Journal of Adolescent Health 53 (2013) 387e393

www.jahonline.org

Original article

A Sex Risk Reduction Text-Message Program for Young Adult Females

Discharged From the Emergency Department
Brian Suffoletto, M.D. a, *, Aletha Akers, M.D. b, Kathleen A. McGinnis, M.S. c, Jaclyn Calabria, M.Sc. a,
Harold C. Wiesenfeld, M.D., C.M. b, and Duncan B. Clark, M.D., Ph.D. d
a
Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
b
Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
c
Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
d
Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Article history: Received October 29, 2012; Accepted April 2, 2013

Keywords: Young adult; Health promotion; Sexual health; Text messaging

A B S T R A C T
IMPLICATIONS AND
CONTRIBUTION
Purpose: To pilot test a text message (SMS) sex risk reduction program among at-risk young adult
female patients discharged from an emergency department (ED).
The results of this pilot
Methods: A convenience sample of 52 female patients with hazardous drinking behavior and study suggest that text
recent risky sexual encounters were recruited from an urban ED and randomized to the SMS message programs may be
program (n ¼ 23) or a control group (n ¼ 29). All participants completed a web-based question- useful to monitor risky
naire in the ED and at 3-month follow-up. For 12 weeks, SMS participants were asked to report sexual encounters and
whether they had a risky sexual encounter in the past week, received theory-based feedback, and provide behavioral support
were asked if they were willing set a goal to refrain from having another risky encounter. to reduce risk for sexually
Results: Thirty-nine percent of SMS participants completed all weeks of SMS reports, and non- transmitted diseases
completion increasing from 12% on week 1 to a 33% by week 12. Three-month follow-up was completed among at-risk young adult
in 56% of participants. In the intervention group, there was an increase in the proportion with condom female patients discharged
use with last vaginal sex from 20% (95% CI 4%e48%) to 53% (95% CI 27%e79%) and an increase in from an emergency
always condom use over the past 28 days from 0% (95% CI 0%e22%) to 33% (95% CI 12%e62%). These department.
changes were not statistically different from control participants.
Conclusions: SMS programs may be useful to reduce risk for sexually transmitted diseases among
at-risk young adults being discharged from the ED. Future trials should examine ways to improve
adherence to SMS dialog over time and measure objective outcomes in a larger sample.
Ó 2013 Society for Adolescent Health and Medicine. All rights reserved.

In the United States, young adults acquire nearly half of all
new sexually transmitted diseases (STDs), with the vast majority
diagnosed in women [1]. In 2010, young adult women ages
20e24 years had the highest rate of chlamydia and the second
highest rate of gonorrhea compared with any other age group [2].
Declaration of conflicts: The authors report no conflicts of interest.
Parts of this study were presented as a poster at the 35th Annual Research
Society on Alcoholism in San Francisco, June 23, 2012.
* Address correspondence to: Brian Suffoletto, M.D., University of Pittsburgh,
3600 Forbes Ave., Iroquois Bldg, Suite 400A, Pittsburgh, PA 15221.
E-mail address: suffbp@upmc.edu (B. Suffoletto).
One major impediment to STD services is that young adults
frequently lack a usual source of ambulatory care [3,4].
Compared with other age groups, a higher proportion of young
adults use the emergency department (ED) for routine medical
care problems [5]. Because the ED serves a population of young
adults who are also disproportionately susceptible to STDs, it
may provide a unique venue to screen young adults for at-risk
behavior and intervene to reduce future risk [6].
Unfortunately, evidence suggests that ED providers do not
typically provide STD prevention services, even when they are
warranted [7]. Multiple barriers exist at the patient and provider

1054-139X/$ e see front matter Ó 2013 Society for Adolescent Health and Medicine. All rights reserved.
http://dx.doi.org/10.1016/j.jadohealth.2013.04.006
388 B. Suffoletto et al. / Journal of Adolescent Health 53 (2013) 387e393
levels. Provider-level barriers include lack of time and/or comfort
performing sexual risk assessments and providing sexual
counseling services [8]. Patient-level barriers include lack of
comfort discussing sensitive topics such as sex with a care
provider or concerns about confidentiality if family and/or
friends are present [9]. Given these barriers, innovative tech-
niques are needed to improve delivery of preventive health
services for sexual health to ED patients.
