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New Frontiers: Using The Internet To Engage Teens In Substance Abuse Prevention and Treatment
By: Harvey Skinner, Oonagh Maley, Louise Smith, Meg Morrison & Shawn Chirrey

Table Of Contents

• Summary
• Internet: New Frontier
• TeenNet Project
• Teens In Action - The Birth of CyberIsle
• A Walk Through Cyberisle
• Evaluation What Do Youth Think About CyberIsle?
• HotTalk: Analysis of Peer Discussion Groups
• Quantitative Results
• Engaging Hard to Reach Population: Street Envolved Youth
• Teen Clinic Online (TCO)
• Conclusion
• References
• Table 1

The research for this chapter was supported, in part, by a grant to Dr. Harvey Skinner (Principal Investigator) from the Hospital for Sick Chlidren Foundation, Toronto.

In Peter M. Monte, Suzanne M. Colby and Tracy A. O'Leary (Eds.), Adolescents and Substance Abuse. New York: Guilford, 1999, in press.

Today's youth have access to more health information than ever in the past. Yet, health risk behaviors such as cigarette smoking, excessive drinking and drug abuse have increased over the past 15 years. The major challenge is: How do we engage youth in health promotion? We live in a highly media oriented world. Music videos and computer games use a dynamic approach that appeals to teens. The Internet, in particular, provides innovative opportunities for reaching youth, including those turned off by traditional health education approaches.

This chapter describes opportunities for using the Internet for substance abuse prevention and treatment with adolescents. A model (Seven Critical Functions) is presented for identifying ways of using information technology (Internet) to support both practitioners and youth in health behavior change. Practical examples are given from the TeenNet project, which has developed an interactive Website for youth called CyberIsle. Information is presented in a non-judgmental, fun environment through quizzes, simulations, fact sheets, self-assessments, personalized feedback and peer discussion groups. A parallel Website called the Practitioner Forum provides practical guidelines and skill-based learning for clinical care and health promotion with youth in health and educational settings. What makes the TeenNet project unique is the interweaving of 'high tech' Website development and community involvement using an action research model.

"Without technological equity, the academic achievement gap between groups can only widen, and that gap will threaten the prospects for employment, community inclusiveness, and ultimately, health in the future." Nancy Milio (1996, p. 113).

We face a dilemma in health promotion with respect to adolescents. This is the developmental stage when potential health risk behaviors (e.g. smoking, alcohol and other drug use) are either initiated, or the individual passes successfully through this transition period into adulthood when the likelihood of initiation decreases substantially. However, it is often difficult to engage teens in a serious examination of health consequences.

Indeed, health risk behaviors such as cigarette smoking and substance abuse have increased over the past 15 years (Brown, D'Emidio-Caston & Pollard, 1997). During middle/high school, both American and Canadian teenagers initiate use of alcohol, tobacco and marijuana at a greater rate than at any other time (Adlaf, Ivis and Smart, 1997, Johnston, O'Malley and Bachman, 1996). For these reasons, adolescents are a primary target for prevention and health promotion initiatives.

Youth today live in an interactive, highly media orientated world. Interactive technologies (e.g. videos, computer games) captivate teens and provide enormous potential for engaging them. The increasing availability of information technology creates an innovative channel for clinical prevention and health promotion with the ability to reach a large number of young people, including those 'turned off' by traditional approaches. Health promotion programs that are interactive and involve peer lead components have been shown to be the most effective (Tobler and Stratton ,1997; Lynagh et al, 1997; Ellickson, 1995; Botvin and Botvin, 1997; Dusenbury & Falco, 1997). The Web provides an ideal environment for this interactivity and peer-to-peer interaction.

This chapter presents insights on the use of the Internet for health promotion and health care based on experiences of the TeenNet project. The overall goal of TeenNet is to increase the number of teens engaged in positive health and social behavior. What makes this project unique is the interweaving of 'high tech' Website development and community involvement using an action research model (Figure 1). A Website called "CyberIsle" is described that was designed for and by teens (http://www.cyberisle.org).

Although computers have been heralded as a technological revolution, today we are at the doorstep of a much bigger transformation. The information revolution is having a profound impact on the way we live, learn and educate. Driving this revolution is the explosive growth of the Internet, especially the World Wide Web (Johnson, Johnson and Handa, 1995).

