Healthy MSM: “Where Health & Safe Sex is a Plus,” A Sexual Health App for Men Who Have Sex with...

Running head: HEALTHY MSM: SEXUAL HEALTH APP FOR MSM 1

Healthy MSM: “Where Health & Safe Sex is a Plus”

Sexual Health App for Men Who Have Sex with Men

Daryl Mangosing

HCOM-0515 | Mobile Health Design

Dr. Lisa Gualtieri & Bradley Moore

July 10, 2013

HEALTHY MSM: SEXUAL HEALTH APP FOR MSM 2

Executive summary

The following paper proposes the design and creation of a

mobile smartphone app – Healthy MSM – for enhancing the health and

sexual practices of men who have sex with men. The app design

process will be delineated in the following sections: background,

needs assessment of the target population, personas and their

scenarios, competitive analysis, description of design,

wireframes, evaluation plan, development plan, marketing plan,

limitations, and references. With the tagline “Where Health and

Safe Sex is a Plus,” the objective of the app is to serve as a

comprehensive sexual health resource for men who have sex with

men in light of their generally high rates of sexually

transmitted diseases (STDs) and contact with the Human

Immunodeficiency Virus (HIV). The app equally serves as an

effective channel for delivering a multifaceted public health

intervention that hypothetically addresses various issues that

this population is experiencing, but more importantly, it

proposes a novel feature that has not been made available yet:

linkage of care between the user and their health care provider.

The Healthy MSM app will be based on evidence-based


guidelines to differentiate it from other sexual health apps. Due

to its potential for storing personal health information, the app

will not only be developed in collaboration with a prominent,

health care professional organization such as the American

Medical Association or the American Public Health Association but

also designed with the highest level of electronic security

software to defend against potential security breaches in

addition to clearly outline terms and conditions for the private

policy. For farther reach into the target audience, the app will

be made compatible with both Apple iOS and Android smartphones

and a complementary website will be made accessible for those who

do not own a smart phone. Healthy MSM will undergo continual

updates and modifications as it seems fit to adapt to the needs

and expectations of the users as well as the health care

providers.

Background

Mobile Phone Applications

As with most technologies, mobile phones and the Internet

have expanded our channels of communication and modes of sharing

information. Smartphone technology in particular has enabled


consumers to do so much more, especially with the growth and

development of applications. Put simply, an application or “app”

is third-party software designed for mobile devices and can

function as games, productivity tools, e-commerce, media

consumption, “geosocial” networking, etc.8 Given the immense

implications for their utility, mobile phone apps have attracted

the attention of public health practitioners and medical

professionals in delivering interventions that are otherwise

delivered through traditional means. Significant health issues of

our time now pose many interesting opportunities for apps to

prove their worth as a medium for effective and feasible

interventions and have done so accordingly.

Sexual Health: HIV and STDs

Mobile devices and the Internet continue to be employed for

the purpose of sexuality or sexual health.8 For instance, HIV/STD

prevention and treatment efforts have just recently started

relying on apps for delivering interventions. Hence, research is

still lacking in the overall effectiveness of the use of apps in

sexual health. One subpopulation in particular that is most

likely to be associated with higher HIV/STD risk likely deserves


more attention than any other group: men who have sex with men

(MSM). MSM are not categorically restricted by sexual orientation

but more so on the act of engaging in sexual activity with men,

thereby including those who claim to be heterosexual. On the

topic of MSM and sexual health, the literature investigating the

Internet and sexual practices is limited and mainly focuses on

young MSM.8 Equally disappointing is that apps for HIV and STI

education and prevention have generally failed to attract user

attention, gain positive reviews, and become popular thus far.8, 13

Mobile health technology (mHealth) tools support HIV

programmatic priorities including linkage to care, retention in

care, and adherence to antiretroviral treatment.11 Specific

technical features may include alerts and reminders, data

collection, direct voice communication, educational messaging,

information on demand, etc. 11 Among a range of technical

capabilities, most actually employ simple text-based SMS.11

However, improved Internet access and the ability to perform

advanced functions have led to the development of the variety of

app functions currently available.13 One review ranked the

following functions of HIV/STD apps by the most to least


utilized: disease information, testing information or resources,

information about condom use or assistance locating condoms, and

safe sex.13 Apps have also sparked initiatives to promote

prevention messages, facilitate test result notification, improve

HIV medication adherence, and increase adherence to clinic

appointments.13 In terms of HIV/STDs, apps generally seem to

focus on providing disease information, with only a few that

cover four areas of a basic prevention strategy (i.e. knowledge

raising, risk reduction, condom promotion, and testing).13

Evidence-Based Guidelines

According to the Centers for Disease Control and Prevention

(CDC), several evidence-based measures can be taken to reduce

one’s risk of contracting STDs.5 Because MSM are at higher risk

for hepatitis A, hepatitis B, and the human papillomavirus, it is

recommended that they be vaccinated. For safer sex, getting

tested regularly and knowing one’s status is foremost important

as well as getting to know someone before having sex and using a

condom correctly every time one has sex. It is also recommended,

when applicable, that one thinks twice before mixing alcohol

and/or recreational drugs with sex and that one limits their


number of sexual partners. Some STDs can be cured with medication

if one completes the regimen while other STDs like HIV cannot be

cured but can be managed when prescribed the medication (CDC).

Healthy People 2020, which are a set of science-based, 10-

year national objectives for improving the health of Americans,

declare both HIV and STDs as critical areas.16, 17 The following

are the objective statements from both categories that are

pertinent to MSM:

Reduce new AIDS cases among adolescent and adult men who have sex with men

Increase the proportion of men who have sex with men (MSM) who have been tested for HIV in the past 12 months

Reduce the proportion of men who have sex with men (MSM) whoreported unprotected anal sex in the past 12 months

Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections

Reduce gonorrhea rates Reduce sustained domestic transmission of primary and

secondary syphilis Reduce the proportion of young adults with genital herpes

infection due to herpes simplex type 2

The integration of a theoretical framework is equally

necessary for the design of this app. Previous interventions that

have targeted safe sex (i.e. condom use) in MSM or HIV/STD

prevention efforts in general have relied on the Theory of

Reasoned Action2, 12, 14 (TRA), Social learning Theory (SLT)14,


Health Belief Model (HBM)14, Transtheoretical Model (TTM) 14, and

an integrated model of behavior theory by the IOM9. Among them,

the theories most suited for the purposes of this app – to

educate on HIV/STD topics related to MSM, to inform on the

location of STD testing sites, to provide linkage of care between

user and health care provider, to coach users on interpersonal

communication with partners, and to allow communication among

users – include HBM, SLT, and TRA (more so its extension, the

Theory of Planned Behavior (TPB). By using a diagram to

illustrate TPB with HBM and SLT constructs as complementary

functions, the following integrated framework (Figure 1) will guide

the design of app.

Figure 1: Integrated Model of Behavior Change Using TPB, HBM, andSLT

Cognitive: knowledge, expectations,and attitudes

Environmental: social norms andcommunity access

Behavioral: skills, practice, andself-efficacy


According to Ajzen, TPB relies on three components

(attitudes, subjective norms, and control) predicts one’s

intention to perform a particular behavior.1 Behavior, then, is

conceptually a function of intention and perceptions of the three

prior components. In the first component, behavioral beliefs in

whether the behavior produces a given outcome determine negative

or positive attitudes toward the behavior. This is tied together

Behavioral Beliefs

Attitude toward the behavior

Normative beliefs

Subjective norm Intention Behavior

Control beliefs

Perceived behavioral control

Actualbehavioralcontrol

Perceivedsusceptibilityof disease

Perceived threatof disease(risk)

Perceivedbenefits andbarriers to


with SLT’s construct of cognitive factors, because it is

hypothesized that knowledge, expectations, and attitudes are

greatly associated and influential in one’s behavioral beliefs.

In the second component, normative beliefs (i.e. expectations

from referent groups) in the behavior determine the overall

subjective norm or perceived social pressure. This is tied with

SLT’s construct of environmental factors, because it is

hypothesized again that social norms and community access must

somehow influence one’s subjective norms on the behavior. In the

last component, control beliefs (i.e. factors that

facilitate/impede performance of behavior) determine the

prevailing perceived behavioral control or ability to perform the

behavior. This is tied with SLT’s construct of behavioral

factors, because it is hypothesized that skills, practice, and

ultimately self-efficacy heavily influence one’s overall

perception over perceived control of the behavior. These three

underlying components and HBM’s construct of perceived

susceptibility (opinion of the probability of getting a

condition) then hypothetically mediate each other back and forth.

