What young people want from a sexual health website: design and development of ‘Sexunzipped’

Background Sexual health education in the United Kingdom is of variable quality, typically focusing on the biological aspects of sex rather than on communication, relationships, and sexual pleasure. The Internet offers a unique opportunity to provide sexual health education to young people, since they can be difficult to engage but frequently use the Internet as a health information resource. Objectives To explore through qualitative research young people’s views on what elements of a sexual health website would be appealing and engaging, and their views on the content, design, and interactive features of the Sexunzipped intervention website. Methods We recruited 67 young people aged 16–22 years in London, UK. We held 21 focus groups and 6 one-to-one interviews to establish sexual health priorities, views on website look and feel, and what features of a sexual heath website would attract and engage them. Two researchers facilitated the focus groups, using a semistructured topic guide to lead the discussions and asking open questions to elicit a range of views. The discussions and interviews were audio recorded and detailed notes were made on key topics from the audio recording. Young people’s views influenced design templates for the content and interactive features of Sexunzipped. Results Young people particularly wanted straightforward information on sexual pleasure, sexually transmitted infections and pregnancy, how to communicate with partners, how to develop skills in giving pleasure, and emotions involved in sex and relationships. Focus group participants wanted social interaction with other young people online and wanted to see themselves reflected in some way such as through images or videos. Conclusions While it is challenging to meet all of young people’s technological and design requirements, consultation with the target audience is valuable and necessary in developing an online sexual health intervention. Young people are willing to talk about sensitive issues, enjoy the discussions, and can offer key insights that influence intervention development.


Introduction
The provision of sexual health information provided in UK schools is taught within the statutory requirements of the National Science Curriculum [1]. It is variable in quality and tends to focus on the biological facts about reproduction, condom use and sexually transmitted infections (STIs) [1].
Consequently, information on skills building, sexual communication, relationship decision making and sexual pleasure are generally missing from young people's sexual learning experience.
Including these elements in young people's sexual education would align with one definition of 'sexual health' put forth by the World Health Organisation: "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". [2] Young people can be seen as a 'hard to reach' group for health promotion. Internet interventions may be one way of reaching young people as they frequently use the Internet to search for health information [3,4,5] and appreciate the privacy, convenience and ease of accessing information on the web [4,5]. These potential advantages are particularly valued for stigmatised or sensitive subjects such as sexual health. A further potential advantage of using the Internet for sexual health promotion is the relative ease of covering a broad range of information including sexual pleasure.
Some argue that since one of the main motivations for engaging in sex is pleasure, pleasure must be addressed in the discourse of sexual health promotion [6]. A systematic review of interactive computer-based interventions (ICBI) found that they can help increase sexual knowledge and have positive effect on safer-sex self-efficacy, intention and behaviour [7].
To determine the feasibility of promoting sexual health on the Internet to young people, we first set out to determine young people's views about whether an Internet intervention could help meet their sexual health needs, and if so, how best this could be done. This paper reports on our findings and also on how they informed the development of an Internet intervention for sexual health known as 'Sexunzipped' (www.sexunzipped.co.uk).

Participants
Young people aged 16-22 were eligible to participate in the study.

Recruitment
Multiple methods of recruitment were used including approaching young people in sexual health clinic waiting rooms, distributing flyers around clinics and colleges, approaching key contacts involved in youth work and placing advertisements on youth websites such as the UK Youth Parliament and college web pages. 'Snowballing', was also used, where initial participants were asked to recruit potentially interested friends.
Participants were initially asked to attend only one focus group but were invited to subsequent groups if they were particularly engaged. Repeated attendance at focus groups over time allowed these participants to build on previous discussions. They were able to comment on refinements made to earlier website content and interactive formats.
Three focus group participants who were particularly engaged were asked to attend a one-to-one interview. Three interviewees were also recruited from online advertisements on youth websites and through key youth work contacts.
All participants provided written consent to their participation before attending a focus group or interview and were offered a £10 ($16) cash incentive if they stayed for the duration.

Data collection
The focus group discussions were used to explore: 1) young people's sexual health priorities, 2) their views on website look and feel and 3) what features of an interactive sexual heath website would attract and engage them.
All focus groups were moderated by two facilitators who introduced the project, explained the purpose of the focus group, set ground rules of mutual respect and confidentiality, and ensured that all participants had provided written informed consent. Participants provided anonymous demographic information by completing a paper form. The discussions and interviews were audio recorded with participants' permission.
Semi-structured topic guides were used to guide the focus group discussions. These guides evolved as data were collected. Open-ended questioning was used to elicit a wide range of views and participants were asked to elaborate on relevant topics beyond the topic guide. Less vocal participants were encouraged to share their views. The Sexunzipped website was developed in parallel with the emerging data from the focus groups, with early website design templates prompting discussion in subsequent focus groups. This enabled participants to comment on the presentation and content of the intervention, leading to iterative changes as a form of participatory design. Focus group discussions ranged from 60 to 90 minutes, depending on the quality of the information gathered and participants' attention spans.
One-to-one interviews lasted 60 minutes and used open-ended questioning. The interviews were used to gather views on early versions of website content and to generate anonymous quotations on sexual health issues to use throughout the website. To test the website content, participants were asked to read and comment on sample content and to give feedback on paper versions of interactive activities. To generate the quotations, the interviewer asked participants for their views on potentially controversial sex-related topics e.g. "What do you think about girls carrying condoms?". Anonymous quotations for the website were also generated by adapting comments taken from youth website discussion boards.