The Web provides an extremely powerful tool for health communication: locally, nationally and internationally. One can rapidly transmit text, images, sound and even movies on a scale not dreamed of a decade ago. The Web also allows real-time communication and connectivity among multiple users that can be used to create virtual communities. As the Web grows and matures, exciting possibilities are opening up for health promotion, health care and mutual support. The Web offers an avenue for:

1. Quickly disseminating and reaching a large number of youth in all areas of a country (indeed, the world)
2. Vibrant graphics and innovative effects that youth find highly engaging
3. Multiple pathways or means of reaching health information from schools, local libraries, homes, community and health care settings
4. Multiple linkages to related topics such as peer-led discussion groups, lifestyle assessment and guided change, as well as specific health information and interactive games related to health issues
5. Information that can be readily updated and refreshed in order to provide a new look,
6. Connectivity (one-to-many) and mutual support, allowing users to assist others and create an environment that stimulates collective action

7 Critical Functions
Both practitioners and patients/clients need various supports if they are to be successful in changing health behavior. Seven Critical Functions are described as essential components of a high performing organization in prevention and behavioral health care (Skinner & Botelho, 1999). Each function encompasses a group of linked activities or processes directed at accomplishing a specific goal. For example, a computerized health behavior assessment administered during intake automatically provides the practitioner with a patient's risk factor profile in a timely fashion before the consultation begins. Integration of the Critical Functions in a dynamic system "opens the window of opportunity" for practitioners to use motivational approaches. The seven Critical Functions include:

1. Professional Development in Behavior Change: individual (patient, practitioner) and organizational levels
2. Priming/Prompting of Patients/Clients and Practitioners: to address prevention and behavioral risk factors
3. Identification of Risk Behaviors and Related Complications: using screening and case-. finding both in clinical encounters and at the community/population level
4. Continuing Care: monitoring, re-assessment, provision of additional care and follow up.
5. Linkages/Networks Among Services and Resources: within and outside the health setting.

6. Options for Help: professional assistance, support groups that are professionally led, self-help groups and community resources.

7. Information Management: systems that support behavior change initiatives; feedback to patients and practitioners.

This model forms a basis for identifying high leverage opportunities for improvement. Table 1 summarize the ways that Internet technology (specifically CyberIsle) can be used be used in a variety of settings for the Critical Functions of: priming/prompting, identification of risk behaviors and options for help.

For example, CyberIsle's It's My Life quiz can be used by youth to assess their areas of risk, while health practitioners working with youth who smoke can use the self-assessment tools on CyberIsle's Smokin' Island (It's your Decision and To Change or not to Change) to assist youth select appropriate smoke-cessation strategies/activities. Youth can also make use of HotTalk - CyberIsle's Peer discussion group - for mutual support with other youth who are quitting. Practitioners can use HotTalk to learn about youth's concerns around smoking. This facilitates better communication and empathy with youth when engaging in motivational counseling.

In addition to using CyberIsle, the TeenNet project is developing a Practitioner Forum for health and education professionals (http://www.cyberisle.org/teennet/) that addresses the Critical Functions of: professional development, linkages/networks and information management.

The overall goal of TeenNet is to increase the number of teens engaged in health promotion activities, such as smoking prevention and cessation. A highly participatory, community-based approach is taken where teens and various community organizations are involved in all stages of project design, development, implementation, evaluation and dissemination. Hence, this project involves a rather unique integration (Figure 1) of information technology (Internet) and "community involvement that are woven together through action research& (Argyris et al, 1985).

This action research model uses a spiral process where ideas are generated by/with community members (in particular youth), implemented with them, evaluated by them, adjusted according to their feedback, then re-implemented and evaluated. This iterative process is ongoing throughout the life of the project beginning with needs assessment and continuing through prototyping and implementation of solutions. Evaluation and refinement take place continuously. This action research process not only fosters participation, self-determination and active learning among youth, but also facilitates a true sense of ownership by youth. The main components of the CyberIsle Website include:

1. Home Page: Gateway to all components. A passport is required in order to enter this teens- only island, which provides a means of gathering background information on users,

2. Health Information: Interactive, multimedia information on a wide range of health, personal and social issues,

3. Self-Assessment and Guided Change: Assessment, individualized feedback and guided self-change strategies that are matched to the individual's readiness for change,

4. HotTalk: Ongoing, peer-led discussion groups and special topics forum using electronic networks.

5. Hot Links: Links to other relevant sites on the Internet. All links have been reviewed and approved by the TeenNet Quality Control Committee, consisting of parents, teachers, school board personnel, health workers and teens.

