Adapting and pilot testing the Healthy Love HIV and sexually transmitted infection prevention intervention with African,Caribbean and Black women in community-based settings in Toronto,Canada

Abstract

We adapted the Healthy Love Workshop (HLW), an HIV prevention workshop for African American women in the United States, for African, Caribbean and Black (ACB) women in Toronto, Canada. We conducted a pilot study with ACB women (n = 80) in ten community-based settings with pre-test (T1), post-test (T2) and three-month follow-up (T3) surveys. Mixed-effect regression results indicated significant increases in condom use self-efficacy and sexually transmitted infection (STI) knowledge scores from T1 to T3. Qualitative feedback revealed increased STI knowledge, confidence using condoms and suggestions for future HLWs. Findings highlight the promise of the adapted HLW for HIV/STI prevention with ACB women in Canada.

Keywords

African Caribbean and Black women sexually transmitted infections prevention Canada testing

Introduction

African, Caribbean and Black (ACB) populations are disproportionately impacted by HIV in Canada.¹ While ACB populations constitute only 3% of the population, they have new HIV infection rates seven times higher than their white counterparts and an HIV incidence rate 6.3-fold higher than other ethnicities across Canada.² A study with ACB women in Toronto, Ontario reported higher rates of certain sexually transmitted infections (STIs), such as HSV-2, in comparison with the general population.^3,4 Social ecological factors across structural, community and interpersonal dimensions converge to reduce access to HIV and STI prevention and care services, and elevate exposure to HIV and other STIs^5,6 among ACB women. For instance, at the structural level, racial discrimination in healthcare services constrains healthcare access; community-level norms stigmatize HIV and contribute to reduced HIV testing uptake; and at the interpersonal level, inequitable relationship dynamics can constrain women’s ability to negotiate safer sex practices.^5,7,8 Despite ACB women’s elevated risks for HIV and STIs in Canada there is a paucity of research on culturally appropriate, efficacious HIV and STI prevention interventions for this population.^8,9 Lessons learned from contextually adapting HIV and STI prevention interventions can inform implementation and adaption in other settings.

While there is an emerging literature on tailored, culturally-relevant HIV and STI prevention interventions for African American women in the United States (U.S.),¹⁰ there is little knowledge of their relevance and efficacy with ACB women in Canada. Canada’s ACB populations are diverse in terms of immigration and cultural experiences,⁸ underscoring the importance of engaging ACB women in contributing to the content development and implementation of HIV/STI prevention strategies.^8,11

The Healthy Love Workshop (HLW)^10,12–14 is a single-session intervention tailored for African American women in the U.S. delivered to small groups of African American women in a setting of their choosing. The HLW was developed through a partnership between sexual reproductive health experts and a community-based organization, SisterLove Inc.,¹³ to prevent HIV among African American women. The HLW intervention is classified by the U.S. Centers for Disease Control and Prevention¹² as a high impact HIV prevention programme that focuses on modifiable risk factors, empowers heterosexual African American women¹⁰ and is based on theoretical models including concepts from the health belief model and social cognitive theory.^15–17 Prior U.S.-based research reports that participation in HLWs has been associated with significantly higher condom use, condom use self-efficacy, HIV knowledge, intentions to use condoms and HIV testing compared to those who attended a didactic teaching intervention.^10,13 HLW field testing results in the U.S. highlight its cost-effectiveness, scalability and potential for adaptation to other settings.¹⁴

We located no published studies that evaluate the efficacy of an HIV/STI prevention programme tailored for ACB women in Canada. To address this knowledge gap, we adapted and piloted tested the HLW with a sample of ACB women in Toronto, Canada. Our primary objective was to evaluate whether, compared with pre-intervention, ACB women who attended the HLW would demonstrate increased condom use self-efficacy. The secondary objective was to assess if, in comparison with pre-intervention, ACB women who attended the HLW would demonstrate (a) increased STI knowledge, (b) increased STI testing rates and (c) increased HIV testing rates. The pilot study will provide evidence on the feasibility and potential efficacy of an adapted HLW for ACB women in Canada.

