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. Author manuscript; available in PMC: 2015 Dec 1.
Published in final edited form as: AIDS Educ Prev. 2014 Dec;26(6):554–564. doi: 10.1521/aeap.2014.26.6.554

Online focus groups as an HIV prevention program for gay, bisexual, and queer adolescent males

Michele L Ybarra 1,*, L Zachary DuBois 2, Jeffrey T Parsons 3, Tonya L Prescott 4, Brian Mustanski 5
PMCID: PMC4379702  NIHMSID: NIHMS664099  PMID: 25490735

Abstract

Seventy-five 14–18-year-old gay, bisexual, and queer (GBQ) males provided feedback about how their participation in national, online focus groups (FG) about GBQ sexual health related topics resulted in behavioral and attitudinal changes. Most sexually experienced youth agreed that their participation positively changed their views and behavioral intentions. Some said that being in the FG made them more comfortable talking about sex, their sexuality, and making safer choices such as negotiating condoms. Others indicated intentions to become more involved in the LGBT community. Sexually inexperienced FG participants similarly said that the FG discussion positively affected them - most commonly by reducing their sense of isolation as young GBQ men who were waiting to have sex. Many also thought that they would become more vocal advocates of abstinence and/or safe sex. Online FGs and facilitated discussion boards should be further explored as a low-cost HIV prevention program for GBQ youth.

Keywords: HIV prevention, LGB, focus groups, adolescents

INTRODUCTION

Adolescent gay, bisexual, queer and other men who have sex with men bear a disproportionate HIV incidence burden (Centers for Disease Control and Prevention, 2012). With few validated prevention programs available (Mustanski, Newcomb, DuBois, Garcia, & Grov, 2011), there is a need for effective HIV prevention programs for this vulnerable population. Certainly, with the almost ubiquitous nature of the Internet (Pew Research Internet Project, 2012), this is likely a compelling way to reach and engage these young men. That said, resources are scarce and the development of technology-based interventions can be expensive (Pequegnat et al., 2007). Low-cost strategies that are affordable to develop and implement are greatly needed.

One such strategy may be a moderator-led focus group or discussion forum. Indeed, lesbian, gay, bisexual (LGB) youth are already using the Internet to look for sexual health information (Hillier, Mitchell, & Ybarra, 2012; Magee, Bigelow, Dehaan, & Mustanski, 2012; Mitchell, Ybarra, Korchmaros, & Kosciw, 2014; Mustanski, Lyons, & Garcia, 2011) and social support (Hillier et al., 2012; Ybarra, Mitchell, Palmer, & Reisner, 2015). LGB youth report not only more online friends compared to non-LGB youth – but also that their online friends are more supportive (Ybarra et al., 2015). Furthermore, LGB young people view online spaces as safe places to receive support from friends (Gay, Lesbian & Straight Education Network, Center for Innovative Public Health Research, & Crimes against Children Research Center, 2013; Hillier, Horsely, & Kurdas, 2004; Hillier et al., 2012), and say that the Internet is often a safer place for them to socialize than offline (Hillier & Harrison, 2007).

Online support groups have been available to consumers for decades (Finfgeld, 2000) and there is some evidence to support their ability to reduce isolation and stress by increasing their access to people going through similar challenges (Tanis, 2007; Winzelberg et al., 2003; Ybarra & Eaton, 2005). As such, online support groups are often linked to increased self-confidence and empowerment (Barak, Boniel-Nissim, & Suler, 2008; van Uden-Kraan, Drossaert, Taal, Seydel, & van de Laar, 2009). For LGB youth, who may feel marginalized and isolated in their communities (Hillier et al., 2012; Mustanski, Lyons, et al., 2011), an online discussion-style format may have a positive impact. There is a lack of research in this area, however. To address this gap in the literature, we examine self-reported behavioral and attitudinal changes among gay, bisexual, and queer adolescent males who took part in online focus groups conducted to inform the design of Guy2Guy, a text messaging based HIV prevention program for this vulnerable population of youth.