One promising modality to promote the adoption of healthier
sexual decisions among young adults is through mobile
communication technology. Ninety-five percent of young adults
own a mobile phone and 97% of these use text messaging (SMS),
either sending or receiving an average of 50 texts per day [9].
SMS has been used to promote health in a wide range of young
adult health issues, including diabetes [10], asthma [11], cigarette
smoking [12], and alcohol use [13]. Within the realm of sexual
health, SMS has been used to improve communication between
sexual health clinics and patients [14], improve partner notifi-
cation and sexual contact tracing [15], and collect sex risk data
from young adults [16]. SMS-based interventions have been used
to improve HIV awareness and knowledge among older adoles-
cents [17] and to improve STD knowledge and testing among
young adult women [18]. We attempted to leverage the full
potential of SMS by developing an automated sex risk reduction
program that provides feedback based on behavioral change
theory [19] tailored to a participants’ reported engagement in
risky encounters [20]. We targeted young adult women who
self-reported baseline hazardous drinking behavior because of
the high rates of alcohol misuse among young adults [21] and
prior research establishing the association between alcohol
consumption and STD acquisition [22].
Methods
Study design
In this pilot study, a randomized control group design was
used to assess whether an SMS program would decrease sex risk
behaviors at 3-month follow-up relative to a no-intervention
control group. Recruitment occurred between September 2011
and April 2012 at a single urban level I trauma and tertiary
care hospital ED in western Pennsylvania. The study was
approved by the Institutional Review Board at the University of
Pittsburgh. The trial was registered with ClinicalTrials.gov
(number NCT01548183).
Recruitment and eligibility
A research associate (RA) identified potential participants who
were female, age 18e25 years old, and not critically ill using an
electronic triage board. The RA then obtained permission from
the ED clinician to approach the potential participant in their
treatment room. If a woman was interested in participating,
informed consent was obtained and an eight-item self-adminis-
tered screening instrument was completed using a tablet
computer to minimize social desirability bias in reporting sensi-
tive information [23,24]. To be eligible, patients had to self-report
hazardous drinking behavior, based on a score >3 on the three-
item Alcohol Use Disorder Identification Test-Consumption [25].
In addition, eligible women had to report at least one of the
following: more than 1 male sexual partner in the past 3 months,
no condom use at last sexual intercourse, or alcohol/drug use
concurrent with their last sexual intercourse [26]. Women were
excluded if they reported current substance abuse or psychiatric
treatment because most already have structured support for risk
behavior prevention which would contaminate the study
outcome assessment. Women were also excluded if they reported
having a monogamous partner for >2 years or were planning
pregnancy in next 3 months because of the low rate of condom
use in these individuals. Those who did not have a personal
mobile phone with text messaging features were also excluded.
Procedures
Women deemed eligible based on the screening assessment
completed a baseline questionnaire on the tablet PC. After
completing the baseline questionnaire, participants were
randomized to either the intervention or control group using
a computer-generated random sequence. Intervention partici-
pants received an information sheet on which a “risky encounter”
was defined as “sex after drugs or alcohol or sex without
a condom.”
Intervention group
Upon entering their phone number into our system, inter-
vention participants received a series of welcome text messages
describing the program. Each Sunday at noon, intervention
participants received a sequence of text messages that assessed
risky encounters over the past week, were provided personalized
feedback on risk behavior, and were prompted collaborative goal
setting to not have a risky encounter for the coming week. We
chose Sunday at noon to initiate health-related dialog based on
proximity to weekend activities to reduce recall bias and pref-
erences determined by participants in our prior study [14]. This
automated conversation used elements of the Health Belief
Model [27] and the Information Motivation Behavior model [28].