Altogether, they lead to one’s intention or readiness to perform


the behavior. However, it is also hypothesized that both

intention and HBM’s construct of perceived threat or severity

mediate back and forth as well since one’s opinion of how serious

a condition and its consequences are may greatly influence

whether one forms the intention of performing a behavior or vice

versa. Before behavior manifests, the pathway between intention

and behavior is further affected by actual behavioral control or

the extent to which skills, resources, and other prerequisites to

perform the behavior is present). HBM’s construct of perceived

benefits and barriers is also hypothesized to impact this link,

because one’s belief in the efficacy for the behavior to reduce

risk or in the costs of the action may determine whether the

behavior will be maintained.

The general purposes of the app should fulfill the primary

components of the integrated model. The education piece of the

app should address behavioral/control beliefs and

cognitive/behavioral factors. Allowing open communication among

users of the app should facilitate positive beliefs and a

positive environment. Providing interpersonal communication

coaching for partners should also strengthen control beliefs and


behavioral factors. Providing linkage of care between users and

health care providers and the location of accessible STD testing

sites heavily contribute to actual behavioral control. The

primary functions of Healthy MSM should collectively reveal the

benefits and limit barriers and thereby lead the user to the

intention of performing the desired behaviors of engaging in safe

sex, getting tested for STDs, and communicating with partners.

Given these guidelines, the creation of a mobile health app for

MSM to effectively manage their sexual health is warranted. Such

will not only serve as a channel for delivering effective and

feasible public health interventions but also contribute to the

body of research in the use of mobile phone apps and sexual

practices among MSM.

Needs Assessment of Target Population

The target audience for this app will include all MSM ages

16 and above at risk for HIV/STDs as well as those already

diagnosed with thereof living in the United States. Although

there are several more defining characteristics to consider such

as demographics (e.g. age, location, race) or socioeconomic

status, being inclusive of all MSM will provide a more universal


experience and intervention that can be mutually shared among

users. As stated previously, evidence is lacking around the use

of mHealth tools to address the need of key populations such as

MSMs.11 For patterns of mobile phone use, however, MSM have been

shown to have greater access to and use of mobile phone

technologies compared to heterosexual populations.8, 13 Some

evidence also suggests that gay and bisexual men may even be

adopting mobile technologies more quickly than the general

population is.8 Moreover, men who preferred to meet partners

online yielded the greatest number of recent sex partners.8, 10 It

is not surprising then that MSM who use the Internet to seek

partners are highly associated with increased sexual risk

behavior.11, 10 Yet, little research has been done on how mobile-

based social networking apps may affect sex-seeking and sexual

risk behaviors of MSM.11 One study confirmed that men who both

use the Internet and mobile apps to seek partners in the study

tended to be younger and reported higher incomes than those who

used the Internet alone.11 Shockingly, the majority of men

engaging in unprotected anal intercourse in another study

perceived themselves to be at low-risk for HIV.8 Nonetheless, we


do not know whether it is the apps that are driving the behavior,

if persons who engage in riskier behavior to begin with are

simply drawn to the apps, or if perhaps technology and self-

selection have a synergistic effect.10

According to Gilbert at al., certain characteristics may

even further diversify the MSM population when it comes to

HIV/STDs.10 “Not being out” to your primary care provider may be

associated with undiagnosed HIV infection as well as less

frequent rates of HIV testing. Furthermore, it has been found

that age and sexual orientation may be influential on the

intention to use Internet-based testing, with greater intention

among men less than 30 years and gay men, bisexual men compared

to straight/other men. In their study, the most commonly reported

perceived benefits of Internet-based testing were greater

privacy, convenience in general, and being able to test at any

time. In contrast, the most common perceived drawbacks were not

seeing a doctor or nurse, not being able to talk to someone about

the results, not wanting results online, or low trust in the

service. Internet sex seeking has then served as the main

motivation for Web-based sexual health interventions. As Gilbert


et al. recommend, nevertheless, program planners must attend to

the potentially different (sometimes opposite) intentions and

needs of subgroups of gay and bisexual men, particularly those

related to sexual orientation and identity.10

Four Personas and Their Scenarios

Once the target audience has been defined, the creation of

personas is warranted. Personas are hypothetical models with

defining characteristics that are representative and translated

from your target audience. Each single “person” is presented with

a realistic, tangible narrative. Within these stories, a trigger

is encountered that would indicate how the persona would

encounter the app and how that app influences the actions

thereafter. These prototypes are then evaluated to guide the

ongoing design of the app. From these personas and their

scenarios, we learn more about our users and realize how the app

should be adapted to their needs. The following personas are

derived from real-life situations as experienced by the author.

The first three typify commonplace users of social-networking

apps for MSM and the last portrays a health care professional


that would encounter the app and find purpose in utilizing the

app.

Zach

Zach is an 18-year-old single gay

white male living in New York City, NY

who is finishing his senior year of

high school. He is not afraid to admit

that he is “out-of-the-closet” and

feminine for the most part among his

peers. He works part-time at H&M

clothing store and aspires to enter a

theater program for college. When he is not busy with classes,

Zach spends his time with the “Glee” club where he feels most at

home with his other musical, unique peers. Recently, he has been

checking out social networking apps for LGBT users, because he

has felt that he needed to go beyond and meet new people.

Although he is “out,” he has not done much to approach crushes or

guys he would potentially ask out on a date. The nearing

conclusion of his senior year has him thinking as well as curious

about what is out there to experience socially, emotionally, and


even physically. He has never had intimate physical contact with

another male, and the lack thereof has left him feeling empty at

times. However, the idea of catching something like an STD has

suppressed his urges to venture out, but he was determined to

find the “one”.

After spending a week looking through profile after

profile, he notices that majority of them were more or less

seeking sexual relations. He wondered whether it would be a good

idea to meet any of them now, but one person caught his

attention. Zach read through the boy’s profile and realized that

he was looking for actual dates. The two of them start talking,

learning more about each other and finding common ground. Zach

finally decides that it is time to meet him in person and go on a

date. The weekend comes around, and they meet each other at the

local shopping mall and have lunch. Come to his surprise, Zach

falls for the guy and even feels more attraction than he did when

they just messaged each other. He invites the boy over the same

night to hang out since his weekend was free. They parted ways

for the afternoon until the time came for his date to come over

to Zach’s house. Zach then began to wonder what could happen.


Feeling that the two may potentially engage in sexual

activity, Zach began to think how he could prepare for the

incoming encounter that was a mere few hours away. He then

remembered that he saw an advertisement about sexual health for

men who have sex with men on the app he used previously. He

opened the app and tapped on the ad; his phone then directed him

to the app store. The app called Healthy MSM had a description

that read that the app was aimed towards MSM and offered features

on STD information, safe sex, social communication, HIV/STD

testing sites, and health care provider support. At first, he was

overwhelmed with how much he could access and utilize. He

downloaded the app anyways, and the first thing the app did upon

opening is ask Zach which features he needed via a checklist (at

least three). He chose STD information, safe sex, and social

communication. The app then assesses his risk for HIV/STDs by

having him fill out a user questionnaire that then generated

recommended topics for him to read. Upon reading them, he now has

an idea of what to expect if anything sexual happens. He has

familiarized himself with common STDs and their symptoms in MSM,


the many ways in which he can engage in safe sex, and how to

negotiate condom use.

The boy came over at the time they agreed, and they ended up

watching a movie. After the movie though, Zach and him slowly

started to make out. This progressed to skin-to-skin contact.

When the boy asked whether Zach was okay with doing anything

sexual, the opportune moment came for him to communicate what he

would expect in terms of safety and boundaries. He revealed that

this was his first time doing anything with a boy, and that he

was worried about his health. The boy, feeling that Zach was

being genuine, direct, and conscious of his wellbeing, obliged

and even reciprocated similar expectations. The night progressed

with no issues at all. Zach was now aware of safe sex practices

and even opted for him and the same boy he started to date to get

tested per the recommendation of the app since he has not touched

the other options.

Devon

Devon is a 24-year-old black man

who has sex with men living in

Chicago, IL who regularly works full-


time. He is considers himself “straight-acting,” meaning he is

“in--the-closet,” and masculine. He works as an automobile

repairman/finisher and currently has no plans to advance his

career or education. When he is out of work, Devon hangs out with

his other group of male friends, who are actually heterosexual.

