digital health advocacy
behaviors than participants in the control condition.
H4a: Participants’ self-report of past direct messaging (DM) or re-tweeting of health-
related online content is associated with the intervention condition.
H4b: Participants in the treatment condition will report greater willingness to disseminate
health information to their social media contacts (i.e., “friends”, “followers”) than participants in
the control condition.
H4c: Participants in the treatment condition will self-report greater willingness to
intervene in potentially risky behavior among peers via social media platforms than participants
in the control condition.
116
H5: Participants in the treatment condition will self-report more online health information-
seeking behaviors than participants in the control condition.
H5a: Participants in the treatment condition will use the Internet for health-related
information more often than participants in the control condition.
H5b: Participants in the treatment condition will use social media sites for health-related
information more often than participants in the control condition.
There was also a set of exploratory research questions:
RQ1: What type of digital health content may be most engaging for youth?
RQ2: Which social media platforms are more likely to encourage higher levels of social media
engagement among users?
RQ3: What are themes in youth health-seeking behaviors when using social media as suggested
by interviews with peer health advocates?

Data collection
Social media-based intervention. Survey data were collected at John C. Fremont High
School (treatment condition site) and Mervyn M. Dymally High School (control condition site)
during the spring 2016 academic semester (January - June 2016). Recruitment was based on
whether students who were enrolled at either campus submitted signed consent or assent/parental
permission documents, adhered to study participation requirements, and were present during the
survey data collection periods. Response rates were based on the number of students
participating in the study who completed the behavioral assessment at the two survey times. At
baseline, 43 students from the treatment and 57 students from the control campuses enrolled in
117
the study. Sixty-five percent of the sample completed immediate-post behavioral assessments (28
from the treatment group, 65.12% and 37 controls, 64.91%).
UMMA Fremont Wellness Center service provision data. The UMMA Fremont
Wellness Center offers 25 medical care services to adolescent patients (see Appendix B for the
list of services and visit codes legend). The researcher obtained secondary data regarding patient
encounters with the Fremont Wellness Center during the academic semester prior to the study
period (August 18 – December 18, 2015) and during the study period (January 11 – June 3,
2016). The service provision data presented here reflect the number of adolescent patient visits
(aged 13-19 years) to the Fremont Wellness Center only (as opposed to both the FWC and
UMMA Clinic Florence Avenue locations). To protect patient privacy, data was de-
individualized by removing any identification information (e.g., name, ID number, age,
race/ethnicity); therefore, the data do not meet assumptions of independence.
UMMA Fremont Wellness Center social media activity. Trained UMMA Student
Health Leaders developed youth-friendly digital health content for the Wellness Center’s official
social media accounts by creating original content and curating information from reputable
health organization websites. Social media content corresponded to youth-relevant health topics
including, healthy eating and active lifestyles, mental health, sexual health (e.g., healthy
relationships, safer-sex behaviors, contraceptives, HIV/STI testing), substance abuse avoidance,
and general health and wellness awareness. Each posting was coded according to its type of
content (static visual, video, fictional narrative, and news article) and platform (UMMA
Facebook, UMMA FWC Instagram, and JohnCFremont Instagram).
UMMA Student Health Leader in-depth interviews. Fourteen students attending John
C. Fremont High School were selected to serve as UMMA Fremont Wellness Center Student
118
Health Leaders for the 2015-2016 academic year
21
. Initially, five of these students were
identified as members of the SHL social media team, which was designated to develop and
disseminate youth-friendly health and wellness content via the UMMA organization’s social
media accounts on popular social networking sites, like Facebook, Twitter, and Instagram.
During the study period, the social media team grew to nine members and expanded its social
media reach to include YouTube and Ask.FM. Data presented here are from in-person, in-depth
interviews conducted by the researcher with eight of the nine members of the SHL social media
team on Thursday, May 19 through Monday, May 23, 2016. Interviews were conducted in a
classroom on the John C. Fremont High School campus and lasted 45-75 minutes. A semi-
structured interview schedule, developed by the researcher, was used to guide the depth
interviews (see Appendix K). Thematic analysis was conducted using grounded theory
techniques, which allowed for concurrent data collection and analysis processes when
developing and evaluating emerging conceptual categories (Charmaz, 2005).

Description of study-related data
Participant characteristics. Demographic, health maintenance, social media activity,
and risk behaviors at baseline for study participants in both groups in shown in Table 2.
Equivalency analyses, using independent samples t-tests and Pearson’s chi-square tests, indicated
that the two groups were not statistically significantly different in terms of demographic
characteristics like participants’ age, gender, or racial/ethnic identity. Study condition was also

21
UMMA Fremont Wellness Center Student Health Leaders: Berenice Barrera (12
th
grade),
Xiaxiang English (12
th
grade), Tamia Fuery (11
th
grade), Irlanda Gonzalez (11
th
grade), Brianna
Hernandez (12
th
grade), Jennifer Meraz (12
th
grade), Mariana Paroda (10
th
grade), Ulma
Rodriguez (12
th
grade), Pedro Romero (12
th
grade), Brian Sanchez (11
th
grade), Anthony Santana
(12
th
grade), Lashonda Shipp (11
th
grade), Gerardo Torres (12
th
grade), and Arianna Ybarra (10
th

grade).
119
not associated with healthcare-related factors, including perceived health status, time since
participant’s last physician visit, lifetime HIV/STI testing, or lifetime receipt of Fremont
Wellness Center services. Additionally, participants did not differ in their social media activities.
Study condition was also not associated with participants’ self-reported alcohol consumption,
marijuana use, tobacco use, use of illicit substances, or riding in a motor vehicle with someone
who had been consuming alcohol or other drugs at baseline.
Differences were detected for home status and academic standing, such that participants
in the treatment group were more likely to live in single-parent households led by the mother,
and participants in the control group were more likely to live in two-parent households (x
2
(4,
N=98) =8.78, p = 0.03). Additionally, a greater percentage of participants in the control
condition reported “mostly A” or “mostly B” grade point averages than participants in the
treatment condition; these differences were significant (x
2
(4, N=98) = 8.32, p = 0.05).
Differences were also detected for risk behaviors between the two groups. Condition was
associated with past 90-day sexual activity (x
2
(2, N=98) = 7.11, p = 0.03), such that a greater
percentage of participants in the control group reported lifetime abstinence (62.5% versus
36.6%); however, more participants in the treatment condition had not engaged in sexual activity
in the past three months (43.9% versus 21.4%). Intention to become sexually active was not
associated with condition at baseline (x
2
(2, N=98) = 3.18, p = 0.21). However, there were
gender differences in each condition in intention to begin sexual activity. In both the treatment
and control conditions, a greater percentage of female participants did not intend to begin having
sex than male participants (72.4% and 79.5%, respectively).
Participants’ social networking site preferences. The vast majority of study participants
in the treatment and control conditions were social media users, as indicated by affirmative
120
responses to ever visiting a social networking site (92.9% and 91.2%, respectively). Table 3
shows the social media platform preferences for study participants in each condition. Instagram,
Snapchat, and Facebook were the social networking sites study participants mainly used.
Condition was associated with following any of the UMMA social media accounts at baseline (x
2

(2, N=98) = 41.42, p<0.001), such that more than half (56.1%, n=23) of participants in the
treatment group were UMMA social media followers at baseline while only one participant
(1.8%) in the control condition was an account follower.

Table 2
Demographics and baseline characteristics of study sample (N=98), % (n)
CHARACTERISTICS Intervention Control
Male Female Male Female
Age
14 years old 16.7 (2) 3.4 (1) 18.8 (3) 22.0 (9)
15 years old 50.0 (6) 65.5 (19) 12.5 (2) 31.7 (13)
16 years old 25.0 (3) 13.8 (4) 12.5 (2) 26.8 (11)
17 years old 8.3 (1) 13.8 (4) 43.8 (7) 14.6 (6)
18+ years old ---- 3.4 (1) 12.5 (2) 4.9 (2)
*Ethnicity & Race
Hispanic/Latino/Chicano 83.3 (10) 82.8 (24) 93.8 (15) 73.2 (30)
African American/Black 16.7 (2) 10.3 (3) 6.3 (1) 26.8 (11)
White 8.3 (1) 10.3 (3) ---- 2.4 (1)
Health maintenance at baseline
Saw a physician in the past 12 months 100 (12) 79.3 (23) 62.5 (10) 73.2 (30)
Received medical care services from UMMA
Fremont Wellness Center
---- 27.6 (8) 12.5 (2) 12.2 (5)
Social media activity
Social media use, 10+ hours per week 16.7 (2) 34.5 (10) 37.5 (6) 17.1 (7)
Risk behaviors at baseline
Ever had sex 14.6 (6) 12.2 (5) 25 (4) 9.8 (4)
Past 90-day alcohol consumption 16.7 (2) 20.7 (6) 31.3 (5) 2.4 (1)
Past 90-day tobacco use ---- 6.9 (2) ---- ----
Past 90-day marijuana use 16.7 (2) 6.9 (2) 12.5 (2) 2.4 (1)
*Percentages do not equal 100% because participants were allowed to check multiple race/ethnic
categories.

121
Table 3
Participants’ social networking site preferences (N=98), % (n)
Study Condition
Social media platform Treatment Control
Facebook 61.9 (26) 57.9 (33)
Instagram 71.4 (30) 73.7 (42)
Twitter 26.2 (11) 22.8 (13)
Snapchat 85.7 (36) 71.9 (41)
Google+ 4.8 (2) 14 (8)
Periscope 2.4 (1) 1.8 (1)
Other 21.4 (9) 21.1 (12)
*Percentages do not equal 100% because participants were allowed to check multiple social
networking sites.

Social media platform characteristics. At the beginning of the study period, the
UMMA organization’s social media presence was limited. Numbers of followers for the
Facebook, Instagram, and Twitter accounts were 49, 40, and 21, respectively. Followers
22
of the
UMMA Fremont Wellness Center Facebook account were nearly evenly split, with women
comprising 51% of people who liked the page. Facebook users aged 18-24 years accounted for
the largest percentage of UMMA Wellness Center account followers (25% women, 22% men),
with 25-34 year olds accounting for the second largest follower base (12% women, 14% men).
Young women and men aged 13-17 years, the target age for the study, comprised only 3% and
6%, respectively of UMMA Facebook fans. Similar analytics were not available for the
Instagram and Twitter platforms.

22
The UMMA Wellness Center Facebook page is a public account; therefore, all followers of the
page were not study participants.
122
Results
Social media-based intervention results
The primary question being addressed in the current work was whether a social media-
based health intervention for adolescents was more effective at increasing youths’ use of school-
based health center healthcare services than standard outreach. Five hypotheses, some with
subcomponents, were tested. Since these were a priori hypotheses, one-tailed tests were used for
all hypotheses.
H
1
: Participants in the treatment condition will self-report more SBHC service use in the past 90-
day period than participants in the control condition.
At baseline, the mean difference between participants in the treatment (M = 1.39, SD =
0.80) and control (M = 1.18, SD = 0.54) conditions was not statistically significant (t(96) = 1.59,
p = 0.12). H1 stated that there would be a difference in the number of past 90-day visits to the
UMMA Fremont Wellness Center between participants in the treatment and control groups. At
immediate-post intervention, participants in the experimental group self-reported more FWC
visits than participants in the control group (M = 1.67, SD =1.00 and M = 1.19, SD = 0.70,
respectively). To test whether the mean difference were significant, a repeated measures
ANOVA was conducted. Using one-tailed significance, findings indicated there was a significant
interaction between time (baseline versus immediate post) and condition (treatment versus
control) (F(1, 62)=3.27, p=0.04). Simple effects probing using multivariate analysis of variance
(MANOVA) indicated no difference between groups at baseline (F (1, 60)=0.00, p=0.99), yet the
difference between groups at immediate post was significant (F (1, 60)=4.57, p=0.04). Thus, H
1

was supported.
H
2
: Participants’ self-report of risk behaviors is associated with intervention condition.
123
At immediate post, differences between the control and treatment conditions in
percentages of participants who engaged in risk behaviors were assessed using Chi-square tests.
Although study condition was not associated with consistent (i.e., 100%) condom use during the
past 90-day period (χ
2
(2)=0.42, p=0.81), it was associated with participants’ intention to initiate
sexual intercourse for the first time (i.e., sexual debut) (χ
2
(2)=27.64, p<0.001). Specifically, a
greater percentage of participants in the treatment group reported positive intentions to become
sexually active than participants in the control group (66.7%, n=18 versus 5.6%, n=2). With
regards to risk behaviors related to alcohol, tobacco and other drug (ATOD) use, condition was
associated with alcohol consumption (χ
2
(1)=3.94, p=0.05), such that a smaller percentage of
participants in the treatment condition engaged in alcohol consumption in the past 90 days than
those in the control condition (11.1%, n=1 versus 88.9%, n=8). Condition was not associated
with use of marijuana, tobacco, or other illicit substances, nor was it related to riding in a motor
vehicle with a driver who had consumed alcohol or other licit/illicit substances. Therefore, H
2
is
partially supported.
H
3
. Participants in the treatment condition will self-report more HIV/STI testing in the past six
months than participants in the control condition.
At immediate-post intervention, HIV/STI testing activities among study participants were
negligible; only one participant in the treatment condition and three participants in the control
condition had undergone testing. Condition was not associated with past 6-month HIV/STI
testing (χ
2
(1)=0.49, p=0.45) at 15-week post intervention; thus, H
3
was not supported.
H
4
: Participants in the treatment condition will self-report greater digital health advocacy
behaviors than participants in the control condition.
124
For this study, digital health advocacy referred to participants’ a) past behaviors in which
they direct messaged or tweeted health-related information to social media followers; and b)
willingness to intervene in social media friends’ potentially risky behaviors. At baseline, the
difference between participants in the treatment and control groups with respect to past
tweeting/DM behaviors was not statistically significant (χ
2
(1)=2.42, p=0.19); there was no
difference in participants who engaged in this behavior based on condition at immediate post (χ
2