Following precepts of the Health Belief Model, we incorporated
messages to increase an individual’s perceived susceptibility
to getting an STD, perceived severity of health risk associated
with an STD, and benefits of adopting protective behaviors
(using condoms). According to the Information-Motivation-
Behavioral Skills model constructs, which may account for up
to half of the variance in condom use [29], we incorporated
messages relaying effective health information about STDs
specific to young adult women, increasing personal motivation
to adopting healthy sexual behaviors and tools to increase self-
efficacy for protected sexual encounters. If participants did
not respond within 6 hours of a query, a second text message was
sent out repeating the initial message. If no response was
received within 12 hours, the data were considered lost and the
participant was retexted the following week. If two consecutive
weeks were missing, the participant was e-mailed regarding
contact information.
Control. Upon entering their phone number into our system,
control participants received a series of welcome text messages
describing what to expect: “Welcome to the Female Health
Behavior Study. Look for our text in 12 weeks to complete your
web-based follow-up.” Each week for 12 weeks, control subjects
received the following text message, “Please look for our text in
X weeks to complete your web-based follow-up,” where [X] was
the number of weeks until study completion. These participants
were not asked weekly whether they had engaged in any sexual
 B. Suffoletto et al. / Journal of Adolescent Health 53 (2013) 387e393
risk behaviors nor did they receive messages about any other
health behaviors.
Follow-up
All participants received a standardized text message 24 hours
after their final assessment (12-weeks after enrollment)
prompting them to log into our web site: “Female Health Behavior
Study. Log into PittStARSS.org using your phone number to
complete follow-up ASAP.” The follow-up questionnaire
measured alcohol use and sex behaviors using the same items
from the baseline questionnaire. Intervention group participants
also completed acceptability items. Participants received $10 for
completion of baseline instruments and $20 for completion of the
12-week instruments.
Outcomes
Feasibility. We examined four feasibility outcomes: (1) the
proportion of female ED patients who screened positive for both
hazardous drinking and risky sex behaviors who were willing to
enroll; (2) the proportion of intervention participants who
completed (all or at least 50% of) weekly SMS risky sex assess-
ments; (3) the proportion of intervention participants willing to
set a goal through SMS to refrain from having a risky encounter
the following week; and (4) the proportion of both the inter-
vention and control participants who completed the 3-month
web-based follow-up.
Acceptability. We also examined the two acceptability items
completed by Intervention participants only. “How informative
did you find the text messages?” and “How useful did you find
the text message in improving your sexual health behavior?”
Response options included a 7-point Likert scale (with 1
indicating “not at all” to 7 indicating “completely”). We explored
how many text interactions per week would be most desired/
acceptable in our population: “How many text message inter-
actions per week do you think would be most beneficial?”
Response options included: none, 1 per month, 1 per week, and
>3 times per week.
Behavioral. We examined self-reported behavioral outcomes
related to sex risk at baseline and follow-up using two single
questions and the timeline follow-back (TLFB) method. Single
questions included: “The last time you had sexual intercourse,
did you or your partner use a condom?” and “Did you drink
alcohol or use drugs before the last time you had sexual inter-
course?” The TLFB method is a calendar-based assessment [30] in
which individuals are asked to recall events each day in the
previous 28 days using holidays as memory triggers, during
which the following occurred: (1) vaginal sex occurred (yes/no);
(2) condoms were used (yes/no); and (3) drugs or alcohol were
used before sex (yes/no). The TLFB method was also used to
assess binge drinking in the past 28 days with binge drinking
defined as consuming four or more drinks [31]. Primary behav-
ioral outcomes of interest at 3-month follow-up included the
proportion of participants reporting condom use with last
vaginal sex and the proportion with always protected sex over
the past 28 days. Secondary behavioral outcomes of interest
included the proportion with alcohol or drugs used before last
sex and the proportion with unprotected sex and concurrent
alcohol use in past 28 days.