To hide his identity and sexual activities from his friends, he

has been an avid user of MSM social networking apps. He has had a

great number of sexual partners, partly due to users being

attracted to his physique and masculine qualities. Devon’s sex-

seeking behavior is highly risky not only because of his non-

monogamous selection of sexual partners but also because he does

not choose to practice safe sex. He seems to prefer the natural

feeling of physical contact, let alone the fact that being not

being “out” has led him to avert from STD resource sites or even

attaining safe sex materials. Moreover, he does not inquire from

his casual partners of their STD status and prefers to head right

into the activity.

Devon has been performing this risky behavior for over two

years without any repercussions or discovery from his friends.

However, his denial of being homosexual has led him to believe


that he was not bound to catch any STDs. This illusion produced

the unfortunate event of his contraction of an STD. One day,

Devon noticed a single sore that was firm, round, small, and

painless on the base of the shaft of his penis. He chose to

ignore this physical sign, and around 4 weeks later, a skin rash

began to form on the palms of the hands and a little on the soles

of his feet. He was shocked to see genital ulcers clearly

manifested, and that he has been feeling flu-like symptoms that

he misattributed to catching it from another person or the

weather. Afraid that his friends and co-workers would notice, he

requested some leave days from work. Devon thought long and hard

as to why he is experiencing these physical signs and symptoms.

He finally realized and accepted the fact that he must have

caught something from a hookup. He attempted searched the app

store with key words like “STD,” “sexual health,” “men,” “anal

sex,” and to his own surprise, “gay”. Upon scrolling among the

apps shown, he came across an app called Healthy MSM, knowing that

MSM stood for men who have sex with men. He downloaded the app

and opened it to find that the app asks for which features – STD

information, safe sex tips, social communication, HIV/STD testing


sites, and health care provider support – he would prefer to have

as his main options via a checklist. For his configuration, Devon

selected STD information, safe sex tips, and HIV/STD testing

sites. He then was asked to fill out a risk assessment

questionnaire that generated a set of recommended topics to look

over. He proceeded with the assessment, which notified him that

he was at high-risk for HIV/ STDs.

Given the assessment, he felt that he had to figure out what

he has. He tapped on the STD information option and the app

opened into a list of STD names by alphabetical order. Since he

had no idea of what he had, Devon typed keywords (sore, bump,

rash, flu) of the physical signs he has been experienced into the

search bar at the top of the window. The search query brought up

“syphilis” as the top result. He read the general information

provided on syphilis and how it is related to men who have sex

with men. He was persuaded that he was in the second stage of the

STD. Knowing that he had to get it treated immediately before it

progressed, he selected the HIV/STD testing sites menu option,

which brought him to a map that used GPS location to detect

testing sites or clinics within close proximity of Devon’s


current location. Description of each testing site allowed him to

discern which would be the most comfortable. Into the future

after making an appointment at the clinic, he was able to receive

treatment for syphilis and advice on safe sex, which he confirmed

from the app as well. He now wears condoms and keeps his STD

status in check despite continuing his sex-seeking behavior of

casual encounters.

Anthony

Anthony is a 28-year-old single

Latino male living in Dallas, TX

working as a businessperson and born

to immigrant parents. He has recently

come to terms with his bisexuality,

being “out” to his friends but not to

his family. He enjoys his current full-time job as well as a good

social life outside of work. When he is not working, he is

hanging out with his friends or dating. He has not had any luck

with the dating websites and apps he has been on. They would try

to match him with other users based on profile compatibility, but

to no avail, no date has ever been completely successful. Part of


this is due to the confusion over his newfound attraction to men,

and his strong suspicions on whether it would be “safe” to be in

a real relationship considering the association – perhaps the

stigma – of MSM with HIV/STDs. His resulting lack of experience

with dating men and potential biases against them has impeded his

willingness to seek them out. While being very consciousness of

his health as well, he beginning to wonder if it was still worth

it to venture out while being safe about it.

After some contemplation, Anthony went online to search for

relationship and sexual health resources for LGBT audiences. He

wanted to know how to enter healthy, intimate relationships with

the same sex since he has only been with women. Upon scrolling

through search results, he came upon a website called Healthy MSM,

which also explained that an app version is also available. He

checked to see who has authored the content of the site/app as he

was skeptical as to whether experts were involved and the

information on STDs were based on cited research; it so happened

that both were true upon looking at the About Us page. Asides from

noticing that he could locate nearby STD testing sites, his

attention was drawn towards another feature: health care provider


support and social communication. He reviewed the terms and

conditions regarding privacy policies to make sure that any

personal health information that was stored by the site/app was

secured and protected. After that, he delved into the social

communication section, which not only featured coaching on

interpersonal communication but also a social networking function

where other nearby users of the app are shown and could be

messaged. What made it more interesting is that users can opt,

with their permission, to display their STD status as verified by

their health care provider with the date of the test and the

results.

Anthony decided to download the app so that he can locate

the closest HIV/STD testing site clinic so that he could be

tested in case he may have caught anything from his past

relationships. After receiving his test results, which were

fortunately negative, he asked the nurse practitioner as to

whether she was familiar with the app. She was not, but she was

open to the idea of verifying his STD status for the site/app so

that he not only could have a record to share with other users

but also keep in contact with her so that he may be able to ask


any specific questions or reschedule for regular testing. This

would work by having the developer send a secured, tracked email

to the clinic site for the specific nurse practitioner to

personally verify his STD status; once a response is received and

recorded on a highly secured storage server, Anthony would be

able to view his STD results on the app or site. He opted for his

status to be visible on his user profile on the social networking

section of the app so that other users know that he has been

tested recently. He then saw others who have been STD tested

“verified,” and began to message a couple of users. He felt good

knowing that he could keep his personal health information safe

and secured on the app and site knowing that the developer was

expert-driven as well as keep things private from family. Anthony

finally felt comfortable going on dates with other men, and that

keeping a close eye on his health as well as of those he met was

a priority.

Tracey

Tracey is a 30-year-old white

educated female living in Boston, MA

working as a nurse practitioner at


Fenway Health. Although she is a woman, she comes into contact

with MSM patients regularly in terms of STD testing. She enjoys

her current full-time position at the clinic, as she works hard

to keep her patients in good health. When she is not working, she

spends her time relaxing at home with her boyfriend or hanging

out with friends if possible. As of late, she has been noticing

that majority of the STD test consultations are from MSM, and

that some of them reveal that they practice risky sexual

behaviors that may have led them to contract STDs. She would try

to assess as to how or why they have been going down this “route”

in terms of sex-seeking. To her realization, most of her MSM

patients have used the Internet to seek out casual partners due

to its convenience, wide use among MSM, and even anonymity for

those who are discreet. Apps like Grindr, Adam4Adam, Man Hunt,

Jack’d, Craigslist, etc. have been mentioned regularly. She has

asked them as to whether they are familiar with safe sex

practices or know their STD status (first admission) and that of

their partners. A disappointing majority admitted to neglecting

such information. Upon hearing so much of this, she was

determined to find to help them.


During one of Fenway’s monthly staff meetings, Tracey has

brought up the issue to her fellow nurses and physicians. One of

them suggested looking up an app called Health MSM as a potential

intervention that may be both attractive for MSM as well as

health care professionals. Coincidentally, the physician that

made the suggestion head about the app from a health professional

conference featuring mobile smartphone technology as the main

theme. After hearing the suggestion, Tracey went online to check

out the app’s main website for further investigation. This

entailed verifying the app’s usability, feasibility, and

relevance for the target audience as well as the effectiveness,

evidence-based guidelines, research, and developer(s) from the

provider perspective. She carefully reviewed the app description

and the features it offers; she proceeded with the About Us page

and reviewed the origin of the app via the developers

(organization and its partners), the sources from which the

content is authored, and the evidence-based guidelines that the

app adhered to. All the features of the app appeared attractive

to her.


One important feature that caught her attention the most,

however, is health care provider support. The privacy policy in

the terms and conditions revealed that the personal information

that users can opt to allow the app to store/utilize included

geographic location via GPS and, more importantly, the user’s STD

status (test results and date) that must be verified by a health

care provider. The app developer assured that such personal

health information would be stored and protected with the highest

level of digital security possible and will only be accessible by

the user, health care provider, and the app developer if needed.

Any security breach would result in immediate notification to the

user and health care provider and the initiation of safety

protocol.

Tracey was persuaded at this point that the app had

potential for improving the sexual practices of her MSM

clientele. After running her idea through her clinical manager,

she was able to recommend Healthy MSM to her patients that came in

for an STD consultation and offered to verify their STD status if

desired. She did not prescribe it as a formal nurse’s order but

rather mentioned the app as advice that she has noted in the


“discharge” summary printout that was handed to patients when

their appointment concluded. Tracey would go over the general

features of the app and recommend those that she thought was

appropriate based on her assessment of the patient’s lifestyle.

