Abstract
Little is known about the experiences of minority stress among Latina women who have sex with both women and men (WSWM), a sexual and gender minority group situated at the intersection of multiple marginalized identities. The current article presents an exploratory study aimed at addressing this knowledge gap. The research utilized a flexible diary-interview method (DIM) to investigate stress-related experiences among Mexican American WSWM residing in an economically disadvantaged community in the U.S. during the third wave of the COVID-19 pandemic. A detailed description of the study is provided, including information on the background, methodology, participants’ experiences, and how the project was managed remotely by a virtual research team. Twenty-one participants were asked to maintain a diary for a 6-week period spanning from March to September 2021. They submitted weekly entries in diverse formats (visual, audio, typed, and handwritten) through a user-friendly website or via mail while communicating regularly with researchers over the phone. Following the diarizing period, in-depth semi-structured interviews were conducted to clarify pertinent information within the entries and validate researchers’ preliminary interpretations. Out of the initial 21 enrollees, 14 participants stopped diarizing at different stages, and nine completed the entire study. Despite facing challenges exacerbated by the pandemic, participants reported the diary-keeping process as a positive experience that offered an authentic outlet to share parts of their lives they seldom reveal. The implementation of this study highlights two significant methodological insights. Firstly, it emphasizes the value of employing a DIM to explore intersectional narratives. Secondly, it underscores the importance of adopting a flexible and sensitive approach in qualitative health research, particularly when engaging individuals from minoritized groups.
Keywords
Introduction
In recent years, emerging research on sexual and gender minority (SGM) health has shown that SGM individuals experiencing additional forms of marginalization, such as racial/ethnic or socioeconomic marginality, are disproportionately burdened by minority stress (Cyrus, 2017; English et al., 2018; McConnell et al., 2018; Perry & LeBlanc, 2021; Shangani et al., 2020). The growing body of quantitative evidence has yielded valuable insights into the minority stress process among multiply marginalized groups. The research has shown that this type of stress is cumulative, intersectional, specific to SGM’s stigmatized status, and related to other stressors such as violence, harassment, and sexual assault. Amid this progress lies a paucity of research on health disparities among SGM Latinas, particularly Latina women who have Sex with Women and Men (WSWM) (Cepeda et al., 2020). Significantly less is known about Latina WSWM who are positioned at the intersection of multiple marginalized identities, which relegates them to a hidden social status as “marginal members within marginalized groups” (Purdie-Vaughns & Eibach, 2008, p. 5).
Bisexual-identified women and WSWM have substantially worse health than women who engage in exclusively lesbian and heterosexual behaviors (Graham et al., 2011). Studies have shown that in the United States, about 20% of women identify as sexual minority or report ever having a same-sex sexual relationship (Everett et al., 2017), and an increasing number of women aged 18–44 are identifying as bisexual (Copen et al., 2016). Moreover, there is a higher prevalence of substance use (e.g., tobacco, alcohol, marijuana) among women who identify as sexual minorities (Lehavot & Simoni, 2011). Despite the increasing number of Hispanic women in the U.S., with over half being of Mexican origin (Flores, 2017) combined with the booming research on SGM stress experience, there is a limited understanding of how intersection minority status affects this population’s marginal members. Left unaddressed, this dearth of evidence could hinder the development of effective interventions to mitigate stigma and reduce health risks among multiply marginalized groups, particularly WSWM living in socioeconomically disadvantaged communities.
We conducted an exploratory qualitative study in this area by employing a flexible approach to the diary interview method (DIM) (Bartlett, 2012; Herron et al., 2018). This method was complemented by the minority stress theory (Meyer, 1995; 2003; 2015). To our knowledge, this is the first study to investigate the subjective experience of minority stress among Latina WSWM who are situated at the intersection of sexuality, race/ethnicity, and socioeconomic marginality. The study also contributes to the wave of research adapting diary methods for online use during the COVID-19 pandemic (Mueller et al., 2023; Rudrum et al., 2022).
This article provides valuable methodological insights into the research process, including the study’s design adapted to meet social distancing requirements, the recruitment strategy employed, and the data collection method used. It outlines the research team’s steps to manage the project remotely with restricted face-to-face interactions.
Study Context
Qualitative research on the lived experiences of vulnerable populations such as sexual minorities requires sensitive approaches that promote the agency and involvement of participants (Fenge et al., 2019; Greenhill & Sergeant, 2013). Sensitive approaches to qualitative research entail designing and implementing a study with consideration, respect, and awareness of the participant’s ways of generating meaning (Cepeda & Valdez, 2010; Couture et al., 2012; Hyers, 2018; Meth, 2003). This includes reflecting on and valuing the cultural values, beliefs, and practices that shape participants’ worldviews. Due to their flexibility, Diary methods are well-suited to meet these criteria (Alaszewski, 2006; Bartlett, 2012; Hyers, 2018; Meth, 2003).