CONCEPTUAL FRAMEWORK: The TeenNet project is based on a person-centered health promotion model described by Skinner and Bercovitz (1997) that underscores the interconnection among self-care, mutual aid and professional assistance ( Figure 2). The development of TeenNet is guided by five principles:

1. Participatory: key involvement (ownership) at all stages by teens,

2. Relevant to teens: focus on health, personal and social issues identified by teens,

3. Autonomy-supporting: encourages individual choice and exploration of options regarding health behavior,

4. Active Learning - Fun: engaging, flexible and highly interactive, stimulates self-directed learning,

5. Accessible: designed and adapted to be accessible and relevant to diverse populations of adolescents.

PARTNERS: TeenNet is based at the Department of Public Health Sciences, University of Toronto. The collaborating partners involve a network of organizations directly involved in education and/or health promotion with youth. These include:

• Bloorview MacMillian Centre (for youth with disabilities)
• Brant County Board of Education (7 secondary schools)
• Centre for Health Promotion (University of Toronto)
• Centre for Addiction and Mental Health (tobacco, alcohol, other drugs, emotional health)
• Council for a Tobacco-Free Ontario
• Frontier College (Beat the Street: street-involved youth program)
• FSC Internet (Web technical consultants)
• Hospital For Sick Children: Teen Clinic
• Ontario Institute for Studies in Education (OISE UT)
• Ontario Tobacco Research Unit
• St. Stephen's House: Youth and New Media Internship Program
• Shout Clinic Toronto (street involved youth)
• Spina Bifida and Hydrocephalus Association of Ontario
• Toronto Public Health Department
• Toronto Board of Education (secondary schools)
• University of Toronto, Department of Public Health Sciences
• YMCA Toronto.
  

During the summer of 1995, the TeenNet project employed three high school students as teen advisors, to direct the development of the TeenNet home page. The three teens differed greatly with respect to their racial background, interests, and health behaviors, such as smoking, drug use, drinking and sexual activity.

The first task undertaken by the teens was to design a home page to house the four main components of the project. They were asked to generate ideas for how the site could be laid out and how a user would navigate within the Website. In brief, the teens were asked to come up with a concept or metaphor. In the process of doing this, the teens surfed the net to establish a list of features, designs, graphics and content they liked. Next, they organized and conducted a discussion group with other teens to brainstorm ideas for the TeenNet Website. The result was the birth of CyberIsle, a teens only island.

The three students then spent weeks discussing and drawing places and activities for the island that are meaningful for youth and reflect issues youth are concerned about. They then worked closely with both the content and technical teams to develop and graphically bring to life the island. The following are the main places they designed in collaboration with project staff:

1. Beach: both day and night beach scenes are represented

2. Cyberia: a nightclub which has a bar, dance floor, pool tables, etc.

3. Bathrooms: both male and female

4. Shuttle bus: for moving around the island

5. Bus pass: this acts as a registration system, allowing the project to obtain demographic information about the users (age, sex and country of origin). Each time a youth returns to the island they use their buspass, which keeps track of the number of times they have visited the island.

6. Quizzes: self-assessment and guided-change activities,

7. Graffiti wall: a place for self expression and to have fun,

8. Resource Center: lists resources on the island, on the web and in the community. Specific resources available for special needs youth are also included, e.g. street-involved youth and youth with disabilities,

9. HotTalk: Online peer discussion groups, where teens gain advice and support from other teens.

CyberIsle's health information, online discussion groups, interactive lifestyle assessment programs, simulations, hot links and games, are hidden under graphics that make up the various places on the Island. For example, information on safe sex can be reached via clicking the mouse on the condom vending machine in the washrooms, or tips for quitting smoking can be reached via clicking on pack of cigarettes at the beach party.

