What's in a message? Delivering sexual health promotion to young people in Australia via text messaging (original) (raw)

The main themes emerging from the focus groups are presented in Table 2.

Table 2 Key Themes

Full size table

Participation

Among the 141 individuals successfully contacted, 108 (77%) were interested in participating in a focus group. There was no significant difference by gender or region of residence for expressing interest in participating (data not shown). Forty three individuals, 21 males and 22 females aged 16 between 24 years, attended one of the eight focus groups held in August 2008. The size of each focus group conducted ranged from four to seven participants. Six focus group discussions were held in central Melbourne, and two in Ballarat, a large regional centre.

Message Style, Content & Delivery

When participants were asked what they through of the messages in general, a number of participants commented that they liked receiving the messages. Although not asked directly, several participants said they like receiving health promotion messages via SMS, as it felt more personal and informal than receiving messages in other forms.

It's different ... It's a new take on rather than sort of seeing sort of posters or billboards like everywhere, bombarding you ... because it's in a text, more personal. (Rick, 22 years)

And especially because it was being told to you over SMS it like made it ... made it more casual, it wasn't a doctor or a teacher. (Christina, 17 years)

The remaining comments related to the messages could be categorised into the following four broad themes: message style, language, content and broadcast schedule.

Theme One: Style

While discussing the messages overall, and individual messages specifically, a number of elements related to the style of the messages emerged in all focus groups. These included the use of humour and rhyming the messages, the variety and length of the messages, tie in with events and the 'sign off' used.

Humour and Rhyming

When responding to what they liked about the messages, participants in all focus groups commented how the humour and rhyming in the messages made them more likely to pay attention to the message and to remember the message and its contents.

It was sort of like, I'd open it and I'd be like, I really don't care about sexual education at the moment, but because it was funny, it just sort of stuck anyway and it's like, information gets through. (Pete, 17 years)

The ones that rhymed are really easy to remember (Tracy, 17 years)

Variety

Some participants noted they liked the variety in the messages sent, in particular the balance between information and humour.

.. That what was really good about the SMS thing. There were some that, like the 50,000 Australians every year, wow that's a lot of people you know, and you might not even know about it. And then there were other ones that were just really lighthearted, "hey you know, remember to use a condom" sort of thing. So it was a good balance. (Natalie, 18 years)

Message Length

Messages varied in length from 71 characters to 160 characters, the maximum allowed in the SMS format. There was no direct question about message length, but a number of comments emerged related to length when reviewing individual messages.

Many participants liked the shorter messages, finding them more straightforward and easier to remember.

[Re Message 10] I, I reckon it's just good because it's just short, sharp. (Luke, 18 years)

Opinions varied about the longer messages - some liked them and acknowledged the need for the extra length, whereas others found them too long which lessened their impact.

Tracy (17 years): Like short and to the point

Christina (17 years): Its easy to remember...

Meg (16 years): Still, some of the long messages are like, very effective though. It's a mixture...

Event Tie In

Participants in all eight focus groups commented that they liked that some of the messages tied into particular annual events, such as Valentine's Day and Easter, and tended to remember these messages the most.

...because you can associate it with something I think it's just more memorable. (Luke, 18 years)

Sign Off

When reviewing the individual messages, a number of participants commented they found the sign off of many of the messages "Love the Burnet Institute" made the messages more personal, and gave the message credibility.

I know it was good they all ended with "Love from the Burnet Institute" rather than just a random message because otherwise I would have wondered "Who the hell is this??!" (Natalie, 18 years)

Theme Two: Language

Along with style, language was another theme that emerged from all groups when reviewing the messages. Most prominent were comments related to the informality of the language use, the positive framing of the messages and the use of indirect versus direct language. Other elements of language that were commented on included the use of 'fear factor' and statistics.

Informal

Many participants commented they liked the informal language used in the message, which resonated with them.

Natalie (18 years): Its not like one of those things the teachers say "When you are having intercourse make sure..." its "If you get lucky..." [laughs]

Belinda (20 years): Its more like our language, than our teachers language in a way

However some participants thought the combination of informal language and serious content wasn't appropriate.