Methods

Study setting, design, sampling and data collection procedures

This was a multi-methods study conducted in Toronto, Canada between June and November, 2016 that involved a focus group followed by a multi-site, nonrandomized intervention. Multi-method research approaches utilize an iterative process of data collection to address a central research question.¹⁸ We first collected qualitative data in a focus group to guide the intervention and survey design and provided the option of open-ended qualitative survey responses to better understand the quantitative results. This research was a community-based collaboration with the Black Coalition for AIDS Prevention (BlackCAP), an ethno-specific AIDS Service Organization focused on promoting HIV prevention and access to the HIV care continuum among ACB persons in Toronto. Eligibility criteria included identifying as an ACB woman aged 16 years old or older and capable of providing informed consent; there was no participation restriction based on HIV or STI status. Ethics Board Approval was received from the University of Toronto. All participants provided written informed consent prior to study involvement.

We used multiple recruitment strategies. We conducted venue-based sampling at the various community centres where the HLW workshop was conducted (e.g. public housing, adolescent pregnancy centres, refugee and newcomer agencies). Each venue posted a flyer about the workshop and shared the information with networks of ACB women. We also shared the flyer with listservs focused on ACB health and HIV prevention, and on BlackCAP's website and Facebook page. We purposively targeted recruitment of diverse ACB women from various areas of Toronto by collaborating with this range of community-based partnering organizations. HLW facilitators collaborated with front-line social and health service providers at each partner agency to assist with recruitment strategies. We also used word-of-mouth strategies, where community agencies shared the HLW information with persons who attend their programmes, and invited potential participants to share the HLW workshop information with their social networks of ACB women. Participants received an honorarium of $30 CAD for attending the focus group, HLW and/or three-month follow-up survey.

Data collection processes included a focus group to adapt intervention content followed by implementation and evaluation of HLW workshops. We conducted a focus group in June 2016 with ACB women (n = 9) with the purpose of enhancing contextual relevance of the HLW intervention for ACB women in Toronto. The research team incorporated the focus group feedback into updated HLW training materials. Our focus group findings identified adaptations that we implemented, including: opening HLWs to all sexualities, including safer sex information for sexual practices with multiple genders, and adding background information about HIV and STI risks for ACB women in the Canadian context. Another adaptation was including information in ‘The Facts’ section about post-exposure prophylaxis, pre-exposure prophylaxis and antiretroviral therapy, in addition to providing participants with a resource list with HIV and testing services across Toronto.

From July to August 2016 the 4-h single-session group-based HLW intervention was conducted with 81 ACB women and facilitated by the research coordinator (DMY) and a research assistant. These facilitators identified as ACB women had extensive training in delivering HIV and STI prevention programmes to ACB women; worked full-time as ACB prevention and engagement outreach workers at BlackCAP; and closely followed the Healthy Love training manual, tools and materials. The HLW was implemented in ten community-based settings, each with 6–10 participants, across the Greater Toronto Area, including: low-income housing community centres, newcomer and refugee centres, agencies for young mothers, ethno-specific HIV centres, and community health centres in central Toronto, as well as other low-income neighbourhoods further from the downtown core. The team used the HLW manual with the adaptations discussed in the subsequent sections of this manuscript. HLWs include three intervention components: (1) Setting the Tone (creating a fun environment to discuss sex and sexuality), (2) The Facts (HIV/STI information) and (3) Safer Sex (identify and discuss safer sex practices, including condom demonstrations).¹⁰ Content was delivered using various interactive forms of learning such as games, skills practice and role play.¹³

HLW participants conducted a survey before the workshop (pre-intervention) (T1), directly following the workshop (post-intervention) (T2), and were invited to complete a survey at three months post-intervention (follow-up) (T3). The T1 and T2 surveys were self-administered on paper by participants, and at T3 participants had the option to complete the survey on paper by meeting the research assistant in person, by phone with the research assistant, or as an online survey. T2 and T3 surveys had the option for participants to provide written feedback on their experiences with the HLW and recommendations. A total of 29 participants provided written feedback.

Measures

At the pre-intervention survey, participants completed questions on demographic characteristics (age, sexual orientation, immigration status, highest level of education, employment status, relationship status). We assessed economic insecurity using two questions on a 4-point Likert scale (always to never): (1) Is your income enough to pay for your bills each month (e.g. rent, transportation)? and (2) How often do you go to bed hungry because you didn’t have enough to eat? At pre-intervention (T1), post-intervention (T2) and follow-up (T3) surveys participants completed questions on STI knowledge and condom self-efficacy outcome measures. STI knowledge was assessed using the STI knowledge questionnaire¹⁹ (Cronbach’s α = 0.75, 0–89) and condom use self-efficacy was assessed with the Condom Efficacy scale²⁰ (Cronbach’s α = 0.89, range 8–40). At T1 and T3 we asked about HIV and STI testing history (I have had an HIV test in my lifetime [yes/no], I have had a test for sexually transmitted infections (STIs) (not including HIV) in my lifetime [yes/no]). At T1 and T3 we asked participants about their perceived HIV and STI risk (How much do you think you are at risk for sexually transmitted infections not including HIV? How much do you think you are at risk for HIV infection?)