Soon, she found that many of her patients tried out the app and

found the content useful to the point where she was being

inquired less of sexual health questions. App users have also

maintained their regular STD testing as recommended.

Lessons Learned from the Personas

Each persona posed a different story with different contexts

triggering the use of the app. For someone as young as Zach, he

already knew a lot regarding STDs, but what he lacked was the

experience of any physical intimacy with another boy. He needed a

way to learn more about safe sex along with interpersonal

communication. Because he was very familiar with popular social

networking apps, he thought that there would be an app on the

market that would address his needs, which were building skills

in the area of safe sex and partner communication. In contrast,

Devon posed a need that Zach already had addressed: disease

information and risk reduction. Devon’s compulsive sex-seeking


let alone being discreet with his casual partners led to the

manifestation of syphilis. Realizing that he needed to get help,

he resorted to also searching for the app on his smartphone since

majority of his partners were found via social-networking apps.

The app then provided him with the information of what STD he

potentially contracted as well as the ability to go to a verified

STD test site that provided treatment. He was even compelled to

review the safe sex tips to reduce his chances of getting another

STD.

Anthony, on the other hand, posed an interesting issue as

well: fear of contracting an STD from dating another guy. His

awareness for his health has led him to struggle with seeing

potential dates, but, upon downloading the app, he was able to

utilize health care provider support. By doing so, he was able to

gain access into the social-networking component of the social

communication feature and meet other app users who are STD tested

verified. This made him realize that he was under the impression

of the stigma that MSM are bound to be infected. Finally, Tracey

comes into the picture not as a user but as a mediator for

recommending the app to her patients who are in fact MSM. Her


role as the medical professional is valued for this app due to

its linkage of care between the user and provider. Moreover, her

advice will spread among app users and therefore produce a

snowball effect as those users tell their friends and they tell

theirs. The conglomeration of experiences from these personas

warrants the comprehensiveness of the app’s features and

functionalities while adhering to evidence-based guidelines. They

also prove that what they thought was one situation they needed

to address would then lead to another, which presents a ripple

effect in the various needs that the MSM population possesses.

Competitive Analysis

The next step in the app design process is to conduct a

competitive analysis. Performing this comparative analysis among

apps currently on the market is crucial in finding out who your

competitors are and how you can succeed by borrowing what others

have shown to be good and useful features, by avoiding what other

do poorly, and by distinguishing yourself from others. For this

analysis, four apps have been selected on two bases: the first

two have been selected based on their being mentioned for their

tailored approach in research articles that have reviewed sexual


health apps and the last two have been selected from being the

top results when searching for sexual health apps with high

ratings and reviews. In Figure 2 below, a chart is presented with

the apps side-by-side for an easy comparison of features and

characteristics that are identified at the left-most column.

Following are listed summaries of what to borrow, avoid, and

distinguish.

Figure 2. Competition Analysis and Evaluation Chart

1 2 3 4

1. App or device name, logo,url

MASTDinfo

https://itunes.apple.com/app/mastdinfo/id4

07553492?mt=8&ign-mpt=uo%3D4

STD411

https://itunes.apple.c

om/us/app/std411/

id395296278?mt=8

Sex Positive

https://itunes.apple.com/us/app/

sexpositive/id705391925?

mt=8

Sexual HealthGuide

https://play.google.com/store/apps/

details?id=com.grabradioworld.sexualhealthguide&hl

=en

2. Objective at a glanceWhat is the

Provides STD information and resources,

Promotes routine sexualhealth for

Provide judgment-free information

Provides textual and visual

https://play.google.com/store/apps/details?id=com.grabradioworld.sexualhealthguide&hl=en



https://itunes.apple.com/us/app/sexpositive/id705391925?mt=8



https://itunes.apple.com/us/app/std411/id395296278?mt=8



https://itunes.apple.com/app/mastdinfo/id407553492?mt=8&ign-mpt=uo%3D4




objective, problem, orchallenge the app or device seems to beaddressing?

including a map of testingcenters in theMassachusetts area

gay, bisexual,and trans guysin San Francisco, CA via latest information onSTDs and activities that are more likely to expose guys toan STD

about STIs, safety, communication tips and healthy adviceon what happens when abody part touches another body part or object

information ona range of topics including Positive Sexual Health,protection andcontraception,STIs, FAQs, myths about sex, support and testing, and current news on sexualhealth

3. Purpose andGoalsHow clear are the purpose andgoals of the app or device at aglance fromname, tagline, and imagery? Does it match the objective at a glance?

Purpose and goals are somewhat clearfrom the name and matches objective but not so much from the imagery of thelogo. The “MASTD” acronym may not be as obvious to some users.

Purpose and goals are generally clear from thename as well as the logo (app name on logo). It appears to match objectives, but unclear asto what targetpopulation forSTDs.

Purpose and goals are generally clear from thename as well as the logo (app name on logo). It appears to match objectives.

Purpose and goal are generally clear from thename and matches the objective but not so much from the imagery of thelogo.

4. UsersIs there any informationabout users

There is no currently available information onusers since

Clear indication from description that app is

Indication in description about “talkingabout what university

Description mentions a wide-variety of topics for both men and


through descriptions, images, stories, testimonials, or usagedata?

the app has been removed from the market and therefore not downloadable.

for gay, bisexual, and transsexual men.

health centersknow best” infers a college student population.

women users, perhaps for all ages and sexual orientations.

5. Ratings andreviewsWhat are the ratings, reviews, and feedback?

Unknown due toremoval from market

iTunes shows atotal of 28 ratings at an average of 2.5/5 stars.

Although limited, iTunes shows 14 ratings at an average of 4/5 stars and Google Play shows 5 ratings at an average of 4.5/5 stars.

iTunes indicates thatnot enough ratings have been received to generate anaverage, but Google Play shows a total of 188 ratingsat an average of 4/5 stars.

6. Downloads and useHow many users/downloads are there? Is there data about retention?

Unknown but CNET.com showsa total of 3 downloads

Unknown with iTunes lackingsuch information

App has been downloaded 16,750 times from both iTunes and Google Play, according to developer’s statistics

App has been downloaded in a range of 50,000-100,000from Google Play, but no information from iTunes.

7. ResearchWas there any research, evidence-based guidelines,or experts involved?

“Experts” may have been involved through the creation of the map of STD/HIV testing centers

Unknown, but app creation by a clinic may infer the possibility ofresearch

Content is written and produced by sex-positive experts at theUniversity of Oregon

Content of onesection displays sources, but creation by anorganization for STD and sexual health education infer the


possibility ofresearch overall

8. DesignHow professional or attractive is the design?

Professional and overly simple yet inconsistent in terms of design; uses ahybrid of a scalable website and app interface for other content, whichappear to be consistent andclear

Not as professional but attractivewith fun, game-like look; more colorful; appearance maylook too busy overall; menu appearance is not as intuitive.

Professional yet eye-catching color-scheme for target audience. Textand formattingappears to generally remain consistent throughout.

Somewhat professional yet attractivewith color scheme. App formatting andtext are generally consistent throughout. More menu buttons than other apps.

9. Layout and navigation (for an app)What sections does the app have and are

Three primary menu options are shown by content type at the main navigation at the bottom: Centers (map),Info, and

App opens to an introductory home page withscrollable general information; three primary menu buttons

Layout is innovative with home pagefeaturing two spinning wheels (inner wheel is user’s body parts and

Five primary menu options are shown by content type at the main navigation at the bottom: news, (positive) sex


they delineated by content type, roles, or user needs?How usable and organized are the layout and navigation (including labels and menus)? Do they make options apparent?

Website. All sections appear to be usable as the content is clear and menubuttons are denoted by icons that areuniversal in apps.

are shown at the bottom (player’s grid, sexual health, and about us); bottom navigation hides and can be accessed bytapping, not swiping; app sections are somewhat consistent in format (e.g. text box placement, etc.)

outer wheel isother body parts or objects to come into contact); below them arethree menu options in a plain list format (STI Risks, Safer Sex Practices,and Communication & Advice); information organized frommost (broad) to least relevant (specific)

health, STIs and contraception,videos, and more). All sections are usable as content is relevant. Icons that maybe universallyunderstood denote menu buttons. “>” symbol indicates further information ahead, but unfamiliar andodd to see

10. Branding and external affiliationsWho createdthe app or device and why? Is there organizational branding, accreditation, sponsorship

Fenway Health created and developed the app. The app is branded by Fenway Health as an indication of its professional/expert origin for Massachusetts users.