389
Analysis
We compared baseline patient characteristics across control
versus intervention exposure, those who completed 3-month
web-based follow-up versus those lost to follow-up and inter-
vention participants who completed at least 50% of weekly SMS
assessments versus not using chi-square tests to examine asso-
ciations between categorical variables, t-tests for normally
distributed continuous variables, and Wilcoxon rank-sum tests
for variables with nonparametric distributions. These variables
were summarized by calculating frequencies (n) with percent-
ages (%) for categorical data and means and standard deviations
(SD) or median and interquartile range (IQR) for count data. Plots
and examination of skewness and kurtosis were used to identify
evidence of nonnormality for continuous variables. Among
intervention participants, we separately examine the proportion
of weekly SMS assessments completed across 12 weeks and
the proportion of participants willing to set a goal through
SMS to refrain from having a risky encounter the following
week, presented as percentages with 95% confidence intervals
(95% CIs). We also examine the proportion of intervention
participants who found the SMS program informative and
useful, as defined by a score of 6 or 7. We compared the primary
and secondary behavioral outcomes of interest in those who
completed follow-up with chi-square tests. We also examine the
strength of association between treatment condition and
behavioral outcomes using logistical regressions. Because of
unbalanced baseline risk behaviors between treatment groups,
we include the presence of baseline risk as an independent
variable in models. All tests are two-tailed and differences are
considered statistically significant if p  .05. All data were
analyzed using STATA 10.0 (Statacorp, Inc).
Results
A total of 392 young adult female ED patients were
approached over a period of 6 months, with patient flow
exhibited in Figure 1. Forty-two percent of young adult female
ED patients screened positive for both hazardous drinking and
risky sex behaviors, among whom 51% were excluded from
participation and 15% were not interested in trial participation.
Demographic characteristics and sex risk behavior characteristics
of the sample are shown in Table 1 for the 52 participants
enrolled in the study. All of the participants were sexually active
and heterosexual.
Adherence to SMS intervention
In the intervention group, 70% (95% CI 64e75%) of weekly
SMS assessments were completed. The percent of participants
not completing weekly risk assessments and those reporting
a risky sex encounter across the 12 weeks of exposure are shown
in Figure 2. Noncompletion was 12% for week 1, peaked at 50% at
week 8, and was 33% on week 12. A total of 39% of intervention
participants completed all weekly assessments, 74% replied to at
least half of assessments, and only one participant missed all
12 weeks. Compared with those who completed at least 50% of
weekly SMS assessments, those who did not were more likely to
be of black race (100% vs. 71%), have more frequent alcohol
consumption (100% vs. 30% at least weekly drinkers), and were
more likely to have more than one sexual partner in the past
3 months (67% vs. 35%).
390 B. Suffoletto et al. / Journal of Adolescent Health 53 (2013) 387e393
Figure 1. Participant flow diagram. AUDIT-C ¼ Alcohol Use Disorder Identification Test-Consumption.
There were a total of 23 risky sexual encounters reported
among the 23 intervention participants over the 12 weeks, which
is 8.3% of all participant-weeks. There was a range of 0e5 total
weeks reported with a risky encounter and 52% of participants
did not report any risky sexual encounters over the 12 weeks.
After a reported risky encounter, participants responded to
a goal-setting query 83% of the time, among which they were
willing to set a goal to not have another risky encounter in the
coming week 70% of the time. If they were willing to set a goal to
not have a risky encounter the following week, there was
a repeat risky encounter only 29% of the time, whereas if they
were not willing to set a goal, they had another risky encounter
100% of the time.
3-Month outcomes
Out of the 52 persons who enrolled in the study, 29 (56%; 95%
CI 41%e70%) completed the 3-month web-based follow-up.
There were no significant differences in the proportion of
participants completing follow-up by demographics, baseline
sex risk, or treatment condition. For those participants who
completed follow-up, the primary outcomes of interest by
exposure are shown in Table 2. Although there were no signifi-
cant differences between the sex risk behaviors reported at 3
months between control and intervention groups, there were
significant differences in the change from baseline to 3 months in
sex risk outcomes. In the intervention group, there was an
increase in condom use with last vaginal sex from 20% (95% CI
4%e48%) to 53% (95% CI 27%e79%; p ¼ .02), whereas in the
control group there was a decrease from 43% (95% CI 22%e66%)
to 38% (95% CI 18%e62%; p ¼ .6). Independent of baseline
condom use with last vaginal sex, the odds of condom use with
last vaginal sex at follow-up for intervention participants
compared with controls was 2.12 (95% CI 0.52e8.70). In the
intervention group, there was an increase in the proportion with
always condom use over the past 28 days from 0% (95% CI 0%e
22%) to 33% (95% CI 12%e62%; p ¼ .01), whereas in the control
group there was no change from 24% (95% CI 8%e47%). Inde-
pendent of baseline always condom use over 28 days, the odds of
always condom use over 28 days at follow-up for intervention
participants compared with controls was 1.32 (95% CI 0.31e5.71).