METHODS

The research protocol was reviewed and approved by the Chesapeake Institutional Review Board (IRB) and the Northwestern University IRB. A waiver of parental permission was obtained to prevent youth from being required to disclose their sexual orientation and gender identity to their parents as a condition of participation.

Participant Recruitment

Two rounds of online focus groups (n = 75) were conducted: Round 1 in November 2012 (n = 37) and Round 2 in January 2013 (n = 38). Participants were recruited nationally, online through advertisements posted on Facebook and outreach by two LGB-focused organizations.

Eligible participants: were 14 to 18 years old; were male sex; self-identified as gay, bisexual, and/or queer; had a cell phone; used text messaging for at least 6 months; enrolled in an unlimited text messaging plan; and provided informed assent/consent including a capacity to consent (Dunn & Jeste, 2001; Moser et al., 2002; Mustanski, 2010; The University of California at San Diego Task Force on Decisional Capacity, 2003).

Participants were able to endorse all sexual identities with which they identified: 87% were gay, 19% were bisexual, and 5% were queer. Participants were purposefully enrolled to ensure a balance on sexual experience (i.e., ever had vaginal or anal sex; and never having either type of sex), age, race, and region. As a result, 55% of participants (n=41) were White race, 25% (n=19) were Hispanic ethnicity, and 29% (n =22) lived in a rural setting (see Table 1).

Table 1.

Demographic Characteristics Overall and by Sexually Experienced and Sexually Inexperienced Subgroups

Variable Combined % (n) Sexually Experienced % (n) Sexually Inexperienced % (n)
Age n (M:SE)
    14-16 n=46 (15.34:0.11) n=25 (15.40:0.14) n=21 (15.29:0.18)
    17-18 n=29 (17.44:0.09) n=14 (17.50:0.19) n=15 (17.40:0.13)
Race
    Caucasian 54.67 (41) 46.15 (18) 63.89 (23)
    African American 5.33 (4) 5.13 (2) 5.56 (2)
    Asian 5.33 (4) 5.13 (2) 5.56 (2)
    Mixed racial background 18.67 (14) 25.64 (10) 11.11 (4)
    Native American or Alaskan Native 1.33 (1) 2.56 (1) 0.00 (0)
    Other 14.67 (11) 15.38 (6) 13.89 (5)
Hispanic ethnicity 25.33 (19) 33.33 (13) 16.67 (6)
Sexual orientation a
    Gay 86.67 (65) 92.31 (36) 80.56 (29)
    Bisexual 18.67 (14) 15.38 (6) 22.22 (8)
    Queer 5.33 (4) 10.26 (4) 0.00 (0)
Urban-rural residence
    Urban 70.67 (53) 66.67 (26) 75.00 (27)
    Rural 29.33 (22) 33.33 (13) 25.00 (9)
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a

Categories are not mutually exclusive.

Data were collected online in November 2012 and February 2013

Procedure

The groups were stratified by self-reported sexual experience: 36 youth had never had anal or vaginal sex (18 in round 1; and 18 in round 2); and 39 had (19 in round 1 and 20 in round 2). Focus groups were conducted online in an asynchronous bulletin board over three consecutive days by two moderators from the research team.

Each day, questions were posted on the bulletin board in the morning and then again, in the afternoon. Participants were instructed to visit the board at least twice a day to respond to questions, reply to moderator probes, and interact in discussions with other group members. Participants received a $25 Amazon gift card incentive for participating fully in the focus groups.

Focus Group Guides

Topics discussed during days 1 and 3 for both rounds of online focus groups provide the primary data for this manuscript. The guide for Day 1 focused on attitudes and logistical aspects of an HIV prevention program being developed. Day 3 focused on participant's thoughts and concerns about the HIV prevention program features, participation incentive ideas, and ways to promote participant retention in the eventual six-week long HIV prevention program.

