Description
Core Elements, Key Characteristics, and Procedures
Adapting
Resource Requirements
Recruitment
Policies and Standards
Quality Assurance
Monitoring and Evaluation
Key Articles and Resources
References

Nia¹ is a group-level, video-based intervention for African American men who are 18 years and older. The intervention delivers at least 6 hours of content in 2 sessions, although it can also be conducted in 3 or 4 sessions. The goal of the Nia intervention is to reduce sexual risk behavior among African American men who have sex with women. The sessions create a context through which men can do the following:

• Learn new information and affirm existing correct knowledge about HIV/AIDS.
• Examine their sexual risks.
• Build motivation and skills to reduce their risks.
• Receive feedback from others.

Nia has been packaged by CDC’s Replicating Effective Programs project. An intervention package, training, and technical assistance are available from CDC. The intervention package will be provided only to participants of the 24-hour Nia training conducted by CDC’s training partners, the STD/HIV Prevention Training Centers. Planning and implementation information (including the starter kit and technical assistance guide) can be found at The Diffusion of Effective Behavioral Interventions (DEBI).

Goals
Nia sessions are interactive meetings that have both an educational and an entertaining aspect. In addition, Nia uses factors, such as male pride, racial and sexual identity, receiving and giving respect, and maintaining sexual pleasure while reducing risk to reinforce procedures for risk reduction. A male facilitator helps create an environment where the men are comfortable learning, while a female facilitator is present to assist with making and communicating safer-sex decisions and to help challenge and change negative attitudes toward women. Nia groups can be held in a variety of settings, as long as they are conducted in a private room where the men will feel comfortable enough to participate. Nia sessions are not classes, lectures, or forums.

How It Works
Nia is based on 2 theoretical models, the information-motivation-behavioral skills (IMB) model and elements of strategies from motivational enhancement.

Theory behind the Intervention
The Nia intervention design comes from the information-motivation-behavioral skills (IMB) model,² with enhanced motivational components that use techniques described by Miller et al,³ as adapted for HIV prevention.⁴ The IMB model states that information about the modes of HIV transmission and methods of preventing transmission is a necessary precursor to risk-reduction behavior. Motivation to change also directly affects whether one acts or intends to act on the basis of information about risk and risk reduction. Finally, the model states that behavioral skills related to preventive actions are needed for information and motivation to make a change in HIV preventive behaviors.

The IMB model assumes that information, motivation, and behavioral skills ultimately create risk-reduction behaviors. The IMB model is, therefore, constructed from elements found in other theories, such as Social Cognitive Theory but configured specifically for HIV risk reduction.

In addition to the IMB model, Nia also uses elements of strategies from motivational enhancement. These strategies encourage favorable group processes by actively involving participants in the behavior change process and in developing risk-reduction strategies that are suited to their own circumstances. Nia includes the following examples of these strategies:

• Fostering a collaborative atmosphere by giving all participants an opportunity to voice their opinions.
• Affirming strengths and self-efficacy as they are identified during group discussion.
• Giving feedback on the basis of the results of a baseline knowledge, attitudes, and risk assessment, which helps the participant identify reasons for change and self-motivating statements.

The IMB model is incorporated in Nia’s curriculum, goals, objectives, activities, and exercises. Strategies for the informational element include educational materials; interactive exercises, such as games and flash cards; and videos. The motivational element is represented in Nia by a video that raises awareness of HIV as a problem in the participants’ community and activities that allow participants to reflect on their own behavior and how that behavior may be placing them at risk for HIV. Behavioral skills in Nia are built by modeling demonstrations of successful behaviors by men like the participants, practicing skills in a supportive group setting, and reinforcing behaviors through supportive responses and suggestions.

Research Findings
Results from the randomized, controlled study showed significant reductions in risk behaviors among men who participated in the Nia intervention compared with men in the control group. At the 3-month follow-up, men in the intervention groups were significantly more likely to report using condoms almost every time they had sex, carrying condoms, and talking with their sex partner about HIV; they also reported significantly lowered rates of unprotected vaginal intercourse. At the 6-month follow-up, these differences were no longer significant, but the men in the intervention group planned ahead of time to have sex and talked with their sex partner about condoms at a significantly greater rate than did the men in the control group. The intervention group participants were also significantly less likely to have used drugs in conjunction with sex and less likely to have used alcohol before sex or other drugs before sex at the 6-month follow-up.

Groups consisted of 6 to 10 men who have sex with women. These small groups were similar in style to support groups. Participants sat in a circle and shared common experiences. The group met for a total of 6 hours, divided into 2 sessions. There were 2 African American facilitators, 1 of whom was a woman. They used 4 videos and 7 movie clips to lead participants through the Nia content.

