“Don’t Deny Yourself a Seat at the Table”: Supporting the Leadership Development of MSM of Color in HIV Services

Abstract

AIDS service organizations have played a vital role in responding to the HIV epidemic, yet many are plagued by an underrepresentation of racial, ethnic, and sexual minorities in leadership positions. In response, the Wisconsin Department of Health Services, HIV Division, created the Wisconsin Health Leaders Fellowship program to provide training and skills to gay and bisexual men of color in HIV service organizations in Milwaukee, Wisconsin. The program was evaluated using in-depth pre- and post-Fellowship interviews with fellows, their agency preceptors, and Fellowship staff (n = 23 interviews). Results indicate that the Fellowship was successful at developing leadership skills and increasing the confidence of the fellows. However, findings revealed the need to address larger social and structural issues alongside supporting individuals in order to create effective, sustainable change. There is a need for cultural diversity trainings for organizational leaders, changes to organizational hiring and promotion practices, and improving opportunities for formal education for racial and ethnic minority men.

Keywords

leadership community organizations workforce diversity MSM of color

Young African American gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by HIV; those aged 13 to 24 years represent over half of all new HIV infections among men in that age group (Centers for Disease Control and Prevention, 2016). These disparities are complicated by the fact that African American MSM are also disproportionately affected by myriad social and structural factors including exposure to community violence, racial discrimination, substance use, and incarceration (Matthews, Smith, Brown, & Malebranche, 2016). One key structural factor underlying these disparities is the underrepresentation of racial, ethnic, and sexual minorities among professionals serving those populations, particularly among leadership. Estimates suggest that although over a third of the U.S. population belongs to a racial or ethnic minority group, less than 5% of the public health workforce are African American (Dean, 2016). Furthermore, nonprofit organizations are predominantly led by White individuals; approximately 5% of nonprofit executives are African American and just 3% are Latino/a (Cornelius, Moyers, Foundation, & Bell, 2011).

There are no studies that explicitly address the association between diversity among health professionals, particularly leadership, and HIV outcomes. However, results from a systematic review indicate that greater diversity among health professionals can lead to improved public health via two theoretical pathways. In the first, research suggests that diversity among health professionals can lead to increased access to care for underserved populations and improved interactions between patients and health professionals through racial, ethnic, and language concordance (U.S. Department of Health and Human Services, 2006). Diversity in HIV community-based organizations (CBOs) is particularly important, as these agencies play a key role in addressing an HIV epidemic that disproportionately affects Black and Latino men. CBOs are most effective when those affected by and at highest risk for HIV are not merely participants or frontline service providers, but rather are able to assume leadership and decision-making positions (Szekeres, Coates, & Ehrhardt, 2008). HIV organizations led by the communities most affected by HIV are better equipped to respond to the HIV epidemic and create trusted relationships with individuals and communities living with and at risk for HIV (Asthana & Oostvogels, 1996; Chillag et al., 2002; Richter et al., 2006), increasing access to care for those most vulnerable to HIV. Minority leaders can ensure appropriate relevance, reach, and quality of services, and can help ensure HIV services being implemented are trusted and appropriate for those most at risk for HIV. For example, minority staff members may be more likely to understand the prevalence and effects of medical mistrust, which affects prevention and treatment of HIV (Quinn et al., 2016).

The second theoretical pathway between diversity and health outcomes is through concordance, the matching of demographics of employees and individuals served, which may improve public health not only by increasing access to care but also by allowing minority clients to see health care professionals and leaders with whom they share a common race, sexuality, or ethnicity (U.S. Department of Health and Human Services, 2006). This concordance is associated with better relationships, communication, and receipt of appropriate care (Dreachslin, 2008). Beyond the practical and health benefits, supporting leadership diversity also reflects the public health principles of equity, fairness, and social justice. Developing effective, diverse leadership structures is imperative to strengthening social justice and promoting diversity and inclusion in all aspects of HIV prevention and care.

Recognizing the importance of leadership diversity in addressing HIV, efforts have been made to support underrepresented minorities in HIV-related medicine and research (Fitzpatrick, Sutton, & Greenberg, 2006; Sopher et al., 2015). For example, the Mentorship Program (RAMP) was developed to attract African American and Hispanic medical students to the field of HIV vaccine research (Sopher et al., 2015) and the Minority HIV/AIDS Research Initiative (MARI) provides support for early career minority scientists in HIV prevention research, designed to address workforce and funding disparities in HIV prevention research (Fitzpatrick et al., 2006; Sutton et al., 2013). While important, graduates of these programs will most likely have careers in medicine and academia rather than in CBO leadership. Fewer HIV diversity programs have focused on leadership in public health and HIV service organizations. The Institute for HIV Prevention Leadership was a Centers for Disease Control and Prevention capacity building training initiative from 2002 to 2004 for employees of CBOs that primarily served African Americans (Richter et al., 2007). An evaluation of the institute demonstrated increased capacity and confidence in providing HIV services in African American communities among participants and indicated a need for continued programs that build capacity for culturally appropriate HIV prevention activities in community organizations (Richter et al., 2007). Additionally, in 2010, the National Alliance of State and Territorial AIDS Directors (NASTAD) created the Minority Leadership Program to enhance leadership opportunities for junior-level minority staff working in health departments (Ruiz et al., 2011). Although important, these initiatives did not directly address leadership diversity or the disparities that exist between frontline staff and leadership within CBOs.

