HIV Prevention (Responsive Web-based) App

ITP student Sonia K. González (Public Health) reflects on her independent study project 

HIV Prevention (Responsive Web-based) App

Photo by Jacinta Lluch Valero on Flickr

Introduction/ Overview

I entered the Interactive Technology & Pedagogy (ITP) certificate program with over 15 years public health experience. I primarily worked to prevent HIV, other STDs, and unwanted pregnancy with young people under 24 years old in Austin, Texas and in New York City. Through this work, I developed a commitment to reproductive justice. In addition to the ITP certificate program, I am also a doctoral candidate in Public Health at the CUNY School of Public Health. For the ITP Independent Study (IS), I developed a beta version of a sexual health education app and conducted focus groups to pretest an early version of the app. Knowing that young people spend many hours on their phones, as a public health doctoral student, I sought a way to supplement my technological skill sets, which led me to the Interactive Technology Pedagogy (ITP) Certificate.

Why focus on Young Women of Color in NYC?

In brief, the STD rates among young women of color are staggeringly high throughout the country and especially in NYC.

Sexual Health Disparities: In 2012, new HIV infections in the U.S were highest among young people aged 20 to 24 (36.3%), Black individuals (58.3%) and young Black women and Latinas compared to White women(Centers for Disease Control and Prevention, 2014). HIV incidence rates among youth in the U.S. by race have either remained constant or are increasing (Prejean et al., 2011). In fact, people ages 15 to 29 accounted for the largest share of any age group: 71.8% of new HIV infections in 2012, primarily via sexual transmission (Centers for Disease Control and Prevention, 2014).

HIV and Women: The HIV epidemic continues to disproportionately affect vulnerable communities, especially young people of color in urban areas (Centers for Disease Control and Prevention, 2014). Total HIV diagnoses in New York City (NYC) in 2013 over-represent Blacks (42%) and Latinos (34%) versus Whites (18%) (Epidemiology, Field Services Program, & Hygiene, n.d.). Over half of Black (57%) and a third of Latina (30%) women receive a concurrent HIV and AIDS diagnoses in NYC (Epidemiology et al., n.d.); suggesting that they are not being tested prior to experiencing symptoms, which can hinder infection management and result in unwittingly placing others at risk for contracting HIV whereas treatment reduces viral load and thus, transmission (Centers for Disease Control and Prevention, 2014; Cohen et al., 2011; Epidemiology et al., n.d.). Known barriers to accessing healthcare among young Black and Latina women include cost, distance, and lack of knowledge regarding need for preventive healthcare (Allison et al., 2012; Malbon & Romo, 2013; Sumartojo, Doll, Holtgrave, Gayle, & Merson, 2000; Sumartojo, 2000).

Low STD testing rates: The CDC reports that most young people are not getting tested for HIV: 60% of all youth, with HIV do not know their status and that they can infect others. In addition, the asymptomatic nature of Chlamydial (Berman & Ellen, 2001; Scholes et al., 1996; Stamm, n.d.) and Gonococcal (Marrazzo, Handsfield, & Sparling, n.d.) infections in women, discourage women from seeking early treatment, leaving them susceptible to unwittingly transmit their infections and to long-term health consequences such as Pelvic Inflammatory Disease (PID). Bridging the gap to testing and treatment is essential to combating HIV and other negative SRH consequences, an app that provides free access to National peer educators as well as directions to nearby clinics could offer an important tool to combating HIV and other STDs. Two controlled trials of chlamydia screening suggest that screening reduce PID incidence. (Oakeschott et al., 2010; Scholes et al., 1996).

In addition, 82% of pregnancies are unintended for women between ages 15 and 19 years (Dalby, Hayon, & Carlson, 2014). Further, since 2010, women ages 20 to 24 and 15 to 19 had the highest and second highest Chlamydia rates respectively compared with any other age or sex group (Disease Control & Prevention, n.d.; Haggerty et al., 2010).

Why an app?