Of the participants, 94% had been tested for HIV; 50% tested negative, 15% tested positive, and 35% did not know their results. Many reported risk for infection with HIV and other sexually transmitted diseases (STDs):

• 82% had been treated for an STD.
• 81% had been in prison or jail.
• 71% exchanged sex for money or drugs.
• 23% had history of mental health treatment.
• 16% had both male and female partners in past 6 months.

Fifteen percent of the men reported use of injection drugs during their lifetime. While only 3% of the participants had injected drugs in the previous 3 months, 25% had a sex partner who injected drugs. Other substance use was also reported among participants in that time period:

• Alcohol: 85%.
• Marijuana: 68%.
• Crack cocaine: 39%.

Core Elements
Core elements are those parts of an intervention that must be done and cannot be changed. They come from the behavioral theory on which the intervention or strategy is based; they are thought to be responsible for the intervention’s effectiveness. Core elements are essential and cannot be ignored, added to, or changed.

Several core elements include the showing of videos and movie clips. The intervention package provides educational videos, but other videos can be used if they are more appropriate for the target population and meet the requirements. Nia has the following 5 core elements:

• Conducting small-group sessions with men who have sex with women that are led by culturally competent male and female co-facilitators who use videos and movie clips appropriate for men to present HIV information, motivate risk reduction, and build skills for handling common risk situations. Facilitators must also challenge negative attitudes.
• Correcting misperceptions and misinformation regarding HIV by using gender- and culture-appropriate videos and interactive exercises, especially the following:
• Personal feedback report on HIV knowledge.
• HIV educational videos.
• “Myths and Facts” activity.
• “HIV Risk Continuum” activity.
• Inducing and enhancing motivation to reduce risks for HIV by having men identify themselves and their behavior with the HIV epidemic through the following:
• Personal feedback reports on sex behaviors and condom attitudes.
• Videos featuring men who have been affected by HIV and with whom participants can identify.
• “HIV Risk Continuum” activity.
• Exploring personal risky sexual situations.
• Building skills for identifying and managing sexual risk situations by doing the following:
• Exploring personal risky sexual situations.
• Building skills to identify triggers and make safer-sex decisions.
• Using movie clips to help participants practice identifying triggers and making safer-sex decisions.
• Enhancing motivation and building behavioral skills for condom use or safer sex by doing the following:
• Exploring attitudes toward and pros/cons for condom use.
• Identifying safer-sex alternatives.
• Building behavioral skills for correctly using condoms and communicating sexual decisions regarding condom use.
• Guiding practice of condom use and safer-sex decisions by using movie clips.

Key Characteristics
Key characteristics are those parts of an intervention (activities and delivery methods) that can be adapted to meet the needs of the CBO or target population. The Nia intervention package materials do not specify key characteristics.

Procedures
Procedures are detailed descriptions of some of the elements and characteristics listed above. Procedures for Nia are as follows:

Keeping clients engaged
Keeping clients engaged in Nia group sessions can be difficult. However, it is one of the best ways to ensure participants complete the intervention. Part of the purpose of the Nia videos and movie clips is to engage participants in the intervention.

The real key to keeping your group interested rests with the facilitators. Facilitators must work hard to make the content exciting, relevant, and engaging to the group. Facilitators have much of the responsibility for ensuring the following for all participants:

• A chance to contribute to the group discussion.
• A chance to participate in the group activities.
• A chance to have their thoughts heard.
• A feeling of being welcome, safe, and supported.

Facilitating videos and movie clips
A variety of types of videos and movie clips are shown during Nia. Each of these has a specific purpose. The videos and clips from the original research study primarily feature African Americans:

• Videos 1, 2, and 3 are used in session 1; video 4 is used in session 2. Most of the second half of session 2 is about applying skills to scenes from 6 clips taken from popular movies.
• Video 1 is shown to make sure everyone has the same correct HIV information, which addresses core element 2: correcting misperceptions and misinformation regarding HIV by viewing and discussing an educational video.
• Video 2 addresses core element 3: increase and enhance the participants’ motivation to reduce risks for HIV. It features men who have been affected by HIV and with whom the participants can identify. The post-video discussion focuses on community responsibility and the protective role the men can play to lessen the impact that HIV/AIDS has on their community.
• Video 3 is a combination of education and entertainment. It is used to reinforce the safer-sex messages, while ending the session on an upbeat, fun note. This is intended to increase the likelihood that participants will return for the next session.
• Video 4, a condom-demonstration video, is shown to help participants continue the process of learning condom use and safer-sex skills. Video 4 addresses core element 5: enhancing motivation and building behavioral skills for condom use or safer sex. It does this by helping the men explore their attitudes toward condom use, identify safer-sex alternatives, and show them how to correctly use condoms. It presents condom information in an informal context and shows an African American couple handling various condoms and discussing condom use.
• The 6 movie clips are used to address core elements 1, 4, and 5. They feature men with whom the participants can identify in a sexually risky situation. Facilitators should look for places in the discussion of the movie clips to challenge negative attitudes toward women and develop empathy for women’s disempowerment and potential risks. The post-clip discussion addresses core element 4 by helping participants identify and manage sexual risk situations.

