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Engaging homeless men and shelter providers to adapt an existing evidence-based HIV prevention intervention
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Engaging homeless men and shelter providers to adapt an existing evidence-based HIV prevention intervention
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Content
ENGAGING HOMELESS MEN AND SHELTER PROVIDERS TO ADAPT AN EXISTING
EVIDENCE-BASED HIV PREVENTION INTERVENTION
by
Hsun-Ta Hsu
A Dissertation Presented to the FACULTY OF THE USC SCHOOL OF SOCIAL WORK
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements of the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)
August 2015
Copyright 2015 Hsun-Ta Hsu
ii
Table of Contents
List of Tables ................................................................................................................................. iv
Introduction ......................................................................................................................................1
Literature Review .............................................................................................................................2
Homeless Men and HIV/AIDS ................................................................................................... 2
Evidence-Based Intervention Adaption ...................................................................................... 7
ADAPT-ITT Model .................................................................................................................. 12
Study Rationale ..............................................................................................................................14
Overall Intervention Adaptation ....................................................................................................19
Design Overview ...................................................................................................................... 19
Description of Sites ................................................................................................................... 21
Participant Eligibility ................................................................................................................ 22
Phase 1. Need Assessment and Intervention Preference Identification .........................................23
Phase 1 Design .......................................................................................................................... 23
Phase 1 Data Analysis ............................................................................................................... 28
Phase 1 Results ......................................................................................................................... 28
Phase 1 Summary ...................................................................................................................... 37
Phase 2: HIV Prevention EBI Review and Selection ....................................................................37
Phase 2 Design .......................................................................................................................... 37
Phase 2 Data Analysis ............................................................................................................... 44
Phase 2 Results ......................................................................................................................... 44
Phase 2 Summary ...................................................................................................................... 67
Phase 3: Manual Development and Pretesting ...............................................................................68
Phase 3 Design .......................................................................................................................... 68
Phase 3 Data Analysis ............................................................................................................... 73
Phase 3 Results ......................................................................................................................... 73
Phase 3 Summary ...................................................................................................................... 83
Conclusion .....................................................................................................................................84
Future Direction ........................................................................................................................ 88
References ......................................................................................................................................90
Appendices……………………………………………………………………………………...115
Appendix 1: HIV Knowledge and Risk Behavior Brief Survey…………………………….115
Appendix 2: HIV Knowledge and Risk Behaviors Brief Survey - with Answers…………..117
Appendix 3: HIV Fact Sheet with Local HIV Statistics…………………………………….118
iii
Appendix 4: HIV Risk and Substance Use Handout………………………………………120
Appendix 5: Brief Resource Guide Selected Areas of Los Angeles County……………....121
Appendix 6: Negotiating Safer Sex: Excuse/Response Sheet……………………………..123
Appendix 7: Condom Features Summary Handout………………………………………..126
Appendix 8: Steps for Effective Condom Use Handout…………………………………...127
Appendix 9: VOICES-HM Manual and Intervention Materials…………………………...128
iv
List of Tables
Table 1: Phase 1 Homeless Men and Shelter Provider Demographic Characteristics ................108
Table 2: Phase 2b Homeless Men and Shelter Provider Demographic Characteristics ..............109
Table 3: Phase 2b Homeless Men and Shelter Provider Consensus Rankings by Group ............110
Table 4: Phase 2b Overall Homeless Men and Shelter Provider Consensus Rankings ...............111
Table 5: Phase 3b Homeless Men and Shelter Provider Demographic Characteristics ..............112
Table 6: Homeless Men and Shelter Providers’ Perceptions of the VOICES-HM Materials .....113
1
Introduction
Individuals experiencing homelessness, including homeless men, are at high risk of
acquiring and transmitting HIV/AIDS (National Alliance to End Homelessness, 2006; National
Coalition for the Homelessness, 2012; Robertson et al., 2004). A high proportion of homeless
men engage in unprotected sex and risky sexual partnerships (Hsu et al., 2015; Kennedy, Brown,
et al., 2013; Kennedy, Wenzel, Brown, Tucker, & Golinelli, 2013; Tucker, Wenzel, Golinelli, et
al., 2013; Wenzel et al., 2012). Promoting consistent and correct condom use may be the best
strategy to reduce sexual risk in this vulnerable population, i.e., protecting homeless men and
their partners from contracting HIV/AIDS.
The Centers for Disease Control and Prevention’s (CDC) HIV prevention strategies
emphasize developing, implementing, and disseminating evidence-based HIV prevention
interventions (EBIs; CDC, 2011; White House Office of National AIDS Policy, 2010).
Increasing the use of EBIs may have a dramatic impact by reducing the incidence of HIV
because these interventions have been carefully developed with sound theoretical foundations
and rigorous implementation and evaluation (Collins, Harshbarger, Sawyer, & Hamdallah, 2006;
Institute of Medicine, 2001; Lyles et al., 2007). Behavioral HIV prevention EBIs have also
demonstrated positive outcomes, such as reducing HIV risk behaviors and promoting health
behaviors among various populations and settings (CDC, 2011; Collins et al., 2006; Lyles,
Crepaz, Herbst, & Kay, 2006; Lyles et al., 2007). However, currently there are no existing HIV
prevention EBIs targeting homeless men. Given the resources and time needed to develop a new
HIV prevention EBI (McKleroy et al., 2006; Roberts & Yeager, 2006) and the various EBIs
targeting vulnerable populations that have been developed and made available (Collins et al.,
2006; Sogolow, Peersman, Semaan, Strouse, & Lyles, 2002), adapting an existing EBI for
2
homeless men is a more practical approach. The ADAPT-ITT model, developed by Wingood
and DiClemente (2008), provides an appropriate step-by-step roadmap for researchers and
community-based organizations to adapt HIV prevention interventions and has been applied in
multiple studies in different countries (Druss et al., 2010; Latham et al., 2010; Saleh-Onoya et
al., 2009; Wu, El-Bassel, McVinney, Fontaine, & Hess, 2010; Wingood & DiClemente, 2008;
Wingood, Simpson-Robinson, Braxton, & Raiford, 2011).
Considering the high proportion of homeless men who use shelter services (U.S.
Department of Housing and Urban Development [USHUD], 2013), this dissertation project
sought to adopt the ADAPT-ITT model (Wingood & DiClemente, 2008) to engage homeless
men and shelter providers in the Los Angeles (L.A.) County area to navigate, select, and adapt an
existing HIV prevention EBI for homeless men in shelter settings. The final product for this
dissertation project is a finalized adapted HIV prevention EBI manual.
Literature Review
Homeless Men and HIV/AIDS
HIV/AIDS remains a serious public health concern in the United States that needs to be
addressed (CDC, 2011; White House Office of National AIDS Policy, 2010). Current HIV/AIDS
prevention efforts emphasize the importance of identifying and preventing HIV/AIDS among
high-risk populations (CDC, 2011; White House Office of National AIDS Policy, 2010).
Homelessness has been identified as one of the major emphases in national efforts seeking to
achieve the goals set forth in the national HIV prevention strategic plan (CDC, 2007). Compared
to individuals with stable housing, homeless individuals are disproportionately affected by
HIV/AIDS. It is estimated that around 1.6 million individuals experience homelessness during
the course of a year in the United States (USHUD, 2010). The prevalence rate of HIV/AIDS in
3
the homeless population ranges from 3.4% to 10.5%, which is 3 to 9 times higher than in the
general population (CDC, 2012; Robertson et al., 2004; Wenzel et al., 2012). Therefore, it is
critical to target homeless individuals in HIV prevention.
Homeless men in particular are at high risk of contracting HIV. One study investigating
HIV seroprevalence among homeless adults in San Francisco suggested that men are 2 times as
likely as women to be seropositive (Robertson et al., 2004). The association between
homelessness and HIV is well documented. Given the challenges and lack of privacy related to
homelessness (Bourgois, 1998; National Coalition for the Homeless, 2012), it is difficult for
homeless individuals to maintain stable intimate partnerships. Therefore, engaging in high-risk
sexual partnerships (e.g., multiple sexual partnerships or concurrent sexual partnerships) is also
prevalent among homeless men (Hsu et al., 2015; Somlai, Kelly, Wagstaff, & Whitson, 1998;
Wenzel et al., 2012). One recent study using a probability sample of more than 300 homeless
men in Los Angeles found that 40% of homeless men reported concurrent partners (having two
or more sex partners overlapping in time during the previous 3 months; Wenzel et al., 2012), and
close to 60% of homeless men reported engaging in multiple partnerships (having two or more
sexual partners during the previous 3 months; Hsu et al., 2015). Furthermore, to satisfy
subsistence needs, survival sex, or trading sex for food or a place to stay, is also prevalent in the
homeless population (Clatts & Davis, 1999; Greene, Ennett, & Ringwalt, 1999; Tucker, Wenzel,
Kennedy, Golinelli, & Ewing, 2013; Weiser et al., 2006). Tucker, Wenzel, Kennedy, et al.
(2013) found that more than 30% of heterosexually active homeless men reported giving a
female partner something in exchange for sex, close to 18% received something from a female
partner in exchange for sex, and almost 13% engaged in both types of sex trade. Another study
focusing on marginally housed or homeless individuals in San Francisco found that more than
4
30% of the male participants had engaged in transactional sex (Weiser et al., 2006). Homeless
men may also be involved in wide range of partnership patterns, including men who have sex
with women only (MSW), with men only (MSM), and with men and women (MSMW).
Homeless MSM and especially homeless MSMW may engage in higher rates of risk behaviors
(Malebranche, 2008; Maulsby, Sifakis, German, Flynn, & Holtgrave, 2013; Robertson et al.,
2004).
Considering the high-risk and complicated sexual partnerships and survival sex that
homeless men engage in, correct and consistent condom use may be the best strategy to prevent
them and their partners from contracting HIV/AIDS (CDC, 2013). Despite the CDC
collaborating with local health departments to promote free condom programs (Blankenship,
Bray, & Merson, 2000; Charania et al., 2011; CDC, 2015a) and the apparent availability of free
condoms to homeless men in Los Angeles (G. Smith, personal communication, October 25,
2013), inconsistent condom use is still prevalent among homeless men. In a probability sample
of more than 300 homeless men in Los Angeles, 51% had unprotected vaginal or anal sex with a
woman during the previous 6 months (Tucker, Wenzel, Golinelli, et al., 2013). In another L.A.
study, 44% of homeless adults were sexually active during the previous month and 85% of them
did not use condoms (Henwood, Hsu, et al., 2013; Henwood, Rhoades, et al., 2013). Inconsistent
condom use among homeless men not only puts them at risk of HIV but also endangers their
partners. Specifically, in heterosexual sexual partnerships, men usually have more power than
women regarding whether condoms are used or not during sexual intercourse (Pulerwitz,
Michaelis, Verma, & Weiss, 2010). In addition, homeless women are likely to engage in survival
sex with men who are also homeless (Tucker, Wenzel, Kennedy, et al., 2013), which may make
condom negotiation even more difficult for women. Compared to stably housed female sex
5
workers, homeless female sex workers are more likely to have clients who refuse to use condoms
and who use violence against them (El-Bassel, Witte, Wada, Gilbert, & Wallace, 2001; Surratt &
Inciardi, 2004). In our previous work with homeless women (Wenzel, 2015), women expressed
fear of being paid less or not at all or being assaulted by homeless men if they discussed condom
use.
Multiple factors have been identified that may influence the inconsistent condom use
behavior of homeless men. High prevalence rates of alcohol and stimulant substance (e.g.,
methamphetamine) abuse may impair homeless men’s judgment regarding using condoms during
sexual intercourse (Hsu et al., 2015; Kennedy, Brown, et al., 2013; Kennedy, Wenzel, et al.,
2013; Tucker et al., 2012). False perceptions regarding HIV transmission and partner HIV status
may also encourage homeless men to engage in unprotected sex, particularly if they perceive that
their risky behaviors are safe or that their partners are HIV negative (Brown et al., 2012;
Kennedy, Brown, et al., 2013). Sensation seeking, negative attitudes toward condoms, lack of
experience or skill with using condoms, and low self-efficacy related to using condoms also
contribute to the decision of homeless individuals, including homeless men, to not use condoms
during sexual intercourse (Gangamma, Slesnick, Toviessi, & Serovich, 2008; Hsu et al., 2015;
Tucker et al., 2012).
Given that these factors may contribute to homeless men’s engagement in unprotected
sex, sexual risk reduction interventions that address condom efficacy, promote positive attitudes
about condoms, encourage discussion of condom use and HIV status with partners, and enhance
correct condom use skills may be of benefit to this population. Recent studies have suggested
that carefully designed behavioral interventions can effectively reduce sexual risk behavior, even
among vulnerable populations (e.g., injection drug users or MSM; Darbes, Crepaz, Lyles,
6
Kennedy, & Rutherford, 2008; Jones et al., 2008; Noar, 2008; Robles et al., 2004; Wilton et al.,
2009), and are available through various venues, such as sexual transmitted disease (STD) clinics
or primary care clinics (Jemmott, Jemmott, Hutchinson, Cederbaum, & O’Leary, 2008; Jemmott,
Jemmott, & O’Leary, 2007; Warner et al., 2008). However, with limited access to health care
services and prevention resources (Sachs-Ericsson, Wise, Debrody, & Paniucki, 1999; Thomas,
Benjamin, Almario, & Lathan, 2006), homeless men are not likely to receive these developed
HIV prevention interventions.
Although the national HIV prevention strategic plan focuses on reducing HIV risks
among populations vulnerable to HIV/AIDS (CDC, 2011; White House Office of National AIDS
Policy, 2010) and the CDC has prioritized reducing HIV incidence through evaluating and
diffusing HIV prevention EBIs (Collins et al., 2006), there are no EBIs designed specifically for
homeless adults that are classified as having “best evidence” or “better evidence” on the list of
HIV prevention EBIs on the Diffusion of Effective Behavioral Interventions Project (DEBI)
website (CDC, 2015b). On the DEBI list, only one EBI (Street Smart) was developed for
homeless youth at drop-in centers (Rotheram-Borus et al., 2003). Recently, there has been an
effort to adapt and pilot test an EBI (Sister to Sister; Jemmott et al., 2008; Jemmott et al., 2007)
geared toward homeless women (Cederbaum, Song, Hsu, Tucker, & Wenzel, 2014; Wenzel et
al., 2015). Nonetheless, there are no interventions being designed or adapted to focus on
homeless men with diverse partnerships who may at high risk of HIV. Considering the gender
power dynamics (Kennedy, Brown, et al., 2013; Tucker, Wenzels, Kennedy, et al., 2013) and
high prevalence of sexual risk and substance use behaviors among homeless men (Hsu et al.,
2015; Kennedy, Brown, et al., 2013; Kennedy, Wenzel, et al., 2013; Tucker et al., 2012; Wenzel
et al., 2012), it is critical to provide sexual risk reduction programs that target homeless men.
7
Evidence-Based Intervention Adaption
In response to the Institute of Medicine’s (2001) call for closing the gap between
intervention science and real-world community-based HIV prevention practices, the CDC
developed the DEBI project with the goal of enhancing the capacity of local health departments
and community-based organizations to implement HIV prevention EBIs (Collins et al., 2006).
Informed by the diffusion of innovations (Rogers, 1995), the CDC has sought to encourage and
disseminate the implementation of EBIs through funding incentives and regulations and by
lowering the barriers to EBI implementation (Collins et al., 2006; McKleroy et al., 2006). To
ensure that local community-based organizations select and implement an intervention with high
efficacy in reducing HIV risks, DEBI includes interventions screened and evaluated with
rigorous standards by the CDC synthesis projects (Lyles et al., 2006; Lyles et al., 2007) on its
website (CDC, 2015b). Organizational capacity evaluation resources, training resources, and
intervention descriptions and development publications are also included on the DEBI site and
made available to community-based organizations (Collins et al., 2006; McKleroy et al., 2006).
Given the diverse population features and settings, interventions developed and included
in DEBI may not be able to cover all populations at risk in all settings (McKleroy et al., 2006;
Roberts & Yeager, 2006). Furthermore, developing a new intervention can consume considerable
time and resources, because building evidence of an intervention can require researchers to go
through the process of intervention development, implementation, and evaluation (Fraser,
Galinsky, Richman, & Day, 2009; Roberts & Yeager, 2006). Adapting interventions that have
been proven to be efficacious may be a promising strategy to expedite the intervention
development process to target different population and settings. In fact, the CDC with the
support of local health departments is encouraging community-based organizations to adapt EBIs
8
listed in DEBI to reflect their organizational capacity and target population’s needs (Collins et
al., 2006; McKleroy et al., 2006).
In general, intervention adaptation may involve adding, deleting, or modifying existing
intervention components (Center for Substance Abuse Prevention, 2002) to ensure the adapted
intervention is consistent with the characteristics, cultural context, and specific needs of the
target population (Kelly et al., 2000; Rogers, 1995). Adaptation may also take place when
intervention modification is needed to accommodate an organization’s cultural background and
available resources (Center for Substance Abuse Prevention, 2002; Kelly et al., 2000; Roberts &
Yeager, 2006; Rogers, 1995). Before being studied systematically, adaptation had already been
implemented in various professions. One study found that only 15% of teachers interviewed
reported to have closely adhered to a school-based substance abuse prevention intervention
manual (Ringwalt, Vincus, Ennett, Johnson, & Rohrbach, 2004). Another study that investigated
the adaptation process of an HIV prevention intervention found that 33 of 34 organizations
implementing an HIV prevention intervention made at least minor changes to the intervention
curriculum (Galbraith, 2004).
Although different levels of intervention adaption are likely to occur (McKleroy et al.,
2006), adaptation without careful attention to the original intervention’s theoretical base and core
behavioral change logic may undermine the fidelity and effectiveness of an intervention
(McKleroy et al., 2006; Roberts & Yeager, 2006). Concerned that adaptation may impair the
effectiveness of the original intervention, some intervention developers are opposed to any
adaptation (McKleroy et al., 2006; Rogers, 1995). Nonetheless, to ensure that the needs of
specific populations and organizations are being satisfied and to avoid using resources and time
developing a new intervention, adaptation conducted carefully with guidance is still needed
9
(Center for Substance Abuse Prevention, 2002; Jason, Durlak, & Holton-Walker, 1984; Roberts
& Yeager, 2006; Rogers, 1995). When the original intervention’s theoretical foundation and
internal logic are taken into consideration during adaptation, the adapted intervention is more
likely to be effective. One study investigating nationally disseminated education and criminal
justice programs suggested that high-fidelity adaptations are more likely than low-fidelity
adaptations to remain effective (Blakely et al., 1987).
To maintain balance between satisfying the needs of the new target populations and
organizations and maintaining the fidelity of the original intervention, some consensus has been
developed with regard to conducting intervention adaptation. According to McKleroy et al.
(2006), during the intervention adaptation process, core elements or internal logic should not be
altered or violated. Core elements represent the required elements derived from the theoretical
foundation of the original intervention to produce the desired outcomes in the original
intervention research (Center for Substance Abuse Prevention, 2002; McKleroy et al., 2006).
These elements should be identified through intervention research and program evaluation
(McKleroy et al., 2006). By maintaining the integrity of core elements, researchers can increase
the likelihood that the adapted interventions will produce similar outcomes as the original study
(McKleroy et al., 2006). Currently, given the promotion of implementing or adapting HIV
prevention EBIs, core elements of each EBI included on the DEBI website (CDC, 2015b) are
also listed for potential adaptors to take into consideration.
Compared to core elements, which are viewed as not modifiable, key characteristics of an
intervention, albeit important, may be the target of adaptation (McKleroy et al., 2006). Key
characteristics are usually an intervention’s activities or delivery methods. These key
characteristics can be modified to fit the cultural context, address specific risk or protective
10
factors, and address behavioral determinism (i.e., variables or factors that theoretically may
shape individuals’ behaviors) of the new target population (McKleroy et al., 2006). In a review
of the adaptation of an HIV prevention intervention called Focus on the Kids, Galbraith (2004)
found that 59% of the organizations implementing the intervention reported using local statistics
regarding the number of youth engaged in sex instead of the national statistics provided in the
curriculum. Similar modification was also found in another study focusing on adapting Sister to
Sister (Jemmott et al., 2008; Jemmott et al., 2007), a brief one-on-one HIV prevention EBI, for
homeless women (Cederbaum et al., 2014). Instead of providing HIV-related statistics for
African American women as listed in the original intervention manual, Cederbaum et al. (2014)
decided to incorporate statistics that reflected HIV risks among different racial and ethnic groups
because homeless women are a racially and ethnically diverse population.
Other than modifying existing intervention elements, adding new components that don’t
compete with the core elements or violate the internal logic of the original intervention may also
be a promising strategy to ensure the original intervention can address specific cultural contexts
or specific problems that the new population or organizations are facing without compromising
the fidelity of the original intervention. Blakely et al. (1987), in their study investigating
adaptation influences on effectiveness, suggested that adaptation focused on adding new
elements to address local needs or contexts may enhance the effectiveness of the original
intervention, whereas modification of existing content has no influence on intervention
effectiveness. Cederbaum et al. (2014), after obtaining feedback from homeless women and
shelter providers, added new content to the original Sister to Sister intervention (Jemmott et al.,
2008; Jemmott et al., 2007), such as providing a resource sheet that lists places to acquire free
female condoms, reminding women about personal safety when negotiating about condom use,
11
and adding new alternative strategies to protect women (e.g., the use of female condoms and
dental dams). The pilot test of the adapted EBI (Wenzel et al., 2015) suggested the new
intervention is effective in promoting condom use among homeless women.
Although, as previously mentioned, some general rules have been developed for
intervention adaptation, without step-by-step guidelines it can be hard for organizations to adapt
and implement EBIs. Furthermore, without detailed adaptation guidelines, intervention adaptors
may not have a standard to evaluate the adaptation process. Galbraith (2004), for example, found
that of the 33 (of 34) organizations that reported modifying the original EBI, only 20 received
some sort of guidance. Even among those 20 organizations, the source of guidance varied
(ranging from assistance from the intervention developer to community board directors). To
ensure that funded organizations have a roadmap to follow when navigating and adapting
existing HIV prevention EBIs, the CDC has developed an adaptation guideline known as the
map of adaptation process (MAP; McKleroy et al., 2006). MAP includes three major phases:
assessment, preparation, and implementation (McKleroy et al., 2006). In each phase, action steps
describe the focus of each phase and tasks to be achieved to move on to following phase. The
MAP model also includes feedback loops throughout the adaptation process to encourage
researchers or organizations to return to a previous phase if encountering difficulties. Wingood
and DiClemente (2008) suggested that MAP is a novel and detailed adaptation model because it
includes ethnographic components in the adaptation process to ensure the adaptation can fit a
new population and organization’s needs and increase the likelihood of the adapted intervention
being sustainable. However, Wingood and DiClemente (2008) also argued that the complexity of
the MAP model may be difficult for some resource-limited community organizations, which are
usually the major HIV prevention program providers in the United States (Collins et al., 2006).
12
Therefore, Wingood and DiClemente (2008) developed an alternative model that is also geared
toward HIV prevention EBI adaptation, the ADAPT-ITT model.
ADAPT-ITT Model
The title of the ADAPT-ITT model denotes its eight phases: assessment, decision,
adaptation, production, topical experts, training, and testing. Throughout the eight phases,
intervention adaptors (e.g., researchers or community-based organizations), the target population,
and community stakeholders should closely collaborate with one another (Wingood &
DiClemente, 2008). Each phase is informed by the findings of the previous phase. During the
assessment phase, intervention adaptors should focus on understanding the risks in the target
population and assessing organizational capacity to implement an intervention (Wingood &
DiClemente, 2008). Wingood and DiClemente (2008) suggested using focus groups or elicitation
interviews during this phase to understand the specific risks and perceived needs of the target
population.
Based on the information generated from the assessment phase, the adaptors then review
existing HIV prevention EBIs and select one that can address the target population’s needs. At
this phase, intervention adaptors should also decide whether adaptation is needed or simply
adopting the intervention would be sufficient (Wingood & DiClemente, 2008). When selecting
an EBI for adaptation, adaptors should evaluate the “goodness of fit” between the identified EBI
and the target population (McKleroy et al., 2006; Wingood & DiClemente, 2008). This fit should
be determined by the target outcomes (e.g., consistent condom use or reduction in number of
sexual partners), the demographics of the target populations (e.g., age and race and ethnicity),
and the required organizational capacity and available resources to implement the intervention.
13
Once an EBI is identified, during the adaptation phase, the adaptors present the selected
intervention to members of the target population. Specifically, Wingood and DiClemente (2008)
suggested using a method known as theater testing, which has been heavily used in product
testing (National Cancer Institute, 2004). The procedure involves demonstrating the modules of
the intervention to the target population and stakeholders (e.g., organization staff members).
After the demonstration, participant feedback about the usefulness and relevance of the content,
activities, and delivery strategies is collected. Information regarding potential elements that need
to be added or modified is also solicited. Based on this feedback, during the production phase the
adaptors produce the first draft of the adapted intervention manual. During this stage, adaptors
should be cautious regarding the balance among organizational capacity, available resources,
target population preferences, and the fidelity of the original intervention (adhering to the core
elements). Once the first draft has been produced, during the topical expert phase, adaptors
consult with experts who may have expertise in areas of major adaptation (Wingood &
DiClemente, 2008). For example, if the feedback from the target population during the
adaptation phase includes a suggestion to add domestic violence components, an expert from
such a domain should be consulted, especially when the adaptors or organizations lack such
expertise.
During the integration phase, the adaptors should integrate feedback from the target
population and stakeholders with suggestions from topical experts (Wingood & DiClemente,
2008). The adaptors can then train individuals to facilitate and implement the adapted
intervention. The final stage is pilot testing the adapted intervention. During this stage, two
discrete testing steps should be implemented (Wingood & DiClemente, 2008). The first is to
implement the adapted intervention with a sample of the target population members. After each
14
session, participant feedback regarding the usefulness and relevance of the content, topics,
activities, and delivery strategies of the specific session should be collected and analyzed. Based
on this testing, a final draft of the intervention is developed. Finally, the adaptors should further
test the adapted EBI manual using a randomized control trial to test its short-term efficacy
(Wingood & DiClemente, 2008).
The ADAPT-ITT model’s detailed roadmap to conducting intervention adaptation,
iterative processes in producing adapted intervention drafts, and focus on consumer and
stakeholder engagement throughout the adaption process helps to ensure that the organizational
concerns and target population needs are addressed (Latham et al., 2010; Wingood &
DiClemente, 2008). Because this model was specifically developed for HIV prevention EBI
adaptation, it has been applied to numerous studies focusing on adapting HIV prevention EBIs
for diverse populations domestically and internationally (Druss et al., 2010; Latham et al., 2010;
Saleh-Onoya et al., 2009; Wingood & DiClemente, 2008; Wingood et al., 2011; Wu et al., 2010).
Study Rationale
As previously mentioned, homeless men are at high risk of contracting HIV/AIDS due to
high prevalence of sexual risk behaviors (Hsu et al., 2015; Kennedy, Brown, et al., 2013;
Kennedy, Wenzel, et al., 2013; Tucker, Wenzel, Golinelli, et al., 2013; Wenzel et al., 2012).
Considering that abundant HIV prevention EBIs have been developed and made available via
DEBI (Collins et al., 2006; CDC, 2015b; Lyles et al., 2006; Lyles et al., 2007) and the time and
resources needed to develop a new intervention (Fraser et al., 2009; McKleroy et al., 2006;
Roberts & Yeager, 2006), adapting an existing EBI for homeless men may be a more appropriate
strategy. The detailed steps and engagement process illustrated in the ADAPT-ITT model
15
(Wingood & DiClemente, 2008) make it a good framework for engaging homeless men and
community-based providers to review, select, and adapt an HIV prevention EBI.
Current strategies to address homelessness focus on providing supportive housing to
homeless individuals and using housing as a channel to deliver services, such as permanent
supportive housing (PSH; U.S. Interagency Council on Homelessness [USICH], 2010). To
address HIV/AIDS among homeless individuals from a holistic perspective, housing intervention
has been suggested as one promising solution (CDC, 2011). For homeless individuals living with
HIV, special housing programs have also been developed (USHUD, 2014a, 2014b) in which
HIV and wraparound services are integrated. However, there is still a large gap between the
number of available housing units and the number of homeless individuals on the streets. For
example, based on USHUD housing reports (USHUD, 2012a, 2012b), there are approximately
9,000 PSH units (including units that have been occupied) for homeless individuals, yet more
than 26,000 unsheltered homeless individuals in L.A. County. Furthermore, although housing
programs devoted to individuals living with HIV/AIDS provide HIV prevention services or
programs (USHUD, 2014a, 2014b), those housing units and services may not be available for
homeless individuals, including homeless men, who are HIV negative or unaware of their HIV
status but still engaging in HIV risk behaviors.
Considering the high prevalence of HIV risk behaviors among homeless men (Hsu et al.,
2015; Kennedy, Brown, et al., 2013; Kennedy, Wenzel, et al., 2013; Tucker et al., 2012) and the
large number of homeless individuals unable to access PSH or housing designed for individuals
living with HIV (USHUD, 2014b), it is critical to deliver HIV prevention intervention services to
homeless men who are living on the streets. Shelters that provide subsistence services, such as
showers, meals, or a temporary place to stay overnight, may be a promising venue in which to
16
approach homeless men because using such services is common. In fact, more than 60% of
homeless individuals use some type of shelter services (USHUD, 2009). However, using shelters
as an HIV prevention intervention delivery channel may be difficult, because shelter providers
may have limited resources (physical or staff resources) available to implement HIV prevention
programs (Glasgow, Lichenstein, & Marcus, 2003; Rotheram-Borus, Swendeman, & Chorpita,
2012; Veniegas, Kao, & Rosales, 2009). To ensure that the HIV intervention being adapted not
only fits the needs of homeless men needs but also accommodates the capacity and resources of
shelter providers, it is critical to involve shelter providers along with homeless men in the
intervention adaptation process.
As the homeless capital of the United States, L.A. County is an ideal environment in
which to collaborate with homeless men and shelter providers to adapt an HIV prevention EBI.
Los Angeles is one of the USHUD Continuum of Care grantee areas with a large homeless
population (USHUD, 2010). On any given night, approximately 51,000 individuals experience
homelessness in L.A. County, including approximately 23,500 in the city of Los Angeles (Los
Angeles Homeless Services Authority [LAHSA], 2011). Downtown Skid Row is a 50-square-
block area with a high concentration of homeless population and service providers (LAHSA,
2011). Specifically, 1 of every 3 individuals on Skid Row is homeless (LAHSA, 2011).
