JMIR MEDICAL INFORMATICS

Jackman et al

Original Paper

Uncovering a Role for Electronic Personal Health Records inReducing Disparities in Sexually Transmitted Infection Rates
Among Students at a Predominantly African American University:
Mixed-Methods Study
Kevon-Mark Jackman1, DrPH, MPH; Stefan David Baral1, MD, MPH; Lisa Hightow-Weidman2, MD, MPH; Tonia
Poteat1, PhD, MPH
1Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, UnitedStates2

Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States

Corresponding Author:
Kevon-Mark Jackman, DrPH, MPH
Center for Public Health and Human Rights
Department of Epidemiology
Johns Hopkins Bloomberg School of Public Health
E7143
615 N Wolfe Street
Baltimore, MD, 21205
United States
Phone: 1 352 871 1286
Email: kjackma2@jhmi.edu

Abstract
Background: Black youth continue to bear an overwhelming proportion of the United States sexually transmitted infection(STI) burden, including HIV. Several studies on web-based and mobile health (mHealth) STI interventions have focused on
characterizing strategies to improve HIV-related prevention and treatment interventions, risk communication, and stigma among
men who have sex with men (MSM), people who use substances, and adolescent populations. The Electronic Sexual Health
Information Notification and Education (eSHINE) Study was an exploratory mixed-methods study among students at a historically
black university exploring perceptions on facilitating STI testing conversations with partners using electronic personal healthrecords (PHRs).
Objective: The purpose of this paper is to use eSHINE Study results to describe perceived impacts of electronic PHRs on
facilitating STI testing discussions between sexual partners.
Methods: Semistructured focus groups and individual in-depth interviews were conducted on a heterogeneous sample of students(n=35) between May and July 2014. Qualitative phase findings guided development of an online survey instrument for quantitative
phase data collection. Online surveys were conducted using a convenience sample of students (n=354) between January and May
2015. Online survey items collected demographic information, sexual behaviors, beliefs and practices surrounding STI testing
communication between partners, and beliefs about the impact of electronic PHR access on facilitating these discussions withpartners. Chi-square analysis was performed to assess gender differences across quantitative measures. A Wilcoxon signed rank
sum test was used to test the null hypothesis that electronic PHRs are believed to have no effect on the timing of dyadic STI
health communication.
Results: Participants described multiple individual and dyadic-level factors that inhibit initiating discussions about STI testing
and test results with partners. Electronic PHRs were believed to improve ability to initiate conversations and confidence in STI
screening information shared by partners. Among online survey participants, men were more likely to believe electronic PHRs
make it easier to facilitate STI talks with potential partners (59.9% vs 51.9%; χ2=3.93, P=.05). The Wilcoxon signed-rank test
results indicate significant increases in perceived discussion timing before sex with electronic PHR access (61.0% vs 40.4%;
P<.001).

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Conclusions: Findings suggest that electronic PHR access in STI screening settings among similar populations of Black youth
may improve both motivation and personal agency for initiating dyadic STI health communication. Results from this study will
likely inform novel interventions that use access to electronic PHRs to stimulate important health-related discussions between
sexual partners. Moving forward requires studying strategies for implementing interventions that leverage electronic PHRs tocreate new sexual health communication channels with providers, peers, and family among black youth.
(JMIR Med Inform 2018;6(3):e41) doi: 10.2196/medinform.9174
KEYWORDS
PHR; STI; HIV; mHealth; intervention; prevention; young people; black; health disparities

Introduction
The High Burden of Sexually Transmitted Infections
Among Black Youth and Dyadic Sexually Transmitted
Infection Testing Talks
Young black people in the United States (US) are largely
overrepresented in cases of sexually transmitted infections(STIs), including HIV. While black people constituteapproximately 15.4% of US youth ages 15 to 24 years, theyaccounted for 29.9% of chlamydia cases, 47.7% of gonorrhea
cases, 43.3% of early syphilis, and 54.7% of HIV cases
diagnosed in this age group in 2016 [1-3]. Getting young people
to talk about STI testing, including HIV, with partners prior tosex is a critical challenge to disease prevention and control [4].
These preventative conversations support testing, disease status
disclosure, condom use, and the use of medicines to preventand treat STIs [5]. The “Get Yourself Tested” campaign
launched nationally in 2009 in effort to reduce STIs in young
people by targeting four key behaviors: STI testing, HIV testing,talking to partners about testing, and talking to providers about
testing. Formative research used to inform the campaign design
found that STIs remain highly stigmatized and as a result, few
young people discuss testing with partners prior to sex [4,6].
In young people, conversations on STI testing are more likely
to be facilitated by those that routinely screen for STIs [7]. In
studies of students at historically black colleges and universities,
women reported higher screening rates and asked partners about
HIV status more than their male counterparts [8,9]. Additionally,
individuals are more likely to discuss STI status and risk
behaviors with a main partner compared to a casual partner [10].
Expected partner reactions of suspicion, accusation, or insult(from inadvertently implying partner distrust) are sometimes
barriers to discussing STI testing [4]. Barriers that inhibit partner
communication regarding STI risk restricts the ability to makewell-informed decisions about the level of risk assumed andemployable methods to prevent disease transmission [11,12].