For the 15 participants in the intervention group who
completed the 3-month follow-up, all reported that they found
the SMS very informative (6/7) and very useful (6/7) in
improving their sexual health behavior. Participants thought
that once-weekly SMS interaction was optimal. There were no
reported adverse events associated with any of the interventions
or study procedures.
Discussion
This study demonstrated that an automated, interactive SMS
program may be useful to track sex risk behavior over time,
deliver sex risk behavioral support messages, and promote goal
setting to reduce risk for sexually transmitted diseases among at-
risk young adults being discharged from the ED. Although
we were not able to show a statistically significant difference in
the sex risk outcomes between control and intervention group at
3 months, we were able to show relative positive changes in
intervention participants not seen in control participants.
We report a moderate adherence to SMS sex risk assessments
over 12 weeks, which is similar to a prior study reporting 80%
 B. Suffoletto et al. / Journal of Adolescent Health 53 (2013) 387e393 391

Table 1 Table 2
Comparison of baseline characteristics and sex risk Change in selected sex behaviors by exposure from baseline to 3-month
follow-up
Variable Intervention Control p
(N ¼ 23) (N ¼ 29) Primary sex behaviors Intervention n ¼ 15 Control n ¼ 21

Age (years), mean (SD) 22 (2) 21 (2) .2 Baseline 3 Change Baseline 3 Change
Black race 18 (78) 16 (55) .1 months months
Hispanic ethnicity 0 3 (10) .2
Condom use with last 3 (20) 8 (53) [5 (33) 9 (43) 8 (38) Y1 (5)
Highest level of education
vaginal sex
<High school 9 (39) 3 (10) .1
Vaginal sex with
High school graduate or GED 5 (21) 10 (35)
condom use in
Some college 7 (30) 11 (38)
past 28 days
College graduate 2 (9) 5 (17)
Always 0 5 (33) [5 (33) 5 (24) 5 (24) 0
Single marital status 22 (96) 28 (97) .9
Sometimes 3 (20) 2 (13) Y4 (7) 4 (19) 7 (43) [3 (24)
Employment
Never 10 (67) 1 (7) Y9 (60) 9 (43) 5 (24) Y4 (19)
Unemployed 8 (35) 6 (21) .6
No sex in past 28 days 2 (13) 7 (46) [5 (33) 3 (14) 9 (43) [6 (29)
Part-time employment 1 (4) 2 (7)
Other risk behavior
Full-time employment 9 (39) 10 (34)
Drugs or alcohol before 7 (47) 4 (27) Y3 (20) 11 (52) 7 (33) Y4 (19)
Student/non-employed 5 (22) 11 (38)
last vaginal sex
Drug use, in last 1 month
Any binge episode in 6 (40) 2 (13) Y4 (27) 9 (43) 8 (38) Y1 (5)
Tobacco 14 (61) 21 (72) .5
past 28 days
Cannabis 9 (39) 17 (59) .3
Any unprotected sex 10 (67) 4 (27) Y7 (40) 8 (38) 2 (10) Y3 (28)
Cocaine 0 0
with concurrent
Prescription stimulants 1 (4) 3 (10) .6
alcohol use in past
Prescription opiates 3 (13) 2 (7) .6
28 days
Others 0 4 (14) .1
Prior history of sexually transmitted infection 12 (52) 18 (62) .6 All values are n (%). No p values were <.05.
Number of sexual partners in past 3 months
1 13 (57) 15 (52) .2
2 6 (26) 13 (45)
may be less likely to use our SMS-based program, suggesting that
>2 4 (17) 1 (3)
Drug or alcohol use prior to last vaginal sex 11 (48) 13 (45) .9 future mobile interventions should be tailored to maximize
Condom use with last vaginal sex 4 (17) 10 (34) .2 interest and ongoing participation in these subgroups.
