Adolescents’ Perspectives on Using Technology for Health: Qualitative Study

Background: Adolescents’ wide use of technology opens up opportunities to integrate technology into health visits and health care. In particular, technology has the potential to influence adolescent behavior change by offering new avenues for provider communication and support for healthy choices through many different platforms. However, little information exists to guide the integration of technology into adolescent health care, especially adolescents’ perspectives and preferences for what they find useful. Objective: This qualitative study aimed to take a broad approach to understanding adolescents’ use of technology for supporting their overall health and to understand whether and how adolescents envision using technology to enhance their health and clinical care, particularly in communicating with their provider. Methods: Adolescents (13-18 years) were recruited to participate in semi-structured, in-depth individual interviews. Potential participants were approached in-person through the Seattle Children's Hospital Adolescent Medicine Clinic while they were waiting for consultation appointments, through outreach to youth who expressed interest in other local research study activities, and via flyers in waiting rooms. Interviews were recorded, transcribed, and analyzed using a thematic analysis approach. Results: Thirty-one adolescents (58% female, mean age 15.2 years) were interviewed and described 3 main uses of technology: (1) to gather information, (2a) to share their own experiences and (2b) view others’ experiences in order to gain social support or inspiration, and (3) to track behaviors and health goals. Perceived benefits and potential downsides were identified for technology use. Teens desired to use technology with their provider for 3 main reasons: (1) have questions answered outside of visits, (2) have greater access to providers as a way to build relationship/rapport, and (3) share data regarding behaviors in between visits. Social media was not a preferred method for communicating with providers for any of the youth due to concerns about privacy and intrusiveness. Conclusions: Although youth are avid users of technology in general, in regard to technology for health, they display specific use preferences especially in how they wish to use it to communicate with their primary care provider. Health care providers should offer guidance to youth with regard to how they have used and plan to use technology and how to balance potential positives and negatives of use. Technology developers should take youth preferences into account when designing new health technology and incorporate ways they can use it to communicate with their health care provider. (JMIR Pediatr Parent 2018;1(1):e2) doi: 10.2196/pediatrics.8677 JMIR Pediatr Parent 2018 | vol. 1 | iss. 1 | e2 | p. 1 http://pediatrics.jmir.org/2018/1/e2/ (page number not for citation purposes) Radovic et al JMIR PEDIATRICS AND PARENTING


Introduction
Adolescents are avid users of new technologies, with a quarter of adolescents online almost constantly and almost all (92%) online daily [1]. Most teens (84%) have used the internet to search health topics online, 21% have downloaded mobile apps, 12% have played a health-related game, and 7% have worn a wearable health device [2]. Across health topics, teens express a desire for online, accessible information and health interventions which are technology-based as opposed to in person, telephone, or paper. [3] When health websites and text messaging services are made available to teens, they are highly utilized [4][5][6][7]. Due to adolescents' frequent use and openness to trying out new technology tools, the trend for technologies directed at health improvement may have an important influence on adolescent health.
Much of the research eliciting adolescents' preferences for incorporating technology in health care has examined the use of patient electronic portals with respect to confidentiality and its influence on adolescent utilization of technology. A systematic review examining pediatric use of patient portals found that in general account activation is low for teens due to barriers such as concerns about confidentiality [8,9]. However, one additional study found when confidentiality was ensured by a patient portal, adolescents used them as frequently as parents of younger children [10]. Other studies have been conducted to quantify what types of technologies adolescents prefer. When considering communication with their provider, one study found adolescents preferred email or text over video communication [3], another found adolescents preferred emails to follow-up after visits over texts [11], and a third found texts were preferred over using social media [12]. While almost all adolescents surveyed in the latter study used social media, only 25% felt social media could give them useful health information [12]. While these studies are useful in summarizing overall adolescent preferences, little attention has been given to what drives adolescents' preferences for technology use and how they use various technological media for their health [13].
Adolescents' predilection for technology suggests they will adopt technology integrated into health visits and health care. As most adolescent health care is centered around prevention efforts, prioritizing use and design of interventions which incorporate technology into behavior change interventions, such as for healthy eating, incorporating exercise, or improving sleep quality may be beneficial. Providers may be able to offer further resources, intervene earlier, and troubleshoot problems in the moment as patients are implementing behavior change more readily using technology than through traditional phone calls and office visits. However, adolescents' perspectives and preferences for what they find useful are needed to guide the integration of technology into adolescent health care. This qualitative study aimed to elicit adolescents' perspectives on how they currently use technology to support their health and to gain insights into what factors may influence their future use of technology to improve their health or communication with their provider. Gathering more in-depth qualitative information on these topics may be useful in informing clinicians how to use technology to engage with their patients and in providing insights into adolescent preferences for people who design new technology tools for health.