Compared to homeless individuals in other areas of L.A. County, individuals on Skid Row are
more likely to live on the streets (Blasi & the UCLA School of Law Fact Investigation Clinic,
2007). However, because services are highly concentrated in the Skid Row area, it can be even
harder for homeless individuals to access shelter or health-related services in other areas of L.A.
County. A previous study focusing on homeless women and providers (Cederbaum, Wenzel,
17
Gilbert, & Chereji, 2013) found a high need for HIV prevention programs in L.A. County,
including on Skid Row.
Given the lack of HIV prevention services in local communities designed for homeless
men, the purpose of this dissertation project was to apply the ADAPT-ITT model (Wingood &
DiClemente, 2008) to engage homeless men and shelter providers located in L.A. County to
navigate, select, and adapt an existing HIV prevention EBI for men who use shelter services.
Specifically, this dissertation project encompassed the assessment phase to the integration phase
of the ADAPT-ITT model, with an adapted EBI manual as its final product.
Based on the ADAPT-ITT model, the suggested tasks are assessing the target
population’s needs and the capacity of organizations to adapt and implement an HIV prevention
EBI, navigating and selecting EBI candidates for adaptation, soliciting feedback regarding
potential modification of the selected EBIs using theater testing, developing a first manual draft,
consulting topical experts, and developing the final adapted EBI manual (Wingood &
DiClemente, 2008).
Although guided by the ADAPT-ITT model, considering the resource and time
constraints of this dissertation project, during the adaptation process of this project, the ADAPT-
ITT model was modified. Specifically, because detailed manuals and intervention materials for
each EBI listed by DEBI are not always available, selecting and presenting an EBI to homeless
men and shelter providers using theater testing was not possible. Furthermore, in the ADAPT-
ITT model, Wingood and DeClemente (2008) suggested mixing the target population and
community stakeholders (e.g., community organization staff members) in the same focus groups
or theater testing to solicit intervention adaptation feedback. However, based on previous
experiences and research (R. Izell, personal communication, October, 26, 2013; also see
18
Cederbaum et al., 2014; Cederbaum et al., 2013), homeless individuals and providers may not
feel comfortable talking about HIV-related topics with each other. Therefore, focus groups in
this project were conducted separately with homeless men and providers. Finally, because the
purpose of intervention adaptation is to ensure that the needs of the new target population and
organizations are met, instead of presenting only one selected EBI using theater testing as
suggested by the ADAPT-ITT model, in this dissertation project multiple selected EBI
candidates were presented and discussed with homeless men and shelter providers using a
consensus group method to ensure shared consensus regarding selection of an EBI to be adapted
(Cederbaum et al., 2014).
A consensus method for shared decision making, with the ultimate goal of resolving
conflicts and reaching consensus, has been used to facilitate dialogue and collaboration between
researchers and stakeholders on challenging topics, including health program provision (Fink,
Kosecoff, Chassin, & Brook, 1984; Jones & Hunter, 1995; Totikidis, 2010). The major
characteristics of successful consensus groups are inclusive, participatory, collaborative,
agreement seeking, and cooperative (Carney, McIntosh, & Worth, 1996). Cederbaum et al. (2014)
successfully used this method to engage homeless women and shelter providers to discuss four
selected HIV prevention intervention options and reached consensus on one EBI for further
adaptation. By using this method, more EBI options can be provided to homeless men and
shelter providers. Furthermore, with consensus groups, homeless men and providers can also be
engaged in EBI selection for adaptation discussion and directions for further adaptation, whereas
in the original ADAPT-ITT model, the adopters review and select one EBI for theater testing.
Therefore, the adaptation phase in the ADAPT-ITT model was modified to ensure homeless men
and shelter providers had a higher degree of engagement in the EBI selection process.
19
Overall Intervention Adaptation
Design Overview
As previously mentioned, guided by the ADAPT-ITT model (Wingood & DiClemente,
2008), this dissertation project included three major phases. Each phase built on findings from
the previous phase. Phase 1 was the needs assessment and intervention preference identification
phase. This phase represented the assessment phase in the ADAPT-ITT model. The first phase
focused on assessing homeless men and shelter providers’ perceived needs, determining the
priority of having an HIV prevention intervention targeting men using shelter services, and
understanding organizational capacity and available resources. To prepare for the next phase
(intervention navigation and selection), information regarding topics critical to reducing sexual
risks among men using shelter services, intervention format preferences, and delivery strategies
were also collected during Phase 1. To ensure that the target population (homeless men) and
stakeholders (shelter directors and shelter staff members) were engaged, Phase 1 activities
included focus group and one-on-one interviews with homeless men and shelter providers.
The following phase was the HIV prevention EBI navigation and selection phase. This
phase constituted the adaptation phase of the ADAPT-ITT model (Wingood & DiClemente,
2008). Based on the findings of Phase 1 (i.e., important topics that need to be covered, preferred
intervention format, and organizational constraints), Phase 2 focused on reviewing existing HIV
prevention EBIs (CDC, 2015b), selecting potential EBI candidates, and determining an EBI for
further adaptation. It is likely that homeless men and shelter providers might have different or
even conflicting opinions regarding intervention preferences. In this case, more weight was given
to providers’ opinions on matters of feasibility in implementing and sustaining an EBI (e.g.,
necessary staffing, required costs, opportunities for integrating with other programming),
20
whereas homeless men’s opinions were emphasized in all other matters of programming (e.g.,
design of program materials, intervention topics). During Phase 2, homeless men and shelter
providers’ opinions regarding preferred modification of the selected EBI were also collected.
Phase 2 activities involved the review and selection of EBI candidates (CDC, 2015b) and
nominal consensus groups with homeless men and shelter providers.
The final phase was the manual development and pretesting phase, which represented the
production, integration, and testing phase of the ADAPT-ITT model (Wingood & DiClemente,
2008). Building on Phase 2, Phase 3 focused on developing and finalizing the adapted
intervention manual. During this phase, activities included drafting and finalizing the adapted
intervention manual and pretesting the manual draft via theater testing (Wingood & DiClemente,
2008) with homeless men and shelter providers in focus groups separately. The final step was to
incorporate the input of homeless men and shelter providers to finalize the intervention manual.
It should be noted that in this dissertation project, homeless men and shelter staff members who
participated in previous phase could still participate in later phases.
Individuals experiencing homelessness may share similar life experiences (e.g., diet,
language, risk behaviors, and shared experiences of being stigmatized or victimized) and thus
can be considered to share “homelessness culture” (Law & John, 2012). Resnicow, Soler,
Braithwaite, Ahluwalia, and Butler (2000) suggested that individuals developing culturally
appropriate interventions should focus on surface structure (matching intervention materials to
location and observable population characteristics, such as language) and deep structure
(integrating the cultural, historical, environmental, and psychological forces critical to
influencing the target population’s behaviors). To ensure the adapted intervention not only fits
the specific needs of homeless men and shelter providers but also reflected homeless men’s
21
shared experiences, in this dissertation project both surface and deep structures were taken into
consideration during the intervention adaptation process. Specifically, regarding surface
structure, the intervention materials and components were verified with homeless men and
shelter providers regarding their usefulness to reduce sexual risks and relevance to their daily
lives. In terms of deep structure, in addition to attend to the shared experiences of homeless men,
major components considered for an HIV prevention intervention targeting homeless men were
also based on previous research on sexual risks among homeless men, including false beliefs
regarding HIV transmission (Brown et al., 2012), risky sexual partnerships (Wenzel et al., 2012),
and psychological correlates of condom use behaviors (Hsu et al., 2015; Kennedy, Brown, et al.,
2013; Kennedy, Wenzel, et al., 2013; Tucker, Wenzel, Golinelli, et al., 2013). This dissertation
project received exempt status from the University of Southern California Institutional Review
Board.
Description of Sites
This dissertation project focused on engaging homeless men and shelter providers located
in L.A. County. In the present study, the researcher collaborated with two shelter providers that
provide subsistence services (e.g., overnight stay, emergency shelter, and meal and shower
services) to homeless individuals, including men and women. These services, except for
emergency shelter, are provided to both emergency shelter residents and homeless nonresidents.
The two shelters are located in two distinct regions of L.A. County. The first shelter provider is a
faith-based organization located in Central City East (the Skid Row area). The homelessness,
HIV, and STD rates in Central City East are among the highest in Los Angeles (Los Angeles
County Department of Public Health, 2013; LAHSA, 2013). Of the six major facilities on Skid
Row that serve homeless men, the researcher collaborated with the busiest and highest-capacity
22
facility for this study because of the greater logistical challenges and complexity of programming
(larger sites should provide a more challenging test in implementing an EBI).
The second shelter provider is located in the Pasadena area. Pasadena is notable because
of its independent public health system and its geographic distance from the downtown area,
limiting potential for men in this area to cycle through services in the downtown area.
Furthermore, given the lack of shelter providers in surrounding areas (San Gabriel Valley and
San Fernando Valley), shelters in Pasadena are the service hubs for homeless individuals from
surrounding cities (e.g., Glendale) to seek out subsistence services (R. Izell, personal
communication, October, 26, 2013). Currently, only two shelters serve homeless men in
Pasadena. Based on the aforementioned rationale, the larger one was selected as the
collaboration site in this project. Allowable shelter stays range from 1 to 12 months, with most
men staying at these facilities for no more than 5 nights at a time. Neither of these facilities
provides evidence-based HIV prevention programs.
Participant Eligibility
In this dissertation project, men were eligible for each study phase if they were at least 21
years old, had experienced homelessness during the previous 12 months, had vaginal or anal sex
with a women or man during the previous 30 days, planned to have sexual intercourse during the
next 30 days, could speak and understand English, and were cognitively able to participate in
discussion groups. Although men’s participation was limited based on English proficiency, it
was expected that few men would be excluded by this criterion. Previous research has suggested
that fewer than 7% of homeless individuals are unable speak or understand English (Wenzel,
2012). In this project, cognitive ability was not formally examined. However, if the recruiters
suspected that a potential participant might have difficulty participating in focus groups or
23
consensus groups due to cognitive ability, a series of simple questions was asked, including the
current date and time, to determine eligibility.
Intervention adaptation should reflect organizational capacity and staff member
preferences to ensure the adapted intervention is more likely to be implemented and sustained
(Collins et al., 2006; McKleroy et al., 2006; Wingood & DiClemente, 2008). Therefore, in this
project, staff members from both shelters were also engaged throughout the adaptation processes.
Specifically, provider participants included staff members with detailed knowledge of current
shelter service delivery programming, administrative and procedural policies affecting men at
each facility, physical layout and technical and other material resources, and first-hand
counseling or case management experience with homeless men. To ensure different levels of
staff members from both shelters were included in this project, directors and frontline shelter
staff members from both shelters were recruited.
Phase 1. Need Assessment and Intervention Preference Identification
Phase 1 Design
Phase 1 consisted of understanding the needs and HIV risks of homeless men, assessing
shelter capacity, and determining the desired intervention elements and format. In this phase,
focus groups with homeless men and shelter staff members and one-on-one interviews with
shelter directors were conducted to collect qualitative data regarding perceived HIV intervention
needs and preferences. Topics covered in all focus groups were similar. However, given the life
experiences and expertise of participants, there were some differences in terms of discussion
topics between homeless men and shelter staff member groups. For example, current
organizational resources were heavily discussed in the staff member groups but not in the
homeless men’s groups.
24
Brief surveys were also conducted to collect participant demographic data. During this
phase, all focus groups had between five and eight participants per group. All focus group
discussions were recorded for later data analysis. A cofacilitator also took detailed notes for
debriefing meetings held immediately after the focus groups. In terms of interviews, shelter
directors could choose to participate via phone or face-to-face interviews. Given that the
directors from both sites decided to be interviewed via phone, the interviewers took detailed
notes because recording was not possible. Two doctoral candidates conducted all focus groups.
Verbal consent of all participants was collected prior to data collection in this phase. All focus
groups and interviews lasted no more than 90 minutes. All homeless men who participated
received $20 to compensate them for their time and input.
Homeless men participant recruitment and data collection. To recruit homeless men
at both shelters for focus groups, the facilitators and staff members posted flyers in areas where
homeless men congregated (e.g., dining area, residential area, and information boards) several
days prior to each group. Given the potential stigma toward HIV/AIDS in the homeless
population, the study was framed as men’s health discussion groups in the flyers. On the dates of
the focus groups, brief presentations were conducted to recruit participants. Interested men were
screened for eligibility prior to the group session. During this phase, 30 of 41 homeless men
(73%) were screened as eligible (one was younger than 21 years old, seven did not have sex with
a man or women during the previous 30 days or did not plan to have sexual intercourse during
the next 30 days; two could not speak and understand English, and one could not comprehend
and complete the screening) and participated in the discussion. Verbal informed consent was
collected, followed by brief surveys. The brief survey consisted of questions covering basic
demographic information (e.g., age, race and ethnicity, and marital status), length of homeless
25
experiences, and shelter service use (e.g., meal lines, education services, support groups, and
residential services). Participants received $20 for their time and input after completion of the
brief surveys. Once all homeless men completed the brief surveys and received the incentives,
the facilitators started the focus groups.
Homeless men focus groups. During this phase, four focus groups (two at each site)
were conducted with homeless men. Each group consisted of seven or eight participants. In
homeless men groups, discussion topics focused on the following domains: perceived needs and
priority of having an HIV prevention intervention for men using shelter services; awareness and
experiences of HIV prevention services provided in the community; HIV risks among men who
use shelter services; and preferences regarding HIV intervention topics (e.g., substance use and
HIV statistics), intervention delivery strategy (i.e., video clips, role-play, and hands-on activities),
and intervention format (single session vs. multisession or group format vs. one-on-one
consultation). The group also discussed potential ways to approach and attract men to participate
and remain engaged in an HIV prevention intervention.
In the homeless men groups, the facilitators allowed participants to suggest important
topics that should be included in HIV prevention interventions for homeless men. However,
based on behavioral theories (Ajzen, 1985; Ajzen & Fishbein, 1980; Bandura, 1978; Bandura,
1982; Bandura, 1986; Fisher & Fisher, 1992), previous empirical research regarding condom use
among homeless men (Hsu et al., 2015; Kennedy, Wenzel, et al., 2013; Tucker et al., 2012), and
common components included in HIV prevention EBIs (Lyles et al., 2006; Lyles et al., 2007),
condom skills training and condom negotiation with the purpose of increasing condom efficacy
are critical to the success of an HIV prevention behavioral intervention. Therefore, instead of
having homeless men discuss whether condom skills training and condom negotiation should be
26
included in an intervention for men using shelter services, the facilitators brought up these topics
and initiated discussions on potential ways to deliver condom skills training and condom
negotiation to men at shelter settings.
Shelter staff participant recruitment and data collection. Participants for shelter
provider groups were recruited through the assistance of the directors of the two collaborating
shelters. Eligibility criteria (detailed knowledge of current shelter service delivery programming,
administrative and procedural policies affecting men at each facility, physical layout and
technical and other material resources, and first-hand counseling or case management experience
with homeless men) were described to the directors via email. Given the workload and schedule
of shelter staff members, discussion topics and questions were sent to the directors to
disseminate to interested staff members before group sessions to increase the efficiency of focus
group discussions.
Informed consent was collected prior to the brief survey. The brief surveys for shelter
staff members covered demographic information (gender, race and ethnicity, and educational
achievement), tenure in the agency, tenure working with homeless men, and HIV prevention
activities (including formal and informal activities) implemented in the agency. Because staff
members participated in the focus groups to provide their professional expertise and insights,
incentives were not provided. Fifteen staff members participated in the two groups (six at one
site and nine at the other; one staff member decided to participate in the discussion after the
group had started).
Shelter provider focus groups. During Phase 1, two shelter staff member focus groups
(one at each site) were conducted. Each group consisted of six or nine staff members. Because
this project aimed to adapt an EBI to be implemented at shelter settings, it was critical to gather
27
information regarding organizational capacity and resources and understand staff members’
concerns and intervention preferences to make the adapted intervention reflect shelter agencies
characteristics. This process may increase buy-in among shelter providers and enhance the
likelihood that the intervention is sustainable in shelter settings. During the shelter provider focus
groups, discussion topics focused on the following domains: current organizational resources
(e.g., physical, staff, and funding resources) to implement an HIV prevention EBI and provide
incentives. Staff members’ intervention preferences (based on organizational capacity), including
intervention format and delivery strategy, were also discussed. To supplement the information
gathered in homeless men focus groups, feedback regarding intervention topics important to men
using shelter services and current available HIV prevention resources in the communities was
also generated.
Shelter director participant recruitment and data collection. Shelter directors were
invited to participate in interviews when the principal investigator initiated collaboration with the
shelters for this dissertation project. Verbal informed consent was collected prior to the
interviews. Because the directors chose to be interviewed via phone, and considering their busy
schedules, brief surveys were not conducted during the interviews. Because the directors
participated in the interviews to provide their professional expertise and insights, incentives were
not provided.
Shelter director interviews. Previous research focusing on HIV prevention intervention
adaptation targeting homeless women (Cederbaum et al., 2013) and studies focusing on
innovation dissemination in organizations (Hasenfeld, 2009; Rogers, 1995) have noted the
importance of developing innovation buy-in at both the administrative level and among frontline
workers. To ensure shelter staff members at different levels were engaged in the intervention
28
adaptation process, in addition to staff member focus groups, one-on-one interviews were also
conducted with shelter directors. During this phase, two shelter director interviews were
conducted. Both of the interviews with the directors were conducted by phone. The topics
included in the interviews were consistent with staff member focus groups.
Phase 1 Data Analysis
To examine the qualitative data collected during focus groups and interviews, content and
thematic analysis (Boyatzis, 1998; Krippendorff, 1980; Weber, 1991) was conducted to identify
themes critical to conducting Phase 2 (navigating and selecting potential HIV prevention EBI
candidates). Because similar topics were covered in the homeless men and shelter provider focus
groups and director interviews, a case summary matrix (Miles, Huberman, & Saldaña, 2013;
Padgett, 2007) was developed for data analysis to compare and contrast the information gathered
in different groups and interviews. Specifically, because the qualitative data were collected
through focus groups and interviews, in this adapted case summary matrix, homeless men,
shelter staff members, and directors were listed in rows, with themes as columns. In terms of
quantitative data collected via brief surveys, basic descriptive analysis was conducted to
understand and describe the characteristics of the participants.
Phase 1 Results
Demographics. Table 1 illustrates the demographic characteristics of homeless men and
shelter staff members. The average age of homeless men participants was 45.23 (SD = 7.76).
Consistent with previous research (Kennedy, Brown, et al., 2013), the majority of the homeless
men identified themselves as Black. One third of the men had never been married. More than
80% of the men had experienced homelessness for at least 3 to 6 months in their lifetime.
Furthermore, approximately 73% of the homeless men expressed having experienced
29
homelessness for at least 3 months during the previous 6 months. More than 75% of the men
participants reported not using condoms consistently during sexual intercourse during the
previous 30 days. In terms of use of shelter services, the most frequently used services were
subsistence services (meal, shower, clothing, and overnight stay; 97%) and substance recovery
groups (77%).
In the provider focus groups, 80% of the staff member participants were men. The two
sites differed significantly in staff member race and ethnicity composition. Overall, slightly more
than half of the staff participants identified as Black and one third as White. However, at one site,
approximately 66.7% of the participants were Black, whereas at the other site, half of the
participants were White (results not shown in the table). Most staff members held at least a high
school diploma or GED. There was a significant variance in tenure in the agency (M = 4.28, SD
= 5.01) and working with homeless men (M = 4.82, SD = 5.47) among the staff participants. In
terms of HIV prevention services, none of the participants reported that formal HIV prevention
programs (including free condom provision) were implemented in the shelters. However,
approximately 53% of the staff participants described talking with homeless men about HIV
prevention.
Homeless men focus group findings. During the group discussions with homeless men,
the following themes were identified.
High perceived needs and priority. Men agreed that there is a high need for an HIV
prevention intervention targeting men using shelter services, because many homeless men
engage in high-risk behaviors, including substance abuse, unprotected sex, and sex trade. Given
these high-risk behaviors, the participants reported that HIV prevention should be a high priority
in the daily lives of homeless men. However, participants also said that for many homeless men,
30
HIV prevention may not be the first priority, considering all the competing subsistence needs
that must be met. Therefore, providing incentives may help men prioritize participation in an
HIV prevention program. Men also expressed that there are few programs in the community
addressing HIV or STD risks among homeless populations, other than HIV testing. HIV testing
services were not provided by the collaborating shelters but by outside health providers. These
testing services were provided via mobile vans. Because HIV/AIDS remains an incurable disease,
men argued that more could be done other than testing and that it was important to prevent
homeless men from getting HIV/AIDS in the first place. One participant stated: “Yeah, it is very
important … to me, too. We don’t talk about sex here, but everybody, you know have sex …
people are fucked up here … with the drugs and all that. … It’s good to have some classes, you
know, ‘cause its [a] fundamental tool.” Another respondent discussed this issue:
It’s very important, there is a epidemea [sic] of HIV or STDs among men here. I once see
that … is it correct that about 50% of homeless people got HIV? … No matter how good
you look like, men still need to protect themselves. Who wants to see a sick penis? I
know I don’t. So I think it’s important to make people aware this issue. … Yeah,
sometimes they have a van here doing HIV testing, you know wiping stuff from your
mouth. … There used to be programs around here doing HIV, those type of stuff, but not
anymore. … The person [name redacted] was very nice, I think she passed away. … Now,
the government are shutting them down, and there is no free condom programs in Skid
Row.
Finally, a third respondent described his thoughts on HIV prevention:
Personally, I think the priority [of having an HIV prevention program] should be high.
Not all people are like me. … People have their own problems, like mental, food. … But
31
it is still important to have it [HIV prevention] out there … to at least get some people.
You might got 20% of them, and 20% is better than no percent. … Yeah, some incentives
can help … you know, money, like what you just did, gift card.
Topics to be included in the intervention. The critical topics to reduce homeless men’s
HIV risks identified in homeless men focus groups included HIV myths and facts, HIV statistics
(in surrounding areas or among homeless men), consequences of HIV, substance use in the
context of sexual risks, and making resources (e.g., free condoms, HIV testing sites, or substance
abuse treatment services) available for homeless men. In terms of condom use skills training and
condom negotiation topics, many men agreed that these topics are important because many men
have never used condoms before and protected sex is the second-best way after abstinence to
protect men from contracting HIV/AIDS. Some men, however, did not think that condom skills
training and condom negotiation would help men reduce their sexual risks, because men tend to
like the “raw feeling” during sexual intercourse or like to “eject into women.” Furthermore, they
also argued that condom sizes might be an issue. Based on these comments, the facilitators
discussed with men the possibility of including an introduction of different types of condoms and
ways to make condom use pleasurable. Responses included: “Definitely drug issues. … You also
need to let them know what the disease looks like, where to go to or what doctor to see when
getting HIV or STDs” and “I can see it [condom skills training] be useful. But men don’t use no
condoms. I never used one. … I need to feel it, you know, I like to feel it raw. … I cannot get the
hard on when I wear it [a condom].”
Intervention preferences. Regarding intervention format, participants did not express a
preference for either a one-on-one or group format. Some men recommended a mixed one-on-
one and group format so that men who had additional questions after a group session could
32
participate in a one-on-one session. To men, one-on-one interventions could ensure their privacy,
especially when talking about highly sensitive issues such as HIV status or personal sexual risk
behaviors. However, men also liked the group format, in which the participants could be
supportive to one another as they shared similar life experiences. In terms of intervention length,
although men did not report that multisession interventions are impossible, they stated that brief
programs would be a more ideal intervention format given the transient nature of homeless men
in shelter settings. If multisession interventions were chosen for adaptation, men suggested that
incentives would be critical to keep men engaged until the completion of such programs.
Regarding incentives to attract men to participate in an HIV prevention program, monetary
incentives were the top choice. However, other incentives such as hygiene kits, blankets, or
refreshments might also attract homeless men to attend such programs. To sustain participation
in a multisession program, strategies such as giving men punch cards in exchange for a final
incentive after intervention completion might be helpful.
In terms of delivery strategy for an HIV prevention program, men said they preferred
programs being delivered by individuals who share a similar background. Men also said they
would feel more comfortable if individuals outside of the shelters implemented the program.
Similar to previous research focusing on homeless women (Cederbaum et al., 2014; Cederbaum
et al., 2013), participants said the gender and race and ethnicity of the facilitators would not be
an issue for homeless men, as long as the facilitators are not judgmental and are familiar with the
homeless population. However, some men expressed concerns about shelter staff members
implementing such programs because they already know too much about service users and have
control over their resources. In terms of activities to include in the program, men suggested
making them interactive and fun. For example, role-playing activities or video clips might help
33
engage men. Specifically, for condom skills training, men described the importance of hands-on
practices because they believed many homeless men have not used condoms before. This
suggestion corresponds with homeless women’s experiences (Cederbaum et al., 2014; Wenzel et
al., 2015). Although the participants also stated that homeless men might not like or feel
comfortable practicing condom use skills, it is still critical to include such practices in the
program. In terms of addressing substance use risks, men suggested that having a resource guide
describing substance abuse treatment resources or needle exchange programs might be sufficient.
Finally, men also stated they preferred the intervention to be more individually tailored, because
although homeless men share some HIV risk behaviors in common, they may be very different in
terms of risk profiles. Focus group participants said it is critical to ensure the intervention reflects
their personal risks, which may also motivate them to engage in HIV prevention.
HIV risks. Consistent with previous literature (Brown et al., 2012), during the focus
groups, men described some false beliefs about HIV transmission, negative attitudes about
condom use, lack of condom use experiences and skills, and engagement in high-risk behaviors
(i.e., sex trade, unprotected sex, and substance use). Furthermore, during the discussion, men
also said they viewed women as responsible for carrying condoms and initiating condom use.
However, similar to previous literature (Kennedy, Brown, et al., 2013), some men also said they
held the view that women who carry condoms may be promiscuous or engaging in sex trade.
Responses included: “I never used condoms. … I rushed to the testing van every time after
sex. … I thank God for giving another opportunity [testing negative]” and “‘I heard you can tell
a women having HIV by looking at her pussy … correct?’ ‘Nah, maybe some STDs … but not
HIV’ ‘Really, I heard you can do that.’” Other participants stated: “Women know what they are
doing around. … Women at this area, they should carry condoms with them, you know … they
34
know what they been doing, they should have it, to protect their men. … It’s not like I’m tripping
on condoms every time” and “Ain’t sleeping with women who carry condoms … just turn me off.
Who know what they have been doing? … Always about fine chicks.”
Provider focus group and interview findings. Because the director interviews and staff
member focus groups covered the same topics and the conclusions were very similar and
complementary, the findings are summarized together. The following themes were identified in
the staff member focus groups and director interviews.
Perceived high needs but low priority. All staff members in the focus groups agreed that
providing HIV prevention programs to homeless men at shelters is important, given the lack of
local HIV prevention programs, sexual risk behaviors among homeless men, and the high
prevalence rates of HIV and STDs in this population. However, compared to homeless men’s
perceptions regarding HIV prevention program priority, shelter staff members did not perceive
having an HIV prevention intervention as of high priority in the daily routine of shelters. The
major goal for shelter providers is to transition homeless individuals or families into housing.
Given current budget cuts, shelter providers are being critically evaluated on their efficiency
transitioning homeless individuals from emergency shelters to housing. Therefore, compared to
programs that can improve housing readiness (e.g., job training and substance abuse treatment),
HIV prevention is not a top priority among shelter providers. One respondent described this issue:
I think it [HIV prevention intervention] is important, and there is definitely a need for
HIV prevention programs here. … We’ve all seen or heard someone died of HIV
here …but as a shelter, our primary goal is to help the residents secure housing, and we
are being evaluated on that. HIV prevention is important, but it is just not our first
priority.
35
Topics to be included in the intervention. Similar to the suggestions of homeless men,
shelter providers also suggested that substance use, facts and myths about HIV transmission,
consequences of HIV, condom skills training, and condom negotiation should be included in an
HIV prevention program for homeless men. Although one shelter is a faith-based organization,
the staff members acknowledged that it is hard to promote abstinence-only interventions among
homeless men, and thus having more options is important. One topic that had not been discussed
in the men’s focus groups but corresponded to homeless men’s HIV risks, namely men’s
responsibility to initiate condom use discussions, was raised in the staff member groups. After
learning condom negotiation skills, homeless men can still choose not to discuss condom use
with their partners. Therefore, providers suggested that the intervention should aim to motivate
men to take responsibility for initiating condom use discussions with their partners. Finally,
some staff members also raised the potential importance of addressing intimate partner violence
in an HIV prevention program, especially for homeless MSM who engage in survival sex.
Organizational capacity. Based on the provider focus groups and interviews, both
shelters have the physical infrastructure to implement an HIV intervention program. These
physical resources include private and group meeting spaces, television, DVD player, whiteboard,
laptops or computers, and office supplies. However, for both shelters, limited staff resources may
pose challenges to implementing an HIV prevention intervention. Providers described
experiencing heavy workloads in their daily routine. It may be difficult to add implementing HIV
prevention programs to any current staff member’s workload. Considering limited funding
resources, it is also unlikely providers will hire or set aside a staff member to work solely on
HIV prevention programs. Nonetheless, the participating providers offered some potential
solutions. Collaborating with outside health providers or working with social work programs to
36
train social work interns to implement HIV prevention EBIs during their field placement at
shelters may be promising strategies. Other than human resources constraints, funding for staff
training to implement HIV prevention programs and monetary incentives are also limited.
However, shelter providers may have in-kind incentives such as blankets, food, hygiene kits, or
water bottles to attract homeless men to participate in such programs. Some staff members also
stated that free condoms can be an appropriate incentive, especially because the intervention
focuses on reducing sexual risks. However, free condoms are not always available because they
are provided as donations.
Intervention preferences. Shelter capacity and limited available resources guided the
intervention preferences of shelter providers. Regarding format, shelter providers preferred
group-based interventions despite acknowledging the privacy and in-depth discussions provided
by one-on-one consultations. Staff members argued that given the limited staff resources, more
homeless men can be reached at one time using group-based interventions. Providers also
preferred the intervention to be as brief as possible. Interventions with multiple sessions may
suffer from low retention rate, because homeless men are usually highly transient. Furthermore,
given the limited staff resources, a brief HIV prevention intervention may reduce staff burden
and increase the likelihood of program sustainability.
In terms of the delivery strategy, corresponding to homeless men’s suggestions, providers
agreed that interactive and hands-on practice activities are critical. They concurred with
homeless men that most men might not have used condoms before or used them incorrectly.
However, they also suggested providing options for men when practicing condom use, because
for some heterosexual men, it may be uncomfortable to practice on anatomical models. They also
suggested strengthening the consequences of HIV through testimonials or video clips. In terms of
37
substance use risks, similar to homeless men participants, providers said discussing the
relationships between substance use and sexual risks coupled with a resource guide for men to
seek out substance use treatment or needle exchange programs may be critical. Another way to
address substance use risks is to couple HIV prevention programs with existing substance
recovery support groups provided in the shelters. However, providers also noted that it is likely
that not all men will want to participate in both programs.