San Francisco City Clinic developed the app through a grant from theCDC; branding is clear from app’s splash page when opened

University of Oregon createdthe app in order to “talkabout what theUniversity of Oregon knows best: what happens when abody part touches another body part or object.” The app features UO for

AIDS West in Ireland developed and created the app with support from ViiV Healthcare (GSK) Ireland.Both organizations are branded onthe splash page upon opening app.


, or advertising?

organizationalbranding.

11. Expert contentWhat are the expert-generated components,if any, available (including text, graphics, audio, video, blogs, directions,ask the expert, glossary, quiz, chat with an expert)? Does expertcontent identify the author and date written andreviewed?

The only verifiable information that could be expert-generated is the geographicmap of STD testing sites;STD information and content cannot be verified for expertise origin.

No indication of who specifically authored content, but the app’s player grid game can be assumed to have been designed by those from theSF City clinic

Overall content written by UO;videos featurestudents from the UO Sexual Wellness Advocacy Team and Health Center Peer Health Educators; an assessment video featurescolleagues from the University Counseling andTesting Center; a lecture from afaculty memberin the UP Dept. of HumanPhysiology

News and positive sex health sections appear to be expert-generated; no indication is given as to how news articles are selected for the app, but the topics under positivesex health displays the sources from which the topics are derived

12. OversightIs there anadvisory board or clinician involvement?

Unknown, but supposedly since Fenway Health is a provider of health services to the LGBT

Unknown, but supposedly since SF City Clinic is a specialty clinic for STDdiagnosis and

No clear advisory boardindication over the “sex-positive experts”

Unknown, but supposedly since support was given fromViiV Healthcare (GSK)


communities treatment

13. Literacy and readabilityIs the content in the app clear and easy to understand?What about any descriptions or instructions for an app or device?

Content is easily comprehensibleas it is written in casual, informal language yet enough to be medically relevant. Textis black on a white background forgood contrast.GPS locations on map are easy to follow.

Content is generally comprehensiblewith a neutraltone, but gamehas casual, contextual language; textsize may be too small to read; instructions are shown at homepage, but user has to scroll down toread them

Content is written in casual language and in the collegecontext, whichmay be confusing for non-college users; jargon is not overwhelming; text is black on white background foroptimal readability; no instructions upon initial use

Content is generally comprehensibleas it is written in casual language with enough medicalrelevance. Literacy appears to aimall general audiences. Text is readable with good color contrast. No explicit instructions for app.

14. User-generated content andsharingWhat are the user-generated components (including discussion forums, blogs, videos, “likes”, comments, ratings,

None, but ratings and reviews were possible when app was still on market

User-generatedcontent is limited to ratings and reviews from app market site

User-generatedcontent is limited to ratings and reviews from app market sites and developer site.

User-generatedcontent is limited to ratings and reviews from app market sites


and reviews)? Which, if any, socialmedia is used?

15. PoliciesAre there explicit privacy policies orones for how informationis used at registration?

Unknown or cannot be found

Unknown; supposedly notnecessary

Yes, upon opening the app every time, disclaimer pops up and clearly statesthat the user agrees to “express and obtain explicit consent from everyone involved before engaging in a sexual act…None of your personal information will be tracked or shared by this app.”

Unknown; supposedly notnecessary

16. RegistrationDo users register and, if so,what can they do before and after registering? What informationis tracked

The only personal information used is location via GPS for testing sites in close proximity

None; no personal information istracked or used.

None; as stated, no personal information istracked or used.

None; no personal information istracked or used


or displayed?

17. CostIs there a cost for the app or device? Arethere premier features?

Free Free Free Free

18. Devices and websitesDoes the app or device tie into any others apps, devices, social media, or websites?

App connects directly to the MASTDinfo website

App provides page to accessrelevant sites(clinic website, national HIV resources, questions on STDs, etc.)

App provides page to accessrelevant UO sites (developer, campus partners/content providers, etc.)

None

19. Support and feedbackIs there a website or support forum for users? Is there a wayto provide feedback? Is there a feedback survey?

Unknown, but supposedly a support link through website

App allows users to access developer website or email address to send thoughts/feedback

App allows users to access developer siteand send feedback via submitting an electronic form

None; website shows no clearway to send feedback to developer

20. Overall assessment

(+): Provides easy-to-

(+): Provides tailored

(+): Provides tailored

(+): Provides a great


What are the overallbest and worst features ofthe app or device?

understand, tailored information onSTDs for thosein MA; provides the location of STD testing sites based onGPS proximity;easy to use overall; affiliation with a health clinic; good text readability(–): Removed from the market or short app life; limited functionality (3 menu options); not appropriate for non-MA users; limitedinformation could be foundon the app

information for STD risks with an innovative game; provideslocal STD clinic information; developed by aclinic(–): Unpopularand low ratings; overall app design may be too busy/cluttered; first impression of not appearing expert-driven or research-based; discontinued updates to app; iOS compatible only

information totarget population andpromotes positive sexuality; facilitates interpersonal communication and safe sex; developed by academic institution and experts; disclaimer shown when appis opened; compatible with iOS and Android(–): Content restricted to targeted college audiences; no advisory boardoversight indicated; somewhat unpopular on app market

diverse range of topics related to sexual health,keeps users up-to-date with news, universality of content reaches more audiences, contains some expert-driven content; dually compatible with iOS and Android(–): Lacks feedback channel for users, does not link to other devices or websites, provision of awide-range of information may be overwhelming or unnecessaryfor some users

Borrow – features or capabilities to be included: GPS technology to locate HIV/STD testing sites8; provide comprehensive sexual health information (STDs, safe sex, testing, interpersonal communication with partners, risk assessment, news) targeted to MSM; incorporate textual and audio/visual content for optimal learning and retention; promote positive sexuality


Avoid – what no to do: Focus on LGBT content (or MSM since some claim to be heterosexual) because the majority of content of someapps focus on heterosexuals only8; ensure explicit disclosure of developer(s), expert-driven and research-based content, and private policies regarding personal information since most apps are obscure about it; welcome user feedback on app rather than onwebsite only; do not ignore social environment and integrate user-generated content (social networking) so users can communicate with each other and share information

Distinguish yourself – capabilities and knowledge to capitalize upon to stand out: Provide linkage of care between user/patient and their health care team (e.g. remote health coaching, symptom and side effect monitoring, and provision of real-time feedback)13; provide functionality to share information, education, diagnosis, care, and self-management of STIs among partners or app users11; provide complementary access on any web browser for viewing storage of health information, sex-education resources, test center directory, contacts, discussion forums, etc.8; and include descriptions of biomedical HIV prevention options (e.g. earlier initiation of antiretroviral therapy or preexposure and postexposure prophylaxis13

Description of Design and Justification for Design Decisions

Accompanied by a complementary website, the Healthy MSM app

will offer several functionalities that the user will select upon

opening the app for the first time. The five primary functions

will include STD Information, Safe Sex Tips, Social

Communication, HIV/STD Testing Sites, and Health Care Provider

Support. The inclusion of these content areas was based on the

findings of the Competitive Analysis as well as other research


that have examined sexual health apps on the market currently

available. Moreover, the motivations for downloading a sexual

related app – whether for sex-seeking or for sexual health – will

vary among users, thereby justifying the integration of multiple

functionalities. To simplify the user interface, the app will

initially ask the user in the form of a checklist to select which

functions that are to be accessible and bookmarked in the main

navigation menu at the bottom of the screen (minimum of three and

maximum of four); unselected functions will remain hidden but

still accessible. This configuration can be changed at any time.

A second introductory window will appear and ask the user to fill

out a risk assessment questionnaire that will attempt to gauge

the user’s health risk based on his responses and generate a set

of recommendations upon completion. This risk assessment will not

be required, as it is more for the uninformed, and may be skipped

if desired.

STD Information

STD Information will serve as a library of STD terms related

to MSM as well as any others that are affiliated with STDs. Terms

will be listed in alphabetical order in a scrollable window. If a


term is selected, the dropdown menu will appear and provide

general information (introduction summary, signs and symptoms,

mode of transmission, risks and consequences, diagnosis and

treatment, prevention, etc.). Visuals will also be presented as

appropriate for demonstration and description of the term.

Vision-impaired users will be able to use the audio text-reader

function on their smartphone if enabled so that any selected text

can be read aloud. The user may also enter keywords (e.g. signs

and symptoms the user may be experiencing) in the search bar

above to generate search queries that are most likely to be

relevant to the user. Content in this function will be updated

with the discovery of new research. As with most sexual health

interventions, providing disease information remains as the

basic, primary channel of promoting behavior change and STD

Information will act as such.