Based upon participants’ responses in the first round of online focus groups, the following four questions, which asked specifically about participant focus group experience, were added in the second round: (1) In what ways do you think your views have changed (if at all) as a result of taking part in this discussion?; (2) In what ways do you think your behavior might change (if at all) as a result of taking part in this discussion?; (3) In what ways (if at all) has this discussion changed your views or thoughts about having/not having sex?; (4) How has the discussion changed your views or thoughts (if at all) about using/not using condoms?

Data Coding and Analysis

All coding and analysis was conducted using individual transcripts with Dedoose mixed-methods analysis software (SocioCultural Research Consultants, 2012). Participant responses to the four view/behavior change questions (above) were coded: 0 = no; 1 = yes, their views or behavior had changed; or 2 = their pre-existing views/behaviors were reinforced rather than changed. Responses also were analyzed thematically in order to identify emergent themes and to apply axial codes that were descriptive of these themes. Consensus coding was completed by two independent coders. Discrepancies were resolved through discussion and consensus. Participant quotes are provided to exemplify findings. They are presented exactly as the youth typed them into the online bulletin board; grammatical corrections are not applied.

RESULTS

Of the 80 youth who provided informed assent/consent, 75 (94%) participated in the online focus groups. As an indication of engagement, 71 (89%) responded to at least one post in each session daily.

Participant feedback during the first round of online focus groups

Sexually inexperienced participants in the first online focus groups spontaneously shared that their involvement in the group was beneficial to them: “It was an amazing experience. It was a pleasure to be part of it, and it has taught me so much more than I thought it would.” Interestingly, similar feedback did not emerge in the sexually experienced focus group. These participants were not negative about the experience, but they were not as effusive either. In both groups, however, participants asked the moderators to create a separate thread that could be used to talk about various aspects of their lives and their interests (e.g., music, boyfriends, family, school). This request for additional space to “chat” reflected to us that participants were enjoying their interactions with the other focus group members and finding the exchange to be beneficial. To further understand how the online focus group experience changed participants’ views or behavioral intentions, we integrated specific questions (described above in Focus Group Guides) into the second round of focus groups.

Responses to the four behavioral/attitudinal change questions

Sexually experienced participants

Of the 20 sexually experienced participants involved in the second round of online focus groups, 17 answered the four exit interview questions about the online focus group experience. In response to our question, “In what way have your views changed (if at all) as a result of taking part in this Discussion,” the majority (11/17) of responses were coded 1, indicating that “yes,” these participant's views had changed in a number of positive ways related to their sexual orientation and/or sexual behaviors as a result of being in the discussion. For instance, some said that being in the group taught them to feel better about their sexual orientation: “It let's me know that it really is okay to be gay” and others shared that they had experienced a change in their views about wanting safer sexual relationships: “The program has actually helped me to recognize that I should look into my sexual relations so that they can be more safe.” Five other responses were coded 0, indicating that, “no,” those participant's views had not changed but had remained the same. One response was coded 2, indicating that that participant's pre-existing views had not changed but had been reinforced: “I still think condoms are a necessity!!”

In response to the question, “In what way do you think your behavior might change (if at all) as a result of taking part in this Discussion”, most (11/17) anticipated that their future behavior would be positively affected. For example, participants described feeling more comfortable and capable talking about sex, their sexuality, and making safer choices: “I will definitely think a lot more about the choices I make and whether or not they are safe as well as finding someone I can communicate my worries with.” Others indicated that they intended to become more involved in the LGBT community: “I know that there are other gay guys out there that need to talk to someone about their personal things and I think it would be awesome to help out.” Five other responses were coded 0, indicating that, “no,” those participant's did not expect their behaviors would change. One response was coded 2, indicating that that participant's preexisting behavior had not changed but had been reinforced: “I don't think much is gonna change after this discussion cause I was already pretty safe prior to the study....It did help reinforce the idea that I wasn't a weirdo for using condoms.”