Program Overview

Although there have been increasing efforts to ensure frontline staff and health practitioners reflect the racial and sexual diversity of clients and program participants, disparities in managerial and leadership positions within many CBOs persist. In response, the Wisconsin Department of Health Services, HIV Division, created the Wisconsin Health Leaders Fellowship program, a yearlong leadership development pilot program for gay and bisexual men of color in Milwaukee, Wisconsin. The Fellowship was developed in response to the lack of leadership positions held by gay and bisexual men of color in agencies providing HIV services in Wisconsin. Milwaukee has the highest rate of HIV diagnoses in Wisconsin; although the city of Milwaukee makes up just 10% of the state’s population, it had 46% of new HIV diagnoses in 2017. From 2015 to 2017, Black and Hispanic men who have sex with men made up 65% of the HIV diagnoses in Milwaukee (Wisconsin Department of Health, 2017). Milwaukee has one AIDS Service Organization that provides comprehensive HIV treatment and prevention. In total, there are nine organizations that receive public funding for HIV prevention activities in Milwaukee, six of which offer HIV testing.

The first cohort of the Fellowship was composed of six fellows from five HIV service agencies. Fellows were nominated by the executive director or another leader in their organization who thought the fellow had the capacity for leadership in the field. Each fellow had a formal preceptor, or workplace-associated mentor, who helped cultivate opportunities in the workplace to support the fellow’s professional growth. Preceptor requirements included being in a leadership position within the organization and willing to meet regularly with the fellow to help them apply concepts learned in the Fellowship to their work. In some cases, the preceptor was the fellows’ direct supervisor, but for others, it was another person in leadership, in a position higher than the fellows’ supervisor. Preceptors agreed to provide mentorship and learning opportunities in the organization for the fellow to apply what they learned in trainings and meetings. Preceptors committed to overseeing fellow participation in the program. The intended short-term outcome of the Fellowship was to equip gay and bisexual men of color with skills and mentors that will help them advance in their careers. The program provided safe learning spaces where fellows could engage in critical conversations around skills necessary for job advancement and institutional barriers to that advancement. The Fellowship curriculum was informed by formative interviews conducted with leaders of HIV service organizations in Milwaukee in the year prior to Fellowship development. Leaders were asked what skills they needed their staff to have in order to be considered for promotion. Although the Fellowship was designed to address inequities in HIV, the content was not HIV-specific. Rather the Fellowship focused on leadership skills, particularly those relevant to the nonprofit sector. Content included skill building on the topics of program development and project management, fiscal management, communication, interpersonal skills, community leadership, and influencing. The inaugural year of the Fellowship was composed of five components, detailed in Table 1.

Table 1

Fellowship Components

Fellowship Component	Description	Lead By	Content and Focus	Timeline
Introductory Nonprofit certificate through University of Wisconsin–Milwaukee School of Continuing Education	11 self-paced online courses on nonprofit management topics	Self-directed	Courses cover nonprofit management topics including budgeting, grant writing, marketing, strategy, and board and volunteer development	Fellows completed the courses in alignment with the Fellowship meetings in Months 3, 5, 7, 9, and 11.
Leadership trainings	Series of 2-day in-person trainings on leadership topics; open to other staff from funded agencies	CDC-funded capacity building assistance providers: AIDS United and PROCEED, Inc.	Technical content and the opportunity to reflect and discuss application of content to their agency’s work; six trainings covered topics including evaluation, fund development, transitioning into management, and self-care.	Trainings occurred in Months 5 through 11.
Fellow meetings	Bimonthly half-day meetings for fellows	Consultant facilitator	Safe spaces for fellows to build community; reflection and sharing experiences around leadership topics. Topics included program development, project management, fiscal management, communication, ethics, boundaries, and supervision	Fellowship meetings were held in Months 1, 3, 5, 7, 9, 11, and 12 including an orientation and graduation.
Coaching	Individual professional career coaching	Consultant coach	Career coaching provided on a monthly basis to guide fellows through structured conversations to gain personal insight and inspiration and move fellows toward their self-selected goals	Coaching was provided in months 2 through 11.
Workplace experiential learning	Opportunity for fellow to work with a workplace mentor (preceptor) to apply Fellowship topics to their work	Preceptor and fellow	A preceptor (workplace mentor) was identified to assist the fellow in applying the information and skills they learned in the Fellowship to their agency.	Workplace experiential learning occurred throughout the 12 months and varied by agency.

NOTE: CDC = Centers for Disease Control and Prevention.