Recruitment and Participants
A total of 31 adolescents (18 females and 13 males) participated in in-depth semi-structured interviews in Seattle, WA. Potential participants were approached in-person at the Seattle Children's Hospital Adolescent Medicine Clinic while they were waiting for consultation appointments, through outreach to youth who expressed interest in other local research study activities, and through posted flyers in the waiting rooms of the adolescent and sports medicine clinics. Of the 31 participants, 26 were recruited from the waiting room of the adolescent clinic, 5 were recruited from community sources, and 1 was recruited via flyer. Purposive sampling methods were used to ensure the sample included nearly balanced numbers of genders (male and female) and age ranges (13-15 and 16-18 years) as well as adolescents representative of racial and ethnic diversity of the Seattle area.
Adolescents were eligible to participate if they were between the ages of 13 and 18 and could read and speak English. Consent or assent was obtained from adolescents who were interested and eligible. Parental permission was required for participants under 18. As described in the consent and assent forms, the youths' responses were kept confidential except in cases where the youths indicated that they were planning to hurt themselves or someone else. Approval was obtained for all study procedures from the Seattle Children's Hospital Institutional Review Board.

Procedures
Prior to being interviewed, adolescent participants privately completed a tablet-based electronic health assessment called Check Yourself, that covered health behaviors including exercise, nutrition, sleep, safety, sexual activity, depression, and alcohol and drug use [12]. The health assessment provided direct feedback to the adolescents on their health behaviors, including how they compared to recommended guidelines for their age. Following completion of the health assessment, adolescents participated in individual interviews lasting approximately 45-60 minutes. Three study team members-2 female (KK and one other) and 1 male-trained in qualitative interview techniques conducted the interviews. The interviewers did not know the respondents prior to the time of the interview. Only 1 interviewer had medical training as a physician and worked in the adolescent medicine clinic where recruitment took place, however, she was not involved in recruitment and did not conduct interviews with any of her patients. Interviews were conducted between February and July, 2015 and took place primarily in a private room in the same building as the adolescent clinic used for recruitment. When scheduling constraints prevented the interview from occurring at the clinic, interviewers met participants in a private and convenient location (eg, a private meeting room at a library).
Interviewers used a semi-structured interview guide which included 3 areas of inquiry: (1) electronic health assessment feedback (results from this published in a previous study) [14]; (2) adolescent preferences for health behavior change support from their provider (results from this have been submitted and are under review); and (3)  , and blogs (eg, TeensHealth, Teen Speak, Tumblr). Interviewers defined "provider" to participants as their primary care physician or someone they see regularly for health check-ups, such as a pediatrician, family medicine doctor, or nurse practitioner. The interview guide was adjusted over the course of the study as questions were added to explore emerging themes or not asked about in-depth after reaching thematic saturation. Adolescents received $30 for participating.

Data Analysis
All interviews were recorded using a digital audio recorder and were professionally transcribed. Interviewers reviewed each of their transcripts for accuracy, correcting errors, and filling in gaps where possible. All interview transcripts were uploaded into the Web-based qualitative analysis software, Dedoose [15], for coding. One study team member developed the initial codebook of themes following a thematic analysis approach outlined by Braun and Clarke [16]. Using an inductive approach to data analysis, development of the final codebook was an iterative process, with coders proposing new codes to the study team as transcripts were reviewed, updating the codebook to encompass emerging themes and recoding previously coded transcripts. Four study team members participated in coding the data with 2 analysts independently coding each transcript, with coding discrepancies resolved by consensus. The authors collaboratively reviewed all text excerpts within each code to identify themes and key quotes illustrating each theme.