Data analysis

Qualitative analysis

We conducted thematic analysis^21,22 of the focus group and participant written comments to identify, synthesise and report themes in the data. Thematic analysis involves deductive inquiry to elucidate themes examined in the HLW manual and survey inductive inquiry was also employed to explore emergent themes²¹ (e.g. recommendations for HLWs to include men). Two authors were involved in analysing the qualitative data (CHL, MO) and member checking was conducted by sharing the findings with co-authors from the collaborating agency.

Quantitative analysis

Descriptive analyses were used to explore the socio-demographic (e.g. age, sexual orientation, employment status, education level) characteristics of the sample. For each variable, we calculated the standard deviation, mean and frequencies. For variables assessed with scales (STI knowledge, condom use self-efficacy) we summed items to calculate scores for the outcome variables. STI and HIV testing, and perceived STI and HIV risk were single item variables. Analysis of variance (ANOVA) and Chi square analysis were conducted to examine the associations between socio-demographic factors and pre-intervention outcome variables.

We investigated differences between participants who withdrew from the study (non-completers) and those who completed the study (completers).²³ We used Chi square analysis to determine if demographic variables differed significantly between completers and non-completers. We conducted independent sample t-tests to determine if participant primary and/or secondary outcomes differed between completers and non-completers.

We used mixed-effects regression to calculate the pre- and post-test outcome mean difference while adjusting for socio-demographic factors, and Chi square difference test to calculate post-intervention differences for HIV/STI testing, perceived HIV risk and perceived STI risk. An advantage of multi-effects regression is that it makes use of all available data in the estimation of model parameters due to its flexible treatment of the time predictor.²⁴ This allows us to avoid non-independence errors that might arise while using ANOVA. In addition, this model allows for the control of socio-demographic covariates.²⁴ We estimated the T1–T2 and T1–T3 outcome score changes, adjusting for socio-demographic covariates. We adjusted for socio-demographic covariates to minimize the overestimation of our model. We conducted all analyses using IBM SPSS 23. After conducting the qualitative and quantitative analyses, we examined the key findings from each method to assess convergence, complementarity and discrepancies.

Results

Focus group findings and intervention adaptation

As the HLW was developed for heterosexual African American women in the U.S.,^13,14,25 we held a focus group to discuss the HLW with ACB women in Toronto, Canada to identify adaptations to enhance relevance for the local context. Focus group participants (n = 9) were between 25 and 34 years of age (mean age: 29.33). Participants were immigrants from Uganda (n = 5), Kenya (n = 2), South Africa (n = 1) and Jamaica (n = 1). Participants’ self-identified sexual orientations included lesbian (n = 5), bisexual (n = 2), queer (n = 1) and heterosexual (n = 1). Focus group findings highlighted: the belief HLWs should be inclusive of diverse sexualities, the need for in-depth STI information, and interest in Canadian-specific information

First, participants requested for the intervention to be designed in a way that there was an ability to provide sexual health knowledge to multiple sexualities and genders:

If we could talk about safer ways of having sex for women who have sex with women because often when they are talking about it [safer sex], basically, they’re talking about sex with men, women who have sex with men. So, if we talk about women, how best can you have safer sex? How best can you negotiate for safer sex, especially when you’re here [in Canada]?

Second, participants described that they had more access to information on HIV but less knowledge of STIs:

Generally speaking, there is not so much information out there on STIs, for example, because when we’re growing up, a number of people had HIV. In some of our countries, it became an epidemic, like there were numerous people dying of HIV, so they started teaching it to us in school. They really, really tell you that HIV, AIDS, and all that, but they were not really talking much about the STIs and how many. They would only maybe mention two, gonorrhea and chlamydia. Even when they would say the signs, the vivid one I remember is the one for men, pain in urinating. That is the one I vividly remember. I don’t remember anything about how women feel or what happens. So, you’ll find that generally speaking, there’s not much information out there about the STIs.