Digital Prevention Tools
The US National HIV Strategy calls for federal agencies toencourage the development and implementation of highly
accessible digital tools to educate and inform the American
people with scientifically accurate information on disease risk,
prevention, transmission, and treatment [13]. Several studies
on Web-based and mobile health (mHealth) HIV/STI
interventions have been conducted and are currently ongoingthat focus on improving outcomes related to testing, risk
communication, reducing stigma, increasing condom use, andhttp://medinform.jmir.org/2018/3/e41/

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improving adherence to biomedical prevention and treatment
among men who have sex with men (MSM), substance using,and adolescent populations [14-19]. Although mHealthintervention studies focused on improving partner
communication on STI testing are promising, most studies do
not account for the role of remote access to STI screening
records in dyadic STI health communication. Electronic personal
health records (PHRs) or patient portal services (eg, Epic
MyChart, Cerner Patient Portal, Kaiser Permanente My HealthManager, Quest Diagnostics Care360) provide patients withremote access to their laboratory test results, including STI
results. Electronic PHRs differ from most mHealth platforms
in STI intervention studies since electronic PHRs containprotected health information managed by covered entities,
therefore, federal regulations require electronic PHR vendors
to adhere to data security and integrity measures outlined by
the Secretary of the Department of Health and Human Services[20]. Nevertheless, electronic PHRs can provide several services
in addition to medical record access, like educational resources
and tools for communicating with healthcare providers.

Study Purpose
The Electronic Sexual Health Information Notification and
Education (eSHINE) Study was a mixed-methods study among
students 18 to 25 years old attending a historically black
university. The project was completed using a dissertation
research funding grant from the Agency for Healthcare Research
and Quality, and explores perceptions of using electronic PHRs
to share electronic STI screening information between sexual
partners. The current study is an analysis of eSHINE Study
qualitative and quantitative data to explore attitudes andpractices surrounding STI testing talks between partners, barriers
to talking about STI testing with partners, and perceived impactsof electronic PHRs on risk discussion facilitation. Thus, thepurpose of our study is to provide a rich contextual
understanding of how diffusing electronic PHR access in ourstudy population may impact health-related communication
between sexual partners.

Methods
Study Design
Exploratory mixed methods are a two-phase sequential study
design that is particularly useful for exploring new researchquestions [21]. It calls for an initial qualitative exploration phase(ie, focus-groups and individual interviews), an intermediatesurvey development phase, and a second quantitative researchphase (ie, an online survey) [22]. A constructivist approach of
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incorporating multiple theoretical frameworks structured ourstudy protocol. The Integrative Model of Behavioral Prediction(IMBP), often used for designing health messages, posits thatbehavioral intentions are a function of attitude, normative, andself-efficacy beliefs [23]. IMBP also considers the impact ofdemographic variables, culture, and environmental constraints
on behavior. If electronic PHR–facilitated STI talks is a novel
concept to the study population, constructs of the Diffusion of
Innovation Theory (DOI), such as innovation attributes andcommunication channels, were incorporated into our exploration[24]. Finally, the Disclosure Processes Model provide
considerations for individuals with a history of STI diagnosis
or exposure; here, disclosing risk is a function of antecedentgoals (ie, approach goals vs avoidance goals) [25].

Recruitment
Eligible study participants were students, ages 18 to 25 years,
enrolled at a southern historically black college and university
at the time of study. Qualitative phase participants were recruited
between May and July 2014 and quantitative phase participants
between January and May 2015. Recruitment flyers were posted
on campus along with multiple announcements sent throughthe university’s student, faculty, and staff email list. Targeted
recruitment efforts were conducted in collaboration with
University Health Services, the Student Counseling Center, theOffice for Residence Life to post study materials and conducttabling events. Study flyers were posted to a university affiliatedFacebook page for lesbian, gay, bisexual, transgendered, andquestioning students. Participants were also recruited at student
organizational meetings, including theatre, peer educator, andfootball. Study enrollment included providing eligible students
with a detailed description of the project, participation
requirements, and terms for receiving incentives. To complete
enrollment, prospective participants signed an informed consent
form in person or online using Adobe Echosign. Qualitativeand quantitative phase research protocols, including focus-group,interview guides and online survey instruments were separately
reviewed and approved by the university’s Institutional Review
Board.
Qualitative phase participants received US $25 cash for eachsession (limited to one focus group or one interview per
participant). Quantitative phase participants received US $20
cash for completing the online survey; and if eligible, qualitative
phase participants could participate in the quantitative phase.
Online survey participants were not asked to provide their nameor email address on the survey. To receive incentives,
participants provided a unique code generated at survey
completion. Participants were additionally entered to win prizes
in one of three raffle drawings (eg, textbook vouchers, US $25
up to US $100 gift cards, Samsung Galaxy tablets). eSHINE
Study data collection and analyses was conducted by KJ as partof his dissertation research, with guidance from project mentors
and dissertation committee members. Prior to the study, KJ
completed training in qualitative and quantitative researchmethods, including academic coursework and work as an STD
prevention and control program disease intervention specialist.

Jackman et al

Qualitative Methods
A total of 35 students participated in the qualitative researchphase (19 male; 16 female). Audio-recorded focus group andindividual interview sessions were conducted by KJ insideprivate conference rooms located on the university’s campus.
In May 2014, 33 students participated in one of three separate
focus group sessions (n=6; n=10; n=17). Semistructured sessions
averaging 70 minutes in length were divided into three
discussion sections: (1) electronic PHR perceptions, (2)experiences and perceptions related to dyadic STI healthcommunication, and (3) perceptions related to using electronic
PHRs in dyadic STI health communication. At the end of eachfocus group, participants were invited to schedule an in-depth
individual interview session. Focus group and interview
recordings were played back after sessions by KJ to constructfield notes and inform any modifications to main questions insubsequent sessions.

