A Qualitative Assessment of the 1996 AIDS Committee of Toronto Educational Brochure: Safer Sex Guide for men having sex with men

James Murray facilitated the focus group. Robert Ray, a volunteer with ACT, worked as a note taker for the focus group and provided the first draft of this report.

Background and Purpose:

A focus group was conducted on September 20, 2000 for the purpose of evaluating ACT’s educational brochure entitled, "Safer Sex Guide for men having sex with men”. This brochure was written and produced in 1996 and is currently out of print. The focus group will inform the re-production of the brochure in 2001.

Research Objectives:

The objectives of the focus group were:

    • To obtain reactions to the ACT 1996 "Safer Sex Guide for men having sex with men” brochure in terms of language (vernacular, level and nature), length (text and brochure), content and design (images and layout).
    • To determine if the 1996 brochure remained relevant by assessing the information needs of focus group participants in 2000.
    • To obtain feedback on the applicability of the brochure as a means of communicating sexual health information to men who have sex with men.
    • To obtain feedback on means and locations for disseminating a sexual health brochure to men who have sex with men.

A FEW NOTES ON QUALITATIVE METHODOLOGY:

As a research methodology, focus groups are a means of generating discussion and eliciting insights into particular questions. The purpose of a qualitative methodology such as focus groups is not to test predetermined hypotheses, but rather to elicit the perspectives of individual participants. Generalizing from a "representative sample" of men who have sex with men to all men who have sex with men in general is not possible; nor is it necessary for the purposes of this research. Rather, the reader should assume that these insights are illuminating and, therefore, directional and not definitive.


Methodology:

A flyer advertising a "focus group to provide feedback on our safer sex brochure” entitled "Safer Sex Guide for men having sex with men” was distributed via the ACT Information Board system in Toronto gay bars, bath houses and other community venues. Recruitment was also done through an ad placed in a gay community newspaper (XTRA!), through links to MSM outreach staff in other, ethno-specific community-based AIDS Service Organizations in Toronto, and through an ACT staff person who has strong links to Spanish-speaking men who have sex with men. Payment for participation was $20.00. Potential participants were asked to contact James Murray at ACT.

Participants were screened for identification as men who have sex with men.

Sample:

The focus group took place on Wednesday, September 20, 2000 at the AIDS Committee of Toronto, 399 Church Street, 4th floor Activity Room, Toronto, Ontario. A total of fifteen participants were recruited.

In total, thirteen (n=13) participants showed up for the focus group.

Information about participants was collected by an anonymous, self-administered questionnaire completed at the beginning of the evening. Participants were told not to place any identifying information on the form. After it was completed participants placed it in an envelope.

The average age of participants was 33.7 years. The median age was 32 years. Ages ranged from 25 years to 46 years. Twelve of the participants identified as gay, with one identifying as bisexual. Seven participants were single, while six were in a relationship with a man, and one was in a relationship with a woman.

The focus group was very ethno-culturally diverse. Two participants identified as ‘Western European’ and one as ‘Eastern European’. One participant identified as ‘East Asian’, one as ‘South Asian’ and one as South East Asian. Three participants identified as ‘First Nations’ and two identified as coming from ‘Central America/Mexico’. One participant wrote ‘Canadian’ on their sheet, so the ethno-cultural background was undetermined.

English was the first language for ten of the participants, with one participant identifying Chinese as their first language and two identifying Spanish. All thirteen participants listed English as the language they would prefer to receive safer sex information, although three participants accompanied English with a second language. These were French, Spanish, and Tagalog.

Five participants had listed their education level as ‘University’, two as ‘Community College’, and six as “High School’.

The income level of the majority of participants was low. Seven made less than $15,000 per year, while two selected $15,000 - $25,000, and one selected $35,000 - $45,000. Two left the question blank. Six participants were on ‘long-term disability’, two were ‘looking for work’ and one was on ‘social assistance’. Three participants were ‘self-employed’ and one was a ‘student’.


Procedure:

After introductions, the facilitator went through a series of formalities with the group. These included the importance and nature of confidentiality, issues related to the collection of information in taped and written formats, their right not to participate and to withdraw participation without penalty, honorarium distribution, referral information related to sexual health issues, and access to the final report. Participants were asked to sign a Consent Form, which outlined their rights and ACT’s responsibilities. (see APPENDIX A).