Days with vaginal sex in last 28 days, median 4 (2,15) 4 (1,10) .9 We were able to show that SMS can be useful to get indi-
(IQR)
viduals to set short-term goals to reduce future sex risk. Goal
Participants with any vaginal sex in last 28 days 19 (83) 26 (90) .5
Condom use
setting has been shown to be effective at promoting behavior
Never 16 (84) 15 (58) .2 change across a number of health conditions [33], but has not
Sometimes 3 (16) 5 (19) been studied specifically in sexual risk behaviors. Based on the
Always 0 6 (23) Social Cognitive Theory [34], an individual can learn to self-
Participants with any unprotected sex and 16 (70) 13 (45) .1
regulate behavior through setting of tangible goals. Based on
concurrent alcohol use in past 28 days
prior work from nonehealth-related industries [35], we
All values are n (%) unless specified otherwise. No p values were <.05. attempted to prompt specific and proximal goals because of their
IQR ¼ interquartile range; SD ¼ standard deviation.
association with better performance than general and distal
goals. Future studies should explore whether behavior priming
completion when young adults were asked similar queries [19]. would be more effective through more specific goal, such as
We asked a single question per week to minimize participant if-then plans (“If situation X arises, then I will perform
burden and improve convenience, which has been highlighted response Y”), also known as implementation intentions [36].
as central importance to young adults when considering SMS as If found to be effective, an SMS-based approach to sex risk
a health promotion tool [32]. We saw a gradual increase in reduction could be easily integrated into standard ED practice.
noncompletion of text messages, suggesting that longer text For example, if a young adult woman was found to have baseline
message programs may face problems with high attrition and/or sex risk behavior during routine care, and if she was interested,
missing data. We also found black participants, those with more she could simply text in to a program to enroll herself. This would
frequent alcohol use, and those with multiple sexual partners free EDs from the cost burden associated with counselor staffing
and provider anxieties about discussing sensitive issues with
patients they do not have time to develop a relationship with.
Alternatively, an SMS program could be the first part in
a stepped-care model where individuals who continue to report
risky sexual behavior after program exposure could be referred
to a trained counselor.

Limitations

Our study has several limitations worth discussing. First, we

Figure 2. Intervention participants who report risky sex encounters through
text messaging (SMS) over 12 weeks.
were not powered to detect significant differences between
intervention and control group behavioral outcomes. Second,
we had sub-optimal completion of text-message dialog in the
SMS group over 12 weeks and a high attrition rate overall to
3-month web-based follow-up. Perhaps allowing intervention
392 B. Suffoletto et al. / Journal of Adolescent Health 53 (2013) 387e393
participants to choose the time of weekly dialog would improve
ongoing participation. Our poor follow-up rate is similar to
other studies conducted in health care settings [37], such as STD
clinics (56% at 3 months) [38]. It is also similar to the attrition
rates of prior studies using SMS interventions for sexual health
promotion (42% at 3 months) [19]. Fortunately, attrition rates
did not vary by treatment condition or baseline risk, likely
limiting the potential for biasing outcomes. Future studies
should determine how to keep participants engaged in clinical
trials after ED discharge and collect multiple “locators” at
baseline assessment to improve follow-up rates. Third, we
cannot account for the potential effect of frequent SMS queries
about risk behavior on differential recall bias compared with
the control group. SMS queries could have “educated” individ-
uals through assisted self-monitoring, thus potentially making
their recall more “accurate” than control group. Fourth, we are
not able to separate the effect of frequent self-monitoring of risk
behavior from the effect of feedback or goal-setting. Future
studies should include a third arm to control for assessment
reactivity. Finally, we collected only self-reported sex risk
outcomes, and although our intervention aimed to reduce
contraction of STDs, we cannot comment on whether it actually
did. Despite this, we assumed that reductions in risk behavior
would in turn reduce diseases that spread as a direct conse-
quence of that behavior.