The final two questions queried participants about how their views related to having or not having sex and about using or not using condoms may have changed. Again, the majority (12/17) agreed that their views on having sex were more positive now as a result of the discussion. As one sexually experienced participant shared: “This discussion has made me realize that sex isn't as much of a terrible thing as people say. Obviously it's still VERY important to be safe, but sex is okay when you're with someone you can trust. (:” Two other responses were coded 0, indicating that, “no,” those participant's views about having or not having sex had not changed but had remained the same. Three responses were coded 2, indicating that these participant's pre-existing views about having or not having sex had not changed but had been reinforced. For example: “The discussion didn't really change my views about having or not having sex. It more reinforced the idea of safe sex as opposed to not having sex. So like I don't think that I will have less sex, but more protective.”

Similarly, just over half of participants (9/17) said that their views about condoms had changed: “The discussion has encouraged me to give condoms a try.” Four other responses were coded 0, indicating that, “no,” those participant's views about using condoms had not changed but had remained the same. For example, “It really hasn't changed although I might use them sometimes.” Four responses were coded 2, indicating that that participant's pre-existing views about using condoms had not changed but had been reinforced: “...it solidified my use of condoms. I guess it made me look at the guys who AREN”T using protection as the minority now and the people who do as the majority.”

Sexually inexperienced participants

Among the 18 sexually inexperienced participants in the second round of focus groups, 15 responded to at least one of the questions about the online focus group experience. Half (8/16) of the respondents agreed that their views changed in a number of positive ways, most commonly by reducing their sense of isolation as young GBQ men who were waiting to have sex: “This discussion has helped me to realize just how many guys out there want to wait for the right guy for sex and relationships in general.” Seven other responses were coded 0, indicating that, “no,” those participant's views had not changed but had remained the same: “I believe my views relatively remained the same. I am going to wait to have sex like I have for awhile now and I am going to urge others to do the same.” One response was coded 2, indicating that that participant's pre-existing views had not changed but had been reinforced: “My views on safe sex were reinforced. I know it's important to stay safe and this discussion helped me to feel like that is the right opinion to have.”

Responses to the question, “In what way do you think your behavior might change (if at all) as a result of taking part in this Discussion” were similar to sexually experienced participants: Most (6/8) indicated that behavioral intentions had been positively affected. For example: “If my behavior changes, it would be the fact that I should probably carry condoms with me at all times.” Many sexually inexperienced participants also thought that they would become more vocal advocates of abstinence and/or safe sex: “I think that if my behavior were to change at all, it would be that I'll advocate safe sex and waiting for the right person around my friends more instead of just being neutral on the topic.” One responses was coded 0, indicating that, “no,” those participant's did not expect their behaviors would change. One response was coded 2, indicating that that participant's pre-existing behavior had not changed but had been reinforced: “I don't see a lot of change occurring, but I know that the discussion will stay in my head, and I'll just remember that staying safe is the most important thing I can do.”

Only a small minority (2/13) responded to the third exit interview question that their views on sex had changed: “I think the discussion has just reaffirmed that people agree with me that I shouldn't have sex until I find someone who is a great guy.” One participant who conveyed a change in his views on sex indicated an increased commitment to waiting to have sex, “Before I...kinda had the mindset if it happened, it happened. But now I know that I definitely wan to wait for someone special.” Instead, most (8/13) indicated that their views about having or not having sex had not changed but had remained the same. Three responses were coded 2, indicating that these participant's pre-existing views about having or not having sex had not changed but had been reinforced for example, “The whole experience just reaffirmed all of my beliefs and stances on sexual topics.”