Although solicited diaries are less commonly used compared to other conventional methods (Alaszewski, 2006; Filep et al., 2018), they are highly applicable across the health and social sciences (Bartlett, 2012; Bartlett & Milligan, 2020; Filep et al., 2018; Herron et al., 2019; Kenten, 2010; Milligan & Bartlett, 2019; Thorne, 2011). Solicited diaries can be designed to be inclusive and equitable (Meth, 2003; Mueller et al., 2023); modified to address the needs of researchers and participants (Bartlett & Milligan, 2020); comply with social distancing guidelines during the pandemic (Mueller et al., 2023; Rudrum et al., 2022); and minimize researchers’ interference during data collection. They may also facilitate participant disclosure of sensitive information about health and sexuality (Bartlett & Milligan, 2020; Filep et al., 2018; Greenhill & Sergeant, 2013). The flexible solicited DIM (Herron et al., 2019) is a dynamic diary method that allowed us to explore the perspectives of a marginalized group. This approach gave participants control over what story they shared with us and how they recorded their diaries, which provided rich and nuanced information.
The sample of our exploratory study is derived from a 20-year longitudinal cohort of Mexican American women (Cepeda & Valdez, 2010; Cepeda et al., 2020) who reported having had sex with both women and men. This cohort represents a subset of participants from the San Antonio Latina Trajectory Outcomes Study (Proyecto SALTO). Proyecto SALTO is a community-based study investigating the long-term health outcomes of drug use and intimate partner violence among Mexican American women in San Antonio, Texas. The city of San Antonio is among the top 10 cities in the U.S. with the highest spatial inequality level between postal codes, and a significant portion of the local population lives in the most socioeconomically disadvantaged areas (Distressed communities Index, 2022). San Antonio’s population is estimated at more than 1 million people, of which more than 50% are of Mexican descent (U.S. Census Bureau, 2016).
To be eligible for Proyecto SALTO, participants had to be female, of Mexican descent, aged 14–18 (during 1999–2001), and associated with one of 27 male street gangs from the catchment area (Cepeda & Valdez, 2010). The quantitative analysis of a follow-up study (Cepeda et al., 2020) revealed that 30% of the Proyecto SALTO cohort reported engaging in sex with both women and men. WSWM experience lengthier and more frequent incarcerations, more stressful life events, higher rates of injection drug use with related Hepatitis C Virus infection, as well as more significant symptomatology associated with depression, PTSD, and suicidal ideation when compared to women who have sex with men only. Due to the scarcity of literature to contextualize these findings and the sensitive nature of the topic of sexuality (Sergeant & Greenhill, 2013), we piloted a qualitative study to gain a preliminary understanding of the experiences of stress among WSWM from the longitudinal study.
Guided by the minority stress theory, our solicited diary interview study aimed to uncover underlying experiences, perceptions, values, and norms related to sexual identity and behavior (Pathela et al., 2006) that shape the meanings these women with marginalized identities interpret and act upon (Zvonkovic et al., 1996). Minority stress theory posits that stigmatized minority statuses, such as those at the intersection of multiple marginalized identities, are associated with disproportionate exposure to discrimination and stressful life events (Meyer, 1995; 2003; 2015).
By leveraging the adaptability of the diary method and the intersectionality-focus of the theoretical framework, our study provided a flexible way for our participants to retrospectively describe and explore experiences with disadvantaged statuses and devalued identities, including sexual orientation and behavior, ethnicity, gender, and/or stigmatized behavior-related statuses. Our objective was to understand how these experiences mutually constitute stressful life events such as violent victimization and incarceration, distal minority stressors such as overt external discrimination, and high-risk substance use behaviors such as binge drinking, polydrug use, injecting drug use, and overdose over the life course. Our study also explored how participants manage stressors, find social support, and develop coping strategies.
Redesign Process
Initially, we planned to conduct in-person fieldwork in San Antonio using a life history method. However, due to the pandemic’s impacts on human subject research (Varma et al., 2021; Watson & Lupton, 2022; Zinn, 2021) and a public health emergency declaration in our field setting (Bexar County, n.d.; (Surveillance). we worked remotely and adapted our study to an online format using a flexible Diary Interview Method (DIM). This approach has proven fruitful, as demonstrated in other successful remote diary studies (Mueller et al., 2023; Rudrum et al., 2022).