Safe Sex Tips

Safe Sex Tips function will also serve as a library of with

instructional topics delivered via text, visuals, and videos.

Because content will be targeted towards MSM, topics pertaining


to safe sex will include but is not limited to the following

sexual practices: penile-anal sex, rectal fisting, oral-penile

sex, and oral-anal sex. Preventive measures such as condom use,

dental dams, preexposure (PREP) and postexposure prophylaxis

(PEP), and addressing drug/alcohol use will also be presented. As

with STD Information, Safe Sex Tips will also feature a search bar at

the top of the screen so users can limit their search to more

relevant topics. Those who have taken the risk assessment upon

initial use of the app will be able to access a personalized set

of safe sex recommendations, regardless of whether they initially

selected this function to be bookmarked on the home page. As with

common sexual health interventions, safe sex, condom use, and

risk reduction are content areas in which the Safe Sex Tips feature

should fulfill for the user.

Social Communication

Social Communication will be composed of two subsections: one

for a list of topics pertaining to interpersonal communication to

serve as a coaching and role-play module and the other for access

into a “social-networking” pool where other app users are listed

based on geographical proximity, resembling that of popular


social-networking/dating apps. The former will provide users with

advice and tips on how to communicate sexual health issues with

partners if the user is experiencing difficulty with expressing

expectations or concerns. Text will serve as the primary medium

for content with accompanying videos if available/applicable. As

for the latter, users will initially be asked to fill out a basic

profile (name, age, race, height, weight, and description), but

they will not be required to complete it. This means that they

can leave those textual items blank; however, it is stipulated

that users upload non-obscene profile photos that clearly show

their faces to ensure unanimity and fairness among app users and

to discourage “prowling”. The app’s focus on sexual positivity

should justify this feature. Users may communicate with each

other via text only with no photo sharing, as to avoid and

prevent the sending of pornographic content. Profiles that are

reported to have been displaying inappropriate content

(description or messages otherwise) will be removed and be

subject to review by the developer. The one feature of this

function that will differentiate this app from others is the

explicit display of “STD testing” status. Per the goals and


objectives of the app, profiles will automatically be marked with

a checkmark or question mark: those with a checkmark will

indicate that the user has been tested for STDs and the date of

the test as verified by a health care provider within three

months whereas a question mark will indicate that the user has

not been tested by a verifiable provider or that the test results

have expired. However, profiles that are deemed “verified” will

not display the STD status (test results) by default unless the

user permits the app to do so. This should to encourage not only

regular STD testing for the sexually active but also the

disclosure of STD status to partners. The option to reveal their

test results will be explicitly clear that it is totally their

choice as stated in the disclaimer containing the privacy policy

on sharing personal information. Again, the user may opt out of

this feature anytime. While being uncommon with most sexual

health apps, the Social Communication feature should not only

facilitate perform effective partner communication but also

promote interactivity via sharing experiences among users as well

as sexual positivity, especially with STD disclosure.

HIV/STD Testing Sites


HIV/STD Testing Sites will resemble location services from two

tailored apps evaluated in the Competitive Analysis. As such,

this function will present a map with the user pinpointed at the

center and bookmarks that highlight the locations of sites or

clinics that offer STD testing according to their smartphone’s

GPS service. Alternatively, the user can choose to view the sites

in list form ranked by distance proximity. The site’s basic

contact information (name, address, email, website, schedule of

operation, etc.) will be integrated into the app. Since Healthy

MSM will cater to all MSM within the continental U.S., a

comprehensive compilation of gay-friendly STD testing sites will

be conducted in each state, specifically regions that are highly

populated or concentrated with sites/clinics during development.

Additional sites will be added consequently, perhaps via users’

feedback, as the app is updated. Users may directly call or email

their preferred site for immediate contact for making an

appointment, following up, or questions. This feature should in

part address issues related to resource accessibility since some

MSM populations are uninformed that testing sites that may be

accessible and available nearby.


Health Care Provider Support

Lastly, the defining feature of the app, Health Care Provider

Support, will serve as a STD status tracking system between the

user and his provider. Integrated with the Social Communication,

this feature will be the most sensitive in terms of holding

personal health information for the user in connection with a

verifiable health care provider. This will require an explicit

display of a disclaimer with the terms and conditions associated

with their STD status (results and test date) being recorded by

the app. Upon agreeing to the terms and conditions, the user

will be asked to fill out a request form for verification by the

health care provider that conducted the test. That request will

be then be sent to the health care provider electronically via

email. If the provider has not responded back to the request, the

user may opt to contact the individual or the clinic directly to

indicate that a request for verification has been submitted to

his respective provider. If successful, the provider will have

received and responded to the request with the necessary personal

health information, confirming that he/she verifies that the user

has been in fact tested along with the date. However, upon


failure to be verified by the provider electronically, the user

may alternatively opt to scan a copy of the STD test results in

print and signed from the clinic itself and send it to the app

developer for crossover confirmation. This function, as expected,

will be closely monitored by the developer with the operation of

a highly secured, encrypted storage system possible. Given the

software’s defenses, data will be closely monitored and regulated

by IT professionals affiliated with the developer. If any

security breach occurs, a standardized safety protocol will be

initiated to resolve the problem. Users and their providers will

be notified and updated regularly of any development made in the

case. To compound on the promotion of HIV/STD testing, this novel

feature will enable the user to keep an accessible record of

their STD status with them as long as they have their mobile

smartphone on them as well as abide by the requirements to use

the feature as defined by the app.

Compliance with Evidence-Based Guidelines

Per the guidelines from the CDC, all the features directly

or indirectly should address MSM-specific issues such as the

following: hepatitis risk, safer sex, regular testing, condom


usage, drug/alcohol use, and treatment adherence. Consequently

the fulfillment of thereof will contribute to the completion of

Healthy People 2020 objectives that pertain to MSM. Healthy MSM

will continue to adapt to evidence-based guidelines in order to

remain beneficial, functional, and effective for both users and

health care professionals that use the app.

The design of the app should also follow a theoretical

framework as demonstrated by the hypothetical integrated model of

behavior change consisting of TPB with SLT and HBM constructs.

STD Information and Safe Sex Tips should influence both behavioral and

control beliefs and cognitive/behavioral factors. Within Social

Communication, the social networking feature for users should

facilitate both positive beliefs and an inclusive environment

whereas the interpersonal communication feature for partners

should also affect control beliefs and behavioral factors. HIV/STD

Testing Sites and Health Care Provider Support should increase actual

behavioral control. Altogether, the app aims to lead users to the

intention of performing the behaviors that maintain sexual

practices and STD status in a healthy manner.

Usability by Personas


As stated, each of the four presented personas had a

specific motivation for using the app and the features they chose

upon initial use. Zach, while being educated on STDs and perhaps

safe sex, did not know how to go about going on a first date and

actually engage in safe physical contact. The Safe Sex Tips and Social

Communication features would have addressed those needs. For

Devon, it was the opposite in which he knew little about STDs and

safe sex. He would have relied on the STD Information and Safe Tips to

be informed of the consequences of practicing risky sexual

practices; he was motivated further by the HIV/STD Testing Sites

feature to seek the nearest clinic for treatment of syphilis. As

for Anthony, it was a matter of recording his STD status on Health

Care Provider Support and being able to use the social-networking

feature of Social Communication to meet other users since he only

started to date men recently. Finally, Tracey was able to promote

the use of the app to her patients who may be having difficulty

in managing their sexual health. She may not have been a direct

user, but her and other professionals alike will be necessary in


supporting users in recording their STD status and maintain

regular testing via the Health Care Provider Support feature.

Improvement on Existing Apps While Capitalizing on Mobility and

Context

Based on the “avoid” results of the Competitive Analysis,

Healthy MSM will focus on LGBT content (or MSM since some claim to

be heterosexual), because the majority of content of some apps

focus on heterosexuals only.8 The app will also be presented in a

way that ensures explicit disclosure of the developer(s), expert-

driven and research-based content, and private policies regarding

personal information since most apps are obscure about it. This

will be significant, considering the use of personal information

(personal location and STD testing status). User feedback on app

will be welcomed rather than on website only in order to

encourage users to express their thoughts and opinions of the

app. The app will also not ignore the social environment, thereby

calling for the integration of user-generated content (social

networking) so users can communicate with each other and share

information


According to Richman et al., mobile phone apps offer

convenience not only to the user but also to the developer since

they serve as a flexible channel to affordably reach large

audiences.13 Apps such as Healthy MSM can more so deliver tailored

and interactive HIV/STD prevention interventions to the target

population that are always accessible; users can seek sexual

health information while maintaining their anonymity (with the

exception of the social-networking feature and provider support).