Finally, when we asked participants if and how their views had changed about using or not using condoms, just under half (6/13) said that their views about using condoms were now more positive. As one participant explained: “Since I don't really talk much about safe sex for gay teens in school or in general, I didn't know much about it except to use a condom. I didn't really know why to use it or really the importance of using it. But here I was able to relate to some of the topics and as I looked at the responses I started to see the more deeper picture about the dangers of unprotected sex. I also could see that I was not alone about what I believed.” Five other responses were coded 0, indicating that, participants’ views about using condoms had not changed but had remained the same. For example: “My views haven't really changed at al, but now I know how to deal with situations I'd never thought about.” Two responses indicated that the participants’ pre-existing views about using condoms had not changed but had been reinforced: It definitely reinforced my idea that condoms ned to be used by everyone. Period.”

Overall, at the end of the online focus group, sexually inexperienced youth expressed a strong belief that condoms should always be used and one participant said that he would now feel more comfortable buying and owning them.

Thematic results

Within the context of participants’ answers to the four exit interview questions (described in Focus Group Script), 121 themes were initially identified. Through a process of discussion, comparison, and refinement of the codes, these were reduced to 36 themes, which were then reduced into 5 discrete axial codes: (1) gained a sense of community; (2) enjoyed participating; (3) felt supported in the focus group; (4) gained an ability to talk about sex or sexuality; and (5) felt inspired to get involved in LGBQ community programming.

Excerpts coded for endorsing the theme “gained a sense of community” included participants descriptions of a new or increased sense of LGBQ community, an awareness of commonalities with other LGBQ youth, and/or a new sense that others are invested in helping the LGBQ community. For example, “My views have changed for the better in regards to seeing and meeting with different gay/bi people and seeing how diverse of a community we are and how many things we all still have in common.” Another theme that emerged indicated that participants enjoyed participating in the group. This code was applied to excerpts where participants explicitly conveyed this; many also shared something that they learned or a way that they felt they benefitted from their participation for example, “I really enjoyed this it showed me it really is important to wear a condom.” Many participants also indicated that they “felt supported in the focus group.” This code was applied to excerpts in which participants conveyed a sense that they felt supported and/or a decreased sense of isolation during their participation, for example:

“It was really helpful to see that other guys had the same view on sex, ‘waiting until it meant something,’ or condom use, ‘always use one for protection against disease.’ The whole experience just reaffirmed all of my beliefs and stances on sexual topics.”

Additionally, many participants shared that their involvement in the online focus group had made them feel more capable and/or more comfortable talking about sex, sexual health, or sexuality. Similarly, some conveyed their new desire to discuss, advocate, or raise awareness about sexual health with other (e.g. their peers) as a result of their involvement with the focus group: “This has allowed me to talk more freely about sex with teens my age,” and: “It's made me more comfortable to talk about sex with my peers.” Finally, becoming “inspired to get involved in the LGBQ community” emerged as a theme among participants: “I will try to help out my GSA more now and participating in the LGBT were I live....”

DISCUSSION

Overall, the majority of the gay, bisexual, and queer young men who participated in the online focus groups reported either changes in attitudes or views about sex, plans regarding future behavior change, and/or a reduced sense of isolation. Among the sexually inexperienced youth, the online focus groups appeared to reaffirm their decisions to not have sex. Most noteworthy, having the opportunity to speak to other sexually inexperienced gay, bisexual, and queer young men in a safe and anonymous environment helped reduce their feelings of isolation and increased feelings of support for their decisions regarding abstinence.

Delaying first sex reduces the likelihood of contracting HIV or other sexually transmitted infections through sexual contact. Currently, there is a noticeable dearth of evidence-based interventions aimed at helping young gay, bisexual, and queer adolescents delay the onset of sexual activity. Indeed, unprotected sex is commonly an inclusion criterion in HIV prevention programs. Findings suggest that moderator-led focus groups have the potential to help sexually inexperienced sexual minority adolescents articulate their reasons for waiting to have sex. With many of the inexperienced participants reporting that their future behavior might change such that they feel more encouraged to obtain and/or carry condoms when they started having sex, focus groups may also provide a space for these young men to build self-efficacy for preventive behaviors prior to their sexual debut. This is particularly important given research that suggests many youth initiate sexual activity before they possess adequate motivation and skills to protect themselves (Fergus, Zimmerman, & Caldwell, 2007). While it is possible that connecting to like others may result in increased sexual risk behavior, the current qualitative data suggest that instead, online focus groups represent a low-cost, scalable intervention that could be implemented for sexually inexperienced gay, bisexual, and queer adolescents to obtain the social support they need to remain committed to their decisions.