The data show that young people are early adopters of new technology. The questions I wanted to explore through my research were: if I build an app with community input, is it something that could be useful to young women in NYC? Would they be interested in it? Would they use it regularly? Or only in instances of “crisis” i.e., the condom broke, or I think I might be pregnant – where do I go from here? I know this may sound hyperbolic, but in a young person’s life, these situations constitute moments of crisis.

These questions are complicated for a number of reasons. First, what would young Black and Latina women want to see in such an app? Second, would the same app be culturally appropriate and meet the needs for both young Black and Latina women? They are obviously different ethnic groups, but are they similar enough to be a singular target audience for this app?

An app offers accessibility anytime and anywhere, as long as the phone battery is charged. This includes a range of private to public settings i.e., bedrooms, bathrooms, on public transportation, in cars, etc. In addition, an app that can be accessed on a phone or a tablet is relatively private. Sexual health is still relatively taboo in this country, and there is a wide range of sexual health education across the county, even within cities.

Connecting the Pieces

In the ITP courses, I learned about usability constructs and applied them to developing a web- based sexual health education tool: usability, user interface (UI), user experience (UX) and user-centered design (UCD); these are fundamental concepts for those interested in technology development. I briefly summarize these concepts here.

Designing user-centered interactive digital technology Usability is a product design process incorporating direct user feedback throughout the interactive digital technology development process to meet user needs; (Usability Professionals’ Association,) and is an inherent measurable property of all interactive digital technologies. (Cockton, 2013) The International Organization for Standardization (ISO 9241-11) defines usability as, “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use”.(Usability Professionals’ Association, ) The U.S. Health and Human Services adds that usability, “refers to the quality of a user’s experience when interacting with products or systems, including websites, software, devices, or applications,” and includes a combination of the following characteristics: intuitive design for the architecture and navigation of the site, ease of learning, efficiency of use, memorability to effectively use it during future visits, error frequency and severity and the ability to recover, and subjective satisfaction (i.e. if the user likes using the system).(U.S. Dept. of Health and Human Services, )

Usability and User-Centered Design Methodology

To achieve positive usability experience and successful user-centered design, teams draw from the following potential processes: understand the context in which users may use the interactive digital technology through personas, and scenarios; design the technological product through visualizations, defining what the site requirements will be, performing card sorting, developing a prototype and launching it; and finally, testing and refining the product through an iterative process (Bowles & Box, 2011; Per Axbom, 2011; U.S. Dept. of Health and Human Services, 2013b). The design team determines which components are implemented, usually driven by the target population and the specific interactive digital technology in development. An example of implementing this process is Rapid Prototyping (RP), an iterative development process involving user input with roots in UI design (Najjar, 1990). First, the design team identifies user needs, general requirements for the product, the objects (i.e. information memo) and actions (i.e. providing directions to health clinics) and assembles these objects and actions in a logical way for target users (Najjar, 1990). Then they develop visual representations known as mock-ups, wireframes, blueprints, sketches and prototypes of an interactive technology product used for early testing, prototyping or proof-of-concept (Per Axbom, 2011). During this phase, designers obtain feedback from other developers and experts who have knowledge and interest in the product to improve the prototype iteratively (Najjar, 1990). The prototype code is then converted into actual code, during which users representing the target population provide feedback to refine code and repeat this process until users respond favorably to the proposed product visualization. User feedback is solicited through a variety of methods including: individual interviews, focus groups, contextual inquiry, surveys, usability testing, card sorting, and analytics (Bowles & Box, 2011). Once again, through an iterative process, prototype code is improved upon until users respond well to the visualization of the proposed product (Najjar, 1990). Finally, the interactive digital technology is released.