These apps must also accommodate self-tailoring and

personalization, allowing the user to choose which features they

wish to use and select messages and notifications they prefer to

receive through the app or alternatively, email or SMS. 13 For

this reason, users will be asked to complete a checklist that

allows them to bookmark 3-4 of the 5 features available for their

home screen while being able to change that configuration any

time. Compared to SMS and automated voice messages that are sent

on a schedule, mobile phone apps have the ability to be

constantly available, responding to the users’ convenience.13


Wireframes Depicting a Subset of the Functionality

Figure 3. Home Screen with Pre-Selected Menu Preferences

Figure 4. STD Information


Figure 5. HIV/STD Testing Sites

Figure 6. Health Care Provider Support


Evaluation Plan and Goals

Given the multifaceted functionality of Healthy MSM, several

evaluations during the app development process will be necessary

to gain user feedback on the appeal, usability, and effectiveness

of the app before finalization. Muessig et al. have noted the

importance of formative research during product design to ensure

that apps are tailored to the user.13 During the evaluation

stages of app development, the collection of self-reported data

from the target population as well as clinical data if possible

will be conducted.11 Collaborating with a local clinic(s) will be

sought to enhance personal data collection about true behavior

change and outreach to the target population.11 For evaluations

to be meaningful, identifying outcome goals and measurement


metrics at the start of app design and development is

essential.13 Based on the goals and objectives of Healthy MSM, the

primary outcomes to be measured include increased knowledge of

STDs and safe sex topics, adhering to regular STD testing,

increased performance of safe sex, and maintaining compliance

with health care provider advice. Moreover, the success of the

app will necessitate collaborations between developers and public

health HIV/STD researchers and practitioners.13 Since formative

evaluations generate user feedback during various stages of the

app creation process, the first formative evaluation (three

subjects) will be conducted upon the generation of screen mock-

ups with descriptions of the app functions and features. The

second evaluation (six subjects) will be carried out on a working

prototype after modifications have been made according to the

first one. The final formative evaluation (nine subjects) will

then be conducted once further modifications have been made based

from the second one, thereby producing the initial release

version of the app.

For each evaluation, a standard structure and script will

be used to conduct the sessions by an evaluator and scribe in a


controlled, comfortable environment. Before participants are

engaged, demographic information (age, race, place of residence,

etc.) will be collected as well as preexisting knowledge and

attitudes on sexual health topics and sexual

practices/preferences. Due to the sensitive nature of these

inquiries, informed consent will be needed prior to each

evaluation session. Participants will be provided the product

name, tagline, and logo to provide a sense of what the app is

about. For the second and third formative evaluations, tasks to

be assigned to the participant will include the following to

ensure coverage of all app features: explore and search for

terms/topics in STD Information and Safe Sex Tips, simulate the search

for a clinic in HIV/STD Testing Sites, create a profile and assume the

role of a “user” in Social Communication, and simulate the storage

and display of personal health information in Health Care Provider.

In addition to the scribe taking notes real time, responses will

be recorded verbally and sessions will be recorded via video

camera for retrospective analysis.

For recruitment among the MSM, key subjects that resemble

any combination of the characteristics described from the three


male personas are first priority. Subjects will be located by

advertising via social media sites (Facebook, Twitter, etc.),

Craigslist, major hospitals or STD clinics, and known gay social-

networking/dating apps. Subjects will be compensated $75 for the

45-minute session. Any subject that may appear to be taking a

longer time than usual will be assisted by the evaluator. Upon

completion of the evaluation session, both the evaluator and

scribe are to review notes for additional comments if warranted.

A summary of each session will then be drafted so that results

are reviewed to highlight specific recommendations on necessary

changes in the app appearance, functionality, content, etc.

Participants will be asked several questions throughout each

evaluation session to gain their perspectives. The types of

questions may include but are not limited to the following:

Before coming in contact with the app: o What they would expect from the app based on its name? o Would they download it based on the name, tagline,

description, etc.? o Would they be interested in the app anyways if they did

not currently have any app related to the health of MSM? Upon opening the app :

o What do they think it is for, and what comes to mind?o What would make you search for it and what search terms

would you use?o What features attract their attention?


During the use of the app:o What are they interested in trying? o What do they think about the layout and navigationo Is it easy to use?o Are they interested in their STD status, safe sex, and

other sexual health topics? Following the use of the app:

o What was attractive about it? o What particular things should be added/changed/removed?o Would they keep the app on their smartphone for future

use?o Did they found it useful?o Would they would recommend the app to other users?

Development Plan, Costs and Schedule

To maximize reach, the app will be designed to be dually

compatible for both Apple iOS and Android smartphones. The

complementary website for viewing the storage of personal health

information among users who agree to the terms and conditions

will also be made accessible on multiple web browsers (Internet

Explorer, Google Chrome, Mozilla Firefox, Safar, and Linux) in

addition to the developer’s homepage. As for the creation of

relevant content, working with communication contractors and

HIV/STD experts (Tufts University School of Medicine, Harvard

University, University of Oregon, etc.) on presentation within

the app will be planned during all phases of app design.

Costs


According to Levine, piloting the solution (the app)

involves figuring out who is creating mobile or new media

solutions, perhaps with a contractor’s help.11 For-profit and

non-profit companies with an emphasis on health will be

considered for development collaborations as well as engineers

who are working other fields who might be interested in the app

project. Partnerships between researchers and web site owners/app

developers are necessary.8 Official and contractual partnerships

will be sought out with professional entities such as the

American Medical Association and American Public Health

Organization. Based on the app design proposed here, the

estimated costs for creating the app consist of development costs

(~$42,500 for database creation, GPS locator services,

complementary website, information sharing, etc.), design costs

(~$7,500 for iPhone and Android coding), and perhaps evaluation

costs (~$2,000 for three sessions and miscellaneous) for a grand

total estimate of $52,000. Because of this, the app will cost

$1.99 for the full, working version of the app. This will not

only allow users to use the app ad-free but also compensate for

the comprehensiveness of features and capabilities.


Schedule

An estimated duration of one year (16 months) will be

anticipated for the completion of the entire app creation process

from conceptual design to development and prototyping to initial

public release. Conceptualization of app design will take 2

months, and development and prototyping will take 8 months.

During this phase, wireframes (see Figures 3-6) will be coded for

the beta version. As mentioned in the evaluation section, this

prototype will be utilized in the second and third evaluation

sessions for user feedback and subsequent revisions. These last

two sessions of the three will take 2 months for sufficient

timing for modifications between the second and third sessions.

In order to finalize the beta version for initial release, 4

months will be necessary to complete all the necessary

modifications and updates from feedback and recommendations based

on the formative evaluations.

Upon initial release, Healthy MSM 1.0 will be made available

to large-size pilot groups across the U.S. in majorly populated

cities. The selection of participants will be based on common MSM

demographics as well as their proximity to potential hospital or


clinical sites that offer STD testing. This will not only allow

for the use and exploration of the novel medical status feature

of the app but also encourage social networking among app users.

The total time needed for adequate data collection for subsequent

updates may be 4-8 months due to the latency/lead-time for most

STDs to manifest. Based on the primary health outcomes of the

app, measurement metrics and quantitative data will be collected

and analyzed. In addition, user feedback/reviews will be inquired

of the pilot groups for design revision to produce H-MSM 2.0.

Marketing Plan

Nearing the conclusion of app development, marketing

strategies will be considered for targeting consumer and will

incorporate multi-pronged approaches to achieve the saturation of

messages by combining online, TV, radio, print, social media,

and SMS communications.11 As with the advertising and marketing

other popular apps on the market, these channels will include

major television networks for MSM audiences will be targeted, top

hits radio channels, major newspaper and popular magazines,

Facebook, Twitter, LinkedIn, popular blogs, and other social-

networking/dating apps for MSM. Collaborations with major


STD/LGBT organizations such as Planned Parenthood, the National

LGBT Health Education Center, AIDS United, etc. will also be

considered for enhancing consumer reach as well as promoting the

use of a sexual health app to MSM in the LGBT population. These

organizations operate in a similar vein with the app, therefore

having the app promoted through them will enhance their goals and

objectives as well as those of the app itself. The combination of

these social marketing approaches should adequately saturate

messages on the app, especially since the majority of MSM are

younger.