(1)=0.95, p=0.26). The mean difference between the treatment group (M= 2.90, SD=1.38) and
control group (M= 3.40, SD=1.44) with respect to intervening behaviors was also not statistically
significant (t(96)=1.73, p=0.09). H
4
stated there would be a difference in participants’ self-
reported digital health advocacy behaviors based on condition. At immediate-post intervention,
participants in the treatment condition reported less willingness to intervene in potential risky
behaviors of their social media friends/followers than participants in the control condition
(M=2.52, SD=1.45 and M=3.19, SD=1.43, respectively). To test whether these mean differences
were significant, a repeated measures ANOVA was conducted. Using one-tailed significance,
findings indicated there was not a significant interaction between time (baseline versus
immediate post) and condition (treatment versus control) (F (1, 59)=2.24, p=0.13). Thus, the
researcher concluded H
4
was not supported.
H
5
: Participants in the treatment condition will self-report more online health information-
seeking behaviors than participants in the control condition.
Hypothesis 5 stated that participants in the treatment condition will self-report more
online health information-seeking behaviors than participants in the control condition. At
baseline, use of the Internet for health information-seeking among participants in the treatment
group (M=2.90, SD=1.11) and control group (M=2.74, SD=1.04) was not statistically
125
significantly different (t(96)=0.75, p=0.45). Statistically significant differences between the
treatment and control groups (M=2.60, SD=1.03 and M=2.37, SD=1.10, respectively) in use of
social media platforms for health information was also not found (t(95)=1.05, p=0.30). Post-
intervention means suggested participants in the treatment condition used the Internet for health-
related information more often than participants in the control condition (M=3.07, SD=1.11 and
M=2.92, SD=0.89, respectively). Similarly, participants in the treatment condition were more
likely to use social media sites for health-related information than controls (M=3.00, SD=1.10
and M=2.35, SD=0.95, respectively). Hypothesis testing was conducted using a repeated
measures ANOVA. Using one-tailed significance, findings indicated there was not a significant
interaction between time (baseline versus immediate post) and condition (treatment versus
control) for Internet information-seeking behaviors (F (1, 62)=0.48, p=0.25), but there was a
significant interaction for social media-based information seeking (F (1, 50)=6.37, p=0.01).
Therefore, simple effects probing was justified. Findings from the MANOVA indicated no
difference between groups at baseline (F (1, 58)=0.01, p=0.94), yet the difference between
groups at immediate post was significant (F (1, 58)=7.61, p=0.01) Thus, H
5
was partially
supported.
In addition to testing for intervention effects among participants in the treatment
condition compared to those in the control condition, the researcher tested the effect of time
(from baseline to immediate post) on study-related dependent variables within the treatment
condition only. Findings from paired t-tests and McNemar chi-square tests supported results
from the previous hypotheses testing. Specifically, mean increases in FWC service utilization
were statistically significant (mean difference=0.41, t(26)=1.66, p=0.055) (Hypothesis 1).
McNemar chi-square statistics were not significant for changes in risk-reduction behaviors,
126
namely past 90-day unprotected sex, past 30-day unprotected sex, marijuana use, illicit substance
use, or riding in a vehicle with an impaired driver; however, the chi-square was significant for
alcohol consumption (p=0.03) (Hypothesis 2). Binomial distributions were used for McNemar
chi-square tests of HIV/STI testing, which did not reach statistical significance (Hypothesis3).
Mean differences in treatment group participants’ willingness to intervene in potentially risky
behaviors of social media friends and followers was not statistically significant (mean
difference=-0.370, t(26)=1.12, p=0.14). Changes in direct messaging/re-tweeting behaviors from
baseline to immediate post trended towards but failed to achieve significance (p=0.06)
(Hypothesis 4). Although mean increases in participants’ use of the Internet for health-related
information did not reach significance levels, mean increases in participants’ use of social
networking sites for health-related information were statistically significant (mean
difference=0.520, t(24)= 1.96, p=0.03) (Hypothesis 5). Lastly, nearly 3 in 10 study participants
in the treatment group at immediate post reported visiting the UMMA Fremont Wellness Center
because of health content posted on one of the organization’s social media pages (28.57%).
However, only two participants in the treatment condition reported visiting the FWC because of
online health content sent directly to them from a friend/peer or online social network
connection.

UMMA Fremont Wellness Center encounter results
Study participants’ self-reports of their interactions with the Fremont Wellness Center
were supplemented by FWC data from all adolescent encounters prior to and during the
intervention period. Data presented here were from healthcare encounters for teen patients aged
14-18 years from August 18 through December 18, 2015, which corresponded with the first and
127
last school days of the Los Angeles Unified School District’s fall 2015 semester, and January 11
through June 3
23
, which corresponded with the spring 2016 semester. During the fall 2015
semester, there were 643 recorded student encounters at the Fremont Wellness Center. The
majority of these encounters were pediatric visits from new Fremont High School students
(24.9%, n=193) and pediatric follow-up visits from Fremont High School students (a distinction
made after a student’s initial FWC encounter) (21.6%, n=197). The number of FWC visits during
the spring 2016 semester (i.e., intervention period) increased nearly 25% (N=800). Again, the
majority of visits were for pediatric follow-up visits from Fremont High School students (20.7%,
n=192). New Fremont High School student pediatric follow-ups and same day/walk in visits
accounted for nearly the same share of FWC adolescent encounters (15.8% and 15.3%,
respectively). Table 4 depicts the number of care-specific encounters during the 2015-2016
academic year and percentage changes in select types of visits from Time 1 to Time 2 (see
Appendix L for a complete list of UMMA Fremont Wellness Center visit codes and their
meanings).
As shown in Table 4, the Fremont Wellness Center experienced an increase in adolescent
patients in several key indicators. With regards to medical care provided to Fremont High School
students specifically, there was a nearly 15% increase in FHS student follow-up visits
(StudPedFU); however, the percentage decrease in pediatric visits among new FHS students
(StudNewPed) was nearly one-quarter. Of particular noteworthiness was the 610% increase in

23
The LAUSD spring 2016 semester ended on June 10, 2016; however, intervention activities
ended on June 3. June 6-10 was finals week at both study sites, and students attended class for
half days. The FWC reported little student activity during the final week of the semester.
128
same-day/walk-in visits (SDV-WI)
24
(from 20 at Time 1 to 142 at Time 2) and 900% increase in
established patient behavioral health visits (from three at Time 1 to 30 at Time 2).

Table 4

UMMA Fremont Wellness Center student service provision

Percentage change values are shown for visit types with >5 encounters during both time periods

24
Adolescent patients who received same day/walk-in visits were not exclusively Fremont High
School students; however, geographic co-location with FHS combined with transportation
barriers and campus attendance policies most likely prevented students from other LAUSD
campuses from accessing the FWC during school hours for same-day visits. Therefore, it is most
likely that the data presented here reflect increases in service utilization by FHS students. This
logic also applies to the 31.25% increase in walk-in visits.

25
SDV-WI: same day visit/walk-in; FU: follow-up; FPEdu: family pact education; WI: walk in;
NP IHA: new patient initial health assessment (physical); PEDEST IHA: established pediatric
patient initial health assessment (physical); StudPedFU: Fremont High School student pediatric
follow up; StudNewPed: New Fremont High School student pediatric visit; PROC: procedure;
IZ: immunization; PED NP IHA: new patient initial health assessment (physical) pediatric
Visit Type
25
Number of Fremont Wellness Center (FWC)
Student Encounters
Percentage (%)
Change
August 18 – December 18,
2015
(N=643)
January 11- June 3,
2016
(N=800)

SDV-WI 20 142 (+) 610%
FU 71 133 (+) 87.32%
FPEdu 15 6 (-) 60%
WI 48 63 (+) 31.25%
NP IHA 16 12 (-) 25%
PEDEST IHA 31 20 (-) 35.48%
StudPedFU 167 192 (+) 14.97%
StudNewPed 193 146 (-) 24.35%
PROC 10 16 (+) 60%
IZ 11 8 (-) 27.27%
PED NP IHA 24 12 (-) 50%
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UMMA social media activity/presence
During the 2015-2016 academic year, which included the 15-week intervention period,
UMMA Fremont Wellness Center Student Health Leaders curated health content from websites
of reputable health organizations and government agencies and developed original, youth-
targeted health and wellness content specifically for the official UMMA social media accounts
(i.e., Instagram and Facebook)
26
. Student Health Leaders populated UMMA social media pages
with four types of health content: static visuals (e.g., photos, charts, graphs, memes), videos,
links to news articles, and two novela-like fictional narratives written by a member of the SHL
social media team. Youth-friendly health content was posted on either or both UMMA social
media accounts. When appropriate, content was modified based on platform-specific constraints
(e.g., video time limits). In addition to UMMA official accounts, all video content developed by
SHLs was reposted on the John C. Fremont Instagram page
27
. Table 5 provides a description of
health content developed for the digital health advocacy intervention (i.e., treatment condition).
Table 6 provides a description of social media activities per platform.
The UMMA Fremont Wellness Center’s social media presence experienced a steady
increase throughout the study period. The number of Facebook followers grew from 49 at
baseline to 442 at immediate post, with the range of post reaches from 23 to 10,774 people. The
number of Instagram followers increased from 41 to 118 during the intervention period, too. The

26
The UMMA Fremont Wellness Center maintains a Twitter account with a small number of
followers (N=29). During the study period, Student Health Leaders developed Twitter-specific
health content; however, after five weeks of content posting with no new followers and little user
engagement (e.g., likes, re-tweets), study personnel decided to abandon efforts to develop
platform-specific original content. Instead, Twitter was used to repost content from the Instagram
and Facebook accounts. Due to negligible activity on this platform (12 total likes for 66 tweets),
the report of study findings excludes Twitter.
27
Four students from Fremont High School created and maintained the John C. Fremont account
(@johncfremont) for a senior-level Leadership project. Content on the Instagram page was
updated weekly and devoted to school events, activities, and announcements.
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UMMA Fremont Wellness Center’s Instagram account was most popular with participants in the
treatment condition, with 73% at follow-up reporting following the account. 23% reported
following the Facebook account, but only 2% followed the Twitter account. Interestingly, 38%
of participants reported following the Snapchat account, although no health content was posted
on this platform during the study duration
28
. No participants in the treatment condition reported
following either the Periscope or Ask.FM accounts.

Table 5
Description of digital health content for intervention condition (N=131)
Type of health content Percentage of social media posts
Static visual 58.0%
Video 34.4%
Fictional narrative 3.8%
News article 3.8%

Social media engagement (e.g., views, likes, comments, and shares) (Marklein & Payne,
2012 as cited in Neiger et al., 2013) was measured for each type of health content on all social
media platforms. In order to assess the effectiveness of content and platform type at achieving
each level of social media engagement among the social media platforms used in this study,
Kruskal-Wallis tests were conducted. This non-parametric test was more appropriate than a one-
way ANOVA because the data presented here did not meet assumptions of normality due to

28
Snapchat has much potential as a health message delivery vehicle, and study personnel
initially believed it particularly suited for digital health advocacy among youths. Snapchat was a
social networking site SHLs wanted to use; however, logistics prohibited successful adaptation
of their content to this platform. Specifically, the limited number of SHLs on the social media
team made it difficult to develop new, creative content for this platform and avoid “talking
heads”. Additionally, SHLs reported that their peers perceive Snapchat to be a social media
platform purely for entertainment purposes and inappropriate for serious health education and
promotion activities.

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significant skew. Rejection of the null hypothesis for all Kruskal-Wallis tests justified post hoc
analyses, using the Dunn-Bonferroni post hoc method. Table 7 and Table 8 show the results of
these analyses.

Table 6

Description of social media platform activity (N=131)
Social media platform Percentage of social media posts
UMMA Fremont Wellness Center Instagram
(@ummawellnesscenter)
66.4%
UMMA Fremont Wellness Center Facebook
(@UmmaWellnessCenter
27.5%
John C. Fremont Instagram
(@johncfremont)
6.1%

Accounting for sizable percentages of the variance in likes and comments (22.26% and 23.62%,
respectively), results indicated video content was the most effective visual type at achieving each
level of social media engagement. In fact, SHLs’ original videos were the only type of health
content to achieve the highest level of user engagement (i.e., shares).
132

Findings from analyses of study-related social media activities also indicated that the John C.
Fremont Instagram page was significantly more effective at encouraging youth users’
engagement with FWC health content than the official UMMA social media accounts. Similar to
video content, this Instagram page accounted for much variance in views and likes (35.31% and
43.28%, respectively) and comments, to a lesser but still sizable extent (16.5%). The FHS
student-run Instagram account accrued statistically significantly more views, likes, and
comments than the UMMA accounts; however, the UMMA Facebook page achieved the highest
level of social media engagement.

UMMA Student Health Leader exit interview results
Data presented here are from in-person, in-depth interviews with eight of the nine
members of the Student Health Leader social media team. Several themes emerged that provide
insight into how trained peer health advocates use new media technologies, specifically social
networking sites, for innovative youth outreach. Implications of these findings for health
organizations are also explored.
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Role of social media in teens’ health information-seeking behaviors. Initially, Student
Health Leaders were skeptical if the social media-based health intervention would even work
because it required target audience members—their peers—to think about the purpose and
functions of social media differently. They didn’t believe their classmates would attend to health
content on social networking sites like Instagram and Twitter because those platforms were
perceived to be for the entertainment domain (e.g., friend updates, celebrity gossip, and general
pop culture). SHLs said they and their peers certainly didn’t think of social networking sites as
reputable health resources, and none of them followed health organizations on their personal
accounts.
LS: Kinda skeptical because, I mean, kids do use social media, but if you’re scrolling
down your news feed or whatever and you see something, like, health related, you not
going to just stop and read it.

BH: It doesn’t seem like it would be the type of place to have, like, the correct
information. ‘Cause you see a lot of memes about, you know, the pull-out game. Those
are, like, kind of humorous ways to portray it, but at the same time I didn’t actually think
you could look for information there.
However, SHLs said they were intrigued by the idea of producing original health content for
social media platforms because young people are frequent users and pseudo-captive audiences.
SHLs and Fremont High School students alike spent significant hours per day on social
networking sites. As a result, consensus among SHLs was that health content distributed via
these platforms was the best way to get young people to attend to health messages, especially
those designed with their knowledge and skills needs in mind.
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PR: And everyone’s always on their phones. And so, we’re like, uh, slowly bringing the
audience towards us, and when we have them, when we catch their attention, we throw
the information out that we want to give them.
SHLs said changing youths’ opinions of social media as acceptable health message delivery
vehicles was doable; however, their peers would be less willing to accept text-heavy information
presentations, regardless of platform. SHLs said they and their peers do not like to do a lot of
reading, in general. So, text-heavy materials about health-related topics are often even less
appealing. Even a few lines of text is “overwhelming” and “boring.” According to social media
team members, since teens are not interested in reading a lot of text, the digital content
developed in this project was effective because it provided users with credible information to
answer their general questions or sparked enough interest in a topic so that students would query
SHLs and/or make appointments at the Wellness Center.
GT: /And they knew it was right because it was, like, based on the Clinic. Since we’re
like an organization through the Clinic, I’m pretty sure they felt more comfortable relying
on us than, like, going online. Because, like you said, they could find misinformation.

Autonomous improvisation. Topics for the digital health content were decided by the
researcher based on formative research with South Los Angeles teens in accordance with a social
media strategy devised by the study team. SHLs were given full creative license to develop
digital content that would capture the attention of the target audience and provide information
within website-specific time constraints (if applicable). Student Health Leaders described their
content creation process as relying heavily on improvisation. SHLs talked about their process
being organic, relatively non-scripted, and relying on brainstorming efforts from the full team.
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Additionally, the content creation process was iterative yet quick. Word play, word associations,
and situations that SHLs had themselves been in that would be relatable to their peers catalyzed
formal content development. “Student-led” and “we’re in charge” were ideas that repeatedly
emerged in the exit interviews.
BH: As SHLs, like, we’re kinda like a family, so that’s what I really enjoyed about it.
And it’s kinda like student-led, so it’s like we’re the ones out there pushing to whatever it
is we’re trying to get across.
Although the content development process catered to team members’ creativities, the
responsibility to develop high-quality, credible health information was not lost on them. Ulma
Rodriguez, 12
th
grader and first-year SHL, summarized this point, saying, “We must keep the
health aspect of online content as the primary focus because it is easy for the message to become
lost among many ideas. We have to keep asking ourselves, ‘Are we making an informational
video or a music video? Or just a movie?’”
Digital health content normalizes health communication among youth. SHLs said
study-related digital health content was the catalyst for the development of a student norm
around health talk, which was supported by access to a school-based health center. Fremont
students became more willing to talk about visiting the Wellness Center in everyday
conversations. Word of mouth and friend testimonials encouraged students to learn more about
the medical care services and resources offered. This led to some students making appointments
to visit the medical care providers at the FWC, which, in turn, encouraged other students to visit
the UMMA Clinic. Many SHLs said despite increased online and on-campus health
communication, their peers and classmates remain reluctant to visit the FWC without personal
recommendation. By serving as liaisons between the FWC and FHS students, they fulfilled this
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function. Teens were inclined to go to peer health advocates for health-related information,
advice, and counseling. SHLs were viewed as knowledgeable, credible, accessible health
resources for their friends and FHS students in general. Since peers are oft-consulted sources of
health information, SHLs said their classmates came to them with a myriad of questions when
initial Internet searches did not provide sufficient answers. Thus, digital health content,
particularly original videos, facilitated SHLs’ peer-to-peer advocacy.
TF: Well, more of my friends talk to me about birth control and stuff.