The value of the island metaphor is that there is infinite potential in what can be added to the CyberIsle Website. As the project develops, more and more places (concepts) are being added. Currently we are developing a Teen Clinic Online where health and medical issues are addressed. As the island matures, rebuilding and upgrading will take place, to both graphics and content. Basically, we view CyberIsle as 'unlimited real-estate' where teen issues can be incorporated into the island metaphor in ways that are engaging, informative and fun. For example, we could include a CyberIsle Café‚ containing nutrition and body image information, and a Gambling Arcade where gambling problem prevention can be addressed in games and simulations.

We encourage you to take a tour of CyberIsle on the Web (http://www.cyberisle.org). To wet your appetite, Figures 3 through 10 display some key locations. The CyberIsle home page is a graphical representation of an island. The first thing a new user must do is register. By clicking the mouse on the "let me register now" statement at the bottom of the island, the user is taken to the "pick your picture" page. Every user of CyberIsle must create their own bus pass. The first step is for each user to pick a picture of a face that they wish to be on their bus pass. After a picture is selected, a form appears on the screen, asking the user to give a nickname, select their own password, give their date of birth, gender and nationality. This page gives a brief description of the research project and asked users to tick a box if they do not wish to consent to being part of the research. This information is strictly confidential and can never be accessed by other users, only by the TeenNet research team. For the proposes of the TeenNet research project, we can identify each user (by nickname and password) and therefore know how old they are, where they are accessing from (country), how many times they have entered CyberIsle, where they go on the island and how long they spend in each place.

After registration, the user is ealth and youth orientated resources, and the lifestyle assessment quizzes.

The most developed area is Smokin' Island (see Figures 7-10) which containswritten and designed by teens. Initial evaluation results have indicated that moving around the island is intuitive for teens and even those with little or no Internet experience appear to be able to navigate the site easily.

First Phase:In addition to ongoing process evaluation, CyberIsle underwent its first formal evaluation in 1996. Altogether 31 teens, ranging from 11 to 18 years, participated in the initial evaluation. Teens were give 30 minutes to explore CyberIsle, and then were asked a series of questions in structured one-on-one interviews with a research officer. Approximately half of the teens were female and half were male, living in major cities and small rural towns in southern Ontario. Twenty seven percent of the teens interviewed smoked sometimes or everyday. Fifty-nine percent of the teens identified with another cultural group other than Canadian. Eighteen different cultural groups were identified. Of the 31 teens interviewed, over 60% had experience using the Internet and 44% used it at least once a week.

Teens reviewed each page of the Website and were asked to comment on what attracted then, the best thing about the page and what could we change. Comments were collated then fed back to the technical team, who incorporated teens suggestion and reconstructed parts of CyberIsle according to evaluation results. The following results indicated to us that we are progressing in the right direction:

• 80% of respondents thought someone afraid of computer would be able to use CyberIsle,

• 65% of respondents thought that someone who has difficulties with English would be able to use CyberIsle,

• 95% of respondents said "yes" they would visit CyberIsle again.

Although the overall response was very positive, several issues were raised which are currently being addressed. In particular, the issue of speed and connectivity. At present, the quality of connectivity to the Internet in schools varies greatly depending on the school and/or the school board. Some schools have highspeed connections, with many computers hooked up to the Net. Other schools have as few as one machine connected to the Net, and a very slow connection.

Second Phase: In 1997, 10 focus group discussions were held in Toronto and Brantford with a total of 41 teens. This component of the CyberIsle evaluation centered around two themes. First, it explored a number of issues concerning the efficacy of the site in engaging teens. Second, attempted to get a sense of the possible impact of CyberIsle on participants' intent to change/modify health risk behaviors and to adopt health enhancing ones.

Each focus group participant spent approximately 45 minutes exploring CyberIsle and then completed a brief questionnaire. During this time, participants were asked to visit Makin' Cents and Smokin' Island and as many other CyberIsle "rooms/places" as they would like in the time available. Following this, focus group discussions were held with the focus group facilitator viewing CyberIsle with the group. The teen's ages ranged between 13 and 22 years, with 15.5 as the mean. 17% (n = 7) were regular smokers. 21 were male and 20 female. 22 participants (54%) have Internet access away from school and 18 did not (46%). Participants identified with 16 different ethnic or cultural groups and 5 teens with physical disabilities participated.