Asides from the more familiar and commonplace interventions

among today’s sexual health apps that integrated in Healthy MSM –

STD information, safe sex, locations of testing sites, and

sharing information among users, the app’s novel function of

linkage of care between the user and health care provider will

require more than just these strategies in order to enter the

market strongly and successfully. This will essentially require

and official partnership and affiliation with a professional

health care organization(s) to not only serve as oversight to the

app’s overall operation among consumers but also present a strong


legitimate sense of professionalism. Trusted and professional

organizations are more than likely to guarantee the security of

their users’ personal information, thereby serving as a powerful

and rapidly accessible resource.10 Of course, it will be

essential that users of the app are made aware of the potential

confidentiality and security breaches.10 It will ultimately be

our responsibility to ensure that this app is not malicious and

employ the best data protection software so users feel safe.10

The concern of credibility arises when an app is not

developed by a named professional health care body/organization

(e.g. the CDC, National Institutes of Health, the American Sexual

Health Association, etc.) and there may be lacking assurance of

confidentiality.10 To address that, measures will be taken to

ensure visibility into the app developer’s entity, terms and

conditions, and where private data is being stored and how it is

being used.10 Additionally, full disclosure of the types of

personal information (e.g. precise location and STD status)

needed for the app to function will be made explicitly.10

Encouraging health care providers and other professionals in the

field to recommend the app to their patients/clients will induce


a stronger sense of security and trust in the app’s benefits.

Altogether, these marketing strategies should be reassuring that

their health information is important to the function of the app

as well as enabling the app to do what it is supposed to do:

enhance the sexual health and safe sex practices of MSM.

Limitations

Surface limitations highlight the fact that little is known

about the feasibility and acceptability of delivering HIV and STI

prevention via smart devices.8 This could be observed in the lack

of popularity among sexual health apps, let alone those targeted

to MSM. More importantly, the divide between users of these apps

exists, with those of lower socioeconomic status, those of lower

education, and those who are older being less likely to own

smartphones and other mobile devices.8 To address this, the

creation of a complementary website will allow those who do not

own smartphones but have access to a computer the ability to

record and store their STD testing results online. The only

limitation is that the user will not be able to share his STD

status automatically if desired. However, the greatest limitation

that is reflected in this app and many other health apps has to


do with privacy and security. The typical issue with personal

health apps brings up questions about how to virtually ensure

protection of patient privacy.8

Apps typically ask the user to authorize the requested

“permissions”.10 While some “permissions” remain harmless, many

raise serious implications regarding the confidentiality and

security of apps requesting them.10 For Healthy MSM, permissions

regarding personal information will not only include user

location via GPS locator services but also the sensitive health

information of one’s STD testing results. This information will

be stored both on the app as well as an electronic database

server to enable the use of the complementary website or if the

user log into the app from another device. To defend against

security breaches, the highest level of security software will be

utilized and the server will be closely monitored for any

weaknesses that may be uncovered. However, even the best security

system will be prone to hacker attacks, and this will have to be

clearly understood by the user. Clear and explicit description of

the vulnerabilities of the Health Care Provider Support feature will


have to be made known not only to the users but also the health

professionals that will be inputting and validating the

information.


References

1. Ajzen, I. (2006). Theory of Planned Behavior Diagram. Retrieved from http://people.umass.edu/aizen/tpb.diag.html

2. Baker, S., Morrison, D., Carter, W., & Verdon, M. (1996). Using the Theory of Reasoned Action (TRA) to understand the decision to use condoms in an STD clinic population. Health Education & Behavior, 23(4), 528-42. doi:10.1177/109019819602300411

3. Brito-Mutunayagam, S. L., & Fernando, I. (2013). Security Concerns to be considered when downloading Human Immunodeficiency Virus/sexually transmitted disease related smartphone applications. Journal of Medical Internet Research, 15(10), e222. doi:10.2196/jmir.2650

4. Catalani, C., Philbrick, W., Fraser, H., Mechael, P., & Israelski, D. M. (2013). mHealth for HIV treatment & prevention: A systematic review of the literature. The Open AIDS Journal(7), 17-41. doi:10.2174/1874613620130812003

5. Centers for Disease Control and Prevention [CDC]. (2013). Gay Men and STDs | Sexually Transmitted Diseases | CDC. Retrieved from http://www.cdc.gov/std/life-stages-populations/STDFact-MSM.htm

6. Gilbert, M., Hottes, T., Kerr, T., Taylor, D., Fairley, C., Lester, R., Wong, T., Trussler, T., Marchand, R., Shoveller, J., & Ogilvie, G. (2013). Factors associated with intention touse internet-based testing for sexually transmitted infectionsamong men who have sex with men. Journal of Medical Internet Research, 15(11), e254. doi:10.2196/jmir.2888

7. Grosskopf, N. A., LeVasseur, M. T., & Glaser, D. B. (2014). Use of the Internet and mobile-based "apps" for sex-seeking among men who have sex with men in New York City. American Journal of Men's Health, 8(4), 1-11. doi:10.1177/1557988314527311


8. Grov, C., Breslow, A. S., Newcomb, M. E., Rosenberger, J. G., & Bauermeister, J. A. (2014). Gay and bisexual men's use of the Internet: Research from the 1990s through 2013. Journal of SexResearch, 51(4), 390-409. doi:10.1080/00224499.2013.871626

9. Hightow-Weidman, L., Fowler, B., Kibe, J., McCoy, R., Pike, E., Calabria, M., & Adimor, A. (2011). HealthMpowerment.org: Development of a theory-based HIV/STI website for young black MSM. AIDS Education and Prevention, 23(1), 1-12. doi:10.1521/aeap.2011.23.1.1

10. Lehmiller, J. J., & Ioerger, M. (2014). Social networking smartphone applications and sexual halth outcomes among men who have sex with men. PLoS ONE, 9(1), 1-6. doi:10.1371/journal.pone.0086603

11. Levine, D. (2011). Using technology, new media, and mobile for sexual and reproductive health. Sexuality Research and Social Policy, 8(1), 18-26. doi:10.1007/s13178-011-0040-7

12. Mclaws, M., Irwig, L., Oldenburg, B., Mock, P., & Ross, M. (1996). Predicting intention to use condoms in homosexual men:An application and extension of the theory of reasoned action.Psychology & Health, 11(5), 745-55. doi:10.1080/08870449608405002

13. Muessig, K. E., Pike, E. C., LeGrand, S., & Hightow-Weidman,L. B. (2013). Mobile Phone applications for the care and prevention of HIV and other sexually transmitted diseases: A review. Journal of Medical Internet Research, 15(1), e1. doi:10.2196/jmir.2301

14. Pulley, L., McAlister, A., Kay, L., & O'Reilly, K. (1996). Prevention campaigns for hard-to-reach populations at risk forHIV infection: Theory and implementation. Health Education Quarterly, 23(4), 488-96. doi:10.1177/109019819602300408


15. Richman, A., Webb, M. C., Brinkley, J., & Martin, R. J. (2014). Sexual behaviour and interest in using a sexual healthmobile app to help improve and manage college students' sexualhealth. Sex Education: Sexuality, Society, and Learning, 14(3), 310-322. doi:10.1080/14681811.2014.889604

16. United States Department of Health and Human Services, Healthy People 2020. (2014). HIV - Healthy People. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=22

17. United States Department of Health and Human Services, Healthy People 2020. (2014). Sexually Transmitted Diseases - Healthy People. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=37


About the Author

Daryl Mangosing is currently enrolled in a Master of Public

Health (MPH) in Health Communication program at Tufts University,

School of Medicine. He received his Bachelor of

Arts degree in Health Sciences from Berea

College in Berea, KY. Daryl is now working

part-time as an administrative assistant for

the Tufts Center for Global Public Health.

Originally from Guam, he has only been living in Massachusetts

for seven months since he immediately relocated from KY after his

undergrad to start the MPH graduate program at Tufts. He remains

undecided as to what to pursue (career or doctorate program)

after graduating with an MPH degree.

Daryl has been interested and engaged in LGBT issues, having

dealt with homophobia directly and indirectly from others. Now,

he is trying to learn more about the challenges of the LGBT

population as well as gender/racial issues that permeate equally

throughout society. He hopes that his concentration in health

communication will enable him to devise and implement strategies

that aim to improve the health of society through various


channels such as social media, journalism, academic research,

community and non-profit work, and technology. In his spare time,

Daryl enjoys hanging out with friends at popular venues, reading

into popular blogs, going out and eating at new restaurants, and

marveling at cute, fluffy animals in life or online.

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