Patient portals are creating new opportunities for youth to disclose high-fidelity sexually transmitted infection (STI) laboratory test result histories to sex partners. Among an online survey sample, we describe latent constructs and other variables associated with perceived behavioral intentions to disclose STI test history using patient portals. Participants were co-ed students aged 18 to 25 years (N = 354) attending a southern United States Historically Black College and University in 2015. Three reliable latent constructs were identified by conducting psychometric analyses on 27 survey items. Latent constructs represent, a) STI test disclosure valuation beliefs, b) communication practices, and c) performance expectancy beliefs for disclosing with patient portals. Multivariable logistic regression was used to estimate the relationship of latent constructs to perceived behavioral intentions to disclose STI test history using patient portals. Approximately 14% (48/354) reported patient portal use prior to study and 59% (208/354) endorsed behavioral intentions to use patient portals to disclose STI test history. The latent construct reflecting performance expectancies of patient portals to improve communication and accuracy of disclosed test information was associated with behavioral intentions to disclose STI test histories using patient portals [adjusted odds ratio (AOR) = 1.15; 95% CI = 1.08 to 1.22; p<0.001]. Latent constructs representing communication valuation beliefs and practices were not associated with intentions. Self-reporting prior STI diagnosis was also associated with intentions to disclose using patient portals (AOR = 2.84; 95% CI = 1.15 to 6.96; p = 0.02). Point of care messages focused on improvements to validating test results, communication, and empowerment, may be an effective strategy to support the adoption of patient portals for STI prevention among populations of college-aged Black youth.
Citation: Jackman K-MP, Murray S, Hightow-Weidman L, Trent ME, Wirtz AL, Baral SD, et al. (2020) Digital technology to address HIV and other sexually transmitted infection disparities: Intentions to disclose online personal health records to sex partners among students at a historically Black college. PLoS ONE 15(8): e0237648. https://doi.org/10.1371/journal.pone.0237648
Editor: Ethan Morgan, Ohio State University, UNITED STATES
Received: January 26, 2020; Accepted: July 30, 2020; Published: August 21, 2020
Copyright: © 2020 Jackman et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The eSHINE Study (PI:KJ) was supported by a 2014-2016 dissertation research grant (R36HS023057) from the Agency for Healthcare Research and Quality (AHRQ). KJ’s efforts were supported in part by the National Institutes of Health (T32DA007292, 2T32AI102623-06, & R25MH08362). SB’s effort was funded by 5R01MH110358-03.
Competing interests: The authors have declared that no competing interests exist.
African-American and other Black residents of the United States bear a disproportionate burden of sexually transmitted infections (STIs), including HIV, compared other race and ethnic groups. In 2018, case rates among Black youth aged 15 to 24 years per 100,000 were: 5,085 for chlamydia (versus 1,104 in Whites); 1,793 for gonorrhea (versus 200 in Whites), 49 for primary and secondary syphilis (versus 8 in Whites), and 67 for HIV (versus 6 in Whites) [1,2]. Disclosing accurate STI test histories to sexual partners is a critical component of STI prevention and the Center for Disease Control and Prevention’s “Talk. Test. Treat.” campaign [3–5]. However, several psychosocial and event-level facilitators and barriers can inform the occurrence and accuracy of STI test history disclosures to sex partners among young people [6–8]. When communication exchanges occur, there are variations in language used (e.g., asking “are you good down there?” versus “when was the last time you were tested for HIV?”) and vulnerabilities to inaccurate recall of STI tests performed, test dates, and test results [8–10]. Strategies are needed to reduce communication barriers, improve the fidelity of information exchange, and support healthy normative behaviors around discussing testing with partners among Black youth.