The research team comprised eight members, including all listed authors, who brought expertise in medical sociology, public health, and social work. Within the team, five members identified as Latina, and two were San Antonio natives in the same age range as the diarists. Four members had established rapport with the participants through their involvement in the longitudinal parent study. Our team was divided into groups to optimize our workflow, each focusing on specific stages of the research process: research design, implementation, and data analysis. Through bi-weekly Zoom™ meetings, the groups coordinated strategies, addressed challenges, and stayed abreast of changes that occurred. During these meetings, we actively embraced reflexivity (Filep et al., 2018; Herron et al., 2019; Hyers, 2018) to cultivate cultural sensitivity throughout the research process. We discussed our research experiences, preconceptions, and interpretations of the study materials and data. This dynamic helped us manage the remote study more conscientiously, leading to a multifaceted view of participants’ needs and stories.
The research design group began the project by conducting a literature review of diary-based articles on health, mental health, sexuality, gender, substance use, and diary methods. They created a literature review matrix using a cloud-based document with article citation, topic, diary-design type, sample size, theory, data collection type(s), study duration, honorarium, frequency, analysis type, and reviewer notes. This review process resulted in the assessment of 28 articles. After evaluation, the group unanimously selected the flexible solicited diary interview as the most appropriate method for the study. The revised research plan aimed to recruit 15–20 individuals who would maintain a diary for a duration of 6 weeks, followed by an exit interview. The exit interviews served as the final step to complement and solidify the stories gathered from the diaries, providing an opportunity for further exploration and clarification of participants’ experiences.
Ethical Considerations
The DIM study obtained approval from the Institutional Review Boards of the University of Miami and the University of Southern California. From March to September 2021, the field research group oversaw participant recruitment, interviews, and direct communication. The data collection group managed the submitted diary entries.
Throughout the study, the team prioritized participants’ emotional well-being, recognizing the potential for diary prompts to evoke strong emotions (Bartlett, 2012). We remained attentive to their needs and implemented clear guidelines and protocols for data collection, storage, and dissemination.
Diary Interview Method (DIM) Design
Our exploratory study incorporated recent technological trends in diary-based research (Bartlett & Milligan, 2020; Hyers, 2018) and employed a flexible approach to the DIM (Bartlett, 2012; Herron et al., 2019). The study consisted of an onboarding interview, followed by a 6-week diary-keeping period, which concluded with a semi-structured in-depth interview based on the diary entries. Participants chose the device (e.g., their personal computer, tablet, phone, or postal mail) and medium (e.g., typed, handwritten text, sketches, images from the Internet, or audio recordings) to record their weekly diary entries. This experimental diary design prioritized participant voices (Meth, 2003) for greater flexibility and control in recounting experiences.
To collect entries online, we developed a custom-made website called SALTO Diary Study on the WordPress platform (Figure 1 below). The website featured individual portals and digital platforms for study materials (e.g., prompts for weekly diary entries and instructions on the diarizing process). After beta testing the online diary system, we commenced recruitment for the study. SALTO Diary Study Website Homepage. Note. This figure displays the homepage of the website showcasing the nested participants’ portals.
Participants Recruitment
Twenty-one participants were recruited through purposive sampling from the Proyecto SALTO cohort (see Study Context). Since Proyecto SALTO participants had previously consented to be relocated for future follow-up studies, the field research group contacted 69 eligible participants using locator information and successfully reached 24 eligible respondents.
In addition to participant recruitment, field researchers conducted onboarding and exit interviews through phone or Zoom™. To keep participant confidentiality, they maintained direct communication with participants and took steps to anonymize background information and message exchanges. This way, sensitive information was redacted before being shared with the rest of the research team. Each participant was assigned a pseudonym, and their diaries were identified using randomly generated ID numbers.
The onboarding process lasted around 20 minutes on average. During these interviews, field researchers obtained verbal informed consent from participants and reiterated the study’s objectives and expectations. Participants were then given a unique username and password to access their personalized diary portals on the study website. Next, they were instructed to complete at least one weekly diary entry using these portals. Finally, they received an instructional video (Proyecto SALTO, 2021) that guided them on browsing the website effectively.
Field researchers recognized the significance of their positionality within the research process (Fenge et al., 2019; Filep et al., 2018; Holmes, 2020) and played a vital role beyond recruiting participants. For example, they provided valuable feedback on incorporating evocative artwork and colors on the website and portals, referencing local landmarks, and integrating regional dialects into diary prompts. These efforts ensured that the research materials resonated with the participants and aligned with Alaszewski’s (2006) recommendations for user-friendly diaries.