It is critical to gather user needs and expectations for design and user interaction design along the way (Hassenzahl, 2013; Moreno et al., April 2013). By conducting usability testing such as RP, the designer is able to make modifications to visualizations and add requirements to make the end product more usable and desirable for the target population. Similarly, the RP process includes other key stakeholders and coding experts to provide early input to work alongside as the code is developed. Finally, this process reduces time required to create a functional product by utilizing prototypes to save significant documentation time and promotes comprehension of concepts by the intended target population. However, a criticism is that the iterative process lacks a clear stopping point. Similar to qualitative research where data collection continues until saturation is reached, there is no standardized end point (Najjar, 1990). Repeating iterative phases until users respond well to that version is subjective and the designer or design team must be able to establish an end point for that version. An important consideration is how many users are needed for usability testing. This consideration is akin to public health researchers calculating power analysis. Nielsen and Landauer established the following formula: where N is the total number of usability problems in the design, L is the proportion of usability problems discovered while testing a single user; therefore, the number of usability problems found in a usability test with n users is: N (1-(1-L)n) (Nielsen & Landauer, 1993; Nielsen, 2000). The first, second, and third test users will identify the most usability problems, but up to five users provide designers with a range of issues that can be addressed; adding more users allows designers to learn less with more tests. While Nielsen and Landauer demonstrated that at least 15 users reveal all usability problems (Nielsen & Landauer, 1993); a more cost-effective approach is to conduct multiple tests with 5 users each to achieve the goal of improving the design and not simply documenting its weaknesses.(Nielsen, 2000). In general, three to four users from each subpopulation of highly distinct groups of users are recommended for two groups of users, or three users from each subpopulation for three or more groups of users; a minimum of three users is recommended to ensure the diversity of the behavior within the group has been covered (Nielsen, 2000).

Limitations of Usability, UX and UCD Concepts

The various design fields covered here are evolving and one of the challenges is a lack of clear definitions and a prolific use of jargon (Bowles, 2013; Carroll, 2013; Hassenzahl, 2013; U.S. Dept. of Health and Human Services, 2013a) with a tendency to collapse all design-related issues under the label of “usability” (Morville, 2004). Circa 2004, Morville created the UX honeycomb still in use today with the following UX constructs: useful, usable, desirable, findable, accessible, credible, valuable (Morville, 2004). While there is some debate as to whether the constructs are a subset of the pillars of information architecture (e.g., context, content, and users), the visualization serves to begin a conversation to prioritize UX needs (Morville, 2004). Different terminology has implications on viewing the construction of software development differently in part because of the various perspectives that each discipline or approach offers. This has implications for understanding constraints and limitations under which the other communities must operate (Moreno et al., April 2013).

One of the challenges of conducting usability or UCD testing is the proliferation of informal literature about how to conduct usability testing. Krug, for example has written two books, one of which is dedicated to coaching non-professionals on executing usability testing. The recommended methods are not rigorous (nor does he claim them to be) such as only using three testers and suggesting taking a non-targeted approach to recruiting users is just as good as using intended users (Krug, 2010). Public health practitioners who are implementing usability practices to build good design and others should be aware of and avoid such recommended practices.

Learning by Doing: From Wireframes to App Prototype Testing

Prior to starting the coding process, ITP Core II provided a forum to teach technology. A few key concepts stand out: first, Professor Michael Mandiberg presented the notion of “failing forward”, which highlights the importance of learning from mistakes to advance progress; I still celebrate when I get a new error as I believe this is an indication of progress. This approach was instrumental in getting me to the next step (and the next one) and kept me focused on one small task rather than getting overwhelmed by the entire project. Getting Real was another important reading that helped me get started and maintain on-going progress. Perhaps one of the most salient messages that influenced me from Getting Real was that the best way to learn most things is by doing and that developing technology is no exception. I revisit this reading as I move forward with each new phase of my dissertation.