Another participant described the need for increased knowledge of STIs, particularly asymptomatic STIs:

So, for the STIs, there is need to educate people more about it, but it needs to go further than HIV when they talk about all these different things and what to look out for in a woman. Because I know some of these STI’s, you might not feel anything physical, like pain or what, but you actually have one, and that means the person is spreading this without actually knowing that they have it.

Finally, participants described that ACB women may have misconceptions about HIV and STIs in Canada. For example, some newcomers were described as viewing HIV as a problem for ‘other’ countries or communities separate from themselves. A participant explained how new ACB immigrants may perceive HIV and STIs: ‘it’s not a Canadian problem, or it’s a problem of a certain group of people, say gay men’. Another participant described how HIV screening of persons before they immigrate to Canada may contribute to these misconceptions:

When you are among the newcomer groups and you’re talking about these things, they’re telling you why should I use a condom? Everyone who comes here is safe because they are tested. The government is testing them, and they don’t allow anyone to come in who is maybe HIV positive, so there is lots of lack of information.

The following participant narrative highlighted the importance of understanding the complete picture of HIV and STI infection rates in Canada and how they impact different populations in order to formulate accurate risk perceptions:

I think I would like statistics in general in regard to STD [sexually transmitted diseases] populations, like around figures, if they would be broken down into the men and MSM (men who have sex with men), that too. I think that would have a clearer view or a clear message in regards to people getting this information because people will be surprised. I honestly did not even know that, so if we really have more of this information to share, I think that would be good. People will then stop having a blind eye because they’re ‘okay, you know what, whether I’m having sex with a man or a woman, I’m still at risk either way because the statistics are right there’.

Taken together, the focus group findings provided valuable insights that we integrated into HLW adaptations for ACB women in Toronto. These adaptations included: (a) adding safer sex information for women who have sex with persons of multiple genders, and (b) including accurate information about HIV and STIs in the Canadian context.

Intervention pilot testing results

Participants

The number of complete responses from the overall sample (n = 80) was 98% at T1, 96% at T2 and 50% at T3. Half of the sample (n = 41, 50%) completed surveys at all three time points. As shown in Table 1, more than half of the participants identified as of African origin (58.8%, n = 47), 30% (n = 24) identified as of Caribbean origin and 11.3% (n = 9) reported other backgrounds. Most (74.7%; n = 59) identified as heterosexual, 19% (n = 15) bisexual and 6.3% (n = 5) identified as other sexual orientations (lesbian, queer). Over one-third (n = 34; 44.2%) reported food insecurity. Nearly two-thirds of participants reported a lifetime HIV (n = 49, 64.5%) and STI (n = 49, 66.2%) test. No participant reported being HIV-positive. Of those tested for STIs, over one-third (36.4%; n = 16) reported a current or past STI diagnosis. Of these, 22.7% (n = 10) reported Chlamydia diagnoses, 4.5% (n = 2) genital herpes (HSV-2), 2.3% (n = 1) trichomoniasis and 6.8% (n = 3) reported they did not know their STI diagnosis.

Table 1.

Socio-demographic characteristics and sexually transmitted infections history of African, Caribbean and Black women Healthy Love workshop participants in Toronto, Canada (n = 80).

Variable	Participants (n=80)N (%)
Age mean (years) (SD)	27.21 (7.93)
Education (n=76)
Less than high school, some college	53 (69.7)
College, some university	8 (10.5)
University	15 (19.7)
Ethnicity (n=80)
African	47 (58.8)
Caribbean	24 (30.0)
Others	9 (11.3)
Sexual orientation
Heterosexual	59 (74.7)
Bisexual	15 (19.0)
Others	5 (6.3)
Immigrant status (n=74)
Citizen	47 (63.5)
Permanent resident	11 (14.9)
Refugee	13 (17.6)
Others	3 (4.1)
Marital status (n=78)
Married/living together	16 (20.5)
Dating, not cohabiting	21 (26.9)
No current partner	31 (39.7)
Casual/multiple partners	5 (6.4)
Others	5 (6.4)
Employment (n=74)
Full-time	2 (2.7)
Part time	16 (21.6)
Not employed	15 (20.3)
Student	17 (23.0)
Receiving social assistance	24 (32.4)
Ever tested for HIV (n=76)
No	27 (35.5)
Yes	49 (64.5)
Ever tested for STIs (n=74)
No	25 (33.8)
Yes	49 (66.2)
History of STIs among tested (n=44)
No history of STI diagnosis	28 (63.6)
Current or past STI diagnosis	16 (36.4)
Reported STIs diagnosed with (n=16)	(n, % tested and reported result)
Chlamydia	10 (22.7)
Genital herpes	2 (4.5)
Trichomoniasis	1 (2.3)
Don’t know/prefer not to answer	3 (6.8)

SD: standard deviation; STI: sexually transmitted infection.