Participants Profile
The participants in this study are a group of Mexican American women aged between 30 and 43, all of whom resided in the underserved Westside of San Antonio (Distressed Communities Index, 2016). Most participants have at least one child (20, 96%) and an average education level of 11th grade (U.S. students are typically between 16 and 17 years old at that level). Just under half (9, 43%) of the participants reported yearly earnings below $23,850 - the poverty threshold for a family of four in San Antonio during the study’s timeframe. Under half of the participants (9, 43%) reported being currently employed during the interview, and 61.5% reported a history of eviction. A quarter of the participants (5, 24%) reported receiving benefits (veteran, disability, or social security), and nearly three-quarters (15, 71.4%) reported receiving public assistance (food stamps, welfare, WIC, etc.). The vast majority (18, 86%) reported being incarcerated at least five times on average in their lifetime, with half of the women incarcerated having been convicted of a felony at the mean age of 20.89 years. Finally, 76.2% (n = 16) of the sample reported having experienced intimate partner violence in a relationship, with an average time of 8.9 years in violent relationships.
Out of the 21 individuals initially enrolled in the study, 57% (n = 12) dropped out at different stages of the diarizing process due to challenges exacerbated during the pandemic. Reasons for withdrawing from the study included increased domestic responsibilities, workload, illness, childbirth, and housing instability. Two participants were living in emergency housing at the time of enrollment. One completed the study, while the other had to withdraw due to unmitigable circumstances. Notably, the decision to stop diarizing was not attributed to any concerns regarding the study’s methodology.
A total of nine participants managed to complete both the diarizing period and the exit interview. While these nine diarists may have had more availability, social support, or self-efficacy to complete the study, it is important to acknowledge that all participants, including those who dropped out, faced significant time constraints related to the abovementioned difficulties. Therefore, to ensure equitable access to the study and accommodate the diverse needs of the participants, we adjusted the study design.
Data Collection
All diaries were recorded in English, the participants’ preferred language. Diarists received a $135 honorarium dispersed in three stages as they reached study-related milestones via IRB-approved payment methods (mailed and electronic). We also offered $10 for completing diary entries before the deadlines. At the study’s end, diarists were given a journal notebook as a token of appreciation for their time and contribution.
To maintain ongoing engagement and monitor participant safety, we implemented text message reminders and executed routine check-ins. Field researchers sent weekly reminders to participants via text message, which participants preferred as their primary communication method. The reminder script was as follows: “Hi [Username]! This is a reminder that your diary entry is due by [Date]. Let me know if you have any questions and remember that you can call me anytime at [university-issued cellphone number].” Participants responded well to the reminders and willingly shared information about their circumstances. For example, participant 1001 replied, “Yes sorry. We’ve had a family emergency, and I haven’t been able to complete it, but I will try to get to it sometimes this wk.” Participant 1010 – “I feel like I’m going to miss doing this weekly study, haha.”
Diarists were required to complete “Temperature Checks” before and after submitting their weekly diary entries. These checks (Figure 2 below) consisted of visual scales that participants used to indicate their emotional state for the day. The data collection group closely monitored these responses and promptly informed field researchers if any concerns arose to ensure that a follow-up was conducted during routine check-ins with the participants. For example, if a participant reported feeling “upset,” the field researchers would investigate. Participants also had access to an interactive map within their personalized portals. The map displayed health and social service resources available in the San Antonio area, categorized by the types of services offered, such as counseling or food procurement. Field researchers assisted some participants in utilizing these resources. Temperature Check Survey. Note. This figure displays the visual analog scale used in Qualtrics to measure participants’ emotional states. The data associated with the study are available upon request.
Online Diary Structure
Each participant’s diary portal began with a personalized homepage displaying their chosen pseudonym at the top. The homepage featured a menu bar with three tabs: 1) the website’s main page (as depicted in Figure 1), 2) a diary dashboard, and 3) a logout button. The dashboard contained essential pages, such as a Glossary, Check-In, Weekly Prompts, Submit Diary Entry and Community Resources. Beneath the menu bar, the SALTO Diary Study logo was prominently showcased. Inspired by Herron et al. (2019) diary design, we added, “Welcome! Write, draw, take pictures, and talk about what is important to you.” The contact information of the primary field researcher, information about the team’s availability, and a diary completion tracker were also conspicuous on the introductory page (Figure 3). Diary Portal Homepage. Note. This figure shows the top section of a diary portal’s homepage on the website.