Participants were then asked to complete a Demographic Survey (See APPENDIX B).

Participants were then asked to read the 1996 " Safer Sex Guide for men having sex with men” brochure and fill out a questionnaire (see APPENDIX C) to solicit their response. Once the written survey was completed participants were encouraged to take a ten-minute break and return for the group discussion.

The group spent about one hour discussing the brochure. The facilitator focused on several key areas: color, images, text, language, content, and distribution (see APPENDIX D for a copy of the facilitator’s questions). The discussion was recorded simultaneously by tape recorder and written notes. The facilitator later transcribed the tape recording.


Interpretive Analysis:

This analysis is based both on the written survey’s completed by participants and the transcription notes from the taped record of the group discussion.


Size of brochure: Using a Likert scale ranked from 1 (very good) to 5 (not good) the mean response to the brochure was: 2.2

Length of brochure: Using a Likert scale ranked from 1 (too long) to 5 (too short) the mean response to the brochure was: 2.8

Design of brochure (images, layout): Using a Likert scale ranked from 1 (very good) to 5 (not good) the mean response to the brochure was: 3.0

Overall impression: Using a Likert scale ranked from 1 (very good) to 5 (not good) the mean response to the brochure was: 2.7

Based on these scales, participants were clearly satisfied with the existing brochure overall. In particular, there was most consensus on the length of the brochure, which participants felt was ‘just right’ and the design of the brochure, which the majority of participants felt was ‘good’. Some participants felt a smaller brochure that would fit in a pocket would be better, although the average response to the size of the brochure falls between ‘good’ and ‘very good’.


Discussion:

The overall sentiment in the focus group was that the brochure contained important information they felt was relevant. However, for all of the men in the group the information was not new. Generally, the group felt that a brochure produced today needed to be more bold, to really grab the attention of gay men, and it needed to contain more direct, practical information about negotiating safer sex and seeking further supports. They agreed on the importance of reducing the impact of so much text by balancing larger images with text, and using bolding and other highlights to stress key point.

Specific issues raised during the focus group were:


Color

There was agreement in the group that the color scheme needed to change. Participants felt the existing color scheme did not catch their eye, and the contrast in color between green and brown left the text on the cover difficult to read.

“It doesn’t stand right out, you don’t see it right away…it doesn’t captivate you”.

“I don’t think it would catch your eye if you were passing by. It’s too dark, no one would pick it out.”

“Just different coloring on the front. The green and brown blends too much. You need something more vibrant”.

“I think a lighter, brighter color”.


Images

There was mixed feelings about the images. Some people liked them, and liked the blurred art work. They felt the pamphlet was about getting information and not about providing erotic images. Others thought they should be clear and sexual, that this would make the pamphlet more attractive and interesting to read.

“The images are fine”.

“Erotic. Yeah”.

“Why is the picture blurred? Why not just show the real picture? If they are having sex with men they’ve seen another man”.

“Something to relate to, instead of just words”.

“I don’t think they have to be pornographic. I think it’s good if it illustrates the subject you are talking about”.

There was a feeling amongst some men that the images were primarily of white men, even thought that wasn’t factually true. The blurring of the images may leave too much to the interpretation of the reader, where some readers will read themselves into the images but others will not.

“They all look pretty waspy to me actually”.

“Some of the images seem like men of colour”.


Participants felt there should be a better balance of images to text, and that the images should be larger and more fun. This is one area where some participants felt the brochure was too clinical in nature, which was a turn off for some, and felt to some like it was prescriptive – like a doctor – and this turned them off.

“Not necessarily more images but just mix it up. Mix the layout of the image and the text so that it’s not…All I see is white and a lot of text”.

“It looks like something you would find in a doctors office under medical conditions. You don’t want it to appear to be rammed down your throat, to be perceived to be more friendly”.

“It looks like a medical pamphlet, like something that would describe bronchitis…”.

“A little more fun”.

“The information is there but it looks so clinical”.


Text

There was general consensus that the nature of the information was good and relevant, but that the brochure felt text heavy. For some participants this was necessary to get all the information in there, but for others it was a turn off.

“No, the text is okay. It’s the layout…you open it up and ‘oh my god, it’s way too much to read, ‘ text all over the place. Like I said before, have one big picture or pose and then pockets of information…”

“But, on first glance it’s very wordy, even myself if I were to see this text I wouldn’t read it all.”