JA: Ok. And so last year they weren’t talking to you about it, huh?

TF: Yeah. And some people were, like, awkward saying “birth control.”

JA: So, if I’m hearing you correctly, you think, like, this year because of the videos and
the social media content, you just made talking about health more normal?

TF: Mhmm.

JA: What do you think was most effective about the social media content?

LS: The fact that more people are talking about, you know, the UMMA Clinic and the
services and things like that and taking advantage of them.

Although digital health content helped normalize health conversations and increase awareness of
the Wellness Center, SHLs said stigma about FWC utilization still persists.
Impact of social media content on target audience behaviors. The primary purpose of
the social media-based project was to use original, youth-created digital health content to
encourage students’ use of FWC healthcare services. Online health content provided social
media users and account followers with consistent reminders and encouragement to go to the
Wellness Center to meet their healthcare needs. SHLs said adhering to the daily posting schedule
was key to keeping health-related issues at the forefront of users’ minds by keeping health
content in their social media timelines. This was theorized to encourage peer-to-peer health
137
communication and increase the likelihood that followers would utilize FWC services. SHLs
said that the combination of social media content and face-to-face tabling on campus was key to
increasing students’ use of the FWC. Youth who had health-related questions asked SHLs
directly in on-campus, face-to-face interactions. However, SHLs acknowledged that some
students may have been reluctant to ask personal questions of their peers. In this case, online
health content with explicit directions to visit the Fremont Wellness Center may have been
preferable. SHLs’ insights suggested a feedback loop, such that online health content activated
top-of-mind awareness of youth-specific health concerns, which prompted online queries (via
DM on social media apps), in-person questions at tabling events, or both. Students then made
appointments at the FWC based on confirmed need of medical care or health resources or
additional questions. SHLs said the digital health content led to more effective peer outreach, and
the synergy between their online and in-person outreach was key to increased use of the FWC.
According to each SHL interviewed, the study achieved that goal, although they were tentative
about quantifying the number of increased clinic visits.
GT: I honestly think it did. At least, um, for my friend. I have a friend. He’s a really close
friend. He would actually talk to me and tell me, “Oh is this really true?” about, like,
certain statistics and facts that we put out there about sexual health and stuff. He would
ask me, and I’m like, “Yeah, it’s true.” He seemed worried, and I guess he would go and
get tested.
JA: Okay. Good.

GT: I’m pretty sure more people, I’ve seen, I’ve witnessed more people go to the Clinic,
but I don’t like to assume what they’re going for. But I’m hoping, um, it’s because we
reached out to them.
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In addition, health content helped Fremont students make better, less risky decisions, particularly
with regards to safer-sex behaviors and ATOD use prevention or reduction.
LS: Because they is not going to be, like, what is that word? No knowledge of something.
Like, say for instance, they go in to having sex with their partner, and then she’s like, “I
don’t want to get pregnant.” And he’s like, “Okay. I’m just going to put on two
condoms.” She’ll be like, “No, no, no! Don’t do that.” You know, certain things they will
have knowledge of to prevent things.
Intervention effects on Student Health Leaders. Student Health Leaders said creating
the intervention content helped them lead healthier lives, particularly with respect to healthy
eating, managing interpersonal relationships (sexual health), self-monitoring, and health
maintenance. SHLs said they were more likely to visit the Wellness Center after participating in
the intervention, either as social support for friends who were nervous about going to the FWC
or for their own healthcare needs. There was consensus among SHLs on the social media team
that developing digital health content for the FWC social media accounts positively impacted
their own health-related knowledge and behavioral decision-making. SHLs said that developing
the content required them to shore up their own health knowledge. Whereas accuracy is critical
to advocacy, these peer health advocates made sure the content was correct—and in the process
cleared up their own health questions. In addition, discussions during weekly work meetings
were effective reminders to engage in healthy lifestyles (e.g., proper nutrition and exercise,
increased water intake, consistent safer-sex behaviors, managing stress and negative affect).
PR: For example, like the prom one. I was asked to go drink, but I was like, “You know
what? My friend actually is the one driving, and you know let me put myself in her
perspective. If someone is telling me to drive and not only am I driving by myself I’m
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driving with other friends, like think about it, I’m putting so many other people’s lives at
risk. Yeah, so we didn’t drink. You know, we went out to eat, go bowling. We
remembered the whole night.
For some SHLS, developing health content for their peers was a way they become more active
and engaged in campus and community activities. They took their role as content creators
seriously and believed developing social media health content was the way they could have a
direct impact on improving the health of their friends and classmates.

Implications
With near consensus, the Student Health Leaders said video content provided the most
effective health content. The messages were fun, straightforward but engaging ways of
presenting health information. Some of the SHLs said that health wasn’t part of their peers’ top-
of-the-mind awareness and they didn’t feel comfortable talking about health topics. Adolescents
are used to text-heavy, didactic health information, so original video content was a new way to
present information, using relevant language and scenarios (e.g., 15-second Netflix & chill rap,
scene depicting a drug overdose at a house party/kickback). So the key to the social media
intervention was a) normalizing health conversations among FHS students; and b) providing
novel, non- “preachy” health content that provided teens with ways to make better health
decisions.
Health organizations that are interested in youth-created digital health content must
convene a group of students who are trained in public health and health message development.
These youths should be opinion leaders in some way (e.g., involved in leadership roles on
campus, student athletes, members of extracurricular activities, or have on-campus popularity).
140
These students should also have friendly yet professional working relationships. Avoiding
cliques is important; however, content creation often requires significant time investments, so
students must enjoy being and working together. Productivity is negatively impacted if teens are
not professionally socialized to work together, and they haven’t internalized the importance of
their roles as health advocates. Additionally, adult program facilitators must strike a balance
between supervising content development for appropriateness, accuracy, and adherence to
organizational goals and micromanaging peer health advocates’ creative processes. The success
of this project was due, in part, to providing exercises and documentation to help scaffold the
SHLs and keep them on track (e.g., social media strategy, monthly calendars, and content
worksheets).

Summary
This study tested the efficacy of a youth-led, social media-based health intervention at
achieving positive behavioral outcomes (e.g., increased use of a school-based health center,
decreased risk behaviors, and increased online information-seeking and information-sharing
behaviors) among adolescents in South Los Angeles. Findings from the quasi-experimental study
with two groups (treatment and control conditions) at two time points (baseline and immediate
post) indicated the intervention resulted in more use of UMMA Fremont Wellness Center
healthcare services, less alcohol consumption, and more use of social media as health resources
among participants in the treatment condition compared to controls. FWC encounter data
supported findings from the experimental study, such that the Wellness Center experienced a
25% increase in visits among adolescent patients (aged 13-19 years), specifically a nearly 15%
141
increase in Fremont High School student follow-up visits
29
. Results from Kruskal-Wallis tests
indicated that video content was most effective at achieving each level of social media
engagement, and this pattern was statistically significant. Additional analyses revealed that the
school-affiliated Instagram account (@JohnCFremont) was significantly more likely to
encourage user engagement; however, the official UMMA Wellness Center Facebook account
was the only platform to achieve the highest level of engagement. Data from in-depth interviews
with members of the UMMA Student Health Leaders social media team reflected quantitative
study findings, namely youth-created, original digital health content is an innovative, effective
method for increasing students’ use of a school-based health center, for it commands audience
attention, normalizes peer-to-peer health communication, facilitates trained health educators’
peer-based advocacy, and increases top-of-the-mind awareness of the importance of consistent
self-monitoring and health maintenance. Based on study-related findings, the feasibility,
acceptability, and benefit of this new health intervention was established; thus, the project
warrants further development. In Chapter Six, findings from this pilot study will be interpreted
and related to areas of further research identified in key literature. Implications for this study for
future research, including further development of the digital health advocacy concept,
intervention development, and theory building will be explored. Limitations, lessons learned
from the research experience, and recommendations for healthcare organizations will also be
discussed.

29
The researcher made several attempts to gain access to the UMMA Fremont Wellness Center’s
patient encounter data beginning in April 2012 (when the electronic health record system was
implemented) in order to examine trends in adolescent patient encounters to make more robust
comparisons about student behavioral patterns; however, data requests were not granted.

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CHAPTER SIX

DISCUSSION

Introduction
Adolescents are the least likely group to seek medical care in a health provider’s office,
and current research indicates that most youths do not receive screening or preventive counseling
at rates consistent with clinical guidelines. Persistent health disparities among adolescents of
color, especially African-American and Latino youths, result in even less access to preventive
health measures (e.g., physical, mental, and sexual health screenings) and needed medical care.
Considering risky behaviors among adolescents are leading causes of their mortality and
morbidity, providing access to medical care services for young people is an important public
health issue. Whereas addressing extant medical care needs increases student health and reduces
absences based on illness, school-based health centers are uniquely positioned to provide the
screening, early detection, and secondary prevention services necessary for adolescents to
achieve age-appropriate health statuses. School-based health centers may not be the main source
of primary health care services for adolescents because of limited coverage, services offered, or
hours of operation (Mason-Jones et al., 2012). However, for underserved urban youths who
traditionally have difficulty accessing quality, comprehensive medical care services, SBHCs are
complementary to community-based health provisions, forming a network of care options for
them.
Teens frequently report that medical professionals are a trusted source of health
information; however, face-to-face communication with physicians can be awkward or
143
embarrassing, especially if the health topic is of a sensitive nature. In these instances, the Internet
is valuable in satisfying youths’ health-related information needs because the web can offer teens
the anonymity they desire. Similarly, Griffiths et al. (2006) suggest social media have the
potential to address inequality issues in healthcare access. In their review of social media-based
health interventions for adolescents, Shaw and colleagues (2015) discuss the potential “hidden
world” of adolescent social media use, highlighting the need for researchers to explore exactly
how young people use social media platforms for health-related behaviors. Considering SBHCs’
health education and promotion efforts may benefit from teens’ technological fluency and
preferences for health communication via mediated channels, research into the role of social
networking sites as message delivery vehicles for youth friendly health content is warranted.
Thus, the purpose of this study was to examine the utility of social media platforms in educating
adolescents about a variety of health topics, so they are encouraged to seek more detailed
medical advice and/or care from trained health professionals.
Specifically, the UMMA Fremont Wellness Center, a South Los Angeles-based SBHC
located in a “health hot spot” (e.g., significant percent of residents living well below the poverty
line, disproportionately high risk for obesity, diabetes, and sexually transmitted infections) and
two Los Angeles Unified School District high school campuses were sites for this research
project that sought to examine the efficacy of youth-created digital health content disseminated
through popular social networking sites as an innovative method for increasing student
utilization of SBHCs. Study outcomes included: a) increased use of the UMMA Fremont
Wellness Center’s healthcare services and resources; b) increased HIV/STI testing; c) reduced
risk behaviors (e.g., unprotected sexual intercourse, sexual initiation, ATOD use, and riding a
vehicle of a driver under the influence of alcohol and/or drugs); d) increased health-related
144
online information seeking; and e) increased peer-to-peer health information sharing and
intervening behaviors (i.e., digital health advocacy). Study outcomes for youth participants in
one of two groups (e.g., treatment and control conditions) were assessed, using behavioral
assessments given at baseline and immediate-post intervention. Hypotheses testing, comparing
participants in either condition at immediate post, was conducted using repeated measures
ANOVAs with simple effects post hoc probing or Pearson’s chi-square tests. Changes in study
outcomes for participants in the treatment condition only were assessed using paired sample t-
tests and McNemar chi-square tests. Findings from hypotheses testing are fully explicated in
Chapter Five. In this chapter, those findings are explored in relation to current literature, and
implications and recommendations for health organizations, namely school-based health centers,
are offered.

Interpretation of study findings
Student utilization of school-based health center services
The primary purpose of this social media-based health intervention was to increase
student utilization of an SBHC’s services. Results indicated that participants exposed to
intervention content sought UMMA FWC services more frequently in the previous 90 days than
participants in the control condition who were not exposed to intervention stimuli but received
standard care (e.g., on-campus health fairs, UMMA FWC health pamphlets). Although
utilization of FWC services among study participants in either condition at immediate post was
skewed toward nonuse (i.e., 0 times in the past 90 days), a greater percentage of participants in
the control condition had not received services than in the treatment condition (91.9% versus
63.0%). In addition, service provision data indicated the Wellness Center experienced a 15%
145
increase in Fremont High School student follow-up visits from the semester prior to the
intervention to the semester during intervention activities
30
. Whereas UMMA Clinic leadership
has established a goal of 40% of the FWC’s client base should be comprised of Fremont High
School students, the increase in student patient visits from the target audience lends support for
the researcher’s claim of intervention efficacy.

Study participants’ engagement in health risk behaviors
In addition to increasing student use of UMMA Fremont Wellness Center healthcare
services and resources, the current work sought to reduce participants’ high-risk health
behaviors, namely unprotected sexual activity, early sexual debut, and alcohol, tobacco and other
drug (ATOD) use. Results indicated that at immediate-post intervention there were no
differences between participants in either condition with respect to past 90-day and past 30-day
consistent safer-sex behaviors (i.e., 100% condom use at each sexual encounter). Of participants
who self-reported consistent, condom-protected sex during the past 90 days (n=10), five were in
the treatment condition and five were in the control condition; of the participants who self-
reported inconsistent safer-sex behaviors during the past 90 days (n=11), five were in the
treatment condition and 6 were in the control condition. The pattern of results was the same for
past 30-day safer-sex behaviors. Whereas the majority of students in the total sample reported

30
UMMA Fremont Wellness Center visits were coded separately for adult versus youth patient
encounters. The FWC had visit codes for students enrolled in John C. Fremont High School (to
keep track of the number of Fremont patient encounters and assess the student visit load toward
the 40% goal); however, there were no differentiating codes for Dymally High School (i.e.,
control condition site) or any other LAUSD campus. Therefore, the researcher cannot determine
the percentage change, if any, in FWC visits by Dymally High School students (including
participants enrolled in the current study).