How Teens Use Technology for Health
Teens described using technology in one of 3 main ways to support their health: (1) to gather information, (2) to share their own experiences and view others' experiences in order to gain social support or inspiration, and (3) to track behaviors and health goals. Each of these uses is discussed below with illustrative quotes in text and additional quotes provided in Table 2. During these discussions, themes also emerged regarding the benefits and potential downsides to using technology for health. These are summarized in Figure 1 and discussed in the following two sections.

Information Gathering
Teens reported seeking resources, ideas, and education using both apps and websites. The most commonly searched topics reported by the youth interviewed were related to nutrition and exercise (ie, healthy foods, portion size, calorie counting, workouts); some also sought information on medical and mental health conditions and consequences to their health from behaviors such as marijuana use. To gather this information, teens reported using various sites including medical websites such as WebMD and Mayo Clinic, Web searches using Google, and Pinterest to "pin" or save healthy recipes or exercise routines. They found YouTube, exercise apps, and Facebook useful for accessing work outs; one teen also used Tumblr, a social media blog, for health information. Teens reported that they valued the accessibility and relatability of online health information:

Inspiration and Social Support
In addition to gathering information, teens felt that they benefitted from others sharing their health experiences online, including: getting ideas of what others are doing to support their health; feeling motivated from others' shared pictures (eg, a friend who shared a picture from a half marathon on Instagram [Female,18]); and feeling social support in their efforts toward better health, especially mental health. For example, one teen shared that Tumblr offers anonymity which allows users to be more comfortable sharing personal stories to wider audiences, as well as access to others who can provide online support:

Perceived Benefits of Using Technology
When talking about the different technologies used, themes emerged regarding characteristics that made health technology especially useful or appealing to teens (Table 3). Themes identified included: convenience, increased access to health information, the nonjudgmental nature of technology, options for increased privacy and personalization, and the motivating aspects of technological platforms.

Potential Downsides to Technology
Several teens described that although technology could be used for health, they also recognized possible downsides, as shown in Table 3. Some factors which kept teens from using certain technologies included: limitations to access such as cost; limitations to the technology itself such as requiring remembering log-ins and passwords or the requirement for frequent or complicated data entry; the possibility of distractions; technology for health not being teen specific; and negative social comparisons. Several teens felt that wearable technology would be useful but, because of the cost, viewed it as inaccessible. Others were frustrated by the lack of accuracy and user-friendliness of the freely available apps: Teens mentioned that if they were drawn to use their smartphone for health, they also may be alerted to other applications and notifications and then use the phone for longer than intended. One teen described how her intention to engage in a healthy behavior (exercise) may be disrupted by smartphone distractions which she feels are difficult to control:

You might get like, "Oh yeah I'm going to go work out." And I've got my phone and it gets in the way because you get sucked in and it's hard to get off. It's addicting. [ID 935, Female, 16]
Another teen made an insightful point that while using technology offers the privacy for a teen to explore and gain knowledge on something they might not otherwise have the courage to ask about; this unmoderated access to information may impede seeking input from others. Some teens also mentioned the potential for negative consequences from technology-based health information, such as sharing risky behaviors, promoting body dissatisfaction and negative competition, losing weight in an unhealthy way, and being exposed to bullying.