The Portals’ Glossary page contained a list of keywords and their definitions. Next, a Check-In page featured the first “Temperature Check” survey to complete before starting a diary entry. The Prompt page contained the theme of the week and corresponding reflection questions. Themes included (general and identity-related) stress, sexuality, sexual behavior, and interpersonal violence (both event and structure based). For example, Week 1’s theme was “Stress & Social Support.” We included the following open-ended reflection questions, “Think about times when you were feeling more stressed than usual. Do you have someone in your life that you go to for support when you are feeling stressed? How do they support you? Are there things that you do or places you go to that help relieve stress? If you would like, include a photo showing what social support and stress management look like. This could be a photo you take, a drawing you make, or an existing image from the Internet.” The prompts were structured to give diarists some leeway, allowing them to choose the events and timeframe to explore as long as they were thematically relevant. In naturalistic research, solicited diaries with prompts can present a challenge as it may hinder participants’ private writing and free expression, particularly when researchers are interested in specific aspects of their lives (Alaszewski, 2006). To address this, we adopted Meth’s (2003) approach and invited diarists to share what they considered relevant regarding specific themes mentioned in the prompts.
After participants submitted a diary entry through the Submit Diary Entry page on the portal, they received a message expressing gratitude with the statement, “Thanks for this great entry!” along with a second “Temperature Check” survey, as detailed in the ‘Data Collection’ section.
Below is a simplified timeline (Figure 4) illustrating the implementation process of the study, highlighting the routine activities of both the research team (labeled RT) and participants (labeled P). The onboarding and exit interviews were conducted in weeks 1 and 8. Weeks 2–7 outline the schedule for specific components of the diarizing process, such as accessing diary prompts and submitting entries, as well as the research team’s weekly tasks, including wellness check-ins, data collection, and honorarium disbursement. Throughout the 6 weeks, a diary prompt was released every Friday, and participants submitted their responses by the following Wednesday. SALTO diary study Flowchart.
Diary Submission
Most participants submitted their diary entries using their smartphones, while others utilized shared or public computers. A few participants switched between different devices. Although the study did not track participants’ device or website usage patterns, we inquired about device availability and accessibility during recruitment. Data and portal access were safeguarded through security measures such as automatic logout after 1 minute of inactivity. Moreover, the website was deactivated upon the completion of all exit interviews.
Diarists were encouraged to submit entries in different formats such as audio recording, typing directly into the portal, uploading pictures of handwritten entries, or mailing entries using self-addressed stamped envelopes.
At the end of the 8-week diary collection period, we received 74 diary entries in different formats, including typed and handwritten texts, drawings, photographs, and voice recordings. Fifty-one entries were typed directly into the diary portals, supplemented with pictures. Seventeen entries were handwritten, with 11 uploaded as photographs, and the remaining six were scanned copies of entries mailed to us. At times, handwritten entries contained sketches in the margins of the pages. For example, Participant 1018 (34, mother of two children) drew a doodle at the bottom margin of her paper-based entry (Figure 5) when reflecting on sexuality. The doodle depicts a motel, which represents the only space where she feels safe and ashamed to explore her sexuality, as it would be perceived as deviant in her close social circle. Finally, we received one audio recording in the form of a two-minute rap song. Handwritten Entry. Note. After reflecting on sexuality, the participant found it more appropriate to handwrite her reflection. She then took a picture of her handwritten entry and submitted it online.
Typed entries ranged from 150 to 2000 words (default Times New Roman 11 font size), while handwritten entries were typically two to three single-sided pages of letter-sized paper (8.5″ x 11″ or 21.59 cm × 27.94 cm). For instance, Participant 1012 (29, mother of three children) mailed a two-page handwritten entry recounting her incarceration soon after finding out that she was pregnant with her third child.
During her third pregnancy, Participant 1012 decided to turn her life around, striving to “get [her] act together” and “stay out of trouble.” However, her path took an unexpected turn when she waited for the unreliable city bus, her only means of transportation that traverses a heavily patrolled neighborhood. On that fateful day, a patrolling officer noticed her presence on the street corner. Participant 1012 perceived that her nervousness at the time may have influenced the officer’s actions, leading to a series of events. The officer questioned her, conducted a background check, and eventually arrested her on suspicion of prostitution. In her entry, she shared the stress she experiences as a person with a history of incarceration and vividly described the incident’s impact on her life. By combining these entries, a picture emerges of how her identities intersect, including being a single mother, a Latina woman who has WSWM with a history of involvement with the criminal justice system, and a resident of a marginalized neighborhood. She delved into the intricate complexities of juggling these intersecting identities within different social spheres, such as her family and the streets. The diary was a private space for her to explore these personal experiences, interpret their meanings, and shape her narrative before her interview.