Semistructured interviews were important to explore in depth
the statements made by participants during focus groups in asetting isolated from peers. On average, interviews lasted 45
minutes. An oral questionnaire was administered during
interviews to collect demographic information, orientation, andsexual risk behavior, such as number of recent sex partners,
condom usage, and sex under the influence of alcohol or drugs
practices. Considering the sensitivity of sexual topics and tosupport higher levels of comfort among participants, thisinformation was not collected during focus groups. Sixteen ofeighteen individual in-depth interviewees were recruited froma focus group session. Transcripts and field notes were uploaded
to ATLAS.ti to facilitate the qualitative analysis [26]. The
analysis included reading through transcripts and field notes
while identifying useful quotes or sentences, creating memos,
coding segments of information, assigning labels to codes, andthe grouping of codes into broad themes [21].

Survey Development
A Qualtrics online survey was developed during the intermediatesurvey development phase between July and December 2014[27]. Qualitative codes were operationalized into IMBP
behavioral construct variables, such as attitudinal, self-efficacy,
and intentional beliefs within broad emergent themes. The
operationalization process included using individual codes
within themes as variables as well as using specific quotes fromparticipants within items on the survey [21]. Behavioral
construct variables, for example, attitudes on the importance ofdiscussing STI testing with partners, were measured using
7-point Likert scale items, scored –3 to 3 [28]. Data was alsocollected on several demographic and sexual behavior variables,such as gender, screening practices, and risky sex behaviors.
The survey was piloted with eight students and revisions madebased upon participant feedback and researcher observations.
The final survey had 116 items and a completion time of
approximately 30-45 minutes.

Quantitative Methods
To access the online survey, a secured and unique Web-link
was sent to the enrolled participant’s student email account

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using the university’s email database. Between January and
May 2015, 1093 participants registered for the online survey
and were emailed secured survey links; 501 surveys werestarted, 380 completed, and 354 completed without missing
data.
Survey data were uploaded into STATA 14 for statisticalanalyses [29]. Chi-squared analyses were conducted by genderto describe distributions of demographic information, risk
behaviors, STI testing talk attitudes and practices, andperceptions of electronic PHR–facilitated discussions by gender.
Effect size (Cohen d) was calculated for variables demonstrating
significant differences by gender related to electronic PHR
impacts on discussions. A Wilcoxon signed rank sum test was
performed to determine differences in perceived discussion
timing with electronic PHR access compared to without
electronic PHR access. To test the null hypothesis that electronic
PHRs are believed to have no effect on the timing of STI
conversations, we compared responses on two survey items:(1) “When do discussions about STD testing typically occur
between you and your partner(s)?” and (2) “When would
discussions about STD testing likely occur if you and yourpartner(s) had electronic PHRs?” Reponses were ranked from
1 to 4; (1) never (2) after sex (3) inconsistently before or aftersex, and (4) before sex.

Results
Qualitative Phase Results
Qualitative phase participants were heterogeneous in academicclassification, degree major, sexual behaviors, sexual orientation,
including for example, student athletes, peer educators, andmembers of Greek lettered social organizations. Table 1 presentsinterview and focus group quotations from our qualitative phasestudy. For this study, quotations were categorized under two
major themes: attitudes and practices surrounding dyadic STI
health communication and expected impacts of electronic PHRs
on dyadic STI health communication. Table 1 also indicates
online survey measures derived from qualitative codes.

Sexually Transmitted Infection Testing Talks:
Qualitative Attitudes and Practices
STI testing talks or risk discussion events were described asverbal exchanges between sexual partners regarding STI testingor status. Soliciting information related to STI risk from partners
was described as demonstrating personal responsibility and an
unalienable right to self-preservation:
You have the right to know.
I feel like if you’re having sex with me you have theright to know my STD history. If I’m having sex withyou, I need to know everything too. I owe that to you,
you owe that to me.
Conversations vary in both timing and depth. Several multi-levelfactors, such as self-efficacy, partner-type, and intoxication,
can impact when and how discussions occur (Table 1). Whentalks occur, they are either distal, proximal, or after the sexual

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encounter. Distal discussions happen in a period whereindividuals are “getting to know each other.” While proximal
discussions occur when participants are “in the moment.”
Discussions can range in depth from simply asking, “are you
good down there?” to requiring current screening informationand information regarding condom use practices with previous
partners.
Valuation for risk discussions varied between participants. For
most, STI talks are very important to always occur, especiallyinterviewees disclosing a history of STI infection.
It’s very important to have that conversation.
Some participants saw no purpose in talking about STI testing
when using condoms. Valuation also varied based on dyadic
characteristics such as, partner type.
If I know that I am going to be in somethingcommitted then I want to know your history. But if
you are just a casual partner then I don’t really care,because I am going to protect myself. I wouldn’t havethe conversation with someone I’m just casually
having sex with.
Participants described sexual partner dynamics ranging fromsolely pleasure-seeking sex and noncommittal partnerships tosocio or emotional interdependent and committed relationships.
To simplify and operationalize, partner types were classified
as: (1) main partners, defined as partnerships intended to be
exclusive relationships; (2) casual partners, defined as recurring
partnerships not intended to be exclusive relationships; and (3)hook-up partners, defined as one-time partnerships. Keeping in
mind that dyad characteristics vary within partner-typeclassifications (for example, casual partners may be long-timefriends or recent acquaintances, and others).
Finally, valuation appears to also be determined by the extent
to which individuals are aware of the importance of discussing
STI testing with partners.
I have never discussed STDs with any of my sexual
partners. I’m young, so it never really came up. I
usually just say, what’s the number of people you
have had sex with and if I feel comfortable with thenumber then, okay.

