Article

The Cellular Generation and a New Risk Environment: Implications for Texting-Based Sexual Health Promotion Interventions among Minority Young Men Who Have Sex with Men.

Charles R. Drew University of Medicine and Science
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium 01/2012; 2012:247-56.
Source: PubMed

ABSTRACT

African American and Latino young men who have sex with men (YMSM) are at the forefront of the U.S. HIV epidemic. As members of the "cellular generation," these youth are very likely to use text messaging; yet, relatively little research has explored use of text messaging as a tool for sexual health promotion, particularly among racial ethnic minorities who are also sexual minorities. We report on the results of ten focus groups conducted among African American and Latino YMSM, aged 18-25, regarding their current texting practices and the feasibility/acceptability of text messaging as a means of conducting sexual health promotion. Our analyses revealed four main themes around their texting behaviors, texting preferences, perceived advantages/disadvantages of texting, and the "etiquette" of texting. We consider implications of these findings for the development of texting-based sexual health promotion interventions, particularly in conjunction with other existing interventions operating in a new risk environment.

Full-text

Available from: Bryce McDavitt, Feb 25, 2015
The Cellular Generation and a New Risk Environment: Implications for Texting-Based
Sexual Health Promotion Interventions among Minority Young Men Who Have Sex with
Men
Sheba George, PhD, Charles R. Drew University of Medicine and Science; Robert Phillips, PhD,
University of Manitoba; Bryce McDavitt, Pacifica Graduate Institute and AIDS Project Los
Angeles; Wallis Adams, MPH, Northeastern University; Matt G. Mutchler, PhD, California State
University, Dominguez Hills and AIDS Project Los Angeles
Abstract
African American and Latino young men who have sex
with men (YMSM) are at the forefront of the U.S. HIV
epidemic. As members of the “cellular generation,”
these youth are very likely to use text messaging; yet,
relatively little research has explored use of text
messaging as a tool for sexual health promotion,
particularly among racial ethnic minorities who are also
sexual minorities. We report on the results of ten focus
groups conducted among African American and Latino
YMSM, aged 18-25, regarding their current texting
practices and the feasibility/ acceptability of text
messaging as a means of conducting sexual health
promotion. Our analyses revealed four main themes
around their texting behaviors, texting preferences,
perceived advantages/disadvantages of texting, and the
“etiquette” of texting. We consider implications of
these findings for the development of texting-based
sexual health promotion interventions, particularly in
conjunction with other existing interventions operating
in a new risk environment.
Introduction
Minority young men who have sex with men (YMSM)
are at the forefront of Human Immunodeficiency Virus
(HIV) epidemic in the United States. It is estimated that
one third of new U.S. HIV infections are among youth
and young adults; 50% of these new infections among
youth are among YMSM
1
with a disproportionate
burden on African American and Latino YMSM.
2,3
A
study of young urban MSM from seven metropolitan
centers found HIV prevalence among 3% of white
YMSM compared with 7% of Latino YMSM and 16%
of Black YMSM.
4
Given that these groups are
particularly at risk to contract HIV, there have been
numerous calls for developing culturally appropriate
targeted and flexible interventions for these groups.
5-8
The extremely rapid increase in the use of mobile
devices for communication, especially among youth and
particularly among minority youth may provide an
outstanding opportunity to leverage such technology for
sexual health communication and prevention efforts.
9,10
Adolescents and young adults are increasingly using
information and communication technology applications
such as text-messaging, Facebook, and other social
networking sites.
11
Such usage creates both a more
complex risk environment since it may allow more HIV-
infected sex partners to meet in different ways but also
the potential for more “just in time” interventions to
occur.
12
The new risk in this environment can be
attributed to how people communicate and interact
differently, mediated by a host of different
communication technologies. Interventions that target
sexual behavior need to accommodate for such changes.
Cell phones are a technology whose usage has
substantially increased in the U.S. In 2011, there were
322.9 million wireless users, signifying a 102%
penetration of the total U.S. population, with nearly
30% of households using only cell phones.
13
There are
some racial differences in usage of cell phones, with
nearly half of African Americans and Latinos accessing
the internet on their mobile phones as compared to a
little over a quarter of the White Americans, signifying
the former two groups’ relative lack of home-based
broadband access
13
.
Text messaging, as a means of communication, has
seen a tremendous increase from 81 billion texts sent in
2005 to 2.12 trillion texts in 2011, a 2617 % increase
over 6 years.
14
The use of text messaging is higher
among racial minorities, specifically African American
(79%) and English-speaking Latinos (83%) as compared
with White Americans (68%) and among young adults
aged 18 – 29 (95%).
15
Consequently, it is important to
explore the uses of text messaging among young people,
and particularly among minority youth, especially with
regards to potential use in health interventions.
Among three general categories of mobile phone
users, the 18 – 24 year olds have been classified as the
“cellular generation” as compared to the “transitioners”
(25 – 34 year olds) and the “adult adopters” (35 and
older).
16
Whereas the adult adopters tend to use cell
phones as a tool for functional purposes, a means to an
end, these devices are more seamlessly integrated and
embedded in the lives of the cellular generation, who
have grown up with cell phones and text messaging.