Phase 1 Summary
Phase 1 focus groups and interviews confirmed that homeless men are at high risk of
acquiring and transmitting HIV (including having false perceptions regarding HIV transmission,
having negative attitudes toward condoms, engaging in unprotected sex, and viewing women as
responsible for initiating condom discussions), and that there are not enough HIV prevention
efforts for homeless men in the community. These findings suggest the high need to adapt and
implement an HIV prevention EBI for men using shelter services. Furthermore, shared opinions
between homeless men and shelter providers on topics that should be included in an HIV
prevention intervention and delivery strategies set the foundation for the next phase of selecting
HIV prevention EBIs. Given the perceptions among shelter providers of HIV prevention as a low
priority and limited organizational capacities and resources, it is critical that the HIV prevention
EBI selected for adaptation and future implementation requires minimal staff time and shelter
resources.
Phase 2: HIV Prevention EBI Review and Selection
Phase 2 Design
Phase 2 consisted of two subphases. Based on the feedback generated in Phase 1, Phase
2a involved reviewing and identifying potential HIV prevention EBI candidates. Phase 2b
38
involved conducting nominal consensus groups with homeless men and shelter providers
separately to review selected EBI candidates, identify the final EBI for further adaptation, and
generate input regarding modification of the final selected EBI.
In Phase 2a, HIV prevention EBIs were selected from the DEBI list (CDC, 2015b) for
review. These interventions were critically reviewed by the CDC synthesis project (Lyles et al.,
2006; Lyles et al., 2007). EBI selection criteria in this phase were based on the primary focus and
target population of this dissertation project and feedback from homeless men and shelter
providers regarding intervention preferences and organizational capacity collected during Phase
1.
In Phase 2b, selected EBI candidates were presented to homeless men and shelter
providers separately using nominal consensus groups (Carney et al., 1996; Fink et al., 1984;
Jones & Hunter, 1995; Totikidis, 2010). Because the findings from the shelter staff member
focus groups and director interviews during the previous phase were highly congruent and
shelter directors reported being able to attend the consensus groups, the consensus groups
included directors and staff members. Similar to the focus groups conducted during Phase 1, all
consensus groups had no more than eight and no fewer than five participants. In the consensus
groups, each EBI candidate was introduced and discussed in sequence. The final EBI that was
identified for further adaptation was determined based on self-ranking by homeless men and
shelter providers. Discussion regarding further modification of the final selected EBI was also
facilitated at the end of the consensus groups. Verbal informed consent was collected prior to the
consensus groups. All consensus groups were audio recorded, with detailed notes taken by the
cofacilitator. At the end of each group, the facilitators had a brief debriefing meeting to review
39
the notes. All groups lasted approximately 90 minutes. Homeless participants received $20 to
compensate them for their time and express appreciation for their input.
Phase 2a review and selection of EBI candidates. During this phase, a detailed review
of DEBI EBIs (CDC, 2015b) was conducted. An initial screening process was conducted to
identify potential EBI candidates for review. Currently, the DEBI list includes community, social
network, and individual interventions (CDC, 2015b). Because this dissertation project focused on
reducing sexual risk among homeless men, only individually focused interventions were
selected. Furthermore, because this project focused on homeless men, interventions designed
solely for women or youth were not included in the review. Interventions geared toward
individuals living with HIV/AIDS were also excluded because this project focused on homeless
men in general, regardless of HIV status. In addition, given that homeless men may engage in a
variety of sexual partnership patterns (i.e., MSM, MSW, and MSMW; Robertson et al., 2004;
Kennedy, Brown, et al., 2013; Maulsby et al., 2013; Wenzel et al., 2012), interventions that
solely addressed MSM were also excluded. Although homeless men constitute a racially and
ethnically diverse population, because this study was conducted in an urban area in which
African Americans are disproportionally influenced by homelessness (Wenzel, 2012),
interventions that specifically focused on African American populations were not excluded. To
address the potential cultural competence of selected EBI candidates, discussion regarding
cultural compatibility was facilitated during Phase 2b consensus groups.
Intervention topics critical to reducing HIV risks among homeless men were identified
during Phase 1; however, not all identified topics may be covered in one EBI. Furthermore, EBIs
covering a variety of topics can be lengthy (i.e., require completion of multiple sessions), which
can reduce future intervention sustainability at shelters. Therefore, when screening for EBI
40
candidates, EBIs did not necessarily need to cover all intervention topics identified during Phase
1. Previous research (Blakely et al., 1987) has indicated that adding new components (without
undermining the core elements) that address the target population’s specific needs may not
influence the effectiveness of the adapted intervention. Therefore, flexibility in terms of adding
new components was taken into consideration when selecting EBI for review, rather than the
comprehensiveness of an EBI. To ensure the selected EBI candidates would be able to be
implemented and sustained in shelter settings, EBI length, number of sessions, and ability to be
integrated into current shelter services were also taken into consideration. Although staff
members stated a preference for group-based interventions, both homeless men and staff
members also acknowledged the advantages of one-on-one interventions (e.g., in-depth
discussion, privacy). Therefore, both one-on-one and group-based interventions were included in
the review. Taking these criteria into consideration, five potential EBI candidates (Focus on the
Future, Nia, Respect, Safe in the City, and VOICES/VOCES) were reviewed in detail and
presented to homeless men and shelter providers during Phase 2b consensus groups (Crosby,
DiClemente, Charnigo, Snow, & Troutman, 2009; Kalichman, Cherry, & Browne-Sperling,
1999; Kamb et al., 1998; O’Donnell, O’Donnell, San Doval, Duran, & Labes, 1998; Warner et
al., 2008).
Phase 2b consensus groups. During this step, modified nominal consensus groups
(Cederbaum et al., 2014) were conducted with homeless men and shelter providers separately.
The consensus groups involved introducing the five EBI candidates to participants; ranking and
selecting the final EBI for adaptation; and discussing modification of the final identified EBI.
Compared to other qualitative decision-making methods, nominal consensus groups employ a
more structured procedure (de Ruyter, 1996) and therefore can be conducted in a more standard
41
fashion. Nominal consensus groups also involve a democratic process (Carney et al., 1996) in
which participants describe their concerns and potential solutions prior to the selection of the
final EBI. This democratic process also helps assess the goodness of fit (McKleroy et al., 2006;
Wingood & DiClemente, 2008) of each of the selected EBI candidates in terms of addressing
homeless men’s specific needs and meeting the resource constraints of shelters. The final EBI
was identified via ranking activities, with the highest-ranking EBI selected for further adaptation.
Homeless men consensus groups were conducted prior to shelter provider consensus
groups. All consensus groups were conducted following similar procedures (Cederbaum et al.,
2014). The facilitators first introduced each EBI to participants, followed by discussion regarding
the benefits and drawbacks of the specific EBI. To introduce the EBI candidates, a handout for
each EBI was developed and provided to participants. To reduce potential reflection bias, the
sequence of EBIs presented during each group differed (Cederbaum et al., 2004). In the first
consensus group, the candidates were presented based on alphabetical order of the EBI titles. In
the following groups, the first EBI presented in the previous group was introduced last, the
second EBI presented in the previous group was presented the first, and so on. Positive and
negative aspects of each EBI raised by participants were documented on a whiteboard or panel.
Once all EBIs were introduced and discussed, the facilitators discussed the benefits and
drawbacks of each EBI candidate with the participants again to prepare for the ranking activity.
Participants were then asked to rank the EBI candidates from 1 to 5, with 1 representing the EBI
that best fit homeless men’s needs and shelter capacity. The facilitators then tallied the ranking
results to identify the final EBI selected for adaptation (the EBI that received the most top-
ranking votes). Discussions regarding potential modification of the specific EBI were also
conducted. If more than one EBI received the same number of top votes, previous discussions
42
regarding those EBIs were reviewed with the participants. Ranking activities for those tied EBIs
were conducted again until one final EBI was identified.
Because it is possible for different groups to select a different final EBI for adaptation,
the ranking votes of all groups were combined and tallied again (homeless men and shelter
provider groups separately) after all groups were conducted, with the EBI receiving the most top-
ranking votes to be the final EBI for adaptation. If there were discrepancies regarding the top-
ranking EBI between homeless men and shelter provider groups, additional consensus groups
with homeless men and shelter providers separately would have been conducted until consensus
regarding the final EBI for adaptation was reached.
Homeless men participant recruitment and data collection procedures. Homeless men
were recruited for consensus groups using the same procedures implemented in Phase 1. The
eligibility criteria for Phase 1 men’s groups (at least 21 years old, had sex with a women or man
during the previous 30 days, planned to have sexual intercourse during the next 30 days, able to
speak and understand English, cognitively able to participate in discussion) also applied to the
consensus group recruitment. Individuals who participated in Phase 1 focus groups were eligible
to participate in the consensus groups. Among 37 homeless men who expressed an interest in
participating, six were deemed ineligible (five were not sexually active during the previous 30
days or did not plan to have sex during the next 30 days; one was unable to speak and understand
English). The remaining 31 individuals participated in the consensus groups. Three men had
participated in the focus groups during Phase 1. Verbal informed consent was collected at the
beginning of the groups. Before the discussion, men were also asked to complete the same brief
surveys used during the Phase 1 focus groups. All men were compensated with $20 for their time
43
and input at the end of their participation. One man left in the middle of the group session to
meet with his case manager and thus missed the ranking activity.
Homeless men consensus groups. During this phase, four homeless men consensus
groups were conducted (two at each site). Each focus group had seven to nine participants.
Because men’s opinions regarding intervention content were given more weight than those of
shelter providers, the EBI handouts developed for the men’s consensus groups described critical
elements, behavioral determinants, major topics, intervention format (e.g., number of sessions
and length), potential activities, and desired outcomes. The discussion was also focused on the
content of the EBIs. Because detailed manuals were not available through DEBI (CDC, 2015b)
or other means, it was not possible to introduce all of the activities that were covered in these
EBIs to the participants.
Shelter provider recruitment and data collection procedures. Shelter provider consensus
group participants were recruited using the same procedures implemented in Phase 1. The same
eligibility criteria used during Phase 1 applied to the consensus group recruitment. Due to the
small number of staff members in both collaborating shelters, most shelter staff members had
already participated in the Phase 1 focus groups. Fourteen staff members (including directors)
participated in the consensus groups. Verbal informed consent was collected prior to the groups.
At the beginning of the groups, each participant completed a brief survey (the same used during
Phase 1 shelter staff member groups). Because shelter providers participated to provide their
professional insights, incentives were not provided.
Shelter provider consensus groups. During this phase, two shelter provider consensus
groups were conducted (one at each site). Similar to the men’s consensus groups, each group had
seven participants. To ensure that the selected final EBI for adaptation fit with the capacity and
44
resources of shelters, in addition to the materials covered in the handouts disseminated in the
men’s groups, the EBI handouts developed for shelter provider groups discussed required
physical (e.g., meeting place, incentives) and staff (e.g., number of persons who should be
trained) resources and training costs. The discussion in shelter provider groups also focused on
the fit between the EBIs and shelter features. However, to supplement the comments of the
homeless men, intervention content was also discussed in provider groups.
Phase 2 Data Analysis
To analyze qualitative data from consensus groups, similar data analysis strategies
employed in Phase 1 were conducted. A case summary matrix (Miles et al., 2013) was developed
with rows representing homeless men and shelter provider consensus groups and columns
representing each of the EBI candidates. Content and thematic analysis (Boyatzis, 1998;
Krippendorff, 1980; Weber, 1991) was implemented to identify perceived positive and negative
aspects of each EBI candidate. The case summary matrix cells (Miles et al., 2013; Padgett, 2007)
therefore contained men and shelter providers’ perceptions of the benefits and drawbacks of the
EBIs. For the final selected EBI, the cells also included potential directions for modification. In
terms of the quantitative data collected via the brief surveys, simple descriptive analysis was
conducted to understand and describe participant characteristics.
Phase 2 Results
Phase 2a findings. As previously mentioned, based on the purpose of this project and
Phase 1 findings, the EBIs initially selected for review should be individually focused (i.e., not
community- or social network-focused interventions); not specifically focused on MSM, women,
or youth; not designed for individuals living with HIV; brief (i.e., no more than two sessions);
and require relatively simple training (i.e., no more than 3 days of training). Based on the
45
selection criteria, 5 of 33 EBIs listed on the DEBI site were identified. Because the EBIs listed
on the DEBI site (CDC, 2015b) that address substance use risks either focused on injection drug
users (e.g., MIP; Robles et al., 2004) or required multiple sessions (e.g., SHIELD and CLEAR;
Latkin, Sherman, & Knowlton, 2003; Lightfoot, Rotheram-Borus, & Tevendale, 2007), none of
the selected EBIs fully addressed substance abuse risks. However, activities included in
substance abuse focused EBIs (e.g., SHIELD) were also presented in Phase 2b when discussing
potential strategies to address substance abuse risks.
Focus on the Future (FOF). FOF (Crosby et al., 2009) is a 45-minute, one-session,
peer-led, one-on-one EBI. This intervention is also classified by the CDC compendium of
evidence-based interventions and best practices for HIV prevention as having the best evidence
(CDC, 2015b). The target population for this intervention is African American men recently
diagnosed with an STD who have used a condom at least once during the previous 3 months. The
target setting for this intervention is STD clinics. The major goal for this intervention is to reduce
sexual risks among participants through consistent and correct condom use. The theoretical
foundation for FOF is the information, motivation, and behavioral skills model (IMB; Fisher &
Fisher, 1992).
IMB was originally developed to explain the psychological determinants of HIV risks
and preventive behaviors (Fisher & Fisher, 1992) and has been adopted to understand other
health risks and behaviors (Fisher, Fisher, & Harman, 2003). IMB was also designed to be
applied to developing theoretically based interventions (Fisher & Fisher, 1992; Fisher et al.,
2003). IMB posits that individuals need to gain health-related information, be motivated to act,
and possess critical behavioral skills before a health behavior can be performed (Fisher & Fisher,
1992; Fisher et al., 2003). In this model, information should be directly relevant to a desired
46
health behavior. The health information should also be easy for individuals to translate into
action. In IMB model (Fisher et al., 2003), information can include knowledge or specific facts
or myths about certain health behaviors (e.g., Fact: Consistent condom use can help reduce HIV
transmission; Myth: You can judge an individual’s HIV status by that person’s appearance).
In addition to being well informed, an individual also needs to be motivated to change a
behavior. IMB posits that personal motivation (i.e., an individual’s attitudes toward a behavior)
and social motivation (i.e., social norms or social supports) are important in influencing the
health behavior performance of individuals (Fisher & Fisher, 1992; Fisher et al., 2003). However,
being well informed and motivated may not be sufficient for individuals to perform a health
behavior if critical skills to implement such a behavior are missing. In IMB, skill refers to
objective ability and self-efficacy (Fisher & Fisher, 1992; Fisher et al., 2003). IMB proposes that
information and motivation may influence health behavior performance through skills, especially
when skills required to implement certain behaviors are complex (Fisher & Fisher, 1992; Fisher
et al., 2003).
In FOF (Crosby et al., 2009), information regarding quality of condom use is provided
(e.g., condoms may have different shapes and sizes). Motivation is incorporated throughout the
intervention. The peer educators in the intervention are trained to be supportive, nonjudgmental,
and encouraging to motivate participants to learn and practice using condoms. A poster
describing HIV epidemics helps motivate men to use condoms to protect themselves and their
communities. Condom skills training via show-and-tell practice activities also helps men learn
and practice condom use skills. At the end of session, men receive a bag with 12 free condoms
(various shapes and sizes) and water-based lubricants.
47
The core components of FOF (Crosby et al., 2009) include using a trained peer educator
to implement one-on-one counseling sessions; developing rapport and a trusting relationship
with participants; teaching correct condom use and negotiation skills; providing multiple
condoms and lubricants; emphasizing that participants’ use of condoms can change the
community; demonstrating unconditional respect to participants; maintaining a nonjudgmental
environment; and using teachable moments (e.g., waiting in STD clinics for individuals who just
received a positive diagnosis). FOF has a demonstrated positive influence on reducing
subsequent 6-month STD diagnosis, promoting condom use skills, and reducing the number of
sexual partners and frequency of unprotected sexual intercourse (Crosby et al., 2009).
In terms of resources required for implementing FOF (CDC, 2015b), two people (one
supervisor or manager and one peer educator) need to be trained. The supervisor or manager
should be a staff member of the organization. The training requires 3 days (2 and a half days for
the peer educator and half a day for the manager). Training is free but because it may not be
provided locally, organizations may have to secure funding for transportation and lodging. In
terms of physical resources, to implement FOF, private space, intervention packages, and
condoms of different shapes and sizes are needed.
Nia. Nia (Kalichman et al., 1999) is a 6-hour, two-session, video-based, group-level
intervention. This intervention is considered to have good evidence in the CDC compendium of
evidence-based interventions and best practices for HIV prevention (CDC, 2015b). Each session
takes 3 hours to complete. The target population for this intervention is inner-city, heterosexually
active African American men (Kalichman et al., 1999). However, MSMW are not excluded. The
original setting of this intervention is community centers that provide multiple social services
(Kalichman et al., 1999). Ideally, this intervention should be implemented in areas with high
48
HIV prevalence rates. Similar to FOF, Nia was developed based on the IMB model (Fisher &
Fisher, 1992; Fisher et al., 2003). However, Nia was also informed by motivational interviewing
and previous behavioral skills-building interventions (Carey et al., 1997; Miller, Zweben,
DiClemente, & Rychtarik, 1992).
In the first session (Kalichman et al., 1999), information regarding HIV knowledge (e.g.,
HIV transmission risks) is provided through a 20-minute question-and-answer video clip.
Participants’ HIV risks are also assessed using an individual feedback form, which is derived
from a baseline survey that participants complete at intake. Correct answers are provided on a
returned feedback form. Participants do not have to disclose or discuss their answers in the group
session. However, with this form and feedback, individuals become aware of their false HIV
knowledge and facilitate group discussion.
Participants then watch a second video clip showing African American men at different
HIV stages, followed by a group discussion of how HIV influences African American men
(Kalichman et al., 1999). The third segment is a rap video that reinforces correct HIV knowledge.
Participants complete a second feedback form that addresses HIV risk behaviors and men’s
personal sexual risks. Similar to the first feedback form, men do not need to disclose their
personal risks. Nonetheless, sexual risk behaviors are discussed.
The second session (Kalichman et al., 1999) covers motivation and skill components.
This session starts with a review of the previous session, followed by completing a third
feedback form. The third feedback form assesses men’s attitudes regarding condoms. Perceived
positive and negative aspects of condoms are discussed. Participants also complete a five-stage
problem-solving skills training activity. Condom skills training is first delivered through a short
video clip and group facilitator demonstration, followed by actual practices (e.g., putting
49
condoms on a wooden model). Discussion regarding barriers to using condoms and potential
strategies to address those barriers is also facilitated. The intervention ends with condom
negotiation skills training using video clip demonstrations and discussion.
The core components of Nia (CDC, 2015b; Kalichman et al., 1999) include using small
group sessions conducted by culturally competent male and female facilitators; addressing HIV
risk misperceptions using gender and culturally appropriate video clips and personal feedback
forms; motivating sexual risk reduction by helping participants identify their behaviors with
community HIV epidemics; and building problem solving, condom use, and condom negotiation
skills.
Nia participants have been found to have lower unprotected vaginal intercourse rates and
higher condom use rates than a comparison group at 3-month follow-up. However, the difference
between the two groups was not statistically significant at 6-month follow-up (Kalichman et al.,
1999).
In terms of the resources needed to implement Nia, organizations may need to have two
staff members (one man and one woman) participate in the 24-hour training. The training may
not be free. Similar to FOF, the organization may also need to pay for lodging, transportation,
and meals for the training. In terms of physical resources, organizations may need to have a
private space that can accommodate six to eight participants, some office supplies, and a
computer or DVD player.
Respect. Currently, Respect (Kamb et al., 1998) has two versions listed on the DEBI site
(CDC, 2015b): one with enhanced counseling, which has four sessions, and one brief version
with only two sessions (each session lasts about 20 minutes). Based on the aforementioned
selection criteria, only the brief version was reviewed. The brief Respect (Kamb et al., 1998) is
50
identified as having best evidence by the CDC compendium of evidence-based interventions and
best practices for HIV prevention (CDC, 2015b). It is a one-on-one, client-focused intervention.
The target population of Respect is heterosexually active STD clinic patients (men and women
are included). However, MSM and men who identified as bisexual were excluded in the original
study. The original intervention was delivered in STD clinics with trained HIV counselors.
Respect is informed by social cognitive theory (SCT; Bandura, 1978, 1982, 1986) and the theory
of reasoned action (TRA; Fishbein, 1980; Fishbein & Middlestadt, 1989).
SCT (Bandura, 1978, 1982, 1986) posits that through cognitive processes, individuals’
behaviors are shaped by personal characteristics and the environment around them. More
specifically, SCT emphasizes the importance of self-efficacy, outcome expectancy, observational
learning, and individual capacity for formulating and determining individuals’ behaviors.
Outcome expectancy and self-efficacy are identified in SCT as the most important determinants
of human behavior (Bandura, 1978). The concept of outcome expectancy (that certain outcomes
will occur by implementing a behavior) is similar to individuals’ attitudes toward the target
behavior (de Vries, Dijkstra, & Kuhlman, 1988). Positive attitudes toward a certain behavior
may lead to initiation or sustainment of that behavior.
Having a positive attitude toward a certain health behavior may not be sufficient
motivation for individuals to implement that behavior. With low self-efficacy, namely
confidence that the behavior can be practiced when facing challenges, individuals may not be
able to initiate or sustain the desired behavior, especially when presented with barriers (Bandura,
1978). On the other hand, an experience of success or positive reward generated by
implementing a behavior can assist an individual in developing his or her sense of self-efficacy
(Bandura, 1978, 1982, 1986). Derived from social learning theory (Bandura, 1978), SCT also
51
suggests that individuals can learn to implement certain behaviors from peers or by watching
videos (Bandura, 1978; McAlister, Perry, & Parcel, 2008). Observational learning can also help
individuals to develop self-efficacy. Through observational learning, individuals can learn skills
critical to performing a health behavior. Individuals can learn strategies from observations to
overcome barriers to implementing a health behavior as well. The flexibility of SCT (not having
a specific theoretical diagram) and its emphasis on self-efficacy has resulted in this theory being
widely applied to health behavior promotion interventions, including HIV prevention (McAlister
et al., 2008).
Compared to SCT, TRA (Fishbein, 1980; Fishbein & Middlestadt, 1989) provides a
detailed theoretical model that helps explain individuals’ behavioral decision making. The major
constructs covered in TRA include behavioral intention, attitude, and social norms (Fishbein,
1980; Fishbein & Middlestadt, 1989). According to TRA, behavioral intention is the strongest
predictor of an individual’s behavioral performance. However, intention is associated with
individuals’ attitudes toward and perceived social norms regarding a specific health behavior.
Attitudes toward a behavior refer to individuals’ expectation of the behavior’s outcomes (e.g.,
using condom can still be pleasurable), whereas a subjective norm refers to individuals’
perceptions regarding how others view the health behavior (e.g., network members support safe
sex; Fishbein, 1980). Multiple studies have adopted TRA to understand determinants of different
health behaviors, including condom use behaviors (Fishbein & Middlestadt, 1989). TRA has also
been used to develop interventions to promote health behaviors (Lyles et al., 2006; Lyles et al.,
2007; Webb & Sheeran, 2006).
Based on SCT (Bandura, 1978, 1982, 1986) and TRA (Fishbein, 1980; Fishbein &
Middlestadt, 1989), Respect focuses on three major constructs: attitudes, perceived norms, and
52
self-efficacy (Kamb et al., 1998). The first session focuses on assessing individuals’ actual and
perceived sexual risks, identifying barriers to risk reduction, and developing a risk reduction plan
(Kamb et al., 1998). To assess individuals’ risks, the counselor reviews each client’s most recent
risk incident and previous risk reduction experiences. Ideally, HIV testing should be incorporated
in Respect to create a teachable moment (Kamb et al., 1998). HIV testing is provided during the
first session and the result is provided and discussed in the second session (Kamb et al., 1998).
The second session focuses on discussing the testing results, reviewing and revising the
developed plan, and providing resources and referrals (Kamb et al., 1998). Given the
incorporation of HIV testing into the intervention, Respect is most suitable for organizations that
are already providing HIV or STD prevention services. The core components of Respect include
conducting one-on-one counseling; using teachable moments to motivate behavioral change;
reviewing the context of recent risk behaviors to increase perceived susceptibility; developing an
achievable risk reduction plan; and maintaining quality assurance (Kamb et al., 1998).
Respect has demonstrated positive effects on increasing consistent condom use and
preventing subsequent STD diagnosis (Kamb et al., 1998). This intervention was found to have a
better effect on younger participants and individuals who were STD positive at enrollment
(Kamb et al., 1998). To implement Respect, organizations should have a staff member
participate in a 1-day free training session. However, similar to other selected EBI candidates,
organizations have to cover all lodging, meals, transportation, and other incidental expenses
associated with attendance. Organizations should also have private meeting space for individual
counseling, office supplies, computers, and program package and related materials (e.g.,
condoms, lubricants, and HIV testing kits).
53
Safe in the City (SITC). SITC (Myint-U et al., 2008; Warner et al., 2008) is a 23-minute,
video-based intervention containing STD prevention messages that is designed for screening in
STD clinic waiting rooms to patients of different racial and ethnic groups and sexual
orientations. SITC is informed by the integrative theoretical framework (Fishbein et al., 2001).
The integrative theoretical model is a model developed via consensus among leading
behavioral theorists (Fishbein et al., 2001). This model combines constructs from major
behavioral change theories, including SCT (Bandura, 1986), IMB (Fisher & Fisher, 1992), and
the theory of planned behaviors (TPB; Ajzen, 1985). The integrative theoretical model (Fishbein
et al., 2001) emphasizes the influence of environmental constraints, skills required to perform
health behaviors, perceived social norms, attitudes and emotions toward health behaviors, self-
image regarding health behavior practice, and self-efficacy on individuals’ intention to practice
health behaviors. Similar to TRA and TPB (Ajzen, 1985; Fishbein & Middlestadt, 1989),
behavioral intention in the integrated theoretical model is viewed as the most critical predictor of
health behavior implementation.
Based on the integrated theoretical model (Fishbein et al., 2001), SITC (Myint-U et al.,
2008; Warner et al., 2008) focuses on increasing individuals’ HIV knowledge and perceived
risks; promoting positive attitudes and perceived norms toward condom use; and increasing self-
efficacy, self-control, and skills in condom use and condom negotiation. SITC includes three
major video clips that depict vignettes of couples of different races and ethnicities and sexual
orientations in dating and casual relationships. In these vignettes, HIV risks are described and
actors model condom negotiation, STD testing, and condom skills (Myint-U et al., 2008; Warner
et al., 2008). SITC also includes two 30-second animations that focus on correct condom
selection and use (Myint-U et al., 2008; Warner et al., 2008). Because SITC is a self-looping,
54
video-only intervention, it does not have core elements that can be altered during adaptation
(Myint-U et al., 2008; Warner et al., 2008). The brief and video-only nature of this intervention
also makes SITC easy to be integrated in different settings. SITC has demonstrated positive
influences on reducing the incidence of new STD infections (Warner et al., 2008). Because SITC
is a video-only intervention (Myint-U et al., 2008; Warner et al., 2008), the resource requirement
is minimal. This intervention does not require staff resources and training. All video clips are
free to download through DEBI. The only equipment needed is a television with a DVD player.
VOICES/VOCES. An acronym for Video Opportunities for Innovative Condom
Education and Safer Sex, VOICES/VOCES (hereafter referred to as VOICES; O’Donnell et al.,
1998) is a 45-minute, group-level (three to eight participants), video-based, single-session,
gender- and ethnic-specific intervention. VOICES is considered to have best evidence by the
CDC compendium of evidence-based interventions and best practices for HIV prevention (CDC,
2015b). The original target population of VOICES was African American and Hispanic patients
attending STD clinics (O’Donnell et al., 1998). The facilitator of group sessions should match
the gender and ethnicity of participants. Built on previous intervention research on the
effectiveness of video-based intervention (O’Donnell et al., 1998) and guided by TRA (Fishbein,
1980), VOICES emphasizes condom use and condom negotiation skills. Depending on
participants’ race and ethnicity (African American or Hispanic), VOICES starts by screening
culturally appropriate video clips portraying condom use and negotiation between partners,
followed by group discussion. Reflecting on the video clip, the facilitator engages with
participants to introduce different condom sizes and features, identify condom use barriers, and
consider strategies to overcome those barriers. The facilitator also demonstrates putting condoms
on anatomical models and encourages participants to practice as well. Condom negotiation is
55
described through role-play and practice exercises. At the end of the intervention, the facilitator
distributes condom coupons for participants to acquire condoms of different sizes and features at
collaboration sites (e.g., drug stores). The brief and culturally competent nature of VOICES
(O’Donnell et al., 1998) makes it easy to be incorporated in different settings (e.g., community
centers, STD clinics, substance abuse treatment centers, private residence, or colleges) and
populations (Harshbarger, Simmons, Coelho, Sloop, & Collins, 2006).
The core elements of VOICES include viewing culturally specific videos demonstrating
condom negotiation; conducting group sessions to develop condom use and negotiation skills;
providing information about different types of condoms; and distributing condoms of different
sizes and features (CDC, 2015b; O’Donnell et al., 1998). VOICES has demonstrated positive
influences on reducing sexual risks (e.g., unprotected sex, STD infection), promoting positive
condom attitudes and condom efficacy, increasing STD and condom knowledge and HIV and
STD risk perceptions, and facilitating condom-acquiring behaviors among African American and
Hispanic populations (O’Donnell et al., 1998).
To implement VOICES, organizations should have trained staff members. However,
training is provided online without charge. Because VOICES is a group-level, video-based
intervention, organizations will need a space for six to eight people and DVD players or
computers (Education Development Center, Incorporated, 2009). Organizations should also
secure funding to purchase the intervention package, condoms, and related materials.
Phase 2b findings.
Demographics. Table 2 illustrates the demographic characteristics of homeless men and
shelter provider participants. Most homeless men participants were in their late 40s (M = 44.61,
SD = 9.47). Approximately 65% of the men identified as Black, 9.7% as White, and 19% as
Latino. Unlike the homeless men focus groups during Phase 1, in which participants were mostly
56
Black or White, more Latino men participated in the consensus groups because during
recruitment at one site, a Latino participant invited his peers to be screened and participate in the
group. Therefore, for that specific group (seven participants), all participants were Latino except
for one man. Similar to Phase 1, most men had experienced at least 3 to 6 months of
homelessness during their lifetime and approximately 71% described having experienced
homelessness for at least 3 months during the previous 6 months. Approximately two thirds of
the participants said they had not used condoms consistently during the previous 30 days.