Method

This is a formative evaluation of the Wisconsin Health Leaders Fellowship to identify successes, areas for improvement, and opportunities to scale and replicate the Fellowship. Formative evaluations are particularly useful during pilot programs to identify unexpected outcomes, implement program changes as needed, and inform decisions about the future of the program (Rossi, Lipsey, & Freeman, 2004). The evaluation approach included pre-and post-Fellowship in-depth interviews with the Fellows and in-depth interviews with preceptors and program staff at the conclusion of the Fellowship. In total, we conducted 23 interviews with 17 individuals. The pre-Fellowship interviews included structured questions about Fellows.

Within the first 2 weeks of the Fellowship, all six fellows were contacted by e-mail by the evaluation team, informed of the evaluation, the voluntary nature of the interviews, and the protection of their confidentiality. We made follow-up phone calls within 1 week and fellows were scheduled for an interview; all fellows agreed to participate. On completion of the Fellowship, we sent emails to all six fellows to schedule a post-Fellowship interview, following the same procedures. All six fellows completed the pre- and post-Fellowship interviews. Interviews occurred in person, or by phone if necessary, were audiorecorded, and lasted approximately 1 hour. Interviewers followed a semistructured interview guide (see Supplemental Material) that provided opportunities for interviewers to ask unanticipated questions, probe for additional information, and ask questions in any order they organically emerged.

On completion of the Fellowship, post-Fellowship interviews were also conducted with fellows’ workplace preceptors (n = 4) and Fellowship staff (trainer [n = 1], facilitator [n = 1], and all HIV program staff involved in the Fellowship [n = 4]). Emails were sent to all preceptors and staff to explain the purpose of the interviews and follow-up calls were made, as necessary, to schedule interviews with interested participants; one preceptor declined to participate. Semistructured in-depth interviews were conducted in person or by phone, were audiorecorded, and lasted between 20 and 60 minutes and followed a semistructured interview guide (see Supplemental Material).

Data Analysis

Interview recordings were transcribed verbatim and uploaded into MAXQDA qualitative data analysis software. Interviews were analyzed by an evaluation team consisting of the lead author, a PhD student, and two research assistants using inductive and deductive analysis techniques and content analysis. No members of the evaluation team were involved in the planning or implementation of the Fellowship program. We used a multistage analytic coding strategy (Corbin & Strauss, 2015). As an initial stage of analysis, the evaluation staff read through two randomly selected fellow interviews, two preceptor interviews, and two Fellowship staff interviews. Through an iterative process of reading and coding interviews, we collaboratively developed a codebook, code definitions, and wrote analytic memos. We met regularly to discuss code application and changes in the codebook until we reached consensus on code definitions and application. We then used open coding by coding all interview transcripts line-by-line. The codebook consisted of a combination of emergent codes (“tokenism,” “promotion opportunities”) and a priori codes from public health literature (“leadership development opportunities”) to categorize the data (Saldana, 2016). Axial coding was then used to identify dominant codes, draw connections among codes, and group codes (Boeije, 2002). All interviews were coded at least twice to identify key themes. Fellows’ pre- and post-Fellowship interviews were compared to determine whether the program achieved its goals, identify barriers to leadership, and highlight opportunities for improvement. All evaluation protocol and analysis procedures were reviewed by the Medical College of Wisconsin institutional review board.

Results

The following highlights the themes that emerged directly from the interviews regarding the need for the Fellowship and participants’ experience with the Fellowship. Given low numbers, “Fellowship staff” collectively includes the facilitator, trainer, and four staff from the HIV Program. To protect participants’ confidentiality, names and other organizational or personal identifying information has been removed. Results are organized around the primary themes that emerged from the interviews and direct quotes are used throughout to highlight main points and support overall themes. Whether the author of the quote is a fellow, preceptor, or Fellowship staff member is noted. The results are organized around the following themes that emerged directly from the interview content: exclusion of racial minority MSM from decision making, leadership readiness and the effect of the program on fellows, program impact on organizations, and the continuing structural and institutional barriers to leadership diversity.

Exclusion of Racial Minority MSM From Leadership

Fellows, preceptors, and Fellowship staff all acknowledged the racial disparities between frontline staff and leadership in the HIV field in Milwaukee and applauded efforts to address the widely acknowledged racial disparities in leadership within the HIV field in Milwaukee. HIV service organizations had generally accepted that diversity among frontline staff was essential to improving service delivery, yet little, if any, work had been done to address diversity among leadership.

I like the rationale, because I think everybody knows that most agencies that are doing HIV prevention things have very good representation of racial minority MSM on the front lines, but they are missing from leadership roles within those organizations. So I think the intent of identifying promising people, and helping them develop skills that they can use to advance from frontline to leadership roles within their agencies is really worthwhile. (Preceptor)

Laudable efforts had been made to hire sexual minority men of color to do client outreach, case management, or HIV testing (roles most of the fellows were in) among the agencies involved in the Fellowship. Yet, several fellows felt that their sexuality, race, and or/ethnicity was all their organization valued, and they were not looked at as potential leaders or managers.

