A closer look at two popular interventions
Mpowerment and Street Smart being adapted
Some HIV prevention researchers are learning firsthand how challenging it is to translate existing evidence-based interventions for different populations and dissemination. Investigators are learning more about how to translate the Mpowerment project and Street Smart for use in communities and populations that are different from the interventions’ original use.
They are discovering that some challenges can be predicted, but many are small nuances that become important as an intervention is changed. Their experiences suggest that it might be naïve of federal and state prevention funders to expect a community-based organization (CBO) to develop its own adjustments to an evidence-based intervention and still achieve effectiveness.
"I think there is merit in implementing programs that have been shown to be scientifically effective, but the idea of coming up with an idea and winging it and expecting that to be effective is ridiculous," says Susan Kegeles, PhD, a professor and co-director for the Center for AIDS Prevention Studies at the University of California-San Francisco.
"It’s a huge challenge to ask CBOs without regard to some of the organization’s characteristics to tailor and adapt on their own," says George Ayala, PsyD, director of the Institute for Gay Men’s Health, David Geffen Center in Los Angeles. He is involved with a translation of Street Smart for use among young Latino men who have sex with men (MSM). Street Smart initially was designed to be used with runaway and homeless youth, ages 11 to 18.
Kegeles and co-investigators developed the Mpowerment project, which was designed as an intervention for MSM, including acculturated Latino men, ages 18-29 years. The intervention’s strategy includes outreach, social marketing, discussion groups, and other methods for providing safe sex and risk reduction messages.
Both Mpowerment and Street Smart are on the Diffusion of Effective Behavioral Interventions (DEBI) list of 12 HIV prevention programs, selected as evidence-based intervention strategies by the CDC.
Mpowerment: Better training needed
- Mpowerment: Investigators had tested Mpowerment in communities of 60,000 to 120,000 people in Oregon, California, Texas, and New Mexico, Kegeles reports.
"As we got good results from our studies and published those results and made presentations, we were struck by the huge numbers of requests for our curriculum," Kegeles says. "We were so busy thinking about getting the project funded, having a randomized control trial, and dealing with the politics in each community that we hadn’t thought about such things."
However, once the CDC provided a funding grant for developing curriculum or replication packages, the investigators applied, received funding, and went to work, she says.
"Our first attempt at a replication package was for young gay and bisexual men, but it was packaged for organizations," Kegeles says.
At first the translation efforts were informal: Mpowerment was put on the CDC DEBI list when the list was started in 2003, and when organizations called for information, investigators would send them the available materials, Kegeles says.
"We’d give it to a local organization and help them write grant proposals to get funding for it," she says. "So we would give the materials to the organization and do some brief training and hope that would work because it would emulate the real world."
But Kegeles and colleagues quickly recognized that it didn’t work; they would need to provide technical assistance to CBOs, and they didn’t know how to fund that service.
"We always describe it as an airplane that was going down a runway and never lifted off," she says. "We realized the manual had to be better, the training had to be better, and we had to have some exercises so people could see what the interventions felt like, and we needed to be involved and have ongoing technical assistance."
This realization led Kegeles and co-investigators to apply for a federal grant from the National Institute of Mental Health (NIMH) to translate the research into practice by developing the Mpowerment Project Technology Exchange System, which provides CBOs with technical assistance, training, web site information, and other materials.
Now the system is being tested with 70 organizations around the country.
So far all the results of this large translation project are anecdotal, but interesting issues have arisen, Kegeles says.
Some of the CBOs who have wanted to adapt the intervention for use among different age groups, and others want to use it for young women as well as young men, she says.
At least one organization called to ask about adapting the intervention for use with incarcerated women, which would be a major stretch, Kegeles says.
"We expressed our concern about that," she adds. "One aspect of the intervention is it’s supposed to be implemented by young men for young men, and they are decision makers of the project. Some organizations’ higher-ups have a hard time with that because they’re concerned young men might make a terrible decision."
Watching CBOs make decisions about translating Mpowerment has been fascinating and aggravating, she notes.