Technology for Health Provider Communication
In addition to questions about history of use, teens were asked how they may consider using technology for working with their health provider and what types of technology they would like to use. Three main categories for potential uses of technology with their providers emerged: (1) to have questions answered by their providers outside of visits; (2) to have greater access to their providers as a way to build their relationship/rapport; and (3) to share data regarding their behaviors in between visits with their provider (Table 4).
Several teens spoke about a desire to use technology to get quick and direct responses to questions in between visits. They felt they would benefit from receiving guidance from their provider on reputable internet resources when conducting a search for health information; and from receiving immediate feedback from their provider on whether the severity of a clinical problem warrants an appointment. Teens particularly valued the ability to receive a rapid response to their questions directly from the provider and not another staff member. At times, teens preferred phone or email when they wished to show the provider they had taken more effort to contact them and compose a message when compared to texting. For more complex questions that might require detail or a lengthy response, teens preferred email communication, in order to safeguard against losing meaning and also to save the information for reviewing in the future. One teen described that opposed to the phone, email could also offer more privacy and its asynchronous nature could help avoid embarrassment: Social media was not a preferred method for communicating with the providers for any of the interviewed teens due to concerns about privacy and intrusiveness.

I think it [social media] could be done I just don't think it's a preferred way to-because I feel like a lot of teens would think that it might be an invasion of their privacy if their provider followed them on all their social media. Then it might be kind of awkward. [ID 915, Female, 13]
A recurrent concern that arose about using any technology to communicate with providers was potential loss of confidentiality. However, the asynchronous and nonjudgmental nature of electronic communication methods had the advantage of reducing discomfort when teens were anxious about disclosing a sensitive clinical topic. Share data regarding their behaviors in between visits with their provider • As a way to communicate or provide proof about their behavioral patterns An additional benefit for some teens was the possibility to connect more personally with their doctors between visits. Teens felt technology offered an opportunity to further build rapport with their provider, particularly if the provider were to reach out to them in between visits. One teen described the possible content of a monthly check-in email:

Discussion
In this qualitative study, teens indicated 3 main categories of technology use for health: (1) gathering information, (2) inspiration and social support, and (3) tracking health behavior and goals. Teens expressed their desire to quickly access nonjudgmental health information in the privacy of their own technology use, but noted some shortcomings of technology for health including prohibitive cost, technology not being youth-friendly, potential for distraction, and exposure to negative behaviors, especially social comparison. Teens were interested in using technology such as email or texting for communication with their providers specifically as a way to get questions answered outside of visits, to have access to their providers to build the teen patient-provider relationship, and as a way to keep their provider up to date with sharing information about progress in health between visits.
In our study, the most commonly mentioned use of technology for health involved use of search engines and websites to learn about health-related issues. This is consistent with a prior study of a nationally representative sample of US teens which found that the vast majority had used the internet for gathering information on their health, despite only 25% being satisfied with the information they found in searches [2]. The perspectives of teens in our study suggests that this may be due to technology for health not being teen specific and written for adult audiences.
This implies that technology developers should include teens in their user-testing and specifically consider their unique needs and reactions. Also, health care providers should assume their patients are using the internet to answer their health questions and check in with them regarding what they have learned and help direct teens to sites that tend to have more reliable and age-appropriate information. Additionally, health care providers and health educators have a role in helping teens develop skills in assessing online health information and health literacy.
Another key finding of our work was that although adolescents appreciated some of the social aspects of technology such as learning about their friends' health accomplishments or feeling they are not alone, for example in mental health symptoms, most did not prefer to use their social media for health and did not want to use social media for communicating with their provider. These results are consistent with a recent cross-sectional survey of adolescents attending a primary care and adolescent clinic in which only about a quarter thought social media would provide useful health information and most would not want to use it to communicate with their provider [17]. Several other studies have also found teens prefer health interventions which do not use their existing social media [3,18,19]. Our study provides an explanation as to why social media does not seem to be the preferred medium for teens. Several youth expressed concerns regarding mixing their private social networks, which they saw as mostly focused on connecting with peers and friends, with health-related initiatives.
In particular, adolescents were concerned about their peers seeing health-related information or their providers seeing information intended for peers. Despite these concerns, there still may be a role for social media in health promotion, as several studies have shown teens will engage with others who have a similar health problem in privately moderated social networks [20][21][22]. Also, in one study, Facebook-based health education posts related to sexual health risk were accessed by teens when the content was obtained in a more passive manner and not shared with their social networks [23].
While recognizing how popular and intriguing technology was to them, teens in our study also identified several possible downsides including distraction from important tasks, such as school work, sleep disruption, and exposure to negative content (eg, risky behavior and overt focus on body image). Increased technology use, especially prior to bedtime, has been associated with sleep disruption [24]. When providers consider the use of health technology with teens, it is important to also be aware of these potential negative effects. For example, if recommending a calorie-counting app or online tool when counseling about behavior change related to weight loss, a provider may consider a discussion about body image and any associated advertisements the tool may have regarding unhealthy dieting. The provider may also help the adolescent think about whether tracking their weight loss with friends through the app may lead to negative social comparison and unhealthy advice on disordered eating or over exercising. Another role for the provider may be to help the adolescent set appropriate goals, knowing that many of the default recommendations used by these tools may be designed for overweight or obese adults.
Although teens recognized potential downsides, many were enthusiastic about using technology to communicate with their provider. Their goals for using technology with providers largely paralleled the reasons they used technology for general health, including getting questions answered outside of visits (gathering information), connecting and building rapport with their provider (inspiration and social support), and sharing data in between visits (tracking behaviors and goals). There was no consistent preference for one type of technological medium (eg, phone, social media, text message, email) for communication over another. More important to teens seemed to be the nature of the content of the communication. As providers consider adding technology, they may want to seek youth input regarding preferred methods. Preference to use technology to communicate may vary based on the health topic [3] and the type of information being exchanged. For example, although teens prefer receiving their sexually transmitted infection test results face to face [25,26], an anonymous question and answer sexual health web portal was very popular [27]. A large multiple focus group study done with adolescents in Ontario similarly found that communication via technology can allow providers to enhance connection and trust with their teen patients and help provide direction to searches and how to critically appraise online health information [28]. Health care providers may not realize the value of using communication through technology to build rapport with their teen patients. To allow for more informal provider-teen interactions, secure messages through patient portals seem to be less used by teens [10], but this may not be because teens do not want to communicate with their provider but possibly due to patient portals not being convenient and as easy to use as communication methods teens are accustomed to (eg, Facebook messenger) due to security standards. Also, the language used to present health information on these portals and website format may not be as easy to use, approachable, and visually pleasing as popular health education websites for young people, such as the online birth control support network, bedsider.org. [29] This small qualitative study is limited by use of a sample recruited from an urban academic health clinic, and it is possible that the views of adolescents living in rural settings with less access to health care may differ. While our purposive sampling method helped to generate a sample that was representative with a range of respondents, this methodology may be prone to researcher bias. However, our findings are similar to those of a larger quantitative study where samples were recruited from a nationally representative population [2]. Another limitation is that teens in this study were given prompts for particular technological platforms and so they may not have considered other technologies which did not immediately come to mind. In addition, it is possible that taking the health assessment primed teens to be more accepting toward technology for health; however, since most had used technology for health in the past, we do not think this would have biased their responses significantly.

Conclusion
Overall, teens use of technology for health is growing. Health care providers should be prepared to inquire about and provide advice for how teens are using technology for their health. Teens would like to use technology-based communication tools with their health care providers. This study offers multiple implications for health providers caring for adolescent patient populations and technology developers. First, providers should assume that teens have used or will use the internet to answer health-related questions and should be prepared both to assess the teen's understanding and to help guide the teen to reputable sites. Anticipating these health searches, health care providers can provide specific guidance including directing teens to trusted websites and assisting teens to use the best health-related terminology. Additionally, when recommending sites, providers should also consider any potential negative consequences and check in with teens regarding their experiences, both positive and negative, with using any recommended sites. Finally, teens are interested in using technology to communicate with providers. Technology developers should consider building more options for teens to communicate with health care providers. As technology grows, more work will need to be done to help providers understand and respond to youth preferences, to develop tools to guide youth to reputable health resources, and to develop strategies for incorporating patient tracking data into clinical practice.