My initial concept for my ITP IS was to rework a sexual health app created by Jenny Blevis, “Chat About That”. I opted to create my own app because Ruby on Rails seemed a more accessible programming language to learn and maintain. Once I made the decision to make my own app, I began to think about the technical pieces that would be required to build an app. First I had to decide if the app was going to be a responsive website or if I would build an app on a native platform that was specific to the Apple or Android platforms. I did not want to build two apps and have them work differently on different platforms, nor did I want to exclude participants based on the kind of phone they had, so I decided to make a responsive web-based application. Through this process there was a lot of failing forward. I explored webinars and other online learning opportunities through sites such as, and Code Academy; however, the amount of information and the number of options were overwhelming. So I relied on my network to help me proceed. By speaking with people with technology expertise from academia, community based organizations, and for-profit tech spheres, I was able to advance the project. These discussions helped me remember to return to developing minimum viable cases and products and personas, an exercise I first did during ITP Core II to identify what gap I was filling with my app, for whom, and how (what the app was going to do?). Here is a link to the closed website that captures this process.

Learning Technology

ITP Core II teaches one how to approach learning technology. This section details the choices made in developing the sexual health education web-based app, which others might learn from in their own efforts to develop interactive technology. Approaching technology projects is akin to learning a language or statistical programming software: regular exposure and constant immersion result in a steeper learning curve. Two class exercises early on in particular helped me become comfortable learning different forms of technology: 1) posting to Wikipedia and “playing in the sandbox”, both as an individual creating a page and collaboratively adding to an existing wiki page in small groups; and 2) using a WordPress blog to interact with fellow students. These exercises built my confidence around learning how to develop technology, as they allowed me to learn basic skills, including HTML, using widgets, and searching web sites such as to address errors. In addition, I learned common technology practices in safe spaces where “breaking” things was not a concern.

Introductory technology workshops were another important step to learning technology. I took a variety of in-person hands-on ITP skills workshops, including Adobe Photoshop, ARC GIS, visualization workshops, and data mining discussions. In addition, the primary author was a member of the New Media Lab (NML), which works with Graduate Center and CUNY faculty and doctoral students to conceive and create groundbreaking multimedia projects based on student and faculty scholarly research. The NML’s goal is to, “integrate digital media into traditional academic practice, challenging scholars to develop fresh questions in their respective fields using the tools of new technology.” Having classmates and an appointment at the NML allowed me to lean on others for technical support and to have a community of people who were experiencing similar challenges. In addition, the NML was another forum to present obstacles as they arose and brainstorm solutions.

There were two critical junctures to developing this app. One was when I began using Balsamiq to generate wireframes (or sketches). This step allowed me to articulate and envision the appearance, content and design of the app. Prior to this step, conversations about my project were very abstract. The act of putting my ideas on paper transformed the project from a theoretical concept to something that was real, and having a wireframe made it far easier to communicate with people about my project. The other pivotal point came from a classmate, who emailed me an announcement for a webinar for $20 called Teach Yourself to Code: One Month Rails. It was through this guided process that I built confidence and started believing that I could make an app. I completed the initial sessions as instructed, but quickly adapted the process for my own needs. I set up the Ruby on Rails (RoR) 9.2.0 environment, installed appropriate gems as the Skillshare webinar instructed, and launched the app on Heroku. I am still very much a novice RoR user, but rolling up my sleeves to set up the beta version of the app gave me to the opportunity to learn the environment and how to troubleshoot. Haing this foundation allowed me to be able to have informed conversations with my RoR developer who I later hired to build out the full app version.

Products, Findings and Conclusions

Building an app is hard work, but it’s also really fun and rewarding. I found that the young women want information they can trust. Young women of color are known to be early adopters of technology and it is critical that public health practitioners figure out how to “meet them where they are”. So even if I’m not necessarily interested in making apps for a living, I am grateful to the ITP program to learn enough to be able to communicate with coders who are. Having invested this time in learning technical skills will allow me to launch a public health career that includes technology as a central focus to addressing public health needs.

Concluding thoughts for ITP students and others taking on their first tech project. Having a vision is important, but the way to getting this work accomplished is by taking on small, discreet tasks.

  • An achievable task gets done; too many large pieces are overwhelming. So I recommend finding ways to break things down to small achievable parts.
  • Celebrate new error messages, it means you have moved past the last error message.
  • If you are at the Graduate Center, use their resources: the knowledge base and camaraderie found at the New Media Lab fueled me. The Digital Fellows have office hours, use them.