Data analysis
One researcher made detailed notes on key themes from the focus group audio recordings. The analytic notes were reviewed and discussed by the core research team consisting of a clinical psychologist, a health services researcher and a sexual health clinician. Key findings were documented and emergent themes were tested in subsequent focus groups until the core team were satisfied that the information gained was sufficient. Information from the one-to-one content testing and quotation generation was used to refine subsequent website content.

Participant characteristics
Sixty-seven 16-22 year olds living in the UK participated in 21 focus groups and six one-to-one interviews over 16 months (Table 1). Three one-to-one interviews were to test website content and three were used to generate anonymous quotations for use throughout the website.
Participants were ethnically diverse with 26 (39%) describing themselves as White British/White Other, 26 (39%) Black British, 2 (3%) Asian British, 7 (10%) Mixed and 6 (9%) Other. The median age of first sex was 15 years for both young women and men, with 33 (66%) young women ever having had sex and 15 (88%) young men ever having had sex. Fifty-seven out of sixty-seven participants (85%) were in education or training. Most participants lived in inner London, with two living outside, but near London. Of the 67 participants, 20 young people (30%) participated more than once. Young people wanted website content presented in a straightforward style that sounds honest, accurate and not 'preachy'. They recommended this style should not sound too serious and should not come across as 'school work'. They preferred content written in the voice of someone credible and knowledgeable but also someone they can relate to and respect such as an older sibling.
They preferred the use of uncomplicated words and phrases, for example 'sex' instead of 'sexual intercourse'. For those situations where an uncomplicated word was unavailable, they suggested providing a definition, such as 'transmit = to pass on to someone'. They were also adamant 'youth speak' or slang (e.g. 'coz' for 'because') should not be used as the website would come across as 'trying too hard', although young people felt that it could sometimes be appropriate to use simpler versions of words such as 'lube' for lubrication and 'come' for ejaculate.
Young people did not want what they interpreted as clichés such as "I feel like I should be having sex because everyone else is" included on the site. They recognised an existence of double standards for men and women regarding sex (e.g. it's acceptable for men to have numerous partners but not for women) and valued a space to address these issues.

Website look and feel
There was no clear consensus on website colours and logo design, with some preferring bold colours and others neutral tones. Participants wanted images of people, scenarios and "real life stuff" they could relate to such as young people partying in clubs, kissing and hanging out on the street. They felt images of young people should reflect the diversity of the UK population.
Participants wanted a website to include specific sexual health images such as photographs of STIs and contraception options. Young people expected the website logo to reflect sex and not require a lot of thought to understand its significance. They suggested the website name should be clear, memorable and suggest the content of the website. Young people wanted the site to feel active with new activities and information added each week. They disliked pages containing a lot of text, which they said that they would not read.

Engaging website features
Focus group participants wanted social interaction with other young people such as through discussion boards. A 'post and comment' format used on social networking websites such as Facebook was a popular suggestion since it is familiar and enables users to interact. Young people said that all communication must be anonymous so as not to disclose their identity if "embarrassing things" were posted.
Young people wanted videos to feature on a sexual health website but specified that they must represent real people talking about real experiences. If this was impossible, high quality actors must be used; if the people and situations in videos were not believable and realistic, they would not relate to them and would not find them valuable. One suggestion was to include short clips of young people sharing real stories on a range of issues with a means of commenting on the videos such as on the website YouTube.
Another feature that appealed to young people was a dramatic story format in which the user could choose different courses of action at pivotal points in the narrative. Participants liked the idea that dramas could have different endings depending on what decisions they made along the way and said they would be disappointed if they received the same feedback after different story endings.

Design and content of the Sexunzipped website
Paying particular attention to young people's desire for interactivity, young people's views were integrated with psychological theories of behaviour change to create the Sexunzipped theorybased intervention website [8]. Reflecting young people's suggestions and priorities, the website content is divided into three major sections: Relationships, Safer Sex and Sexual Pleasure. Each section contains a combination of interactive quizzes and decision-making activities as well as textbased information. Links to other related topics on the site are provided at the end of all activities and text-based pages.