146
never having had sexual intercourse (67.2%), the lack of sexual activity among participants in
either condition decreased the likelihood of detecting intervention effects, if they existed.
However, at immediate-post intervention, there was a statistically significant difference
between the two conditions with regards to participants’ intention to delay sexual debut (i.e.,
engage in sexual intercourse for the first time). Of the 20 participants who self-reported an
intention to begin engaging in sexual intercourse, 18 of them were in the treatment condition.
This unintended intervention effect may be attributed to maturation of study participants during
the intervention period. Although abstinence, including sexual debut delay, has been identified as
a protective sexual practice (e.g., reducing the likelihood of unplanned pregnancy, STI/HIV
contraction, and other poor health outcomes), sexual activity is part of the human developmental
stage of adolescence (Brooks-Gunn & Furstenberg, Jr., 1989). It may also be the case that
because participants in the treatment condition were exposed to digital health messages that
highlighted the importance of safer-sex behaviors, those participants who had not yet
experienced their sexual debut had enhanced self-efficacy beliefs about their ability to engage in
safer-sex practices and thus were less likely to delay sexual debut. Future work should examine
participants’ intentions to engage in safer-sex behaviors upon sexual initiation.
Overall, the ATOD risk behaviors in this sample were low. No students in the sample
self-reported tobacco use, and few reported use of marijuana or illicit substances. Due to low
baseline levels of risk behavior in the sample, the likelihood of intervention effects at immediate-
post were reduced. However, the behavioral assessment in the current work did not explicitly ask
about participants’ vaping behaviors. There is a possibility participants perceived behavioral
assessment items that referred to tobacco use were referring to traditional combustible cigarettes
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and not electronic nicotine device systems (ENDS). Future work should refine the survey
instrument to get a more accurate assessment of this kind of nicotine-related risk behavior.

Study participants’ digital health advocacy behaviors
Digital health advocacy refers to youths’ use of social media platforms to disseminate
theory-based, health-related messages to peers and social network members and intervene in
potentially risky, online behaviors. Digital health advocacy is theorized to increase youths’
health-related knowledge and alter norms about risk behaviors, including unprotected sex,
ATOD use, violence, and other risk activities, by activating social-influence mechanisms.
Sharing health information with close friends. Social media platforms, including social
networking sites, encourage users to share content; this interactive engagement is key to outreach
(Korda and Itani, 2013). In addition to satisfying health information needs, social media afford
youth the opportunity to create their own content, share with peers, and engage in peer-to-peer
learning, all of which have been identified as key to behavior change. In a study by Divecha et
al. (2012), 20% of teens said they would share sexual health tips with friends via social
networking sites, and 15% said they would share that they had taken an STD test through a social
networking site. These results indicate some teens’ willingness to engage in online sharing of
health-related information and behavior with peers—even if they do not feel comfortable
engaging in face-to-face conversations about those same topics. In the current work, differences
in willingness to share information about a host of health-related topics (e.g., ATOD, healthy diet
and nutrition, exercise, safer sex, STIs) with participants’ closest male and female friends failed
to reach statistical significance (and in most cases, means were higher for participants in the
control group); however, participants in the treatment group did report considerable willingness
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to engage in health-related information sharing. One-quarter of teens in the treatment condition
were “likely” or “very likely” to share information about sexual/reproductive health and safer-
sex behaviors with their closest female friends; this percentage increased to more than 30% for
closest male friends. Participants in the treatment condition were most willing to share
information about healthy diet and nutrition and exercise with close friends of either gender
(approximately 42%), and participants were more likely to engage in information sharing about
UMMA healthcare resources with female than male friends (33.3% and 24.0%, respectively).
Intervening in potentially risky behaviors of online friends and/or followers. In this
study, participants in the treatment and control conditions exhibited low willingness to intervene
in social media friends’ risky online behaviors, a key component of digital health advocacy. The
researcher attributes this to two main factors: participants’ age and low baseline risk in the
sample. Older adolescents (i.e., high school students) are less likely to directly intervene in the
potentially dangerous behaviors of their peers or friends, including substance use (Flanagan,
Elek-Fisk, & Gallay, 2004; see Smart & Stoduto, 1997 for an exception) and violence
(Syvertsen, Flanagan, & Stout, 2009). These studies examined adolescents’ willingness to
intervene in in-person contexts; to the researcher’s knowledge, no studies have examined older
adolescents’ willingness to intervene in online environments. Flanagan, Elek-Fisk, and Gallay
(2009) found that older adolescents only intervened in friends’ behaviors they deemed serious
(e.g., illicit substance use, potential DUI), which perhaps suggests that teens believe normative
risk behaviors among their peers (e.g., alcohol consumption, sexual activity, marijuana use) does
not warrant peer intervention—in either online or offline contexts. Additionally, a small minority
of participants in this sample engaged in risk behaviors, namely unprotected sexual intercourse,
alcohol consumption, and marijuana use; no one in the sample self-reported tobacco use.
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Therefore, participants’ relative lack of willingness to intervene in peers’ behaviors may have
been a function of having friends who also engage in few risk activities. Sample characteristics at
baseline support this idea: among participants in the treatment group, 71.1% had no friends who
consumed alcohol once per week, more than half (53.8%) had no friends who had ever used
illegal substances, and 80% said “all” or “most” of their friends did well in school.

Study participants’ online health information seeking
Data from exit interviews with Student Health Leaders suggested that the UMMA FWC
may have increased in importance in students’ information landscape (Henwood, Wyatt, Hart, &
Smith, 2003), and social media-disseminated health content may have encouraged more health
information seeking among their classmates and friends. Findings from the study supported the
SHLs’ assertions, such that participants in the treatment condition were more likely to use social
media platforms as health information resources than participants in the control condition. Jones
and Biddlecom (2011) queried whether the Internet was filling the sexual health education gap
for today’s teens and found that few teens engage in proactive searches for sexual information
and were wary consumers of the information they did find. One of the implications of this
current study is that teens’ passive reception of youth-centered health messages via popular
social media platforms may be sufficient to spark active searches of health information in more
traditional spaces (e.g., real-time conversations with trained peer health advocates and
consultations with medical care professionals at SBHCs). Social networking sites—as
unconventional yet familiar message delivery vehicles—may facilitate focused searches for
health-related information and close health information gaps. This pilot justifies continued
research in this vein.
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Evaluation of youth-created and youth-curated social media content
Social media offers an opportunity for healthcare providers to tap into existing online
communities as well as create new ones with a health and wellness focus. In this study, several
online environments were developed—with the creation of youth friendly health content—to
provide Fremont High School students and followers of UMMA FWC social media accounts
with access to answers and advice from trained peer health advocates (i.e., Student Health
Leaders). In addition to direct/private messaging functions on Facebook and Instagram, an
account on Ask.FM.com was established to provide users with an anonymous Q&A experience.
Even before the study had concluded, SHLs and UMMA FWC leadership began discussions
about how to expand the social media aspect of the organization’s student outreach. Video
content was by far a vital key to the intervention’s success. Results suggest that video content is
more likely to garner audience engagement than static, photo-based posts. Conversations with
SHLs suggested that in their experiences video content is also more effective than other types of
digital content at encouraging peer-to-peer health communication in online and offline settings as
well as intentions to begin or maintain risk-reduction activities.
Digital health content for this study was designed for adolescent and young adult
audiences, namely high school-aged teens. Student Health Leaders said they developed content
with their peers and friends in mind, most of whom had the same kinds of health-related
questions and concerns they had prior to their formal public health and digital media training.
Whereas each social media posting made explicit reference to services offered at the UMMA
Fremont Wellness Center, the digital content was most relevant to students attending schools
serviced by the FWC, which includes both the treatment condition campus (i.e., John C. Fremont
High School) and the control condition site (i.e., Mervyn M. Dymally High School). Online
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health content employed negative consequences and identity appeals, two common persuasion
strategies for youth-created health content (Krieger et al., 2013). SHLs’ online content was
authentic and reflected students’ lived realities (e.g., drinking and substance use at “kickbacks”,
fear of visiting the FWC because of misperceptions that social workers would be involved,
stigma related to visiting the FWC, and intimate partner violence among same-sex and
heterosexual couples). Members of the target audience could relate to the substance of the digital
content as well as their friends/peers in the narrative videos. Some content efficacy can also be
attributed to the relative homophily among SHLs and their peers on campus (e.g., school
enrollment, age, race/ethnicity, cultural context, and neighborhood stressors), which positioned
SHLs as credible social models and enhanced study participants’ and social media
users/followers’ identification. Although the digital health video content only featured UMMA
FWC Student Health Leaders (and Fremont HS students), the peer modeling potential of this
content persists because of similarities in demographics and environmental context among teens
in the South Los Angeles area.
Peer-to-peer health communication. Communication between peer health advocates
and target audience members was more dynamic than was initially conceptualized by the
researcher. Social media platforms afforded users the opportunity to converse in either real-time
or with protective asynchronicity about health-related topics that were relevant to them. Mano
(2014) suggests that use of online services is not preferred by some online users because the lack
of participatory health communication is seen as reducing healthcare quality. In other words, for
some patients, communication via social media apps means lower quality healthcare provision.
Findings from this pilot did not substantiate that claim. Rather, students engaged in online and
in-person communication about health-related topics prior to and after obtaining information
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from other sources, including the FWC. Communication was a cue to action that also may have
served as a catalyst for dynamic feedback loops among peers that influenced student use of the
Wellness Center over time. Similar to the ways in which HIV counseling can serve as a cue to
action for adopting safer-sex recommendations (Mattson, 1999), online and in-person peer-to-
peer communication between Student Health Leaders and their classmates and/or friends served
as cues to action for adopting healthy lifestyle activities or refraining from negative risk
behaviors.
Achieving high levels of social media engagement. Student Health Leaders said they
were not concerned that much of their original, youth-created and youth-curated health content
did not achieve high levels of social media engagement. Although social media users, including
youths, frequently share online content they find interesting, novel, or relevant as part of their
engagement with social networking sites of their choice, differences in sharing behaviors do
exist. Yang and colleagues (2010) found that male and female YouTube users differ in their
intentions to share videos. Women were more likely to share YouTube videos if they found the
platform personally useful to them; however, men were more likely to share videos if individuals
with whom the user felt close suggested the user engage in video-sharing behavior. Differences
in user engagement with social media content can also occur because of the type of content
shared, namely content about sensitive, health-related topics. This may be especially pronounced
during adolescence. Therefore, teens’ low-engagement lurking or passive following activities of
health organization sites affords them access to health messages without disclosures. Pseudo-
anonymity is afforded teens in their online interactions via the FWC’s social media accounts,
particularly through the use of social media monikers instead of real names and private, direct
messaging functions offered via the apps. Since some youth may not feel comfortable engaging
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with their peers about health-related topics in physical spaces, limited identity disclosure, and
asynchronicity offered by online interactions may lead to the kind of social compensation
necessary for effective peer-to-peer online health advocacy.
Impact of intervention activities on Student Health Leaders. Data from exit
interviews with Student Health Leaders indicated that involvement in the digital health content
creation process positively impacted their health behaviors and risk-reduction efficacy. Current
literature suggests that youth’s involvement in health-related participatory action research
activities increases their self-confidence, perceived competences, problem analysis, and ability to
create personal and professional networks of community activists (Goto, Pelto, Pelletier, &
Tiffany, 2010). Thus, moving forward, studies similar to this one should incorporate formal
assessments of study-related health outcomes as well as self-esteem, collective efficacy, and
perceived youth empowerment among peer health advocates.

Theoretical framework revisited
The Health Belief Model (Rosenstock, 1966) was initially developed to explain uptake of
medical screening services and why individuals failed to adopt preventive health behaviors. This
theoretical model was selected for the current work based on formative research with Black and
Latino teens in South and East Los Angeles about their protective and high-risk behavioral
practices. Additionally, during pre-intervention social media strategy meetings between the
researcher and UMMA Student Health Leaders, SHLs described reasons for the lack of student
utilization of Fremont Wellness Center services and persistent risky behaviors (e.g., unprotected
sex, alcohol, tobacco, and other drug (ATOD) use, and poor dietary habits) with language that
reflected Health Belief Model constructs. Thus, the HBM was accessible such that trained peer
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health educators were able to develop theory-based content according to theoretical constructs.
Despite the use of this model in many health interventions, it is not without its weaknesses. In a
recent meta-analysis, Carpenter (2010) found variance in the effectiveness of HBM constructs to
predict health behaviors. Benefits and barriers were the strongest predictors of behavior; severity
was the weakest, and susceptibility was always unrelated to behavior change. Based on findings
from the meta-analysis, Carpenter suggested that future work should abandon the four-variable
model (severity, susceptibility, benefits, and barriers) in favor of meditation and moderation
between variables.
In the current work, Health Belief Model constructs were not explicitly measured (see
Limitations section); however, the conceptual model used in this pilot study (see Chapter 3)
expanded upon the four-variable HBM to include self-efficacy, cue to action, and youth
empowerment constructs. Youth empowerment was conceptualized to bring about intermediate
behavioral changes, namely an increase in online health information-seeking and information-
sharing activities and visits to a school-based health center among participants in the treatment
condition. Additionally, youth empowerment was a critical component to positive behavioral
changes and health maintenance among the peer health advocates who developed the
intervention stimuli (e.g., digital health content). Future work should examine the relationship
between participants’ perceptions of self-empowerment and HBM constructs as well as whether
these perceived feelings of empowerment impact peer information sharing and intervening
behaviors (i.e., digital health advocacy) and risk-reduction behavioral changes.
Self-efficacy is an individual’s belief in his or her capacity to execute behaviors
necessary to produce specific performance attainments (Bandura, 1997). Participants’ self-
efficacy was addressed in intervention stimuli (e.g., digital health content) and peer-to-peer
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health communication (in online and offline contexts). Video content provided opportunities for
participants to increase self-efficacy through observational learning because each video depicted
SHLs, who are campus opinion leaders and trusted health resources, engaging in preventative or
protective behaviors and/or avoiding risky behaviors. For example, one 70-second video
explicitly addressed stigmas associated with visiting the UMMA Fremont Wellness Center.
Erroneous perceptions about the FWC persisted among Fremont High School students,
specifically that the Center was only an STD clinic and students visited the clinic because of
their STI-positive status. The video depicts three students poking fun at another for visiting the
Fremont Wellness Center, who they assume has herpes. The video showcases the angst the
student feels knowing his peers are laughing at him, which almost causes him to skip his
appointment. A FWC staff member invites the teasing students into the Center to learn more
about its resources (beyond STI treatment). Viewers are then fast-forwarded to three weeks later
when the same students who were initially poking fun at FWC visitors are themselves coming in
for appointments.
Another video depicts two teenagers kicking back on a Friday night, engaging in alcohol,
tobacco, and illicit substance use. The scene shows them laughing, dancing, texting—generally
having a good time. The female teen looks up from her texting session to notice her male friend
has passed out. She thinks he’s playing a joke on her, so she jostles his arm. He is unresponsive.
The panicked scene continues in the background while in the foreground the following text
scrolls across the screen, “These minutes are the most crucial…In these situations call 911.”
Viewers witness the female teen dialing 911 for help with one hand while holding the limp body
of her friend with the other arm. The screen fades to black, and this text scrolls across the screen,
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“If you or anybody you know is dealing with substance abuse issues the UMMA Wellness
Center is here to help. Call (323) 406-5782.”
These two examples are illustrative of the type of video content SHLs developed for the
current intervention, which sought to develop viewers’ self-efficacy through vicarious learning
experiences. By observing others’ behaviors, namely the prosocial behaviors of peer models, an
individual can develop guides that influence his or her personal behaviors. Moreover, video
content demonstrates that the target audience has the resources and/or capacity to improve their
health outcomes—if they reach out to the Fremont Wellness Center for education, counseling,
health goal-setting and maintenance plans. SHLs are effective social models because, like study
participants, they experience similar temptations. Model similarity positively impacts users’ self-
efficacy beliefs because when individuals assess a model’s capacity to be highly divergent from
their own, then the influence of the vicarious learning experience is greatly reduced. For this
reason, SHLs are effective social models for youth viewers of the digital health content, namely
study participants, because their similarity to the target audience in terms of environmental
context/constraints, social norms, and temptations to engage in high-risk behaviors helps
facilitate growth in beliefs about self-efficacy for healthy behaviors. Whereas findings from the
current pilot suggest the intervention was effective as increasing student utilization of school-
based health center services, increasing peer-to-peer health communication, and reducing risk
behaviors (i.e., alcohol consumption), future work should more fully examine how the activation
of HBM constructs and youth empowerment can lead to the achievement of study-related health
outcomes.

