Transcript Adapting a proven intervention for African American MSM: The Mpowerment Project Susan M.

Adapting a proven intervention for
African American MSM: The
Mpowerment Project
Susan M. Kegeles, Ph.D.
Gregory Rebchook, Ph.D.
David Sweeney
Center for AIDS Prevention Studies
University of California, San Francisco
The Mpowerment Project is an
Evidence-based Program
• MP was tested through 2
scientifically designed
randomized-controlled trials
• Developed after careful work in
many communities
• Currently being implemented
by many CBOs throughout the
U.S. and internationally
• Listed in CDC’s Compendium
MP Research in the Community
• MP was tested and found effective through
RCTs in several communities
– We first implemented MP in 3 West Coast
communities
– Later implemented in 2 larger, Southwestern cities
– Ran the program ourselves
• Hired & supervised staff
• Worked in the community
– Negotiated with local CBOs and state HDs to keep
the projects going after the research ended
– Periodic consultation with CBOs after research
ended
• Currently being implemented by many
CBOs throughout the U.S. and
internationally—including our 3 most
recent research sites
Who is the Mpowerment Project for?
• Tested on young gay/bisexual
men ages 18 - 30
• Men were mostly “out” -- at
least to themselves
• Doesn’t directly reach MSM
who don’t self-identify
• Hasn’t been tested for:
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Youth
Homeless
Runaways
People with other major
psychosocial problems (e.g., major
mental illness, serious substance
use problems)
Guiding Principles: Social Focus
• Need to be able to reach
young MSM, many of
whom are not interested
in HIV/AIDS
• Address young gay/bi
men’s social needs
• Link HIV prevention to
the fulfillment of these
and other unmet needs
• Infuse HIV prevention
into all social activities
Empowerment
• Behavior change is most
lasting when we’re actively
involved in creating and
implementing solutions to
our own problems
• Young men are the
decision makers of the
Project
• It is their own Project
Peer influence
• Peer-influence is very
powerful
• The Mpowerment Project
mobilizes peers to act as
agents of change within
their social networks
Diffusion of Innovations
• Young MSM talk with and
encourage their friends to
be safe
• They spread this message
throughout the community
• A norm of safer sex is
established and reinforced
Multi-level
• Young men engage in high risk sex for a variety of reasons
 individual factors (e.g., perception that safer sex is dull)
 interpersonal factors (e.g. unable to negotiate safer sex w/partner)
 social factors (e.g., lack of support for safer sex)
 environmental factors (e.g., “risky” venues, no targeted programs for
young gay/bi men)
• The Mpowerment Project operates at all these levels and
addresses multiple predictors of risk
Sex Positive & Affirming of All
Sexual Orientations
• Enrich and strengthen young
men’s sexual identity and
pride about their sexual
orientation
• Eroticize safer sex--not just
focused on condoms
• Images reflect diversity of the
community
Community-Building
• Create healthy community
• Promote supportive friendship networks
• Disseminate a norm of safer sex throughout the community
Mpowerment Project Core
Elements
Operating Structure
• Core Group
• Volunteers
• Coordinators
• CAB
Program Components
• Formal Outreach
• Informal Outreach
• M-Groups
• Project Space
• Publicity Campaign
MP is Designed to be Adapted by
Different Communities
• Core Groups are empowered to plan activities
that match the needs of their communities
• CAPS provides TA in a way that helps CBOs
adapt the intervention for their community’s:
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Culture
Target population
Organizational issues
Funding
• We’ll explore examples of translation of each core
element
Core Group (CG)
• 12 - 15 YGM
• Represent the community
• Include leaders, YGM
who are well-known,
respected and liked
• Meetings are fun/social
• Weekly meetings best
• Have ground rules &
committees
• Decision-makers of the
Project
• Constant reflection process
• CG is the key to the
empowerment process
Coordinators
• Coordinate activities
• Start the diffusion process
• Facilitate the empowerment of
YGM
• Responsibilities include:
 Conduct community assessment
 Recruit for and facilitate M-groups
 Conduct Formal Outreach
 Encourage Informal Outreach
 Run Project Space & Publicity
• Behavioral objectives help
coordinators function effectively
Project Volunteers
• Heart of project
 diffuse safer sex messages to
peers
 a small staff can only run the
Project with many volunteers
 integrated into every aspect
of Project operation
 reflect the community’s
diversity
 all levels of involvement are
valued and important
 Volunteers have authority,
leadership, and responsibility
for the Project
Community Advisory Board
• Opportunity for “elders” to
get involved to support the
Project
• Men and women who
represent AIDS, lesbian/ gay,
public health, business (e.g.,
gay bars), and university
communities. . .