Therefore, in order to develop appropriate sexual health
promotion interventions that can be targeted and more
easily integrated into the daily lives of at-risk members
of the cellular generation, it is essential to understand
better the general contexts and circumstances in which
they use text messaging.
Unlike other channels of mass communication for
the delivery of health promotion and intervention,
mobile phones with texting capabilities are unique in a
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number of ways. They have immediate two- way,
response capabilities; they are wearable and always on –
a ubiquitous and pervasive form of communication; they
are relatively low cost; they offer a relatively
confidential form of communication, particularly given
the potential stigma associated with sexual health
communication among YMSM; they can offer instant
access to health information and cues for action that
promote behavioral intervention and change; they could
be a tool for social support; and a data collection and
feedback tool.
17
Cell-phone based short messaging service (SMS),
or text messaging has been increasingly utilized to
support various types of health intervention efforts,
including: diabetes management
18
; weight loss
19
; and
smoking cessation
20
. A recent review of non-STD/HIV
text-message intervention RCTs (focused primarily on
diabetes, but also on hypertension, smoking, and
obesity) concluded that 13 of the 14 trials had positive
short-term behavioral outcomes.
21
There is also research
that specifically shows the acceptability of text
messaging used in HIV related health interventions,
including improving HAART adherence among HIV
positive youth
9
and more recently STI prevention and
health promotion among youth
22
, young adults
23
, and
hard to reach populations at high risk for HIV and other
STIs
24
.
While there is some research that shows the
acceptability of text messaging used in health
interventions among youth
18,25
, including as a means of
providing sexual health information
7,10,22,26-28
, there is
no research to date that focuses on the feasibility and
acceptability of such interventions among YMSM and
particularly at-risk minority YMSM. Previous research
has found that YMSM do communicate about sexual
health with their friends but that there were
misconceptions within their sexual health
communication, which may impede communication
about safer sex behaviors.
29
Given the potential stigma
around same-sex sexual activity, YMSM may be less
comfortable receiving sexual health information via text
messaging. The widespread availability of mobile
phones and text messaging presents a novel consumer
health informatics opportunity “to develop mobile-
mediated incentives and reinforcers and create new
ways of providing support” to at risk populations,
especially of the cellular generation.
17
But in order to do
so, we need to understand cell phone use in their
everyday lives and the acceptability of using this
medium for sexual health promotion. This paper is a
first effort to address this gap in our understanding of
their current texting practices and the feasibility and
acceptability of text messaging in sexual health
communication and promotion among minority YMSM.
Methods
This project was conducted in greater Los Angeles, an
area with sizable Latino and African American
populations. The Charles R. Drew University of
Medicine and Science Office for the Protection of
Human Subjects Institutional Review Board approved
the study.
Study Participants
Participants were recruited via flyers posted at local
educational institutions and through direct face-to-face
interaction at community based health and social
venues. After initial contact and an expression of
interest, potential participants underwent eligibility
screening and if eligible for the study were invited to
enroll. Upon enrolment, eligible men were asked to
participate in a brief demographic survey and focus
group. A total of 50 minority YMSM men took part in
the study. They self-identified as men who have sex
with men (MSM) and ranged in age from 18 – 25, with
a mean age of 21 years and a mode of 19 years. Fifty-six
percent of respondents identified as Latino or Hispanic
and 48% as African American or black. (It should be
noted that some of the young men claimed multiple
racial and/or ethnic identities.)
(See Table 1). All respondents answered either “gay” or
“bi-sexual” when asked about sexual orientation. More
than half of all respondents reported attending “some
college,” whereas 6% had completed a college degree.
In addition to their minority status and sexual
orientation, they were recruited based on a self-reported
frequency of texting and sharing of information via their
cell phones. Ninety-eight percent of respondents
reported owning a cell phone, while 2% (1 respondent)
texted using instant messaging on other devices via
social networking sites.
Table 1. Characteristics of study respondents
Characteristic Number Percent
Race and
Ethnicity
Latino/Hispanic 28 56%
African
American
24 48%
Sexual
Orientation
Gay 39 81.3%
Bisexual 9 18.8%
Employment
Employed 30 62.5%
Unemployed 20 37.5%
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Cell Phone
Ownership
Yes 48 98%
No 1 2%
Frequency of
Texting
“many times a
day”
48 98%
"once a day" 0 0%
“once or twice a
week”
1 2%
Social
Networking
Sites
“many times a
day”
30 61.2%
“once a day” 12 24.5%
“twice a week” 7 14.3%
Research Design and Implementation
The data and results described here are taken from ten
semi-structured focus group interviews conducted
between August and December 2010. The focus group
method was utilized because, in addition to producing
ethnographically rich data, it is useful in eliciting group-
level assessments and meanings.