Allison, Susannah, Jose A Bauermeister, Sheana Bull, Marguerita Lightfoot, Brian Mustanski, Ross Shegog, and Deb Levine. 2012. “The Intersection of Youth, Technology, and New Media with Sexual Health: Moving the Research Agenda Forward.” Journal of Adolescent Health 51 (3): 207–12.

Berman, S M, and J M Ellen. “Adolescents and STDs Including HIV Infection.” In: P F Sparling, W E Stamm, P Piot, J N Wasserheit, L Corey, M S Cohen, and D H Watts (editors). Sexually Transmitted Diseases, 4th Ed. New York: McGraw Hill Medical; 2001: 165–85.

Centers for Disease Control and Prevention. 2014. “HIV Among Youth: Age, Risk & HIV/AIDS.”

Cohen, Myron S, Ying Q Chen, Marybeth McCauley, Theresa Gamble, Mina C Hosseinipour, Nagalingeswaran Kumarasamy, James G Hakim, et al. 2011. “Prevention of HIV-1 Infection with Early Antiretroviral Therapy.” N Engl J Med 365 (6): 493–505.

Dalby, J, R Hayon, and J Carlson. 2014. “Adolescent Pregnancy and Contraception.” Primary Care 41 (3): 607–29.

Epidemiology, H I V, New York City Department of Health Field Services Program, and Mental Hygiene. “HIV Surveillance Annual Report, 2013.”; Disease Control, Centers, and Prevention. “Trends in Reportable Sexually Transmitted Diseases in the United States, 2007: National Surveillance Data for Chlamydia, Gonorrhea, and Syphilis.”

Haggerty, C L, S L Gottlieb, B D Taylor, N Low, F Xu, and R B Ness. 2010. “Risk of Sequelae after Chlamydia Trachomatis Genital Infection in Women.” J Infect Dis. 201 (Supplement 2): S134–55.

Malbon, K, and D Romo. 2013. “Is It Ok 2 Txt? Reaching out to Adolescents about Sexual and Reproductive Health.” Postgrad Med J 89: 534–39.

Marrazzo, J M, H H Handsfield, and P F Sparling. “Neisseria Gonorrhoeae.” In: Mandell GL, Bennett JE, Dolin R (editors). Principles and Practice of Infectious Diseases, 7th Ed. Philadelphia, PA: Churchill Livingstone; 2010: 2753-2770.

Oakeschott, P, S Kerry, A Aghaizu, H Atherton, S Hay, and et al. 2010. “Randomised Controlled Trial of Screening for Chlamydia Trachomatis to Prevent Pelvic Inflammatory Disease: The POPI (prevention of Pelvic Infection) Trial.” BMJ 340: c1642.

Prejean, J, R Song, A Hernandez, R Ziebell, T Green, F Walker, L S Lin, et al. 2011. “Estimated HIV Incidence in the United States, 2006–2009.” PLoS ONE 6 (8).

Scholes, D, A Stergachis, F E Heidrich, H Andrilla, K K Holmes, and W E Stamm. 1996. “Prevention of Pelvic Inflammatory Disease by Screening for Cervical Chlamydial Infection.” N Engl J Med 34 (21): 1362–66.

Stamm, W E. “Chlamydia Trachomatis Infections in the Adult.” In: Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, et Al, (editors). Sex Transm Dis. 4th Ed. New York: McGraw-Hill; 2008: 575-93.

Sumartojo, E. 2000. “Structural Factors in HIV Prevention: Concepts, Examples, and Implications for Research.” AIDS (London, England) 14 Suppl 1: S3–10.

Sumartojo, E, L Doll, D Holtgrave, H Gayle, and M Merson. 2000. “Enriching the Mix: Incorporating Structural Factors into HIV Prevention.” AIDS (London, England) 14 Suppl 1: S1–2.