Brian Mustanski, Ph.D. George Greene, Ph.D. Michelle Birkett, Ph.D.

1. Mixed Method Analyses of the Role of the Internet in Sexual Health Information SeekingPresented at WT Grantmixed methods meeting2011 Brian Mustanski, Ph.D. George Greene, Ph.D. Michelle Birkett, Ph.D.

2. Talk Overview • Research on the internet,sexual health, and LGBT youth • Formative qualitative researchsee • Quantitative researchbased on qualitative findings • Intervention development

3. Defining sexual health • “Sexual health is more than the absence of disease, but instead a state of physical, emotional, mental, and social well-being in relation to sexuality” (WHO, 2004). • For Lesbian, Gay, Bisexual, and Transgender (LGBT) youth important dimensions include • Knowing and being empowered to avoid infection with HIV/STIs • Understanding and feeling acceptance of one’s sexuality • Having a positive approach to sexual/romantic relationships. Mustanski et al. (2011) Arch Sex Behav

4. Need for sexual health research on LGBT youth • High prevalence of HIV among young MSM, transgender women, and sexual risk behaviors among WSWM. Lack of prevention response. • Difficult process of achieving sexual self-acceptance and potential for family and peer rejection and internalization. • Barriers to developing healthy romantic relationships.

5. The role of the Internet as a “risk environment”

6. The role of the Internet as a positive environment • A 1998 online study found the majority of LGBT youth were coming out online before doing so offline (!OutProud!, 1998) • 2 qualitative studies suggests it can be a lifeline for LGBT youth to make friends, find information and support, and form intimate relationships (Hillier & Harrison, 2007; Mustanski et al., 2011)

7. But… • Little is known about how LGBT youth use the internet to address sexual health, what obstacles may exist, and what is the best way to reach them. • No established quantitative measure of needs, usage, and obstacles.

8. Qualitative Sample • Recruited through flyers, websites, and word of mouth. • Targeted sample diverse in terms of sexual and gender identities, age (16-24), and race/ethnicity. • Sample size reached when saturation of information occurs (N = 31). Magee et al., (In Press). Health Education & Behav

9. Saturation • Recruitment of participants continued until the information collected during qualitative interviews was judged to be saturated. • Progress towards saturation was assessed by brief notes written by each interviewer to summarize new information that emerged during the interview. Notes were shared with the research team and reviewed against prior notes to determine when interviews were no longer revealing novel information about the topics under study.

10. Qualitative Interview • 60-90 minute semi-structuredinterview focused on the role of the Internet in the development of sexual health: • Identity development • Coming out • Sexual health knowledge • Romantic relationships • Likes and dislikes of existing relevant websites and suggestions for our coming site • Semi-structured = set questions and probes, but flexibility to add and refine items over time, ask follow-up questions, and be an “active listener.” • 4 interviewers conducted interviews after extensive training. All were culturally competent with target population. Before doing interviews each listened to audio of my interviews. I listened to audio of each of their interviews and provided feedback. Magee et al., (In Press). Health Education & Behav

11. Coding methodology • Interviews were transcribed nearly verbatim and then coded in ethnonotes • Iterative process of codebook development (i.e. constant comparison Method; Taylor & Bodgan, 1998) • Coders independently developed initial set of codes from first 2 transcripts. • Codes discussed and refined. • Coders attempted to apply refined codes to next 2 interviews. • Coders discussed results and made further refinements. • Reliability established on next 2 transcripts and again on final 2 transcript. • Coders required to achieve at least .7 kappa across codes before doing independent coding (Hruschka et al., 2004) • I served as the “master coder” • Average kappa was .84 Magee et al., (In Press). Health Education & Behav

13. Thematic analysis • Topics set based on publication plans. • Excerpts relevant to publication were retrieved (e.g. “sexual health information” and “Internet”). • Coders first read the same subset of excerpts independently, then discussed the preliminary themes they perceived. • Themes generating agreement across coders were retained for analysis of the next subset of excerpts. • During the subsequent reading of the next subset of excerpts, coders attended to evidence supporting or contradicting proposed themes, while also noting novel themes (Ryan & Bernard, 2003). • To finalize the analysis, coders organized the list into a hierarchy of themes and subthemes and as a group decided whether overlapping themes could be merged. • Once themes and subthemes were finalized, two coders applied themes to the full set of coded excerpts. Magee et al., (In Press). Health Education & Behav

14. Results • In thematic analyses, three primary themes emerged from the excerpts coded with “sexual health information “ and “Internet”. • Topics of online searches • Motivation for searching online • Reasons for not searching online • Information is not relevant (31%) • Stigma if caught searching (19%) • Mistrust of online information (16%) Magee et al., (In Press). Health Education & Behav

15. Group comparisons • Few standards for how to make group comparisons in mixed-methods research. • Particular issue in interview that is not 100% structured. • We considered gender, race, and age differences to be meaningful to describe if they met 3 criteria: • Differences had to be noticed as a theme • Themes being compared had to be endorsed by at least 5 participants (> 15% of sample) • Code application rates within each group had to differ by at least 20% • We emphasize these are exploratory patterns for generating a framework for continuing research rather than a test of group differences. Magee et al., (In Press). Health Education & Behav

16. Results: Thematic Analyses: Group Comparisons: Race Magee et al., (In Press). Health Education & Behav

17. Mixed-methods Mixed

18. Project Q2:Quantitative component • Longitudinal study of 246 LGBT youth ages 16-20 at baseline. • 49% Female, 43% Male; 8% transgender • 86% Racial/Ethnic minorities • Waves 1- 6 completed (91% retention at 1 year) and ~80% retention in 5-6 • Data presented here is from wave 6 collected using CASI at 30 months from baseline (N = 190).

19. Online activities in the last year

20. What sort of Information did you search for online? 65 % had made an LGBT Friend Online

21. HIV Information Online

22. Intervention development

23. Intervention Development • Watch video here: • http://www.impactprogram.org/?page_id=153

24. Thank you project staff and collaborators! Thank you funders! IMPACT Program Staff Howard Brown Health Center Broadway Youth Center Joshua Magee, Ph.D. Samantha Dehaan, BA Robert Garofalo, MD, MPH Erin Emerson, MA Michael Newcomb, MA Amy Johnson, MSW Peter Freeman, BA Katherine Samuels, BA Consultants: Eli Lieber, PhD Jeffrey Parsons, Ph.D. Colleen Monahan, DC, MPH Ritch Savin-Williams, PhD

25. Find out more • http://www.impactprogram.org/?p=365 To download copies of the talk, journal article reporting findings, qualitative interview guide, and qualitative codebook. Password: Mixed