[Re Message Four]

Barry (20 years): I don't like the bit about the long weekend afterwards ... have a nice weekend. It's putting a dampener on things

Mark (24 years): I think it's, it's too far. Like it's too laid back to the point of this isn't a serious issue.

Positive

Another recurring sentiment that emerged while reviewing the messages was the positive angle of the messages, which was liked by a number of participants.

....it's not like, "use a condom or you're going to die!", it's like, "hey if you're lucky enough to get sex, why don't you use a condom?!" (Kate, 17 years)

Indirect vs. Direct

A third recurring emerging sentiment related to the use of indirect or direct language. Some participants felt the messages were quite indirect, and liked this.

Its not telling you to do something, its kind of like you want to do something. (Sarah, 20 years)

Other participants found the messages quite direct.

It was like every message accused you of having chlamydia [laughter] (Mick, 23 years)

However there was a sense that the directness could be interpreted as positive or negative - some liked it, and thought this approach would act as a good motivation, while others thought it could be seen as offensive.

[Re Message Six] Change your partner ... it makes it sound like changing your partner is an everyday kind of thing ... It's amusing .....[but] some people would probably get offended by that. (Kenny, 18 years)

Fear Factor

In one focus group there was a lot of discussion about mixing the informality of the language with an element of 'fear' to prompt action, and whether this was effective or not.

I think its really difficult, because one of the best ways to get through to people is through fear ... ....but, I mean saying "you could become infertile" is not going to make people want to go out and find out if they've got chlamydia. But at the same time, if you say "its not really that big a deal, you know, its easy to treat" well then they are going to go "well don't worry about it". Yeah, so its difficult either way (Natalie, 18 years)

Others though the use of fear wouldn't be effective.

And its kind of one of those things you know, all those ads that just say all those statistics and try to scare you and just like yeah, whatever, I can't be bothered (Rebecca, 18 years)

Use of Statistics

Only message three included a statistic. When reviewing this message, opinions varied greatly as to whether this was effective to include. Some found the statistic impressive and important to include.

[Re Message Three] I reckon it's a good one ... it kind of does suggest that a lot of people do have it, so you might want to be a bit careful (Kate, 17 years)

Others didn't like the use of the statistic, finding it boring, not memorable and not relevant personally.

That's like the Easter one, protect you and your partners eggs. It was like, it was hitting home, look after yourself rather then all that 50,000 Australians, I don't know them! [laughter] (Michalea, 22 years)

When asked how the messages could be improved, participants in three of the focus groups specifically nominated making the messages more personal, rather than the more generic statistics, and that this would have a bigger impact.

Maybe make them more personal to you, like if in the message if it says something like, I dunno, like it said think about 10 of your friends, one of you will get chlamydia, you're going to remember it. (Meg, 16 years)

Theme Three: Content

Comments related to message content emerged both out of direct questioning related to opinions of the overall content of the messages, as well as during review of the individual messages. The strongest theme to emerge related to content was repetition, specifically the focus of many of the messages on chlamydia. Other elements related to content include content relevance, ease of understanding, and the 'different' take of one particular message.

Repetition

A few male participants remarked they found the messages repetitive.

Ben (18 years): Yeah with the repetitive thing it sort of, I mean, like, sort of got bit old, just the way there wasn't really anything new to it.

Participants in all focus groups commented there was too much focus on chlamydia in the messages. This repetition made them pay less attention to the message content, and it would be more effective to include information about a wider range of topics in the future.

I think, look so many were just about chlamydia, I think if they had different information every time, quite clearly different, then I reckon it would have been more, like less annoying, because it was new (Jim, 17 years)

However others thought that the repeated focus on chlamydia was effective in building their knowledge about the infection.

I don't think necessarily it was too much [focus on chlamydia]. Like I feel like I know a fair bit about--now you know (Rob, 19 years)

Relevance

Some participants reported they found the messages very relevant to themselves and their peers.

Yeah, I think they, I think they were on the money ... geared towards the age that you're working towards. Like I think they were pretty accurate and resonated with everyone (Luke, 18 years)

Others remarked they didn't think the messages were relevant to everyone, and this may have affected how they reacted to the messages.

