3 Cultural Understanding and Awareness

The importance of cultural competency cannot be overstated or overemphasized.  It is the ability to “deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients.” (NIH, clear communication, http://www.nih.gov/clearcommunication/culturalcompetency.htm. Retrieved 12/29/14) Experts and programs experienced in IPS have found that DIS competence and comfort with IPS contributes to a successful IPS program.  This includes understanding and functioning effectively in diverse environments, as well as being able to comfortably communicate with patients and their partners who use these sites for sex-seeking.   

Internet communities often have their own culture, which may include language and behaviors.  It is critical that staff conduct themselves in a professional manner and have a true openness to, and respect for, the differing sexual lifestyles, viewpoints and experiences of others. Staff members are expected to possess the same level of awareness, insight, and skill at communicating with online communities and people as they do when interacting face to face with individuals and offline communities.   Assumptions and judgments regarding an individual’s sexual orientation or their actual sexual behavior should be avoided.  For instance, the lack of an HIV status in an online profile does not imply that the member does not know their status or that the individual is positive; it may simply be that they choose not to include this in the profile, or prefer to discuss it in person.  Partner services staff are expected to be culturally appropriate regardless of the venue within which they are working.   Any concerns or prejudices DIS have need to be addressed and discussed prior to conducting IPS within online communities.  

It is important to understand that the online community offers individuals an opportunity to interact in a way that they may not feel comfortable doing offline.  For example, the anonymity of the Internet may allow someone to be more sexually open or direct.  However, it is important to not profile or “label” a patient based on any perceived observations or information.  A profile is simply a tool that offers a glimpse into one or more aspects of a personality that the user is intending to use that day. One person may join several different online communities in an effort to have different needs met (this can include sexual networking and social activities). It is not unusual for a person to login to a sex-seeking site where the focus is on seeking a partner for immediate, anonymous sex, while simultaneously maintaining a separate profile on a dating site where their intention may be to find a life partner.   Personal information and identifiers like sex, race, age, HIV status, drug use, or sexual orientation are self-disclosed or self-selected and may be exaggerated or completely false.  Often these self-selected options are limited and do not account for the wide variety of sexual behaviors and desires.  For example, it is not uncommon to encounter individuals that disclose their sexual orientation as heterosexual, but who also engage in same sex behaviors.

Online and mobile-based communication is different from what occurs face to face or over the telephone.  The fast-paced and anonymous nature of digital technology has added a new level of communicating and sex-partnering that could be perceived as inappropriate or unacceptable in any other medium or venue.  Names and phone numbers may not be exchanged and, in some cases, the email or messages may be purged shortly after the encounter. This is particularly true for online venues and communities that are focused on facilitating real-time contact, where communication may be brief and lacking information.  These activities can range from finding a group sex party to finding an anonymous sex partner for a discreet encounter. Many people may use the Internet specifically so that they can engage in a desired behavior while protecting their offline identity.  Fantasy is also an element of some adult-oriented websites. Some online descriptions of sexual pursuits may be nothing more than an expression of fantasy.

Unlike traditional names, email addresses, screen names, and online identifiers can be changed easily and quickly. It is not unusual to lose contact with a person because of a changed screen name. It may be possible to track down a contact that has changed their screen name by reviewing profile information, pictures and other identifying information, but caution should be heeded to confirm that the profile name belongs to the person being sought. Some communities also allow for duplicate profile names based on geographic locations. That is, the same profile name can be used by more than one person as long as the geographic locations are different.  So an online community can have two members with the name of, for example, BigBoi69, but those members will be located in two different states.  

3.1 COMMUNICATING IN DIGITAL VENUES

When communicating with persons online or via text, it is important to remember that this form of communication can be void of voice inflections or facial expressions that typically mitigate conversations.  

Anecdotal evidence suggests that maintaining professionalism when reaching out to patients and their partners is important.   This includes avoiding the use of acronyms (e.g., LOL), icons, and emoticons (e.g., ),  and  other terminology or vernacular that gives the appearance of being overly casual or familiar with the person with whom you are trying to communicate.   

When joining any website or app, you are required to agree to the terms of service (TOS).  TOS are important to understand before you begin using the site for IPS because it might affect whether you are allowed on the site at all.  These service agreements will describe both acceptable and unacceptable behaviors allowed on the site or app.   The TOS will also define if communications between persons on that specific website/app will be confidential.  All TOS are legally binding agreements that outline the site's operating policies.  

3.2 CODE OF CONDUCT IN DIGITAL VENUES

When conducting IPS through a website, it is important to be aware that you are a member of the community and are subject to the rules and regulations of the website or app. DIS conducting partner notification within online communities are, in essence, “invited guests” as they aren’t, nor should they be, conducting PN as a member of the venue. It is important to remember that you are representing your agency.  

Rules and regulations regarding Internet interventions will vary from site to site.  Some websites will allow one type of Internet effort and not another. For example, a website may allow passive outreach, but not IPS.  Other websites may require separate profiles for IPS and outreach and will state that they should not be used interchangeably.  Awareness of the rules and regulations for each website and following those policies will help to ensure that Internet efforts can be continued. Some sites may initially be indifferent to IPS or Internet outreach, but if complaints are received from members of the site, IPS accounts may be suspended or deleted.   

It is important to remember that the websites/apps where patients meet sex partners and from which IPS is being conducted do not have a public health mission.  Most of them are private businesses whose primary mission is to generate revenue either from membership subscriptions or ad sales.  It is possible that a health department or CBO presence will be perceived as a threat to that mission. It is imperative to be aware of such rules and regulations pertaining to IPS prior to joining the site. In sites that do not explicitly allow IPS, conducting IPS activities will most likely be considered a breach of the TOS and could result in suspension or banishment from the website/app.  

3.3 ENGAGEMENT OF APPROPRIATE STAKEHOLDERS

Engagement of key stakeholders can affect the success or failure of an IPS program. In addition to providing support, engaging stakeholders can help validate IPS efforts to clients and partners.  Often patients will call their private physicians or other trusted agencies to confirm that the attempt to reach them is valid, and the verification and positive support can expedite the time the patient takes to respond to the email notification.  Stakeholders can be an additional source of information in identifying local populations who use technology to find sex partners and the specific websites and venues to be targeted.  Important internal stakeholders include, among others, the health department medical director, the health department information technology (IT) director, the health department legal department, STD/HIV program directors, managers, and DIS.

For the IT department, specifically, engaging managers and staff early on can help alleviate potential barriers that may prohibit initiating program-wide IPS services.  

External stakeholders may include community-based organizations (CBOs), private providers, the affected population, and online and mobile businesses where individuals might seek sexual relationships.

It is important to recognize that the different stakeholders will each have different goals and interests.  Some stakeholders simply need to be made aware of a program’s intention to proceed with IPS; others may need to be involved in the creation of IPS policies, IPS implementation, and evaluation.