Finally, all men reported using subsistence services (meal, shower, clothing, and overnight stay)
at shelters. Unlike Phase 1, only 16% of the participants reported having used substance abuse
recovery services.
In terms of shelter provider consensus groups, because many providers also participated
in Phase 1 focus groups, the demographic characteristics were similar to Phase 1. The
participants were predominantly male (more than 70%). Approximately one third of the staff
members were Black and around 57% were White. Staff member racial and ethnic differences
between the two shelters were similar to those found during Phase 1; participants in one provider
group were predominantly Black, whereas most respondents in the other group were White
(results not shown in the table). All shelter provider participants reported having at least a high
school diploma or GED. Average tenure in the organization was 4.08 years (SD = 5.64).
Although no formal HIV prevention services were provided at either shelter, almost all staff
members (85.7%) reported talking about sexual risk reduction with homeless male clients and
reminding them of places to get free condoms.
Homeless men consensus group findings. Based on the EBI introduction handouts, men
discussed in detail the perceived benefits and drawbacks of each EBI candidate. Regarding FOF
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(Crosby et al., 2009), men said they appreciated the peer educator component. Men also reported
that they liked that FOF covers condom skill training with hands-on practice activities in detail.
The provision of bags with free condoms was also welcomed by participants. However, some
men said they did not appreciate the one-on-one format of FOF. It might be uncomfortable for
men to discuss sexual risks in depth directly with facilitators. Men also said HIV facts and myths
should be discussed more, rather than simply being demonstrated via a poster. Furthermore,
participants noted that discussion of HIV consequences and substance use risks was missing in
this intervention. The cultural competence of FOF (and other interventions as well, except for
VOICES) was raised as a potential issue by the group predominantly composed of Latino men.
However, in other groups, men argued that because sexual risks behaviors among homeless men
would be similar across race and ethnicity, cultural competence should not be a problem for FOF
(and other interventions).
Regarding Nia (Kalichman et al., 1999), men said this intervention covers almost every
aspect of HIV prevention except for substance use risks. Some men also said they liked the
group-based approach because interacting with individuals with similar backgrounds might
facilitate more strategies to address sexual risks and barriers. Men also expressed interest in the
incorporation of different activities (i.e., video clips, hands-on condom practice, and feedback
forms) in this intervention. However, they said the length of the program might be an issue.
Three-hour discussions per session might cause some men to drop out of the program. Although
some men said they preferred a group format, others expressed concerns regarding talking about
sexual risks in detail and practicing condom use in groups. Similar to FOF, the cultural
appropriateness of Nia was also discussed.
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In terms of Respect (Kamb et al., 1998), men said they liked its individually tailored in-
depth discussion regarding personal HIV risks, even though some men expressed concerns
regarding not feeling comfortable sharing personal risk behaviors with facilitators. Participants
also expressed a preference for developing an achievable step-by-step action plan to reduce
sexual risks. Although some men said they favored incorporating HIV testing to increase men’s
understanding of their HIV susceptibility, some men reported that they would prefer not to be
tested or to share results with others. Respondents also noted that condom skills training and
negotiation were missing in Respect. Finally, the participants said they liked the brevity, in terms
of the length of each session, of Respect.
Regarding SITC (Myint-U et al., 2008; Warner et al., 2008), group participants reported
that this intervention had few benefits except for its brevity. Although SITC covers many
domains of HIV risk reduction, targets diverse populations, and integrates condom skills training
and negotiation, the participants were not confident that men would be able to pay attention to
the videos, let alone learn and perform the described skills. Men also questioned the potential
implementation setting. Unlike STD clinic waiting rooms, where SITC was originally designed
to be implemented (Myint-U et al., 2008; Warner et al., 2008), there are usually children and
youth at shelters, making playing the video clips not appropriate in open areas (e.g., cafeteria).
In terms of VOICES (O’Donnell et al., 1998), participants said they liked the group
discussion following viewing the videos. Because VOICES has three culturally specific videos
(including English and Spanish versions), men in the Latino-dominant group reported high
preferences for this intervention. Similar to other EBI candidates, the group-based nature
attracted some men who preferred to discuss issues with peers. Furthermore, because this
program heavily emphasizes condom skills training and negotiation rather than sensitive
59
personal risks, some men said they would feel comfortable participating in groups. Men also said
they liked the free condom voucher component of VOICES. However, the negative aspects
expressed about this intervention were that it failed to address HIV risks and consequences and
substance risks in detail. Finally, participants noted that VOICES is not individually tailored to
respond to individual risk profiles.
Shelter provider consensus group findings. Shelter provider consensus groups focused
on the fit of selected EBI candidates with current shelter resources and homeless men’s needs.
Regarding FOF (Crosby et al., 2009), similar to homeless men’s comments, provider participants
expressed a preference for the peer educator component, because peer educators may be familiar
with men’s sexual risk context, develop better rapport with men, and provide a more comfortable
discussion environment. Furthermore, by using peer educators, this program might not create as
much of a burden on staff members. The providers also said they liked the provision of free
condoms, because men could put the learned skills into practice after the intervention. Otherwise,
men might not have the time or motivation to get condoms before sex, especially when the
sexual encounters are opportunistic rather than planned. Because FOF focuses on African
Americans in general, regardless of their sexual partnership patterns (as long as participants
expressed having at least one vaginal sexual experience), this program might be attractive to men
with diverse sexual partnerships. However, providers expressed concerns regarding the definition
of peer educator. If only men who are currently using shelter services are considered as potential
peer educators, it may be hard for shelters to implement this intervention, because the turnover
rate may be high for trained peer educators considering the highly transient nature of homeless
populations. The major provider concerns about FOF were related to required resources. Both
shelters may not have enough funding and staff resources for training. Furthermore, if peer
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educators receive payment to implement the program, both shelters do not have resources to hire
additional peer educators. On the other hand, if peer educators implement FOF voluntarily, the
retention rate for these volunteers may be an issue.
With regard to Nia (Kalichman et al., 1999), providers said they liked the
comprehensiveness of the program, because it covers most topics raised during Phase 1.
Providers also reported a preference for the group format of Nia, stating they believed interaction
among group participants could help men develop more strategies and be motivated to reduce
sexual risks. The providers also said they liked that Nia covers HIV knowledge and transmission
risks in detail through individualized feedback forms. However, Nia was perceived to be the least
likely sustainable EBI in shelters by provider participants, because it involves two sessions that
last about 3 hours each. Providers from both shelters expressed not having staff resources to
implement Nia. Many frontline staff members also expressed no interest in implementing this
program, because Nia would require them to lead two 3-hour group discussions a week.
Resources required for training also pose a major barrier for shelter providers to implement Nia.
In terms of Respect (Kamb et al., 1998), providers said they liked that it reviews personal
triggers and the context of participants’ most recent sexual risk practices. Providers also said
they believed that through HIV testing and discussion of results, individuals might have strong
motivation to change their risky behaviors. Similar to comments during group sessions with
homeless men, providers also said they liked how Respect helped participants develop
achievable plans with opportunities to modify those plans. Finally, the providers stated a
preference for the harm reduction approach adopted in Respect.
Although the incorporation of HIV testing made Respect stand out from other EBI
candidates, HIV testing may also become a barrier for shelter providers to implement and sustain
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the intervention. To combine Respect with HIV testing, organizations should have a qualified
HIV consultant (Kamb et al., 1998). At the time of this study, both shelters were not providing
on-site HIV prevention services; therefore, none of the staff members was a certified HIV
counselor. Although both shelters were occasionally visited by HIV testing vans, which may be
an opportunity for integrating Respect with HIV testing, the frequency of mobile testing visits
had decreased in recent years. At one shelter, the most recent mobile testing van visit was 6
months prior. Given the high turnover rate of staff members at shelters, it may be hard to
maintain trained staff members to conduct HIV counseling. Furthermore, shelters may not have
the resources for staff members to be trained, whether in HIV counseling or Respect. Because
Respect is a two-session program (Kamb et al., 1998), with HIV testing conducted at the end of
the first session and results disclosed during the next session, the providers said they were not
confident that men would attend the second session, especially if they are fearful of learning their
test results and knowing that they will need to discuss the result with the counselor.
Regarding SITC (Myint-U et al., 2008; Warner et al., 2008), providers said they liked
that this intervention covers diverse sexual relationships and is not limited to a specific race or
ethnicity. The minimal physical and staff resource requirement of SITC also was attractive to the
providers. Because no training is needed to implement SITC, providers stated that this
intervention is likely to be sustainable in shelters with limited resources. However, because SITC
is a video-only intervention, providers concurred with homeless men’s concerns regarding
whether the sexual risk reduction messages or skills delivered can actually be absorbed and
performed by men. Because both shelters provide subsistence services to homeless families with
children, the providers agreed with homeless men that the video clips included in the program
might not be appropriate for open areas, such as dining areas. If shelters only play the SITC
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videos in an activity room to ensure only men view them, the intervention may lose its advantage
of not needing staff resources, because shelters will need a staff member to chaperone men
during the intervention.
In terms of VOICES (O’Donnell et al., 1998), the providers said they believed that
coupling videos with a group discussion is a cost-effective approach to reducing sexual risks
among homeless men. The information and skills delivered through the video clips can be
reinforced by the discussion and hands-on practice. The culturally specific video clips also would
help this intervention attract homeless men with different racial and ethnic backgrounds.
However, compared with FOF (Crosby et al., 2009), provider participants expressed concern that
the provision of vouchers for condoms of various sizes and features may not be as effective as
simply providing condoms. Because the training is free and can be completed online, the
providers said that this procedure would help increase the probability that VOICES would be
sustainable in shelters. If a staff member leaves the organization, the new staff member would be
able to take the online training to implement VOICES. The brevity and group format of VOICES
would also help reduce the staff burden related to implementing this intervention. The major
concern regarding VOICES expressed by the providers was that the intervention does not
provide detailed information about HIV knowledge and personal risks. Furthermore, the
providers said VOICES should encourage men to take responsibility for initiating condom use.
Ranking results. Table 3 illustrates the ranking votes by groups. Table 4 demonstrates
total ranking votes among homeless men and shelter providers. As previously described, one
man left the group before the ranking activity and therefore did not participate in the ranking
activity. In addition, because another man ranked all interventions as his top choice, his votes
were excluded. The total number of votes in the homeless men consensus groups was therefore
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29. Among the four homeless men consensus groups, three groups selected VOICES (O’Donnell
et al., 1998) due to its brevity, integration of videos and group discussions, hands-on skill
training and negotiation role-play, and provision of free condoms of various sizes and features.
One group, however, chose Respect as the top-ranking EBI for further adaptation because it is
more individually focused and helps participants develop a step-by-step achievable plan. Among
the three homeless men groups that identified VOICES as the final EBI for adaptation, one group
had a tie between VOICES and Respect after the first vote. However, in the second vote,
VOICES received more votes than Respect (six vs. three, respectively). Although not all groups
selected VOICES as the final EBI for further adaptation, after tallying the total votes among
homeless participants, VOICES received the most top-ranking votes (results not shown in the
table). Even though Respect is more individually tailored and facilitates discussions on
developing an achievable plan, some men expressed not feeling comfortable talking about HIV
risk behaviors, taking HIV tests, and discussing test results with facilitators. Men expressed that
compared to Respect, they preferred discussing personal sexual risks using the activities in Nia,
which include providing personal feedback forms and discussing the forms in groups without
having individuals disclose their sexual risk behaviors.
In terms of the provider consensus groups, both groups chose VOICES as the final EBI
for adaptation. However, one group did not reach the final decision until the second vote. For
that specific group, in the first ranking there was a tie between SITC and VOICES. VOICES
received more top-ranking votes than SITC in the second round (five vs. three, respectively).
Although SITC covers diverse sexual partnerships and requires minimum staff and
organizational resources, providers expressed concern about the lack of discussion and hands-on
practice components. Furthermore, one of the video clips included in VOICES is the SITC video.
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Although new elements could be added to SITC, providers noted that VOICES is also brief,
requires minimum resources, and incorporates video clips with discussion and hands-on practice.
Adaptation direction. All consensus groups except for one homeless men group chose
VOICES as the final EBI for further adaptation. Therefore, in those groups, potential directions
for adaptation of VOICES were discussed. All groups were notified by the facilitators that the
listed core elements are critical components that ensure the interventions achieve their desired
outcomes and hence are not subject to modification. Both men and providers suggested making
VOICES more individually tailored; stressing HIV knowledge and transmission facts; adding a
substance use risk component; and providing local community resources related to HIV
prevention.
Both homeless men and service providers argued that because VOICES is a single-
session program (O’Donnell et al., 1998), men would only have one opportunity to acquire
knowledge and skills to reduce their sexual risks. However, homeless men might be diverse in
terms of level of HIV knowledge and sexual risk behaviors. Participants expressed concern that
if men are not engaged at the beginning of the intervention, it might be difficult for them to
concentrate on the messages or skills covered in VOICES. This suggestion is consistent with the
IMB model (Fisher & Fisher, 1992), which argues that individuals need to be motivated to
perform health behaviors. Individuals’ motivation can be triggered through social supports and
personal attitudes toward health behaviors or perceived susceptibility (Fisher & Fisher, 1992) to
health consequences. The original VOICES intervention might not encounter this issue because,
similar to other single-session HIV prevention interventions (Crosby et al., 2009; Eaton et al.,
2012; O’Donnell et al., 1998; Warner et al., 2008), it emphasizes the importance of teachable
moments. The original target population of VOICES was STD patients. These patients might
65
already be anxious about their STD symptoms or diagnoses (high perceived susceptibility or
consequences), thus constituting a teachable moment to motivate participants to concentrate on
health information and skills delivered in the intervention.
Considering that homeless men may not be as engaged as individuals attending STD
clinics, revising VOICES to respond to individual homeless men’s context may create a
teachable moment (i.e., raise men’s awareness of their personal HIV risk behaviors or risk level)
to engage and motivate homeless men. Specifically, homeless men and providers who
participated in consensus groups identified the personal feedback forms used in Nia as a
promising strategy to increase the individual focus of VOICES while maintaining participants’
sense of privacy.
Adding components that promote HIV knowledge and address myths of HIV
transmission can also address the limitation of the original VOICES intervention. VOICES
focuses specifically on promoting condom use and condom negotiation behaviors; therefore,
other HIV-related risks are not discussed in detail in the groups, although participants can
discuss other related sexual risks after the group with facilitators one-on-one (Education
Development Center, Incorporated, 2009). However, because false knowledge regarding HIV
transmission is prevalent among homeless men (Brown et al., 2012), it is critical to incorporate
HIV myths and facts into HIV prevention interventions for homeless men. Because adding
components may lengthen the time needed to implement VOICES, both homeless men and
providers suggested that using Nia’s personal feedback forms may not only address the previous
concern (more individually tailored), but also deliver HIV knowledge and describe HIV
transmission risks. In addition to HIV knowledge and transmission risks, the providers suggested
noting HIV statistics in the community (e.g., Skid Row) or among the racial and ethnic groups
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corresponding to participants’ race and ethnicity. This information can be delivered through a
brief information sheet or a poster (similar to the one used in FOF; Crosby et al., 2009).
In terms of substance use risks, none of the selected EBIs address this issue. Considering
time constraints to ensure HIV prevention programs are sustainable in shelter settings, it may be
difficult to incorporate a full discussion of substance use risks among homeless men, as in other
EBIs listed by DEBI (CDC, 2015b; Latkin et al., 2003; Lightfoot et al., 2007; Robles et al.,
2004). Furthermore, both shelters did not have enough resources to provide needle exchange
services. During the Phase 1 focus groups, homeless men suggested providing a resource sheet
that describes local needle exchange programs and recovery services, whereas providers
suggested coupling an HIV prevention intervention with existing substance recovery support
groups. Both potential strategies were discussed in Phase 2b. Providers acknowledged that by
combining substance abuse groups with HIV prevention groups, the participants might be limited
to men who already have substance use issues because men who do not perceived having
substance use issues may not participate in the support group. Both homeless men and providers
suggested that engaging in a very brief discussion about how substance use relates to sexual
risks, coupled with a resource sheet listing substance abuse treatment services and needle
exchange programs, may be feasible and helpful.
During the consensus groups, homeless men and shelter providers also discussed adding
a resource sheet that can direct men to services related to HIV prevention. Based on the
discussion, the resource sheet should list places that provide free condoms, local needle
exchange programs, HIV testing sites, STD clinics, and substance abuse treatment locations.
Although not a major suggested modification, some men raised the issue of adding a discussion
regarding female condoms in VOICES because they said some men may prefer the feeling of
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“ejecting in” women. However, providers did not support this idea; teaching men how to use
female condoms may not help female partners use those condoms because many women have
never used female condoms before. Instead, providers suggested describing the use of dental
dams in VOICES, stating that this component would reduce sexual risks among homeless MSW,
MSM, and MSMW.
Although not specifically included in this dissertation project, these modification
suggestions were discussed with a local HIV services expert for further consultation, as
suggested by the ADDAPT-ITT model (Wingood & DiClemente, 2008). The expert agreed with
most of suggestions, such as making VOICES more individually tailored and adding discussion
of substance use and HIV transmission risks. However, the expert suggested that homeless men,
especially heterosexual men, might not feel comfortable practicing condom use on an anatomical
model and recommended providing options such as putting condoms on other materials (e.g., a
banana). Finally, the expert did not support adding training on the use of female condoms and
dental dams to VOICES. The expert argued that given the time constraints, incorporating another
skills training would prolong VOICES to more than an hour. The expert stated that because
female condoms are not widely available and required certain procedures and skills to use, men
may not be able to acquire them and pass the skills to women. The expert also said that even
though women are able to use female condoms, the appearance may prevent men from using
them during subsequent sexual encounters. In terms of dental dams, the expert stated that similar
to female condoms, they are rare and not likely to be used by men. Therefore, the expert
suggested describing places to acquire dental dams or female condoms in the resource sheet
without going into in-depth discussion of these items with intervention participants.
Phase 2 Summary
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During Phase 2, based on the dissertation project focus and feedback generated from
homeless men and shelter providers during Phase 1, five EBI candidates (Crosby et al., 2009;
Kalichman et al., 1999; Kamb et al., 1998; O’Donnell et al., 1998; Warner et al., 2008) were
reviewed in detail and presented to homeless men and shelter providers during consensus groups.
Although discrepancies regarding the preferred EBI for adaptation were identified between
homeless men and providers, consensus regarding the final EBI for further modification
(VOICES; O’Donnell et al., 1998) was identified.
Homeless men and providers suggested certain modifications to ensure VOICES better
met the needs of homeless men and reflected shelter capacities and resources. The consensus
groups concluded that HIV knowledge and transmission risks, local HIV statistics, substance use
risks, and local resources to prevent HIV should be added to VOICES. Providers and homeless
men also suggested tailoring VOICES to reflect individuals’ HIV risk profile and knowledge so
that intervention participants can relate to the intervention, which may create a teachable moment
for participants to absorb the message and skills covered in VOICES.
Phase 3: Manual Development and Pretesting
Phase 3 Design
Phase 3 consisted two major subphases. Based on the feedback generated during the
consensus groups, Phase 3a involved revising the original VOICES program (O’Donnell et al.,
1998) and developing a draft manual for an adapted VOICES intervention for homeless men
(hereafter referred to VOICES-HM). Phase 3b involved pretesting VOICES-HM with homeless
men and providers using focus groups with the goal of collecting final comments to finalize the
manual.
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During Phase 3a, based on information collected from homeless men and shelter
providers during the previous phases, activities that could address the concerns raised by men
and providers were carefully reviewed and added to the original VOICES manual (Education
Development Center, Incorporated, 2009). Core elements of VOICES (i.e., viewing culturally
specific videos demonstrating condom negotiation, conducting group sessions to develop
condom use and negotiation skills, providing information about different types of condoms, and
distributing condoms of different sizes and features (Education Development Center,
Incorporated, 2009) were not modified to ensure the adapted VOICES-HM would produce
similar outcomes as the original intervention.
During Phase 3b, to pretest the adapted VOICES-HM manual draft with homeless men
and providers separately, four focus groups were conducted (two with men and two with
providers). In the focus groups, the facilitators adapted the theater-testing method proposed in
ADAPT-ITT (Wingood & DiClemente, 2008) to present the VOICES-HM manual draft. The
facilitator described the adapted VOICES-HM with participants step by step, including
presenting all of the intervention materials (i.e., posters, brief surveys, resource guides, handouts,
and video clips). Discussion focused on the appropriateness and feasibility of the intervention
materials. During the focus groups, in addition to demographic surveys, homeless men and
providers also completed a brief survey to provide their opinions on the intervention materials
and contents. Although the original VOICES intervention includes culturally specific materials
targeting African American and Hispanic or Latino individuals, and both homeless men and
provider consensus groups concluded that cultural flexibility was one of the advantages of
VOICES, given the lack of Spanish-speaking members involved in this project, the Spanish
materials in the original intervention were not modified or tested. Feedback regarding the final
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modification of the adapted VOICES-HM was generated. The manual draft was finalized based
on the focus groups findings.
Phase 3a: Adapted VOICES-HM manual development. Phase 2 consensus groups
helped identify modifications for this phase. According to feedback from homeless men and
service providers, the major revisions should include tailoring VOICES to respond to personal
risk profiles; emphasizing HIV knowledge and transmission facts; adding a substance use risk
component; and listing local community resources. In response to homeless men and providers’
suggestions regarding VOICES modification, activities incorporated in HIV prevention EBIs
reviewed in Phase 2b were revisited to select activities to address those suggestions. Because
homeless men and shelter providers also provided opinions regarding potential activities to
address their concerns (e.g., using a resource sheet to address substance use risks), these
strategies were also taken into consideration when selecting activities to add to VOICES.
Selection criteria included that the activity: does not violate the core element
requirements of VOICES, fits into the theoretical foundation of VOICES, requires minimal time,
is able to address multiple concerns raised during consensus groups if possible, and can be
implemented in group settings. Once activities were selected, the wording and delivery methods
were modified to ensure the added components could be seamlessly incorporated in the VOICES
program. Other than adding components, because VOICES was originally designed for both men
and women, all wording and activities related to women in the manual (Education Development
Center, Incorporated, 2009) were revised or excluded.
Phase 3b: Pretesting of VOICES-HM. To pretest VOICES-HM, brief focus groups
were conducted with homeless men and shelter providers separately. Specifically, this project
adopted the theater-testing method proposed in the ADAPT-ITT model (Wingood & DiClemente,
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2008) in that the group facilitators described the adapted intervention step by step to homeless
men and providers. Similar to the Phase 2b consensus groups, homeless men’s groups were
conducted prior to provider groups. All focus groups were conducted following similar
procedures. The facilitators introduced VOICES-HM to the participants step by step based on the
adapted manual draft. The facilitators introduced the procedure, rationale, and goals of each
activity. The facilitators also presented handouts or materials related to the corresponding
activities. After each activity was introduced, group discussions were conducted to identify areas
for improvement. Men and providers also completed a brief survey to rate the relevance and
usefulness of the presented activity and materials. During the men’s groups, the discussion
focused on content relevance and usefulness, whereas during the providers’ groups, the emphasis
was on activity feasibility. Based on feedback gathered during the groups, a finalized VOICES-
HM was developed.
Homeless men recruitment and data collection procedures. Homeless men were
recruited for the pretesting focus groups using the same procedures implemented in Phase 1 and
2, including the eligibility criteria (at least 21 years old, had sex with a women or man during the
previous 30 days, planned to have sexual intercourse during the next 30 days, could speak and
understand English, cognitively able to participate in discussion). Individuals who participated in
Phase 1 or Phase 2 groups remained eligible to participate in the pretesting groups. Among 15
homeless men who expressed interest in participating, three were deemed ineligible (not sexually
active during the previous 30 days or did not plan to have sex during the next 30 days). The
remaining 12 men participated in the pretesting groups. Four men had participated in the focus
groups during Phase 1 or Phase 2 (all at one site). Verbal informed consent was collected at the
beginning of the group sessions. Before the discussion, men were also asked to complete the
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same brief demographic surveys used during the previous phases. All men were compensated
with $20 for their time and input at the end of their participation. During the pretesting process,
men competed another brief survey assessing their perceptions regarding the relevance and
usefulness of the VOICES-HM procedure and materials.
Homeless men pretesting groups. During this phase, two focus groups with homeless
men were conducted (one at each site). Each focus group had six participants. Because these
groups emphasized men’s opinions regarding intervention contents, the discussion focused on
the relevance and usefulness of the intervention activities (e.g., whether homeless men would
understand the handouts, whether the poster would encourage men to discuss condom use).
Activities that men identified as not useful or inappropriate were discussed and suggestions were
elicited to further revise the manual.
Shelter provider recruitment and data collection procedures. Shelter providers recruited
for pretesting focus groups were recruited using the same procedures implemented in Phase 1
and Phase 2. The same criteria used Phase 1 and Phase 2 applied to pretesting group recruitment.
Due to small body of staff members at both collaborating shelters, most provider group
participants had already participated in the Phase 1 or Phase 2 groups. Fifteen staff members
(including directors) participated in the pretesting consensus groups. Verbal informed consent
was collected prior to the groups. At the beginning of the group sessions, each participant
completed a brief survey (the same used during Phase 1 and 2 shelter provider groups). Because
shelter providers participated to provide their professional insights, incentives were not provided.
Shelter provider pretesting groups. During this phase, two shelter provider pretesting
focus groups were conducted (one at each site). Each groups had seven or eight participants. The
discussion in shelter provider groups was focused on the fit between VOICES-HM and shelter
73
features (i.e., available resources and capacity). However, to supplement homeless men’s
comments, intervention content relevance and usefulness were also discussed.
Phase 3 Data Analysis
To analyze the qualitative data collected during the pretesting groups, similar data
analysis strategies employed in Phase 1 and Phase 2 were conducted. A case summary matrix
(Miles et al., 2013; Padgett, 2007) was developed with rows representing homeless men and
shelter provider pretesting groups and columns representing each VOICES-HM activity. Content
and thematic analysis (Boyatzis, 1998; Krippendorff, 1980; Weber, 1991) was implemented to
identify homeless men and shelter providers’ comments on each VOICES-HM activity and
materials. In terms of the quantitative data collected through the brief surveys (both demographic
surveys and VOICES-HM relevance and usefulness surveys), simple descriptive analysis was
conducted to understand and describe participant characteristics.
Phase 3 Results
Phase 3a findings. After reviewing the activities incorporated in the EBIs (Crosby et al.,
2009; Kalichman et al., 1999; Kamb et al., 1998; O’Donnell et al., 1998; Warner et al., 2008)
selected during Phase 2, the following modifications were made to the original VOICES manual
(Education Development Center, Incorporated, 2009). Although in the original manual, HIV
myths and facts and HIV transmission risks are covered, these components are not addressed in
detail. Rather, HIV facts and transmission risks are provided as a resource to facilitators to
address concerns raised during the group discussion. Furthermore, VOICES encourages
facilitators to focus on condom negotiation and condom use during group discussions and to
address other HIV-related risks during after-group discussions if needed.
74
To address the need to enhance HIV knowledge, provide local HIV statistics, and
describe transmission risks as suggested by homeless men and shelter providers and to create a
teachable moment by raising men’s awareness of HIV susceptibility (Eaton et al., 2012), the self-
feedback form activities from Nia (Kalichman et al., 1999) were adapted for integration with the
original VOICES intervention (O’Donnell et al., 1998). Nia’s self-feedback forms (Kalichman et
al., 1999) were selected primarily because the activity is brief and was suggested by homeless
men in the consensus groups as a promising strategy to increase homeless men’s HIV knowledge,
raise their awareness of personal HIV risk behaviors, and create a teachable moment to set a
foundation for later activities. Only the first two feedback forms from Nia were integrated in
VOICES-HM—those addressing HIV myth and facts and personal HIV risk behaviors; the third
for focuses on condom attitudes and condom use barriers, which is already heavily covered in
VOICES.
Modifications of the feedback form were made to reduce the burden on shelter staff and
further reduce the time needed to conduct this activity. To develop the original feedback forms in
Nia, facilitators need to derive information from a baseline survey, which is conducted at the
intake stage (prior to the intervention). Considering the constraints of shelter staff resources,
having providers conduct a baseline survey during intake may not be feasible. Furthermore,
because the process from intake to implementation of the intervention in Nia may take weeks,
the derived feedback forms may not reflect participants’ current HIV knowledge and HIV risk
behaviors. In this project, the first two forms were combined into a brief HIV knowledge and risk
behavior survey (see Appendix 1) that included questions measuring individuals’ HIV
knowledge and personal risk behaviors. After intervention participants complete the survey, the
facilitator then passes out an answer sheet (an identical survey marked with correct answers; see
75
Appendix 2). The facilitator asks participants to compare their survey with the answer sheet,
make mental notes, and discuss HIV myths and facts and HIV transmission risks with fellow
group members. To enhance the HIV knowledge and transmission risks covered in this activity,
an HIV fact sheet with local HIV statistics (see Appendix 3) was developed based on VOICES
resources to help facilitators initiate the discussion and for men to keep after completion of the
program (Education Development Center, Incorporated, 2009). In addition to HIV facts and
myths and transmission risks, this fact sheet lists local HIV statistics among homeless men and
different racial and ethnic groups. To ensure privacy, similar to the original Nia feedback form
activity, the facilitator emphasizes that men do not need to disclose or discuss their personal risk
behaviors and their answers to the survey. The discussion focuses on going through each item
and how it influences homeless men’s HIV risks. Through the brief survey, fact sheet, and
discussion, the added component addresses the suggestions raised in Phase 2, including HIV
knowledge, HIV statistics, HIV transmission risks, and individual tailoring.
This brief survey and discussion is the first activity after the facilitators briefly introduce
the VOICES-HM intervention and set the group ground rules, followed by video clips integrated
in the original VOICES intervention. This activity, which emphasizes HIV knowledge and
personal HIV risks, was strategically placed at the beginning of the intervention because
VOICES’s theoretical foundation, TRA (Fishbein, 1980; Fishbein & Middlestadt, 1989),
emphasizes the influence of perceived susceptibility and evaluation of behavioral consequences
on behavioral intention, which is the strongest determinant of behavioral decision making.
Furthermore, brief HIV EBIs highlight the importance of teachable moments (Eaton et al., 2012);
therefore, having homeless men to fill out the HIV knowledge and risk behavior survey at the
beginning of the program followed by discussion of HIV risks may help raise participants’
76
awareness of their vulnerability and thus create a teachable moment for the following activities.