Although the SMS intervention showed some promise, the
sample size was too small and loss to follow-up too high to show
a significant effect. Mobile communication technology such as
SMS may be an ideal modality to reach older adolescents and
young adults, who have significant needs related to sexual health
promotion, yet do not interact with the health care system
sufficiently to allow for traditional risk assessment and coun-
seling. Further evaluation is needed to determine the optimal
design of a mobile sexual health assessment and promotion
program and its effect on reducing acquisition of STDs.
Acknowledgments
The authors thank Jack Doman in the Office of Academic
Computing at the Western Psychiatric Institute at the University
of Pittsburgh for all computer programming support. B.S. is
supported by an EMF-Century Council grant, A.A. is supported by
the Robert Wood Johnson Foundation Harold Amos Medical
Faculty Development Program, and D.B.C. is supported by
R01AA016482 and P50DA05605.
References
[1] Weinstock H, Berman S, Cates Jr W. Sexually transmitted diseases among
American youth: Incidence and prevalence estimates, 2000. Perspect Sex
Reprod Health 2004;36:6e10.
[2] Centers for Disease Control and Prevention. Sexually transmitted disease
surveillance 2010. Atlanta, GA: U.S. Department of Health and Human
Services; 2011.
[3] Fortuna RJ, Robbins BW, Halterman JS. Ambulatory care among young
adults in the United States. Ann Intern Med 2009;151:379e85.
[4] Callahan ST, Cooper WO. Uninsurance and health care access among young
adults in the United States. Pediatrics 2005;116:88e95. http://dx.doi.org/
10.1542/peds.2004-1449.
[5] Fortuna RJ, Robbins BW, Mani N, Halterman JS. Dependence on emergency
care among young adults in the United States. J Gen Intern Med 2010;25:
663e9.
[6] Haukoos JS, Mehta SD, Harvey L, et al. Research priorities for human
immunodeficiency virus and sexually transmitted infections surveillance,
screening, and intervention in emergency departments: Consensus-based
recommendations. Acad Emerg Med 2009;16:1096e102.
[7] Rhodes KV, Bisgaier J, Becker N, et al. Emergency care of urban women with
sexually transmitted infections: Time to address deficiencies. Sex Transm
Dis 2009;36:51e7.
[8] Bachmann LH. Provider-delivered sexually transmitted infection preven-
tion counseling in the emergency department setting: Another nail in the
coffin? Sex Transm Dis 2009;36:33e4.
[9] Lehrer JA, Pantell R, Tebb K, Shafer MA. Forgone health care among U.S.
adolescents: Associations between risk characteristics and confidentiality
concerns. J Adolesc Health 2007;40:218e26.
[10] Pew Research Center. Americans and text messaging. Available at:
http://pewinternet.org/Reports/2011/Cell-Phone-Texting-2011.aspx. Accessed
January 5, 2012.
[11] Franklin VL, Waller A, Pagliari C, Greene SA. A randomized controlled trial
of Sweet Talk, a text-messaging system to support young people with
diabetes. Diabet Med 2006;23:1332e8.
[12] Prabhakaran L, Chee WY, Chua KC, et al. The use of text messaging to
improve asthma control: A pilot study using the mobile phone short
messaging service (SMS). J Telemed Telecare 2010;16:286e90.
[13] Rodgers A, Corbett T, Bramley D, et al. Do u smoke after txt? Results of
a randomised trial of smoking cessation using mobile phone text
messaging. Tob Control 2005;14:255e61.
[14] Suffoletto B, Callaway CW, Kraemer K, Clark DB. Text-message-based
drinking assessments and brief interventions for young adults discharged
from the emergency department. Alcohol Clin Exp Res 2012;36:552e60.
[15] Bourne C, Knight V, Guy R, et al. Short message service reminder inter-
vention doubles sexually transmitted infection/HIV re-testing rates among
men who have sex with men. Sex Transm Infect 2011;87:229e31.
[16] Bilardi JE, Fairley CK, Hopkins CA, et al. Let Them Know: evaluation of an
online partner notification service for chlamydia that offers e-mail and
SMS messaging. Sex Transm Dis 2010;37:563e5.