Barriers to Talking About Sexually Transmitted
Infection Testing With Partners: Attitudes andPersonal Agency
Self-efficacy contributes to whether STI testing talks are
initiated. While some participants described being very
comfortable with initiating conversations, many generally
describe it as an “[i]t’s an awkward conversation.” The impactof these beliefs as an inhibitor is based on the level of disruption
an individual believes the conversation will cause to a potential
sexual encounter or relationship. Low self-efficacy to facilitaterisk discussions was mostly described in the context of proximal
discussions, where consequences of these events may “ruin the
mood.” Lack of self-efficacy to initiate STI testing talks without
ruining the mood presents as a primary barrier to some.

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Table 1. Focus-group and individual in-depth interview quotations and online survey measures derived from qualitative codes. PHR: personal healthrecord; STI: sexually transmitted infection.
Themes and online survey measure

Quotations

Attitudes and practices surrounding dyadic STI health communication
Timing of dyadic STI health communication••

It usually occurs before anything else. After I get to know the person, it
comes up in the conversation because this person is a potential partner. I
always ask to be on the safe side.
Before I have sex, we don’t have the conversation. It slips my mind until
after we have sex.

•

It is very important to have that conversation, especially if you are going
to be dealing with that person sexually, “Have you been tested?” “Are you
going to get tested?” “When was the last time you were tested?

Valuation for dyadic STI communication when using condoms; •communications barrier: condom use

If I know that I am going to be in something committed, then I want to know
your history. But if you are just a casual partner then I don’t really care,because I am going to protect myself.

Self-efficacy to initiate dyadic STI health communication•

It doesn’t make me uncomfortable, I am straightforward. If I feel that weare about to get serious or have any sexual encounters, I simply ask “whenwas the last time you got tested?” If it’s too long, I tell them where to go
for testing.

Communication barrier: precontemplation••

When I was fresh out of high school, out of my parent’s house, I was[sleeping with] 6 or 7 guys at the same time. I was young, so I did not think
to ask, have you gotten tested, how many people have you been with?
I have never discussed STDs with any of my sexual partners.

Communication barrier: awkward••

It kills the mood.
(It can be awkward) when you have known the person.

Communication barrier: people lie•

People lie. One of the big lies is “I’ve been tested” or “I don’t have anything.” Especially when you’re in the moment, it happens all the time.

Valuation for dyadic STI health communication

Expected impacts of electronic PHRs on Dyadic STI Health Communication
More confidence in STI testing information shared by a partner •It’s another way of verifying the truth and showing that they did get tested
or if we need to get tested—we can go [to a test site] together.

•

Ultimately the app would make it much easier to have these conversations
with someone you are going to have sex with—whether it’s casual or longterm.
I can just show my partners casually when I got tested and my results. It
will ease the tension and make it more comfortable, especially if I am
willing to share that information with you.

Easier for potential partners to talk about STI testing; easiercheck-in talks with partners on STI testing•

Impact on frequency of STI talks; earlier STI talks (proximity
to potential encounter)••

Intentional beliefs to only use electronic PHRs when distrusting •of partners

I wouldn’t have a need for it, but then again if I do want to, you shouldn’t
be offended, because I’m just trying to be safe. So, if I do bring it up, don’t
be upset because it’s good health.

•If I tell you something and you don’t believe it, we shouldn’t be having sex
in the first place. If I tell you something, that’s what you should believe. If
I am lying, then strap up [use a condom].
It’s tricky, it’s one thing to ask someone something, but then to tell themto verify it, it messes up the trust. Unless if they are very comfortable.

Soliciting a partner’s electronic record will be awkward•

Self-efficacy for sharing a positive STI electronic PHR; preferred method to share STI positive status••

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If the norm was for people to have the app at hand, then more people would
ask to see results. Now, it’s not that realistic, because people can easily
say, I don’t have it with me, it’s on paper.
If the app is popular, then I’m asking everybody.

People who are negative would gladly show their results. People who arepositive, it would be harder for them.
I don’t see anyone showing a partner the app unless if they are clean.

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Themes and online survey measure
Suspicious of partners unwilling to share electronic PHR

Jackman et al
Quotations•

Some participants described talking with partners about STI
testing as an exercise in futility because of limitations in theability to verify shared information.
People lie. One of the big lies is “I’ve been tested”
or “I don’t have anything”. Especially when you’rein the moment, it happens all the time.
Allaying a partner’s STI transmission concerns can takeprecedence over communicating accurate information about
STI screening and risk. Several approaches are employed tomitigate risk associated with receiving inaccurate information.
For example, some participants reported choosing to avoid risk
discussions all together and use condoms. Conversely, someparticipants said that they engaged in couples testing or requirepotential partners show verification of STI test results prior tosex.
Any boy I ever ask that question to, I make sure I see
papers. Paper says clearly negative or positive.
Though some participants commented that it is unlikely for“papers” to be readily available to validate STI screening
information.
Other barriers exist to starting dyadic talks on STI testing.
Substance use prior to sex was considered to inhibit ability forfacilitating risk discussions with partners.
If someone is drunk, then it’s not going to be
discussed.
Self-efficacy to initiate risk discussions may also be diminishedwhen dyads have a previously established intimate relationshipor a friendship. Difficulty discussing STI testing “when you
have known the person” was described by participants as
implying distrust.