• Link the Project to their
respective organizations
• Offer support and guidance
only--must trust YGM to run
the Project
Mpowerment Outreach Model
• Formal Outreach
 Outreach Events (Large, Medium,
Small)
 Outreach Team
• 10 - 15 out-going volunteers
• others involved in team but don’t actually
do OR
• Promotes safer sex at large events and
other community venues
• Outreach Team Performances
• Informal Outreach
 Taught and encouraged in M-groups
 1 to 1 Conversations
Formal Outreach Events
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Allow YGM to meet each other
Have fun
Build community
Promote Safer Sex
Attract YGM into other Project
activities
• Reach higher-risk YGM
• Appeal to a variety of men with
large, medium, and smaller events
Large Events
• >75 YGM
• Extensive publicity
– Event promotion
– Advertising (Print, Internet)
– Word of mouth
• Scheduling is critical
• Safer sex promotion
– Materials
– Interactive Activities
– Condom/lube distribution
• Attract YGM into other project
activities
Medium Size Events
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40 - 75 YGM
Less time to plan
Not labor intensive
Cheaper
Targeted publicity
Narrower target group
Examples: house parties,
art shows, community
forums
Smaller Events
• 10 - 30 YGM
• Little effort
• Minimal publicity (calendars,
free listings, e-mails,
invitations)
• Attracts small numbers of
homogenous YGM
• Volunteer coordinated
• Examples: video/movie nights,
television nights, book clubs,
discussion groups, games,
sports
Safer Sex Written Materials
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Visually appealing
Thematic
Pocket-size
Positive & Upbeat
Address factors that
contribute to unsafe sex (e.g.,
alcohol/drug use, eroticizing
safer sex, boyfriends, selfesteem, encourage alternatives
to anal sex, treatment
optimism)
Project Space
• Project Headquarters
• Serves as young men’s
community center
• Space for most events and
activities
• Young gay/bi men’s dropin center
• Resources and referrals
• Volunteers decorate and
maintain space
• Home-like, safe, gaypositive atmosphere
Publicity Goals
• To reach all parts of the
community—not just the social
networks that the Project has
involved at the time
• Contributes to the empowerment of
project volunteers by fully involving
them in publicizing the Project.
• Volunteers learn new skills and feel
ownership of the Project and its
events
• Involving volunteers like this is
sometimes more difficult than
Coordinators doing it all themselves
Publicity Plan
• The plan spells out how to saturate the
young MSM community with publicity
without broadcasting the Project to the
larger community
• Publicity plans include advertising in:
– Gay, alternative, and student newspapers
– Bars, coffee houses, cafes, gay student unions,
college campuses, music stores
– Testing clinics, gay doctors, etc.
• Newspaper articles can also be great
publicity
• Balance general project promotion,
advertising events and promoting safer
sex
Publicity Strategies
• Posters, handouts, pass along
cards
• Newspaper articles
• Free listings in papers
• Calendars
• Electronic media: Internet,
websites, e-mail, chatrooms
• Referrals: all relevant agencies
should know about project and
have materials
• Word of mouth, networking,
personal invitations to get
involved
Small Groups (“M-Groups”)
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Peer-led
8-10 young gay/bi men
1 time group
About 3 hours long
Promoted as a way of
meeting other young gay/bi
men, fun, discussion of
important issues (NOT a
“safer sex workshop”)
• Goal is to reach about 15%
of local young gay/bi men
via M-groups
Informal Outreach
• Taught and motivated in
M-groups
• Core Group revisits the
informal outreach topic
regularly
• All Mpowerment Project
participants are
encouraged to engage
their friends in informal
conversations about safer
sex
Appropriate HIV prevention
interventions for YBMSM
• YBMSM at highest risk for HIV in
CA & U.S.