30
All focus groups
included an average of five participants and were
composed exclusively of either Latino or African
American YMSM with the exception of one focus group
that was mixed. Focus group sessions were conducted in
English by two individuals and, after a brief
demographic survey, were guided by a script with
questions arranged by category to facilitate content
analysis. The focus group script was comprised of
predetermined questions organized as introductory,
transition, key, closing and summary questions. After an
introductory “ice-breaker” question, facilitators posed a
series of transitional questions addressing the frequency
and content of text messages between the participants
and their friends as well as use of social networking
sites. The young men were then asked a series of
questions related to their comfort level with and the
potential benefits of text messaging and sexual health.
The focus groups also involved the facilitators
distributing a handout containing potential safer sex text
messages and asking the participants to review and
score each message in terms of its acceptability. This
was followed by in-depth discussions of participant’s
perceptions of these messages, including their thoughts
about the meaning of the messages and their potential
for impact on risk behavior. Upon each subject’s
completion of the focus group session, they were
provided with $40 cash for their participation.
The focus groups lasted approximately 90 minutes
and were audiotaped and subsequently transcribed by an
independent professional transcription service.
Transcripts were then analyzed and managed using
NVivo qualitative analysis software. A sample of the
resulting data was then coded by several team members
and indexed in order to develop a preliminary codebook.
In an iterative process of coding and discussion and
incorporation of emerging codes, all the transcripts were
then coded and any disagreements were discussed and
resolved by consensus. Ultimately, 24 unique coding
categories were identified which were further
consolidated into four broad themes. Following this, via
an intensive series of discussions with the whole study
team, outlines were developed for each theme, the data
were summarized, and analytical insights were
discussed as they emerged.
Results
The four major themes that emerged are discussed
below and include: a) texting behavior; b) perceived
advantages and disadvantages of texting; c) texting
etiquette and d) preferences in texting. In order to
protect the confidentiality of participants, all names and
identifying information have been changed.
Texting behavior
One major area the focus groups examined was texting
behavior. We explored the pervasiveness of texting, its
many uses, and the strategies that individuals adopted to
protect their privacy when texting. The young men who
were part of the study revealed that technology is a
ubiquitous and pervasive part of their everyday lives -
this includes text messaging and the use of cell phones
as well as those that were more peripheral to the main
study such as the use of email or social media such as
Facebook. These young men have integrated texting
into their lives, have grown used to the speed of this
mode of communication, and have become very
comfortable with its use. As Tommy explained,
“It’s something that you get used to because
it’s way easier than talking to people on the
phone because it’s less interruptive. You can
just be like in class or something like that, or
just like sitting here, and you cannot know that
I’m texting right now.” (African-American)
Many of the young men were also quite proficient
in using multiple modes of communication. This
includes using various modes of communication
simultaneously (chatting and texting at the same time,
for example) as well as switching back and forth
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between technologies, what we have called
“multinetworking” (by analogy to “multitasking”).
There is very little “loyalty” to one technology or
another. In other words, while participants may be using
cell phones to text message one minute, they may switch
to laptop or desktop computers for sending text
messages the next. Nonetheless, with the advent of
“smart” phones, many of the young men in the study
had no need for a separate computer. Daniel explained,
“I have a Droid, so it adds so many capabilities
where I can like Internet or texting or Facebook
all the time, like I can Facebook chat or
whatever I have to do, and it’s like all on my
phone. So, I don’t use pretty much any other
technology except my phone to do everything
including text.” (African-American)
Texting was used for a wide variety of recreational
and practical purposes. In addition to socializing with
friends, texting was an important tool for accessing
information (such as job openings) and lending social
support (including mentoring younger MSM). Perhaps
most significant, for purposes of this paper, is that
texting allowed the young men in the study to develop
sexual and/or romantic relationships as seen in the
following exchange,
Samuel: “I see the whole entire scene on
Adam4Adam. I see the whole entire scene on
Grindr. There’s an app for iPhone. It’s called
Grindr, and then you’ll see how far are gay
people – how many feet away from you.”
Matt: “Kind of like a GPS system. Like if I’m x
feet away. . ..”
Matt: “The radius of the gay guy next to you.
Oh you’re here. Oh let’s meet up.
Phil: it’s an android, there’s one called
Encounter, and it goes around the people who
live around you.”
Samuel: “Grindr, the app for the iPhone is also
good for the iPod Touch and Blackberry and
the new type of phone. They’re trying to expand
that. Because I can’t get it for my Sidekick, but I
can get it for my iPod Touch.
Phil: I can’t get it on my phone, but I have a
different one, and they’re free too.” (Latino)
The quote above typifies a discussion surrounding
the use of internet-based sites for meeting men, such as
Adam4Adam and Grindr. While both sites are certainly
aimed more at “hooking up” than for building
relationships, men still meet potential suitors that could
end up being long-term relationships using such
technology. Their discussion of the different types of
smart phones and other technological devices again
underscores the increasing ubiquitousness of
multinetworking in this population and their relative
fluency in different types of technologies.