Impact of Electronic Personal Health Records on
Sexually Transmitted Infection Testing Talks: Beliefs
and Expectations
Information verification was considered the foremost benefit
of incorporating electronic PHRs into risk discussions between
sexual partners.
It’s another way of verifying the truth and showingthat they did get tested or if we need to get tested—
we can go (to a test site) together.
Participants used terms such as, “truth-detector,” “proof,” and“confirmation,” in referring to electronic PHR use with partners.
Participants also described limitations of electronic PHRs indetermining a potential partner’s real-time infection status.
There is no way to say you are clean today, but you
can say you were clean that day.
Together, electronic PHRs are believed to be a compatible
innovation for adding assurance to STI talks.
I think this will be something good for the gay
community. The gay community is big on electronic
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Red flag.

dating and meeting people online, Grindr and Jack'd
and all that. I feel that it would be really good forthat.
Gaining electronic PHR access was believed to ease the ability
to facilitate conversations on STI testing.
I can just show my partners casually when I got tested
and my results. It will ease the tension and make it
more comfortable, especially if I am willing to sharethat information with you.
Another participant explained:
Ultimately the app would make it much easier to havethese conversations with someone you are going tohave sex with—whether it’s casual or long term.
Participants added that electronic PHRs could make it easier tohave “check-in” conversations with partners who have priorestablished intimate relationships or friendships. Someparticipants maintained that practices will be determined bypartner-type.
If I have a one-night stand, I will use protection. I
would not want to ask that question.
However, for most, the idea of an easier STI talk eliminates
partner-type related factors as a barrier.
If the app is popular then I’m asking everybody.
Improvements to personal agency was not anticipated acrosssome constraining conditions, such as intoxication or being
infected with an STI.
If you’re drunk, I don’t think people would use it,
because you really wouldn’t be thinking about that,your mind is somewhere else.
Similarly, it was expressed that individuals with electronic
records positive for STI infection may employ strategies toavoid talking with partners about STI screening records.
People who are negative would gladly show theirresults. People who are positive, it would be harderfor them.
Nevertheless, some participants believed that incorporating
educational resources within electronic PHR products mightprove useful in explaining positive test results and prevention.
While electronic PHRs were compatible with most participants
as a potential tool for facilitating STI talks, some participantssuggest electronic PHR solicitation as intrusive or implying
distrust.
It’s tricky, it’s one thing to ask someone something,but then to tell them to verify it, it messes up the trust.
Unless if they are very comfortable.
Additionally, partners unwilling to share electronic screening
records are anticipated to raise a “red flag” regarding future
sexual decisions and relationship progression. Overall, electronic

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PHR access was anticipated to have the population-level impact
of increasing discussions on STI testing.
If the norm was for people to have the app at hand,then more people would ask to see results. Now, it’s
not that realistic, because people can easily say, I
don’t have it with me; it’s on paper.

Quantitative Phase Results
Table 2 shows demographic information and sexual risk
behaviors among online survey participants (n=354). The sample
consisted of 167 male and 187 female participants. Forty outof 354 participants (11.3%) reported no history of sexualintercourse and 44.3% reported 2-5 partners. Approximately
43.2% (153/354) reported STI testing seven months prior to thestudy; 80 out of 354 participants with sexual exposure reported
no history of screening (22.1%). Almost half (172/354) ofparticipants reported sex under the influence of alcohol or drugs
and 134 out of 354 participants reported recent sex without
discussing STI testing (Table 2). Sixty-four percent ofparticipants (38/59) with a history of STI diagnosis reported
chlamydia infection. Additionally, five participants reporting
gonorrhea, two participants reporting HSV-2, and twoparticipants reporting human papilloma virus also reported
chlamydia infections, there was no overlap between any other
STIs (not shown).

Sexually Transmitted Infection Testing Talks:
Quantitative Attitudes and Practices
Table 3 presents behavioral perceptions on risk discussion
practices among online survey participants. Conversations
consistently occur before sex for 143 out of 354 participants(40.4%) and inconsistently occur before or after a sexual
encounter for 41.0% (145/354). Some participants (51/354)
reported never discussing STI testing with partners. Most
participants (312/354) value discussing STI testing with partners,
however, valuation was slightly greater among women (χ2=3.79;
P=.05). In fact, 71.7% (254/354) believed it is extremely
important or very important irrespective of condom-use,
however over two-fifths (158/354) reported recent sexual
encounters where risk discussions were skipped due tocondom-use. Furthermore, less than half (169/354) believe that
it is easy to talk with partners about STI testing and 28.2%(100/354) reported skipping a recent discussion due toawkwardness. One-third of participants (118/354) reported
recently skipping risk discussions due to the possibility ofreceiving inaccurate information. Many participants (112/354)
also reported discussion omission because it never came tomind.

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Impact of Electronic Personal Health Records on
Discussion Timing
Out of 354 online survey participants, 184 (60.0%) believedthat electronic PHR access will lead sexual partners to start
conversations on STI testing earlier in the relationship (Table4). The Wilcoxon signed-rank test results shown in Figure 1
indicate significant differences between perceived discussion
timing with and without electronic PHRs (P<.001). Discussions
occurring before sex increased 20.6% with electronic PHR
access; while omitting talks and inconsistent timing bothdecreased by 10% (Figure 1).

Impact of Electronic Personal Health Records on
Personal Agency, Information Assurance, andAssessing Partner Risk
Table 4 presents bivariate relationships between perceptions on
incorporating electronic PHRs into risk discussion events andgender. Almost two-thirds (225/354) of participants felt thatelectronic PHRs would help to improve communication between
partners about STI prevention. Similarly, most participants(235/354) believed electronic PHRs would increase theirconfidence in STI testing information shared by a partner.
Electronic PHRs are believed to make it easier to facilitate risk
discussions between new potential partners (197/354) andongoing sexual partners (195/354). Nearly a quarter ofparticipants (85/354) believed soliciting a partner’s electronic
record would be awkward. Furthermore, two-fifths (154/354)
believed it would be difficult to share a positive result with apartner. In fact, more participants (158/354) indicated aconversation without electronic PHRs as the preferred method
for STI disclosure compared to using electronic PHRs (81/354).
The most commonly held belief was that participants will be
suspicious of potential partners unwilling to share electronic
PHRs (268/354).