Youth feel CyberIsle is innovative-"Very different than what I've seen before", that the site is graphically appealing - "Pretty cool. I like it.", that it is accessible "Easy to access", and that CyberIsle is relevant to youth -"Interesting, something [teens] could relate to." Smokers said that CyberIsle would encourage teens to think about changing their smoking behavior - "It made me start thinking, maybe I should start quitting", "(CyberIsle) really puts things into perspective...it would make me think twice". Teens find the comprehensiveness of CyberIsle particularly appealing; "It's just good, you could find it somewhere else but this is a huge package deal". Teens also feel that CyberIsle is a more interactive and fun way to learn compared to traditional health promotion approaches; "you don't want to ask the teacher because everyone will (ask) why do you want to know that. So when you go into CyberIsle you can read...what you want to know about...you can be embarrassed at school."

HotTalk is a communication platform that facilitates discussion among teens about relevant health and social issues, via computer networking. HotTalk offers both a real time chat room called The Underground (MOO fordvice, referring others to community and web based resources, discussing current affairs, and debating ideas.

Teens identified that they wanted HotTalk to be a self-regulated or a teen-moderated discussion forum. To respect this decision, project team members read HotTalk conversations on a daily basis but only respond to ensure that HotTalk remains a safe environment for youth to exchange thoughts and ideas. TeenNet project team members also direct users who are struggling with serious issues (e.g. suicide or date rape) to contact a professional. For example, if the user identifies that they live in Canada, project team members direct them to Kids Help Phone.

In total HotTalk has had over 83,942 hits or visits, and almost 4,027 messages have been post as of June, 1999. 'Visits' differs from 'messages posted' as not all people write messages in Chat It Up. Many are "lurkers". This means they follow other discussions, but never contribute themselves. This can, however, be just as useful for a teen as posting their own message.

The following is a list of some of the discussion topics:

• Smoking: Butt Out, Teenage smoking, To Quit or not to Quit

• Sex: sex and age, Gay Teens, I just had a baby, I need a friend!!, Date Rape, Damit why me (being pregnant)
• Alcohol and drug use: Drugs What do you do and What do you think?, Alcohol, my friends and weed, Be Wise Legalize, pot smokin, flower children

• Depression and suicide: tHe sUN sHInEs~but i don't, I Feel Like Tearing Out My Spleen 'Cause I'm a teen, My so called life, Anyone ever been through this

• Body image and dieting: Beauty Is Only Skin-Deep, Being Overweight Ain't That Fun.

CyberIsle was officially launched at the end of February 1997. Usage took off (Figure 10). As of June, 1999 there have been over 99,000 visits to CyberIsle:

• 63.2% female : 38.8% male
• Average age is15.57 years old
• Most visited place: HotTalk (peer discussion forum)
• Registered visitors spend an average of 19.39 minutes per visit
• Visitors have come from: Canada, USA, Australia, Bahamas, Estonia, Kuwait, Poland, Thailand, Iceland, Israel, etc.

In 1998, TeenNet explored the possibility of using the web for drug education with street- involved and low socioeconomic youth. Street-involved or street-connected youth refers to people under the age of 25 who participate in street life. Many are homeless, but some may live in shelters, hostels, with friends or relatives and some may still live a home, but all participate in street life.

Twenty youth (13 female, 5 male, 2 transgender) who attended Shout Clinic (a downtown Toronto clinic which provides comprehensive health services to street-involved youth) were interviewed for approximately 15 minutes and asked questions related to: what drugs they take (both medical and recreational), what specific information they want to know about those drugs, where they currently obtain drug information, and questions related to Internet usage. Even though this was a small sample, the study showed a willingness to use the Internet for accessing drug information:

• 95% of youth were currently receiving drug information
• 70% disliked the information they received
• 90% were willing to use the Internet for accessing drug information
• 75% currently had Internet access through friends, caf‚s, schools, home, & public libraries
• 41% of those with access used the Internet 2 to 3 times per week

The Teen Clinic Online will be a new component ("place") on CyberIsle. Using an action research model, the project team is working with youth and adolescent health care practitioners to investigate and develop a Web-based Teen Clinic that meets teens' needs and engages them in meaningful ways. The Teen Clinic Online will provide youth with self-directed learning on:

• Information resources on health issues identified by teens, such as body image & eating disorders, alcohol & drug use, stress coping, violence, suicide & depression, safe sex & STDs
• How to access and navigate the health care system and related services
• Critical appraisal skills when searching, selecting and using Web-based material
• Decision making around health issues