Participants also had much to say about how they
protect themselves and their personal information when
engaged in texting. This extended to protecting their
cell phone itself and taking steps to preserve the
confidentiality of their messages. Protecting one’s cell
phone was an important way of preserving privacy and
personal space; many young men stated that they kept
an eye on their phone at all times, in some cases using
password protection as well. Miguel detailed his
concerns regarding privacy,
“I’m usually protective of my phone. I try not to
let it out of my sight because I don’t want
people reading my stuff, but if it’s something
like I don’t know – like I wouldn’t mind the
texts, anything gay or anything like that, I
wouldn’t mind it, but I’d just be that much more
careful of like where I leave my phone or who
uses it.” (Latino)
These privacy measures were commonly taken
because the phone was considered to confer access to
private information, as though the phone were an
extension of their most personal selves. The young men
preserved their confidentiality by ensuring that others do
not observe sensitive conversations or view texts
containing private information. These concerns tended
to be greater for those young men who were not openly
gay and thus vulnerable to disclosure. For instance,
Xavier related the following example,
“You could lock your texts. So, only you could
see them. Also, if it comes from a specific
source, let’s say you’re getting all your gay
needs from a certain site; you can obviously use
a pseudonym for that. Come on, how many of
you guys – I’ve changed maybe a guy I was
dating from like Mario to Maria...because my
mom is 65, and she’s from El Salvador.”
(Latino)
Additionally, there appears to be a dependency
upon texting technology for what many consider simple
day-to-day conversation. In other words, the
connectedness of cell phones and the types of
interaction that they allow are coming to replace
physical “face-to-face” interactions. This says a great
deal about how these young men view technology and
the place that it has come to assume within their social
worlds. There was a sense of anxiety, described by
many of the participants, when they were away from
their phones. In particular, many young men described
the idea that they will miss something important if they
do not see and respond to messages right away. These
two young men spoke to this idea,
Michael: “I’m like, “Who texted me?” I just
like to know.” (Latino?)
Carlo: “I keep it in my pocket all the time so I
know.” (Latino)
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There were numerous conversations during the
focus groups, which revealed a sense of anxiety when
these young men were in situations when they could not
text. There were some interesting word choices among
participants – “comfortable,” “irresistible,” “tempted,”
and “habit." As Alonzo said,
“I [text] all day until my battery dies, and then I
turn it off because then I’ll be tempted to touch
it, and I have to put it under the pillow, and just
like an hour later it’s charged, and I can text.”
(Latino)
In fact, many of the young men went so far as to used
variations of the word "addiction" to describe the
relationship with their phone. Though not "addiction" in
the clinical sense of the word, Matt characterized his
experience in the following manner:
"At the same time, I believe texting is like pretty
much irresistible. When you see it, you read it,
and reply back."(African-American)
For many of the young men, texting (or being unable to
text) changed the way that they felt. When asked what it
felt like if he put down his phone, Alonzo answered,
“I keep looking at it. I need my light to go on to
say I got a new text.” (Latino)
Advantages and Disadvantages
Participants had much to say about the advantages and
disadvantages of texting as a mode of communication.
The strengths of texting included increased privacy,
control, and convenience, as well as the fact that texting
enabled individuals to manage their connectedness with
others in a variety of unconventional ways. However,
numerous disadvantages of the medium were cited as
well, including a feeling that texts were less intimate
and concerns that they often displaced valuable
opportunities for in-person relating as well as the
permanency of text messages.
Text messaging allowed the young men to
compartmentalize various aspects of their social
communication. Many spoke to the separation that they
have created in their lives between the “public” and the
“private.” This dichotomy extends to how participants
generally felt regarding when texting was and was not
appropriate, especially when it came to conversations of
meaningful substance. Richard related the following,
“If somebody sounds depressed over a text
message, I would feel like – I’d feel bad. They
have to say it to me. If you feel bad, you better
call me.” (African-American)
The advantages of texting were numerous and
included such features as speed and ease of use, which
center on the technological aspects of such
communication. However, while this statement holds
true in most instances, texting also had other advantages
that were not related to the technological aspects of
speedy communication. For some “shy” young men,
texting allows for easier discussions of “embarrassing”
issues with close friends. In reference to a conversation
he had with a girlfriend regarding STD’s, Cristian said,
“…I do believe in the texting generation, we’ll
just text as opposed to calling, and then calling
and actually saying it’s probably much more
embarrassing than just texting it.” (Latino)
As this quote demonstrates, there are certain topics
which these young men felt uncomfortable talking
about, especially those surrounding issues of sexual
health, and texting about them is much more bearable.
Texting thus allows young men to communicate ideas
and feelings that they would not or could not tell
someone face-to-face. This leads to greater feelings of
control.
Analysis also demonstrated that in addition to the
quotidian uses of texting mentioned above, it could be
used to give or receive social support and guidance,
such as sending encouraging comments or reminding a
friend to use condoms. The major theme that resonated
throughout was a sense that texting enabled the
expression of “caring” amongst friends and a
concomitant concern for the well-being of these friends.