Electronic Personal Health Record–Facilitated Sexually
Transmitted Infection Talks: Beliefs by Gender
Male participants were more likely to believe that electronic
PHR access would make it easier for sexual partners to discuss
STI testing compared to female participants (59.9% vs. 51.9%;
χ2=3.93; P=.05). However, the effect size by gender was small(d=0.27). Gender differences between beliefs that electronic
PHR facilitated conservations would be awkward andself-efficacy beliefs for sharing electronic STI records withpositive results had larger effect sizes. A smaller proportion ofmales (18.0% vs 29.4%) consider electronic PHR–facilitateddiscussions to be potentially awkward and were additionallymore confident in their ability to share a STI-positive electronic
result compared to female participants [(χ2=10.85; P=.001;
d=1.04) and (χ2=6.48, P=.01; d= 0.80)].

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Table 2. Demographic information and sexual risk behaviors among eSHINE Study online survey participants (n=354). IQR: interquartile range; STI:
sexually transmitted infection.
Variables

Total, n (%)

Men, n (%)

Women, n (%) Chi-square

Age
Median age (IQR)

20 (19-22)

20 (19-22)

Freshman89 (25.1)

57 (34.1)

32 (17.1)

Sophomore

82 (23.1)

42 (25.1)

40 (21.4)

Junior87 (25.6)

37 (22.2)

50 (26.7)

Senior88 (24.9)

31 (18.6)

57 (30.5)

Graduate student

8 (2.3)0 (0.0)8 (4.3)Sexual preference by gender
Men only

172 48.6)

10 (6.0)162 (86.6)

Women only

156 (44.1)

149 (89.2)

7 (3.8)Men and women

26 (7.3)

8 (4.8)18 (9.6)

Reported sex partners (in 12 months prior)
No partners in 12 months prior to study or no history of sexual intercourse 56 (15.8)

34 (20.4)

22 (11.8)

1116 (32.8)

45 (26.9)

71 (38.0)

2

79 (22.3)

27 (16.2)

52 (27.8)

3-5

78 (22.0)47 (28.1)

31 (16.6)

25 (7.1)

14 (8.4)

11 (5.9)

Reported partner-types

—

—

23.64

<.001

267.15

<.001

18.88

<.001

—

—

21.14

<.001

20 (19-22)

Academic classification

6+

P valueaMain partner(s)213 (60.2)

84 (50.3)

129 (69.0)

Casual partner(s)153 (43.2)

77 (46.1)

76 (40.6)

Hook-up partner(s)72 (20.3)

47 (28.1)

25 (13.4)

STI screening history< 7 months

153 (43.2)

53 (31.7)

100 (53.5)≥ 7 months

81 (22.9)

39 (23.3)

42 (22.5)

Never tested

80 (22.6)

51 (30.5)

29 (15.5)

No history of sexual intercourse

40 (11.3)

24 (14.4)

16 (8.6)

History of STI diagnosis

59 (16.7)

14 (8.4)

45 (24.1)

15.62

<.001

Concurrent sexual partners

68 (19.2)

38 (22.8)30 (16.0)

2.56

.11

Sex under the influence of drugs or alcohol

172 (48.6)

65 (38.9)

107 (57.2)

11.82

.001

Condom-less sex with a casual partner

106 (30.8)

44 (26.3)

65 (34.8)

2.92

.09

Condom-less sex with a hook-up/one-time partner

26 (7.3)

12 (7.2)

14 (7.5)

0.01

.91

Met sex partners using social websites or applications

56 (15.8)

39 (23.4)

17 (9.1)

13.47

<.001

Sex without discussing STI testing

134 (37.8)

62 (46.3)

72 (38.5)

0.07

.79

STI diagnosis history and risky behaviors in 12 months prior to studyaPartner type categories reported by participants are not mutually exclusive.

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Table 3. Behavioral attitudes and practices related to dyadic conversations on sexually transmitted infection (STI) testing among eSHINE Study online
survey participants, bivariate analyses by gender (n=354).
Variables

Total, n (%)

Men, n (%)

Women, n (%) Chi-square

Valuation belief for talking about STIs with partners (n=315)
Very important/important

312 (88.1)

137 (82.0)

175 (93.6)

Very unimportant/unimportant

3 (0.8)3 (1.8)0 (0.0)

Valuation belief for talking about STIs with partners when using condoms(n=263)
Very important/important

254 (71.7)

105 (62.9)

149 (79.7)

Very unimportant/unimportant

9 (2.5)6 (3.6)3 (1.6)

Self-efficacy belief to initiate risk discussions (n=213)
Very easy/easy

169 (47.7)

76 (45.5)

93 (49.7)

Very difficult/difficult

44 (12.4)

20 (12.0)

24 (12.8)

Intentional belief on likelihood to solicit STI screening from a partner(n=254)
Very likely/likely

226 (63.8)

93 (55.7)

133 (71.1)

Very unlikely/unlikely

28 (7.9)

15 (9.0)

13 (6.9)

Timing of STI testing talks with partners discussion (n=354)

P value

3.79

.05

2.29

.13

0.00

.95

1.57

.21

2.77

.43

Before sex

143 (40.4)

68 (40.7)

75 (40.1)

Sometimes before sex and sometimes after sex

145 (41.0)

64 (38.3)