I just think that sometimes I’m looked at as that token guy. The token Black gay man that can do token Black gay man responsibilities. . . . I’m looked at as that Black MSM that can connect with the population that we need to get in [through our doors]. . . . I feel that I’m not being utilized completely to my capabilities here. (Fellow, pre-Fellowship interview)

As he explained, this fellow’s job responsibilities were closely linked with larger organizational goals of reaching Black MSM in the community and bringing them into the organization, which limited his opportunities for growth and involvement in other activities and initiatives. Although he felt “needed” to connect with the community and be the face of the organization, the lack of leadership opportunities in his organization contributed to him feeling tokenized and underused.

Without opportunities for these men to move up and take on leadership positions, organizations maintained staffing disparities, wherein leadership was predominantly White and frontline staff, responsible for “connecting with the population,” were MSM of color.

If you look at all the CBOs in Wisconsin or even Milwaukee County, only one African American is an Executive Director. All the EDs from CBOs that I can point out, all of the leadership is predominantly White . . . it is important that when people walk through that door, that they not only see people like themselves, but the people who are making decisions, making informed decisions on how this epidemic should be led. That should be reflected of the people who are disproportionately affected by HIV. (Program staff member)

Fellows were also acutely aware of these disparities.

We are a state where we have a high percentage of people of color being affected by HIV or AIDS, but when it comes to being a leadership role in these agencies, there’s minimal to none . . . once you go up that ladder and start to look more at management and leadership responsibilities, you don’t see yourself anymore. Now you’re seeing another culture, another race, giving you what they feel works for your community. (Fellow, pre-Fellowship interview)

Several fellows discussed frustrations with upper management who were not reflective of the population most at risk for HIV but made decisions about programming and services they thought were best for the community. Like the fellow quoted above, another fellow described tension within his organization with a well-intended supervisor who, despite their best efforts, did not, and could not, understand what members of his community were facing.

The community, in general, there is always going to be that tension when they see somebody that’s not like them across the table try to tell them what to do or where to go, or not to do those things that they are doing. Especially since [leadership] don’t know the struggles that the people are going through or never faced the barriers that the people have had. . . . they can say that they are from the block, but they have never lived on the block or ever experienced the block. (Fellow; pre-Fellowship interview)

Not only did a lack of diversity in leadership lead to challenges with services and program decisions but it also affected fellows’ perceived career trajectories and opportunities.

I don’t see the hierarchies encouraging different races to move up into leadership . . . it makes individuals of different races feel that this is the highest we can go. It feels like we’re heading to the top of the glass building. Like, our head keep hitting the top. This is the highest we can go. This is as much as we can do; you’re not going to be viewed to do anything else. I think it keeps the staff morale down. (Fellow, pre-Fellowship interview)

Several fellows noted that when people of their race or sexuality, and moreover the combination of the two, were not reflected in leadership positions in their agencies, it signaled to fellows that those positions were not available to them, and they did not necessarily see themselves as being able to be promoted within their organization or other HIV service organizations in Milwaukee.

“Don’t Deny Yourself a Seat at the Table”: Leadership Readiness and the Effects of the Fellowship Program

Fellows reported an overwhelmingly positive personal and professional experience with the Fellowship and cited increased confidence, improved management-related skills (grant writing, budgeting, program planning), and stronger leadership skills. During the Fellowship, two of the six fellows received promotions (one within his agency and one in a new agency), but all six fellows reported an increased confidence in their leadership skills and felt they were prepared to take on additional responsibilities and move into leadership roles within their agencies. As one fellow noted,

I think my day-to-day activities have been pushed to see if the Fellowship has really moved me into that kind of leadership positions. A lot of my responsibilities are what I feel a leader should be doing. I think my direct supervisor has given me a lot of those responsibilities that I haven’t been given in the past. (Fellow, post-Fellowship interview)

Despite fellows’ confidence in their ability to move into leadership positions, preceptors believed that although fellows certainly gained new and useful skills, they were not necessarily ready to take on formal leadership roles.

To start, what is the Fellowship’s definition of leadership? If by leadership you mean is he ready for a managerial position? My answer is not quite. If by leadership we mean stepping up, taking ownership, being proactive, actively thinking about projects, then yes, I think he does have a lot of qualities that he can exert in a leadership position. (Preceptor)

Preceptors were often more hesitant about promotion and leadership potential than fellows. All six fellows described themselves as leaders with the drive to take on managerial and supervisory tasks, yet their preceptors often felt they did not understand the administrative daily tasks and expectations of being a formal leader in the organization. As another preceptor said, “I think everybody likes the idea of being a leader, but not everyone understands what that means in the context of a work environment.”

Whether or not fellows were “ready” for leadership positions, one of the most ubiquitous themes that emerged when discussing the effect of the Fellowship on fellows was their increased confidence to speak up and find “their place at the table.” Fellows described typically being left out of decision-making processes, not being given opportunities to use their leadership skills and abilities, and generally not being invited to the actual or metaphorical “table.” While most fellows initially accepted their exclusion from leadership as the status quo, several noted that the Fellowship helped them find their voice and confidence to be at the table.