This arrangement is consistent with other HIV prevention EBIs using similar activities (Jemmott
et al., 2007; Kalichman et al., 1999).
To ensure the learned HIV knowledge and transmission risk behaviors carry over to the
following activities, wording of the other activities was modified to remind men to think about
information covered in the brief survey and the HIV fact sheet. For example, when introducing
the video clips, facilitators are asked to encourage men to consider the information learned from
the HIV knowledge and risk behavior brief survey and the HIV fact sheet when viewing the
videos.
In addition to the aforementioned added element, the other major component added to the
original VOICES program (O’Donnell et al., 1998) was content describing substance abuse risks
associated with HIV risks. Because interventions listed by DEBI (CDC, 2015b) that address
substance use risks are usually lengthy and to ensure the adapted VOICES-HM program can be
completed in 60 minutes, a resource guide coupled with discussion was developed to address
substance use risks, as suggested during consensus groups with homeless men and providers. An
HIV risk and substance use handout (see Appendix 4) and a resource guide handout (see
Appendix 5) were developed. In the substance use and HIV risk handout, the influence of
injection drugs, other drugs, and alcohol on individuals’ HIV risks are covered. Suggestions to
decrease substance use risks and HIV risks are also covered. The resource guide covers local
(Skid Row, Pasadena, and other L.A. areas) drug treatment and recovery programs and shared
needle programs. These two handouts are designed for men to keep following the intervention.
Because in the original VOICES, reducing sexual risks through condom negotiation and
consistent and correct condom use is the major focus, to maintain the logical flow of the
77
intervention, the substance use risks component was added to the end of the adapted VOICES-
HM. This decision is consistent with the original VOICES program (i.e., discussing substance
use risks or other sexual risks after completion of the intervention) and the recently developed
STS-HW intervention (Cederbaum et al., 2014; Wenzel et al., 2015). In response to providers’
suggestions during Phase 1 that men should take responsibility for introducing condom use to
their partners, wording adapted from FOF (Crosby et al., 2009) that connects condom use and
men’s responsibility with the HIV epidemic in the homeless community was added throughout
the program.
Other than the aforementioned major added components, the development of the
VOICES-HM manual draft focused on making the original VOICES manual (Education
Development Center, Incorporated, 2009) fit with the target population and shelter settings. The
original VOICES program was designed to target both men and women; therefore, to reduce
confusion, all materials or wording related to women were removed. However, because the video
clips were not modifiable and the three videos did not seem likely to interfere with the ability of
homeless men to learn about condom negotiation and condom use, all three videos were retained
and later presented to men and providers for discussion. Finally, due to language constraints,
materials in Spanish were not modified or tested; therefore, all Spanish materials were removed
and only the English version was brought to the pretesting groups for final discussion.
Phase 3b findings.
Demographics. Table 5 illustrates the demographic characteristics of homeless men and
shelter provider participants. The mean age of homeless men was 43.83 years (SD = 8.70). Three
fourths of the men identified as Black and the rest were White. No Latinos participated during
this stage. Consistent with Phases 1 and 2, most men had experienced 3 to 6 months of
homelessness during their lifetime and more than 90% expressed having experienced
78
homelessness for at least 3 months during the previous 6 months. Approximately 58% of the
participants expressed not using condoms consistently during the previous 30 days. Finally, all
men reported using subsistence services (meal, shower, clothing, and overnight stay) at shelters.
More than half of the participants reported using substance abuse recovery services at shelters.
However, most men who reported using substance recovery services were from one site (five
from one site and two from the other; results not shown in the table).
In terms of the shelter provider pretesting groups, approximately 40% of the staff
members were Black and one third were White. Consistent with Phase 1 and 2, one provider
group’s participants were predominantly Black, whereas most of the other group’s members
were White (results not shown in the table). Almost all shelter provider participants reported
having at least a high school diploma or GED. Average tenure in the organization was 4.60 years
(SD = 5.13). Consistent with previous phases, no formal HIV prevention services were provided
at either shelter.
Homeless men pretesting group findings. Table 6 shows homeless men and shelter
provider ratings regarding the usefulness and relevance of activities and materials included in the
VOICES-HM draft manual. Both homeless men groups provided a high rating of the activities
and materials included in the draft, except for the role-playing component. Participants stated
that homeless men might not feeling comfortable role-playing condom negotiation with other
people, especially if they are heterosexual. Alternatively, facilitators can ask men what excuses
they have heard about not using condoms and have the group as a whole to discuss potential
response strategies. Another alternative is to have facilitators describe excuses listed in the
activity handouts without showing responses and have men discuss potential responses.
79
In addition to the condom negotiation role-play activity, although men all stated that the
videos were highly useful and relevant, most men said they preferred the third video, titled “Safe
in the City,” over the other two, titled “Do it Right” and “All About You.” The rationale was that
the third video not only raises individuals’ awareness of consequences (i.e., the male character
had sex with a casual partner who later notified him that she has an STD), but also has characters
with diverse ethnic backgrounds, compared to the other two. Furthermore, in “Do it Right,”
characters consumed alcohol before sexual events but still managed to negotiate condom use,
which group participants said might contradict the messages included in the substance abuse risk
component. When asked whether the videos should include condom negotiation from women’s
perspectives, respondents said it would be fine to include those scenarios because they made the
videos more coherent. Men also had a minor suggestion regarding the condom introduction
activity. They suggested coupling poster presentations with sample condoms to allow men to see
and touch different types of condoms included in the poster. Finally, homeless men suggested
that after the intervention, participants may have many handouts and it might be better to have
these materials clipped together. Another alternative is to minimize and laminate the handouts
for men to carry in their wallets or pockets.
Shelter provider pretesting group findings. Although they did not rate the adapted
intervention as high as homeless men, shelter providers still rated all VOICES-HM activities and
materials highly in terms of usefulness, relevance, and feasibility at shelters. Because provider
groups were conducted after the men’s groups, feedback from men’s groups was also discussed
during the provider groups. Providers concurred with the suggestion that role-playing may not
suitable for men to practice condom negotiation. Providers also supported having men provide
scenarios or excuses for not using condoms and having the group develop response strategies.
80
In terms of the videos, because VOICES-HM is a race- and ethnic-specific intervention,
providers said they would like to keep all three video clips in the intervention. This way,
facilitators can choose videos that best fit their clients. However, the providers agreed with
homeless men that the video displaying alcohol consumption before condom negotiation
scenarios contradicts the message that the intervention is trying to convey. One strategy to
address this issue is to discuss this scenario during the substance use risk section, if the relevant
video clip is being presented. Providers expressed concerns regarding whether introducing
condom features, although very attractive and interactive, would actually help men acquire
suitable condoms, given limited free condom options available.
Finalized VOICES-HM manual. Appendixes 6 to 8 include other handouts modified
from the original VOICES handouts to be used in VOICES-HM. Appendix 9 features the
finalized VOICES-HM intervention protocol with tips and resources, including online training
resources, to help facilitators implement this program. Appendix 9 also includes the
aforementioned handouts for homeless men to keep after program completion. Aligned with the
theoretical foundation of the original VOICES, TRA (Fishbein, 1980; Fishbein & Middlestadt,
1989), VOICES-HM aims to address attitudes toward condom use, subjective norms, and
condom use intention (Fishbein, 1980). Although not explicitly addressed in TRA, the skills
training components of the original VOICES also enhance participant condom use efficacy
(Bandura, 1978; Fisher & Fisher, 1992), which has been suggested as a critical factor in
homeless men’s condom use (Hsu et al., 2015; Tucker, Wenzel, Golinelli, et al., 2013) and are
included in VOICES-HM.
In VOICES-HM, homeless men’s attitudes toward condom use (i.e., behavioral beliefs
and evaluation of behavioral outcomes) are first addressed by participants completing and
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discussing a brief survey about HIV knowledge and behavior risk. Participants finish the brief
survey and then compare their answers with the answer sheet. The brief survey is destroyed once
this section is completed; however, the answer sheet is for men to keep. The facilitator
encourages participants to make mental notes about their incorrect HIV knowledge and risky
behaviors. The facilitator then initiates a discussion regarding HIV myth and facts and sexual
risk behaviors. The facilitator ensures all items included in the brief survey are discussed. To
enhance the discussion, the facilitator briefly reviews the HIV/STD information and local
statistics handout with the participants. When discussing the statistics, the facilitator highlights
that participants’ behaviors will have a great effect on the HIV epidemic in their communities.
All these activities are designed to improve homeless men’s evaluation of behavioral outcomes
and beliefs about HIV risk behaviors. The brief survey and statistics are used with the purpose of
increasing homeless men’s perceived HIV susceptibility, thus creating a teachable moment to
engage homeless men in the subsequent activities.
The next activity, showing culturally specific videos, helps address subjective social
norms and condom negotiation efficacy and further enhances positive attitudes toward condom
use. As suggested by providers, all three videos, “Do it Right,” “All About You,” and “Safe in
the City,” were retained in VOICES-HM. Facilitators can choose the most appropriate video to
present based on participants’ cultural background and characteristics. These videos convey
strategies to overcome condom use barriers, practice correct condom use procedures, and
enhance condom negotiation skills. Because the video characters discussing condom use share
similar cultural backgrounds to the participants, this activity can help shape participants’
perceptions regarding condom use norms. Furthermore, with the characters modeling condom
82
negotiation and condom use procedures, this video-viewing activity can also promote homeless
men’s self-efficacy in condom use and negotiation.
To enhance the messages conveyed in the videos, the facilitator, assisted by the video
activity sheets and negotiation of safer sex excuse-and-response sheet, uses scenarios included in
the videos as trigger points to facilitate discussions to enhance participants’ perceived
vulnerability, positive condom attitudes, condom use, negotiation self-efficacy, and condom
negotiation skills (condom use skills are addressed in the next activity). Role-playing to practice
condom negotiation is also facilitated. However, unlike interventions targeting women (Jemmott
et al., 2007; Wenzel et al., 2015), per the feedback from homeless men and providers, VOICES-
HM does not require participants to perform a negotiation scenario. Instead, the facilitator asks
participants about potential excuses to prevent condom use, with the group as a whole
developing corresponding negotiation strategies. If participants have difficulties developing
scenarios, the facilitator can use the video and negotiation of safer sex excuse-and-response
handout to facilitate discussion.
The next activity addresses condom attitudes and enhances condom use skills. The
facilitator uses the condom feature poster to show condoms of different features and sizes. Per
men’s suggestion in the pretesting groups, when introducing condom features, sample condoms
(the same as those listed on the poster, except for female condoms) are provided to the
participants so they can experience different condoms. The facilitator then demonstrates the
correct procedure of applying condoms using an anatomical model, followed by participants
practicing putting condoms on anatomical models. An effective condom use handout is also
provided to men to keep for future reference. These activities aim to help homeless men address
83
condom use barriers (e.g., condom breaks, the belief that condoms make sex not pleasurable),
foster positive attitudes toward condom use, and enhance correct condom use skills.
The following section of the intervention discusses substance use risks associated with
HIV transmission and risky sexual behaviors. The facilitator reviews the HIV risk and substance
use handout, referencing the resource guide to help increase men’s knowledge about substance
abuse and HIV risks. The facilitator also uses the scenarios in the video to discuss alcohol use
before or during sexual intercourse. The purpose of this section is to encourage participants to
reduce substance use and seek substance abuse treatments, thus reducing unprotected sex while
under the influence of substances. The other purpose is to introduce local needle exchange
resources to participants to prevent HIV transmission through needle-sharing activities.
Finally, the facilitator summarizes the major messages covered in VOICES-HM and
reviews the resource guide with the participants. The facilitator also highlights the importance of
safe-sex practices to ending the HIV epidemic in participants’ communities and protecting their
loved ones. At the end of the program, the facilitator provides condoms of different features and
sizes to men.
Phase 3 Summary
Based on Phase 2 consensus group suggestions, without modifying the core elements,
new components were added to the original VOICES intervention (O’Donnell et al., 1998) with
the goal of making the intervention respond better to homeless men’s individual risks, strengthen
HIV knowledge and transmission risks, and address substance use risks to develop an adapted
manual draft. This VOICES-HM draft was pretested using the theater-testing method with
homeless men and shelter providers. Both men and shelter providers rated the intervention
materials and activities highly, with minor suggestions about condom negotiation role-play and
84
videos showing contradicting messages (e.g., characters consuming alcohol before condom
negotiation). Men and providers also provided suggestions to help VOICES-HM better engage
participants (e.g., provide sample condoms when discussing condom features). These
suggestions were integrated into the finalized VOICES-HM.
Conclusion
Providing sexual risk reduction interventions at shelters targeting homeless men is critical
to preventing HIV among homeless men and their partners and reducing HIV incidence in the
homeless community. This dissertation project confirmed findings from previous research
(Cederbaum et al., 2013) that although there is significant need for HIV prevention interventions,
currently there are no HIV prevention services for homeless individuals in the Central City East
and Pasadena areas, where homeless individuals are concentrated or seek subsistence services.
Furthermore, consistent with Brown et al. (2012), homeless men who participated in this study
held false perceptions regarding HIV transmission and negative attitudes toward condom use. In
addition, homeless men were found to lack experience and skills related to using condoms.
Currently, the lack of HIV prevention EBIs targeting homeless adults, including homeless men,
and the needs assessment finding of this dissertation project highlighted the importance of
developing or adapting efficacious HIV prevention interventions that fit shelter services. Guided
by the ADAPT-ITT model (Wingood & DiClemente, 2008), this dissertation project engaged
homeless men and shelter providers to navigate, select, and modify existing EBIs to address the
HIV prevention needs of homeless men in shelter settings.
The first phase of this project illustrated the importance of incorporating substance use
risks, HIV knowledge, and condom use and negotiation skills into HIV prevention interventions
targeting homeless men. This project also took into account the limited resources available to
85
shelter providers in the intervention adaptation process. Specifically, the constraints of
organizational capacity pose a major challenge for shelter providers in delivering comprehensive
HIV prevention services to homeless men. To ensure that the interventions would be able to be
implemented and sustained in real-world settings (i.e., shelters), five brief EBIs from DEBI
(CDC, 2015b) were reviewed and presented to homeless men and shelter providers for final
selection and modification.
VOICES (O’Donnell et al., 1998) was selected for further adaptation by homeless men
and shelter providers through consensus groups. Although acknowledging that VOICES features
diverse activities (e.g., video-viewing activities, condom use and negotiation skills practice, and
group discussions), high cultural competence, and attractive incentives (e.g., condoms of
different sizes and features), men and providers still suggested that to better meet homeless
men’s needs and engage men at the beginning of this brief intervention, VOICES should be more
individually tailored, emphasizing HIV knowledge and transmission risks and adding substance
abuse components.
Responding to homeless men and providers’ suggestions, the VOICES-HM manual and
intervention materials were developed and pretested using theater testing (Wingood &
DiClemente, 2008). Because of the intensive engagement of homeless men and shelter providers
in previous processes, in the pretesting groups, homeless men and shelter providers were
satisfied with the modifications, offering only minor suggestions. The high rating of the
intervention materials and activities suggests that the constituent engagement element and
iterative procedures in the ADAPT-ITT model (Wingood & DiClemente, 2008) are suitable for
collaborating with homeless men and shelter providers to identify and adapt an existing HIV
prevention EBI.
86
Given that VOICES-HM was adapted from VOICES (O’Donnell et al., 1998), which has
been adapted and disseminated globally in variety of settings and populations (Harshbarger et al.,
2006), VOICES-HM may be flexible in terms of dissemination to other providers offering
services to homeless men. However, despite being adapted from a widely disseminated HIV
prevention EBI via intensive engagement with homeless men and shelter providers, VOICES-
HM was developed based on input from men and providers at two shelters in L.A. County. The
sexual risk reduction approach through consistent and correct condom use in VOICES-HM may
limit its application in some shelters. Specifically, VOICES-HM may not be suitable for faith-
based shelter providers that maintain an abstinence-only approach when addressing HIV
prevention. Condom use practices and negotiation training, which are core elements of the
original VOICES (O’Donnell et al., 1998), may conflict with abstinence-only HIV prevention.
Modification of such core elements would not be considered an intervention adaptation, but
rather an intervention reinvention (Mann et al., 2014). Therefore, for faith-based shelter
providers that may not accept a sexual risk reduction approach other than abstinence only, other
HIV prevention interventions developed based on promoting abstinence should be considered
(Jemmott, Jemmott, & Fong, 1998; Underhill, Montgomery, & Operario, 2007). It should also be
noted that both shelters involved in this dissertation project provide subsistence services to the
general homeless population, rather than specific homeless subpopulations that may have
specific needs. Therefore, further modification of VOICES-HM may be needed in organizations
targeting homeless individuals with specific needs (e.g., agencies targeting homeless men
recovering from substance addiction). Nonetheless, considering the flexibility of adaptation and
dissemination of the original VOICES, VOICES-HM is likely to be disseminated once evidence
of efficacy of this intervention is tested.
87
Strengths and Limitations
To our knowledge, this intervention adaptation project was the first effort to engage
homeless men and shelter providers in reviewing, identifying, and adapting an HIV prevention
EBI to reduce sexual risks among homeless men in a shelter setting. Considering the false HIV
knowledge and negative condom attitudes among some homeless men and the high-risk sexual
partnerships and HIV risk behaviors in which they engage, it is imperative to deliver
interventions at shelters to reduce sexual risks among homeless men. Guided by the ADAPT-ITT
model (Wingood & DiClemente, 2008) and by homeless men and shelter providers actively
engaged in the adaptation processes, this dissertation project was able to develop a
comprehensive intervention manual with associated materials. The manual and materials aim to
address critical constructs proposed in TRA (Fishbein, 1980; Fishbein & Middlestadt, 1989) and
other behavioral change theories (Bandura, 1978; Fisher & Fisher, 1992), including highlighting
homeless men’s perceived susceptibility; creating teachable moments; enhancing HIV
knowledge and transmission risks; improving condom efficacy (e.g., condom use and negotiation
skills); promoting positive subjective condom use norms; addressing substance use risks; and
facilitating condom use intentions.
Despite these strengths, the project has some limitations. First, because of the time and
resource constraints, this project was not able to pilot test the feasibility and preliminary effects
of the adapted VOICES-HM, as suggested by Rounsaville, Carroll, and Onken (2001). However,
the finalized manual produced by this dissertation project sets the foundation for future pilot
testing and randomized controlled trials to investigate the feasibility and efficacy of this adapted
intervention related to reducing sexual risks among homeless men at shelter settings. Another
limitation is that because no project members had Spanish language proficiency, the Spanish
88
version of the original VOICES could not be reviewed, modified, and pretested with homeless
men. Although previous studies have suggested that homeless individuals in L.A. County,
especially in Central City East, are predominantly African American, with Whites representing
the second-largest group, considering the growing Latino population in L.A. County, it is critical
that future studies review and verify the Spanish version of the VOICES materials. Finally,
because homeless men self-selected to participate in this dissertation project, selection bias may
be another limitation. However, considering that it would be neither possible nor appropriate to
force homeless men to participate in an HIV prevention intervention, the intervention developed
through this project may fit better with homeless men who are motivated to protect themselves
and their partners from HIV.
Although guided by the ADAPT-ITT model (Wingood & DiClemente, 2008), this project
did not fully conform to the ADAPT-ITT model, modifying it to accommodate resources
available on the DEBI website (CDC, 2015b) and provide more options for homeless men and
shelter providers in selecting the EBI for final adaptation. The major modifications included not
using the theater-testing method at the adaptation stage, but rather using the nominal consensus
group method, as supported by previous research (Cederbaum et al., 2014), to present multiple
EBI candidates to homeless men and shelter providers and generate modification directions.
Finally, because this project was only implemented in two regions of L.A. County (Central City
East and Pasadena), with participants recruited through convenience sampling, the information
generated in this project may be limited in terms of external validity. Because Central City East
and Pasadena are both urban areas, the adapted VOICES-HM may be suitable to homeless men
in urban settings, rather than other geographical areas.
Future Direction
89
Despite the aforementioned limitations, this project successfully engaged homeless men
and shelter providers in developing an adapted VOICES-HM manual and materials. The next
step for this research is to complete the remaining steps of the ADAPT-ITT model (Wingood &
DiClemente, 2008) and follow the stage model (Rounsaville et al., 2001) to pilot test the
feasibility and preliminary effects of the VOICES-HM manual. Based on the results of the pilot
testing, the next stage is to use randomized controlled trials to fully examine the efficacy of the
VOICES-HM intervention. The final phase of this project is to examine the effectiveness of
VOICES-HM in real-world settings to ensure that the adapted VOICES-HM can be sustained
and implemented in shelter settings to reduce HIV risks among homeless men.
90
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108
Table 1: Phase 1 Homeless Men and Shelter Provider Demographic Characteristics
Homeless Men
(N = 30)
Shelter Providers
(N = 15)
n (%) n (%)
Age
a
45.23 (7.76)
Gender (male) 12 (80.0)
Race and ethnicity
Black 22 (73.3) 8 (53.3)
Latino 2 (6.7) 2 (13.3)
White 5 (16.7) 5 (33.3)
Mixed or other 1 (3.3) 0 (0.0)
High school degree or GED 13 (86.67)
Ever married 10 (66.7)
Time working in current shelter
a
4.28 (5.01)
Time working with homeless men
a
4.82 (5.47)
Experienced 3–6 months homelessness in life 25 (83.3)
Experienced 3–6 months homelessness in past 6 months 22 (73.3)
Always used condoms during sex in past 30 days 7 (23.3)
Subsistence services 29 (96.7)
Job training 4 (13.3)
Education assistance 1 (3.3)
Computer literacy 0 (0.0)
Legal aid 0 (0.0)
Substance abuse treatment or recovery 23 (76.7)
Needle exchange 0 (0.0)
Mental health counseling 17 (56.7)
HIV prevention services 0 (0.0)
HIV testing 3 (10.0)
Formal HIV prevention services 0 (0.0)
Provide free condoms on a regularly basis 0 (0.0)
Provide HIV/STD referrals 15 (100.0)
Discuss HIV/STD prevention with clients 8 (53.3)
a
Figures represent M (SD).
109
Table 2: Phase 2b Homeless Men and Shelter Provider Demographic Characteristics
Homeless Men
(N = 31)
Shelter Providers
(N = 14)
n (%) n (%)
Age
a
44.61 (9.47)
Gender (male) 10 (71.4)
Race and ethnicity
Black 20 (64.5) 5 (35.7)
Latino 6 (19.4) 1 (7.1)
White 3 (9.7) 8 (57.1)
Mixed or other 2(6.5) 0 (0.0)
High school degree or GED 14 (100.0)
Ever married 7 (22.6)
Time working in current shelter
a
4.08 (5.64)
Time working with homeless men
a
4.56 (6.20)
Experienced 3–6 months homelessness in life 27 (87.1)
Experienced 3–6 months homelessness in past 6 months 22 (71.0)
Always use condoms during sex in past 30 days 10 (33.3)
Subsistence services 29 (96.7)
Job training 4 (13.3)
Education assistance 1 (3.3)
Computer literacy 0 (0.0)
Legal aid 0 (0.0)
Substance abuse treatment or recovery 5 (16.1)
Needle exchange 0 (0.0)
Mental health counseling 19 (61.3)
HIV prevention services 0 (0.0)
HIV testing 2 (6.5)
Formal HIV prevention services 0 (0.0)
Provide free condoms on a regular basis 0 (0.0)
Provide HIV/STD referrals 13 (92.9)
Discuss HIV/STD prevention with clients 12 (85.7)
a
Figures represent M (SD).
110
Table 3: Phase 2b Homeless Men and Shelter Provider Consensus Rankings by Group
Homeless Men
(N = 29)
Shelter Providers
(N = 14)
Group 1
(n = 6)
Group 2
(n = 8)
Group 3
(n = 9)
Group 4
(n = 6)
Group 1
(n = 8)
Group 2
(n = 6)
n (%) n (%) n (%) n (%) n (%) n (%)
Focus on the Future 1 (16.7) 1 (12.5) 0 (0.0) 1 (16.7) 1 (12.5) 1 (16.7)
Nia 1 (16.7) 1 (12.5) 1 (11.1) 0 (0.0) 0 (0.0) 0 (0.0)
Respect
a
1 (16.7) 2 (25.0) 4 (44.4) 4 (66.6) 1 (12.5) 0 (0.0)
Safe in the City 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 3 (37.5) 2 (33.3)
VOICES/VOCES
a
3 (50.0) 4 (50.0) 4 (44.4)
1 (16.7) 3 (37.5) 3 (50.0)
Note. The number of participants in the homeless men groups was 31. However, because one man ranked all EBIs as
the top choice and one left the group before the ranking activity, their ranking votes were excluded.
a
The results shown here are the first-round votes for homeless men Group 3 and provider Group 1.
111
Table 4: Phase 2b Overall Homeless Men and Shelter Provider Consensus Rankings
Homeless Men
(N = 29)
Shelter Providers
(N = 14)
n (%) n (%)
Focus on the Future 3 (10.3) 2 (14.3)
Nia 3 (10.3) 0 (0.0)
Respect 11 (37.9) 1 (7.1)
Safe in the City 0 (0.0) 5 (35.7)
VOICES/VOCES 12 (0.41) 6 (42.9)
Note. The number of participants in the homeless men groups was 31. However, because one man ranked all EBIs as
the top choice and one left the group before the ranking activity, their ranking votes were excluded. Results shown
here are cumulative first-round votes.
112
Table 5: Phase 3b Homeless Men and Shelter Provider Demographic Characteristics
Homeless Men
(N = 12)
Shelter Providers
(N = 15)
Variable n (%) n (%)
Age
a
43.83 (8.70)
Gender (male) 11 (73.3)
Race and ethnicity
Black 9 (75.0) 6 (40.0)
Latino 0 (0.0) 3 (20.0)
White 3 (25.0) 5 (33.3)
Mixed or other 0 (0.0) 1 (6.7)
High school degree or GED 14 (93.3)
Ever married 2 (16.7)
Time working in current shelter
a
4.60 (5.13)
Time working with homeless men
a
5.30 (5.54)
Experienced 3–6 months homelessness in life 12 (100.0)
Experienced 3–6 months homelessness in past 6 months 11 (91.6)
Always use condoms during sex in past 30 days 5 (41.7)
Subsistence services 12 (100.0)
Job training 1 (8.3)
Education assistance 0 (0)
Computer literacy 0 (0)
Legal aid 0 (0)
Substance abuse treatment or recovery 7 (58.3)
Needle exchange 0 (0)
Mental health counseling 9 (75.0)
HIV prevention services 0 (0)
HIV testing 4 (33.3)
Formal HIV prevention services 0 (0.0)
Provide free condoms on a regular basis 0 (0.0)
Provide HIV/STD referrals 15 (100.0)
Discuss HIV/STD prevention with clients 14 (93.3)
a
Figures represent M (SD).
113
Table 6: Homeless Men and Shelter Providers’ Perceptions of the VOICES-HM Materials
Homeless Men
(N =12)
Shelter Providers
(N = 15)
M (SD) M (SD)
HIV knowledge and risk behaviors brief survey
Usefulness in understanding HIV risks 3.92 (0.29) 3.87 (0.35)
Relevance to homeless men 4.0 (0.0) 3.93 (0.26)
Feasibility of implementing in shelters 4.0 (0.0)
HIV fact sheet with local HIV statistics
Usefulness in understanding HIV risks 4.0 (0.0) 3.67 (0.49)
Relevance to homeless men 4.0 (0.0) 3.41 (0.21)
Feasibility of implementing in shelters 3.47 (0.52)
Brief survey and fact sheet with group discussion
Usefulness in motivating homeless men to engage in later
activities
3.92 (0.29) 3.87 (0.52)
Feasibility of implementing in shelters 3.60 (0.50)
Video clip: “Do it Right”
Usefulness in understanding HIV risks 3.75 (0.45) 3.33 (0.49)
Usefulness in modeling condom negotiation 3.75 (0.45) 3.33 (0.62)
Relevance to homeless men 3.66 (0.65)
Feasibility of implementing in shelters 4.0 (0.0)
Video clip: “All About You”
Usefulness in understanding HIV risks 3.91 (0.29) 3.80 (0.41)
Usefulness in modeling condom negotiation 3.83 (0.39) 3.53 (0.52)
Relevance to homeless men 3.75 (0.45) 3.20 (0.68)
Feasibility of implementing in shelters 4.0 (0.0)
Video clip: “Safe in the City”
Usefulness in understanding HIV risks 3.91 (0.29) 3.20 (0.41)
Usefulness in modeling condom negotiation 3.91 (0.29) 3.20 (0.41)
Relevance to homeless men 3.91 (0.29) 3.13 (0.35)
Feasibility of implementing in shelters 3.87 (0.35)
Group discussion regarding condom negotiation
Usefulness in increasing homeless men’s condom
negotiation skills
4.0 (0.0) 3.07 (0.59)
Relevance to homeless men 4.0 (0.0) 3.53 (0.52)
Feasibility of implementing in shelters 3.27 (0.46)
Role-play and negotiating safer sex excuse-and-response
sheet handout
Usefulness in increasing homeless men’s condom
negotiation skills
2.75 (0.45) 2.60 (0.74)
Relevance to homeless men 3.67 (0.78) 3.07 (0.60)
Feasibility of implementing in shelters 3.67 (0.48)
Video viewing with group discussion and role-play
Usefulness in increasing homeless men’s condom
negotiation skills
4.0 (0.0) 3.87 (0.35)
Relevance to homeless men 3. 25 (0.75) 3.40 (0.63)
114
Feasibility of implementing in shelters 3.33 (0.49)
Condom feature introduction and condom feature poster
and handout
Usefulness in motivating homeless men to acquire
condoms
4.0 (0.0) 3.20 (0.54)
Feasibility of implementing in shelters 3.13 (0.52)
Condom skill demonstration and practice
Usefulness in helping homeless men use condoms
correctly
4.0(0.0) 4.0 (0.0)
Attractiveness to homeless men 3.08 (0.90) 3.27 (0.46)
Feasibility of implementing in shelters 3.0 (0.38)
Discussion of HIV risks and substance abuse and HIV
risks and substance abuse handout and local resource
guide
Usefulness in helping homeless men recognize the
connection between substance use and HIV risks
4.0 (0.0) 3.33 (0.49)
Relevance to homeless men 4.0 (0.0) 3.80 (0.41)
Feasibility of implementing in shelters 4.0 (0.0)
Overall VOICES-HM intervention
Attractiveness to homeless men 3.91 (0.29) 3.67 (0.49)
Feasibility of implementing in shelters 3.47 (0.52)
Note. All items measured using a 4-point Likert scale ranging from 1 (not at all) to 4 (very).