Electronic personal health records (PHRs) are creating new opportunities to increase fidelity and habits around disclosing STI test histories [8,11]. However, little data among Black youth are available on behavioral intentions to adopt patient portals for sharing STI PHRs with sex partners. Patient portals are secure online websites that provide patients with convenient, 24-hour access to their personal health information, such as laboratory test results and prescription medications, referred to as PHRs [12,13]. Patient portals are available as downloadable web-based applications on smartphones, which are widely accessible and used among U.S. populations of Black youth [14–17]. According to Health Information Trends Survey (HINTS) data, a nationally representative survey, 51% of individuals were offered access to their online records in 2018 (versus 42% in 2014); nearly six in 10 of which viewed their PHR at least once . Patient portals are projected to become ubiquitous in healthcare [18,19].
The adoption of patient portals to disclose test history in youth populations can be understood through constructs of behavior theory . Latent constructs are measures of “behaviors, attitudes, and hypothetical scenarios we expect to exist as a result of our theoretical understanding of the world”, assessed using an instrument consisting of survey items or psychometrics [21,22]. Performance expectancy is a construct of technology adoption theory referring to the degree to which the technology provides benefits or relative advantages to executing a task or set of tasks [22,23]. It may be hypothesized that performance expectancies about the interpersonal use of patient portals to disclose STI test history are key determinants of behavioral intentions within populations of Black youth.
According to the Integrative Model of Behavioral Prediction (IMBP), behavioral attitudes, normative beliefs, personal agency, salience of behavior constructs, along with background variables (e.g. biological sex, history of STI infection) determine intentions to perform health behaviors [20,24]. Beliefs about the importance of discussing testing with partners may be anticipated in theory to inform disclosure intentions [25,26]. However, valuation beliefs may vary based on contextual factors, for example, whether condoms are being used. Among youth in Historically Black College and University (HBCU) studies, valuation beliefs among males for soliciting or disclosing STI test history to prospective sex partners hold lower levels of importance compared to female counterparts; slightly smaller proportions of women report sex with partners of unknown HIV status [8,27,28]. History of infection also informs how youth engage in conversations involving test disclosure; for example, by empowerment after receiving chlamydia infection counseling and treatment, or by inhibition related to HIV stigma [29,30]. Identifying the latent constructs and factors relevant to adopting patient portals for disclosing STI test results offers formative data for implementing novel STI prevention strategies.
The goal of this study is to describe perceptions and psychometrics related to using patient portals to disclose test results among an online survey sample of students attending a southern HBCU. Further, to determine whether behavioral intentions to disclose STI test history using patient portals are statistically associated with differences in gender, history of infection, STI test disclosure beliefs, or performance expectancies for disclosing with patient portals.
The current study uses online survey data from the Electronic Sexual Health Information Notification and Education (eSHINE) Study. eSHINE (2014–2016) was a two-phase sequential qualitative and quantitative study among co-ed students ages 18–25 years at a southern HBCU exploring perceptions about using patient portals for STI prevention [8,31]. Survey participants were recruited in collaboration with student organizations and university administration to send email blasts advertising the study, table in high-traffic areas, and post study materials across campus spaces. Informed consent was signed in person or online using Adobe EchoSign prior to enrollment. Once consented and enrolled, a secured Qualtrics online survey link was sent to the university email address of each participant. The online survey consisted of 116 items and took an average of 30–45 minutes to complete. Participants were remunerated $20 USD to complete the survey. Study protocols were approved by the Morgan State University Institutional Review Board—(IRB #13/12-0151). eSHINE Study research methods, online survey development, and demographic sample characteristics have been previously described in detail .
To measure intentions to use PHRs to disclose STI test histories with sex partners, participants were asked to indicate agreement with the statement “I plan to use PHRs in future when discussing STI testing with my partner(s).” Responses ranged from strongly disagree to strongly agree using a 7-point Likert scale. PHRs were defined to participants as “electronic applications that give you electronic access to your medical records (e.g. test results, prescriptions etc.) using your computer, smart phone or tablet.”