The first step in the process of creating the Teen Clinic Online was for youth to identify their health issues and needs, and the barriers to having those needs and issues addressed. Nine focus groups were held at locations in and around Toronto, including the Teen Clinic at the Hospital for Sick Children (HSC), Shout Clinic, Beat the Street, Davenport-Perth Community Centre and The Youth Centre in Ajax. Youth identified issues around the "process" of getting their health needs met and discussed areas for development in Teen Clinic Online. Since technology is an integral part of Teen Clinic Online, the youth were asked about their perceptions of and experiences with interactive technologies (hotlines, chat and the Internet). They identified a number of concerns around the use of health information on the Internet, including whether or not you could trust the information, and difficulties in finding and sorting through information and making decisions. Youth also discussed the potential for chat or email to be used to ask specific health questions and share experiences with other youth.

The Teen Clinic Online is now under development - guided by the project's Youth Advisors. Through brainstorming sessions, rapid prototyping and pilot testing of prototypes, the Youth Advisors guide the development of the graphical layout, navigation, components and content for the Teen Clinic Online Website.

Practitioner Forum Website

Parallel to CyberIsle and Teen Clinic Online Websites for teens, TeenNet is developing a Practitioner Forum Website. This is a place where practitioners (teachers, health professional, youth workers, those in social services) can meet, share ideas, access relevant hot links and resources, and gain an understanding of the TeenNet project and how to effectively use CyberIsle and the Teen Clinic Online with youth. The site has its own Internet address or URL (www.cyberisle.org/teennet), but can be reached via the TeenNet logo on CyberIsle (also it is the small outer island off CyberIsle's north east coast). Key components will include:

1. Practitioner Guides to using TeenNet and its project Websites. Currently the TeenNet Website includes a guide to CyberIsle and a teaching resource called the Smoke Free Class of 2000. Written by a public health nurse, the CyberIsle Guide briefly outlines; What is TeenNet?, How do I use the TeenNet homepage?, What is CyberIsle?, and How can I use CyberIsle? Developed by a voluntary group of Ontario teachers, public health nurses and parents, the Smoke Free Class of 2000 is a teaching resource related to smoking prevention and cessation for grades 5 to 8. The Smoking and the Environment part of the Smoke Free Class of 2000 curriculum, including lesson plans, handouts and activities, has been adapted for the web by TeenNet. The web allows practitioners from across the country, and around the globe, to quickly access this excellent package. Teachers can easily print-off teaching notes, handouts, overhead transparencies and activities. Similar guides will be created for the Teen Clinic Online when this Website is completed.

2. Resource links to both Websites and community organizations. Existing resources are grouped under the following subheadings to make finding specific information easier for the user: Evaluation, Government on the Web, Health Organizations, Health Professionals & Researchers, Health Promotion & Disease Prevention, Journals & Libraries, Parents, Professional Associations, Public Health, Teachers, and Tobacco. A public health nurse with experience working in both school and community settings research and designed the Resources Page.

3. Group Discussions for health practitioners, parents and teachers will be created to allow for sharing of ideas, problems, successes and strategies related to engaging youth in health promotion and smoking cessation.

4. Continuing Education Modules for Adolescent Health Practitioners: The modules, scheduled for completion in spring 2000, will consists of interrelated workshops that include both face-to-face and web-based learning components regarding:
   1. The ABC's of getting connected to and using the Internet,

   2. The ABC's of using the Internet and the Seven Critical Functions to support health Promotion and behavior change with youth (Table 1)

   3. The ABC's of using Teen Clinic Online and CyberIsle in Practice.

We began this chapter posing the question: how do we engage teens in health promotion? The Internet offers an exciting and versatile way of attracting their attention, even hard to reach and high risk populations such as street-involved youth. But information technology by itself is insufficient. Our experience on the TeenNet project underscores the value of having a high level of youth participation 'from day one'. Two teens involved expressed their sense of ownership and pride in the what they were creating with TeenNet:

"It makes me as a teen feel good that people care about what teens think and what they have to say. Most of the time we are overlooked. Not many teens get the chance to actually be heard. . . thank you."

These reflections capture the essence of health promotion using information technology.

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