[17] Lim MS, Sacks-Davis R, Aitken CK, et al. Randomised controlled trial of
paper, online and SMS diaries for collecting sexual behaviour information
from young people. J Epidemiol Community Health 2010;64:885e9.
[18] Cornelius JB, Cato M, Lawrence JS, et al. Development and pretesting
multimedia HIV-prevention text messages for mobile cell phone delivery.
J Assoc Nurses AIDS Care 2011;22:407e13.
[19] Lim MS, Hocking JS, Aitken CK, et al. Impact of text and email messaging on
the sexual health of young people: A randomised controlled trial.
J Epidemiol Community Health 2012;66:69e74.
[20] Mellanby A, Phelps F, Tripp J. Sex education: More is not enough. J Adolesc
1992;15:449e66.
[21] Substance Abuse and Mental Health Services Administration Public Health
Service U.S. Department of Health and Human Services. Summary of the
2009 National Survey on Drug Use and Health. J Pain Palliat Care Phar-
macother 2010;24:434e8.
[22] Cook RL, Clark DB. Is there an association between alcohol consumption
and sexually transmitted diseases? A systematic review. Sex Transm Dis
2005;32:156e64.
[23] Richens J, Copas A, Sadiq ST, et al. A randomised controlled trial of
computer-assisted interviewing in sexual health clinics. Sex Transm Infect
2010;86:310e4.
[24] Schroder KE, Carey MP, Vanable PA. Methodological challenges in research
on sexual risk behavior: II. Accuracy of self-reports. Ann Behav Med 2003;
26:104e23.
[25] Bradley KA, DeBenedetti AF, Volk RJ, et al. AUDIT-C as a brief screen for
alcohol misuse in primary care. Alcohol Clin Exp Res 2007;31:1208e17.
[26] CDC. Youth risk behavior surveillancedUnited States, 2011. MMWR 2012;
61(SS-4).
[27] Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the
Health Belief Model. Health Educ Q 1988;15:175e83.
[28] Fisher JD, Fisher WA. Changing AIDS-risk behavior. Psychol Bull 1992;111:
455e74.
[29] Fisher JD, Smith L. Secondary prevention of HIV infection: The current state
of prevention for positives. Curr Opin HIV AIDS 2009;4:279e87.
[30] Sobell LC, Sobell MB. Timeline followback: A technique for assessing self
reported alcohol consumption. In: Litten RZ, Allen J, eds. Measuring Alcohol
Consumption: Psychosocial and Biological Methods. Totowa, NJ: Humana
Press; 1992:41e72.
[31] National Institute of Alcohol Abuse and Alcoholism. NIAAA council
approves definition of binge drinking. NIAAA Newsletter 2004;3:3.
Available at, http://pubs.niaaa.nih.gov/publications/Newsletter/winter2004/
Newsletter_Number3.pdf. Accessed January 5, 2011.
[32] Perry RC, Kayekjian KC, Braun RA, et al. Adolescents’ perspectives on the
use of a text messaging service for preventive sexual health promotion.
J Adolesc Health 2012;51:220e5.
[33] Strecher VJ, Seijts GH, Kok GJ, et al. Goal setting as a strategy for health
behavior change. Health Educ Q 1995;22:190e200.
 B. Suffoletto et al. / Journal of Adolescent Health 53 (2013) 387e393 393

[34] Bandura A. Human agency in social cognitive theory. Am Psychol 1989;44:
1175e84.
[35] Locke EA, Latham GP. Building a practically useful theory of goal setting
and task motivation. A 35-year odyssey. Am Psychol 2002;57:705e17.
[36] Gollwitzer PM, Schaal B. Metacognition in action: The importance of
implementation intentions. Pers Soc Psychol Rev 1998;2:124e36.
[37] Pedlow CT, Carey MP. HIV sexual risk-reduction interventions for youth: A
review and methodological critique of randomized controlled trials. Behav
Modif 2003;27:135e90.
[38] Metzler CW, Biglan A, Ary DV, Noell J. A randomized controlled trial of
a behavioral intervention to reduce high-risk sexual behavior among
adolescents in STD clinics. Behav Ther 2000:27e54.