81 (43.3)

After sex

15 (4.2)

6 (3.6)9 (4.8)Never

51 (14.4)

29 (17.4)

22 (11.8)

Condoms were being used

158 (44.6)

86 (51.5)

72 (38.5)

0.00

.97

The topic would make things awkward

100 (28.2)

47 (28.1)

53 (28.3)

0.14

.71

People can lie about it regardless

118 (33.3)

54 (32.3)

64 (34.2)

6.03

.01

The topic never came to mind

112 (31.6)

58 (34.7)

54 (28.9)

1.40

.24

Reasons for omitting dyadic STI health communication for sexual encounters in 12 months prior to study (n=354)

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Table 4. Perceptions on incorporating personal health records (PHRs) into risk discussion events among eSHINE Study online survey participants(n=354). STI: sexually transmitted infection.
Variables

Total, n (%)

Men, n (%)

Women, n (%) Chi-square

Semantic belief on the effect of electronic STI record access on communi-

P value

1.74

.19

0.19

.66

3.93

.05

0.53

.46

10.85

.001

6.48

.01

0.70

.40

24.14

<.001

1.49

.22

2.39

.49

cation on STIs between partners (n=227)a
Very helpful/helpful

225 (63.6)

105 (62.9)

120 (64.2)

Very harmful/harmful

2 (0.6)0 (0.0)2 (1.2)

Semantic belief on the effect of electronic STI record access on confidence
in STI testing information shared by a partner (n=238)a
Very helpful/helpful

235 (66.4)

108 (64.7)

127 (67.9)

Very harmful/harmful

3 (0.9)1 (0.6)2 (1.1)

Belief that electronic PHRs make it easier for potential partners to talkabout STI testing (n=213)a
Strongly agree/agree

197 (55 .6)

100 (59.9)

97 (51.9)

Strongly disagree/disagree

16 (4.5)

4 (2.4)

12 (6.4)

Belief that electronic PHRs make it easier to check-in with partners on
STI testing and prevention (n=206)a
Strongly agree/agree

195 (55.1)

93 (55.7)

102 (54.5)

Strongly disagree/disagree

11 (3.1)

4 (2.4)7 (3.7)

Belief that soliciting a partner’s electronic record will be awkward (n=171)a
Strongly agree/agree

85 (24.0)30 (18.0)

55 (29.4)

Strongly disagree/disagree

86 (24.3)

52 (31.1)

34 (18.2)

Self-efficacy belief for sharing a positive electronic STI record with apartner (n=213)

aVery easy/easy

59 (16.7)

36 (21.6)

23 (12.3)

Very difficult/difficult

154 (43.5)

64 (38.3)

90 (48.1)

Belief that partners using electronic PHRs will start talking about STI
prevention earlier in a relationship (n=200)a
Strongly agree/agree

184 (52.0)

89 (53.3)

95 (50.8)

Strongly disagree/disagree

16 (4.5)

6 (3.6)

10 (5.3)

Intentional beliefs to only use electronic PHRs when distrusting of partners(n=232)Strongly agree/agree

93 (26.3)

62 (37.1)

31 (16.6)

Strongly disagree/disagree

139 (39.3)

47 (28.1)

92 (49.2)

Attitudinal belief of being suspicious of partners unwilling to share electronic PHR (n=270)a
Strongly agree/agree

268 (75.7)

117 (68.9)

153 (81.8)

Strongly disagree/disagree

2 (0.6)0 (0.0)2 (1.1)

Preferred method for sharing a positive infection status (n=354)aUsing an electronic PHR

81 (22.9)42 (25.2)

39 (20.9)

A conversation without electronic PHRs

158 (44.6)

68 (40.7)

90 (48.1)

Avoid sharing infection status

16 (4.5)9 (5.4)7 (3.7)

No preference

99 (28.0)

48 (28.7)

51 (27.3)

Scores between –1 and 1 for belief variables are not reported.

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Figure 1. Perceived sexually transmitted infection communication timing with sexual partners with and without electronic personal health record (PHR)
access among eSHINE Study online survey participants (n=354). The Wilcoxon signed-rank test indicates significant increases in perceived discussion
timing before sex with electronic PHR access (P< .001).

Discussion
Principal Results
Together, qualitative and quantitative findings offer several
considerations for the potential role of electronic PHRs in
facilitating STI health communication between partners. STI
health communication is generally an important practice for ourstudy population; however, whether and how discussions occur
are functions of multiple individual and dyadic level factors.
Inability to validate disclosed STI testing information, low
personal agency for initiating discussions, nonawareness of STI
testing talks as a health practice, and low discussion valuation
related to partner-type or condom use may inhibit STI healthcommunication from occurring. Electronic PHR access for STI
screenings pose a viable solution to barriers preventing STI
talks. Participants anticipate that access will be accompanied
by testing discussions earlier in relationships and more
frequently occurring prior to sexual encounters. Electronic PHRs
are expected to add novel validation to screening information
shared by partners and make it easier to initiate conversations.
Male participants were more likely to believe electronic PHRs
improve self-efficacy for discussions and in their ability to sharepositive results. Thus, electronic PHRs additionally offer new
avenues for increasing male participation in STI prevention.
Self-reported behaviors potentiating STI transmission such as:
sex without discussing STI testing, partner concurrency, sex
while intoxicated, and condom-less sex practices is evidenceof the need to continue targeting young black populations for
STI interventions. Our study supports an increasing amount ofburgeoning research on the feasibility and acceptability ofdelivering effective sexual health interventions through weband mobile-based platforms [17,19,30-32]. Furthermore, it
provides new insight into the role of patient electronic accessin improving dyadic communication on STI risk. Participants
almost ubiquitously anticipate that refusing to share STI
screening results will warrant partner suspicion. These beliefs
perhaps indicate that electronic PHR access will influence
decisions related to sexual behavior.
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Limitations
This study has many strengths and limitations. Our findings
offer rich data on electronic PHR access beliefs within our
sample population in context of when, how, and why STI talks
occur. The mixed-methods design allowed us to formatively
identify important variables to study quantitatively for a novel
practice. Similarly, the context of perceptions emerging fromour study is largely in absence of prior participant exposure toelectronic PHR access. Resources were not available for research
assistants nor secondary coders; thus, qualitative findings lackinter-coder reliability and are therefore subject to researcher
biases. Additionally, significant differences were observed inacademic classification by gender in our non-random
convenience sample of online survey participants.
Although we determined that many participants reported
electronic PHR access would lead to earlier dyadic talks on STI
prevention, future studies are needed to better understandwhether electronic PHR access would truly extend proximity
in time between STI talks and sexual encounters. Furthermore,
to determine whether an increase in time between the two events
minimizes the length of time to next STI screening between
dyad members.
Low self-efficacy beliefs for sharing positive electronic results
are likely an indicator of stigma associated with being diagnosed
with an STI. Given the sample, our study does not provide
substantial insight into perceptions about electronic
PHR–facilitated STI talks among people with chronic infections
like HIV and genital herpes. Nevertheless, reducing stigma andenabling individuals infected with STIs to safely andcomfortably disclose infection status to partners remains animportant challenge to prevention and care. Reducing stigma
associated with discussing infection with partners may reducebehaviors that accompany non-disclosure of diagnosis, such as
condom-less sex; in addition to stigma-related impacts on the
HIV treatment cascade [33-36]. Future studies are needed to
explore feasibility of addressing stigma-related outcomes withelectronic PHRs.

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JMIR MEDICAL INFORMATICS

Conclusions
mHealth interventions incorporating electronic PHRs will offer
new insight into strengthening infrastructure and the capacity
to target disparities in STIs. Findings suggest that access toelectronic PHRs for STI screening among subpopulations ofblack youth may improve both motivation and personal agency
for initiating dyadic talks about testing. Results from this study
will likely inform novel interventions that use access toelectronic PHRs to stimulate important health-related
discussions between sexual partners. The preventative capacityof electronic PHRs envisioned by our sample cannot be achieved

Jackman et al
without policies that support equipping them with patient portal
access to STI screening records. Messages presented byhealthcare providers on adopting electronic PHR–delivered STI
results and electronic PHR–facilitated risk discussions willundoubtedly be key in adoption decisions. Moving forward
requires studying strategies for implementing interventions thatleverage electronic PHRs to create new sexual healthcommunication channels with providers, peers, and family
among black youth. With anticipated proliferation of electronic
PHR adoption in generations to come, close attention is needed
to ensure that black youth have equitable healthcare access toquality electronic PHR services [36].

Acknowledgments
The eSHINE Study was supported by a 2014-2016 dissertation research grant (R36HS023057) from the Agency for Healthcare
Research and Quality (AHRQ). R36HS023057 Project Mentor, Farin Kamanagar, MD, PhD, MPH (Associate Dean for Research,
Morgan State University (MSU), School of Computer, Mathematical and Natural Sciences) and Dissertation Committee Chair,
Bazle Mian Hossain PhD, MHS, MS (Professor, MSU, School of Community Health and Policy). Manuscript development was
funded by a 2017-2019 T32 NRSA Postdoctoral Training Fellowship in HIV Epidemiology and Prevention Sciences(2T32AI102623-06) within the Johns Hopkins University Center for Public Health and Human Rights. SDB’s effort was fundedin part from the Johns Hopkins University Center for AIDS Research, an NIH funded program (P30AI094189), which is supportedby the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA,
FIC, NIGMS, NIDDK, and OAR. The content is solely the responsibility of the authors and does not necessarily represent theofficial views of the NIH nor AHRQ.

Conflicts of Interest
None declared.

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Abbreviations
CDC: Centers for Disease Control & Prevention
CMS: Centers for Medicare & Medicaid Services
DOI: Diffusion of Innovation Theory
eSHINE: Electronic Sexual Health Information Notification and Education
HITECH: Health Information Technology for Economic and Clinical Health Act
HSV-2: herpes simplex virus-2
IMBP: Integrative Model of Behavioral Prediction
MSM: men who have sex with men
PHR: personal health record
PI: principal investigator
STI: sexually transmitted infection

Edited by G Eysenbach; submitted 21.10.17; peer-reviewed by HJ Rendina, R Robbins, M Gallo, T Winder; comments to author
07.12.17; revised version received 01.02.18; accepted 15.04.18; published 12.07.18
Please cite as:Jackman KM, 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 StudyJMIR Med Inform 2018;6(3):e41
URL: http://medinform.jmir.org/2018/3/e41/
doi: 10.2196/medinform.9174
PMID: 30001998©Kevon-Mark Jackman, Stefan David Baral, Lisa Hightow-Weidman, Tonia Poteat. Originally published in JMIR Medical
Informatics (http://medinform.jmir.org), 12.07.2018. This is an open-access article distributed under the terms of the Creative
Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work, first published in JMIR Medical Informatics, is properly cited. The
complete bibliographic information, a link to the original publication on http://medinform.jmir.org/, as well as this copyright andlicense information must be included.

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JMIR Med Inform 2018 | vol. 6 | iss. 3 | e41 | p. 14(page number not for citation purposes)