"They’re struggling right now with less money, and they’re trying and are passionate about these issues," Kegeles says.
For example, when investigators ran the Mpowerment intervention it cost $130,000 a year, but some organizations might be trying to implement it with a budget of $15,000 per year, she reports.
Through the technology exchange program, investigators are learning more about how interventions work in the real world, including what’s possible and what barriers exist, Kegeles says.
One challenge is adapting an intervention for different ethnic groups, particularly when all of the original researchers are white. "So what I’ve been trying to do is bring people of color onto my research team," she explains. "And I make sure I work with communities closely to make up for the fact that I’m not black."
In working with black CBOs, investigators learned that the terms MSM, gay, and bisexual are not the words black MSM use to describe themselves, Kegeles notes.
"The other term is same gender loving (SGL), and it’s becoming an acceptable term in Los Angeles," she explains. "Gay is white middle class and effeminate, and SGL is just men who are attracted to other men regardless of whether they’d call themselves gay or bi or straight."
Through boards of cultural experts and focus groups, researchers learn what is missing and what needs to be addressed in their intervention.
"We needed to get into issues about internalized homophobia and internalized racism," Kegeles says. "We have not finished developing the revised Mpowerment project, but this is an issue we know we have to get into."
The cultural experts and focus groups indicated that there are many other issues that need to be addressed before Mpowerment can be translated for a black population, including helping participants deal with life skills, including finding homes and jobs, she says.
"You have to do more because the complexities of life for young black men are just so much greater," Kegeles says.
While Kegeles and colleagues would like to further develop the program and assess its efficacy, but finding funding in these tight budgetary times will be difficult, she says.
At the very least, investigators might be able to provide a criteria list for how Mpowerment should be used by CBOs, Kegeles says.
"We’re hoping at the end of the project we can say, These kinds of organizations make sense to implement these interventions under these kinds of conditions, but under these other conditions it doesn’t make sense,’" she says.
Street Smart: Making it age appropriate
- Street Smart: With funding from the University of California and the state of California, Ayala and colleagues have been studying the translation process involving the Street Smart intervention.
"One thing we liked about Street Smart was it was adapted once before for use with gay youth in New York City," he says.
First, researchers convened a core group of health educators and facilitators to review the original Street Smart curriculum, and then they met with focus groups of young Latino MSM, who would be the target population, Ayala explains.
"The core group decided to rename it "Life Smart" or Nuestras Vidas, and that adaptation process took about 12 months to do," he says.
As researchers conducted in-depth interviews with facilitators and staff, they found that young Latino MSM wanted more experiential education, while the staff said they needed more didactic approaches, Ayala notes.
Also, health educators wanted researchers to incorporate into Life Smart some of the features of another intervention called Hermanos de Luna y Sol, which had been created a decade earlier but was not an evidence-based intervention. Because it was not part of the DEBI list, researchers had to decline the suggestion, he says.
You need more than one
Some of the nuances of Street Smart that needed to be changed as it was translated into Life Smart, included the way the original intervention had facilitators help participants identify their feelings. The original program had facilitators put up a large picture of a thermometer on the wall, numbered from zero to 100, where 100 represented very anxious, very sad, or very angry feelings. Since Life Smart was being adapted for the age group of 18-24, instead of the Street Smart’s 11-18 population, it was decided that type of tool would not work, Ayala says.
"The group wisely wanted to have a pedagogical approach that was more age appropriate, but didn’t lose the importance of the discussion of affect in the context of problem-solving," he explains.
Another minor change was reducing the 10 sessions to eight because the educators and participants said the target population wouldn’t sit for the 10-session intervention, Ayala adds.
The translation study ended in June, and data still are being analyzed, Ayala says.
Researchers have observed that organizations that had an easier time integrating the intervention were those who had a broader prevention program already in place, Ayala says.
"The intervention when integrated represented a complement to those rather than a free-standing intervention, and that’s a very important finding," Ayala notes. "They work better when they are a part of a complement of programs."
Some HIV prevention researchers are learning firsthand how challenging it is to translate existing evidence-based interventions for different populations and dissemination.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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