115
Appendix 1
HIV Knowledge and Risk Behavior Brief Survey
Please do not put your name or nicknames on this brief survey. This survey will be
discussed in the group. However, please remember, you do not need to disclose your
answers to others as well. The survey will be destroyed right after the group.
Your Answer
1. Are AIDS and HIV two names for the same thing? __________
2. Does a person who has HIV always have AIDS? __________
3. Can a person be infected with HIV and
not show signs? __________
4. Does a negative HIV test always mean a person
does not have HIV? __________
5. Does getting tested for HIV help protect a person
from getting the virus? __________
6. Does a negative test mean a person cannot get HIV? __________
7. Can a person with HIV who looks healthy pass the
virus to others? __________
8. Can a person get HIV through contact with saliva? __________
9. Does having sex with more than one partner
increase a person’s chance of getting HIV? __________
10. Can a woman give HIV to a man? __________
11. Do people get HIV the same way that they get
Gonorrhea and Syphilis (VD)? __________
12. Can a person who got HIV from shooting up drugs
give the virus to someone by having sex? __________
13. Does using shortening and other oils to lubricate
latex condoms help them work better? __________
14. Does washing drug equipment with warm
water kill HIV? __________
116
15. Do most types of birth control also protect
against HIV? __________
Please circle the response that most describe your situation
1. You (do or do not) worry about getting HIV - the virus that causes AIDS.
2. You (have or have not) thought about protecting yourself from HIV.
3. You are (definitely not, somewhat, or definitely) confident that you could bring up the
need to use a condom.
4. You are (definitely not, somewhat, or definitely) confident that you could refuse to
have unsafe sex even if your partner pressured you to be unsafe.
5. You had _____________ partners in the past 3 months (Please fill in numbers).
Below please provide information regarding sexual activities you have practiced in
the past 3 months:
6. Getting oral sex without a condom ____ times.
7. Giving oral sex without a condom/latex barrier _____ times.
8. Vaginal sex without a condom ______ times.
9. Vaginal sex with a condom ______ times.
10. How often did you use condoms during vaginal sex in the past 3 months:
Always Usually Sometimes Rarely Never
11. Anal sex without a condom times.
12. Anal sex with a condom times.
13. How often did you use condoms during anal sex in the past 3 months:
Always Usually Sometimes Rarely Never
14. In the past 3 months, you drank alcohol times just before sex.
15. In the past 3 months, you used drugs times just before having sex.
16. You have been treated __times for a sexually transmitted disease (STD, VD) in
the past year.
117
Appendix 2
HIV Knowledge and Risk Behaviors Brief Survey - with
Answers
Correct Answer
1. Are AIDS and HIV two names for the same thing? __NO_____
2. Does a person who has HIV always have AIDS? __NO_____
3. Can a person be infected with HIV and
not show signs? __YES____
4. Does a negative HIV test always mean a person
does not have HIV? __NO_____
5. Does getting tested for HIV help protect a person
from getting the virus? __NO_____
6. Does a negative test mean a person cannot get HIV? __NO_____
7. Can a person with HIV who looks healthy pass the
virus to others? __YES____
8. Can a person get HIV through contact with saliva? __NO_____
9. Does having sex with more than one partner
increase a person’s chance of getting HIV? __YES____
10. Can a woman give HIV to a man? __YES____
11. Do people get HIV the same way that they get
Gonorrhea and Syphilis (VD)? __YES____
14. Can a person who got HIV from shooting up drugs
give the virus to someone by having sex? __YES____
15. Does using shortening and other oils to lubricate
latex condoms help them work better? __NO_____
14. Does washing drug equipment with warm
water kill HIV? __NO_____
15. Do most types of birth control also protect
against HIV? __NO_____
118
Appendix 3
HIV Fact Sheet With Local HIV Statistics
Local HIV Statistics
• 5% of individuals experiencing homelessness at Skid Row have
HIV/AIDS, which is 8 times higher than the rate among general
population.
• 2% of individuals at Pasadena experiencing homelessness have
HIV/AIDS, which is 3 times higher than the rate among general
population
• Men accounted for 76% of all adults and adolescents living with HIV
infection at the end of 2010 in the United States.
• African American adults are 8 times higher than White adults to
contract HIV/AIDS
• By race/ethnicity, black men have the highest rates of new HIV infections
among all men.
• Hispanic/Latino adults are 3 times more likely than Whites to contract
HIV/AIDS.
• White adults account for 29% of the new HIV incidents in 2011.
HIV and STDS: The Basic Facts
• Men and can have STDs that cause damage without symptoms.
• People with HIV or other STDs can look perfectly healthy.
• Having an STD puts you at increased risk of getting another STD.
• STDs can be transmitted through oral sex as well as vaginal or anal sex.
• STDs can be life threatening.
• Repeat STD infections may leave a woman infertile.
• Current treatments may control HIV temporarily, but are not a cure.
• Birth control pills will not prevent you from getting HIV.
• HIV can be transmitted from mother to child prior to birth. HIV can be
transmitted through breast milk.
Risk Factors
• Engaging in vaginal, anal, or oral sex without latex or polyurethane condoms
• Having a prior STD
• Using injection drugs or having unprotected sex with an injection drug user
• Using alcohol or drugs to relax or have fun
• Inconsistently using condoms with your primary partner
• Inconsistently using condoms with non-primary partners
119
• Having no experience using condoms or getting partners to use condoms
• Having a bad experience using condoms, such as having a partner get angry
or violent at the suggestion of condom use
• Having sex with someone who may have other partners
• Having multiple sex partners
• Being forced to have unprotected sex
120
Appendix 4
HIV Risk and Substance Use Handout
Remember you can get HIV by sharing dirty needles, works, syringes, cookers, spikes
and cotton.
Remember having sex under the influence of drugs, not necessary injection drugs, and
alcohol can increase sex without condoms
SO…
1. Try not to use drugs, especially before or during sex.
o Drugs and Alcohol loosens you up and makes you engage in riskier behaviors. It
makes you forget about condoms.
o If you do use drugs or alcohol, don't mix them with sex. Remember to protect
yourself and your loved ones. You can help end the HIV epidemics in your
community!
2. If you cannot fully stop the use then...
o Reduce your use.
o Consider entering a substance abuse treatment program (Please refer to the
resource guide for local substance treatment or recovery programs).
o Use your own works for shooting drugs.
o Do not share your works.
o Get free clean works at the needle exchange program (Please refer to the resource
guide for local needle exchange programs).
o Always clean your works with bleach and water for 1 minute before using them.
ALCOHOL AND DRUG
RECOVERY SERVICES
ADAPT
PROGRAM,
INC.
1088
South
La
Brea
Ave.
LA
90019
213-‐483-‐5703
2ND
CHANCE
FOR
RECOVERY,
INC.
600
E.
7th
Street,
Suite
104
and
105
LA
90021
(213)
537-‐0110
CLARE
FOUNDATION,
INC.
11325
Washington
Blvd.
LA
90066
310-‐314-‐6200
DIDI
HIRSCH
SERVICES
1157
Berendo
St.
LA
90006
213-‐385-‐3752
HIS
SHELTERING
ARMS,
INC.
10615
South
Avalon
Blvd.
LA
90003
323-‐754-‐6900
HOMELESS
HEALTH
CARE
LOS
ANGELES,
INC.
2330
West
Beverly
Blvd.
LA
90057
213-‐744-‐0724
JWCH
INSTITUTE,
INC.
303
East
52
nd
.
St.
LA
90011
323-‐232-‐6228
LA
COUNTY
DISTRICT
ATTORNEY
HOTLINE
210
West
Temple
St.
Suite
18-‐709
LA
90012
800-‐978-‐3600
AFRICAN
COMMUNITY
RESOURCE
CENTER
532
S.
Vermont
Ave.
Suite
104
LA
90020
213-‐637-‐1450
BILINGUAL
SHELTER
FOR
VICTIMS
OF
DOMESTIC
VIOLENCE
315
W.
9
TH
ST.
Suite
101
LA
90015
800-‐548-‐2722
LEGAL
AID
FOUNDATION
OF
LOS
ANGELES
1102
Crenshaw
Blvd.
LA
90019
800-‐399-‐4529
PEACE
OVER
VIOLENCE
605
W.
Olympic
Blvd.
Suite
400
LA
90015
213-‐955-‐9090
HARRIET
BUHAI
CENTER
FOR
FAMILY
LAW
3250
Wilshire
Blvd.
Suite
710
LA
90010
213-‐388-‐7505
GLBT
STOP
Domestic
Violence
323-‐860-‐5806
Rainbow
Services
453
w
7
th
St,
LA,
90731
(310)
547-‐9343
*
There's
a
period
of
time
after
a
person
is
infected
during
which
they
won't
test
positive.
This
is
called
the
"HIV
window
period,"
and
can
be
from
9
days
to
3-‐6
months,
depending
on
the
person's
body
and
on
the
HIV-‐test
that's
used.
During
that
time,
you
can
test
HIV
negative
even
though
you're
HIV
infected.
If
you've
had
high-‐
risk
exposure
to
HIV
within
the
last
few
days,
you
should
ask
your
test
counselor
about
PEP
-‐
Post
Exposure
Prophylaxis.
DOMESTIC VIOLENCE
ASSISTANCE
CENTRAL
HEALTH
CENTER
214
N.
Figueroa
St.
LA
90012
213-‐240-‐8203
HOLLYWOOD
WILSHIRE
HEALTH
CENTER
5205
Melrose
Ave.
LA
90038
323-‐769-‐7932
RUTH
TEMPLE
HEALTH
CENTER
3834
S.
Western
Ave.
LA
90062
323-‐730-‐3576
PLANNED
PARENTHOOD
1014
N.
Vermont
Ave.
LA
90029
213-‐284-‐3160
STD AND HIV TESTING
(CALL FOR HOURS)*
Appendix 5
Brief Resource Guide
Selected Areas of
Los Angeles County
121
FREE CONDOMS
AIDS
PROJECT
LA
3743
S.
La
Brea
Ave
LA
90016
323-‐329-‐9900
BIENESTAR
5326
E.
Beverly
Blvd
LA
90022
323-‐727-‐7896
CENTER
FOR
COMMUNITY
HEALTH
522
S.
San
Pedro
St.
LA
90013
213-‐486-‐4045
COMMON
GROUND
2401
Lincoln
Blvd.
Santa
Monica,
CA
90405
310-‐314-‐5480
JWCH
1910
W.
Sunset
Blvd.
LA
90026
213-‐484-‐1186
T.H.E.
CLINIC
3834
S.
Western
Ave.
LA
90062
323-‐730-‐1920
WATTS
HEALTHCARE
–
AIDS
PROGRAMS
10300
Compton
Ave.
LA
90002
323-‐564-‐4331
WESTSIDE
FAMILY
HEALTH
1711
Ocean
Park
Blvd.
Santa
Monica
CA
90405
310-‐450-‐2191
NEEDLE
EXCHANGE
PROGRAMS
CLEAN
NEEDLES
NOW
627
San
Julian
St,
LA
213-‐483-‐5846
HOMELESS
HEALTH
CARE
LOS
ANGELES
1926
Beverly
Blvd
&
Bonnie
Brae
St,
LA
213-‐617-‐8408
BIENESTAR
Arroyo
Glen
&
Avenue
64/512
4
th
St.
LA
323-‐727-‐7896
AADAP
32
nd
St.
&
Broadway
323-‐294-‐4932
COMMON
GROUND
604
Rose
Ave.
Santa
Monica
310-‐314-‐5480
CITY
OF
PASADENA
RESOURCES
If
you
are
homeless
and
need
help
in
Pasadena
please
contact
Passageways
at:
1020
S.
Arroyo
Parkway,
Suite
100
Pasadena,
CA
91105.
Phone:
(626)
403-‐4888
Monday-‐Friday
8:00am-‐5:00pm.
Passageways
is
a
multi-‐service
center
that
is
the
sole
entry
point
into
the
City
of
Pasadena’s
continuum
of
care
system
for
homeless
families
and
individuals.
FOR ADDITIONAL
INFORMATION CONTACT
CDC
National
STD
&
AIDS
Hotline
800-‐227-‐8922
Project
Inform
National
HIV/AIDS
800-‐822-‐7422
AIDS
Hotline
in
Spanish
800-‐344-‐7432
National
Domestic
Violence
Hotline
800-‐799-‐7233
CDC
National
Prevention
Network
800-‐458-‐5231
AIDSINFO
800-‐HIV-‐0440
National
Institute
on
Drug
Abuse
(NIDA)
Hotline
800-‐662-‐4357
122
123
Appendix 6
Negotiating Safer Sex: Excuse/Response Sheet
Excuse: Condoms kill the mood for sex.
Response: Only if you let them. Condoms can make it better. You can help
me put it on.
Excuse: Condoms don't feel as good. They aren't natural.
Response: Thin condoms feel really natural. Some of them have textures
that can make sex really good and last longer. We'll both like
that. We can put a drop of lubrication inside the tip of the
condom to give us extra feeling.
Excuse: When I stop to put it on, I'll lose my erection.
Response: You can ask your partner to help you put it on. Don't worry,
your partner will help you get it back.
Excuse: Why do I need to use condoms if we're using the pill?
Response: The pill only prevents me from getting pregnant.
Condoms will keep us from getting HIV and other STDs.
Excuse: You don't trust me. You think I'm dirty.
Response: It's not about trust. I care about you and me. I don't want
anything to happen to either of us. We both share the
responsibility for using condoms to stay healthy.
Excuse: I love you. Would I give you an infection?
Response: Not on purpose. But most people don't know when they are
infected with HIV or an STD. Lots of times there are no
symptoms.
124
Excuse: Why do we need to use condoms? Don't we have a special
thing going?
Response: You know we do. But that's why I'm trying to protect us.
Because I want us to be safe.
Excuse: But we've been having sex without condoms for a while. Why
do you want to use them now?
Response: I know, but we could enjoy each other a lot more if I didn't have
to worry about STDs. That doesn't mean it's not a good idea from
now on. I've learned a lot more about HIV and STDs, and I want
to protect you and myself.
Excuse: Condoms are for people with diseases. Do I look sick to you?
Response: No, you look fine! But you can't tell by looking at people if they
have HIV or an STD. A person can look and feel healthy and still
be infected.
Excuse: I don't have a condom with me.
Response: I do, and I'm glad I brought it.
Let's satisfy each other without having sex. I know a lot of
good ways. Let's wait and have sex another time when we do
have a condom.
Let's go get one.
Excuse: You're punishing me because I had an STD.
Response: Of course I'm not! I'm just concerned and want us both to stay
healthy.
125
Excuse: Condoms break too often.
Response: Maybe we're using the wrong size or need more lubricant. Let's
try a different brand. Maybe it was put on wrong.
Excuse: But the first time always feels so good. I just want to feel
you for real.
Response: Don’t worry you’ll still feel me. I have these thin
condoms the feel really natural.
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Appendix 7
Condom Features Summary Handout
This handout provides a summary of condoms featured on the Condom
Features Poster Board. Other condom brands with special features are also
available through local vendors and departments of public health.
Type of Feature Condom Name (* shown on poster)
Snug Fit Prime Snugger Fit* Lifestyles Snugger Fit
Exotica Snugger Fit Trojan Ultra Fit
Large Size (thin) Trojan Magnum* MAXX*
Extra-large size (thin) Magnum XL*
Regular size (thin) Beyond 7 Crown*
Nubbed (inside) Kimono Sensation*
Nubbed (outside) Rough Rider* Trojan Pleasure Mesh
Ria Wrangler Trojan Shared Sensation
Ribbed Durex Her Sensation* Trojan Ribbed*
Contour Beyond 7 Trojan Ribbed*
Desensitizing Agent Durex Performax* Trojan Extended Pleasure*
Polyurethane (thin) Durex Avanti* Trojan Supra
Reality*
Jelly Lube Trojan Naturalube*
Non-lubricated Trojan Non-Lube*
Flavored Trustex*
Female Condom Reality*
Glow in the dark Night Light
Extra head room Bareback Midnight Desire
InSpiral Pleasure Plus
Lifestyle Extra Trojan Her Pleasure
Pleasure Trojan Twisted Pleasure*
TYPES OF CONDOM FEATURES TO CONSIDER:
Lubrication options: Silicone, jelly, non-lubricated
Types of fits: Snug, snug/regular, regular, large size, extra-large
Textures: Smooth, ribbed, nubbed
Type of material: Latex, polyurethane
Type of end: Plain (e.g. Trojan non-lube), receptacle end
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Appendix 8
Steps for Effective Condom Use Handout
Putting It On
• Check the expiration date on the package.
• Make sure the condom is made of latex or polyurethane.
• Open package at the corner and be careful not to tear the condom.
• If using a water-based lubricant, squeeze a few drops into the tip of the condom.
• Pinch the tip of the condom to leave a pocket for the ejaculation later on.
• Put condom on the end of the penis when it is hard (before it comes in contact with
your partner's mouth, genitals, or anus).
• Keep the pocket at the end and keep air out of it.
• Unroll condom all the way down to the base of the penis.
• Make sure pocket is still at the end.
• Apply water-based lubricant on the outside of condom.
Taking It Off
• After ejaculation, withdraw penis from vagina while penis is still hard.
• Hold condom rim while pulling out so no semen spills.
• Remove condom by rolling it down and off the penis.
• Throw away condom. (Don't flush it down the toilet.)
• Use a new condom each and every time you have sex. When ready to have sex
again, start over with a new condom. Don't reuse old condoms
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Appendix 9
VOICES-HM Manual and Intervention Materials
Video
Opportunities for
Innovative Condom
Education and Safer
Sex for
Homeless
Men
Original intervention (VOICES/VOCES) Developed by
Health and Human Development Programs
Education Development Center, Inc.
With funding from the
Centers for Disease Control and Prevention
Cooperative Agreement # UG2/CCU113446
Adapted by Hsun-Ta Hsu, MSW
University of Southern California, School of Social Work
© 1999 Education Development Center, Inc.
© 2009 Education Development Center, Inc.
129
Convening Small
Groups and Running
VOICES-HM Sessions
130
Overview: Convening Small
Groups and Running
VOICES-HM Sessions
Purpose
The purpose of this section is to help shelter staff convene and facilitate small-group
skill-building sessions. Please notice that VOICES-HM is adapted from
VOICES/VOCES for homeless men at shelter settings. Because most materials and
procedures in VOICES/VOCES are retained in VOICES-HM, before implementing
this intervention, agency staff should complete the original VOICES/VOCES training.
Free online training is available at:
https://effectiveinterventions.cdc.gov/en/TrainingCalendar/course-
registration?SessionID=1716&SessionTypeID=79&type=R
Preview
This section includes:
• useful tips on what facilitators should know in order to facilitate a small-group skill-
building session
• a protocol for leading effective, video-based, skill-building sessions
• strategies that will help men negotiate safer sex and protect their partners
• effective ways to provide men with education about condom use and condom features
Objectives for Staff
After reviewing this section, shelter staff will be able to:
• convene small groups to participate in VOICES-HM sessions
• lead effective interactive group skill-building sessions following video-viewing
• tailor prevention messages to meet men' needs
• identify and address men' barriers to condom use
• educate men about condom varieties and special features
• provide men with strategies that will help them protect themselves and their partners
from HIV and other STDs
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Tips on Effective Small-Group
Facilitation
A well-run group session can leave men feeling confident, ready, and able to adopt simple safer sex
practices. Whether or not you have experience conducting interactive small-group counseling, it may be
helpful to review the tips below to ensure that the process goes as smoothly as possible.
• Establish ground rules about the group discussion and encourage confidential and respectful
boundaries.
• Be clear about your expectations for how group members treat one another and how they
participate.
• Give everyone a chance to participate.
• Be supportive.
• Be nonjudgmental.
• Use humor when appropriate.
• Respect men' feelings and boundaries.
• Encourage group spirit.
• Model appropriate assertive behavior.
• Be firm when necessary.
• Demonstrate concepts and examples when possible.
• Share only appropriate personal experiences.
• Keep the language simple and concise.
• Encourage group members to share their experiences at their own pace.
• Listen.
• Let group members react, think, and analyze.
• Be flexible.
• Be patient with the process, and try different approaches until you find one that works.
• Demonstrate acceptance and respect for all men, regardless of race, religion, social class,
or sexual orientation.
• Keep in mind that discussions about condom negotiation may lead to disclosures by men
about interpersonal violence and other sensitive issues. If this occurs, decisions and referrals
of men for addressing such issues must be made within the boundaries of shelter policy.
Even men may not specifically disclose these issues, facilitators should go through the
resource sheet at the end of the group for men to be familiar with local resources.
Adapted from Jemmott, L. S., Jemmott, J. B., & McCaffree, K. A. (1994). Be Proud! Be Responsible! Strategies to
Empower Youth to Reduce Their Risk for AIDS. New York: Select Media.
132
Protocol for Facilitating a
Small-Group Session
Note to facilitators:
This protocol offers a step-by-step guide to conducting small-group skill-building sessions using the
VOICES-HM materials. We strongly suggest that VOICES-HM facilitators adhere to this protocol
closely. VOICES-HM is a brief, single-session intervention. Because it is so brief - only 60 minutes,
including 15-20 minutes of video-viewing, the time allotted for discussion must be spent helping men
develop the skills they need to negotiate and perform condom use successfully. This can be done most
effectively by following the steps outlined below. As handouts are developed to prepare facilitators for
conducting brief and effective group discussions and skill training, facilitators should be familiar with all the
handouts included in the manual. Please complete the original VOICES/VOCES online training before
implementing VOICES-HM. Free online training is available at:
https://effectiveinterventions.cdc.gov/en/TrainingCalendar/course-
registration?SessionID=1716&SessionTypeID=79&type=R
1. Thank men for participating in the brief HIV/STD prevention
Session
2. Establish Ground Rules
Before the group discussion, explain to men that there are certain ground rules for group conversation.
These rules address issues of respect and confidentiality, such as:
• Using no last names
• Agreeing that everything said in the group stays in the group
• Recognizing everyone's experiences and suggestions as valuable
• Not making fun of or judging others
Ask men if they have any other ground rules they would like to see apply to the group, and write
down any suggestions.
3. Conduct the HIV Knowledge and Risk Behavior Brief Survey
Pass out the HIV Knowledge and Risk Behavior Brief Survey to men with pens. Tell men that this is
just a brief survey trying to understand how much they know about HIV and what are the behaviors
that may be associated with HIV risks. Tell men that the reason you give them this survey is that, when
people see things on paper, it makes things a little more real than what is just in their thoughts. Let
men know that the survey will be discussed in the groups after men complete the surveys. Emphasize
that they do not need to share their answers with others. Ask men not to put their names, including
Introduction part of the manual can be very helpful: how you introduce yourself, explain the video, that
it is a bilingual video, how long it's going to be, what to expect, and that there will be a discussion
afterwards.
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nicknames, on the survey. Let men know that the survey will be destroyed after the discussion.
Reiterate the confidentiality and non-judgmental ground roles just set. Encourage men that they can be
as honest as possible. Once men finish the surveys, pass out correct answer sheet to men.
4. Go Through The HIV Knowledge and Risk Behavior Brief Survey
Stress that this activity is about everyone getting the correct information. Ask men to make a mental
note of the questions and whether they got each right or not. Review each item with the group. Ask
men to think about the information on their form as you review each item. Be sure to mention the
correct response to each item. Remind men as you refer to the STD testing item that HIV is an STD
and that having other STDs can increase the risk of getting or giving HIV. It is important not to
embarrass any of the men for their past or current behaviors.
Pass out and go through the HIV Fact Sheet with Local Statistics handout. Let men know that the
handouts are for them to keep. When going through the statistics, the facilitators should emphasize the
high prevalence of HIV within the community and homeless population, and their participating in this
program is the first step not only to protect themselves and their partners from HIV, but also prevent
HIV epidemic in their communities.
Potential discussion topic:
• How do you feel about the information on your survey (remind men that they do not need to
share their answers, rather, talk about their feelings)?
• How might your decisions about sexual behaviors be affected by what you have learned
today?
• Pass out the HIV Fact Sheet with Local Statistics handout to men
3. Show the Video
Tell men that you are going to show them a video that will take about 15 minutes (The facilitator can
based on men’s cultural background to select the cultural appropriate video to be played). Let them
know that they will have the opportunity to spend 25 to 30 minutes discussing the video afterward.
Explain that the video was developed to help initiate conversation about how people like those in the
group can protect themselves and their loved ones from HIV and other STDs. Explain to men that
some of the video clips may portray women’s perspective, and men should focus on scenes relevant
to their life experiences. The facilitator should also encourage men to pay specific attention on
messages covered in the video that are discussed in the previous activities or covered in the HIV
knowledge and risk behaviors brief survey. If the facilitator thinks that the living conditions included
in the video may not reflect homeless men’s current living condition, facilitators can tell men to
focus on the messages included in the videos and the strategies the characters use to discuss condom
use.
Show the video to men.
4. Facilitate the Small-Group Discussion
VOICES-HM was designed to help men develop the skills they need to practice safer sex and negotiate
condom use. During the session, men may pose questions on a variety of topics, including substance
abuse, domestic violence, or the latest drug therapies for HIV. These are important topics that should
be addressed in corresponding sections or after the program. Discussion during the video
discussion session, however, should stay focused on condom use and negotiation. Facilitators should
134
be familiar with the handouts included in this manual provided, to be able to answer men’s questions
or further the discussion.
As facilitator you should guide the discussion, but talk as little as possible and resist giving advice.
Let men make suggestions for reducing risk and negotiating behavior change, then let them tryout
these suggestions, getting feedback from others. The following steps will help you to facilitate the
discussion. For more specific tips on facilitating a group session with each of the videos, see
“Additional Tips for Facilitating Small Group Discussions” section.
• Use the characters and situations depicted in the video to launch group discussion. After
showing the video, ask men questions that relate directly to what they have just seen. Use
the Activity Sheets for each video to identify specific “trigger points” that you will want to
discuss. Reinforce the knowledge and risk behaviors discussed in the previous section
here. For example, the first trigger point on the Do It Right activity sheet is Will saying,
“My girls are clean. Besides, I don’t sleep with prostitutes, and sure don’t sleep with
men.” Ask men what they think of his statement, whether they agree or disagree, and why.
You can then discuss people’s misconceptions about STDs and HIV infection and the
importance of using condoms during all sexual encounters—since people with HIV or
other STDs can look perfectly healthy. Continue to refer to the activity sheets throughout
the group discussion to help you stay “on track.”
• As men discuss these issues, encourage them to strategize together about ways they can talk
to their partners about condom use. Use the scenario identified in the scenes. Ask men what
are the characters’ excuses not to use condom, and how would men response differently?
• Have men role-play different condom negotiation strategies. For example, remind men of the
scene in Do It Right in which Tiffany says to Justin, “We don’t need these [condoms]
tonight…things are getting more serious with us so I started on the pill.” Have the group as a
whole to discus about “What would they have said if they were Justin?”
• Have men generate common excuses their partners might use for not wanting to use condoms
(see "Negotiating Safer Sex: Excuse/Response Sheet”). Ask men to suggest replies to these
excuses.
• Refer to specific scenes and encounters in the videos to illustrate ways to introduce condoms
in different relationships. Ask, how Eddie talked to Marianela? Eddie says to Marianela, “I’ll
even let you put it on. I got it in ribbed for your pleasure,” so she feels like he is trying to
please her.
• Provide men with specific strategies - things to say and do - that will help them to protect
themselves and their partners. Make sure you tailor these messages to the men's individual
circumstances.
• Pass out the Negotiating Safer Sex: Excuse/Response handout to men, and tell men this
handout is for them to keep.
5. Provide Condom Feature Information
Some men know a lot and some know very little. Facilitators can work with them on how to negotiate
condom use, whether they know a lot or know a little. It is not really necessary for them to understand
the in-depth transmission information. For some reason they are able to operate without it. It is more
important for men to identify their personal risk behaviors with the characters and learn skills and
strategies modeled in the video clips.
135
• Refer to the Condom Features Poster Board and highlight the varieties of condoms and their
features available to meet men' needs, including the female condom, condoms of different
sizes (large and small), levels of thickness, textures, shapes, varying degrees and types of
lubrication, and which ones are best for vaginal, oral, and anal sex. During this part of the
discussion, use the condom features summary sheet as a quick and easy reference. When
introducing the condom features, pass out sample condoms to men so that they can see, touch,
and experience the differences among these condoms.
• Identify, with men, their objections to using condoms, as well as the objections of their
partners.
• Help men recognize why they may not have used condoms consistently in the past, and
provide the information and support they need to change their behavior.
• Demonstrate how and when to put condoms on, how and when to remove them, and how to
dispose of a used condom. Remind men about the importance of checking expiration dates
on condom packages.
• Pass out the Steps for effective condom use handout and invite men to practice putting
condoms on the anatomical models. If men do not feel confortable putting on the
models, provide alternatives, such banana for men to practice condom skills.
6. Go through and discuss the HIV Risk and Substance Use handout
• Discuss with men about how using substances influence unprotected sex.
• Pass out the HIV Risk and Substance Use handout and the resource guide.
• Go through the HIV Risk and Substance Use handout with men. Refer to the resource guide
for local substance abuse treatment/recovery services and needle exchange programs.
• Facilitators can also add services provided in shelters that may help men address substance
use issues in the resource guide.
• Discuss with men regarding their thoughts about the characters in the videos consuming
alcohol before sex/condom negotiation.
6. Summarize the Session
• Thank the group for participating in VOICES-HM.
• Provide men with sample condoms and encourage them to tryout what they have learned.
• Briefly go through the resource sheet with men. Let men know if they have any questions
regarding the resources listed, they can ask after the program.
• Let men know they can return to ask questions and get more support or advice about
protecting their partners and themselves.
• Remind men of the full range of services available at shelters.
136
VOICES-HM Handouts for
Participants
137
HIV Knowledge and Risk Behavior Brief Survey
Please do not put your name or nicknames on this brief survey. This
survey will be discussed in the group. However, please remember, you do
not need to disclose your answers to others as well. The survey will be
destroyed right after the group.
Your Answer
1. Are AIDS and HIV two names for the same thing? __________
2. Does a person who has HIV always have AIDS? __________
3. Can a person be infected with HIV and
not show signs? __________
4. Does a negative HIV test always mean a person
does not have HIV? __________
5. Does getting tested for HIV help protect a person
from getting the virus? __________
6. Does a negative test mean a person cannot get HIV? __________
7. Can a person with HIV who looks healthy pass the
virus to others? __________
8. Can a person get HIV through contact with saliva? __________
9. Does having sex with more than one partner
increase a person’s chance of getting HIV? __________
10. Can a woman give HIV to a man? __________
11. Do people get HIV the same way that they get
Gonorrhea and Syphilis (VD)? __________
12. Can a person who got HIV from shooting up drugs
give the virus to someone by having sex? __________
13. Does using shortening and other oils to lubricate
latex condoms help them work better? __________
14. Does washing drug equipment with warm
water kill HIV? __________
15. Do most types of birth control also protect
against HIV? __________
138
Please circle the response that most describe your situation
1. You (do or do not) worry about getting HIV - the virus that causes AIDS.
2. You (have or have not) thought about protecting yourself from HIV.
3. You are (definitely not, somewhat, or definitely) confident that you could bring up the need to use a condom.
4. You are (definitely not, somewhat, or definitely) confident that you could refuse to have unsafe sex even if your
partner pressured you to be unsafe.