Note: Percentages represented in the table were calculated based on only reported values.

We examined differences in attrition across all socio-demographic and outcome variables. No differences were found between completers and non-completers on any of the demographic variables or any primary and secondary outcome variables.

Bivariate analyses

We found statistically significant difference between pre-intervention measures of HIV testing and certain socio-demographic characteristics: education, sexual orientation, immigration status and STI history. ACB women who identified as bisexual were less likely to have had an HIV test (31.3%, n = 15) compared to heterosexuals (62.5%, n = 30), Χ² (2, N = 74) =10.23; p < 0.01, w = 0.37. Participants with less than high school were more likely to have had an HIV test, compared to those who completed college (28.3%, n= 13) and those who completed some college (6.5%, n = 3), Χ² (2, N = 72) =7.84; p < 0.05, w = 0.33. ACB women differed statistically significantly on HIV testing by immigration status, Χ² (3, N = 70) =10.43; p < 0.05, w = 0.39. ACB women who were Canadian citizens were more likely to have had an HIV test (53.3%, n = 24), compared to refugees (28.9%, n = 13), permanent residents (15.6%, n = 7) and others (2.2%, n = 1). Participants with an STI history were less likely to have tested for HIV (30%, n = 12), compared to participants without an STI history (70%, n = 28), Χ² (1, N = 44) =7.7; p < 0.01, w = 0.42. There were no significant differences in STI testing history by socio-demographic status.

Pre-test, post-test and three-month follow-up outcome variable differences

Table 2 presents results from mixed-effects analyses of pre-intervention (T1) scores and changes in these scores at post-intervention (T2) and three-month follow-up (T3) among participants with complete data (n = 41). The primary outcome, condom use self-efficacy, showed significant increases in scores at T2 (β₁ = 5.02, p < 0.001, 95% CI 2.39, 7.64) and T3 (β₂ = 3.41, p < 0.009, 95% CI 0.88, 5.94). The secondary outcome, STI knowledge, showed significant changes in scores at T2 (β₁ = 3.42, p < 0.001, 95% CI 1.79, 5.06) and T3 (β₂ = 4.15, p < 0.001, 95% CI 2.52, 5.78).

Table 2.

Adjusted^a changes in outcome scores from pre-to-post-intervention and pre-intervention to three-month follow-up among African, Caribbean and Black women participants in the Healthy Love workshop, Toronto, Canada (n = 41).

Variables	Pre- to post-intervention			Pre-intervention to three-month follow-up
	β	95% CI	p	β	95% CI	p
STI knowledge	3.42	1.79, 5.06	0.001	4.15	2.52, 5.78	0.001
Condom use self-efficacy	5.02	2.39, 7.64	0.001	3.41	0.88, 5.94	0.009

CI: confidence interval; STI: sexually transmitted infection.

^aAdjusted for food security, education, sexual orientation and ethnicity.

Using Chi square difference tests, we found that the T1 and T3 differences in STI testing rates, Χ² (1, N = 35) =3.67; p < 0.056, and HIV testing rates, Χ² (1, N = 38) =2.56; p < 0.060 were approaching significance. We also found that ACB women differed in their T1 and T3 perceived STI risk, Χ² (1, N = 38) =5.147; p < 0.050, but there was no observed difference in perceived HIV risk, Χ² (1, N = 38) =2.056; p = 0.152.

Qualitative feedback from intervention participant surveys

Increased condom use efficacy: ‘I can now talk about condoms and sex freely’

Qualitative data from participant survey responses revealed an attitudinal shift in perceptions towards condom use, corroborating the quantitative survey measures. As a participant expressed: ‘I can now talk about condoms and sex freely with my friends’ (T3). Following the HLW, participants explained they felt more confident to carry or use condoms to prevent HIV/STIs. One participant described: ‘I got more knowledge in the condom demonstration and especially the female condom use demonstration and safer sex tools’ (T2). Another stated that because of participating in the intervention, ‘I carry around the condoms I got from the workshop and I feel more confident about practicing safe sex’ (T3).