• Only 1 intervention for Black MSM
men has been developed and
rigorously tested
• New community-level interventions
that address multiple issues through a
variety of channels and activities
needed
• Mpowerment Project has not reached
great numbers of YBMSM before;
needs to be translated to meet needs
New Translation Research
• In 2004 – 2005 we convened
two Boards of Cultural
Experts (BOCEs)
• Partnered with 3 AA CBOs –
one in Oakland and 2 in LA
in a UARP Translation
study.
• Worked through
implementation issues and
catalogued suggestions for
change in MP that we are
currently pursuing
Goals of Translation Project
1. Determine how to modify the
Mpowerment Project for
YBMSM, ages 18-29 (Phase I)
2. Implement the modified Project
(Phase II) for 12 months
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Evaluate success of the translation
process
Identify organizational, setting,
researcher, and population
characteristics that impede or
facilitate implementation
Formative Research to Modify MP
• Boards of Cultural Experts (BOCEs)
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N=21, older men, all “MSM”, identities varied (gay, SGL, het)
1 Board each in LA & Oakland area
10-11 members each
Knowledgeable and thoughtful about the target population
Received $500 for participation
One 2-day training and 8 Board meetings (4 in Oakland, 4 in LA)
• Focus Groups with YBMSM (18-29 year olds)
– N=34
– 6 groups of 8-10 men (4 in LA, 2 in Oakland, additional groups
will be held in Oakland)
– Participants received $50
• Analyzed themes that arose in various groups
Dual identity/Internalized Oppression
Privacy Concerns
Cultural appropriateness
of M-groups
Whole-man approach
Issues
that
emerged
HIV testing
Diverse sexual identities
Bisexuality
Lack of role models
More HIV+ men
Fatalism
Creating young black gay/SGL community
HIV is just one of
many issues
Violence
Class distinctions
Sexual abuse
Stigma
Other
key
issues
that
emerged
Treatment optimism
Racism in gay
community
Inter-generational sex
Drug use
Masculinity/Femininity
Church/religiosity
Black institutions and
expectations
Internalized Oppression
• YBMSM are an oppressed minority within a stigmatized
minority
– Many YBMSM internalize homophobic messages from the black
community and internalize racist messages from the larger society
– Negative consequences result in how regard & care for self & partners
• How to modify MP:
– Emphasize pride in being African American & pride in same sex
attractions
– Adapt existing small group component to focus on these issues and/or
develop new group
Emphasize Whole-man
• YBMSM do not want to be reduced to their sexual
activities, sexual desires
• Recognize that their identity includes family,
spirituality, community, history…
• They face difficult issues:
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Discrimination
Biased criminal justice and socioeconomic systems
Institutional and overt acts of racism
Fatalism, hopelessness, and loss of control
An unwelcoming and unsupportive “mainstream” gay
community
• How to modify MP:
– address multiple facets of becoming a fully functioning adult
man
• Wellness, exercise, connection to spirituality
• Job and life-skills training, resume writing, interviewing,
finances, banking, housing, literacy
Diverse Sexual Identities
• YBMSM have a variety of sexual identities
& many are reluctant to join a “gay” project
• Many YBMSM have sex with women
• However, many black MSM do have a
strong gay identity and are at risk for HIV
• How to modify MP:
– Keep project as welcoming as possible for gay/SGLidentified men and men who don’t self-label based
on their sexual activities
– Avoid the term gay
– Primarily design the project for men with some
sense of identity around their same-sex desire or
attraction
– Use more subtle language and be more ambiguous in
visual imagines and words than previous projects
– Modify publicity of project, activities, groups
Lack of Adult Male Role Models
• Many YBMSM have not had adult
men in their lives
• No vision about what an older
BMSM’s life is like
• BOCEs and focus groups raised
mentoring as an important issue
• How to modify MP:
– Change CAB - members as mentors
– Train mentors in work
– Create safe venues for mentors to
socialize with YBMSM
• Seminars, panel discussions and other forums
for YBMSM to learn from the mentors
HIV Testing & Treatment Issues
• High seroprevalence rates
• Increased emphasis on getting HIV+
men to know serostatus & obtain
treatment
• How to modify MP:
– Not focused on previously in MP
– Develop messages that YBMSM can use to
encourage each other to get tested & feel
okay about treatments
– Important to de-stigmatize HIV+ men (see
Arnold et al.)
– Enhance referrals to HIV testing sites
where YBMSM will feel welcome
Adapting Formal Outreach
• New types of Outreach
events
• Large events: Balls, hip
hop and R+B parties,
Poetry slams
• Diversity of outreach
events very important
• Not everyone wants to go
to balls!
Formal Outreach Events
• Medium Events: Choir,
community forums, discussion
groups on black issues
• Small Events: card games (bid
whist, spades), Bible Study
groups, book clubs or video or
movie nights focusing on
Black issues
• Job training / GED / Interview
skills or Resume Writing
• Life skills (balancing a
checkbook, or nutrition)
Outreach Team
• New strategies for events
and community venues
• Outreach team will go out
to promote Project,
Events, and Safer Sex
• There will be a
community identity –
something that makes
them stand out – but a
little bit more low key
than these guys!!
Adapting Informal Outreach
• Continues to serve as a
mechanism to reach men
who don’t frequent
traditional gay venues
• Serves to desensitize; a
foot-in-the-door for men
who may be initially
reluctant to participate in
the project
• Skill taught and
encouraged in M groups
Adapting Publicity Strategies
• Establish awareness of the
Mpowerment Project
• Demonstrate endorsement and
credibility by leaders and
organizations in the YBMSM
community
• Must be respectful of the
community boundaries so as
not to out anyone, or spread
their business
• But it has to get the word out
about the Project!
Addition of Guiding Principles
• Cutting back on the gay
positive aspect of Project
• Many men don’t identify as
gay – off putting
• But Black Positive, Black
Pride can be reinforced
through the Guiding
Principles
• Strengthen Men’s pride and
satisfaction with blackness
and the culture and history of
African Americans and other
black persons
Changing small group
component
• Issues in current M-groups are relevant &
important to YBMSM - but insufficient
• Address “whole-man”: empowerment,
internalized racism & homophobia
• Trust & rapport - concern about
“spreading my business”
• Change format of teaching (“pedagogy”)
– More culturally relevant & appropriate exercises
(eg, music, affirmations, spoken word)
– Create safety so sharing can be less superficial
– Increase variety to allow more role-playing with
different kind of sexual partners
• Expand beyond 1 session - yet balance
with how many sessions young men are
willing to attend
Church/Religiosity/Spirituality
• Frequently mentioned
• Mentioned by those who feel alienated
from the church and those who still
participate in it
• A need exists for YBMSM to discuss
how religion affects them
• How to modify MP:
– Help men identify options for spirituality &
faith
– Help men find peace with their spirituality
and sexuality
– Panels, discussion groups, etc.
– Possibly connect with an opening &
affirming church
Final Thoughts about our
translation research
• Oakland project was at a point where a GREAT deal could
have been learned about HIV prevention for YBMSM: how
to incorporate all we’ve learned into a program
• Program was up & running, CBO was committed to it, a
great deal of effort had been invested • But funding has ended: missed opportunity not to spend
additional resources for at least one more year
• Nonetheless: MUCH has been learned from this project including teaching researchers
• Researchers: grateful for opportunity to work with the CBOs
and Black community
When is a new efficacy study
required?
• When new core elements are
required, when existing core
elements are substantially
modified, & when intervention is
conducted in very different context
• Hope to do this in randomized,
controlled trial eventually
• First goal is to learn if the
modified Project is acceptable to
the new target population
A funding opportunity:
CDC-RFA-PS06-618
• HIV Prevention Projects for Young Men of Color Who Have Sex
with Men and Young Transgender Persons of Color
• Fund nonprofit organizations to conduct selected, standardized
HIV prevention programs for the above populations and to
complement HIV prevention activities and interventions
conducted by state and local health departments.
• To view the entire announcement and learn more about the CDC
application process, go to www.grants.gov and click on Find Grant
Opportunities then click on Search Grant Opportunities enter the
word "HIV Prevention" in the Key Search field.
Contact Information
• Center for AIDS Prevention Studies
50 Beale Street, Suite 1300
San Francisco, CA 94105
Fax: 415-597-9213
mpowerment.org
• Ben Zovod: 415-597-9306, [email protected]
• David Sweeney: 415-597-9218, [email protected]
• John Hamiga: 415-597-9241, [email protected]