Francisco spoke to this idea,
“It could be like someone sends you a text and
it could be, “Don’t forget to try to make a goal
to talk to your friend about being there for them
in certain situations,” like sending a text telling
them – not telling them, but asking them to set a
goal for the day, and texting someone else, but
not forwarding that same message.” (Latino)
Far from being solely advantageous, texting was
seen as having a number of drawbacks in comparison
with other forms of communication. While some young
men preferred texting about emotionally difficult topics,
the majority, felt that texting is not a suitable medium
for discussing “serious” matters, including those
involving sexual health. Participants discussed the
disadvantages of texting in great detail. For example,
what was missing from the texting experience was a
feeling of actually connecting with another person - a
somatic experience. Communication that takes place
across social spaces via texting is still in many respects
“meeting face-to-face,” but with reconfigured
definitions of both “meet” and “face,” as this comment
from Ricky demonstrates,
“Basically, you can talk as much as you want.
You can even talk through a text message. You
can fill up the whole page if you would like,
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screaming and yelling and telling them off.”
(African-American)
Participants also needed the sound and intonation
of someone’s voice, the look on their face, their bodily
comportment etc. in order to feel that they were truly
communicating. Across all focus groups, too, was the
sense that texting is not “serious,” especially in
comparison to speaking with someone face-to-face.
Further, a pattern emerged of young men using
text messaging to talk about deeper issues, especially
relating to “feelings” or circumstances of a personal
nature. However, there was a definite limit to the nature
of these discussions. Even though the men were open to
using texting for social support (including talking about
safer sex issues), it was insufficient for more “intense”
conversations such as those that are deeply emotional or
personal, including those dealing with “coming out” or
HIV status. “…A text can only do so much,” as one
young man put it. Or as Sergio said of his preference for
face-to-face or telephone conversations,
“You can actually see their reaction or hear it
instead of just like seeing it on text. Some people
wouldn’t see it the same way.” (Latino)
The use of emoticons, “shorthand,” and private
and semi-private codes and signs, is one way in which
participants accommodate this need via texting, but it
was sometimes viewed as a poor substitute for face-to-
face expressions of emotions. One further disadvantage
mentioned by participants related to the fact that
messages are stored in the telephone until the user
deletes them. This created a potential vulnerability, as a
boyfriend or parent might view private messages.
Stephen related,
“(I) get some dirty texts, but then the person that’s
sending the text, they don’t know who is reading it.
Anybody can read it because I leave my phone
anywhere, and then if I’m working, somebody is going
through it.” (African-American)
Texting Etiquette
Texting etiquette emerged as an important and
frequently cited theme across the focus groups.
Etiquette included a variety of “do’s and don’ts” for
texting, as well as strongly held views regarding what
kinds of texts were inappropriate and when a response
was or wasn’t warranted. One of the most striking
findings was the intensity of participants’ feelings about
the importance of etiquette. Because individual
participants often differed markedly in their views about
etiquette, the focus groups sometimes involved
impassioned discussions about what did or did not
constitute suitable texting practice.
Generally, participants articulated a range of
guidelines for when and how texting should be done.
These guidelines included such categories as when they
would prefer to receive text messages, the length of such
messages, and the types of requests made via text. Many
of the young men in the focus groups voiced the opinion
that there were certain times of the day (and night)
during which they did not want to receive text messages.
Trevor detailed his frustration with late night texts:
When I’m sleeping, that’s the most annoying
thing when my phone is going off and I’m
asleep…I usually leave it on for the fact that if I
get an emergency call from a friend, work
anything, so it’s annoying. I have to hear the
text messaging go off.”(African-American)
Another category of “don’ts” about which
participants had much to say focused on texts that were
considered inappropriate or indecent. These included
texts whose tone was angry and those that contained
“rude” language, as well as those with “someone
cussing you out, starting drama.” Further, many young
men stated that they would not respond to texts of a
sexual nature (“sexting”) or those that contained gossip.
The etiquette of texting also encompassed when and
how the recipient of a text would be expected to reply,
and the circumstances under which a reply would not be
necessary or appropriate.
For the most part, these etiquette guidelines are
fairly flexible depending on the relationship between the
parties. If the message was coming from someone that
the receiver was close to or wanted to get closer to,
these rules could be waived. For instance, Carlo related
the following,
“Like a friend texted me saying, “Hey what’s
up, you bitch? What are you up to?” That’s
okay with me because she’s my best friend.”
(Latino)
In contradistinction to those times when
respondents did not want to receive texts, there were
several situations in which the young men wanted to
receive them. In a majority of the cases, participants
stated that their willingness to receive texts depended on
whom they were from. D’Andre explained his criteria
for responding to texts:
“I think I just individually decide how I feel
about it, each level I have friendship with.
Family friends whoever it is, relationship… it’s
always different with certain texts you get.”
(African-American)
In addition to these overall “rules” of texting,
participants had much to say about their understanding
of the semantic aspects of texting language. The very
nature of text-based interaction demands that it be
heavily dependent upon conventions such as the use of
“emoticons.” In this vein, some of our participants felt
that professional organization staff should not use
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abbreviations even though this is expected from friends.