Increased STI knowledge: ‘I have more knowledge about STDs’

Participant qualitative survey responses also corroborated quantitative results regarding increased STI knowledge. For example, one participant described this increased knowledge provides motivation for engaging in sexual healthcare: ‘I am more knowledgeable about sexually transmitted diseases, even about those I never knew about like the genital warts. I now know I have to keep myself safe and I should keep going for checkup’ (T3). The practical nature of the HIV/STI information was perceived to be able to be put into practice by participants. One participant described she learned ‘to protect myself more with a partner and to be very careful who you mess around with because you won’t know who has an STI or HIV, and most partners wouldn’t tell anybody’ (T3).

Participant recommendations for future HLW interventions

Participants provided specific recommendations on how the intervention could be improved, centered on the need for expansion: increased time for discussion, increased number and frequency of workshops, and inclusion of men. ‘More time for discussion’ was a common theme in written feedback about the intervention at both T2 and T3, with concerns that ‘we ran out of time’ (T2). Others discussed the need for expansion to the wider community: ‘It was a very good session, these could be put out in the community more often because they are educative’ (T2). Other recommendations were to increase the frequency of the workshops: ‘the facilitators should be organizing the same workshops for women at least twice a week’ (T2). A common belief was that an increase in reach and frequency of HLW could increase community HIV/STI awareness: ‘more people would participate and become aware of some of the things that can happen in a moment’ (T3). Others recommended involving men in the workshops: ‘I suggest men should be involved in this type of study’ (T3), and another asked: ‘when will you do a workshop for young men?’ (T2) Finally, participants recommended ‘more demonstrations’ (T2) to enhance understanding of the topics and be able to apply the information.

Discussion

The HLW HIV and STI prevention intervention¹⁰ adapted for ACB women in Toronto showed promising results with regards to increasing condom use self-efficacy and STI knowledge. Qualitative feedback corroborated the quantitative findings that HLWs enhanced STI knowledge and safer sex efficacy skills in ways that participants were able to integrate into sexual health practices, including using and discussing condoms and STI testing uptake. Participants included women experiencing food insecurity (44.2%, n = 34), women on government assistance (32.4%, n = 24) and persons with less than high school or who had attended some college (69.7%, n = 53).

Over one-third of participants reported a lifetime STI history – higher than a population-based study of Canadian women with reported lifetime STI rates of 7.6% for heterosexual women, 9.1% for lesbians and 22.7% for bisexual women.²⁶ Out of participants in our study that reported STI testing and the result (n = 44), 22.7% of persons reported a Chlamydia diagnosis, 4.5% HSV-2, 2.3% trichomoniasis and 6.8% did not know. Remis et al.’s Toronto study with ACB women reported that among the HIV-negative participants (n = 291) who had been tested for STIs, rates included: Chlamydia: 3.8%, HSV-2: 46.6% and gonorrhoea: 0.0%. Another population-based study⁴ reported HSV-2 rates of 16% and Chlamydia rates of 0.7% among general populations in Canada. Trichomoniasis is not a reportable infection in Canada so there is limited knowledge of prevalence rates; our findings are comparable to the U.S. prevalence²⁷ among women of 3.1%. While our study is limited by self-report STI data, findings suggest that participants had higher rates of Chlamydia and gonorrhoea, and lower rates of HSV-2, than other studies with ACB women in Toronto³ and higher rates of Chlamydia⁴ than general populations in Canada. Exploring the rates of HSV-2 among ACB women is an important area for future investigation as prior Canadian research reported that 94% of Canadians diagnosed with HSV-2 were previously unaware of the infection.²⁸ The self-reported lifetime diagnosis of STIs and rates of Chlamydia, HSV-2 and trichomoniasis suggest that our study participants were at elevated risk of STIs.

Our approach to implementing HLWs was aligned with prior work in developing and pilot testing the HLW. The workshop was women focused, group based and tailored for diverse cultural and geographic settings with interactive teaching skills and creation of non-judgmental environments to enhance information retention and support behaviour change.^14,29 Our findings highlight the potential of a group-based single-session intervention as a strategy to increase ACB women’s STI knowledge and condom self-efficacy^10,30,31 – key to sexual health.¹³ Findings also provide additional evidence for the HLW as an acceptable way to deliver sexual health information for ACB women in Toronto¹⁰ with diverse marginalized backgrounds, including participants who are immigrants, low income and with lower levels of education. Differences in STI and HIV testing uptake following the intervention only marginally increased. Future research can explore motivations and barriers to HIV and STI testing among ACB women, offer incentivized testing and provide mobile and/or point-of-care testing to increase testing uptake.