5. You had _____________ partners in the past 3 months (Please fill in numbers).
Below please provide information regarding sexual activities you have practiced
in the past 3 months:
6. Getting oral sex without a condom ____ times.
7. Giving oral sex without a condom/latex barrier _____ times.
8. Vaginal sex without a condom ______ times.
9. Vaginal sex with a condom ______ times.
10. How often did you use condoms during vaginal sex in the past 3 months:
Always Usually Sometimes Rarely Never
11. Anal sex without a condom times.
12. Anal sex with a condom times.
13. How often did you use condoms during anal sex in the past 3 months:
Always Usually Sometimes Rarely Never
14. In the past 3 months, you drank alcohol times just before sex.
15. In the past 3 months, you used drugs times just before having sex.
16. You have been treated __times for a sexually transmitted disease (STD, VD) in the past year.
139
HIV Knowledge and Risk Behaviors Brief Survey - with
Answers
Correct Answer
1. Are AIDS and HIV two names for the same thing? __NO_____
2. Does a person who has HIV always have AIDS? __NO_____
3. Can a person be infected with HIV and
not show signs? __YES____
4. Does a negative HIV test always mean a person
does not have HIV? __NO_____
5. Does getting tested for HIV help protect a person
from getting the virus? __NO_____
6. Does a negative test mean a person cannot get HIV? __NO_____
7. Can a person with HIV who looks healthy pass the
virus to others? __YES____
8. Can a person get HIV through contact with saliva? __NO_____
9. Does having sex with more than one partner
increase a person’s chance of getting HIV? __YES____
10. Can a woman give HIV to a man? __YES____
11. Do people get HIV the same way that they get
Gonorrhea and Syphilis (VD)? __YES____
14. Can a person who got HIV from shooting up drugs
give the virus to someone by having sex? __YES____
15. Does using shortening and other oils to lubricate
latex condoms help them work better? __NO_____
14. Does washing drug equipment with warm
water kill HIV? __NO_____
15. Do most types of birth control also protect
against HIV? __NO_____
140
HIV Fact Sheet With Local HIV
Statistics
Local HIV Statistics
• 5% of individuals experiencing homelessness at Skid Row have HIV/AIDS, which is 8
times higher than the rate among general population.
• 2% of individuals at Pasadena experiencing homelessness have HIV/AIDS, which is 3
times higher than the rate among general population
• Men accounted for 76% of all adults and adolescents living with HIV infection at the end of
2010 in the United States.
• African American adults are 8 times higher than White adults to contract HIV/AIDS
• By race/ethnicity, black men have the highest rates of new HIV infections among all men.
• Hispanic/Latino adults are 3 times more likely than Whites to contract HIV/AIDS.
• White adults account for 29% of the new HIV incidents in 2011.
HIV and STDS: The Basic Facts
• Men and women can have STDs that cause damage without symptoms.
• People with HIV or other STDs can look perfectly healthy.
• Having an STD puts you at increased risk of getting another STD.
• STDs can be transmitted through oral sex as well as vaginal or anal sex.
• STDs can be life threatening.
• Repeat STD infections may leave a woman infertile.
• Current treatments may control HIV temporarily, but are not a cure.
• Birth control pills will not prevent you from getting HIV.
• HIV can be transmitted from mother to child prior to birth. HIV can be transmitted through
breast milk.
Risk Factors
• Engaging in vaginal, anal, or oral sex without latex or polyurethane condoms
• Having a prior STD
• Using injection drugs or having unprotected sex with an injection drug user
• Using alcohol or drugs to relax or have fun
• Inconsistently using condoms with your primary partner
• Inconsistently using condoms with non-primary partners
• Having no experience using condoms or getting partners to use condoms
• Having a bad experience using condoms, such as having a partner get angry or violent at the
suggestion of condom use
• Having sex with someone who may have other partners
• Having multiple sex partners
• Being forced to have unprotected sex
141
Negotiating Safer Sex:
Excuse/Response Sheet
Excuse: Condoms kill the mood for sex.
Response: Only if you let them. Condoms can make it better. You can help me put it
on.
Excuse: Condoms don't feel as good. They aren't natural.
Response: Thin condoms feel really natural. Some of them have textures that can
make sex really good and last longer. We'll both like that. We can put a
drop of lubrication inside the tip of the condom to give us extra feeling.
Excuse: When I stop to put it on, I'll lose my erection.
Response: You can ask your partner to help you put it on. Don't worry, your partner
will help you get it back.
Excuse: Why do I need to use condoms if we're using the pill?
.
Excuse: Why do I need to use condoms if we're using the pill?
Response: The pill only prevents me from getting pregnant. Condoms will keep us
from getting HIV and other STDs.
Excuse: You don't trust me. You think I'm dirty.
Response: It's not about trust. I care about you and me. I don't want anything to
happen to either of us. We both share the responsibility for using
condoms to stay healthy.
Excuse: I love you. Would I give you an infection?
Response: Not on purpose. But most people don't know when they are infected with
HIV or an STD. Lots of times there are no symptoms.
Excuse: Why do we need to use condoms? Don't we have a special
thing going?
Response: You know we do. But that's why I'm trying to protect us. Because I want
us to be safe.
142
Excuse: But we've been having sex without condoms for a while. Why
do you want to use them now?
Response: I know, but we could enjoy each other a lot more if I didn't have to worry
about STDs. That doesn't mean it's not a good idea from now on. I've
learned a lot more about HIV and STDs, and I want to protect you and
myself.
Excuse: Condoms are for people with diseases. Do I look sick to you?
Response: No, you look fine! But you can't tell by looking at people if they have
HIV or an STD. A person can look and feel healthy and still be infected.
Excuse: I don't have a condom with me.
Response: I do, and I'm glad I brought it.
Let's satisfy each other without having sex. I know a lot of good
ways. Let's wait and have sex another time when we do have a
condom.
Let's go get one.
Excuse: You're punishing me because I had an STD.
Response: Of course I'm not! I'm just concerned and want us both to stay healthy.
Excuse: Condoms break too often.
Response: Maybe we're using the wrong size or need more lubricant. Let's try a
different brand. Maybe it was put on wrong.
Excuse: But the first time always feels so good. I just want to feel
you for real.
Response: Don’t worry you’ll still feel me. I have these thin condoms the
feel really natural.
143
Condom Features Summary Handout
This handout provides a summary of condoms featured on the Condom Features
Poster Board. Other condom brands with special features are also available
through local vendors and departments of public health.
Type of Feature Condom Name (* shown on poster)
Snug Fit Prime Snugger Fit* Lifestyles Snugger Fit
Exotica Snugger Fit Trojan Ultra Fit
Large Size (thin) Trojan Magnum* MAXX*
Extra-large size (thin) Magnum XL*
Regular size (thin) Beyond 7 Crown*
Nubbed (inside) Kimono Sensation*
Nubbed (outside) Rough Rider* Trojan Pleasure Mesh
Ria Wrangler Trojan Shared Sensation
Ribbed Durex Her Sensation* Trojan Ribbed*
Contour Beyond 7 Trojan Ribbed*
Desensitizing Agent Durex Performax* Trojan Extended Pleasure*
Polyurethane (thin) Durex Avanti* Trojan Supra
Reality*
Jelly Lube Trojan Naturalube*
Non-lubricated Trojan Non-Lube*
Flavored Trustex*
Female Condom Reality*
Glow in the dark Night Light
Extra head room Bareback Midnight Desire
InSpiral Pleasure Plus
Lifestyle Extra Trojan Her Pleasure
Pleasure Trojan Twisted Pleasure*
TYPES OF CONDOM FEATURES TO CONSIDER:
Lubrication options: Silicone, jelly, non-lubricated
Types of fits: Snug, snug/regular, regular, large size, extra-large
Textures: Smooth, ribbed, nubbed
Type of material: Latex, polyurethane
Type of end: Plain (e.g. Trojan non-lube), receptacle end
144
Steps for Effective
Condom Use
Putting It On
• Check the expiration date on the package.
• Make sure the condom is made of latex or polyurethane.
• Open package at the corner and be careful not to tear the condom.
• If using a water-based lubricant, squeeze a few drops into the tip of the condom.
• Pinch the tip of the condom to leave a pocket for the ejaculation later on.
• Put condom on the end of the penis when it is hard (before it comes in contact with your
partner's mouth, genitals, or anus).
• Keep the pocket at the end and keep air out of it.
• Unroll condom all the way down to the base of the penis.
• Make sure pocket is still at the end.
• Apply water-based lubricant on the outside of condom.
Taking It Off
• After ejaculation, withdraw penis from vagina while penis is still hard.
• Hold condom rim while pulling out so no semen spills.
• Remove condom by rolling it down and off the penis.
• Throw away condom. (Don't flush it down the toilet.)
• Use a new condom each and every time you have sex. When ready to have sex again, start
over with a new condom. Don't reuse old condoms
145
Additional Tips for Facilitating
Small Group Discussions (By
Video)
The following section provides additional tips for facilitating a small group discussion using each of the
five available videos. The tips refer only to the small group discussion component of a VOICES-HM
group. For information on the additional steps (i.e., thanking men, establishing ground rules, showing the
video, condom features education, and passing out sample condoms), please refer to the previous
protocol section.
Do It Right
• Use the characters and situations depicted in the video to launch group discussion: After showing
the video, ask men questions that relate directly to what they have just seen. Use the Activity Sheets
to identify specific “trigger points” that you will want to discuss. For example, in the scene in the pool
hall, Will says, “My girls are clean. Besides, I don’t sleep with prostitutes, and sure don’t sleep with
men.” Ask men what they think of his statement whether they agree or disagree, and why. You can
then discuss misconceptions about STDs and HIV infection and the importance of using condoms
during all sexual encounters—since people with HIV or other STDs can look perfectly healthy.
Continue to refer to the Activity Sheets throughout the group discussion to help you stay “on track.”
This is also a good time to reinforce the previous discussion on HIV knowledge (fact and myth) and
transmission risk behaviors.
• Ask men to discuss these issues, encourage them to strategize together about ways they can talk
to their partners about reducing sexual risk and increasing condom use. For example, you can
bring up the scene between Will and Monique when Will says, “I take real good care of myself.” You
might ask them, “What is Will suggesting through this statement? If a partner said that to you, how
could you respond and convince him or her to use a condom?”
• Have men role-play different condom negotiation strategies. For example remind men of the scene
where Tiffany says to Justin, “We don’t need these [condoms] tonight…things are getting more
serious with us so I started on the pill.” Have the whole group assume the role of Justin, and discuss
how they would have handled the situation. Ask participants, “What would you have said if you were
Justin?”
• Have men generate other common excuses their partners might use for not wanting to use
condoms (see “Negotiating Safer Sex: Excuse/Response Sheet,” in the manual). Ask men to suggest
replies to these excuses.
• Refer to specific scenes and encounters in the videos to illustrate ways to introduce condoms in
different relationships. Monique asks simply, “Will, do you have any protection?” Justin says, “I got
them just for you, ribbed for your pleasure” so that Tiffany feels he’s trying to please her and take care
of her. • Provide men with specific strategies—things to say and do—that will help them to
protect themselves and their partners. Talk about how the characters in Do It Right made condoms
sexy and fun. (“This one looks like it could be fun, ultra thin, and I heard condoms make you last
longer.”) Make sure you tailor these messages to the men’ circumstances.
146
It’s About You
• Use the characters and situations depicted in the video to launch group discussion: After showing
the video, ask men questions that relate directly to what they have just seen. Use the Activity Sheets to
identify specific “trigger points” that you will want to discuss. For, example, in the scene in the pool
hall, Eddie says, “A condom? Nah, man…I can tell when a girl’s clean….I don’t sleep with prostitutes,
or with men.” Ask men what they think of his statement, whether they agree or disagree, and why.
You can then discuss misconceptions about STDs and HIV infection and the importance of using
condoms during all sexual encounters—since people with HIV or other STDs can look perfectly
healthy. Continue to refer to the Activity Sheets throughout the group discussion to help you stay “on
track.”
This is also a good time to reinforce the previous discussion on HIV knowledge (fact and myth) and
transmission risk behaviors.
• Have men role-play different condom negotiation strategies. For example, remind men of the last
scene where Eddie is with Marianela and she says, “No, I’m on the pill, Eddie. We don’t need to
worry about that.” Have the whole group assume the role of Eddie, and ask participants to discuss
how they would have handled the situation. Ask participants, “What would you have said if you were
Eddie?”
• Have men generate common excuses their partners might use for not wanting to use
condoms (see “Negotiating Safer Sex: Excuse/Response Sheet,” in the manual). Ask men to
suggest replies to these excuses.
• Refer to specific scenes and encounters in the videos to illustrate ways to introduce condoms in
different relationships. Eddie says to Marianela, “I’ll even let you put it on. I got it in ribbed for
your pleasure,” so she feels like he is trying to please her.
• Provide men with specific strategies—things to say and do—that will help them to protect
themselves and their partners. Make sure you tailor these messages to the men’ circumstances. You
may want to talk about how the characters in It’s About You made condoms sexy and fun. (“I’ll even
let you put it on. I got it in ribbed for your pleasure.”)
Safe in the City
• Use the characters and situations depicted in the video to launch group discussion: After showing
the video, ask men questions that relate directly to what they have just seen. Use Activity Sheets to
identify specific “trigger points” that you will want to discuss. For example, in Safe in the City, Luis
tells Teresa, “I’m not worried about you. I don’t think you’re the kind of girl that--,” and Teresa
finishes, “sleeps around?” Ask men what they think of his statement and what it implies about who
gets infected and who doesn’t. You can then discuss misconceptions about STDs and HIV infection
and the importance of using condoms during all sexual encounters since people with HIV or other
STDs can look perfectly healthy. Continue to refer to the Activity Sheets throughout the group
discussion to help you stay “on track.”
This is also a good time to reinforce the previous discussion on HIV knowledge (fact and myth) and
transmission risk behaviors.
• As men discuss these issues, encourage them to strategize together about ways they can talk to
their partners about condom use. For example, remind men of the scene with Paul and Jasmine on
the couch where Paul says he wants to “go without one tonight.” Ask men to think about what Paul is
suggesting when he says “I want to feel you for real.” What strategy did Jasmine use? What are
147
some other strategies? What if they were Paul and knew they might have an STD? What could they
say to their partner and protect her?
• Have men role-play different condom negotiation strategies. With men, you can refer to the scene in
which Jasmine suggests they take things to the “next level,” while Paul realizes he might have an STD.
Ask the group as a whole to discuss how they would have handled that situation.
• Have men generate common excuses their partners might use for not wanting to use
condoms (see “Negotiating Safer Sex: Excuse/Response Sheet,” in the manual). Ask men to
suggest replies to these excuses.
• Refer to specific scenes and encounters in the videos to illustrate ways to reduce sexual risk and
introduce condoms in different relationships. How did Teresa negotiate condom use even after
Luis got angry? What kind of things did she say to appeal to him? (“It’s not about you; I like you;”
“When I use one I feel safe…and free.”)
• Provide men with specific strategies—things to say and do—that will help them to protect
themselves and their partners. Make sure you tailor these messages to the men’ circumstances.
You may want to talk about how the characters in Safe in the City made condoms sexy and fun.
(“Unroll nice and easy, all the way down.”)
148
VOICES-HM Resources
for Facilitators
149
Do It Right Activity Sheet
Note: Although some scenarios may include views from women’s perspective, the facilitator can
remind men to focus on scenarios relevant to their situation.
Scene
Trigger
Points
Issues/Barriers
Addressed
Four
guys
playing
pool
(Will)
“My
girls
are
clean.
Besides,
I
don’t
sleep
with
prostitutes,
and
sure
don’t
sleep
with
men.”
(Justin)
“..and
you
can
tell
when
a
girl’s
clean
just
by
looking
at
her?”
(Will)
“So
what
is
the
big
deal
about
an
STD
anyway?
All
you
gotta
do
is
take
a
few
pills!”
(Justin)
“It’s
not
just
about
you
bro’—
it’s
about
protecting
the
whole
community.”
Condom
demonstration
Increasing
risk
perception;
countering
misperceptions
Peer/community
support
Promotion
of
condom
skills
Beauty
salon
scene
with
Tiffany
and
Monique
(Tiffany)
“I’m
just
saying
girl,
you
need
to
watch
out.”
Self-‐efficacy/control;
attitudes
about
being
prepared,
peer
support
The
two
couples
are
watching
TV
in
Monique’s
apartment.
Monique
and
Tiffany
chat
in
the
kitchen
about
Monique
wanting
to
spend
more
time
with
Will.
(Monique)
“I
can
take
care
of
myself.
Trust
me!”
(Tiffany)
“Take
this
just
in
case…I’m
just
saying
if
something
starts
jumping
off
tonight,
be
sure
to
use
a
condom.”
(Tiffany)
“There
are
a
lot
of
diseases
going
around.”
(Tiffany)
“Do
your
thing,
but
do
it
right…take
this
condom
and
use
it.”
(Tiffany)
“We’ve
talked
about
not
using
condoms—we’ve
been
going
out
for
months
and
have
stopped
seeing
other
people…it’s
totally
different.”
Acknowledging
attitudes
and
barriers
to
condom
use
in
new
relationships
Self-‐efficacy/control;
attitudes
about
being
prepared,
having
condoms
available
Increasing
risk
perception
Self-‐efficacy/control;
promotion
of
condom
skills;
peer
support
Acknowledging
attitudes
and
barriers
to
condom
use
in
ongoing/steady
relationships
150
Scene
Trigger
Points
Issues/Barriers
Addressed
Justin
addresses
the
camera
expressing
his
concerns
about
how
to
continue
using
condoms
with
Tiffany.
(Justin)
“I
know
there’s
no
excuse
for
it,
but
what
can
I
say,
it
just
happened.”
Modeling
relationship
change;
responsibility
to
steady
partner;
protection
and
concerns
about
not
using
condoms
Justin
and
Tiffany
are
talking
on
Tiffany’s
bed.
(Tiffany)
“We
don’t
need
these
[condoms]
tonight…things
are
getting
more
serious
with
us
so
I
started
on
the
pill.”
(Justin)
“To
be
on
the
safe
side,
we
should
continue
using
condoms
until
we
get
tested.
The
pill
doesn’t
protect
you
from
diseases.”
(Justin)
“I
wanna
be
with
you.
Just
you.
But
before
we
do
anything
stupid
we
should
be
sure…
Me
taking
care
of
you.”
(Justin)
“And,
I
got
them
just
for
you,
ribbed
for
her
pleasure.”
Acknowledgement
of
barriers
to
continued
condom
use
in
ongoing
relationships
Modeling
safer
sex
negotiation
in
ongoing
relationship;
values
of
responsibility,
protection
of
partner
Condom
negotiation;
knowledge
of
condom
features
Monique
talks
about
having
unprotected
sex
with
Will,
its
consequence,
and
what
she
has
learned
(Monique)
“I
wanted
to
bring
up
protection
but
I
didn’t
know
how.”
(Monique)
“Saving
myself
the
embarrassment
of
bringing
out
a
condom
that
one
night
sure
cost
me
a
lot
in
the
end.”
Acknowledging
barriers
to
condom
negotiation
and
use
in
new
relationship
Increasing
risk
perception;
acknowledgment
of
consequences
Retake
of
Monique
shows
how
she
should
have
handled
the
situation
with
Will
(Monique)
“Will,
do
you
have
any
protection?”
(Will)
“Come
on
baby,
I
ain’t
no
teenager.
I’ll
pull
out
before
I
cum.”
(Will)
“I
take
real
good
are
of
myself:
I
eat
well,
I
workout
and
I
keep
myself
very,
very
clean.”
(Will)
“The
first
time
is
always
so
good.
I
just
wanna
be
able
to
feel
you.”
(Will)
“I
don’t
know
if
I’ll
be
able
to
stay
hard
with
that
thing
on.”
(Monique)
“This
one
looks
like
it
could
Self-‐efficacy/control;
modeling
condom
negotiation
Addressing
attitudinal
barriers
and
misconceptions,
modeling
condom
comebacks
Addressing
physical
barriers
to
condom
use
Promotion
of
condom
skills;
151
Scene
Trigger
Points
Issues/Barriers
Addressed
be
fun,
ultra
thin
and
I
heard
condoms
make
you
last
longer.”
(Monique)
“That’s
the
way
I’ll
do
it
from
now
on.
Any
other
way
just
isn’t
worth
it.”
knowledge
of
condom
features
Self-‐efficacy/control,
empowerment
Justin
addresses
camera
(Justin)
“Tiffany
and
I
went
to
the
health
clinic
and
got
checked
out….we’re
still
using
condoms-‐-‐-‐some
STDs
take
a
few
months
to
register”
Modeling
importance
of
testing,
mutual
monogamy
before
stopping
condom
use
in
ongoing
relationship
152
It’s About You Activity Sheet
Note: Although some scenarios may include views from women’s perspective, the facilitator can
remind men to focus on scenarios relevant to their situation.
Scene
Trigger
Points
Issues/Barriers
Addressed
Carmen
and
Joanna
talking
in
the
beauty
parlor.
(Carmen)
“In
this
day
and
age,
a
woman
should
always
be
prepared.
Just
in
case;
you
never
know.”
(Carmen)
“It’s
not
just
men
who
have
sex
with
men
that
get
venereal
diseases
or
HIV.
Anyone
can
catch
something
without
knowing
it.”
(Joanna)
“But
how
do
you
bring
this
up
with
a
guy?
He’s
going
to
think
that
I
don’t
trust
him
and
that
I’m
some
little
tramp
or
easy.”
(Carmen)
“What
matters
the
most
is
to
take
care
of
yourself.
And
if
they
really
want
it,
they’ll
deal
with
it.”
(Carmen)
“If
your
man
doesn’t
care
about
you
enough
to
protect
you
then
he
doesn’t
care
about
you,
period.”
Self-‐efficacy/control;
attitudes
about
being
prepared,
having
condoms
available
Increasing
risk
perception;
countering
misperceptions
Acknowledging
attitudes
and
barriers
to
condom
use;
addressing
relationship
concerns/potential
rejection
Self-‐efficacy;
promotion
of
condom
skills;
peer
support;
positive
norms
about
condom
use
Self-‐efficacy;
promotion
of
condom
skills;
peer
support;
modeling
values:
respect
and
protect
153
Eddie
playing
pool
and
talking
with
his
friends
(Eddie)
“A
condom?
Nah,
man…I
can
tell
when
a
girl’s
clean.”
(Jaime)
“It’s
not
just
about
birth
control—there’s
all
types
of
diseases
you
can
catch
through
sex…”
(José)
“If
you’re
gonna
mess
around,
you
gotta
use
a
condom;
A
man’s
gotta
take
care
of
his
wife
and
family.”
Countering
misconceptions;
increasing
risk
perception
Knowledge;
increasing
risk
perception
Family/community
norms:
respect
and
protect;
responsibility
to
family/partner
Scene
Trigger
Points
Issues/Barriers
Addressed
Eddie
talking
with
his
friend.
(Jaime)
“I
fooled
around
with
this
girl
once
and
I
got
a
venereal
disease…I
told
[my
girlfriend]
I
caught
it
off
a
public
toilet,
but
you
know
her,
she’s
not
dumb.”
(Eddie)
“It
didn’t
feel
right…I
had
it
up,
but
then…”
(Eddie)
“…if
you
put
a
little
lubricant
on
the
tip
of
your
penis…it
will
feel
more
natural.”
(Jaime)
“They
even
help
you
last
longer
so,
you
know,
give
your
woman
special
pleasures...Make
it
into
a
little
game.”
(Eddie)
“I
think
wearing
a
condom
really
kills
the
mood.”
Addressing
misconceptions,
attitudinal
barriers;
peer
support
Addressing
physical
barriers
to
condom
use,
including
loss
of
erection
(negative
experiences);
promotion
of
condom
skills
(lubrication;
incorporating
into
sex)
Addressing
attitudinal
barriers
Eddie
and
Jaime
in
the
pharmacy
picking
out
condoms
(Jaime)
“All
right,
man…you
got
your
lubricated,
non-‐lubricated,
ribbed
for
her
pleasure,
extra
sensitive.”
(Jaime)
“They
come
in
different
colors,
but
best
ones
are
made
of
latex.”
Knowledge
of
condom
features
154
Joanna
talking
to
camera
about
having
unprotected
sex
despite
having
a
condom
(Joanna)
“I
wanted
to
use
a
condom,
but
how
was
I
supposed
to
bring
it
up?
(Joanna)
“I
didn’t
want
him
to
think
that
I
am
that
kind
of
woman.”
(Joanna)
“Whatever
embarrassment
I
saved
myself
that
night,
it
wasn’t
worth
it.”
Condom
negotiation
skills
Addressing
attitudinal
barriers
Increasing
risk
perception
Eddie
talking
to
camera
about
having
unprotected
sex
despite
having
a
condom.
(Eddie)
“I
had
one
right
there
in
my
pocket…don’t
know
why
I
didn’t
use
it.”
(Eddie)
“Maybe,
I
was
worried
about
how
she’d
react…or
I
was
scared
about
not
being
able
to
perform.”
Addressing
attitudinal
barriers;
increasing
self-‐efficacy
to
use
condoms
Scene
Trigger
Points
Issues/Barriers
Addressed
Six
months
later,
Joanna
and
David
discuss
using
a
condom.
(Joanna)
“I
need
you
to
protect
me…”
(Joanna)
“I
have
a
rule
for
myself
to
always
use
them.
They
make
me
feel
safe
and
free.”
(David)
“Look,
I
don’t
have
sex
with
prostitutes!”
(David)
“You’d
better
have
more
than
one.”
Modeling
condom
negotiation
skills;
self-‐efficacy/control;
empowerment
Acknowledging
and
overcoming
attitudinal
barriers;
modeling
condom
acceptance
Six
months
later,
Eddie
with
another
woman
(Marianela).
(Eddie)
“I
always
use
them.”
(Eddie)
“I’ll
even
let
you
put
it
on.
I
got
it
in
ribbed
for
her
pleasure.”
(Eddie)
“This
is
about
you.”
(Marianela)
“No,
I’m
on
the
pill,
Eddie.
We
don’t
need
to
worry
about
that.”
Modeling
condom
negotiation
skills;
condom
use
skills;
self-‐
efficacy/control
Acknowledging
and
overcoming
attitudinal
barriers;
modeling
condom
acceptance
155
Safe in the City Activity Sheet
Note: Although some scenarios may include views from women’s perspective, the facilitator can
remind men to focus on scenarios relevant to their situation.
Scene
Trigger
Points
Issues/Barriers
addressed
in
this
scene
Paul
and
Jasmine
talk
in
Paul’s
apartment.
(Paul)
“Want
to
go
without
one
tonight?
See
how
it
feels?”
(Paul)
“I
want
to
feel
you
for
real..”
(Jasmine)
“I
just
want
to
be
careful…for
the
both
of
us.”
(Paul)
“She
wants
to
use
condoms.
She
makes
them
work
just
fine.”
(Jasmine)
“Just
roll
nice
and
easy
all
the
way
down.”
Acknowledging
attitudes
and
barriers
to
condom
use
in
ongoing/steady
relationships
Modeling
safer
sex
negotiation
in
ongoing
relationship;
values
of
responsibility,
protection
of
partner
Modeling
of
condom
negotiation
and
use
Paul
goes
to
the
convenience
store
to
buy
a
condom
Modeling
purchase
of
condoms;
being
prepared
Teresa
calls
Paul
to
tell
him
she
has
an
STD
(Paul)
“Why
you
callin’
me?
We
used
a
condom
remember?”
(Teresa)
“Only
part
of
the
time.
You
didn’t
put
it
on
until
the
end.”
(Teresa)
“The
clinic
says
you
can’t
always
tell
if
you
have
something.
You
should
stop
by
and
get
tested.”
Increasing
risk
perception;
acknowledgment
of
consequences
Promotion
of
condom
skills;
knowledge
about
how
to
use
a
condom
correctly
Increasing
risk
perception;
peer
support
for
getting
tested
Paul
goes
to
the
STD
clinic
Modeling
importance
of
testing
for
yourself
and
to
protect
your
partner
156
Paul
and
Jasmine
have
a
late
night
conversation
about
their
relationship
(Jasmine)
“Things
are
getting
serious…and
I’d
be
into
taking
this
to
the
next
level
with
you.”
Acknowledgement
of
barriers
to
continued
condom
use
in
ongoing
relationships
Scene
Trigger
Points
Issues/Barriers
addressed
in
this
scene
(Paul)
“I
went
to
the
clinic
the
other
day
to
get
checked
out,
just
for
you.”
(Jasmine)
Okay,
well,
let’s
wait
on
your
results.”
Modeling
responsibility
to
steady
partner;
Modeling
importance
of
testing
and
knowing
results
Animated
Penile
Character
Selects
a
Condom
Modeling
correct
condom
use
Teresa
and
Luis
are
in
Luis’s
apartment
(Luis)
“What
is
it
you’re
worried
about?
I
don’t
have
a
disease.
And,
I’m
not
worried
about
you.
I
don’t
think
you’re
the
kind
of
girl
that…”
(Luis)
“This
is
starting
to
turn
me
off!”
(Teresa)
“It’s
not
you.
I
like
you.
It’s
just
that
I
always
use
one.
And
when
I
do,
I
feel
safe..and
free.”
Acknowledging
attitudinal
barriers
to
condom
negotiation
and
use
in
casual
relationships;
addressing
misconceptions
Modeling
condom
negotiation
skills;
self-‐efficacy/control;
empowerment;
modeling
condom
acceptance
Animated
Penile
Character
Uses
a
Condom
Promotion
of
condom
skills;
knowledge
of
condom
features
Ruben
and
Tim
meet
at
a
Bar
(Ruben)
“Maybe
I
had
too
much
to
drink,
maybe
I
was
a
little
high….I
always
saw
him
with
the
same
guy
so
I
didn’t
think
he
was
a
risk.”
(Tim)
“
I
had
a
condom
with
me
too,
I
just
got
carried
away
and
didn’t
use
it.”
Acknowledging
barriers
to
condom
use
in
casual
relationships;
addressing
misconceptions
and
increasing
risk
perception.
157
Christina
confronts
Ruben
about
getting
an
STD
again
(Cristina)
“I
don’t
want
to
get
AIDS
or
not
be
able
to
have
a
baby.”