Most diary entries contained rich information from the start of the diary-keeping process, which may be attributed to the nature of the method described as a “form of social activity” (Alaszewski, 2006, p. 20). Each diarist submitted one entry per week, with minimal style variations observed across entries, regardless of the chosen format. Typed and handwritten entries engaged with the diary prompts, recounting events, emotions, behaviors, and perspectives diachronically. This level of engagement enabled us to discover how interpretations of events changed at different stages of the lifespan. Like other participants, Participant 1003 (age 30, mother of five children) described her experience with mental health challenges during her adult life. Throughout her adult life, she identified her husband and best friend as her primary source of social support. In one entry, she also reflected on her health behavior. She explicitly identified the frequent consumption of alcohol as a mechanism to cope with chronic stress. She wrote, “What I usually turn to when I am stressed is alcohol and dancing…One day I hope to be able to get stronger and manage stress in healthier ways.”
Exit Interviews
Diarists were invited to schedule a 45-minute, in-depth, semi-structured one-to-one exit interview via phone or Zoom ™. Nine participants completed this interview, most lasting more than 50 minutes, and three interviews over an hour. All interviews were recorded, transcribed verbatim, and anonymized.
The exit interviews served as a valuable tool for elucidating details within the diary entries, validating researchers’ initial interpretations of participants’ narratives, and collecting feedback on participants’ overall experiences in the study. The data collectors synthesized essential elements from the diary entries and shared meaningful insights during bi-weekly team meetings. These summaries shaped the interview guide used for each exit interview.
During the exit interviews, all participants were asked a common question about their overall study experience: “Overall, what do you think of the study?” The interviewer would then explore specific topics such as the research format, the use of technology, participants’ interests, challenges they faced, and any suggestions for improvement. After discussing these general aspects, the inquiries about participants’ diary content would vary, focusing on the reflections documented in diaries. For instance, one participant reflected on her “hard upbringing” and a history of violence within her family, where a now-deceased stepfather abused her. During her exit interview, the participant provided additional insights into the impact of domestic violence on her childhood and adolescence. This clarification shed light on scattered references in her digital diary entries about her stepfather’s ominous presence. Below is an excerpt of that interview transcript:
This participant openly shared experiences of discrimination, financial insecurity, substance abuse, and lack of family support due to bisexuality. Her diary entries mainly consisted of typed text and pictures. The field researcher discussed a specific image she shared (Figure 6), showing a puppet controlled by strings. The participant’s response was enlightening, revealing the multiple layers of meaning she attributed to the image and establishing connections between tentative categories in her entries that initially appeared unrelated, challenging our initial interpretations. This participant highlighted a significant connection between the violence she experienced, her identity as a Mexican American WSWM, and the impact of others’ perceptions in her daily life. Image in A Diary Entry. Note. The image of the controlled puppet was added to an entry on April 21, 2021. It was sourced from the internet, and its creator is unknown. However, the image has been used in multiple projects accessible to the public and can be traced back to an online blog dating back to 2005 (Bostian, 2005).
The combination of diaries and interviews provided a more profound look into participants’ experiences that may not have been evident during the preliminary analysis. This example points to the value of DIM as a tool for engagement, particularly for individuals who require time and space to express themselves and whose stories may not be easily deciphered.
Data Management and Analysis
Participants who kept a diary online submitted entries through a Qualtrics survey embedded in their diary portal’s Submit Diary Entry page. The entries were automatically uploaded to a Qualtrics panel, downloaded by data collectors weekly, and securely stored on Box, a cloud-based file storage service, rather than the website.
To analyze the diary entries of each participant, the data collection group used NVivo and followed a general inductive approach proposed by Thomas (2006). The approach allowed data collectors to present a preliminary view of the raw data to the team and adapt the exit interview guides. Data collectors identified relevant categories within and across diary entries aligned with the weekly themes and reflection questions (refer to ‘Online Diary Structure’), forming initial themes. These interpretations were validated through exit interviews.
Upon completing the data collection phase, the data analysis group conducted an in-depth thematic analysis of participants' diaries by grouping textual, audio, and visual segments using basic query techniques (Braun & Clarke, 2006). The resulting findings will be discussed in future publications.
Insights Gained
All 21 participants initially enrolled in the study expressed enthusiasm and curiosity regarding the diary study. Of the initial enrollees, 14 completed at least one diary entry and voluntarily provided feedback via text messages without prompting. After analyzing the feedback received through texts, exit interviews, and field researchers’ notes, we categorized our insights into three areas: 1) the dynamics of the research-participant relationship, 2) the perspectives and experiences of the participants, and 3) the adjustments made to the study design.