Information pages
The text-based information pages throughout each of the three sections cover the major issues raised by the young people under the headings Relationships, Safer Sex and Sexual Pleasure ( Figure 1).

Interactive quizzes
Drawing from behaviour change theory [8], the quizzes on Sexunzipped were designed to prompt active learning and reflection by providing feedback according to responses given by users ( Figure   2). Response options were designed to encourage users to reflect on their views, emotions and experiences as well as providing information on social norms, and encouraging beliefs and attitudes associated with safer-sex behaviour. Incorporating what was learned from the focus groups, the quizzes were designed and written to be entertaining as well as educational, keeping in mind young people said they valued an honest tone that does not "try too hard".

Interactive decision-making activities
The decision-making activities were designed to provoke self-reflection about sexual behaviour, focusing on problematic situations or dilemmas concerning relationships or risky or regretted sexual situations (Figure 3). Participants had strong feelings about the length of these activities, which they said must be short and not require a lot of writing. To address this, a format was created whereby the user 'dragged and dropped' pre-specified response options but could also add their own. The website also includes quotations with aliases reflecting a range of views intending to give the feel of a peer-to-peer exchange of views ( Figure 4).

Principal results
Participants were actively engaged in the focus group discussions and enjoyed taking part. They offered key insights into the content, look and feel and interactive features of the Sexunzipped sexual health website. The resulting intervention has been tested in a pilot online trial [Trial The strongest message to emerge from this research was the importance of providing young people with honest sexual health information that features content on sexual pleasure and relationships. Participants desired a website that reflected a mature, trustworthy and true-to-life feel, conveyed through the voice of a knowledgeable youth worker or older sibling. The need for the website to appear trustworthy [9,10] along with the potential to share and compare "real life" experiences [11] is consistent with previous findings. Our focus group findings align with other research, which found that young people are interested in receiving sexual health information through digital technologies such as the Internet and mobile phones [10,12], and are interested in knowing more about sexual pleasure, feelings and emotions [13].
The integration of pleasure and relationship information with 'traditional' risk-focused sexual health promotion was seen as novel and attractive, with participants preferring this approach to their experiences of sexual health education delivered by schools or by health authorities. Giving equal weight to traditional risk-based messages and sexual pleasure (including masturbation for example) would give the message that both are important for healthy sexual lives [14,15].

Addressing what young people want in a website
Perhaps the greatest challenge was to integrate young people's preferences with psychological theory [8] within technical and budgetary constraints to create an acceptable and engaging sexual health website.
Participants expressed the desire for direct social interaction with other young people online (e.g. via discussion boards and instant messaging). These features are expensive, require moderation, and raise ethical issues, for example regarding online bullying or disclosure of illegal or dangerous activities. There was also a risk that if no one used the discussion board, the site would appear unpopular and therefore unattractive. Young people wanted to see themselves reflected on the site (e.g. in videos and drama), but this is expensive to produce and is difficult to pitch correctly. Young people are accustomed to the actively changing landscape on the Internet and wanted new activities and information added on a regular basis, which is resource-intensive.
Consultation with users is essential in the development of websites targeted at young people as this group can be particularly influenced by look and feel. This research and previous research suggests that listening to and meeting young people's desires in terms of website design and content is essential in achieving their engagement [9,11]. However, websites may quickly look and feel out of date due to the rapidly changing online environment, which necessitates regular user consultation and updating. This requires careful financial planning by those involved in site maintenance in order to support the continued user consultation and updating.

Limitations
Focus group participants were London-based young people, which could mean that any differences in sexual health priorities due to geographical location may be under-represented in the content of Sexunzipped. However, it was thought that young people in other areas of the UK would be able to recognize and relate to inner-city youth culture to some degree. The Sexunzipped website design was intended to appeal to a broad range of young people, avoiding any specific styles that could alienate particular groups or become quickly out of date.
The sample contained 75% (50 out of 67) women because greater numbers of young women attend community sexual health clinics. This may have resulted in views more representative of female needs and priorities. Attempts to include more young men were made such as contacting male youth organizations but this group proved to be less accessible than young women.
Although most focus groups included participants that did not know each other, the snowballing method of recruitment meant that the sample could have resulted in participants having similar views.

Conclusions
Consultation with the target audience is valuable and necessary in developing sexual health interventions, particularly in developing interventions for young people. It can be difficult to pitch content correctly, but is possible with repeated consultation with users. It is challenging to incorporate all of young people's technological desires but digital technology makes it possible to create an engaging online intervention that includes a variety of interactive formats covering a broad range of topics. Young people are willing to talk about sensitive issues, enjoy the discussions and can offer key insights that influence intervention development.