There are several study limitations. The non-random sample and lack of control group reduce the generalizability of findings. The high attrition rate might bias the outcomes of the study. Although potential threats to attrition are under-reported in most research studies,^23,32,33 our study conducted attrition analysis of socio-demographic and outcome variables to examine correlates of attrition, finding no significant differences between completers and non-completers. The high attrition rates suggest that in further trials we need to develop comprehensive strategies before the HLW implementation with participants to minimize loss to follow-up.³³ We could also go back to each setting and meet the group again to conduct T3 follow-up surveys, rather than relying on individuals to connect by phone, in person or online. Due to the pilot nature of the study,³⁴ we relied on self-reports of indicators of HIV/STI vulnerability and these may be impacted by social desirability. Future studies can include point-of-care HIV testing and serological STI outcomes, including partnerships with HIV/STI clinics and connecting patient data to survey data.

Despite these study limitations, we provide evidence for the feasibility of the HLW as an HIV/STI prevention intervention for both heterosexual and sexually diverse low-income ACB women for future trials. With an urgent need for evidence-based HIV/STI prevention interventions for ACB women who are over-represented in HIV infections, and certain STIs, in Canada,^8,11,35 our study demonstrates the HLW as a promising strategy for this population. Future multi-centre studies can use a randomized design and control group with serological outcomes to further test the efficacy of the adapted HLW with other ACB women in Canada. Our study extends findings of the HLW intervention implemented among heterosexual African American women in the U.S.¹⁰ to suggest this approach can be adapted for women of diverse sexualities, cultural and contextual backgrounds.

Footnotes

Acknowledgements

We would like to thank all the participants, peer research assistants and collaborators: Black Coalition for AIDS Prevention (BlackCAP), Women’s Health in Women’s Hands Community Health Centre, African and Caribbean Council on HIV/AIDS in Ontario, Black Creek Community Health Centre, Africans in Partnership Against AIDS, Taibu Community Health Centre.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Canadian Institutes of Health Research Transitional Operating Grant, Institute of Aboriginal Peoples’ Health, Grant #342702. CHL is funded by the Ontario Ministry of Research & Innovation Early Researchers Award, the Ontario Research Fund and Canada Foundation for Innovation.

References

UNAIDS. Global AIDS update 2016. Geneva, Switzerland, UNAIDS, 2016.

Public Health Agency of Canada. Summary: estimates of HIV incidence, prevalence and proportion undiagnosed in Canada, 2014. Government of Canada, Ottawa, Canada, 2015.

Remis

Liu

Loutfy

et al . The epidemiology of sexually transmitted co-infections in HIV-positive and HIV-negative African-Caribbean women in Toronto. BMC Infect Dis 2013; 13: 550.

Rotermann

Langlois

Severini

et al . Prevalence of chlamydia trachomatis and herpes simplex virus type 2: results from the 2009 to 2011 Canadian health measures survey. Heal Reports 2013; 24–4: 10–15.

Baral

Logie

Grosso

et al . Modified social ecological model: a tool to guide the assessment of the risks and risk contexts of HIV epidemics. BMC Public Health 2013; 13: 482.

Loutfy

Logie

Zhang

et al . Gender and ethnicity differences in HIV-related stigma experienced by people living with HIV in Ontario, Canada. PLoS One 2012; 7: e48168.

Williams

Newman

Sakamoto

et al . HIV prevention risks for Black women in Canada. Soc Sci Med 2009; 68: 12–20.

Shimeles

Husbands

Tharao

et al. African, Caribbean and Black Communities in Canada: a knowledge synthesis paper for the CIHR social research centre in HIV prevention. Dalla Lana School of Public Health, University of Toronto, Toronto, Canada, 2011.

Loutfy

Tharao

Logie

et al . Systematic review of stigma reducing interventions for African/Black diasporic women. J Int AIDS Soc 2015; 18: 19835.

10.

Diallo

Moore

Ngalame

et al . Efficacy of a single-session HIV prevention intervention for black women: a group randomized controlled trial. AIDS Behav 2010; 14: 518–529.

11.