[The Fellowship taught us to] demand your seat at the table. Don’t let them make a seat for you at the table. You demand your seat at the table. And this is how you do it in a nice, political, friendly way. (Fellow, post-Fellowship interview)

One of the preceptors described the effect of that message on that agency’s fellow:

There is a certain sense of empowerment. . . . an appropriate emphasis on, “don’t automatically take yourself from the table. Don’t deny yourself a seat at the table. You have appropriate experience that you can have a seat at the metaphorical table.” I think many people need to hear that. Our fellow needed to hear that because he does speak up more. He does tend to express his opinion, which is an important opinion. He more readily expresses that opinion now. (Preceptor)

The Fellowship validated fellows’ experiences and gave them the confidence to voice their opinion within the work environment. This is significant, as a combination of personal, professional, and structural barriers have often prevented fellows from being at the “table” and voicing their opinions. A few fellows also described how they felt their voice was more respected after completing the Fellowship. One fellow, for example, described the respect he gained from his preceptor during the Fellowship process:

I think my preceptor can actually me hear me now. I think sometimes in the past, maybe they heard me, but there wasn’t really an emphasis on, okay, what he’s saying is important. There wasn’t any respect behind it. (Fellow, post-Fellowship interview)

The Need for Organizational Change

While improving individual-level leadership skills is an important part of the promotion process for fellows, participants also recognized the need for change at the organizational level if the Fellowship program was going to result in leadership diversity. For example, Fellowship staff described a need for additional trainings for preceptors and their agencies to better support their fellows. Fellowship meetings and trainings provided fellows with opportunities to discuss institutional and systemic racism and discrimination, yet there were no Fellowship efforts to address those issues with preceptors or participating agencies.

In the first cohort, we didn’t do anything to address the agency-level barriers to people of color moving up to leadership. So we worked on the fellows’ side of things, building their skills, but they are working in an environment that poses a lot of barriers. I think a lot of that implicit bias among those who are currently leaders and just policies and systems that are not set up to accommodate. (Fellowship program staff member)

This limitation was also acknowledged by preceptors, who admitted to their limited ability to address these issues within their organizations and with their fellows and recognized the need for such a focus. As one preceptor noted, despite a desire for more equity, “There is still sometimes a reluctance to place men of color into formal management and supervisory positions,” pointing to the continued effects of institutional- and individual-level racism that will continue to pose barriers for fellows. Another Fellowship staff member similarly noted the need to support organizational management in addressing disparities in leadership.

There needs to be some development with supervisors, direct supervisors, upper management, and even Executive Directors . . . This is about HR, this is about culture, and this is about people in leadership who have the power to create change. (Fellowship program staff member)

Fellows were seen as doing their part by going through the Fellowship and completing the certificate program. Although they were never guaranteed a promotion or access to advancement opportunities, in many cases, organizational change was seen as a necessary part of increasing diversity.

Structural and Institutional Barriers to Leadership

Individual-level barriers to leadership were the focus of the Fellowship, but it was also clear that many organizations are structured in a way that makes it difficult for fellows to advance in their careers. For example, preceptors often struggled with the ability to hire or promote individuals without a bachelor’s degree, even if that individual has lived experience or organizational knowledge. For most organizations involved in the Fellowship, modifying educational requirements would likely be necessary in order to improve diversity in their leadership, particularly in the short-term. As one Fellowship staff member noted,

I think one of the barriers is, what will the agencies do as far as their hiring and promotion practices? We all have a sort of culture, we want people that are academically prepared, and so we are looking for both those who have degrees out of well-respected universities. And if you are coming from a setting where you’ve not had that opportunity, but now you’ve done some personal training and developed your skills, if the expectation is that someone has to have a college or even graduate degree, it’s not going to be successful. . . . I think removing those academic barriers wherever possible is good. (Fellowship program staff)

The challenge for preceptors and their agencies is that they now have fellows who have successfully completed a Fellowship program to better prepare them for leadership, yet fellows are still systematically excluded from leadership positions within the agency via educational requirements. Fellows also described the role of racism, homonegativity, or microaggressions as barriers to leadership in their organizations, yet none of the preceptors were aware of or acknowledged these experiences. These microaggressions and workforce decisions may not have been discussed, as microaggressions are often implicit and unintentional and thus, often go unaddressed. Furthermore, while there was racial, gender, and sexual identity diversity among preceptors, none of the preceptors identified as MSM of color and thus, may not have been able to identify or label these microaggressions. Fellowship program staff, however, acknowledged how organizational and structural barriers remained significant challenges to the fellows.

Sometimes within their own organizations the racism is so pronounced that they’re not seen fully, they’re not trusted, their abilities are not ultimately respected. . . . Not only were they dealing with potential experiences of racism within their organizations, but they’re also dealing with homophobia—or internalized homophobia—and they’re at an intersection point as gay men of color. And how do you manage all of that stuff happening and figure out your role and place when not everyone in leadership in your organization understands what that means? (Fellowship program staff)

This staff member raised an important point about intersectionality and the multiple layers of stigma fellows were often subject to because of their identities. While leadership within fellows’ organizations was likely well-intended, without sharing those intersectional experiences, leaders were unable to fully understand fellows’ experiences.