To estimate the proportion of participants with prior PHR experience, participants were asked to indicate (yes/no) whether they have electronically viewed a medical laboratory result. Communication channels were tabulated to provide novel data on the kinds of mass media and interpersonal channels which college-aged Black youth consider important to disseminate messages about using PHRs to disclose STI test history with sex partners. Communication channels refer to sources and characteristics of messages an individual or population receives about adopting new health behaviors, for example, web advertisements (i.e., mass-media sources) or healthcare provider (i.e., interpersonal sources) . Participants were asked to indicate (yes/no) “Who or what would influence your decisions to use PHRs with a partner?” Potential channels emerging from an initial qualitative study included, healthcare providers, sex partners, family, peers, online information, media advertising, and celebrities. Latent constructs representing STI test disclosure beliefs and performance expectancies for disclosing with patient portals were identified using psychometric analysis on a set of 27 survey items described in the following section.
Univariate analyses were conducted to describe the study sample by demographic characteristics, sexual risk behaviors, endorsed communication channels, and intentions to disclose.
Psychometrics: Latent variable analysis.
Exploratory factor analysis (EFA) was used to reduce data and develop reliable latent constructs. First, a principal component analysis (PCA) was performed on 27 survey items measuring a very broad set of communication variables emerging from prior qualitative research, including, (1) beliefs and practices related to STI health communication with sex partners, and (2) performance expectancies related to disclosing test history using PHRs . Item responses used 7-point Likert scales corresponding to scores of -3 to 3. For example: -3 = strongly disagree; -2 = disagree; -1 = somewhat disagree; 0 = neither agree nor disagree; 1 = somewhat agree; 2 = agree; 3 = strongly agree. A complete list of items can be found on S1 Table. Examination of eigenvalues and a parallel analysis were used as the basis for selection of the number of factors to retain in the EFA. In EFA analyses, a minimum factor loading of 0.40 was used as a cut-off for each item . A promax rotation was used, as correlation between factors exceeded 0.32 .
Summation of raw scores corresponding to items loading on a specific factor was used to estimate latent construct scores . To measure the internal consistency, Cronbach’s alpha reliability coefficients were calculated overall for each latent construct as determined by the EFA results. To make binary comparisons between, a) participants willing to disclose STI PHRs to partners and b) participants unsure or unwilling to disclose STI PHRs to sex partners, scores of -3 to 0 were categorized as unsure or unwilling to disclose STI PHRs, and scores of 1 to 3 categorized as willing to disclose STI PHRs. Reliability coefficients were calculated by willingness to disclose STI PHRs (willing vs. unsure/unwilling) and by gender (male vs. female). A Cronbach’s alpha value of 0.70 was used as a cut-off value for acceptable internal consistency . Two-sample t-tests were conducted to test differences in mean latent constructs subscale scores by willingness to disclose STI PHRs (willing vs. unsure/unwilling) and by gender at significance p<0.05. The Kaiser-Meyer-Olkin (KMO) score for measuring of sampling adequacy for factor analysis was also calculated, with a value of 0.8 or greater considered evidence of adequacy per standard practice .
Logistic regression analysis.
Unadjusted and adjusted multivariable logistic regression models were developed to test associations between emergent latent constructs and background variables on perceived willingness to disclose STI PHRs to sex partners. The perceived willingness variable was categorized as described above, either: a) unsure or unwilling, or b) willing. To build our model, chi-square analyses were conducted on a priori variables anticipated to be associated with willingness to adopt PHR-facilitated STI testing discussions; variables with statistical associations of p <0.20 were included in the multivariable model. We then adjusted the models for gender, class standing, and willingness to access STI test results using PHRs (Likert scale variable scores -3 to 3). The latter variable was included in the model since the adoption of STI PHRs is imperative for using such online health services with sex partners. All analyses were conducted using STATA statistical software . Level of statistical significance was pre-defined as p< 0.05.