(Christina)
“Don’t
you
want
to
take
care
of
yourself?”
(Cristina)
“We’re
going
to
the
clinic.
Vamanos!”
(Ruben)
“We
still
have
to
go
back
in
6
months
to
get
tested.”
Responsibility
to
partner/family;
acknowledgment
of
consequences;
Self-‐
efficacy;
peer
support
Modeling
importance
of
getting
tested
right
away
and
following-‐up
for
HIV
158
Negotiating Safer Sex:
Excuse/Response Sheet
Facilitator Tips
Practicing safer sex often requires "on-the-spot" responses and negotiation skills to encourage condom
use. Men need to think about the excuses their sexual partners may give for not wanting to use condoms.
The skill-building sessions that follow video-viewing offer VOICES-HM men the opportunity to
practice what to say in response to these excuses, and get feedback from others on which responses may
work and which probably won't.
During the discussion, refer to examples of excuses and responses used in the video.
• Ask men whether they have ever tried to get their partners to use condoms in the ways
shown in the video.
• Discuss how they might negotiate condom use in the future, and generate ideas for what they
might do or say.
• Encourage the use of statements that don't invite contradictions, such as personal statements
about how the client is feeling.
• Reinforce the message that sometimes saying less is more and that communication can be
nonverbal as well as verbal.
• Elicit suggestions from the group about ways to communicate and negotiate condom use
successfully.
You can use the list of excuses and responses that follows to help men develop negotiation strategies.
Excuse: Condoms kill the mood for sex.
Response: Only if you let them. Condoms can make it better. You can help me put it
on.
Excuse: Condoms don't feel as good. They aren't natural.
Response: Thin condoms feel really natural. Some of them have textures that can
make sex really good and last longer. We'll both like that. We can put a
drop of lubrication inside the tip of the condom to give us extra feeling.
Excuse: When I stop to put it on, I'll lose my erection.
Response: You can ask your partner to help you put it on. Don't worry, your partner
will help you get it back.
Excuse: Why do I need to use condoms if we're using the pill?
.
Excuse: Why do I need to use condoms if we're using the pill?
159
Response: The pill only prevents me from getting pregnant. Condoms will keep us
from getting HIV and other STDs.
Excuse: You don't trust me. You think I'm dirty.
Response: It's not about trust. I care about you and me. I don't want anything to
happen to either of us. We both share the responsibility for using
condoms to stay healthy.
Excuse: I love you. Would I give you an infection?
Response: Not on purpose. But most people don't know when they are infected with
HIV or an STD. Lots of times there are no symptoms.
Excuse: Why do we need to use condoms? Don't we have a special
thing going?
Response: You know we do. But that's why I'm trying to protect us. Because I want
us to be safe.
Excuse: But we've been having sex without condoms for a while. Why
do you want to use them now?
Response: I know, but we could enjoy each other a lot more if I didn't have to worry
about STDs. That doesn't mean it's not a good idea from now on. I've
learned a lot more about HIV and STDs, and I want to protect you and
myself.
Excuse: Condoms are for people with diseases. Do I look sick to you?
Response: No, you look fine! But you can't tell by looking at people if they have
HIV or an STD. A person can look and feel healthy and still be infected.
Excuse: I don't have a condom with me.
Response: I do, and I'm glad I brought it.
Let's satisfy each other without having sex. I know a lot of good
ways. Let's wait and have sex another time when we do have a
condom.
160
Let's go get one.
Excuse: You're punishing me because I had an STD.
Response: Of course I'm not! I'm just concerned and want us both to stay healthy.
Excuse: Condoms break too often.
Response: Maybe we're using the wrong size or need more lubricant. Let's try a
different brand. Maybe it was put on wrong.
Excuse: But the first time always feels so good. I just want to feel
you for real.
Response: Don’t worry you’ll still feel me. I have these thin condoms the
feel really natural.
161
VOICES-HM Condom Features
Summary Handout
This handout provides a summary of condoms featured on the Condom
Features Poster Board. Other condom brands with special features are
also available through local vendors and departments of public health.
Type of Feature Condom Name (* shown on poster) Tipo de Característica
Snug Fit Prime Snugger Fit* Lifestyles Snugger Fit
Exotica Snugger Fit Trojan Ultra Fit
Ajustado
Large Size (thin) Trojan Magnum* MAXX* Tamaño grande (fino)
Extra-large size (thin) Magnum XL* Tamaño extra grande (fino)
Regular size (thin) Beyond 7 Crown* Ajuste regular (fino)
Nubbed (inside) Kimono Sensation* Protuberancias internas
Nubbed (outside) Rough Rider* Trojan Pleasure Mesh
Ria Wrangler Trojan Shared
Sensation
Protuberancias externas
Ribbed Durex Her Sensation* Trojan Ribbed* Con nervaduras externas
Contour Beyond 7 Trojan Ribbed* Contornado
Desensitizing Agent Durex Performax* Trojan Extended
Pleasure*
Con ingrediente
desensibilizante para
extender la erección
Polyurethane (thin) Durex Avanti* Trojan Supra
Reality*
Poliuretano (fino)
Jelly Lube Trojan Naturalube* Lubricación con gelatina
Non-lubricated Trojan Non-Lube* No lubricado
Flavored Trustex* A sabores
Female Condom Reality* Condón femenino
Glow in the dark Night Light Candescente a oscuras
Extra head room Bareback Midnight Desire
InSpiral Pleasure Plus
Lifestyle Extra Trojan Her
PleasurePleasure Trojan Twiste
Pleasure*
Con más espacio para el
bálano (glande)
TYPES OF CONDOM FEATURES TO CONSIDER:
Lubrication options: Silicone, jelly, non-lubricated
Types of fits: Snug, snug/regular, regular, large size, extra-large
Textures: Smooth, ribbed, nubbed
Type of material: Latex, polyurethane
Type of end: Plain (e.g. Trojan non-lube), receptacle end
162
Steps for Effective
Condom Use
Putting It On
• Check the expiration date on the package.
• Make sure the condom is made of latex or polyurethane.
• Open package at the corner and be careful not to tear the condom.
• If using a water-based lubricant, squeeze a few drops into the tip of the condom.
• Pinch the tip of the condom to leave a pocket for the ejaculation later on.
• Put condom on the end of the penis when it is hard (before it comes in contact with your
partner's mouth, genitals, or anus).
• Keep the pocket at the end and keep air out of it.
• Unroll condom all the way down to the base of the penis.
• Make sure pocket is still at the end.
• Apply water-based lubricant on the outside of condom.
Taking It Off
• After ejaculation, withdraw penis from vagina while penis is still hard.
• Hold condom rim while pulling out so no semen spills.
• Remove condom by rolling it down and off the penis.
• Throw away condom. (Don't flush it down the toilet.)
• Use a new condom each and every time you have sex. When ready to have sex again, start
over with a new condom. Don't reuse old condoms
163
Tailoring Messages to Meet Client
Needs
Each VOICES-HM session will differ somewhat, depending on the group's composition. As you begin the
skill-building session, do a quick assessment of who you are talking to. How old are they? Each
participant comes to the group with a set of experiences that affect how he or she will respond to the
video, safer sex messages, and condom use. If you want to have a strong impact on your men' attitudes
and behaviors, you will need to tailor your prevention messages to their beliefs, life experiences, and
readiness to change.
The information included in this manual can be tailored in the following ways:
Culture and Language
Messages should be consistent with the values, norms, dialect, and terminology of the client
population.
Sex Practices and Relationships
Individuals often have different types of relationships. They may have sex with primary or non-
primary partners, or have same-sex or heterosexual sex encounters, for example. Each of the
situations in which men may be exposed to unsafe sex must be considered, with a plan for
changing risky behavior in each circumstance.
Life Circumstances
Recognize that a man's ability to adopt risk-reduction strategies may be influenced by economic and
other barriers, such as homelessness, shelter living, the exchange of sex for drugs or money, and
access to condoms.
Literacy and Developmental Abilities
The facilitated sessions should be delivered at a level that the men can understand.
Individual Strengths and Skills
Risk-reduction planning should consider the client's ability to problem solve, plan behaviors in
advance, persuade and negotiate with partners, and use the skills and resources necessary to enforce
the desired behavior.
Motivating Factors
Staff can help men identify personal motivations for behavior change and should recognize that
these motivations may differ by culture, and individual characteristics of a person. For example,
explore what is the strongest motivation for a client to change risky behavior, considering such
factors as caring for one's own health, protecting family, fear of disease consequences, not wanting
to get pregnant or get a partner pregnant, and so on.
164
.Determining a Participant’s Stage
of Readiness to Change
Some researchers describe behavioral change as a continued process in which men move through a series
of motivational and behavioral stages. Changing behavior is not a simple process that happens all at once,
and different men may be more or less ready to adopt safer behaviors. By first assessing your client's stage
of readiness to change their behavior, you can tailor messages so they are more likely to be heard and
followed. It is important to understand that men seldom move through these behavioral changes in a linear
fashion. Rather, change usually occurs unevenly, with patients relapsing and then moving forward again.
The different stages of change are described below:
Precontemplation
The client is stuck in his or her ways and has no intention of changing behavior. A precontemplator might
be a client with a history of gonorrhea who has never considered using a condom.
¾ Client: "I don't need to wear a condom. My girlfriend is on the pill."
¾ Provider: "Did you know that the pill doesn't protect against HIV and other STDs?"
Contemplation
The client is thinking about changing behavior some time in the future. A contemplator might be a client
diagnosed with chlamydia who is thinking about asking her boyfriend to wear condoms.
¾ Client: "Okay. I'll take these condoms, but I'm not sure I'll ask my boyfriend to start using them.
He might get angry and leave."
¾ Provider: "What would you gain by asking him to use condoms?"
Action
The client has been practicing a new behavior for 1 to 6 months. A client "in action" might tell you that he
uses condoms but they still aren't a habit with him.
¾ Client: "I usually remember to use a condom."
¾ Provider: "In which situations did you not use a condom? How can you avoid those situations in
the future?"
Maintenance
The client is practicing long-term, consistent behavior change. A client in the "maintenance" phase has
been using condoms in the past and expresses a willingness to continue using them.
¾ Example: "I always ask my men to wear condoms and usually have some with me in case they
don't."
¾ Provider: "You've done great! How do you feel about using condoms?"
Relapse
The client resumes old behaviors, which can end the new behavior or restart the process. An example of a
client in the "relapse" stage is a man who used to use condoms but had too many negative experiences
with them, and, as a result, stopped using them.
¾ Example: "I tried using condoms, but I don't use them any more. They break too often."
¾ Provider: "Changing any behavior is tough and things don't always work out right away. Why do
you think condoms were breaking on you?"
Adapted from Prochaska J., DiClemente C., Norcross J. (1992). "In Search of How People Change: Application to Addictive
Behaviors." American Psychologist. 47: I 102-1114.
165
Talking About Risk for
Facilitators
VOICES-HM is designed to encourage condom use and improve men' negotiation skills. However, people
will not practice safer sex if they do not think they are at risk. VOICES-HM facilitators should utilize the
HIV knowledge and risk behavior survey to help men recognize the things they or their partners do that
increase their risk of transmitting or becoming infected with an STD or HIV. When educating men about
STDs or HIV:
• Never assume that men fully understand the variety of sexually transmitted diseases and
their routes of transmission.
• Do assume that they may have some misinformation about HIV and other STDs that needs
gentle correction.
• Remember that men may have misconceptions about .
• Try to present basic information on sexual health and safety.
During the HIV knowledge and risk behavior survey session, you will not need to share all of the
information provided below. However, you should be prepared to field questions about risk factors and
modes of transmission, when they arise.
HIV and STDS: The Basic Facts
• Men can have STDs that cause damage without symptoms.
• People with HIV or other STDs can look perfectly healthy.
• Having an STD puts you at increased risk of getting another STD.
• STDs can be transmitted through oral sex as well as vaginal or anal sex.
• STDs can be life threatening.
• Repeat STD infections may leave a woman infertile.
• Current treatments may control HIV temporarily, but are not a cure.
• Birth control pills will not prevent you from getting HIV.
• HIV can be transmitted from mother to child prior to birth. HIV can be transmitted through
breast milk.
Risk Factors
• Engaging in vaginal, anal, or oral sex without latex or polyurethane condoms
• Having a prior STD
• Using injection drugs or having unprotected sex with an injection drug user
• Using alcohol or drugs to relax or have fun
• Inconsistently using condoms with your primary partner
• Inconsistently using condoms with non-primary partners
• Having no experience using condoms or getting partners to use condoms
• Having a bad experience using condoms, such as having a partner get angry or violent at the
suggestion of condom use
• Having sex with someone who may have other partners
• Having multiple sex partners
• Being forced to have unprotected sex
166
Risk Reduction
Men can reduce their risks for HIV/STD infection by reducing the number of partners with whom they
have sex and by insisting on consistent condom use. Research shows that most men know that using
condoms can help protect them from getting AIDS and other STDs. Most will have used a condom at
some time in the past. However, since many people have had unsuccessful experiences using condoms,
barriers to consistent condom use must be addressed.
Use the situations in the videos to explore risk-reduction plans for men who have different sexual
relationships and practices. For example, men may be using condoms in relationships with their non-
primary partners, but not with their primary partners. Others may use condoms for contraception during
vaginal sex, but feel they are not necessary during anal sex. Discuss the risks associated with these
behaviors, stress the importance of using condoms in all situations, and develop strategies for negotiating
condom use in the future.
When discussing risk reduction, it is important to do the following:
• Offer men realistic options for reducing their risk, taking into account their specific
circumstances and experiences.
• Acknowledge past attempts to have safe sex and/or use condoms that failed. Find out why
men think those attempts failed and what they might do differently next time.
• Use successful (even temporarily successful) attempts at behavior change to reinforce
continued, positive behavior. Suggest ways that men can build on these efforts in the
future.
• Use failed attempts to help men recognize strategies that don't work and to identify
strategies that may be more effective.
• Acknowledge that trying to begin condom use with a steady partner is different from using
condoms in new or more casual relationships.
• Don't wait for men to initiate discussion of risk behaviors with different partners; instead,
open discussion by acknowledging that many people engage in different types of sex with
different kinds of partners. Emphasize that your goal is to help them find a strategy for using
condoms and having safer sex that works for them.
167
Educating Men About
Condoms
Identify Barriers to Condom Use
Work with men to identify their objections to using condoms, as well as the objections of their
partners. Address common problems, such as:
• Physical problems and complaints about condoms, including reduced pleasure and sensation,
latex allergies, loss of erection, or fears about interrupting the moment
• Concerns about condom breakage and the ineffectiveness of condoms in preventing disease
• Difficulties communicating effectively with partners about condom use
• Men's concerns about using a condom with partners:
• She will be angry or turned off.
• I'll lose my erection and spoil the moment.
• She'll think I'm fooling around.
• She'll think I think she's fooling around.
• It doesn't feel good.
• It's not macho/manly.
• Cultural norms that prevent condom use, such as it not being acceptable for to
purchase or carry condoms or to talk about condoms or sex with their partners
• Men underestimating their personal risk for HIV/STD or assuming that partners are aware of
risk and are not withholding information
Address Barriers to Condom Use
While most adults have used condoms, they actually know very little about the features or availability
of different condoms on the market or how they can choose a condom that best fits their needs. They
often don't know how to use condoms correctly or where they can obtain free condoms. Some men,
may be embarrassed or feel self-conscious about purchasing condoms because they lack information,
and because retail settings are not confidential and stores don't necessarily have staff who can
sensitively or knowledgeably respond to questions. Language, cost, and cultural norms may present
additional barriers to men accessing condoms. Help men recognize why they may not have used
condoms consistently in the past. Provide the information and support they need to change their
behavior in the future.
• Refer to the Condom Features Poster Board and match appropriate condom feature(s) to
address specific complaints.
• Stress that a current infection can provide an "opportunity" to discuss condom use with their
partners.
• Emphasize that anyone having sex without a condom is at risk.
• Emphasize that condom use can prevent problems with fertility and maintain the ability to
have children.
Be clear that:
• It is not unreasonable for people to fear the consequences of unprotected sex - whether they are
involved in a primary relationship or not, and whether they know and trust their partner or not.
168
• Condom use is a sign of protecting and caring for one's partner as well as for oneself.
• You can trust your partner and still insist on condom use.
• Problems such as loss of erection or perceptions that condoms "interrupt the moment" are
normal and will pass or can be worked out over time.
• Planning and preparation can make condom negotiation easier and more successful.
• It is possible to select condoms that eliminate problems that may have been experienced in
the past, including lack of lubrication or loss of sensation.
• Condom failure usually results from improper use, not from product defect.
• Condom use with special features can enhance pleasure for both men and
169
\
Common Questions About
Other Barrier Methods
Men often have questions and concerns about how to stay safe while engaging in oral sex. Oral
sex – including mouth-to-penis, mouth-to-vulva, and mouth-to-anus contact – can transmit STDs
and HIV. Latex condoms have been tested and are recommended as barriers for mouth-to-penis
contact. However, there are neither materials nor devices specifically manufactured, tested, or
approved as barrier methods for other types of oral sex.
This section was designed to help you respond to questions your men may have about barrier methods
other than condoms, based on the information currently available to us. Statements included in this
section are only suggestions, not recommendations or endorsements.
What kind of barrier method can I use for oral sex?
A non-lubricated latex condom should be used in mouth-to-penis contact (fellatio) and should be put
on before contact. It is the only barrier method recommended for this type of sex. There have been no
materials or devices specifically manufactured, tested, and approved as barrier methods for mouth-to-
vulva (cunnilingus) or mouth-to-anus ("rimming") contact. However, some people have used dental
dams, cut-open condoms, cut-up latex gloves, and household plastic wrap for these purposes. The latex
from condoms or gloves conceivably could have some degree of effectiveness in stopping the
exchange of body fluids, provided it is not punctured and that it completely covers the area of contact.
Plastic wrap is also a proven, temporary barrier to moisture. If these barriers are used, they should be
used only once and disposed of immediately afterward.
Does it matter what kind of plastic wrap I use? Someone told me not
to use the kind for microwaves.
Household plastic wrap has not been manufactured, tested, and approved as a barrier method for oral
sex. We have little data on its barrier properties in regard to bacteria and viruses. Therefore, we
cannot recommend or endorse it as an effective barrier to HIV and other STDs. However, the three
formulas used for the major brands of household plastic wrap - including those recommended for
microwaves - have all proven to be effective, temporary barriers to moisture. The plastic films used to
make sandwich, dry cleaner, grocery, and trash bags are weaker, have numerous tiny holes, tear and
puncture easily, and should not be used as barrier devices. Any item used as a barrier should be thrown
away immediately after use.
170
Facts About Sexually
Transmitted Diseases (STDs)
STDs are infections spread from person to person, most often by sexual contact. Many kinds of sexual contact can spread STDs. Any intimate contact that
involves the penis, vagina, mouth, or anus can transmit disease.
You can be infected with an STD any number of times and can be infected with more than one STD at the same time. We do not become immune to any of these
diseases, so we can get them again and again.
Some STDs, such as AIDS, syphilis, and gonorrhea, are serious diseases, while others, such as vaginitis and crabs, are very annoying but not dangerous.
Many STDs occur without any signs or symptoms. Therefore, if you are sexually active, see a health care provider regularly and get screened for STDs. Go to a
doctor or clinic promptly if you have been exposed to an STD or even think you may have been exposed. Treating yourself won't work, and it can be dangerous.
There are several ways to reduce your risk of getting an STD. These include:
• Abstinence. Many people choose not to have sex at some time in their lives. This is the surest
way to avoid exposure to STDs.
• Having one sexual partner who only has sex with you. If your partner is having sex with other people, you can still get an STD.
• Using condoms or other barriers every time there is a chance of body fluid being passed from one person to the other. Use condoms every time you
have intercourse, and latex barriers for oral (mouth-to-genitals) sex. Condoms made of rubber (latex or polyurethane) have been proven to prevent
disease. Some people cannot use latex because of allergies. If so, try using polyurethane condoms. This kind of condom is marked on the package. If
you use "sex toys," keep them clean.
• Choosing sexual behavior that is less likely to transmit disease-like dry kissing, touching, hugging, and massage.
• Looking at your partner's body and, if you see any signs of STDs, not having sex. STD signs include lesions (openings in the skin), growths (bumps
or cauliflower-like patches of skin), sores (dry, wet, or scabby), or discharges (thick or thin fluid that comes out of the penis, vagina, or anus). But
remember, you can't always tell if a person has an STD by looking at her or him!
• Avoiding using alcohol and other drugs before or during sex. Alcohol and other drugs can make sex unsafe by causing you to take chances that
you otherwise wouldn't take.
Adapted from the Massachusetts Department of Public Health
171
What You Should Know about Sexually
Transmitted Diseases (STDs)
Adapted
from:
http://www.cdc.gov/std/healthcomm/fact_sheets.htm
INFECTION
(CAUSE)
HOW
SPREAD
WHEN SYMPTOMS
APPEAR
COMMON
SYMPTOMS
TESTS
TREATMENTS
COMPLICATIONS
CHLAMYDIA
(bacteria)
Sexual contact Symptoms are usually mild
or absent.
If they do occur, they usually
appear within 1–3 weeks of
exposure.
Abnormal discharge
from the vagina, penis,
or rectum and/or burning
sensation while
urinating.
• Some laboratory
exams can be
performed on urine
• Others require that
a specimen be
collected from penis
or cervix
• Antibiotics can
treat and cure
: If untreated it could cause Pelvic
Inflammatory Disease (PID),
damaging the fallopian tubes, uterus,
and surrounding tissues; may cause
infertility; may infect baby at birth,
causing eye infection and/or
pneumonia.
MEN: Although rare, if untreated it
can spread to the epididymis (long,
oval-shaped structure attached to the
rear upper surface of each testicle)
causing pain, fever, and, rarely,
sterility.
GENITAL
HERPES (virus)
Sexual contact
(both during
and in absence
of an
outbreak)
Most people are unaware of
their infection due to lack of
symptoms.
However, a painful primary
outbreak usually occurs
within 2 weeks and is a
predictor of future
outbreaks.
Cluster of ulcerated,
painful blisters in the
genital area or rectum;
may have swollen
glands, fever, and body
aches.
• Visual exam
(most effective
during an outbreak)
• Microscopic exam
(most effective
during an outbreak)
• Blood tests can
also be performed,
although they are not
always accurate
• No cure
• Antiviral
medications can
shorten and
prevent outbreaks
• Daily
suppressive
therapy can
reduce
transmission to
sexual partners
Person remains infected for life;
symptoms can occur often; can cause
psychological distress; may infect
baby at birth, possibly causing
fatality.
172
INFECTION
(CAUSE)
HOW
SPREAD
WHEN SYMPTOMS
APPEAR
COMMON
SYMPTOMS
TESTS
TREATMENTS
COMPLICATIONS
HUMAN
PAPILLOMA-
VIRUS
or HPV
(virus)
Sexual contact Most people have no
symptoms.
When had, they will occur
within weeks or months
after exposure.
Genital warts: small
bumps, sometimes with
itching and irritation.
• No general test for
or men
• Visual exams can
diagnose genital
warts
• Pap tests can
identify early
cervical cancer
• Vaccination
(series of shots) is
available to
protect females
from 4 common
cervical cancers
• No cure for the
virus
• Antibiotics can
treat the
symptoms
Person remains infected for life; can
lead to cancers of the cervix, vulva,
vagina, anus and penis (which all
have no symptoms).
GONORRHEA
(bacteria)
Sexual contact Most and some men never
have any symptoms.
When had, they will usually
occur between 2–5 days, but
could take up to 30 days.
Abnormal penile or
vaginal discharge (pus)
and/or a burning during
urination; with anal
gonorrhea, there may be
rectal discharge, anal
itching, bleeding, or
painful bowel
movements; with oral
gonorrhea, may have
sore throat.
• Urine samples
• Throat cultures
• Most strains
can be cured by
antibiotics
• However,
drug-resistant
strains are
increasing in
certain areas of
the world
: If untreated it may cause
PID (see above); may infect baby at
birth, causing blindness, joint-
infections, and/or blood infections.
MEN: If untreated, it can cause
epididymitis (see above), possibly
leading to infertility.
HEPATITIS B
(virus)
Sexual
contact;
sharing
needles or
razors;
through birth
Many people have no
symptoms.
When had, they will usually
occur between 6 weeks–6
months.
Fatigue, no appetite,
fever, headache, muscle
pain, and/or dark urine.
• Blood test • There is a
vaccination
(series of shots) to
prevent it
• However,
there is no cure
once infected
• Antibiotics can
help treat
symptoms
Some infected people become
chronic carriers; can lead to chronic
liver problems and/or cancer.
173
INFECTION
(CAUSE)
HOW
SPREAD
WHEN SYMPTOMS
APPEAR
COMMON
SYMPTOMS
TESTS
TREATMENTS
COMPLICATIONS
HIV/AIDS
(virus)
Sexual
intercourse;
sharing
needles;
being exposed
before or
during birth;
through breast
feeding
HIV: Often no symptoms;
only way to know whether
you are infected is to be
tested.
AIDS: May take 10 years
or longer to develop; only
way to know is to be tested.
Often no symptoms for
years; early symptoms
include weight loss,
sores in mouth, sore
throat, swollen glands,
night sweats.
• Blood test
• Oral fluid test
• Urine test
• No cure
• No
preventative
vaccine
• Highly Active
Antiretroviral
Therapy
(HAART) exists
to improve
quality of life and
lessen
complications
Pneumonia and/or other infections;
Karposi’s sarcoma (tumors).
SYPHILIS
(bacteria)
Sexual
contact; being
exposed
before birth
From 10–90 days after
exposure (average 3 weeks).
Primary stage: Painless,
round, small sore on or
around penis, vagina,
mouth, anus.
Secondary stage: Non-
itchy rash on hands or
feet, flu-like symptoms,
swollen glands.
Late or Latent Stage:
Difficulty coordinating
muscles, gradual
blindness, and/or
paralysis.
• Blood test • A single shot
of penicillin can
cure it, if
performed within
a year of exposure
• For those
allergic to
penicillin, other
antibiotics will
cure it
If untreated, brain damage or
paralysis in later years.
SCABIES
& CRABS
(mites & lice)
Sexual
contact;
direct,
prolonged
skin-to-skin
contact;
sometimes
from bedding
and clothing
From 1 day to 6 weeks after
exposure.
Intense itching; crabs
and eggs attach to hair;
mites burrow under skin;
pimple-like rash.
• Visual exam • Antibiotic
lotions will kill
live mites and lice
• Eggs (nits) can
be manually
removed with
fine-toothed comb
Skin infections from scratching.
174
INFECTION
(CAUSE)
HOW
SPREAD
WHEN SYMPTOMS
APPEAR
COMMON
SYMPTOMS
TESTS
TREATMENTS
COMPLICATIONS
BACTERIAL
VAGINOSIS
or BV
(bacteria)
Douching;
sexual
intercourse;
other unknown
ways (but not
through toilet)
Most have no
symptoms.
When had, it is usually after
intercourse.
Abnormal, white or gray
discharge with an
unpleasant, fish-like
odor especially during
intercourse; burning or
itching during urination.
• Laboratory test on
a sample of vaginal
fluid
• No definite
cure
• Antibiotics can
treat symptoms
(although
symptoms are
likely to reappear)
In most cases, it causes no
complications; however, it can
increase one's susceptibility to other
STIs and PID (see above).
Abstract (if available)
Abstract
Homeless men are at high HIV risk. Sexual risk reduction interventions may help preventing homeless men and their partners from acquiring or transmitting HIV. However, currently there are no existing evidence-based HIV prevention interventions (EBIs) developed targeting this high-risk population. Considering the majority of homeless individuals utilize shelter services, it is critical to develop HIV prevention interventions targeting homeless men that can be implemented at shelter settings. Guided by the ADAPT-ITT model, this study engaged homeless men and shelter providers with the goal of adapting an existing HIV prevention EBI to be compatible with homeless men’s needs and shelter providers’ resources. ❧ This dissertation project was conducted at two shelters located at Los Angeles County. The adaptation process involves three major phases. The PI first conducted 4 focus groups with homeless men (N=30) and 2 focus groups with providers (N=15) to assess perceived HIV intervention needs and intervention preferences. We also completed 4 consensus groups with homeless men (N=31) and 2 consensus groups with providers (N=14) to rank and select one of five EBI’s for adaptation. Finally, an adapted intervention manual was developed and pretested via 2 focus groups with homeless men (N=12) and 2 focus groups with providers (N=15). ❧ Content and thematic analysis was conducted to identify themes critical to investigate intervention preferences, select EBI candidates, and identify adaptation directions. Adapted case summary matrices were developed for data analysis to compare and contrast the information gathered in different focus groups and consensus groups. ❧ Homeless men and providers identified a high need for HIV prevention intervention at shelter settings. Homeless men and providers also expressed a need for interventions that are brief, integrate condom use and negotiation skills training, incorporate substance use risks, and are tailored to individual risks. Five EBI candidates were selected based on these findings. VOICES/VOCES (VOICES), a single session video-based intervention, was selected for further adaptation through consensus groups. Without modifying the core elements of VOICES, based on men’s and providers’ suggestions, a brief HIV knowledge and risk behaviors survey was added to help the intervention better respond to individuals’ risk profiles and enhance men’s perceived vulnerability to HIV risks to create a “teachable moment” to engage men in the later activities. Alcohol and substance use associated with sexual risks was also added to VOICES. Men and providers in the pretesting groups stated the adapted intervention manuals and materials are useful in reducing HIV risks among homeless men and are relevant to homeless men’s experiences.
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Asset Metadata
Creator
Hsu, Hsun-Ta
(author)
Core Title
Engaging homeless men and shelter providers to adapt an existing evidence-based HIV prevention intervention
School
School of Social Work
Degree
Doctor of Philosophy
Degree Program
Social Work
Publication Date
07/16/2015
Defense Date
05/04/2015
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
evidence-based intervention,HIV prevention intervention,Homeless men,OAI-PMH Harvest
Format
application/pdf
(imt)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Wenzel, Suzanne L. (
committee chair
), Henwood, Benjamin (
committee member
), Rice, Eric R. (
committee member
), Unger, Jennifer (
committee member
)
Creator Email
gangiao@gmail.com,hsuntahs@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c3-596388
Unique identifier
UC11300353
Identifier
etd-HsuHsunTa-3618.pdf (filename),usctheses-c3-596388 (legacy record id)
Legacy Identifier
etd-HsuHsunTa-3618.pdf
Dmrecord
596388
Document Type
Dissertation
Format
application/pdf (imt)
Rights
Hsu, Hsun-Ta
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...
Repository Name
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Repository Location
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Tags
evidence-based intervention
HIV prevention intervention