Oh, I was aware that there was a lot of sort of illnesses and that sort of thing which there aren't any symptoms for but um, I'm pretty confident that I wouldn't be affected at the moment so I've got nothing to worry about personally. And then, I suppose, in that case I haven't taken as much notice to these messages. (Paul, 20 years)

Ease of Understanding

When reviewing the individual messages, a number of participants commented they found some of the messages hard to understand, which reduced their effectiveness.

There were some that were okay but then ... there was a few that I found that were a bit round about. Um, I wasn't--they were a bit hard to follow. (Carol, 22 years)

Different

A few participants commented that they liked, and specifically remembered, the mother's day message that had a different take on condoms from the 'standard' health promotion messages.

[Re Message Eight] Yeah and I like the way that one makes you think because it turns it around, saying condoms can help you have kids. Because normally it's just like, you wear a condom, you don't want to have kids kind of thing. (Kate, 17 years)

Theme Four: Broadcast Schedule

Participants were asked to comment when and how often they recalled the messages coming, whether this was appropriate, and if and how this should be changed in the future. SMS were always sent in the afternoon, generally either on Friday's, or the day of a particular event (e.g. on Valentine's Day). Messages were broadcast approximately fortnightly (Table 1).

Message Timing

Many participants recalled that most messages came on Friday afternoons, and thought that this was an appropriate time.

Mark (24 years): Friday afternoon seems to work because it's like, you know, easing into the weekend.

Paul (20 years): Yeah, you're in a good mood anyway.

Some participants didn't particularly notice when the messages were arriving, and liked this.

If you had recorded dates it would have been boring. Because like it could be any time of day and I'd just be like, hey! (Bec, 18 years)

In terms of alternate times for message broadcasts, several participants suggested it would be beneficial to have messages sent 'after the fact' (on weekend mornings or Monday's). However others thought this wouldn't be an effective strategy.

Message Frequency

When prompted, the majority of participants recalled the messages as coming approximately monthly (not fortnightly), but felt the frequency was appropriate.

And they were nicely spread, it wasn't like, you know, all the time, like bombarding. That would have got annoying (Karen, 18 years)

A minority of male participants felt the messages came too frequently, and became too routine.

Yeah, but like toward--like, you know, it started being a routine thing. You're like, you know, they should be messaging me pretty soon about this. And then you do and you're like oh, yeah. So I think that could be why. It became a bit routine. (Josh, 23 years)

Impact of the Messages

As well as gaining an understanding of what characteristics of the messages participants liked, the focus group discussions were also structured to examine if and how the messages had an effect on participants knowledge and behaviour as has been demonstrated by quantitative findings [17]. Given the group setting, we did not require participants to detail exactly how the messages impacted them (if at all), however a number of participants volunteered how they perceived the messages affected them.

The impact of the messages was broadly categorised into information and behaviour change, as well as sharing the messages with others.

Theme One: Information

Information emerged as a key impact of the messages, both the provision of new and specific information and a reminder of information already known to participants.

New and Specific Information

Participants in all focus groups commented they learnt new information from the messages, particularly about chlamydia causing infertility, and often not having any symptoms. Some remarked they liked how the SMS gave them specific information, particularly about STI transmission and methods of STI testing, that they didn't know previously.

Another one I remember was like ... to protect you from being able to have children in the future or something. That was actually new to me. (Pete, 17 years)

... the bits about the chlamydia testing and everything, I had no idea how it got tested or anything like that. (Tracy, 17 years)

Highlighting the value of the messages even further, several participants thought that they wouldn't have found out the information that was new to them in other ways.

Like it's not kind of information you really get um, through other sources really (Freddy, 20 years)

Reminder

Alongside new information, participants in all focus groups also reported that some messages acted as a reminder them of things they already knew.

Yeah.... I don't know how much of it was new information. It was like, jogging my memory sort of (Pete, 17 years)

Several participants commented they didn't mind being reminded of information they already knew.

It was like, some of it was stuff you already knew but it was like, cause they were funny, they weren't like up in your face kind of thing, it was just a reminder (Kate, 17 years)

One participant thought being reminded about information was really useful.

.. it's kind of like you need to be reminded ... Because there's knowing something and then being reminded about it as well. (Manisha, 22 years)

A number of participants commented the information they were reminded about was information they had originally learnt in school.