Results and discussion
A total of 1,093 participants registered for the eSHINE Study Online Survey and were sent secured survey links using the university’s student email server. There were 45.8% (501/1,093) who started the survey, of whom 75.8% (380/501) completed the survey and 93.2% (354/380) who completed the survey without missing data. The final analytic sample consisted of 47.2% (167/354) cis-male and 52.8% (187/354) cis-female participants with a median age of 20 years; 96.9% (343/354) identified as Black or African American. Approximately 13.6% (48/354) reported experience viewing an electronic laboratory test result prior to study. Less than half (43.2%; 153/354) reported STI screening in six months prior to the study; 16.7% (59/354) reported a history of STI diagnosis. Messages delivered through healthcare providers (81.4%; 288/354), sex partners (65.2%; 231/354), and family, (54.5%; 193/354) were the most salient communication channels endorsed to influence decisions on adopting the use of HIV/STI PHRs to share test histories (Table 1).
Fig 1 presents the sample distribution of perceived behavioral intentions to use PHRs for disclosing STI testing histories to sex partners. To summarize, willing participants, scores = 1 to 3, constituted 58.8% (208/354) of the sample. Unwilling participants, scores = -1 to -3, constituted 11.3% (40/354) of the sample. Approximately 29.9% of participants (106/354) neither agreed nor disagreed (score = 0) on intentional beliefs to use PHRs to disclose STI test histories to sex partner.
The PCA analysis produced six eigenvalues greater than 1, accounting for 53.3% of the variance. Based on the parallel analysis, we chose a three-factor solution for EFA. The overall KMO score was 0.8231, suggesting the data was adequate for factor analysis. Findings from the 3-factor EFA are presented in Table 2. In total, 16 of the 27 items loaded above the 0.4 thresholds and were retained for the final scale. The remaining 11 items were eliminated from inclusion on any subsequent subscales; no items had cross-loadings above 0.4.
Based on factor loadings, three latent constructs were identified, communication valuation, communication practice, and PHR impact (Table 2). PHR impact had seven items load over 0.4; these items reflect the performance expectancies of using STI PHRs in communication with partners. The highest loading items centered on attributes of improved health communication between sexual partners, assurance in shared screening information, and control over sexual health and decision making. Communication valuation had five items load over 0.4; items assess the perceived importance of discussing STI testing with sexual partners. Communication practice had four items load over 0.4; items represent the thoroughness of STI risk information solicited from sexual partners, e.g., likelihood to solicit information about prior sex partners, number of lifetime partners, or STI status disclosure.
Table 3 shows the Cronbach's alpha reliability coefficients and mean scores for latent construct, and additionally disaggregated by behavioral intentions to use PHRs for disclosing STI test history and by gender. Reliability coefficients ranged from 0.74–0.86 with the PHR impact subscale having the highest internal consistency. Reliability coefficients in bivariate comparisons were lowest (0.69) for the communication practice latent construct. Compared to male participants, scores for communication valuation (mean = 11.62 vs. mean = 9.70; t = 4.58; p<0.001) and communication practice (mean = 8.04 vs. mean = 6.15; t = 3.40; p = 0.001) were significantly higher among female participants.
Unadjusted and adjusted multivariable logistic regression
Table 4 shows odds ratios for unadjusted and adjusted multivariable logistic regression models. In the unadjusted model, PHR impact and communication valuation are both significantly associated with intentions to share STI test histories with PHRs. When adjusted for gender, student classification, screening history, history of STI diagnosis, and emergent latent factors; only PHR impact remains as a significant factor predicting willingness to adopt PHRs to share STI test history [adjusted odds ratio (AOR) = 1.15; 95% CI = 1.08 to 1.22; p<0.001]. Neither communication valuation nor communication practice were significantly associated with perceived behavioral intentions for STI PHR disclosure.