Discussion

The results of this formative pilot evaluation of a small leadership development initiative demonstrate a clear need for leadership programs and opportunities for persons of color, particularly persons of color who also identify as lesbian, gay, bisexual, or transgender. Although HIV and LGBT community organizations have successfully supported diversity among frontline staff, greater diversity among decisionmakers and leaders may be a critical step toward improving HIV prevention services and reducing HIV disparities. Research on community empowerment suggests that health outcomes are improved when individuals are engaged in advancing the health of their own communities and working with their peers and partners in health promotion and services (Latkin, Weeks, Glasman, Galletly, & Albarracin, 2010). Similarly, the equity in service provision perspective suggests that a diverse public health workforce can help sustain the focus on community-identified priorities and raise the responsiveness of the health care system to diverse populations (García & Sharif, 2015; Giles et al., 2004; Marrast, Zallman, Woolhandler, Bor, & McCormick, 2014), which may help reduce disparities in HIV (Saha et al., 2013). Programs like the Fellowship can increase individuals’ leadership capacity, yet, as is true of the racial disparities in HIV, the lack of diversity among HIV service organization leadership is driven by myriad factors, not all of which can be addressed through mentoring and leadership programs. There remain systematic barriers to leadership for people of color including implicit bias, racism, homonegativity, and unequal access to formal education. Although the Fellowship was geared toward HIV service organizations, numerous components of the Fellowship are generalizable and scalable and the findings from the evaluation are applicable to other public health and social service fields where racial and ethnic disparities persist.

The intersecting stigmas of racism and homonegativity is a significant barrier to leadership advancement among sexual minority people of color and was evident among our sample. Individuals with multiple stigmatized identities are subject to discrimination, alienation, and marginalization, which reflects community and social norms and uphold inequality and systems of power (Logie, James, Tharao, & Loutfy, 2011). For the fellows, this was often evident in microaggressions, tokenism, and organizational norms that made promotion difficult, if not impossible. For example, fellows reported a glass ceiling effect, recognizing that there were few, if any, gay men of color in leadership positions in their organizations, a known barrier to promotion opportunities (Thomas-Breitfield & Kunreuther, 2017b). Furthermore, the fellows were also members of the “target population” the organizations were working with, and fellows described feeling tokenized and expected to speak on behalf of their demographics.

Although the Fellowship program gave fellows important leadership skills and tools, our findings highlight the need for additional work at the organizational level. Efforts to increase educational opportunities and enhance leadership skills at the individual-level are an important aspect of the equation, but additional work should be done to enhance organizational capacity to train and support minority staff members and provide them with opportunities for advancement and leadership, even in the absence of a formal degree. Nonprofit boards of directors and executives are predominantly White and need training in identifying and supporting potential leaders of color (Thomas-Breitfield & Kunreuther, 2017a). Implicit bias can underlie nebulous promotion criteria such as “fit” and “readiness,” which may lead to biased hiring and promotion decisions. One way to support change is to create more effective mentors, as a lack of qualified minority mentors can limit individuals’ ideas about their opportunities for advancement. Many of the preceptors in this program acknowledged disparities between frontline staff and leadership and expressed desire to help fellows and other frontline staff with professional development. Yet, they also acknowledged they lacked the necessary skills and resources to address the unique needs of racial and ethnic minority MSM. For example, one preceptor explicitly noted a need for training on microaggressions and how to help their mentees deal with racism and homonegativity they may experience in the community or within their organization. Mentoring programs for mentors and supervisors have demonstrated success at increasing confidence in mentoring competencies and topics related to diversity including unconscious bias, microaggressions, and discrimination (Gandhi & Johnson, 2016). Accordingly, future Fellowship programs should consider explicitly including efforts related to training in unconscious bias and microaggressions aimed at organizational leadership. Such efforts should address the unique challenges faced by sexual minority individuals of color.

There are limitations to our evaluation. This is an evaluation of a small pilot project and a more rigorous summative evaluation is needed to understand the long-term effects of such a program. This is also a small sample (n = 6) of fellows. Thus, we cannot draw conclusions about the outcomes of the program, although it does show promise. Additionally, to protect the confidentiality of the men and the organizations that participated, we were only able to include information that was not identifiable. Thus, detail about the two men who received promotions, challenges within specific agencies, or unique individual experiences could not be shared. It should also be noted that the lead evaluator and first author of this article is a White, heterosexual, cisgender woman. Although this did not seem to deter fellows from talking about race or their dissatisfaction with the race and sexuality of program leadership, it is possible that responses were framed differently based on the race or sexuality of the interviewer. Additionally, we recognize that merely having similar skin tones or sharing an ethnic heritage or sexual orientation does not mean that individuals have similar life experiences, values, cultural norms, or perspectives on health or leadership. However, given the ways in which race, ethnicity, and sexuality have been used to establish and uphold disparities in health, education, and opportunity, these are important socially constructed phenomena that can influence individuals’ perceptions of HIV and leadership opportunities. While fellows in the program shared certain characteristics, their experiences and perspectives are unique and cannot be generalized to all MSM of color.