Findings suggest that involvement in these types of online focus group discussions have the potential to reduce the negative effects of gay-related stigma, particularly among sexually experienced adolescents. Indeed, stigma has been associated with HIV sexual risk behaviors, including an increased number of sexual partners and unprotected anal sex (Hart & Heimberg, 2005; Rosario, Schrimshaw, & Hunter, 2006). Moreover, recent meta-analyses have documented the association between internalized homophobia and mental health (Newcomb & Mustanski, 2010). If online discussion groups for these young men could reduce internalized homophobia, there could be subsequent beneficial effects on mental health.

The sexually experienced young men indicated that their views became more sex-positive in general, but they also developed or strengthened existing positive attitudes regarding sexual safety. They also reported that involvement in the online focus groups increased their ability to talk about sex and inspired them to get involved in the LGB community. Involvement and identification with the LGB community has been shown to promote resilience in terms of helping young people consolidate their sexual identity and protect against HIV sexual risk behaviors, depression, and consequences of homophobia (Lelutiu-Weinberger et al., 2013; McDavitt et al., 2008; Vincke & Heeringen, 2002). A focus group-based intervention that both increases positive attitudes about condom use and fosters a desire to develop a stronger connection to the LGB community could have significant protective benefits for young gay, bisexual, and queer men.

It should be noted that a group moderator is likely essential to invigorating a thoughtful discussion about sexuality and sex, even though these topics might naturally emerge in youth discussions on social networking sites. A guided discussion that includes topics that are likely to lead to self-reflection and a deeper sharing of experiences and beliefs is what is posited to affect change.

CONCLUSION

To our knowledge, this is the first evidence that online focus groups for gay, bisexual, and queer adolescent males may have an impact on their HIV preventive behavioral intentions. This is in many ways, consistent with previous research that has found the simple task of completing a survey can inspire self-reflection as well as behavioral intentions (Ingersoll et al., 2011; Lightfoot, Rotheram-Borus, Comulada, Gundersen, & Reddy, 2007; Safren, O'Cleirigh, Skeer, Elsesser, & Mayer, 2013). Whether these intentions would lead to actual behavior change – that is sustained over time – is unknown. However, the current findings suggest that online focus groups or moderated-led social support groups could be further explored as a low cost intervention for this vulnerable population of young people.

Acknowledgements

We would like to thank the entire Guy2Guy Team from Center for Innovative Public Health Research and Northwestern University. We'd also like to acknowledge the contributions of Dr. Sheana Bull. Finally, we thank the participants for their time and willingness to participate in this study. An earlier version of this manuscript was presented at the 2013 AIDS Impact conference.

Funding source: The project described is supported by Award Number R01 MH096660 from the National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health.

Abbreviations

LGB

lesbian, gay, and bisexual

FG

focus group

Footnotes

Conflict of interest statement: The authors declare that there are no conflicts of interest.

Contributor Information

Michele L. Ybarra, Center for Innovative Public Health Research.

L. Zachary DuBois, IMPACT Program, Northwestern University, Feinberg School of Medicine; Current Affiliation: University of Massachusetts Boston.

Jeffrey T. Parsons, Center for HIV/AIDS Educational Studies and Training (CHEST), Hunter College and the Graduate Center of the City University of New York (CUNY).

Tonya L. Prescott, Center for Innovative Public Health Research.

Brian Mustanski, IMPACT Program, Northwestern University, Feinberg School of Medicine.

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