Participants reporting a history of prior STI diagnosis were significantly more likely to support sharing STI PHRs with partners (AOR = 2.84; 95% CI = 1.15 to 6.96; p = .02). Additionally, compared to participants reporting recent STI screening, reporting STI screening more than six months prior to the study was significantly associated with lower odds of adoption (AOR = 0.43; 95% CI = 0.20 to 0.94; p = .04). Finally, compared to freshman students, sophomore and junior students were significantly less willing to use HIV/STI PHRs for sharing test histories [(AOR = 0.34; 95% CI = 0.14 to 0.79; p = .01) and (AOR = 0.36; 95% CI = 0.15 to 0.84; p = .02), respectively].
With the goal of offering formative data to research focused on empowering populations of Black youth to disclose high-fidelity STI test information to sex partners, we identified the latent constructs and background variables relevant adopting patient portals for STI test disclosure among a sample of students attending a HBCU. Overall, most participants are willing to use the PHRs within patient portals to facilitate conversations with their partners on STI testing. We identified three latent constructs representing psychometric domains of STI test disclosure communication between partners. Latent construct factors had good internal consistency with reliability coefficients ranging from 0.74–0.86 overall with similar findings when stratified by intentions to adopt PHRs for STI test disclosure and by gender. Intentions to use PHRs to disclose STI test histories was significantly associated in adjusted multivariable analyses with class standing, screening history, history of STI diagnosis, intentions to use STI PHRs, and the PHR impact latent construct.
Findings add to scientific literature on the acceptability of adopting online health technology to foster engagement with sexual health care and communication with sexual partners among youth [38–40]. Further, it builds upon our prior work dissecting motivations and norms around discussing STI testing and disclosure with partners . Although moderately correlated, communication valuation and communication practice subscales are distinct and help delineate between sometimes-contradicting dynamics between behavioral attitudes and personal agency when constraining conditions are present . Gender differences in communication valuation and communication practice scores supports research suggesting that facilitating conversations may be more important to young Black women compared to men in a largely heterosexual context [27,28]. Nevertheless, there are no significant gender differences with respect to perceptions about using PHRs for disclosure. In fact, male participants had higher PHR impact scores and were more willing to adopt use PHRs in communication with sex partners–however, these differences were not significant. Patient portals may be a promising vehicle to deliver tailored interventions to uniquely address gender-based risk patterns for STI among youth [41,42].
The role of PHRs as a private, convenient, and easy to use sexual health management tool that supports sexual health awareness may have upstream effects on decisions to use STI PHRs in disclosures [23,31,43]. Trust in privacy and security may be particularly important for youth with a history of STI diagnosis. The significant association between prior STI diagnosis and willingness to adopt PHRs for disclosure is supportive qualitative findings where participants described that the experience of receiving a STI diagnosis increased the importance of discussing testing with future partners . Further studies are needed to determine how patient portals may help sero-discordant sexual partners in navigating complexities of discussing prevention and care; particularly for chronic infections, such as HIV and herpes simplex virus type-2 .
Clinicians and allied health professionals may be key influencers of how youth adopt the use of patient portals for STI test disclosures as new health behaviors. The PHR impact latent construct may be collected (i.e., using an electronic health record (EHR) e-form) in clinical settings to prioritize the delivery interventions empowering STI test disclosure [45,46]. Sex partners and family may additionally be effective interpersonal communication channels to support the adoption of sharing STI PHRs. Similarly, patient portals may also include modules to with role plays for how to discuss testing with sex partners. Still, mass media communication channels are initially important to broadly spreading awareness about new innovations . Messages should focus on beneficial innovation attributes, particularly improvements to validating test results, communication, and empowerment. In college settings, freshman students may be more receptive to dyadic STI PHR use. Freshman orientations may provide an opportunity for promoting such interventions.
There are several limitations to our study. Reported intentions to share STI PHRs may be biased where participants with attitudes opposed to STI test disclosures perceive support for disclosure as a more socially acceptable survey response, referred to as social desirability bias . Limited real-life experiences accessing STI PHRs in the sample may have contributed to the large number of participants undecided about using patient portals in disclosures. Deciding on intentions may also be difficult without explicating the myriad contextual factors that influence individual-level attitudes and practices related to STI test disclosure between sex partners . Extrapolation of our findings are limited by the study population and convenience sampling. Future studies are needed to explore behavioral intentions among Black and other minority adolescents and young adults with less than or equivalent to a high school education.