Following the completion of the evaluation, the Wisconsin Health Leaders Fellowship staff began preparing for the second cohort of fellows. In response to the evaluation, the Fellowship expanded training opportunities for preceptors to help increase preceptors’ awareness of the stigma and microaggressions faced by fellows. Additionally, eligibility criteria expanded to include sexual minority men of color in any public health or social service agency in Milwaukee, recognizing that the leadership barriers faced by sexual minority men are not unique to those in the HIV field. Evaluation efforts will be ongoing and may help further identify opportunities for program improvement.

In sum, the Wisconsin Health Leaders Fellowship is an example of a successful leadership development program for sexual minority men of color working in HIV services. While the HIV field has generally recognized the importance of having frontline staff that reflect and can relate to program participants or clients, less progress has been made at increasing leadership diversity. Leadership development programs for people working in HIV services and public health are a critically important aspect of addressing HIV disparities. Although there have been several federally funded programs to increase diversity among HIV researchers and physicians, little has been done to address the lack of leadership diversity among nonprofits and AIDS service organizations, who often have the most frequent and important interactions with persons living with and at risk for HIV. Future initiatives should emphasize the role of institutional policies and norms in upholding disparities in leadership and place the onus on organizations and their leaders to create environments more conducive to leadership diversity.

Supplemental Material

HPP850563_suppl_mat – Supplemental material for “Don’t Deny Yourself a Seat at the Table”: Supporting the Leadership Development of MSM of Color in HIV Services

Supplemental material, HPP850563_suppl_mat for “Don’t Deny Yourself a Seat at the Table”: Supporting the Leadership Development of MSM of Color in HIV Services by Katherine G. Quinn, Hester Wolfe and James Vergeront in Health Promotion Practice

Footnotes

Authors’ Note:

We are grateful for the participation of the fellows and their employers for their participation in this work and their dedication to reducing racial disparities in HIV.

Supplemental Material

Supplemental material for this article is available online at .

References

Asthana

Oostvogels

(1996). Community participation in HIV prevention: Problems and prospects for community-based strategies among female sex workers in Madras. Social Science & Medicine, 43, 133-148. doi:10.1016/0277-9536(95)00348-7

Boeije

(2002). A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Quality and Quantity, 36, 391-409.

Centers for Disease Control and Prevention. (2016). Diagnoses of HIV infection in the United States and dependent areas, 2016. HIV Surveillance Report, 2016, 28. doi:10.1017/CBO9781107415324.004

Chillag

Bartholow

Cordeiro

Swanson

Patterson

Stebbins

. . . Sy

(2002). Factors affecting the delivery of HIV/AIDS preventino programs by community-based organizations. AIDS Education & Prevention, 14(3 Suppl. A), 27-37.

Corbin

Strauss

(2015). Basics of qualitative research: Techniques and procedures for developing grounded theory (4th ed.). Thousand Oaks, CA: Sage.

Cornelius

Moyers

Foundation

Bell

(2011). Daring to lead 2011: A national study of nonprofit executive leadership. Oakland, CA. Retrieved from http://daringtolead.org/wp-content/uploads/Daring-to-Lead-2011-Main-Report-online.pdf

Dean

H. D.

(2016). Achieving health equity through public health workforce diversity. Retrieved from https://www.cdc.gov/minorityhealth/internships/2016/AchievingHealthEquityThroughPublicHealthWorkforceDiversity.pdf

Dreachslin

J. L.

(2008). Racial and ethnic disparities: Why diversity leadership matters: EBSCOhost. Journal of Healthcare Management, 53(1), 1-13.

Fitzpatrick

L. K.

Sutton

Greenberg

A. E.

(2006). Toward eliminating health disparities in HIV/AIDS the importance of the minority investigator in addressing scientific gaps in Black and Latino communities. Journal of the National Medical Association, 98, 1906-1911.

10.

Gandhi

Johnson

(2016). Creating more effective mentors: Mentoring the mentor. AIDS and Behavior, 20, 294-303. doi:10.1007/s10461-016-1364-3

11.

García

J. J. L.

Sharif

M. Z.

(2015). Black lives matter: A commentary on racism and public health. American Journal of Public Health, 105, e27-e30. doi:10.2105/AJPH.2015.302706

12.

Giles

W. H.

Tucker

Brown

Crocker

Jack

Latimer

. . . Harris

V. B.

(2004). Racial and ethnic approaches to community health (REACH 2010): An overview. Ethnicity & Disease, 14(3 Suppl. 1), S5-S8. doi:10.1177/1524839906288671

13.