I think I did [know chlamydia causes infertility]. I think we did get taught something like that in school but like you don't really listen much in school, it all kind of blurs together (Christina, 17 years)

Theme Two: Behaviour Change

Alongside provision of information, the messages aimed primarily to change two key behaviours; 1) encourage uptake of STI testing and 2) reinforce consistent condom use. Participants generally viewed the messages as having no direct impact on their behaviour, but may have had indirect effects, such as reducing apprehension of STI testing and causing them to consider their risk of contracting an STI.

No Direct Effect

Many participants stated they didn't think the messages had a direct effect on their behaviour related to STI testing or condom use, especially if they thought they already were doing the things they should already.

Yeah, I was--I don't think I like I particularly thought I better put on a condom because of those messages. (Luke, 18 years)

Um ... I haven't really changed anything because pretty much everything that I learnt from the SMS I sort of already know before and taken whatever measures, things like that. (Natalie, 18 years)

However a number of participants thought the messages may have had indirect effects, particularly in keeping sexual health 'up in their mind'.

....it was regular, it kept me on my toes a bit, because if you don't have that.... I mean you don't see billboards of it so if you don't hear it from your mum, you just don't hear it. (Steph, 21 years)

When asked to reflect what had directly caused behaviour change in the past, participants in all groups described the impact of a crisis situation that had occurred, either to themselves or to a friend.

... I've had like little scares along the way which have made me go "I really need to use more condoms, this is ridiculous" (Belinda, 20 years)

... a friend of mine thought she was pregnant for like, for a while and that sort of like shocked her into being more careful. Whereas, you know, a cute SMS will never, can never really have the same impact (Chris, 20 years)

Perceptions of STI testing

Participants in almost all focus groups remarked how the messages made them less apprehensive about STI testing, particularly with the (new) knowledge that it didn't have to involve an invasive procedure.

... a lot of people when they like talk about STI testing, it's like, you know only at doctors, it's a big deal and you've got to feel embarrassed about doing it and the SMSs kind of put into context that it's not actually a stupid thing to do..... I haven't had one, but it made it seem a lot more easier to get one (Tracy, 17 years)

... I thought it was going to be the whole drop your daks* and everything, like yeah. If it's just a urine sample and a blood test then that's alright. (Bruce, 18 years) *pants

A few participants stated it made them consider getting an STI test, although they didn't necessarily go and get one.

Like think about it, like, "oh maybe I should get an STI test", eventually. (Brett, 17 years)

Consider Risk

A few participants felt that the information in some of the messages made them consider their risk of having an STI.

.. it makes you feel that you, that everybody could um, sort of have something in a way. Because usually you just assume that you don't have something because you, you feel okay or whatever. (Josh, 23 years)

Theme Three: Spreading the Word

Participants were asked if they shared the messages with others, whether by showing them the text or forwarding them on. Most had shared the messages, mainly with friends, family members and workmates. One participant did not show the messages to others, apart from a friend who also received the messages.

When and Why

Participants reported they were most likely to show other people the message if there were others around when they received the message, or if they found the message funny. A couple of females reported they also passed messages onto others when it was relevant to those individuals.

.... there was one that was really really funny and like I showed it to my friend and told him it was a joke but it was kind of like....it like jokingly like suited him in a way! [laughter] I told him like "someone sent me a message for you!" (Karen, 18 years)

In one focus group there was some discussion about it being easier to share messages that were linked into an event, because it gave a reason to pass the message on without risking accusing or offending individuals.

....it gives you a reason to pass it on because [it's] like an Easter greeting or a Valentines Day greeting (Mainisha, 22 years)

Reactions

Reactions from others were generally positive, although participants often needed to explain why they were receiving these messages.

They [people I work with] liked them. And they were like "how do you get these" and you have to like explain "I did this survey, and la la la" (Jess, 17 years)

Some participants commented they thought that reading out the messages to others help to reinforce the content within the message.

Samuel (17 years): ..... you read them out to your friends and not only do you get the message across when you read out the message but then they ask you more about it...

...

Luke (18 years): And because, because you read it aloud you I think you remember it a lot more as well.