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Limitations of the study
Sample size
The small sample size, which resulted in an underpowered study, is the most significant
limitation of this pilot. A total sample size of 214 adolescents (107 participants per condition)
was needed for the study to be sufficiently powered at the 80% level. Despite months of
recruitment efforts, limited access to potentially eligible participants at both study sites prevented
the achievement of recruitment goals, which would have ensured that committing Type II errors
was avoided. Despite the small sample size, significant differences in some study related
outcomes were detected, such that Hypothesis 1 was fully supported; Hypothesis 2 and
Hypothesis 5 were partially supported. In addition to statistically significant differences between
the treatment and control groups at immediate-post intervention, significant patterns of
differences were also found among participants in the treatment group from baseline to
immediate post for these hypotheses. Moving forward, the researcher and study team will refine
recruitment strategies in order to increase the sample size. It is important to note that the USC
IRB-approved consent/assent documents were participation deterrents for potential study
volunteers and their parents. Students who were exposed to the researcher’s recruitment
presentation but declined to participate expressed skepticism about the incongruence between the
simplicity of the oral, in-person recruitment speech and the formality of the consent documents.
For parents with low literacy and/or little experience with social scientific research, consent
forms may have been intimidating and invited similar skepticisms. The researcher believes IRB-
approved documentation scared away some students from participating in the study, which,
ultimately, denied them access to health education opportunities.

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Potential threats to validity
Study participant selection. John C. Fremont High School was selected as the treatment
condition site due to its co-location with the UMMA Fremont Wellness Center and established
UMMA Student Health Leaders peer health educators program; thus, students who were enrolled
in this school and volunteered to participate in this study were assigned to the treatment
condition. Mervyn M. Dymally High School, the control condition site, had been a priori
designated as the control condition site; therefore, study participants enrolled on this campus
were assigned to the treatment group. It is also worth noting that the treatment and control
condition sample sizes were not equal at baseline. As such, selection bias due to the
nonrandomness of the study assignment was a potential threat to validity. Equivalency analyses
were conducted (e.g., independent samples t-tests and Pearson’s chi-square tests), which
determined that participants in either condition were not statistically significantly different from
one another in terms of demographic, health maintenance, social media activity, and risk
behaviors. Likewise, at baseline, differences between the two groups on study outcome variables
were not significant.
Cross contamination. Cross contamination posed one of the biggest threats to the
internal validity of the current work. The small geographic distance between the treatment and
control condition sites (less than one mile) and inclusion of both campuses in the Los Angeles
Unified School (LAUSD) District Fremont Zone of Choice meant that communication among
students at study sites was feasible, if not likely. An item in the immediate-post behavioral
assessment asked participants in the control condition only whether they follow any of the
UMMA Fremont Wellness Center social media accounts (e.g., Facebook, Twitter, Instagram,
and/or Snapchat). Two participants in this condition reported following one or more of the
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UMMA social media accounts on Facebook, Instagram, and Snapchat. Intervention content
exposure or contamination occurred for less than five percent of the control condition sample,
which was not significant enough to reduce the estimate of intervention effects.
Geographic co-location of the SBHC and treatment site. Another potential threat to
validity was the co-location of the UMMA Fremont Wellness Center and the treatment condition
site, which may have resulted in greater student familiarity with FWC services among students
attending Fremont High School than those attending Dymally High School, the control condition
site. Geographic colocation also made it easier for Fremont students, including study
participants, to visit the FWC during the school day. Thus, it is possible that the boost in
attendance that was found is partially attributable to co-location. Therefore, in order to mitigate
any differences in student access to FWC services, Ms. Fatima Valdez, a paraprofessional
member of the UMMA healthcare team, was stationed on the control condition campus every
Friday from 9 a.m. to 12 p.m. for 10 weeks to conduct sexual health education and counseling
and make student appointments with a FWC physician or nurse practitioner. At the end of the
study period, 20 walk-in visits with the UMMA paraprofessional were completed. Yet, only one
student from the control condition self-reported visiting the UMMA paraprofessional for health
education services or to make an actual FWC appointment.
Instrumentation. Study-related inclusion criteria required potential participants in the
treatment condition to be willing to follow UMMA FWC social networking site accounts;
however, potential participants in the control condition did not have this as an inclusion criterion
because these study participants were not going to be exposed to social media-based digital
health content. Furthermore, willingness to follow FWC social networking site accounts would
have alerted participants in the control condition to UMMA’s social media presence. Because
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UMMA’s accounts are public and anyone can follow and/or view the content, highlighting
intervention stimuli would have increased the likelihood of cross-contamination. Therefore, there
was no social media-related eligibility requirement for potential participants in the control
condition.

Measures
Another limitation of the current work is not having mediators fully measured to assess
whether intended short-term change occurred and if these changes predicted subsequent changes.
This combined with an absence of continuous variables (instead of nominal variables) to assess
actual changes in participants’ risk behaviors (e.g., number of unprotected sex acts) limited the
researcher’s ability to evaluate intervention efficacy. Self-esteem, social support, and
neighborhood issues were measured in the baseline and immediate-post behavioral assessments
because they were conceptualized to be moderators in the theoretical model; however, due to the
small sample size, which resulted in an underpowered study, moderation analyses were not
conducted. Korda and Itani (2013) highlight a challenge of using social media for behavior
change: measuring meaningful engagement. The authors note that it is difficult to distinguish
users who simply stop by a website or platform versus those who actively engage with the
content. This study attempted to address this concern by using participants’ targeted information-
sharing behaviors as an indicator of content engagement. Information sharing is one way,
particularly if youth share health-related information to members of their social network who
engage in risky behaviors identified in the media posts. However, few posts reached the highest
level of social media engagement, and self-reported, information-sharing behaviors among study
participants were low.
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Participant inattention to intervention messages
Neiger and colleagues (2012) assert that social media should not be considered a solution
to solving complex behavioral change problems or achieving health outcomes. Instead social
media should be considered a potentially effective method for creating an environment that
heightens audience awareness of health-related issues and encourages participation with an
organization’s health promotion programs and services. Some participants in the study did not
attend to social media-disseminated health content, as evidenced by 11% (n=3) of participants in
the treatment condition at immediate post reporting they did not follow any of the UMMA FWC
social media accounts. All FWC social media accounts are public, so it is possible that study
participants accessed the health messages without following the accounts; however, it is unlikely
these participants visited the UMMA Facebook and Instagram pages daily. As such, these
participants’ intervention dosages were presumably low. Non-following study participants may
have believed they are not susceptible to the health conditions addressed in the content (e.g.,
risky sexual behaviors, substance use, intimate partner violence, poor diet and lack of exercise,
mental health concerns). A significant portion of the teens in the study was behaviorally low risk
(e.g., not sexually active, not engaging in ATOD behaviors); therefore, they may have perceived
their susceptibility to negative health outcomes (e.g., unintended pregnancy, HIV/STI
contraction, drug overdose) as low. Thus, a small part of the study sample may have simply
ignored health messages (and not shared them with peers) because of the perceived absence of
personal relevance. Another limitation of this study is that the researcher was not able to isolate
the effect of social media. The researcher could not parse out the effect of the social media
component alone or a potential synergistic effect of social media messages combined with SHLs’
on-campus outreach efforts.
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Implications
One critique of web 2.0 and its “produser” phenomenon is that more lay authors create
information that contributes to information overload for lay users. Information is presented in
diverse formats on multiple platforms, resulting in end-users becoming lost in layers of
information and reliability concerns. Findings from this project suggest an interesting
workaround to information overload. Social media health messages, in the form of video
narratives and image-text posts, served as triggers that encouraged peer-to-peer dialogue between
students and trained peer health advocates. SHLs reported that their peers thwarted potential
information overload and online information credibility concerns by creating their own
information supply chain that began with social media-mediated health content, continued with
more in-depth conversations (either in person or via social media platforms) with peer health
advocates and ultimately ended with FWC staff or medical care professionals. This behavior
reflects claims in medical sociology and media studies about the diverse information ecology
from which individuals draw.

Youth leadership development
Prior literature has established the importance of incorporating youth into SBHC
decision-making, particularly when it comes to finding ways to increase student use of SBHC
services. Rafferty (2014) found that adolescent males who were enrolled in a peer leadership
program increased their leadership and health literacy skills and were able to effectively
advocate for reduced stigma associated with seeking preventative care at a SBHC among their
peers. Mandel and Qazilbash (2005) describe the success of a 34-week pilot program that
established a youth advisory board in a Boston-area SBHC. Development of the advisory board
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led to identification of SBHC gaps in services for male adolescents and overall patient needs and
development of peer leadership. Health organizations may be reluctant to invest in peer outreach
programs because development of youth leadership can be a slow process. Student leaders who
are interested in health topics require more than one-off public health training, no matter how
extensive, to become effective peer health advocates who are ready to meet the challenges of
continuous health advocacy in online and offline spaces among their peers. Unfortunately, many
school-based health interventions are still created and implemented without the full collaboration
(or even input) of youths in the target audience. Even in the case of interventions with explicit
participatory action research methodologies, the core curriculum is most likely devised without
participant input, and relevance may be less than optimal.
Peer-led health promotion interventions are received favorably by participants. Youth
express being able to relate to peer leaders they deem to be credible sources of information, who
don’t lecture of flaunt their knowledge, and are better able to understand the problems young
people face than adults (Harden, Oakley, & Oliver, 2001). Increasingly, health communication is
mediated by mobile devices. During adolescence, peers and peer-to-peer technology gain
attractiveness and relevance (Eysenbach, 2007). New media technologies, particularly social
networking sites, afford school-based peer leaders the opportunity to interact with other teens in
authentic ways. Youth who develop skills in digital content development and peer-to-peer
communication increase their efficacy to affect change in their environment, which may translate
into self-efficacy in other domains, including self-protective health behaviors (Bandura, 1977;
McAlister, Perry, & Parcel, 2008). In a systematic review of peer-led sexual health interventions,
Kim and Free (2008) arrived at a similar conclusion—there is insufficient evidence that peer-led
education improves desired behavioral outcomes (e.g., increased condom use, reduced odds of
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pregnancy or reduced odds of new sex partner). The authors did note that most interventions
improved knowledge, attitudes and intentions, and the high heterogeneity of results suggests real
differences in program efficacy among included studies. Increasing the connection between
participants and program facilitators (e.g., peer facilitators, youth advisory board members and
adult staff) increases the likelihood of internalization. Despite extant literature that suggests the
efficacy of peer leadership in helping achieve SBHC goals and objectives, to the researcher’s
knowledge there has been no study conducted to see the impact of peer health advocates
leveraging social media for health outreach. Findings from this pilot study support the need for
future research.

Lessons Learned
Lesson #1: Peer health advocates should be valued as members of a healthcare organization’s
care team.
Peer health advocates are integral parts of the healthcare provision process. The
collaborative relationship between peer health advocates and their adult supervisors is one with
great potential for co-learning, critical dialogue, skills building, and consciousness raising
(Wong, Zimmerman, & Parker, 2010). Youth health educators (i.e., Student Health Leaders) are
uniquely positioned to encourage health behavior changes because they assume dual roles:
healthcare patient and healthcare organization liaison. As such, peer health educators may also
assume the role of apomediaries, trustworthy peers who lead others to credible information or
add value to the information (Eysenbach, 2007). Apomediary credibility becomes just as
important—if not more important—than source credibility or even message credibility. This
notion is reflected in the current study. UMMA Student Health Leaders are opinion leaders on
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their high school campus; friends and peers trust them to answer pressing health-related
questions. In the current work, Fremont High School student body knowledge of SHLs’
development of social media health content created an apomediated environment, which
facilitated increased peer-to-peer health communication via social networking sites and in-person
contexts. For adolescents in particular, the shift from an intermediated to apomediated health
information-seeking environment facilitates empowerment that may positively impact the
physician-patient partnerships. Findings from this study suggest that among teens the power shift
from adult intermediaries (e.g., parents) to peer apomediaries (i.e., Student Health Leaders) may
result in increased communication and healthcare engagement, namely patient encounters with a
school-based health center. Thus, youth-serving healthcare organizations with established peer
health educator programs should consider those trained youth to be valuable members of the care
team.

Lesson #2: Peer health advocates require administrative scaffolding and oversight.
Youth health educators must be continually trained, monitored, and reminded of the
importance of professionalism when engaging in peer-to-peer health communication in online
and offline contexts. Adult supervisors should prepare youth health advocates for the
responsibilities they assume when discussing the wide range of health-related topics they will
encounter from their peers. Peer health advocates must also be trained how to engage their
friends and classmates in a professional yet authentic manner (e.g., providing accurate
information, acknowledging gaps in their own understanding, referring peers to credible online
resources/websites, encouraging peers to make appointments with medical care providers).
Youth must also be reminded that just because a message is private (e.g., direct message on
166
Facebook or Instagram) does not mean the information exchanged is secure and protected
(Grajales et al., 2014).
Leadership and staff members at youth-serving healthcare organizations, namely school-
based health centers, must realize that youth health educators are still students, so they require
adult supervision and guidance in order to get their work done. The Pluralistic-Independent
hybrid (Wong, Zimmerman, & Parker, 2010) proved effective in this study because the
researcher was able to maximize Student Health Leaders’ capacities for creative programming
and digital content creation while minimizing the negative effects their lack of expertise in
implementing a social media strategy current with their in-person outreach efforts.
Initially, the researcher invoked a true Independent type of adult-youth collaboration,
believing a hands-off approach would yield the best outcomes, considering SHLs’ familiarity
and savvy with social networking sites and online apps for editing, graphics, and visualization
enhancements. The researcher assumed that the once the social media strategy was developed
and discussed and theoretical constructs by which content was supposed to adhere was
understood, the SHLs would be able to develop content independently. The researcher was
working with the premise that adults should just get out of the way and let teens do what they do.
The result was several missed launch dates of the social media portion of the intervention. SHLs
were having a difficult time thinking about Instagram and Facebook posts from a health
advocacy standpoint, and although they were able to understand Health Belief Model constructs,
they needed assistance developing content that would activate those constructs in content
viewers. Yet, many of them failed to reach out for assistance from adult members of the research
team because they wanted to appear competent and able to act independently. Wong,
Zimmerman, and Parker (2010) suggest that youth empowerment “requires adults to be actively
167
involved in fostering conditions and opportunities for youth to develop critical consciousness”
(p. 106). Once the researcher invoked a more hands-on and supervisory Pluralistic approach to
working with SHLs, the peer health educators became more engaged and the digital content
development process became more efficient.