For Luis, taking the time to spell words out completely
as opposed to using “text language” shows “that you at
least care.” The topic of emoticons elicited the most
prolonged discussions among participants. Quite simply,
an emoticon is a series of keyed characters used in text
messages (as well as in email and/or chat rooms) to
indicate an emotion, such as happiness :-) or anger :-(,
or the senders’ mood or personality. They can also
change the tone of a text message as Alejandro
described his experience:
“Let’s say I’m picking someone up. I can say,
“Come out now,” like it can sound like “Come
out now!” or if I put the smiley face on the end,
“Come out now,” it’s like “Okay, I’m here. So,
it’s okay.”(Latino)
The etiquette of texting also encompassed when
and how the recipient of a text would be expected to
reply, and the circumstances under which a reply would
not be necessary or appropriate. George addressed one
significant finding in this area that surrounded issues of
time, specifically the importance of the timeliness of
response and how it is dependent on different factors,
Mark: That depends. I text back when you text
back instantly. If you waited fifteen minutes, I’m
waiting thirty, but I will count.
Blake: People really do that?
Mark: I will type the message ready to press
send, but I will not send.
Facilitator: Can you tell me why?
Dan: Because it annoys you. Like, why would
you text me and then take so long to answer my
text messages back?
Preferences in Texting
The young men we spoke with also had clear
preferences about text messages – about the kinds of
texts they wanted to receive, how, when, and from
whom. Preferences differed from etiquette in that they
were more flexible and did not represent unwritten
codes of conduct, but rather individuals’ personal
feelings about how they liked to use and receive texts.
In general, they enjoyed getting messages that showed
the sender cared about them, or that were personalized
for the receiver. Nearly everyone seemed to dislike
texts that lacked a personal touch, and, like Tommy,
they were particularly emphatic in their negative
feelings about highly impersonal “chain messages,”
“What I don’t like about those is I don’t like to
see that that text has been sent to a ton of
people already, and it’s like, ‘Well, if we’re
supposed to be great friends’…”(African-
American)
“Caring” messages from friends (or at least people
who address them by their first name) are preferable to
forwarded messages or messages sent in bulk.
Participants stated that when their first name was used,
that they felt that the facilitator or sender “knew” them.
Nathan explained,
“…if you’re going to send me something like
that, I’d rather have you personalize it and say
my name because I feel like that could be a text
that could be sent to a bunch of people to see
what they would say, and that’s kind of
irritating…” (African-American)
Lastly, many of the young men in the study were
extremely receptive to receiving sexual health messages
from friends. The emphasis here is on the word
“friends.” All of the comments in this section focus on
the idea that these messages are welcome, but only
because they are sent and received within a context of
“caring” that exists only amongst friends.
In all cases, the young men who receive the messages
state clearly that the intent is to tell them that (friends)
“still care about you” and “this person genuinely cares
about me.”
While a very small minority of the young men
expressed hesitation at receiving messages dealing with
sexual health, the bulk of the young men are open to the
idea. Participants in the focus groups spoke of several
variations on this theme, but ultimately, it boiled down
to the idea that if friends or acquaintances are going to
send these young men text messages that they prefer to
receive messages that are positive and show a degree of
concern. Nathan’s comment was exemplary,
“…if it’s (from) a best friend who knows your life who
grew up with you, you’d be like, “All right, this person
genuinely cares about me, so I will listen to that
person.” (African-American)
Discussion
Using qualitative methods, we report on the results of 10
focus groups conducted among African American and
Latino young men who have sex with men regarding
their current texting practices and the feasibility and
acceptability of text messaging as a means of
conducting sexual health promotion. Our analysis
resulted in the generation of four main themes around
their texting behaviors, texting preferences, perceptions
of advantages and disadvantages of texting, and what
they consider as texting etiquette. The qualitative nature
of our study makes it difficult to generalize to results to
a wider population. Below, we consider five key
implications of these findings for the development of
texting-based sexual health promotion interventions, a
topic we intend to address in future research.
Our participants’ description of their texting
behaviors confirms their membership in what has been
described as the cellular generation in that they reported
a high level of integration and embeddedness of cell
253
Page 7
phones and texting practices in their daily lives. The
relative speed, ease of use and greater connectivity
afforded by smart phones and other such cellular
technology results in a pervasive and ubiquitous use of
cell-phone based communication, demonstrated in
comments about “sleeping with my phone,” anxiety
about missing a text and feeling “addicted to my
phone.” However, texting, along with other types of
ICTs, also facilitates a more complex risk environment
even as it increases potential for “just in time”
interventions and for social support. This was evident
from our participants’ descriptions of the use of GPS-
enabled smart phones and Internet sites for “hooking
up” with other men even as they supported friends with
safe-sex texts. The fact that texting at once facilitated
flirtatious exchanges and sexual encounters while at the
same time being utilized in sexual health promotion is
demonstrative of the power as well as the complex
implications of the expanding use of such
communication technology. Sexual health promotion
interventions using such technology need to identify
new ways to incentivize and reinforce provision of
social support while promoting avoidance of potential
risky behaviors.