Getting youth to talk with sex partners about testing and healthy sexual behaviors remains a public health challenge and a critical component of the “Talk. Test. Treat.” campaign [5,6]. Adding a STI prevention infrastructure and capacity-building lens to the implementation of patient portals offers new strategies for addressing longstanding racial disparities. Such interventions may focus on reducing the stigma around STI health communication among youth, their sex partners, and their health care providers [6,48–50]. However, the success of future interventions requires public health priorities focused on patient portal access to STI PHRs and incentives to design patient portal platforms to support sexual and reproductive health among Black youth.
S1 Table. Items included in exploratory factor analysis, willingness to adopt PHR delivered results and willingness to adopt PHR facilitated risk discussions–eSHINE Study Online Survey (2015).
The authors thank Farin Kamangar, Chris Beyrer, Taha Taha, Mian Hossain, eSHINE Study participants, the Morgan State University School of Community Health and Policy, the Morgan State University Office of Sponsored Programs & Research, and the Johns Hopkins Center for Public Health and Human Rights for their research support.
- 1. Centers for Disease Control and Prevention (CDC). Sexually Transmitted Disease Surveillance 2018. Atlanta: U.S. Department of Health and Human Services;2019.
- 2. CDC. HIV Surveillance Report, 2018 (Updated). 2020; http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Accessed 06/24/2020.
- 3. CDC. Start Talking. Stop HIV. 2015; https://npin.cdc.gov/campaign/start-talking-stop-hiv, 2019.
- 4. Pinkerton SD, Galletly CL. Reducing HIV transmission risk by increasing serostatus disclosure: a mathematical modeling analysis. AIDS Behav. 2007;11(5):698–705. pmid:17082982
- 5. McFarlane M, Brookmeyer K, Friedman A, Habel M, Kachur R, Hogben M. GYT: Get Yourself Tested Campaign Awareness: Associations With Sexually Transmitted Disease/HIV Testing and Communication Behaviors Among Youth. Sexually Transmitted Diseases. 2015;42:619–624. pmid:26457487
- 6. Friedman A, Bloodgood B. ‘‘Something We’d Rather Not Talk About”: Findings from CDC Exploratory Research on Sexually Transmitted Disease Communication with Girls and Women. 2010;19.
- 7. Yang C, Latkin C, Tobin K, Seal D, Koblin B, Chander G, et al. An Event-Level Analysis of Condomless Anal Intercourse with a HIV-Discordant or HIV Status-Unknown Partner Among Black Men Who Have Sex with Men from a Multi-site Study. AIDS Behav. 2018;22(7):2224–2234. pmid:29779160
- 8. Jackman K-M, Baral SD, Hightow-Weidman L, Poteat T. Uncovering a Role for Electronic Personal Health Records in Reducing Disparities in Sexually Transmitted Infection Rates Among Students at a Predominantly African American University: Mixed-Methods Study. JMIR Medical Informatics. 2018;6:e41. pmid:30001998
- 9. Lunze K, Cheng DM, Quinn E, Krupitsky E, Raj A, Walley AY, et al. Nondisclosure of HIV infection to sex partners and alcohol's role: a Russian experience. AIDS and Behavior. 2013;17(1):390–398. pmid:22677972
- 10. Dariotis JK, Pleck JH, Sonenstein FL, Astone NM, Sifakis F. What are the consequences of relying upon self-reports of sexually transmitted diseases? Lessons learned about recanting in a longitudinal study. J Adolesc Health. 2009;45(2):187–192. pmid:19628146
- 11. Jackman K-M, Latkin CA, Maksut JL, Trent ME, Sanchez TH, Baral SD. Patient portals highly acceptable tools to support HIV preventative behaviors among adolescent and young sexual minority men. Journal of Adolescent Health. 2020;In press.
