Principal Findings
Our review identified a large number of smartphone apps that have sexual content or promote dating. We found that the majority of these sex-related and dating apps contained no information about sexual health promotion. We chose to review all apps found using our search terms, regardless of app store category, rather than focusing on apps that aim to provide sexual health information and education. The reason behind this decision was that previous research has shown that apps designed for educational purposes are infrequently downloaded and underused [23]. We made the same observation in our review. For example, Sexually Transmitted STDs, an app that provides information about STIs, including definition, transmission, symptoms, treatments, and prevention, had fewer than 1000 downloads to January 2015. On the other hand, some game apps were downloaded far more frequently; for example, Bliss – The Game for Lovers was downloaded more than 100,000 times from the Android Google Play marketplace (this app is also available in iTunes). This finding demonstrates the advantage of integrating sexual health information within popular entertainment apps in order to reach out to more people. We found that 73% of the apps with sexual health content had the primary purpose of education, which means that they might not be attractive to people who are not specifically seeking out sexual health information. Only 2 sex aid apps and 1 entertainment app contained sexual health content, demonstrating room for improvement. We hypothesize that exposing users to sexual health content while they are using these sex-related apps (presumably while they are thinking about sex or during foreplay) might be a good way to remind them of safe sex practices. This hypothesis will need to be examined in future research.
In the first part of the study, we found that 19 sexual apps had the primary purpose of providing support and information for sexual assault or violence. These apps offered a variety of information about topics including mental health support after sexual assault, prevention of sexual assault, and general information regarding sexual assault. However, none mentioned the potential adverse sexual health outcomes faced by sexual assault victims. The risk of unwanted pregnancy and contracting STIs, and steps that can be taken to prevent or treat these, are critical in the aftercare of sexual assaults [25]. Many victims of sexual assault do not seek help from health professionals [25]; therefore, providing such information via smartphone apps might encourage victims to seek medical advice for STI and pregnancy prevention.
Our review of dating apps showed that very few included any sexual health content (9 of 60 dating apps reviewed, 15%). The majority of these apps were targeted at an MSM population (7 out of 9). These findings suggest that there is more focus on the sexual risks of MSM who use dating apps than other groups. MSM are disproportionately affected by HIV globally and are a key population for HIV infection and STI prevention [26-28]. These geosocial-networking apps can potentially function as an entry point for HIV intervention delivery, assisting health professionals to reach the key populations, particularly where populations are hidden or difficult to access [7,15]. Delivering sexual health interventions via dating apps is an important area to be addressed in prevention of HIV infection.
It is unfortunate that the opportunity to deliver messages to other groups via these apps is being missed. Only 1 of the 44 heterosexual dating apps reviewed had any sexual health content (STI status in users’ profile). People who use dating apps seem likely to have more casual sexual partners than people who do not, which means higher risk of contracting STIs [13]. While sexual health content appears to be acceptable to MSM who use dating apps, its acceptability among other groups is unknown [15,24]. More work needs to be done to increase the sexual risk awareness of users of heterosexual dating apps.
Dating apps used four different modes to display sexual health content: pop-up messages, infection status in users’ profiles, safe sex preferences in users’ profiles, and blog posts or links to sexual health information in the apps or linked websites. Each of these messages has its own limitations in reminding users of their sexual risk. First, the frequency and timing of pop-up messages might influence users’ acceptance. If the frequency is too high, it might desensitize users. Messages appearing during chats could cause annoyance, which could lead to users unsubscribing and turning to other apps that exclude these kinds of messages. Second, having HIV or STI status and safe sex preference on a profile can be a good way to assist users’ partner filtering processes. Nevertheless, these messages are highly dependent on users’ self-reports and their knowledge of infection status. These disclosures may also expose users to stigma and discrimination or cyberbullying [29]. In the 2 apps that enabled indication of preference for safe sex practice, the concept was not defined. Moreover, since this information appears on users’ profiles, users can decide to disclose the status or preference, or not. Third, in-app blog posts can be a good place to display information regarding STIs and HIV if these posts are updated frequently and the information provided is correct. On the other hand, having links to sexual health clinics in the websites rather than within the apps might be less effective, since users have to be actively looking for sexual health information and using the website at the same time to be exposed to these messages. This type of message is less likely to effectively remind users about their sexual risks. Further research is needed to understand the impact these messages have on users’ behavior and health outcomes.
We identified another potential platform for intervention during the app review: the advertisement space within apps. Advertisements (ads) mostly exist in two forms: pop-up ads and ads that appear on the bottom of the screen; users can close pop-up ads, but they usually cannot remove bottom-of-the-screen ads. Once users click on the ads, they will usually be directed to a new page that contains more information about the product being advertised (most likely another paid app). Health promoters could purchase these ad spaces to display sexual health information or links. Some app developers sell ad spaces as pop-ups for advertisers to purchase. For example, Grindr sells mobile Web banner ads, which can link directly to advertisers’ websites, emails, or mobile numbers [30]. These ads are sold as cost per thousand banner impressions, with the price ranging from USD $9 to $25 per thousand banner impressions for iPhone and Android devices. It is potentially a cost-effective way of promoting sexual health, as it is cheaper and more focused on target groups than traditional media ads. However, the limitation of this method is that users are usually encouraged to subscribe to premium membership (by paying a monthly fee or upgrading to the paid version of the apps) in order to avoid seeing the ads. Once users upgrade to the paid versions, they might no longer be exposed to sexual health information through this medium. More research is needed to evaluate the effectiveness of advertising through in-app ads and how to make sure all users receive the messages being advertised.
Research has shown that 80% of Internet users in the United States search online for health information, and that young people are gathering health information using mobile devices with increasing frequency, including sexual health information [31]. However, while new technologies, including smartphone apps, are used to facilitate health information seeking, health-related apps are infrequently downloaded and rarely used [32]. This suggests that, to promote sexual health through smartphone apps, researchers could partner with app developers in order to integrate sexual health promotion interventions in popular sex-related or dating apps [24]. Such partnerships will be difficult to form when the interests of the parties conflict. For dating app developers, sexual health content that reminds users of their sexual risk might be unattractive, as it could jeopardize their popularity among users [24]. However, it is evident that these apps provide novel opportunities to engage at-risk populations in sexual health interventions [7,8,11,15,24].
Several studies have suggested that young adults consider sexual health promotion via apps acceptable [10,15,24]. Sun et al found that approximately two-thirds of MSM were willing to receive sexual health-related information through apps, and 26% of them requested referrals for HIV and STI testing [15]. The willingness to participate in future HIV infection and STI prevention programs is even higher among MSM aged between 19 and 24 years [24]. Holloway et al found that 80% of young MSM recruited through Grindr expressed an interest in joining such programs, and 71% preferred to have the information delivered through smartphone apps [24].
Limitations and Strengths
Our study had some limitations. First, smartphone apps are changing rapidly, including their content, popularity, and even availability. The ranking of popularity varies over time; therefore, our search results might be different if repeated. Updates of the apps can change apps’ features and functions, including the sexual health content that we looked for. For example, since our review, Tinder has agreed to provide information for STI testing locations [33]. Second, our categorization of pop-up sexual health content might have been inaccurate: we could have missed infrequent pop-up messages, or those appearing only around major events. We used only 1 device for each platform, which prevented us noticing variation in app function between devices (if any). We also did not identify any differences in the frequency or availability of sexual health content using different profiles. Third, the terms “sexual” and “dating” used to search app stores for sex-related apps and dating apps may have constrained our search. Other terms such as “sex” or “networking” could be considered for future searches. Fourth, our search was limited to the Apple iTunes store and the Android Google Play store, and thus neglected apps from other smartphone operating systems (eg, Microsoft, Palm, Blackberry). However, this decision was justified by the fact that 96% of smartphone users worldwide use either Apple or Google operating systems [34].
Despite these limitations, this study is, to our knowledge, the first to review the inclusion of sexual health content within sexual and dating apps that are not primarily aimed at sex education. We are unsure how much influence these messages have on users. Further research in this field is needed to understand the effectiveness and efficiency of promoting sexual health through in-app messages.