“There is a lot of text but I also think it’s pertinent. I don’t know if it’s too much. Like I say, when I open it up there is text and I see there’s lots to read, but it is interspersed with pictures a bit, and I find that fine.”


Some participants expressed the feeling that the text was written in too passive a voice. They felt it needed to be more directive. This suggestion fit in with an overall sense of a need to make the brochure more bold and aggressive at this time, given the extent of information gay men have been given over the years and the sense that many gay men feel they already know it all, but do not.

“The title could be a lot bigger and brighter”.

“I think it’s passive. I don’t think it’s pro-active”.

“The ACT information is great but I don’t think it’s written in the active voice. I don’t think it comes across that way”.


Participants were asked if they thought the text was difficult to understand. The consensus from the participants, which included participants for whom English is not their first language, was that the level of literacy in the text was reasonable and that they could understand what it was saying.


Language

The participants supported the use of graphic language in the brochure, and supported the variation in language to describe individual sex acts, as a means of ensuring readers understand the intent of the brochure.

“It’s very, ‘anal sex’ with ‘fucking’ in brackets. I mean, that hits ya…cool. The language itself is very easy to read and very approachable”.

“I love that!”

“Definitely. It makes it approachable”.


When we discussed the issue of language levels there was a couple of specific suggestions. One person was unclear about the acronym ‘STD’, and had to ask for clarification. Another, speaking as a person for whom English is not their first language, expressed concern about the subtle distinctions between language like ‘safe’ and ‘safer’. He suggested clearly differentiating the terms in some way so people understand the distinction. This concern echoed the concern of another participant who suggested that the brochure provide greater clarity about the difference between ‘high risk’, ‘low risk’, and other risk levels.

“I’m coming from the perspective of someone whose language is not English. That may be a barrier. Words like ‘safe’ and ‘safer’, they may understand the root of it, but they may not understand the implications of the differences between the two…”

“I could use a break down of the high risk and the low risk, because that’s actually something I don’t understand. I really don’t. A risk is a risk is a risk”.

“Like rimming is low risk for HIV, but how low? That’s vague to me. ‘Rimming is low risk for HIV.’ Meaningless really, for me”.


Content

Again, participants felt the content was generally relevant and important information. All of the men stated that there was nothing new for them in the brochure. They all felt they already had the information listed there currently.

They spoke about the need to include practical information for men. They felt it was important to acknowledge the difficulty men have with condoms, and the difficulty men can have talking about sex and condoms with their sex partners. Some participants questioned how realistic this advice is, and felt it was important to accompany this kind of advice with suggestions on how to do it.

“The line, ‘talk to your partner’ to me it made it sound like it’s easy, and I find that very difficult. The wording of it was like, it made it sound too easy. And, it’s a lot harder. It doesn’t mention anything about like if your partner won’t talk”.

“It’s hard to discuss it with your partner”.

“If you say, ‘try to discuss it, but if you can’t really try hard to use protection”.


Some participants felt it was important to target safer sex information directly at HIV positive men, and to include information about why two HIV positive men might want to choose safer sex together. A number of participants also felt it was important to clarify the reality of HIV treatments on the lives of people with HIV, and that HIV is not cured or manageable. They felt that some men no longer feared getting HIV and that that was having an impact on safer sex.

“Or, reasons why two people with HIV should practise safer sex, a little paragraph about that because when two people have HIV they wonder why should I bother having safe sex because they’re HIV positive anyway”.

“Probably something saying that HIV still results in death despite the cocktails and everything else…”

“You don’t realize until you’re HIV positive what you are going to go through once you’re on these medications”.


Participants felt it was important to have more referral information on the brochure. Some men suggested listing other ACT brochures about safer sex, especially because this one brochure doesn’t address some sexual activities, such as S/M activities, and may not attract youth. Meanwhile, ACT has brochures targeting those communities. As well, some participants felt it was important to provide a number that could link people to a one-on-one contact if they have questions stemming from the brochure, or if they prefer to get information in that way. Similarly, participants generally agreed it was important to provide information on where men can get free condoms and lube in Toronto.

“Might actually be good to mention the other pamphlets on the back of it”.

“Do you have a 1-800 number?”

“…getting contact with a direct human being as opposed to words on paper would be helpful for a lot of people, and maybe people who couldn’t read the language or for whatever reason wouldn’t have the patience”.

“You might want to mention where you can get them (condoms) for free…”


Distribution

When asked about where the pamphlet might reach them participants listed a range of possibilities. These included bars and bath houses, doctors offices, coffee shops, drop-in centers, gay media, the internet, libraries, community centers.

There was some feeling that it was more important to get the brochure to places where men are meeting socially and casually, as opposed for sex (such as a bath house), since at that point they may not take the time to read a pamphlet through. Similarly, some men felt it was important for the brochure to be in a place where men can read it on the spot, with some privacy, and not have to take it away.

“Some place where it’s going to stand out from everybody else where someone can look at that and read it really quick and put it back…”

“Do you think when someone goes into a bar or bath house they’re going to pick this up? They’ve got one thing on their minds – sex”.

”I’m the one who will go into a bar like 501 and go to the back with the brochures and see if there’s anything new and exciting. So, that’s me personally. I assume a lot more people do that…”


Recommendations:

1.That ACT re-produce a safer sex brochure targeted at gay and bisexual men. The brochure will be made with primary emphasis on reaching gay and bisexual men, and will reach some non-gay identified men who have sex with men due to it’s placement in venues where MSM meet for sex.

2. That the following changes be made to the brochure’s design and layout:
    a.The title needs to be bolder.

    b.The colour scheme needs to have greater contrast to allow it to be more visible in darker setting, such as bath houses and bars. Similarly, the text color contrast with the background needs to be greater.

    c.The images should include a mix of clearer photographic images with altered lines, as in the original brochure. The images should clearly reflect men from a range of ethno-cultural backgrounds.

    d.There needs to be a greater balance of images to text. A reduction in text would be ideal, allowing for more ‘white space’, ensuring that the reader is not put off by the quantity of text when they open the brochure.


3.The following changes should be made to the text and content of the brochure:
    a.The language needs to be more direct, less passive. Included in the brochure should be practical strategies for dealing with challenging sexual situations where condom use is more difficult, and should acknowledge the reality for men that condom use is not always easy or desirable.

    b. More referral information should be included clearly linking men to a one-on-one contact via telephone. Information should be given as to where men can acquire free condoms and lube.

    c. There should be information included about the sexual health needs of people living with HIV, who should be targeted with prevention messages directly.

    d. There should be an acknowledgement of the reality of living with HIV at the present, to send the message that it’s worth continuing to avoid HIV infection.


4.That the brochure be distributed in a variety of venues where gay and bisexual men might meet for sex, and for health services. These include bars and bathhouses, doctor’s offices, health clinics, coffee shops, on the internet, and in the gay press.

5.That there be information in the brochure that reflects the current realities of safer sex for gay and bisexual men. This would include bareback sex, sex between HIV positive men, the impact of HIV treatments on safer sex, information about circumcision, and information about the importance of preventing STIs, etc…The brochure needs to feel current and needs to provide information to men that they may not currently feel they have.


APPENDIX A
CONSENT FORM

Focus Test
‘Safer Sex Guide for men having sex with men’ Brochure

James Murray
AIDS Committee of Toronto
Toronto, Ontario
416-340-8484, ext.247


The purpose of this focus test is to support ACT in re-producing our safer sex guide for men who have sex with men. ACT is seeking your feedback on our current material and your thoughts on how we should proceed to best serve the sexual health information needs of men who have sex with men.

In signing this consent form, I am agreeing to participate in an interview for this study. The interview should last approximately 60 minutes. It will be audio-taped only with my permission.

I understand that I do not need to answer any question that I feel uncomfortable with and that I can end my participation at any time.

I have been assured that all of the information that I provide will be treated with the strictest confidence. The tapes or written notes concerning my comments will be kept in a secure place where only the interviewer and a transcriber, will have access to them. I will not be identified by name in any written, verbal, aural, or tape-recorded documents related to the study, and any identifying information I may provide will be deleted or changed to protect my identity. I have the option of asking ACT to attach a coded identifier, rather than my name, to any documentation stemming from my participation in the study.

I understand raw data, without any identifying information, may be reviewed by ACT staff.

ACT recognizes that there are potential risks inherent in discussing behavior, or observations of behavior, that are stigmatized and/or illegal. ACT has available to me information related to the safer use of illicit drugs, safer sex, and referral options where I can further discuss any issues of concern to me which arise during the focus group.

I understand that I will have access to the final report produced by ACT.


______________________________________________________________
Signature Date

______________________________________________________________
ACT Representative Date



APPENDIX B
Focus Test
Participant Demographics


The following information will help us to better understand who is giving us feedback today. This information is anonymous. Please do not attach your name to this sheet of paper.

Age _____

Sexual Identity
    Gay
    Bisexual
    Straight
    None of the above


Relationship Status
    Single
    In a relationship with a man
    In a relationship with a woman
    Other _________________________


HIV Status
    Positive
    Negative
    Don’t Know
    Prefer not to say


Ethno-cultural Background
    Western European
    Eastern European
    African
    Carribean
    South Asian
    East Asian
    Southeast Asian
    First Nations
    Central American/Mexico
    South American
    West Indian
    Mixed
    Other __________________________


What is your first language? ____________________________

What is the language you would prefer to receive information about safer sex? _______________________________________________________________

What level of education have you completed?
    Pre-high school
    High school
    Community College
    University


What is your current employment situation?
    Self-employed
    Part-time
    Full-time
    Social assistance
    Looking for work
    Student
    Long-term disability insurance
    Retired


What is your current level of income in one year?
    Less than $15,000
    $15,000 – $25,000
    $25,000 - $35,000
    $35,000 - $45,000
    more than $45,000





APPENDIX C
Focus Group
‘Safer Sex Guide for men having sex with men’ Brochure

Please read through the brochure and answer the following questions.


What is your first impression or first thoughts as you read through the brochure?

What are the main messages of this brochure?

What did you like about the brochure?

What didn’t you like about the brochure?

Did you have difficulty understanding any of the terms? If yes, please list those terms here:

Is anything missing in this brochure?

Was any of the information new to you? If so, please comment here:


Please circle the number that best suits how you feel about the brochure:

What do you think about the size of the brochure?

Very Good
good
not good
12
3
4
5


What do you think about the brochure’s length?

Too long
just right
too short
12
3
4
5


What do you think about the design of the brochure? (images, layout)

Very Good
good
not good
12
3
4
5


What is your overall impression of this brochure?

Very Good
good
not good
12
3
4
5


Please use the space below to write any additional comments or thoughts about the brochure. Thank you.


APPENDIX D
Focus Group
(MSM Brochure)


Goals and Facilitator Notes


1. To obtain reactions to the ‘Safer Sex Guide for men having sex with men’
brochure produced by the AIDS Committee of Toronto in 1996 in terms of language (level & nature), length (text & brochure), content, and design (images & layout).

Does anyone want to share their initial reactions to the pamphlet?

What did you like about the brochure?

Was there anything that really stuck out about the brochure for anyone?

If yes, what attracts you to the brochure?

If no, why not? What about it would lead you to turn away? What could we do to make it more attractive or enticing to pick up and read?

How do you feel about the images? What was your reaction to the images when you saw them?

What kind of images would you like to see? (explicit, cartoon, real photo’s, drawings, non-sexual)

How did you feel about the text? Is there too much?

Were there any terms you didn’t understand? What were they?

What about the explicit language? How did you feel about that?

What do you think about the size of the brochure? Is it too long? Is it too big?


2. To identify information needs of participants in order to determine the relevance of the existing brochure content to current HIV prevention needs of Toronto MSM.

Was there any information in the brochure that was new to you?

What would you say is the main message of the brochure?

Is there anything missing? If you think about questions you might have, or issues you are aware of, that relate to gay men and HIV/sexual health, what would that include that’s not in the brochure?

What do you think are the most important issues facing gay men today in terms of safer sex and fighting HIV?



3. To obtain feedback on the applicability of the brochure as a means of communicating sexual health information to men.

Where do you look when you want information about HIV? Safer Sex? Where have you gotten that information in the past?

How useful is a brochure as a means for you to obtain sexual health information or information about HIV and safer sex

Would you pick up this brochure?
If no, why not?
If yes, why?


4. To obtain feedback on means of disseminating a sexual health brochure to men.

Where would you be most likely to take a brochure like this? (bar, bath house, doctors office, Hassle Free Clinic, video store or other community venue, etc…)

Where do you think ACT should make this brochure available? How do you think we could be most successful at getting this brochure out to men?