Lesson #3: Consistency is key to an impactful social media presence.
This lesson is often repeated in literature regarding social media activity. A consistent
presence is necessary to attract new users and maintain existing ones. In the current study, no
more than 72 hours passed without new content posts (the goal was daily). At times, this created
a significant workload on peer health advocates, many of whom were juggling honors classes,
extracurricular activities, and part-time employment. Nevertheless, the researcher and peer health
advocates agreed that not adhering to a consistent, frequent posting schedule could negatively
impact users’ perceptions of UMMA’s social media accounts, which may result in less viewing
and less access to online health content.

Lesson #4: Be flexible.
Within the context of this current work, flexibility was critical to ensuring intervention
development, implementation, and evaluation. Rigidity prevents partners in a university-
community research collaboration or adult and youth members of a research team from
capitalizing on unforeseen opportunities or making necessary adjustments to the research
protocol to avoid potential problems. Principled opportunism is applicable. This concept
highlights collaborators’ willingness to take advantage of strategic opportunities when they arise,
instead of following a formulaic plan, all while remaining true to initial principles (Wiewel &
168
Lieber, 1998). All collaborators, including youth partners, must be willing and able to adapt to
changing project components based on information gathered during the research process.
Flexibility allows collaborators to maintain fidelity to the essence of the work while adapting to
changes required by fieldwork experiences. The nature of fieldwork ensures that unexpected
things will happen (e.g., unanticipated problems with the research design, unexpected feedback
from target audience members, initial findings that contradict expectations).

Recommendations
The hallmark of this project was the use of UMMA Student Health Leaders for the design
and dissemination of youth friendly health messages on behalf of its Fremont Wellness Center.
The intervention piloted in this current work is not youth-targeted digital health content alone.
Rather, the intervention is digital health content that is curated and created by trained youths and
disseminated via popular social networking sites. The role of peer health advocates (i.e., UMMA
Student Health Leaders) is as central to the effectiveness of intervention stimuli (digital health
content) as is the dissemination vehicle (social media). Grajales and colleagues (2014) suggest
that one of the guiding principles for healthcare professionals who decide to use social media in
their professional/clinical practices is to “be authentic, have fun, and do not be afraid” (p. e13).
The current work demonstrates the importance of authentic, youth-driven health outreach using
new media technologies. Findings from this study suggest that youth-created and youth-curated
digital health content disseminated via social networking sites encouraged content engagement
and peer-to-peer health communication that catalyzed formal engagement with a school-based
health center (i.e., UMMA Fremont Wellness Center). Findings from this pilot suggest SBHCs
should incorporate peer health advocacy in their youth patient outreach efforts. Results from this
169
project indicate that social networking sites can be effective means of disseminating youth-
centric health content to adolescent audiences, which in turn has been shown to increase health-
information seeking behavior, digital health advocacy and utilization of school-based health
centers. SBHCs seeking to diversify their youth outreach methods should consider social media-
mediated content.
The work of youth researchers must be supported with appropriate human, financial, and
logistical resources (Powers & Tiffany, 2006). Youths need adult scaffolding in order to ensure
a) accuracy of digital health content; b) appropriateness of content and its adherence to a
cohesive social media strategy; c) administrative oversight (e.g., meeting deadlines, technical
troubleshooting). Moreover, health organizations must invest in that digital health content
creation (e.g., human capital, financial resources, training and online tools and software). Time is
also required for staff (e.g., adult paraprofessional, peer health educators) to develop high-quality
digital media content. Quality and accuracy parameters should be established, but youth should
be given creative liberty to develop content for their peers. In this study, this resulted in content
that was authentic to the target audience and addressed relevant topics, using language and
references unique to the users/followers. With this in mind, peer health advocates benefit from
health education refresher sessions to ensure the accuracy of online content and protect the
integrity of content creation processes. In this project, digital health content disseminated via
popular social networking sites encouraged peer-to-peer health communication; thus, it may be
assumed that in similar contexts peer health advocates will routinely be confronted with their
peers’ questions—some of which they will be unable to answer. Thus, health organizations that
decide to initiate innovative social media-based youth outreach, using youth-created digital
health content must prepare peer advocates to accurately provide health information by creating
170
infrastructure (e.g., pocket guides, Google documents, or wikis) where these youths can access
information quickly.
Having a diverse group of peer health leaders to develop content is also important. Youth
should not be from the same social “clique”—instead, peer health advocates should be recruited
based on varied backgrounds, interests, campus and community involvement, and dedication to
peer health advocacy. Establishment of peer health educator programs within school-based
health centers (SBHCs) is the kind of service innovation that may lead to organizational
performance improvements—and ultimately youth patient care. Aided by geographic co-
location, increased interactions between SBHC service providers and campus nursing staff,
including specific protocols for student referrals from the school nurse to the SBHC, is likely to
increase overall student utilization of school-centered healthcare services. However, it is
important that implementation of youth paraprofessional programs be spearheaded by trusted
medical care providers (Adler, Riley, Kwon, Signer, Lee, & Satrasala, 2003).
It is important to note that social networking site popularity is ephemeral; platforms that
are popular can be quickly usurped by newer ones. During the course of this study, the popularity
of Snapchat among adolescents at both study sites grew, which prompted conversations about
how to modify health content to attract Snapchat users. SHLs voiced concern about if the
entertainment platform was appropriate for serious health content and if platform features (e.g.,
stories disappear in 24 hours if not saved) would be conducive to achieving project aims.
Ultimately SHLs and study personnel decided tailoring content for this new platform was beyond
existing capacity. In addition, SNS features change. On August 2, 2016, Instagram added a new
feature to its platform: Instagram stories. Similar (if not a direct replica) to the hallmark Snapchat
feature, Instagram stories are 15-second live videos that disappear after 24 hours. Users can
171
choose who is able to see their stories and incorporate drawings and texts. During the study
period, several significant changes were made to the social media platforms used in the
intervention (e.g., Facebook Live, popularity-based ordering of Instagram newsfeeds, Instagram
stories), which highlights the changing nature of social media platform affordances. Healthcare
organizations, including SBHCs, should view changes to the SNS landscape with optimism. New
platforms and features create opportunities for targeted and potentially tailored social media-
mediated content. Ultimately, Altman (1995) suggests researchers and community members
must engage in critical thought about how interventions will be maintained, the future of
organizations that have modified their actions to meet research goals as part of the partnership,
and how individuals who have increased their social capital through the acquisition of
knowledge and skills will be used in the next phase of community development.

Future research
There are two dimensions of youth decision-making in social change research projects—
“authority” (autonomy of decisions) and “inclusion” (number of decisions) (London, 2002 as
cited in Suleiman, Soleimanpour, & London, 2006). This study incorporated both types of
decision-making among trained peer health advocates. Whereas study goals and objectives as
well as the research protocol were decided prior to Student Health Leaders’ implementation, the
project cannot be described as completely youth-led. However, digital health content,
specifically the narrative videos, were completely youth led. Youth health educators must be
given autonomy to develop health content in a natural, organic way. Findings from this pilot
suggest narrative videos are most effective at achieving user engagement with mediated health
messages. Future research will continue the work by Krieger and colleagues (2013) and explore
172
the praxis of narrative engagement among youth—both trained and lay—to examine how these
messages, disseminated via online platforms, can aid in health education and risk-reduction
behaviors.
Eysenbach and colleagues (2004) conducted a meta-analysis to examine the effects of
peer-to-peer communication on health outcomes, yet of the 38 studies included in the sample
only 6 directly evaluated the effect of the communication component on the outcome, making
results difficult to interpret. Whereas data from in-depth interviews with Student Health Leaders
suggests peer-to-peer communication in online and offline contexts contributed to student use of
the Fremont Wellness Center (primary outcome measure), future work should directly measure
the impact of this component. Future work should also explore the impact of youth-focused
digital health advocacy on other health issues relevant to adolescent health (e.g., stress
management, violence, injuries, sleep hygiene). Whereas peer-based social norms and friendship
groups influence youth behaviors in a variety of domains, additional studies should employ
network analysis to examine how the intervention stimuli catalyzed peer-to-peer health
communication among Fremont High School students, with specific attention to centrality of
SHLs (and other student opinion leaders) within the network. Although the current work focuses
on the digital health advocacy efforts of peer health leaders in high school, middle school
students could also be trained to engage in similar work. However, adult supervisors and medical
care professionals must be mindful of the different capacities for planning, decision-making and
activities based on the ages and cognitive developments of young people involved.

173
Conclusion
With increased frequency, individuals engage their healthcare system like consumers or
customers—adolescents are no exception. As such, school-based health centers must meet the
difficult challenge of providing comprehensive medical care service, including mental health and
reproductive health care, to youth consumers (and their parents) who may not be convinced of its
importance. Since health professionals understand and value the potential of new media
technologies to influence in-the-moment behavior change, they must be willing to work within
the social norms of youth-centric online spaces. Findings from this study indicate that social
media-disseminated health content has promise as an effective way to increase Latino and
African-American adolescents’ use of school-based health centers. Thus, social media platforms
present new opportunities for better patient-provider communication, especially among
healthcare providers and adolescents (Yonker et al., 2015). A challenge for similar research is
developing platform-specific health content considering the transient popularity of social media
sites, especially among youth whose preferences change relatively quickly. This is why it is so
important to maintain a team of peer health advocates to help healthcare organizations stay on
top of trends in youth social media use.

174
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Appendix A
UMMA Student Health Leaders Mini Public Health School Social Media Training Agenda

Communicating Health Messages via Social Media
August 11, 2015
12:30-3:00 p.m.

I. Welcome/Introductions (5-7 minutes)
a. SHL introductions! name, grade, 5 favorite accounts you follow, health
concern/interest
b. Speaker introduction
c. Provide overview of this session
i. Identity creation
ii. Branding
iii. Audience analysis
iv. Fundamentals of journalism (news values, storytelling)
v. Characteristics of social media communication
vi. Effective photojournalism
vii. Social media platforms
viii. Practice/Play

II. Identity creation (10-12 minutes)
Activity: ID worksheet
Discussion: How do teens create their identities? What characteristics describe them?
Internal versus external traits; group affiliations

[transition]
Q: What are some of your favorite brands? Why? What does it mean when someone says,
“This is part of my brand?” or “I don’t do this because it will hurt the brand?”

III. Branding (15 minutes)
Activity: Exploring favorite brands on Instagram
Discussion:
Definition: The process involved in creating a unique name and image for a product in
the consumers' mind, mainly through advertising campaigns with a consistent theme.
Branding aims to establish a significant and differentiated presence in the market that attracts
and retains loyal customers.
i. What does this definition mean to you?
ii. Would you define it differently?
b. How do people brand themselves? What do people use to convey their personal
brands? What do you do?
c. How should public health institutions brand themselves?
i. Why should public health institutions think about branding?
1. Differentiate one from another, attract target audience
2. Develop/maintain credibility, authority
3. Branding is the foundation for social media strategies
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4. It serves as a guide when creating content
5. Aids in decision making (does this help/hurt the brand? How does
this decision/content/post/visual help/hinder people in
understanding who we are?)
d. Voice!health institutions should maintain a professional, friendly tone in writing
i. This is especially important when trying to reach adolescent and young
adult audiences!some topics may be uncomfortable for young people to
discuss in face-to-face settings with adults (e.g., drugs/alcohol, sex &
sexuality, violence, mental health), so it’s important that institutional
writing is both informative and authoritative but also accessible
[transition]
So, since we’ve started talking about the audience, let’s dive in to what I think is one of the most
important components of creating effective messaging: audience analysis
Have students complete Section I of the social media worksheet

IV. Audience Analysis, sometimes called audience segmentation (12-15 mins)
Discussion:
1) What is audience analysis?-->Discovering as much as possible about an audience for
the purpose of improving communication (i.e. message delivery)
2) Why is it important?-->
a. Improved message transmission
b. Improved message acceptance & retention
c. Avoid projecting! acting on the belief that others believe as you do when they
actually may not.
3) What factors should you think about?
a. Gender
b. Race/ethnicity
c. Economic status
d. Age
e. Education
4) Q1: Think about your own health information seeking behavior (the times you went
online looking for info about any health-related topic). Did you find the information
you were looking for? Do you think it was targeted to you? What was effective? What
was missing that would have made your search more helpful/successful?
Q2: What should public health professionals know about youth like you that they
don’t? If they had this knowledge, how do you think health information would change,
be better?

V. Fundamentals of journalism (7-10 minutes)
a. Content! lesson on new values
i. Impact, consequence
ii. Timeliness
iii. Prominence or celebrity
iv. Proximity
v. Conflict or controversy
vi. Novelty
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vii. Currency or a trend
viii. Magnitude
ix. Human interest
x. Entertainment (humor)
xi. Helpfulness (news you can use)

VI. Social media communication (15 minutes)
1) 3 P’s of communication! Personalization, Presentation, and
a. Personalization: targeted content to needs of primary, secondary target audiences
b. Presentation: timely, relevant content accessible in multiple formats
c. Participation: engagement with audiences
2) Consistency!time, quality, targeted messaging
3) Official government sources are often used for content when creating social media
messages BUT it’s not as simple as copy-and-paste! Messages must be re-written for
maximum impact
a. Length per platform
b. Action words
c. Direct address (1
st
and 2
nd
pronouns! you)
4) Health messages must be science based. Messages must, MUST be accurate. Do not
sacrifice message accuracy for catchy writing. Yes, keep within text limits but make sure
you include enough key information to inform your audience.
a. Some youth may not seek additional information. When seeking health
information, they may rely on a FB post, a few tweets, etc to make a decision or
decide to find out more information! creating social media-based health
information is fun and a RESPONSIBITLTY
5) DIVERSIFY! each social media platform allows for different types of messaging (e.g.,
text, photos, memes, videos, live stream, infographics
a. The most effective method is accurate, targeted to the right audience, developed
for maximum impact (action writing), tailored to the functions of the platform

VII. Principles of Photojournalism (20 minutes)
Social media photography: Photos should show health (healthy decisions, healthy foods,
healthy activities)

Practice and Play
⎯ Divide students into groups of 3-4
⎯ 1 person will draw a health issue from a hat
⎯ Each group has 30 minutes to create a social media strategy
⎯ Create content for 3 major platforms (FB, IG, Twitter) + 1 of their choice (Snapchat,
Periscope)
⎯ Present the strategy & content to peers

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Appendix B
University of Southern California Institutional Review Board Approval Letter

217
Appendix C
University of Southern California Institutional Review Board Renewal Letter

218
Appendix D
Los Angeles Unified School District Committee for External Research Review Approval Letter

219
Appendix E
UMMA Student Health Leader Social Media Strategy Pre-planning Worksheet

SOCIAL MEDIA COMMUNICATIONS STRATEGY WORKSHEET
Adapted from the CDC Social Media Toolkit

Directions: In small groups, use this worksheet to help you create a strategy to brand and promote the
UMMA Wellness Center via popular social media platforms (FB, IG, Twitter, Snapchat, etc.).

