Cultural Understanding and Awareness

The importance of cultural understanding

The importance of cultural competency, including culturally and linguistically appropriate resources and tools, cannot be overstated or overemphasized. Cultural competence 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. Retrieved 11/1/2019). Experts and programs experienced in IPS have found that DIS competence and comfort with diverse cultures and communities as well as with technology contributes to a successful IPS program. This includes understanding and working effectively in sex-focused environments, as well as being able to comfortably communicate with patients and their partners who use these sites.

Digital communities often have their own culture, which may include their own language and behaviors. It is critical that staff conduct themselves in a professional manner and have an 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 people in online communities as they do when interacting face to face with individuals and offline communities.

Assumptions and judgments regarding an individual's sexual identity, orientation, or sexual behaviors should be avoided. Partner services staff are expected to suspend judgment and remain 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.

Website and dating app profiles are marketing tools. It is important to understand that online communities offer individuals an opportunity to interact in ways 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. Users build profiles to convey a desired image; this often results in promoting certain details while withholding others. The content reflected in the profile will often reflect the theme or interests of the website or app.

It is also important to know that sex-seeking websites and apps may also be used for reasons other than finding a sex partner. Many people will also use these sites to learn about a new town or city and to find out about upcoming events or popular venues for socializing. Disease intervention specialists should avoid profiling or labeling a patient or partner based on observations or information read online, read in an app profile, or shared during an interview. 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 log in to a sex-seeking site where the focus is on seeking a partner for an immediate sexual encounter, 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 often self-disclosed or self-selected and may be omitted, exaggerated, or false.

These self-selected options are often limited and may not account for a full variety of sexual behaviors and preferences. For example, individuals who engage in same-sex behaviors may disclose their sexual orientation as heterosexual, or users may choose not to indicate their preferences in an effort to attract more partners. In addition, online and mobile app activities can range from finding a group sex party to finding a casual sex partner for a discreet encounter where names are neither exchanged nor asked. Fantasy is also an element of some adult-oriented websites, and some online descriptions of sexual pursuits may be nothing more than an expression of this fantasy.

Online and mobile-based communication within apps and websites is also different from what occurs face to face or over the telephone. The mobility of networking apps in particular allows for rapid networking and connections. Names may not be exchanged and minimal identifying information (e.g., a phone number or address) may be shared in order to facilitate the physical encounter. In some cases, the email or profile messages may be purged shortly after the encounter, or entire accounts may be deleted.

Email addresses, screen and profile names, and online identifiers can also be changed easily and quickly, unlike traditional names. 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 networking apps and online sites allow for the same profile name to be used by more than one person. For example, an online community may have multiple members with the username ATLDavid. This is when additional information is needed to ensure the correct individual is being reached.

3.1 Communicating in digital venues

When communicating with persons online, through an app, or by 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, 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). Before you begin using a site for IPS, it is important to understand the TOS, as they describe the appropriate behaviors and standards that are expected of members. 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 between the operators and members of the website/app. The TOS are subject to change.

3.2 Code of conduct in digital venues

When conducting IPS through a website or mobile app, it is important to be aware that you are perceived as a member of the community. Disease intervention specialists and programs in these venues are subject to the rules and regulations of the website or app. Those conducting partner notification within online communities are, in essence, “invited guests,” as they aren’t (nor should they be) conducting partner notification as a member of the venue.

It is important to remember that you are representing your agency. At the writing of this toolkit, we only know of one dating site, Adam4Adam, that allows DIS and other health specialists to operate on their site. No other dating apps have provided express permission allowing partner services on their sites.

3.3 Terms of Service (TOS) in digital venues

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. Supervisors and IPS assigned staff should be familiar with each venue’s TOS and review them periodically for changes and updates.

It is important to remember that the websites and apps where individuals 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.

3.4 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. Anecdotally, it is known that patients will often 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 the health department medical director, the health department information technology (IT) director, the health department legal department, STD/HIV program directors, managers, and DIS, among others.

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 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.