- 12. Office of the National Coordinator for Health Information Technology (ONC). What is a personal health record? Frequently asked questions 2016; https://www.healthit.gov/faq/what-personal-health-record-0. Accessed 10/23/2019, 2019.
- 13. ONC. What is a patient portal? 2017; https://www.healthit.gov/faq/what-patient-portal, 2019.
- 14. ONC. 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program. Department of Health and Human Services;2020.
- 15. Pew Research Center. Teens, Social Media & Technology 2018. 2018.
- 16. Pew Research Center. African Americans and Technology Use: A Demographic Portrait. 2014.
- 17. Pew Research Center. The Smartphone Difference: U.S. Smartphone Use in 2015. 2015.
- 18. Patel V, Johnson C. Trends in Individuals’ Access, Viewing and Use of Online Medical Records and Other Technology for Health Needs: 2017–2018. ONC;2019.
- 19. Ford EW, Hesse BW, Huerta TR. Personal Health Record Use in the United States: Forecasting Future Adoption Levels. Journal of medical Internet research. 2016;18:e73. pmid:27030105
- 20. Glanz K, Rimer B, Viswanath K. Health Behavior and Health Education. 2008:72.
- 21. RF D. Scale Development: Theory and Application. Los Angeles, CA: Sage Publications; 2012.
- 22. Boateng GO, Neilands TB, Frongillo EA, Melgar-Quiñonez HR, Young SL. Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer. Frontiers in Public Health. 2018;6.
- 23. Tavares J, Oliveira T. New Integrated Model Approach to Understand the Factors That Drive Electronic Health Record Portal Adoption: Cross-Sectional National Survey. J Med Internet Res. 2018;20(11):e11032. pmid:30455169
- 24. Cho H. The Integrative Model of Behavioral Prediction as a Tool for Designing Health Messages. Health Communication Message Design: Sage; 2012:21–40.
- 25. Simon Rosser BR, Horvath KJ, Hatfield LA, Peterson JL, Jacoby S, Stately A. Predictors of HIV disclosure to secondary partners and sexual risk behavior among a high-risk sample of HIV-positive MSM: results from six epicenters in the US. AIDS care. 2008;20:925–930. pmid:18777221
- 26. Hickson DA, Mena LA, Wilton L, Tieu HV, Koblin BA, Cummings V, et al. Sexual networks, dyadic characteristics, and HIV acquisition and transmission behaviors among black men who have sex with men in 6 US cities. American Journal of Epidemiology. 2017;185:786–800. pmid:28402405
- 27. Hou S-I. HIV-related behaviors among black students attending Historically Black Colleges and Universities (HBCUs) versus white students attending a traditionally white institution (TWI). AIDS Care. 2009;21:1050–1057. pmid:20024762
- 28. Thomas PE, Voetsch AC, Song B, et al. HIV risk behaviors and testing history in historically black college and university settings. Public Health Rep. 2008;123 Suppl:115–125.
- 29. Chaudoir SR, Fisher JD, Simoni JM. Understanding HIV disclosure: a review and application of the Disclosure Processes Model. Social science & medicine (1982). 2011;72:1618–1629.
- 30. Sullivan K, Voss J, Li D. Female disclosure of HIV-positive serostatus to sex partners: a two-city study. Women & health. 2010;50:506–526.
- 31. Jackman K-M, Hightow-Weidman L, Poteat T, Wirtz AL, Kane J, Baral S. Evaluating psychometric determinants of willingness to adopt sexual health patient portal services among Black college students: A mixed-methods approach. Journal of American College Health. 2019.
- 32. Rogers E. Diffusion of Innovations. 5th Edition ed. New York, NY: New York: Free Press; 2003.
- 33. Comrey A, Lee H. A first course in factor analysis. 1992.
- 34. Costello A, Osborne J. Best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. Practical Assesment, Research and Evaluation. 2005;10.