Second, for many YMSM, since their selves maybe
under siege, their phones and text messages they receive
on their phones can become an arena requiring intense
protection as seen in our results above. Because cell
phones can become an extension of the self, protecting
their phones became representative of protecting
themselves. In the case of text message -based sexual
health promotion interventions, privacy and
confidentiality can have greater import for these
populations because being associated with interventions
targeted for YMSM may have the potential to be
stigmatizing. Unlike other texting-based health
interventions such as for diabetes, any breaches in
confidentiality could have serious consequences for
these sexual minorities. Consequently, texting-based
sexual health promotion interventions need to take
extensive measures to ensure confidentiality and
communicate these efforts to their targeted population to
promote their buy-in.
Third, the use of cell phones and texting tended to
occur within the context of their use of multiple forms
of information and communication technologies (ICTs),
such as internet-based social networking sites, email,
instant messaging, etc. Being multinetworked in this
manner, they displayed little allegiance to any one type
of technology. Consequently any texting-based
intervention effort may be more effective when
integrated with other commonly used modes of
communication by the targeted population, such as
social networking sites like Facebook.
Fourth, while our study participants were
constantly texting on their cell phones and for many, it
is the accepted mode of communication, yet it often
“fails” or is felt by them to be insufficient for “serious”
or “intense” conversations. Notwithstanding the small
minority of our participants who preferred to
communicate “embarrassing” emotional messages via
texting, the majority preferred face-to-face interaction
when addressing “deeper issues.” Furthermore, they also
preferred personal texts to mass or chain texts, where
personalization was seen as a sign of caring. The
importance of caring being communicated in texts,
particularly when receiving sexual health promotion,
became a recurring theme in our conversations with
these young men, which is, perhaps, a reaction to the
lack of intimacy that accompanies texting. Of special
significance here is the finding that many of the young
men are receptive to receiving sexual health messages
from friends. These messages are welcome if they are
sent and received within the context of “caring” that
exists amongst friends, consistent with previous
research on sexual communication between young gay
men and their friends.
2929
Consequently, sexual health
promotion interventions based only on text messages as
a mode of communication maybe limited in the scope of
content and depth of communication that can be
achieved through this singular form of communication.
Given their equation of personalization with caring, text
message-based interventions that find ways to
personalize content to the degree possible and to engage
social networks so that messages are being sent to and
from friends will be likely more effective with this
population. Furthermore, the importance of conveying
caring in sexual health promotion efforts suggests that
text-message-based interventions would be more
acceptable to this population if combined with face-to-
face intervention components.
Lastly, one of the most remarkable findings of our
study was the presence of a texting etiquette that was
uncovered through the analysis of our conversations
with our study participants. While this etiquette consists
of unwritten and informal codes of conduct, its
importance became confirmed in the intensity of
participants’ feelings about it. Interventions employing
texting-based messages that are interactive would
require sensitivity to the norms of such etiquette, such as
timeliness of response and appropriateness of texting
language. That this etiquette is unwritten and dynamic
suggests that any texting- based intervention would need
to do the context specific ethnographic work to develop
an understanding of the specific codes of texting
etiquette for such subpopulations within their
geographical and lifestyle specificities.
On a final note, we were not able to find any
thematic differences between African Americans and
Latino groups; however, we believe that future research
with larger numbers of focus groups may identify
currently undetectable differences.
Conclusion
Any texting-based interventions targeted to minority
YMSM would be well served in investing the effort to
understand cell phone use in their everyday lives
because their texting contexts, etiquette, and meanings
254
Page 8
of use are embedded within beliefs and behaviors that
are highly meaningful to members of this cellular
generation. Such understanding will facilitate the
development of better strategies on how to deliver “just-
in-time interventions” in the face of an increased ICT-
mediated risk environment. Our study points to the
need for integration of texting-based interventions with
both other ICT media and face-to-face intervention
components.
Acknowledgments: This project was funded by a pilot
grant from AXIS (Accelerating Excellence in
Translational Science) NIH NCRR Grant #U54
RR026138
References
1. HIV/AIDS and Young Men who Have Sex with
Men. Centers for Disease Control and Prevention.
Atlanta, GA: U.S. Department of Health and
Human Services; 2009.
2. Bingham TA, Harawa NT, Johnson DF, Secura
GM, MacKellar DA, Valleroy LA. The effect of
partner characteristics on HIV infection among
African American men who have sex with men in
the Young Men's Survey, Los Angeles, 1999–2000.
AIDS Education and Prevention. 2003;15(1
Supplement):39-52.
3. MacKellar D, Valleroy L, Karon J, Lemp G,
Janssen R. The Young Men's Survey: methods for
estimating HIV seroprevalence and risk factors
among young men who have sex with men. Public
Health Reports. 1996;111(Suppl 1):138.
4. Harawa NT, Greenland S, Bingham TA, et al.
Associations of race/ethnicity with HIV prevalence
and HIV-related behaviors among young men who
have sex with men in 7 urban centers in the United
States. JAIDS Journal of Acquired Immune
Deficiency Syndromes. 2004;35(5):526.
5. Sifakis F, Hylton JB, Flynn C, et al. Racial
disparities in HIV incidence among young men
who have sex with men: the Baltimore Young
Men's Survey. JAIDS Journal of Acquired Immune
Deficiency Syndromes. 2007;46(3):343.
