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Table 4 Barriers and facilitators to successful implementation of the empowerment project

From: Facilitators and barriers to effective scale-up of an evidence-based multilevel HIV prevention intervention

Overarching issues Related themes Illustrative examples Quotes from notes interviewer or TA providers wrote
HIV prevention system factors The entire HIV prevention system affects intervention implementation Coordinators, supervisors, EDs, funders, and national HIV prevention policies all greatly influenced implementation. For example, in numerous situations, funders would not financially support a core element (see quote). Additionally, coordinators were sometimes eager to implement the intervention with fidelity, but issues with CBO management would adversely affect implementation. For example, one of the MP’s guiding principles (see Table 1) is that since most YGBM do not seek HIV prevention services and often intentionally avoid AIDS organizations, HIV prevention must incorporate a social focus to attract them. There were a number of situations in which a coordinator and core group developed ideas for an event but were stopped from enacting them because CBO management did not support using social events in HIV prevention efforts or disliked the event. Stopping the core group from enacting their ideas undermined their sense of ownership of the project, caused them to lose interest in volunteering, and may have resulted in their not sharing MP’s prevention messages within their social networks. HIV prevention policy initiatives also negatively affected implementation of the MP. To obtain funding from the CDC or state health departments, CBOs were usually required to implement a DEBI intervention, i.e., an intervention that had been shown through rigorous research to have evidence of its effectiveness. Initial resistance to DEBI cast a shadow on the MP and resulted in some CBOs distrusting the MP as suitable for their populations, while others were reluctant even to learn about the MP through using the MPTES. Antagonism towards DEBI often had to be overcome in order to develop rapport with those receiving TA. A second HIV prevention policy that stymied implementation was the push for CBOs to conduct more HIV testing, since the resources for this generally came from redirecting funds away from the EBI. The third policy-related issue that affected implementation was the requirement that all publicity or safer sex materials that were even partially supported by the CDC had to be reviewed by a local Program Review Committee. Since some committees rejected materials that were sex- or gay-positive, some CBOs’ management would self-censor the materials before review. “When he [the coordinator] met with XXX, the guy from the health department…they don’t want to pay for him to do activities that are associated with social events [a major Core Element of the intervention]…they only want to pay him to do the M-groups and the outreach.”
Knowledge about intervention Funders, CBO management and staff needed to know about MP to implement with success. Funders who lacked an understanding of the program often developed contracts that contained unrelated “deliverables,” objectives that the CBO was required to achieve (see quote). The CBOs then had to choose between fulfilling their contractual obligations or implementing the MP with fidelity. For example, weekly core group meetings and regular social events are necessary to implement MP with fidelity, but many contracts did not include core group meetings or social events in them, and instead required an unrealistic number of M-groups resulting in an unsuccessful MP implementation. CBOs that were funded under these circumstances were in a dilemma about how to implement the intervention with fidelity—needing to put a “round” community-level intervention into a “square” group- or individual-level oriented contract. Knowledge about the program’s core elements and guiding principles was also important for CBO management and staff alike. For example, some coordinators did not understand the guiding principle that the project should facilitate the empowerment of YGBM, and wanted to make all decisions for the project themselves instead of supporting the core group to analyze the issues facing their community and determine solutions they would enact. Similarly, supervisors were helpful when they understood the intervention well enough to assist coordinators to prioritize tasks, or problem-solve issues that arose. However, some supervisors did not understand the intervention, and a few expressed beliefs that it was unnecessary for them to learn about it since the MP is for YGBM, and YGBM could therefore conduct the program with little supervision. Likewise, EDs varied in their understanding of the intervention, and some felt uncomfortable with its innovative aspects. For example, some EDs disliked YGBM being the decision-makers for the program because they worried that the young men would make decisions that could harm the organization and/or its reputation. “The biggest difference between the way they do the model is that they have to follow the contract that the county lays out, which takes it far from the intervention…they have to do tons of things that are different from the model.”
Belief in efficacy of intervention Coordinators who believed that the MP would be effective were most enthusiastic about implementing the MP with fidelity. For example, some coordinators believed that the MP would not work in large urban settings, and approached the intervention with defeatist attitudes that became a self-fulfilling prophecy (see quote), whereas coordinators working with similar populations and approached the intervention with enthusiasm and creativity appropriately adapted the MP to reach their communities successfully. Beliefs about the efficacy of the intervention were especially important in projects targeting young ethnic/racial minority men. “They [the core group] don’t plan anything as a group…the curriculum is ideal but unrealistic for real life as they know it…people are busy…so the coordinators do the events…she thinks that that part of the program, the core group planning stuff, is a joke and needs to be changed…maybe in a place where there is nothing to do but pick your nose, but in [a large city], it isn’t going to happen.”
Desire to change agency’s existing prevention approach Challenges occurred when staff did not want to change what they were doing or didn’t care that much about changing what they were already doing (see quote). “They had been trying to get it [MP] going…or something like it….they had a lot of people coming, but it wasn’t focused…it didn’t look like the model…the agency didn’t really care. They do outreach once a week at the clubs, and they do referrals for [HIV] testing and STD testing… they go through and give out safer sex kits to anyone who will take them from them....[but] they haven’t redeveloped the kits for Mpowerment.”
Planning for intervention Before implementation MP worked best when CBO management planned ahead to secure proper space and staff (see quote). When pre-implementation planning did not occur, poor decisions were often made that had long-term deleterious effects. CBOs often hired someone outside the organization to write the grant proposal, and did not analyze what would be needed for the program to function adequately or if the organization was truly poised to implement the intervention if they were funded. Often organizations only learn one month beforehand that they are funded, which does not facilitate careful planning for implementation. “The room they’ve ended up using is quite sterile and housed within the AIDS project.”