- 35. Nunally J. Psychometric theory. 1978.
- 36. Kaiser HF. An index of factorial simplicity. Psychometrika. 1974;39:31–36.
- 37. StataCorp. Stata Statistical Software: Release 14. 2015.
- 38. Ramsey A, Lanzo E, Huston-Paterson H, Tomaszewski K, Trent M. Increasing Patient Portal Usage: Preliminary Outcomes From the MyChart Genius Project. Journal of Adolescent Health. 2018;62:29–35. pmid:29169768
- 39. Widman L, Golin CE, Noar SM, Massey J, Prinstein MJ. Projectheartforgirls.com: Development of a Web-Based HIV/STD Prevention Program for Adolescent Girls Emphasizing Sexual Communication Skills. 2016;28:365–377.
- 40. LeGrand S, Muessig KE, Horvath KJ, Rosengren AL, Hightow-Weidman LB. Using technology to support HIV self-testing among MSM. Current Opinion in HIV and AIDS. 2017:1.
- 41. Satre DD, Leibowitz AS, Leyden W, Catz SL, Hare CB, Jang H, et al. Interventions to Reduce Unhealthy Alcohol Use among Primary Care Patients with HIV: the Health and Motivation Randomized Clinical Trial. J Gen Intern Med. 2019.
- 42. Hill AV, De Genna NM, Perez-Patron MJ, Gilreath TD, Tekwe C, Taylor BD. Identifying Syndemics for Sexually Transmitted Infections Among Young Adults in the United States: A Latent Class Analysis. J Adolesc Health. 2019;64(3):319–326. pmid:30447953
- 43. Hoque MR, Bao Y, Sorwar G. Investigating factors influencing the adoption of e-Health in developing countries: A patient's perspective. Inform Health Soc Care. 2017;42(1):1–17. pmid:26865037
- 44. Muessig K, Knudston K, Soni K, et al. “I didn’t tell you sooner because I didn’t know how to handle it myself.” Developing A Virtual Reality Program To Support Hiv-Status Disclosure Decisions. Digit Cult Educ. 2018;10:22–48. pmid:30123342
- 45. Marcelin JR, Tan EM, Marcelin A, Scheitel M, Ramu P, Hankey R, et al. Assessment and improvement of HIV screening rates in a Midwest primary care practice using an electronic clinical decision support system: a quality improvement study. BMC Med Inform Decis Mak. 2016;16:76. pmid:27378268
- 46. Goyal MK, Fein JA, Badolato GM, Shea JA, Trent ME, Teach SJ, et al. A Computerized Sexual Health Survey Improves Testing for Sexually Transmitted Infection in a Pediatric Emergency Department. J Pediatr. 2017;183:147–152 e141. pmid:28081888
- 47. Rao A, Tobin K, Davey-Rothwell M, Latkin CA. Social Desirability Bias and Prevalence of Sexual HIV Risk Behaviors Among People Who Use Drugs in Baltimore, Maryland: Implications for Identifying Individuals Prone to Underreporting Sexual Risk Behaviors. AIDS Behav. 2017;21(7):2207–2214. pmid:28509997
- 48. Fisher CB, Fried AL, Macapagal K, Mustanski B. Patient-Provider Communication Barriers and Facilitators to HIV and STI Preventive Services for Adolescent MSM. AIDS Behav. 2018;22(10):3417–3428. pmid:29546468
- 49. Marcell AV, Morgan AR, Sanders R, Lunardi N, Pilgrim NA, Jennings JM, et al. The Socioecology of Sexual and Reproductive Health Care Use Among Young Urban Minority Males. J Adolesc Health. 2017;60(4):402–410. pmid:28065520
- 50. Córdova D, Lua FM, Ovadje L, Fessler K, Bauermeister JA, Salas-Wright CP, et al. Adolescent Experiences of Clinician-Patient HIV/STI Communication in Primary Care. Health Commun. 2018;33(9):1177–1183. pmid:28686489