I. Target Audience
Describe the person(s) you want to reach with your health messages. Be as SPECIFIC as
possible. More than one audience may be listed. Include a primary and secondary (influencers)
audience if appropriate.

Target audience #1: ____________________________________________________________

Why is this audience important?: ___________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Target audience #2: _____________________________________________________________

Why is this audience important?: ___________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Target audience #3 (influencer): ___________________________________________________

Why is this audience important?: ___________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________
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II. Determine your objective
What do you want to achieve through your social media communication outreach? What do you
want the target audience(s) to do as a result of seeing your messages?
1)

2)

3)

4)

5)

III. Audience analysis! defining communication & health needs
Think about your target audience(s). What are communication habits? For instance, what
platforms do teens like you use? When/what time? How many times per day? Where?

Use the space below to describe the best strategy for reaching your audience, keeping in mind
their social media habits.

What are their health information needs?

IV. Define social media activities
Now that you’ve identified the target audiences, their characteristics and health information
needs, what are you going to say? What messages should be delivered to achieve your
objectives? What online activities will get your audience(s) interacting with you and other
followers? BRAINSTORM BELOW! Remember, this is just a brainstorming activity. Write
down anything/everything that comes to mind!
221
V. Identify social media tools

All social media platforms are not created equally. Users have their favorites. It’s your job to
determine which platform will best convey your health message to your target audience. Match
messages/activities from above with the platform that is most appropriate for the activity.

Facebook:

Instagram:

Twitter:

Snapchat:

222
Appendix F
UMMA Student Health Leader Digital Health Content Worksheet

223
Appendix G
Web links to UMMA Fremont Wellness Center Digital Health Content (intervention stimuli)

Digital Health Content on Facebook (www.facebook.com): @UMMA Wellness Center
Video content: https://www.facebook.com/pg/UmmaWellnessCenter/videos/?ref=page_internal

Photo content: https://www.facebook.com/pg/UmmaWellnessCenter/photos/?ref=page_internal

Digital Health Content on Instagram (www.instagram.com): @ummawellnesscenter
All content: https://www.instagram.com/ummawellnesscenter/

224
Appendix H
Behavioral Assessment for Study Participants
STUDENT HEALTH QUESTIONNAIRE
University of Southern California
Annenberg School for Communication & Journalism

UMMA Wellness Center at Fremont High School
&
Los Angeles Unified School District

Tear off this page when told do to so
225
Instructions for Students

We are asking you to complete this survey so we can learn how to use resources, including social
media, to improve services at the UMMA Wellness Center.

This survey asks questions about your general health, social media use and self-esteem. There
are also questions about sexual behavior.

You do not have to answer any questions that make you feel uncomfortable. Your participation is
voluntary. It is YOUR CHOICE to answer the questions on this survey. Your grades in school
will not be affected by answering this survey.

Your answers will be private. No one at your school will know your answers. No one will
contact your parents, teachers or school administrators based on your responses to this survey. It
is very important that you answer every question truthfully.

When you are finished, raise your hand. The researcher will collect the survey and provide
compensation.

Thank you for your help!

MARKING INSTRUCTIONS

" Mark your answers with a black or blue pen or #2 pencil
" Make dark marks that fill the box
" Erase cleanly any mark you change (pencil) or draw a single line through the mark (pen)
" Make no stray marks on the survey, please

Please turn page and begin !

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Instructions:
Read each question carefully. Mark your answer in the square next to the question. Mark one
answer for each question, unless the instructions say to mark more than one answer.

BACKGROUND INFORMATION

PLACE STICKER WITH YOUR UNIQUE ID NUMBER HERE!

[DEMOGRAPHIC INFORMATION: Q1-Q6]

1. What is your gender? Circle One: Male Female Transgender Other

2. How old are you today? Circle One: 12 13 14 15 16 17 18+

3. What grade are you in? Circle One: 9
th
10
th
11
th
12
th

4. What is your race and/or ethnicity? (Mark the boxes for all that apply)
❏ Black or African American
❏ White
❏ Latino/Hispanic/Chicano
❏ Middle Eastern
❏ Native American or American Indian, Alaskan Native
❏ Asian, South Asian or Pacific Islander
❏ Other (please list) _________________________

5. During the past 12 months, how would you describe your grades in school?
❏ Mostly A's
❏ Mostly B's
❏ Mostly C's
❏ Mostly D's
❏ Mostly F's
❏ None of these grades

6. Who do you live with? (Check one box only)
❏ I live with both of my parents
❏ I live with my mother only
❏ I live with my father only

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❏ I live with other relatives/guardian(s)
❏ I live in a group home or shelter
❏ I am currently homeless
❏ Other/Refuse to answer
[HEALTH STATUS: Q7-Q10]
7. In general, how would you rate your health?
❏ Excellent
❏ Very good
❏ Good
❏ Fair
❏ Poor

8. When was the last time you saw a physician for a check-up, routine exam, follow-up appointment, or
other procedure?
❏ During the past 12 months
❏ Between 12 and 24 months ago
❏ More than 24 months ago
❏ Never

9. (For females only) Do you use any kind of birth control (e.g., oral contraceptive pills, IUD,
hormone patch, Depo-Provera shot)?
❏ Yes
❏ No
❏ I’m not sure

10. Did you complete a health screening survey in your PE class this semester?
❏ Yes
❏ No
❏ I’m not sure

[UMMA FREMONT WELLNESS CENTER USE: Q11-Q12]

11. Have you ever received medical care services from the UMMA Fremont Wellness Center?
❏ Yes
❏ No

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12. In the past 3 months, how many times have you visited the UMMA Fremont Wellness Center
for any kind of health care or medical services, including counseling or testing?
❏ 0 times
❏ 1 time
❏ 2 times
❏ 3-6 times
❏ 7-10 times
❏ 10+ times

13. Do you follow any of the UMMA Fremont Wellness Center social media accounts (e.g.,
Facebook, Twitter, Instagram, and/or Snapchat)?
❏ Yes
❏ No
14. This semester, have you visited the UMMA Fremont Wellness Center because of something
you saw posted on one or more of the Center’s social media accounts?
❏ Yes
❏ No

15. This semester, have you visited the UMMA Fremont Wellness Center because a friend sent
you something that was posted on one or more of the Center’s social media accounts?
❏ Yes
❏ No

FRIENDS

16. Who are your closest female friends at Fremont? Name up to 5 people. Please include their
first AND last names.

1) ___________________________ 3) ___________________________ 5) _______________

2) ___________________________ 4) ___________________________

17. Who are your closest male friends at Fremont? Name up to 5 people. Please include their
first AND last names.

1) ___________________________ 3) ___________________________ 5) _______________

2) ___________________________ 4) ___________________________

229
18. Among the people you consider to be your closest friends, how many would you say…?

None A few Some Most
All
Drink alcohol once a week or more ☐ ☐ ☐ ☐
☐
Have used illegal drugs ☐ ☐ ☐ ☐
☐
Do well in school ☐ ☐ ☐ ☐
☐
Get into trouble at school ☐ ☐ ☐ ☐
☐

SOCIAL MEDIA USE

[SOCIAL MEDIA ACTIVITY: Q19-Q29]
19. What is your experience with social media (e.g., Twitter, Instagram, Facebook, Snapchat)?
❏ I have tons of experience!
❏ I feel comfortable with social media.
❏ I’ve heard about it, but I don’t use social media.
❏ I don’t know anything about social media.
❏ Not sure/ Rather not say

20. On average, how many hours per week do you use social media?
❏ 0-2 hours
❏ 3-5 hours
❏ 6-8 hours
❏ 9-10 hours
❏ 10+ hours

21. Have you ever…? (Check all that apply):
❏ Sent or received text messages on a cell phone
❏ Visited a social networking site such as Facebook or Instagram
❏ Chatted online through instant messaging or a similar program
❏ Used video chat, such as Skype, Facetime, Google Chat, or iChat with video
❏ Sent or received a Twitter message (or tweet)
❏ Used Tumblr
❏ “Checked in” with a location service on your cell phone, like FourSquare or Loopt
❏ Written a blog or commented on someone else’s blog
230

22. What social networking site do you mainly use? (Check all that apply)
❏ Facebook
❏ Instagram
❏ Twitter
❏ Snapchat
❏ GooglePlus
❏ Periscope
❏ Other (please list) _______________________

23. About how many times a day do you check your social networking site?
❏ 2-5 times
❏ 6-10 times
❏ 11-15 times
❏ 16-20 times
❏ 21-25 times
❏ 26-30 times
❏ More than 30 times a day

24. How often do you post things to your own or someone else’s social networking site?
❏ Several times a day
❏ Once a day
❏ Several times a week
❏ Once a week
❏ Less than once a week

25. Do you currently have a Twitter account?
❏ Yes
❏ No
❏ I don’t know

26. About how many people do you follow on Twitter, if any?
❏ None
❏ 1-100
❏ 101-200
❏ 201-300
231
❏ 301-400
❏ 401-500
❏ More than 500 (please write in the approximate number) ____________

27. About how many people follow you on Twitter, if any?
❏ None
❏ 1-100
❏ 101-200
❏ 201-300
❏ 301-400
❏ 401-500
❏ More than 500 (please write in the approximate number) ____________

28. About how many people follow you on Instagram, if any?
❏ None
❏ 1-200
❏ 201-400
❏ 401-600
❏ 601-800
❏ 801-1000
❏ More than 1000 (1k) (please write in the approximate number) ___________

29. About how many times a day do you send or receive Twitter messages?
❏ 2-5
❏ 6-10
❏ 11-15
❏ 16-20
❏ 21-25
❏ 26-30
❏ More than 30 times a day

[DIGITAL HEALTH ADVOCACY: Q30-31]
30. Have you ever re-tweeted or direct messaged (DM) a health-related message to one, more
than one or all of your Twitter followers?
❏ Yes ☐ No ☐ I don’t know

232
31. How likely are you to get involved if one of your social media “friends” posted a message
about them engaging in risky behavior (e.g., alcohol or drug use, driving while under the
influence of drugs or alcohol, risky sexual behavior, violence, or criminal activity)?
❏ Very unlikely
❏ Unlikely
❏ Neutral
❏ Likely
❏ Very likely
[ONLINE HEALTH INFORMATION SHARING: Q32-Q33]

32. Think about your five closest female friends at Fremont (the friends you named in Q12).
How likely are you to share information via social media (e.g., Facebook message, Twitter DM,
Instagram tag) about the following health-related topics…?

Very unlikely Unlikely Neutral Likely Very
likely
Sexual/reproductive health ☐ ☐ ☐ ☐ ☐
Unplanned pregnancy prevention ☐ ☐ ☐ ☐ ☐
Safer sex behaviors ☐ ☐ ☐ ☐ ☐
HIV/STD prevention ☐ ☐ ☐ ☐ ☐
Healthy diet and nutrition ☐ ☐ ☐ ☐ ☐
Exercise ☐ ☐ ☐ ☐ ☐
Mental health ☐ ☐ ☐ ☐ ☐
Drugs and alcohol ☐ ☐ ☐ ☐ ☐
UMMA Wellness Center resources ☐ ☐ ☐ ☐ ☐

33. Think about your five closest male friends at Fremont (the friends you named in Q13). How
likely are you to share information via social media (e.g., Facebook message, Twitter DM,
Instagram tag) about the following health-related topics…?

Very unlikely Unlikely Neutral Likely Very
likely
Sexual/reproductive health ☐ ☐ ☐ ☐ ☐
Unplanned pregnancy prevention ☐ ☐ ☐ ☐ ☐
Safer sex behaviors ☐ ☐ ☐ ☐ ☐
HIV/STD prevention ☐ ☐ ☐ ☐ ☐
Healthy diet and nutrition ☐ ☐ ☐ ☐ ☐
Exercise ☐ ☐ ☐ ☐ ☐
Mental health ☐ ☐ ☐ ☐ ☐
Drugs and alcohol ☐ ☐ ☐ ☐ ☐
UMMA Wellness Center resources ☐ ☐ ☐ ☐ ☐

233
SOCIAL MEDIA IN DAILY LIFE

[SOCIAL MEDIA INTEGRATION: Q34-Q43]

The following questions refer to Facebook; however, if you prefer another social networking
site, like Twitter or Instagram or Snapchat, then answer the questions with that site in mind.

34. I feel disconnected from friends when I have not logged into Facebook.
❏ Strongly disagree
❏ Disagree
❏ Neither agree nor disagree/Neutral
❏ Agree
❏ Strongly agree

35. I would like it if everyone used Facebook to communicate.
❏ Strongly disagree
❏ Disagree
❏ Neither agree nor disagree/Neutral
❏ Agree
❏ Strongly agree

36. I would be disappointed if I could not use Facebook at all.
❏ Strongly disagree
❏ Disagree
❏ Neither agree nor disagree/Neutral
❏ Agree
❏ Strongly agree

37. I get upset when I can’t log on to Facebook
❏ Strongly disagree
❏ Disagree
❏ Neither agree nor disagree/Neutral
❏ Agree
❏ Strongly agree

38. I prefer to communicate with others mainly through Facebook
❏ Strongly disagree
❏ Disagree
234
❏ Neither agree nor disagree/Neutral
❏ Agree
❏ Strongly agree

39. Facebook plays an important role in my social relationships
❏ Strongly disagree
❏ Disagree
❏ Neither agree nor disagree/Neutral
❏ Agree
❏ Strongly agree

40. I enjoy checking my Facebook account
❏ Strongly disagree
❏ Disagree
❏ Neither agree nor disagree/Neutral
❏ Agree
❏ Strongly agree

41. I don’t like to use Facebook
❏ Strongly disagree
❏ Disagree
❏ Neither agree nor disagree/Neutral
❏ Agree
❏ Strongly agree

42. Using Facebook is part of my everyday routine
❏ Strongly disagree
❏ Disagree
❏ Neither agree nor disagree/Neutral
❏ Agree
❏ Strongly agree

43. I respond to content that others share using Facebook
❏ Strongly disagree
❏ Disagree
❏ Neither agree nor disagree/Neutral
235
❏ Agree
❏ Strongly agree
❏
NEIGHBORHOOD ISSUES

Below is a list of problems that could happen in any urban area. Now think about your
neighborhood.

44. How much of a problem are these issues where you live?
Not a problem Some problem Serious
problem
Litter in the streets ☐ ☐ ☐
Smells and fumes ☐ ☐ ☐
Walking around after dark ☐ ☐ ☐
Problems with dogs ☐ ☐ ☐
Noise from traffic or other homes ☐ ☐ ☐
Lack of entertainment for youth ☐ ☐ ☐
Traffic and road safety ☐ ☐ ☐
Places to shop ☐ ☐ ☐
Vandalism ☐ ☐ ☐
Disturbances by neighbors (adult or youth) ☐ ☐ ☐

RISKY BEHAVIORS

[ATOD USE: Q45-Q53]

Circle one. Answer as honestly as possible. Your answers will not be shared with anyone.

