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Adapting a stigma reduction and mental health promotion program for Black gay / sexual minority men in DC

Julie Pulerwitz, ScM, ScD - Population Council & GWU

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Cody Henry, MPH - Us Helping Us

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Rationale

  • High and disproportionate HIV incidence / burden among Black sexual minority men (SMM) in DC area
  • Evidence suggests stigma major driver of HIV epidemic among marginalized groups including Black SMM
  • Few Evidence-Based Interventions to address these challenges
  • Positive framing of HIV ‘wellness’— addressing mental health etc. in the context of HIV—in line with local government priorities

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Study objectives

    • IDIs with stakeholders (e.g., providers, DC Health), FGDs with end users - Black SMM
    • Production of a program prototype (following ADAPT-ITT framework)

Adapt a group-based stigma reduction / HIV wellness curricula using cognitive behavioral therapy strategies for Black SMM in DC

    • Pilot program among 60 Black SMM
    • Baseline and 3-month follow-up survey
    • IDIs with participants and program staff

Assess the acceptability, feasibility, and appropriateness (including potential for stigma reduction / supporting HIV wellness) of the intervention

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Study Team / Partnership

4

MPI/D:

Julie Pulerwitz, ScD

Population Council and George Washington University

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Co-I: Ann Gottert, PhD

Population Council

MPI/D:

DeMarc Hickson, PhD

Us Helping Us

Co-I: Jennafer Kwait, PhD

Whitman-Walker Institute

Study Coord:

Cody Henry

Us Helping Us

Arona Dieng, Population Council

Adedotun Ogunbajo,

Us Helping Us

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Original curriculum

Sessions

Objective(s)

1. Understanding our different identities, and stigmas and other effected related to these identities

  • Promoting critical reflection around multiple stigmas, e.g., related to being a sexual minority or living with HIV
  • Understanding how these stigmas can be internalized
  • Affirming universal human rights

2. Understanding how thoughts affect feelings, and how to use thoughts to change feelings

  • Learn cognitive behavioral therapy (CBT) skills
  • Practice CBT skills

3. Understanding resilience/coping strategies

  • Practice resilient / positive coping skills related to physical, social, and mental health
  • Self-care – including HIV prevention and treatment
  • Identifying negative coping strategies to avoid

4. Developing safe, supportive networks, and getting the help we need

  • Understanding violence and rights to safety
  • Identifying ways of building a supportive network
  • Promoting shared resilience

Developed / tested by Population Council amongst sexual and gender minorities in Nigeria

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ADAPT-ITT: Framework for adaptation process

Assessment – Obtain a comprehensive understanding of the anticipated audience / community and context.

Decision – Research team will decide how to best build upon, adapt, and/or complement the program.

Administration – Run through (theater test) the intervention with community, intended audience, elicit reactions.

Production – Create prototype of adapted curriculum.

Topical experts – Review materials for further input of the adapted intervention.

Integration – What will be included in the pilot intervention? Integrate into intervention

Training – Train all relevant personnel. Who needs to be trained?

Testing – Pilot test to examine acceptability, feasibility, and appropriateness of the intervention in 60 Black sexual minority men

ADAPT - Phase I

ITT - Phase II

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Our Phase I adaptation steps

  1. Full study team reviews the original curriculum; identifies any changes needed before entering into adaptation process with Draft 1
  2. Conduct a series of focus group discussions with BSMM, and in-depth interviews with BSMM/end-users and other local stakeholders*:
    • Acceptability, appropriateness, feasibility (including AIM-IAM-FIM measures)
    • Curriculum topics / exercises / content
    • Optimal format / number of sessions, and facilitators
  3. Study team analyzes the formative data; integrates findings to produce Draft 2
  4. Draft 2 is reviewed by topical experts (e.g., Stigma program developers, CBT experts, etc)
  5. Feedback from topical experts integrated to produce Draft 3 for piloting

* Local stakeholders may be DC Health officials; HIV and mental health service / CBT providers

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Key themes to explore during Phase I

  • How best to balance necessary reflection/skill-building around stigma (including internalized stigma), with positively affirming identities
  • Exploring any issues related to HIV status neutral program
  • Enhancing the advocacy / shared resilience aspects
  • Adding a lens related to structural racism / stigma related to race

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Recruitment process

Led by Us Helping Us (UHU)

Eligibility criteria – range of participant characteristics (age, area of DC, and HIV status)

Drawn from existing network at UHU

Those not available for FGD series, consider for IDIs

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Initial themes re: structure from FGD cohort

  • Structure works well: 4 sessions, 2.5 hours good
  • Give options for timing of session (eg weekends vs weekdays)
  • CHW facilitation good
  • Recommended against grouping by age, where live in DC area
  • Preferred in-person to virtual, but virtual option important to offer
  • Preferred combined groups (vs. having separate group for participants with HIV)
  • Suggestion to have a “workbook”/“journal”

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Reflections from FGD participants

Provides rare opportunities to discuss life challenges

Builds skills to address internalized stigma

Provides space for mutual support

Improves awareness about/linkages to services available

Important to frame HIV as self-care within the context of wellness, and not to overemphasize HIV services

“100 percent” will help to reduce stigma

Just being part of FGDs has positively influenced own views, practicing tools

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Cross-cutting themes to explore further

  • How to build group cohesion among participants (since most may not know one another), and what happens when the program ends?
  • Idea of follow-on sessions for those who want more practice with skills/learn additional skills (e.g., to promote mental health)
  • How to think about privacy/confidentiality for group sessions
  • Further exploring issues re: advocacy, HIV status neutral program, balance of stigma / resiliency

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Program adaptation - takeaways

Multi-step process that incorporates local epidemiology, context and perspectives

Useful to draw upon one or more frameworks to systematically take into account key issues (eg logic model, RE-AIM, ADAPT-ITT)

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Most often will focus on acceptability, feasibility, and appropriateness but can also examine preliminary effects – to prepare for larger evaluation

Community-partnered model is key for many reasons…

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“I don't know how frequent these focus groups are in the making or the birthing of these interventions…But I think this is very necessary because you get an idea of who you're trying to get in touch with and what is acceptable and what's not acceptable. Because a lot of times people just throw programs on us and they wonder why we don't show up…And I think this is preventing that from happening because we feel included. And because we feel included, we can promote it.”

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-FGD participant