Rich L and Interagency Coalition on AIDS and Development (ICAD) African and Caribbean Council on HIV/AIDS in Ontario (ACCHO) Women’s Health in Women’s Health Community Healthy Center. Towards the improvement of HIV prevention services for African, Caribbean and Black communities in Canada: a gap analysis. ICAD, Ottawa, 2011.

12.

United States (US) Centers for Disease Control and Prevention. Healthy love a single session, group-level HIV prevention intervention for African American Women. U.S. CDC, Atlanta, U.S.

13.

Painter

Herbst

Diallo

et al . CDC. Community-based program to prevent HIV/STD infection among heterosexual black women. Morb Mortal Wkly Report Surveill Summ 2014; 63: 15–20.

14.

Galindo

Few

Daniels

et al . Lessons learned from the field-testing of healthy love: an HIV prevention intervention for Black Women. Health Promot Pract 2017; 18: 381–390.

15.

Bandura

Social cognitive theory in cultural context. Appl Psychol 2002; 51: 269–290.

16.

Prochaska

Velicer

WF.

The transtheoretical model of health behavior change. Am J Health Promot 1997; 12: 38–48.

17.

Becker

MH.

The health belief model and personal health behavior. Heal Educ Monogr 1974; 2: 324–473.

18.

Collier

Elman

Qualitative and multi-method research: organizations, publication, and reflections on integration. In: Box-Steffensmeier

Brady

Collier

(eds) The oxford handbook of political methodology. Oxford: Oxford University Press, 2008, Chap 34.

19.

Jaworski

Carey

MP.

Development and psychometric evaluation of a self-administered questionnaire to measure knowledge of sexually transmitted diseases. AIDS Behav 2009; 11: 557–574.

20.

Brafford

Beck

KH.

Development and validation of a condom self-efficacy scale for college students. J Am Coll Health 1991; 39: 219–225.

21.

Attride-Stirling

Thematic networks: an analytic tool for qualitative research. Qual Res 2001; 1: 385–405.

22.

Braun

Clarke

Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77–101.

23.

Dumville

JC.

Reporting attrition in randomised controlled trials. BMJ 2006; 332: 969–971.

24.

Raudenbush

Bryk

AS.

Hierarchical linear models: applications and data analysis methods. Thousand Oak, CA: Sage, 1997.

25.

United States (U.S.) Center for Disease Control and Prevention. Healthy Love a single session, group-level HIV prevention intervention for African American Women. U.S. CDC, Atlanta, U.S.

26.

Steele

Ross

Dobinson

et al . Women’s sexual orientation and health: results from a Canadian population-based survey. Women Health 2009; 49: 353–367.

27.

Sutton

Sternberg

Koumans

et al . The prevalence of Trichomonas vaginalis infection among reproductive-age women in the United States, 2001–2004. Clin Infect Dis 2007; 45: 1319–1326.

28.

Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections: Genital Herpes simplex virus (HSV) infections. Government of Canada, Ottawa, Canada, 2011.

29.

Logie

Daniel

Newman

et al . Psycho-educational HIV/STI prevention intervention for internally displaced women in Leogane, Haiti: results from a non-randomized cohort pilot study. PLoS One 2014; 9: e89836.

30.

Eaton

Huedo-Medina

Kalichman

et al . Meta-analysis of single-session behavioral interventions to prevent sexually transmitted infections: implications for bundling prevention packages. Am J Public Health 2012; 102: e34–e44.

31.

Sagherian

Huedo-Medina

Pellowski

et al . Single-session behavioral interventions for sexual risk reduction: a meta-analysis. Ann Behav Med 2016; 50: 920–934.

32.

Allott

Chanen

Yuen

HP.

Attrition bias in longitudinal research involving adolescent psychiatric outpatients. J Nerv Ment Dis 2006; 194: 958–961.

33.

Gustavson

von Soest

Karevold

et al . Attrition and generalizability in longitudinal studies: findings from a 15-year population-based study and a Monte Carlo simulation study. BMC Public Health 2012; 12: 918.

34.

Thabane

Chu

et al . A tutorial on pilot studies: the what, why and how. BMC Med Res Methodol 2010; 10: 1.

35.

Maticka-Tyndale

Kerr

Mihan

et al . A profile of the sexual experiences of African, Caribbean and Black Canadian youth in the context of Canadian youth sexuality. Can J Hum Sex 2016; 25: 41–52.