During the study, participants attempted to establish a virtual connection with the field researchers, similar to Rudrum et al. (2022). For example, one participant (1008) texted, “Don’t know if ur a mother but happy Mother’s Day,” while another (1010) asked, “Help! Lol is there any way you can check [study-related matter] for me?” One advantage we had was the lead field researcher’s prior involvement in the parent study. This existing relationship was crucial in establishing trust and rapport with the participants, creating an open remote research environment. The team’s commitment to cultural sensitivity and reflexivity throughout our study strengthened the mutual respect between participants and field researchers. We obtained participants’ ongoing consent and reminded them of their option to withdraw from the study at any point. This connection fostered consistent participant engagement and improved the data quality. An example of this connection is evident in the fact that some diarists began completing their entries before the deadlines and promptly notified field researchers of their progress, even before early submission incentives were implemented as a retention strategy. This proactivity reflects their investment in the project. For example, a participant (1021) texted, “Hi good morning! I finished the first part… whenever u get this message just lmk what to do next thanks (winky face emoji).”
Taking notes on participant interactions and heeding their suggestions proved instrumental in facilitating equitable participation. An example of the positive impact of this practice was the inclusion of a mail-in option based on a participant’s preference for handwriting. This participant, who had prior experience with journaling, inquired about the possibility of submitting handwritten reflections after submitting her first entry online. Recognizing the value of accommodating this preference and promoting participant inclusion, we introduced the option for all participants to photograph or mail in paper-based entries. We provided necessary materials such as self-addressed stamped envelopes (S.A.S.E) and paper to enable this process. Participant 1012 encountered an internet connectivity issue due to reaching her monthly data limit. She texted a field researcher, explaining: “My internet doesn’t work because I used up it [data] for the month, so I won’t be able to finish it [entry] up.” Since we had already implemented the diary delivery adjustment early on, she wrote her reflections on paper and mailed the pages without any delays. Once her data plan was replenished, she chose to resume online submissions. Two other participants also adopted a similar approach at different stages of the study, opting for mailed entries when they found it necessary.
The adjustments made to the submission options effectively tackled obstacles to active participation and engagement. However, we acknowledge that the effects of specific structural challenges persisted throughout the study. Diarists were impacted by experiences of loss and grief, unemployment, housing instability, increased responsibilities for childrearing (mainly due to the shift to virtual learning in local schools), increased caregiving responsibilities, burnout, and concerns about virus exposure. Supporting participants remotely during this period presented a delicate endeavor, as in-person check-ins could have provided a more personal touch and positively impacted retention rates. Amidst these extraordinary circumstances, it is important to disclose that several diarists, including those who eventually withdrew, proposed video recording as a more convenient medium. Unfortunately, we could not fulfill this specific request due to the measures in place to ensure anonymity and confidentiality. This demand for video diaries underscores their potential as valuable avenues for future diary research (Watson & Lupton, 2022), especially if researchers and participants have continuous access to the appropriate types of equipment and a stable internet connection with sufficient bandwidth.
Despite the constraints on accepting video submissions, we remained responsive to submission preferences by using the available options as prescribed by the method (Herron et al., 2019). For instance, one participant, who had a passion for music, shared her story by creating a rap song as an entry. We made a technical adjustment by increasing the maximum file upload size, thereby enabling the submission of larger digital files within entries. Based on the feedback we received, participants who completed online diaries responded positively to this added feature and reported no instances of encountering error messages when using it.
During exit interviews, nine diarists elaborated their perspectives on keeping a diary. They reported enjoying their autonomy to choose the fragments of their lives that they found meaningful. They conveyed satisfaction with the ability to share these pieces in a way that felt authentic to their individual experiences, thoughts, and emotions. For example, Participant 1007 (age 31, mother of seven children) commented that the study encouraged her to reflect on her life and take stock of her trajectory.
The other eight participants shared similar sentiments about the study, finding the process of keeping a diary cathartic and enjoyable. They found solace in the routine of private self-reflection amidst the vicissitudes of the pandemic. We noticed that participants preferred to use pictures and sketches to describe trauma and the self, especially when exploring different social identities. The diary format provided an intimate space for participants to disentangle their everyday experiences with stress and explore the complex interplay of factors that shaped their responses. Unlike other methods, such as stand-alone interviews, the diary entries allowed participants to express themselves freely, capturing subtle nuances that may not be apparent to an observer or spontaneously articulated in an interview.
Even though some prompts were deemed delicate (e.g., queries about sexuality), participants reported pondering the questions posed. Through keeping a diary, they revisited moments they may have forgotten and explored them afresh. During this practice, many participants recognized the fluidity of their social identities and the cumulative impacts of different social forces (e.g., institutional discrimination) on their daily lives. For example, participant 1010 (age 32, mother of three children, married to female partner) explained: It was weird, like the questions about sexuality and so forth. I was like, okay! (giggles) Other than that, I think it kind of also helped me vent, you know? I don’t keep an everyday diary. So, talking about those things was pretty cool. I mean, it makes you kinda like stop and realize… oh my God! This was meee…Have you ever experienced when you talk about your past experiences, and you’re like…okay! [Have an epiphany].
For Participant 1015 (age 33, mother of two children), the reflection questions allowed her to ruminate on her experience as a Latina WSWM living in San Antonio. She shared:
All participants welcomed the opportunity to explore facets of their lives that they seldom divulge. For example, participant 1210 (age 35, mother of two children, recently released from the county jail for possession of methamphetamine) perceived this study as a platform to share stories that may resonate with other people who, like herself many years ago, might be silently enduring harrowing experiences alone. This understanding became her motivation for completing the study while facing uncertainty and being unhoused during her recruitment:
Participants who completed diary entries online found the digital diary portals and study materials accessible and convenient. They appreciated the option to use their own devices without downloading an app and the ability to mail in their entries if necessary. They responded positively to the website’s design and personalization of their portals, which elicited a sense of ownership of the digital diary. When they needed technical support, they contacted field researchers and appreciated the team’s timely response to their inquiries. Below is a transcribed text exchange for illustration:
[field researcher troubleshoots the issue in concert with a member of the data collection group]
Participants also faced challenges keeping an online diary, with more than half requiring additional time to familiarize themselves with the website layout and submit their entries. That is why an instructional guide was created (see Participant Recruitment). The video was well-received, and by the end of the second week, all participants who kept online diaries navigated the website independently and smoothly delivered their entries. There were a few instances where participants misunderstood or misinterpreted the diary prompts, resulting in the submission of short or off-topic entries at the beginning of the diarizing period. The data collection group altered the field researchers, who provided personalized support to address the problem. Communication between field researchers and data collectors facilitated the early identification of technological and comprehension issues, allowing for the timely implementation of research interventions.
Lastly, maintaining confidentiality throughout the study was paramount, given the research’s remote nature and the participants’ unpredictable living environments. While some participants kept a diary or were interviewed alone, others participated in research activities in the presence of family members, including children or romantic partners. Regardless of the circumstances, field researchers confirmed that participants were comfortable before commencing the interviews. Before that, they reiterated the significance of safeguarding their entries and advised against sharing their login information with anyone else.
The virtual team cultivated a collaborative environment, actively supporting each group toward the shared goal of protecting research participants. Through this effort, we completed the study, receiving positive feedback from participants who described the diarizing process as “fun,” “enjoyable,” “rewarding,” and “different in a good way.” After the study, one participant planned to introduce journaling to her teenage daughter and even requested an additional journal notebook (see Data Collection) specifically for that purpose.
Conclusion
We described the process of designing and implementing a pilot study on the experiences of minority stress among Latina WSWM at the intersection of sexuality, race/ethnicity, and socioeconomic marginality. Our research stands out in three ways. Firstly, we focused on the stress-related experiences of members of an understudied SGM group residing in an economically disadvantaged community. Secondly, we leveraged the circumstances of stay-at-home orders and social distancing to innovate our research approach, using a combination of online and paper-based solicited diaries through a dedicated website and mail. Last, we carefully crafted our research to empower participants to express themselves creatively.
The design of our study highlights the importance of upholding ethical standards, maintaining flexibility, ensuring methodological rigor, and practicing reflexivity to investigate issues that impact the health of SGM individuals (Cepeda et al., 2020; Cepeda & Valdez, 2010). A flexible solicited DIM facilitated the gathering of information on participants’ intersectional experiences while shedding light on sensitive subjects such as drug use, intimate partner violence, stigma, discrimination, gender identity, sexuality, self-esteem, social support, and stress within minority communities. Our approach not only enhanced our understanding of our participants’ experiences with minority stress but also facilitated the promotion of equity and sensitivity throughout the research process. As a result, we successfully created a research space that amplified participants’ voices.
This article illustrated the potential benefits of employing a flexible solicited DIM, an approach that holds relevance for future health research with multiply marginalized populations. The method shows promise as an effective tool for exploring sensitive topics and conducting research remotely, especially in situations where there are movement constraints or limited access to research sites, extending beyond the scope of a pandemic. The insights gained from both participants and researchers contribute to the growing methodological literature on solicited diary research, offering new design strategies, logistical considerations, and assessment alternatives for participant-centered diary research.
Footnotes
Acknowledgments
We would like to thank our research assistants, Suraya Buffong and Adriana Trevino, for their contributions to this study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute on Minority Health and Health Disparities (NIMHD)-funded Center for Latino Health Research Opportunities (CLaRO) under U54MD002266 and the National Institute on Drug Abuse under R01DA03926. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