Accountability for work A lack of accountability affected how tasks were performed and deliverables achieved. Sometimes coordinators were largely left on their own and did not necessarily follow through on tasks. Besides the work not getting done, when this occurred core group members and other volunteers wondered why they should work for free when paid staff did not, and the volunteers would drift away from the program. A few supervisors were aware that the coordinators were underperforming but did little about it. Similarly, occasionally EDs did not hold their supervisors responsible for their staff members’ productivity, and funders did not hold the CBOs accountable for their work. Although deliverables that were part of contractual agreements were not achieved, sometimes there seemed to be little attention given to this deficit. In contrast, when staff were held accountable for their work, implementation went far more effectively. “When she [the supervisor] goes to talk to [the ED] and she tells him about stuff that is going on with the project, he just sits there and nods…he doesn’t provide any direction for her and is more apt to err on the side of supporting the coordinators rather than questioning if they are a good fit or not…this makes it difficult for her…when she thinks that they may need to be fired.”
Appropriateness and capacity of individuals for coordinator positions It was sometimes difficult for agencies to recruit and hire appropriate coordinators. In contrast, projects were typically run well when the coordinators were YGBM who were outgoing, analytical, impassioned about HIV prevention, and hardworking; were enmeshed in gay community social networks; and had or obtained a variety of skills (e.g., to create databases, facilitate groups, create a publicity plan). “She hired someone on recently who has a marketing background…who is tuned in with what is attractive and fun… but when it comes to promoting something…he is like ‘I don’t know, I don’t know…I don’t know’…she thinks that even with the training, and with the weekly meetings…he feels a bit overwhelmed…he is good at databases and stuff like that…but publicity, marketing, recruitment…it is very hard.”
Evaluation of intervention’s functioning Staff must be willing to evaluate the program in order to improve the program. “And now they are starting to think about who they aren’t reaching…who are the people that you aren’t reaching out to…he doesn’t want it to be just about handing out flyers…he spends a lot of time getting the guys to reflect on what they are doing with the project.”
Organizational stability When the CBO experiences financial crises it is difficult to implement the MP. One organization, for example, showed high fidelity in implementation when it had stable funding, but considerable changes occurred at the CBO over time. The ED left, and the new one was not supportive of the MP. Then the organization went bankrupt. “He [the funder] thinks that the project needs to go to a different organization…the agency isn’t stable enough.”
Community factors Geography The size of the city and its proximity to a gay magnet city affected the ability of coordinators to recruit and retain YGBM in the intervention. Small communities sometimes presented challenges to implementation because there could be too few men to mobilize and build a YGBM community. Some CBOs dealt with this by expanding the age range of the project participants to include more men. Small communities that included a large university, however, usually implemented MP well. Implementing the intervention in rural areas where there were insufficient young men was often challenging. Implementation in large cities varied. Although larger cities would seem to provide more pre-existing social opportunities, this is not always the case for YGBM. Often implementation worked well, as MP filled the niche of social activities for YGBM. When the project focused on one ethnic/racial group in large urban environments, it seemed easier to implement successfully than when the project attempted to reach all YGBM, again because it filled a niche. Another community issue that impacted implementation was proximity to a “gay magnet city.” It was difficult to attract men to the project when it was implemented near such a locale since often they would rather go to the city rather than stay in their own community to attend MP outreach events. “Trying to compete with San Francisco [to attract YGBM] wasn’t working” [respondent’s CBO was located in a county only a few miles away].
Sociopolitical context It can be challenging to implement some core elements with fidelity because of hostile responses in conservative areas. “Publicity was hard because they couldn’t even have a website that was geared toward gay men because the county is so conservative and the funder [the county health department] didn’t want to risk creating a commotion.”
Intervention factors Intervention characteristics As a multilevel, multicomponent, community-wide program, the MP is complex and requires significant staff time and funding. Programs with insufficient funding were more likely to flounder as they decided how frequently to implement the core elements since they could not follow our recommendations about this. CBOs and funders alike were uncertain how to implement the MP since they could not afford to have large outreach events frequently or much of a publicity campaign, for example. They wanted more guidance about how to adapt the project with less funding. “When he went to Atlanta [to a conference], he saw [a presenter connected with the MP research] and he talked to him and went to his presentation, and at the time they didn’t like the [intervention] because they thought that they [the researchers] had all this money to do it and it wasn’t the real world…because they were talking to CBOs that were working on shoestring budgets and they don’t have lots of money for training and planning like they [the researchers] had.”
Adaptation issues CBOs wanted guidance about adapting the MP to diverse locales and young gay Black or Latino populations to ensure fidelity with the guiding principles. For example, a number of projects added building life skills to the core group; used balls (performance events) as social outreach events; added mental health counseling or linkages to other services (e.g., HIV testing, linkage to care for HIV-positive men, emergency housing); paid stipends to core group members; and altered the structure of the core group, all of which could be done in accordance with the guiding principles. Other adaptations, however, did not contribute to successful implementation. For example, several CBOs changed M-groups into ongoing discussion groups. Since new young men were not recruited for these groups, informal outreach into new social networks was limited. “The question of fidelity is something that they talked about a lot…the boxed [DEBI] interventions are great, but what people really need is more TA about how to effectively adapt these interventions while retaining the theoretical core. They [the agency] needs to build their capacity to understand the internal logic of the M-group piece of the intervention so that they can say ‘here is the logic of this activity, and the behavior it is seeking to address…here is our target population for this intervention…how do we change M-groups for this target population while retaining fidelity to the original design?’”