Latkin

Weeks

M. R.

Glasman

Galletly

Albarracin

(2010). A dynamic social systems model for considering structural factors in HIV prevention and detection. AIDS and Behavior, 14(Suppl. 2). doi:10.1007/s10461-010-9804-y

14.

Logie

C. H.

James

Tharao

Loutfy

M. R.

(2011). HIV, gender, race, sexual orientation, and sex work: A qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Medicine, 8, e1001124.

15.

Marrast

L. M.

Zallman

Woolhandler

Bor

D. H.

McCormick

(2014). Minority physicians’ role in the care of underserved patients: Diversifying the physicianworkforce may be key in addressing health disparities. JAMA Internal Medicine, 174, 289-291. doi:10.1001/jamainternmed.2013.12756

16.

Matthews

D. D.

Smith

J. C.

Brown

A. L.

Malebranche

D. J.

(2016). Reconciling epidemiology and social justice in the public health discourse around the sexual networks of black men who have sex with men. American Journal of Public Health, 174, 289-291. doi:10.1001/jamainternmed.2013.12756

17.

Quinn

K. G.

Kelly

J. A.

DiFranceisco

W. J.

Tarima

S. S.

Petroll

A. E.

Sanders

. . . Amirkhanian

Y. A.

(2016). The health and sociocultural correlates of AIDS genocidal beliefs and medical mistrust among African American MSM. AIDS and Behavior, 22, 1814-1825. doi:10.1007/s10461-016-1657-6

18.

Richter

D. L.

Dauner

K. N.

Lindley

L. L.

Reininger

B. M.

Oglesby

W. H.

Prince

M. S.

. . . Potts

L. H.

(2007). Evaluation results of the CDC/ASPH Institute for HIV Prevention Leadership: a capacity-building educational program for HIV prevention program managers. Journal of Public Health Management and Practice, Suppl., S64-S71.

19.

Richter

D. L.

Potts

L. H.

Prince

M. S.

Dauner

K. N.

Reininger

B. M.

Thompson-Robinson

. . . Jones

(2006). Development of a curriculum to enhance community-based organizations’ capacity for effective HIV prevention programming and management. AIDS Education and Prevention, 18, 362-374. doi:10.1521/aeap.2006.18.4.362

20.

Rossi

P. H.

Lipsey

M. W.

Freeman

H. E.

(2004). Evaluation: A systematic approach (7th ed.). Thousand Oaks, CA: Sage.

21.

Ruiz

Batchelor

Coleman

Greabell

Jenkins

Shaull

(2011, October). A leadership development program for junior-level minority health department staff. Paper presented at American Public Health Association Annual Meeting, Washington, DC.

22.

Saha

Korthuis

P. T.

Cohn

J. A.

Sharp

V. L.

Moore

R. D.

Beach

M. C.

(2013). Primary care provider cultural competence and racial disparities in HIV care and outcomes. Journal of General Internal Medicine, 28, 622-629. doi:10.1007/s11606-012-2298-8

23.

Saldana

(2016). The coding manual for qualitative researchers. Thousand Oaks, CA: Sage.

24.

Sopher

C. J.

Adamson

B. J. S.

Andrasik

M. P.

Flood

D. M.

Wakefield

S. F.

Stoff

D. M.

. . . Fuchs

J. D.

(2015). Enhancing diversity in the public health research workforce: The Research and Mentorship Program for future HIV vaccine scientists. American Journal of Public Health, 105, 823-830. doi:10.2105/AJPH.2014.302076

25.

Sutton

M. Y.

Lanier

Y. A.

Willis

L. A.

Castellanos

Dominguez

Fitzpatrick

Miller

K. S.

(2013). Strengthening the network of mentored, underrepresented minority scientists and leaders to reduce HIV-related health disparities. American Journal of Public Health, 103, 2207-2214. doi:10.2105/AJPH.2013.301345

26.

Szekeres

Coates

T. J.

Ehrhardt

A. A.

(2008). Leadership development and HIV/AIDS. AIDS (London, England), 22(Suppl. 2), S19-S26. doi:10.1097/01.aids.0000327433.90419.61

27.

Thomas-Breitfield

Kunreuther

(2017a). Race to lead: Confronting the nonprofit racial leadership gap. Retrieved from https://www.buildingmovement.org/pdf/RacetoLead_NonprofitRacialLeadershipGap.pdf

28.

Thomas-Breitfield

Kunreuther

(2017b). Working at the intersections: LGBTQ Nonprofit staff and the racial leadership gap. Retrieved from https://www.buildingmovement.org/pdf/Working_at_the_Intersections.LGBTQ_Nonprofit_Staff.pdf

29.

U.S. Department of Health and Human Services. (2006). The rationale for diversity in the health professions: A review of the evidence. Washington, DC: Author.

30.

Wisconsin Department of Health. (2017). Wisconsin HIV surveillance annual review addendum: City of Milwaukee. New diagnoses, prevalent cases, syphilis diagnoses, and HIV testing through December 31, 2017. Retrieved from https://www.dhs.wisconsin.gov/publications/p0/p00484a.pdf

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.59 MB