6. Mays VM, Cochran SD, Zamudio A. HIV
prevention research: Are we meeting the needs of
African American men who have sex with men?
Journal of Black Psychology. 2004;30(1):78-105.
7. Prado G, Schwartz SJ, Pattatucci-Aragón A, et al.
The prevention of HIV transmission in Hispanic
adolescents. Drug and alcohol dependence.
2006;84:S43-S53.
8. Warren JC, Fernández MI, Harper GW, Hidalgo
MA, Jamil OB, Torres RS. Predictors of
unprotected sex among young sexually active
African American, Hispanic, and White MSM: the
importance of ethnicity and culture. AIDS and
Behavior. 2008;12(3):459-468.
9. Puccio JA, Belzer M, Olson J, et al. The use of cell
phone reminder calls for assisting HIV-infected
adolescents and young adults to adhere to highly
active antiretroviral therapy: a pilot study. AIDS
Patient Care & STDs. 2006;20(6):438-444.
10. Wright E, Fortune T, Juzang I, Bull S. Text
messaging for HIV prevention with young Black
men: formative research and campaign
development. AIDS care. 2011;23(5):534-541.
11. Rosen LD. Me, MySpace, and I: Parenting the net
generation: Palgrave Macmillan; 2007.
12. Rietmeijer CA, McFarlane M. Web 2.0 and
beyond: risks for sexually transmitted infections
and opportunities for prevention. Current opinion
in infectious diseases. 2009;22(1):67.
13. Horrigan J. Wireless internet use. 2009;
http://www.pewinternet.org/~/media//Files/Reports/
2009/Wireless-Internet-Use-With-Topline.pdf.
Accessed December 27, 2011.
14. Wireless Quick Facts. . Washington DC: CTIA:
The Wireless Association.; 2011.
15. Smith A. Mobile access 2010. Washington, DC:
Pew Internet & American Life Project. 2010.
16. Consumers in the 18-24 age segment view cell
phones as multifunctional accessories: crave
advanced features and personalization options.
2007;
http://www.comscore.com/Press_Events/Press_Rel
eases/2007/01/Cell_Phones_and_18-
24_Year_Olds.
17. Lefebvre C. Integrating cell phones and mobile
technologies into public health practice: a social
marketing perspective. Health Promotion Practice.
2009;10(4):490-494.
18. Franklin VL, Waller A, Pagliari C, Greene SA. A
randomized controlled trial of Sweet Talk, a
textmessaging system to support young people
with diabetes. Diabetic Medicine.
2006;23(12):1332-1338.
19. Patrick K, Raab F, Adams MA, et al. A text
message–based intervention for weight loss:
randomized controlled trial. Journal of medical
Internet research. 2009;11(1).
20. Rodgers A, Corbett T, Bramley D, et al. Do u
smoke after txt? Results of a randomised trial of
smoking cessation using mobile phone text
messaging. Tobacco Control. 2005;14(4):255.
21. Fjeldsoe BS, Marshall AL, Miller YD. Behavior
change interventions delivered by mobile telephone
short-message service. American journal of
preventive medicine. 2009;36(2):165-173.
22. Levine D, McCright J, Dobkin L, Woodruff AJ,
Klausner JD. SEXINFO: a sexual health text
messaging service for San Francisco youth.
American Journal of Public Health.
2008;98(3):393.
23. Menon-Johansson A, McNaught F, Mandalia S,
Sullivan A. Texting decreases the time to treatment
255
Page 9
for genital Chlamydia trachomatis infection.
Sexually transmitted infections. 2006;82(1):49-51.
24. van den Oever P, & van Mens, L. . . The Combined
Use of Internet and SMS Targeting Hard to Reach
Sex Workers Working as Escorts. AIDS 2006 - XVI
International AIDS Conference. Toronto 2006.
25. Franklin V, Waller A, Pagliari C, Greene S. "
Sweet Talk": text messaging support for intensive
insulin therapy for young people with diabetes.
Diabetes technology & therapeutics.
2003;5(6):991-996.
26. Gold J, Lim MSC, Hocking JS, Keogh LA,
Spelman T, Hellard ME. Determining the impact of
text messaging for sexual health promotion to
young people. Sexually transmitted diseases.
2011;38(4):247.
27. Lim MSC, Hocking JS, Aitken CK, et al. Impact of
text and email messaging on the sexual health of
young people: a randomised controlled trial.
Journal of Epidemiology and Community Health.
2011.
28. Cornelius JB, St Lawrence JS, Howard JC, et al.
Adolescents' perceptions of a mobile cell phone
text messagingenhanced intervention and
development of a mobile cell phonebased HIV
prevention intervention. Journal for Specialists in
Pediatric Nursing.
29. Mutchler MG, & McDavitt, B. . “Gay Boy Talk”
Meets “Girl Talk”: HIV Risk Reduction
Assumptions in Young Gay Men’s Sexual Health
Communication with Best Friends. Health
Education Research. 2011;26(3):489-505.
30. Bloor M. Focus groups in social research: Sage
Publications Ltd; 2001.
256
Page 10
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