45. During the past 3 months, did you drink any alcohol (more than a few sips)?
YES NO

46. During the past 3 months, did you smoke any marijuana or “weed”?
YES NO

47. During the past 3 months, did you use any tobacco products?
YES NO

48. During the past 3 months, did you use anything else to get high? “Anything else” includes
illegal drugs, over the counter and prescription drugs, and things that you sniff or huff.
YES NO

49. Have you ever ridden in a car driven by someone (including yourself) who was high or had
been using alcohol or drugs?
YES NO

236
50. Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
❏ I have never used alcohol or drugs
❏ Yes
❏ No

51. Do you ever forget things you did while using alcohol or drugs?
❏ I have never used alcohol or drugs
❏ Yes
❏ No

52. Do your family members or friends ever tell you that you should cut down on your drinking
or drug use?
❏ I have never used alcohol or drugs
❏ Yes
❏ No

53. Have you ever gotten into trouble while you were using alcohol or drugs?
❏ I have never used alcohol or drugs
❏ Yes
❏ No
SEXUAL HEALTH EDUCATION

54. From where do you get the majority of your information about sex, sexuality, and
relationships? (Check all that apply)
❏ school classes
❏ friends
❏ parents or family elders
❏ older siblings, cousins, or similar family (or family equivalent)
❏ cultural values
❏ media (television, radio, YouTube videos, Facebook, etc.)
❏ internet searches (Google, Yahoo, etc.)
❏ other (please list)_____________________________________

55. How many times have you had classes in school that taught you about the following topics?
Never Once Twice 3-4 times
5+
Alcohol and drugs ☐ ☐ ☐ ☐
☐
237
Sexuality ☐ ☐ ☐ ☐
☐
The importance of nutrition/diet ☐ ☐ ☐ ☐
☐
The importance of exercise ☐ ☐ ☐ ☐
☐

[SEXUAL COMMUNICATION: Q56-Q57]

56. In the past 6 months, how often have you and your parent(s) talked about the following
things?
Never Rarely Sometimes
Often
Sex ☐ ☐ ☐
☐
How to use condoms ☐ ☐ ☐
☐Protecting yourself from HIV/STDs ☐ ☐
☐ ☐
Protecting yourself from becoming pregnant ☐ ☐ ☐
☐
Postponing or not having sex ☐ ☐ ☐
☐
Peer/sexual pressure from a dating partner ☐ ☐ ☐
☐

57. In the past month (30 days), have you been able to talk openly to a friend, family member or
boyfriend/girlfriend about sexuality?
❏ Yes
❏ No
❏ I’m not sure

[SEXUAL SELF-EFFICACY: Q58]

58. In the last month, have you been able to say “no” to unsafe sexual behaviors?
❏ Yes
❏ No
❏ I’m not sure

238
SEXUAL BEHAVIORS
The next set of questions asks about your sexual experiences and other recent behaviors.

[SEXUAL BEHAVIORS: Q59-65]

59. Did you begin having sexual intercourse (e.g., become sexually active for the first time, lose
your virginity) this semester?
❏ No, I had already begun having sexual intercourse before this semester began
❏ No, I did not begin having sexual intercourse this semester
❏ Yes, I began having sexual intercourse this semester

60. Having sexual intercourse is a “cool” thing for a boy or girl at my school to do.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

61. Have you had sex in the past 3 months?
❏ I have never had sex
❏ Yes, I have had sex in the past 3 months
❏ No, I have not had sex in the past 3 months

62. Have you had sex in the past month (30 days)?
❏ I have never had sex
❏ Yes, I have had sex in the past month
❏ No, I have not had sex in the past month

63. The last time you had sex (sexual intercourse), which of the following did you use? (check
all that apply)
❏ I have never had sex.
❏ used nothing
❏ condoms
❏ birth control pills
❏ Depo-Provera (injectable birth control/ a “shot”)
❏ withdrawal or pull-out
❏ I don’t know
❏ Other ____________________________
239

64. Have you consistently used condoms (100%, condom each time you had sex) during the last
3 months?
❏ I have never had sex
❏ Yes, I have used condoms consistently in the past 3 months
❏ No, I have not used condoms consistently in the past 3 months

65. Have you consistently used condoms (100%, condom each time you had sex) during the last
month (30 days)?
❏ I have never had sex
❏ Yes, I have used condoms consistently in the past month
❏ No, I have not used condoms consistently in the past month

STD TESTING BEHAVIORS
Remember, your answers will not be shared with anyone. Please answers openly and
honestly.

[HIV/STD TESTING BEHAVIORS: Q66-Q68]
66. Have you ever (in your lifetime) been tested for a sexually transmitted infection (STI)?
❏ Yes
❏ No
❏ I don’t know

67. Have you been tested for an STI in the last six months?
❏ I have never been tested for an STI
❏ Yes
❏ No

68. Select the reason(s) you did not get tested for your STI-related symptoms. (Check all that
apply)
❏ I have not experienced STI-related symptoms
❏ I did not ask for an STI or HIV test at my most recent doctor visit
❏ I do not have insurance
❏ I cannot afford the out-of-pocket costs
❏ I do not have a doctor or healthcare provider
❏ I do not know where to get an STI test
❏ I thought I had to get my parent’s permission since I’m under 18
❏ I assumed the doctor or health care provider would test me without me asking him/her
240
❏ I was afraid someone would see me visiting the health department STI clinic
❏ I was/am not convinced my test results would remain confidential. I don’t want my
business to get out.
❏ Language barriers or inability to understand medical paperwork

PERSONAL VIEW ABOUT YOURSELF & FAMILY/FRIENDS

[SELF-ESTEEM: Q69-Q78]
69. On the whole, I am satisfied with myself.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

70. At times, I think I am no good at all.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

71. I feel that I have a number of good qualities.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

72. I am able to do things as well as most people.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree
241

73. I feel I do not have much to be proud of.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

74. I certainly feel useless at times.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

75. I feel that I’m a person of worth, at least on an equal plane with others.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

76. I wish I could have more respect for myself.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

77. All in all, I am inclined to feel that I am a failure.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

242
78. I take a positive attitude toward myself.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

[SOCIAL SUPPORT: Q79-Q88]
79. There is a special person who is around when I am in need.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

80. There is a special person with whom I can share my joys and sadness.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

81. My family really tries to help me.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

82. I get the emotional help and support I need from my family.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree
243

83. I have a special person who is a real source of comfort to me.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

84. My friends really try to help me.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

85. I can count on my friends when things go wrong.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

86. I can talk about my problems with my family.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

87. I have friends with whom I can share my joys and sadness.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

244
88. There is a special person in my life who cares about my feelings.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

[YOUTH EMPOWERMENT: Q89-Q94]

89. I feel that I could work with other young people and adults in my neighborhood to make it
better
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

90. Young people my age are able to make a difference in my school
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

91. Young people my age are able to make a difference in my neighborhood
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

92. I feel that I could work with teachers and principal(s) in my school to make it better
❏ Strongly disagree
❏ Disagree
❏ Neutral
245
❏ Agree
❏ Strongly agree

93. If I felt strongly about an issue, I would talk to people in power (such as the mayor, school
board, city council, etc.) about my opinion.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

94. If I felt strongly about an issue in my school or neighborhood, I would use social media to
make my voice heard.
❏ Strongly disagree
❏ Disagree
❏ Neutral
❏ Agree
❏ Strongly agree

END OF THE STUDENT HEALTH QUESTIONNAIRE

THANK YOU!

246
Appendix I
Safety Plan for Minor Study Participants

1. Monitoring
The PI and UMMA Wellness Center health lead Rosario Rico will monitor all UMMA Clinic
social media accounts multiple times per day (e.g., late morning, early afternoon/after school,
evening, late night). Frequent monitoring of social media pages will ensure the PI and UMMA
Wellness Center staff are aware of questionable, inappropriate or concerning behavior in a timely
manner. Student Health Leaders (SHLs) will receive many hours of social media training to
prepare them to provide professional responses to peers’ online questions or comments. If a SHL
believes a user has unwittingly “overshared” (e.g., disclosed more information than intended),
the SHL will send a PI-approved direct message to the user, asking if the candid post was
intended. This allows a user to edit or remove the content, if they desire. Student Health Leaders
will also be responsible for alerting the PI (within 24 hours of a post) of any users’
activities/communication that are cause for inquiry or investigation.

2. Content removal
It is standard practice to remove any incendiary language or offensive images. The monitoring
protocols outlined above will ensure that the PI is alerted of content that is racist, sexist,
homophobic, of a bullying nature or otherwise offensive to friends/followers. A user’s first
offense will result in the content/comment he or she posted being promptly removed. The second
offense will result in the friend/follower being blocked, effectively preventing the user from
posting content on the UMMA Clinic’s page for that particular social media platform. In the
event that an offender’s content is especially egregious or he or she seems to be actively
encouraging a negative online environment, this user will be blocked from all of UMMA’s social
media accounts. Content removal, when necessary, is critical to maintaining UMMA’s pages as
safe spaces for peer-to-peer communication about relevant health topics. In all content removal
cases, the PI will take a screenshot of the offending post/comment(s)/image (if possible) and
store it in a locked container with other study-related documents (e.g., consent/assent forms).
The PI will provide any content that is removed to UMMA Wellness Center/study personnel.

3. Individual intervention
In the event someone discloses information online that indicates that person is in distress, a
Student Health Leader will immediately contact the PI via phone call and/or text. The PI will
then immediately contact the user through the social media platform using the most discreet
function available. For instance, Facebook has an instant messaging functionality that works in
real-time. Depending on an individual’s settings, direct messages sent from Twitter, Instagram
and Snapchat will signal alerts on their smartphone. The point is that the PI will contact the user
immediately upon notification and inquire about his or her mental or physical state. If it is
determined that the individual is in a dire circumstance, 911 will be contacted on the individual’s
behalf. In less than life-threatening situations, the PI will direct message the user to obtain
contact information (e.g., email and phone number) for him or her that will be used to send
resource materials and medical care referrals.

If a Fremont HS student (particularly a study participant) discloses information that indicates he
or she is in distress, the PI will immediately contact (via telephone) UMMA Wellness Center
247
staff (i.e., Rosario Rico) and inform her of the emergency. Ms. Rico will then log on to the
appropriate social media platform, direct message the student and ask if it is okay to contact him
or her via telephone. Rico will engage in a brief, private conversation in order to provide the
student with hotline resources that will connect him or her with trained professionals that will
assist in the moment and can also provide resources/referrals for specialized care. Ms. Rico will
notify the PI (via email) of the occurrence for documentation purposes.

248
Appendix J
Description of Thematic Analysis Process for UMMA Student Health Leaders In-depth
Interviews

Phases of thematic analysis

Phase

Description of the process
1. Familiarizing yourself with your data Transcribing data (if necessary), reading and
re-reading the data, jotting down initial ideas.
2. Generating initial codes: Coding interesting features of the data in a
systematic fashion across the entire data set,
collating data relevant to each code.
3. Searching for themes: Collating codes into potential themes,
gathering all data relevant to each potential
theme.
4. Reviewing themes: Checking if the themes work in relation to the
coded extracts (Level 1) and the enter data set
(Level 2), generating a thematic ‘map’ of the
analysis.
5. Defining and naming themes: Ongoing analysis to refine the specifics of each
theme and the overall story the analysis tells,
generating clear definitions and names for each
theme.
6. Producing the report: The final opportunity for analysis. Selection of
vivid, compelling extract examples, final
analysis of selected extracts, relating analysis
back to the research question and literature,
producing a scholarly report of the analysis.
Source: Braun & Clarke (2006)

249
Appendix K
UMMA Student Health Leaders Exit Interview Guide

Exit interviews with UMMA SHL Social Media Team

1. Why did you want to become/remain a Student Health Leader? What about the position
was most attractive to you?

2. [for those who were initially selected to be apart of the social media team] You were
selected to be a part of the social media team.
a. Probe #1: What did that initially mean to you?
b. Probe #2: Did you think social media could be an effective way to education teens
about health issues? Why or why not?

3. Compared to your peers/students your age, how would you compare your social media
use?

4. Have you ever used social media for health information-seeking or social support? In
other words, have you used popular social media platforms to find out information or
connect with people online about the problem or issue?
a. Probe #1: If so, which platform(s)?
b. Probe #2: Did you find what you were looking for? Was the information helpful?
Credible?
c. Do you think your friends/peers use social media for health information [before
this year]?

5. Where do you think your peers/friends/classmates get their health-related information?
a. Probe #1: Do you think the UMMA/Fremont Wellness Center is where they get
none/some/most/all of their health information?
b. Probe #2: Do you think students obtained information from the social media
accounts, by going into the clinic, both, or none of those ways?

6. How do you think the UMMA social media content impacted Fremont students’ health
awareness?
a. Probe #1: Do you think the content encouraged students to talk about health-
related issues?
b. Probe#2: Do you think the content encouraged students to make appointments at
the FWC?

7. What do you think was most effective about the social media content? Why?
a. Probe #1: Is there any particular aspect of social media content (e.g., type of
videos, subject matter, timing of post, etc.) that made it more effective?

8. What do you think was least effective? What could have made this aspect better?

250
9. What did you enjoy most about being part of the content-creation process? What did you
like the least?

10. Do you follow the UMMA accounts? Why or why not?
a. Probe #1: What made you “like” or comment on a post?

11. Did creating the health content for social media impact your own health awareness or
behavior? Why or why not?

12. Anything else you’d like to add?

251
Appendix L
Legend: UMMA Fremont Wellness Center visit codes

Visit Type Code Meaning
SDV-WI Same day visit/walk in

FU

Follow up

FPEdu

Family pact education

LAB

Laboratory testing
PAP

Pap smear

WI

Walk in

NP IHA New patient initial health assessment (physical)

PEDEST IHA

Established pediatric patient initial health assessment
(physical)

StudPedFU

Fremont High School student pediatric follow up

StudNewPed

New Fremont student pediatric visit

PROC

Procedure
BCEdu

Birth control education

BCRO

Birth control refill only

NPBH

New patient behavioral health visit

EstBH

Established behavioral health visit

PREG

Pregnancy visit

OBC

Obstetric care

PED FU

Pediatric follow up

FPFU Family pact follow up

IZ

Immunization

252
PPD

PPD placement

PPDR

PPD reading

STD

STD visit
PED NP IHA New patient initial health assessment (physical)
pediatric
EST IHA Established patient initial health assessment
(physical)
HealthED Health Education

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Asset Metadata

Creator Anderson, Janeane Nicole (author)

Core Title School-based Health Centers 2.0: Using social media to increase utilization of UMMA Wellness Center Services

School Annenberg School for Communication

Degree Doctor of Philosophy

Degree Program Communication

Publication Date 07/24/2017

Defense Date 12/13/2016

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag adolescent behavioral health,OAI-PMH Harvest,peer-to-peer learning,school-based health care,social media,youth-centered health intervention

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Miller, Lynn Carol (committee chair), Clark, Leslie (committee member), Cruz, Nancy (Tess) Boley (committee member), McLaughlin, Margaret (committee member)

Creator Email janeaneanderson@gmail.com,jnanders@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-414931

Unique identifier UC11213878

Identifier etd-AndersonJa-5624.pdf (filename),usctheses-c40-414931 (legacy record id)

Legacy Identifier etd-AndersonJa-5624.pdf

Dmrecord 414931

Document Type Dissertation

Format application/pdf (imt)

Rights Anderson, Janeane Nicole

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA