XatJove Anoia, as a tool to bring health services closer to teenagers (Preprint)
Authors: Sauch Valmaña Glòria , Vidal-Alaball Josep , Garcia Victoria , Testoni Giorgia , Espelt Albert , Exposito Karen , Saigí Francesc , Carré Núria , Vicens Victor 
Published: October 2020

BACKGROUND

The internet has become an important tool for many people with health concerns, especially for adolescents. Concerns regarding confidentiality, coupled with the stigma and shame associated with certain conditions, especially sexually transmitted infections and other health-related problems make the internet a safe environment within which adolescents can seek information. This is thought to lead to an under-utilization of traditional providers such as primary care health services.
Such consultations, which are often made by young people, include sexual and reproductive health problems and mental health disorders. This can be a major problem, since the under-utilization of primary care services for certain topics and the search for advice on the internet which may not be trustworthy can subsequently lead to health related complications that may require more expensive specialized medical interventions in the long-term. This could ultimately result in an increase in healthcare costs.
Programs such as Health and School aim to improve the health of adolescents through health promotion measures, risk prevention and early care for problems related to mental health, emotional and sexual health and the consumption of drugs, alcohol and tobacco, in collaboration with schools and community health services present in the territory.
Patients in general and adolescents in particular are often reluctant to seek counselling and/or health treatment for "embarrassing" or stigmatized conditions, which can lead to them underutilizing primary care health services. In addition, searching for medical information on the internet, for example via Google, is increasingly common. These consultations, often made by young people, include sexual and reproductive health problems [1] and mental health disorders [2]. This could lead to serious problems, since the underutilization of primary care services for certain issues and seeking online advice which are often untrustworthy can subsequently lead to health complications which may require more expensive specialized medical interventions in the long run and may therefore result in increased care costs [3].
To avoid this situation, a tool is required to which adolescents have easy, constant and effective access. Digital health interventions have been shown to minimize hesitancy in seeking health advice on stigmatizing and embarrassing problems. Innovations in digital health proposed by the company Abi Global Health (AGH) could be a possible solution [4]. AGH has developed an asynchronous mobile text-based communication agent which connects users with healthcare professionals. These professionals provide appropriate guidance to users to help them make informed decisions about their health. AGH already operates in more than ten countries with a network of more than 300 health professionals. This pre-existing tool will form the basis of XatJove Anoia [‘YouthChat Anoia’]. According to a pilot study on e-Consulta (known at the time as WebGP), cystitis and (women’s) contraceptive problems were among the top ten reasons why patients used the virtual tool to conduct a consultation [5]. Although these conditions can be embarrassing and difficult to talk about, nevertheless, it is important that they are dealt with by healthcare professionals. If ignored, these conditions can lead to serious, unwanted, and costly complications (a failure to use contraception can lead to unwanted pregnancies and sexually transmitted diseases. [6,7] The fact that users routinely report these problems by means of digital health interventions such as e-Consulta is a positive sign with regard to the greater use of health services for sensitive yet serious conditions. As an anonymous digital health intervention, XatJove has the potential to address inefficiency of costs caused by the underutilization of health services in terms of embarrassing and stigmatized disorders.
In the current climate of a health crisis caused by the COVID-19 pandemic and in an attempt to reduce the risk of infection, it makes more sense than ever to try to avoid face-to-face consultations with nursing staff in schools and also visits by young people to Primary Care Centres (PCCs). It should be borne in mind that this does not mean there will be a reduction in the number of consultations on issues related to the health and school program. On the contrary, the health crisis is expected to generate an increase in the need for emotional support for young people and it requires agile tools which make use of technology which this sector of the population is familiar with and uses regularly [8].
The main objective of this study is to show that the use of mobile phones and messaging apps leads to an increase in the number of health consultations by adolescents aged between 12 and 16 as part of the Health and School program in the Anoia region.
Evaluating the satisfaction of XatJove users.
The main hypothesis is that the use of XatJove improves the early detection of problems, young people’s accessibility to reliable information and communication with nursing professionals in the PCCs in relation to issues related to drugs, diet, emotional health and sexuality as well as helping to detect cases of child abuse.

OBJECTIVE

The main objective of this study is to show that the use of mobile phones and messaging apps leads to an increase in the number of health consultations by adolescents aged between 12 and 16 as part of the Health and School program in the Anoia region.
Evaluating the satisfaction of XatJove users.

METHODS

Study design
Quasi-experimental study comparing the total number of consultations (face-to-face and via XatJove) as part of the Health and School program in the Anoia region during the 2020-2021 academic year with the number of face-to-face consultations as part of the same program in the Osona region.
Scope and period of study
Scope: Anoia (intervention group) and Osona (control group) regions.
Study period: 2020-2021 academic year.
Problems which affect adolescents related to mental health, emotional and sexual health, drug use, alcohol and tobacco will be recorded.
Study population
Adolescents aged between 12 and 16 attending secondary schools in the Anoia region.
Sample size and sampling procedure
The total number of visits (face-to-face and via XatJove) as part of the Health and School program in the Anoia region during the 2020-2021 academic year will be recorded.
Universal variables: Sex, age
Dependent variables:
Study period: 2020-2021 academic year.
Total visits (face-to-face and via XatJove) as part of the Health and School program.
Independent variables:
Subject of the consultations: sexual health, alcohol, drugs, eating disorders, bullying, domestic abuse, mental health, COVID-19, other.
Students will be asked to participate in a follow up study involving a focus group to learn more about the usefulness of XatJove.
Data collection and sources of information
The platform made available by AGH makes it possible to collect information concerning the cases involving a written query. User data can be obtained by means of this database (users will remain anonymous). The information will include: age, gender, date and time of the query and the answer. In addition, all the professionals involved will sign a document in which they agree to respect data confidentiality.
At the end of each response from a healthcare professional, the user will be able to respond to a questionnaire in which they can evaluate the quality of the service and their level of satisfaction (see Appendix 1). The data in this questionnaire will also be collected and processed by AGH.
Statistical analysis
Spreadsheets will be used to record the mean and median of the various fields. The statistical analysis will be carried out on the data entered by the users in the registration form and on the date collected via the questionnaire that will be sent after the consultation is concluded. The questionnaire consists of multiple-choice questions, making it possible to assign a numerical value to the various answer options which can be used in the corresponding statistical analysis.
Questionnaire:
Age in years
Sex: M, F, other
Have we helped you solve a problem related to your health or well-being? (1 = insufficient; 5 = excellent)
Would you have made an appointment with your PCC or the Health and School program for this problem? (yes/no)
Would you recommend this service to a friend, family member or acquaintance? (1 = no; 5 = strongly agree)
Would you be prepared to take part in a follow up study on XatJove? If so, please provide an email address or mobile phone number so we can contact you.
Limitations of the study
An insufficient number of users who rate the service and respond to the questionnaire. If this happens, the deadline for more data could be extended.
It will be possible to send questions via XatJove 24 hours a day. Answers will only be sent during specific time slots (from 8 am to 8 pm, including weekends). This may limit access, however, any inquiries made outside of this time slot will be responded to by the medical professionals at the start of their working day.
As this is an anonymised service, it will not be possible to verify whether users meet the inclusion criteria. Nevertheless, the service will only be offered to pupils at secondary schools in Anoia.

RESULTS

The IDIAP Jordi Gol (Barcelona, Spain) independent ethics committee has approved the trial study protocol, code 20/137-P. It has been registered at the Clinical.Trial.gov registry NCT04562350 (24 September 2020).
The study is projected to start at the beginning of November 2020 and its will finish in June 2021 when data analysis is expected to start.
Written informed consent will be requested from all patients participating in the study.

CONCLUSIONS

This aim of this pilot study is to investigate the use of a health chat service using mobile phones involving adolescents from secondary schools in Anoia and nursing professionals from PCCs in the same region.
The various studies we have previously participated in have shown that the use of a virtual communication tool involving patients and professionals reduces the number of face-to-face visits [9], which is a very positive aspect during a pandemic.
The results and the impact of the service in both the short and the long term will be used to revise the Health and School programs offered by the Department of Health. In other words, it is a tool which will serve to review existing protocols. Virtual visits and consultations are gaining in popularity in the new healthcare arena, particularly as a result of the COVID-19 pandemic.
Offering online consultations could help avoid self-diagnosis, since it is common for people to search for information on the internet, which is not always reliable.
Current evidence points to the importance of innovating and improving the treatment processes offered by these programs.
We feel that one of the study’s strengths is that the results will be obtained from usual clinical practice without considerable organizational or structural changes.

CLINICALTRIAL

NCT04562350 (Registration data September 24, 2020)