Creating a learning environment consistent with male culture
It is important to create a group environment for Nia groups that will promote learning by the participants. As stated in the core elements, the first step in doing this is to include culturally competent co-facilitators, both a man and a woman. While both facilitators need to be respectful of and work well with the group members, the male facilitator provides a positive role model and can help make the men more comfortable in the group setting.

Challenging negative attitudes toward women
In the Nia intervention, both facilitators work to reduce the participants’ sexist beliefs, since these can fuel violent and risk-related behavior. The female facilitator needs to be able to stand up for herself without being overbearing; group members should feel safe to speak openly.

Evaluating and debriefing the sessions
Each of the facilitators should complete a copy of the appropriate session evaluation form and session consistency outline as soon as possible after each session is completed. Conducting Nia groups can raise issues, both personal and professional, for the facilitators. The facilitators should meet to debrief as soon after each session as possible and definitely before the next meeting time. At least some of these debriefings should also include the program manager and, possibly, other staff who work on the project.

Use required forms
Staff will conduct an initial intake session with participants. The purpose of this session, which may be combined with an enrollment or screening meeting, is to complete the pre-intervention assessment survey. The personal feedback report (PFR) forms support core element 2, correcting misperceptions and misinformation regarding HIV, and core element 3, inducing and enhancing motivation to reduce risks for HIV. PFR-1 gives the participants a chance to compare their answers to accurate HIV information. PFR-2 makes participants aware of sexual behaviors that might put them at risk for infection, and PFR-3 addresses their attitude toward condom use. The forms can motivate participants to change their risky behaviors in 2 ways: 1) help participants compare what they do to what they want to do and 2) reinforce existing safer behaviors that participants want to maintain.

While Nia was developed for and tested with African American men who have sex with women, some agencies may choose to implement it in a different target population. Nia may be adapted in a number of areas of intervention delivery, such as the length of sessions and the frequency with which they are held.

People
Nia needs the following:

• 1 half-time, paid, experienced program manager for start-up; during the implementation, the manager could function at 25% time.
• 1 part-time, paid administrative assistant at 20% for start-up; during the implementation, the administrative assistant could function at 10% time.
• 2 full-time facilitators (preferably 1 man and 1 woman to challenge any negative stereotypes some men may have about women) during start-up for screening, recruitment, and other preparatory activities; during the implementation, the 2 facilitators could function at 25% time.

The facilitators should have experience in small-group behavioral interventions, which is different from 12-step or other self-help counseling group meetings. In addition, the facilitators should have experience working with African American men.

Each facilitator should attend the 24-hour Nia training conducted by CDC’s training partners, the STD/HIV Prevention Training Centers. Program coordinators/managers, who oversee the intervention and supervise the group facilitators, are also encouraged to attend the 24-hour Nia training. Program coordinators/managers and those interested in learning more about the intervention are encouraged to read the Nia starter kit found at The Diffusion of Effective Behavioral Interventions (DEBI).

Space
Nia needs space that meets the following requirements:

• Along major transit routes, so that participants without private transportation can easily access the location.
• Large enough for the audiovisual equipment and easel to be placed near the facilitator.
• Large enough to comfortably accommodate a group of 8 to 12 men.
• Accessible at a variety of times for flexible scheduling.
• Child care provided on the premises.
• Private and secure, so that confidentiality of clients can be ensured.
• Quiet and without interruptions (such as people entering and exiting the room or outside noise).

Supplies
The Nia package comes with generic marketing tools, such as printed promotional literature. Nia will also require the following:

• A DVD player and television or video monitor, with a remote control (or laptop computer capable of playing DVDs).
• An easel, easel chart paper, markers, pencils.
• Penile and vaginal anatomic models for condom demonstration.
• Male and female condoms and packets of lubricants.
• Take-home packets of male and female condoms and lubricants.
• Snacks and small incentives (optional).

Agencies should concentrate their recruitment efforts in areas with high concentrations of African American men. Conducting a community assessment with the target population can provide feedback about the best places, times, and methods for recruiting men to the sessions. If applicable, it can also cover incentives, both monetary and non-monetary, that will be most effective. This information will help agencies develop a recruitment plan that details where and how participants will be recruited, recruitment/marketing tools, and number of participants to be recruited.

After the first few cycles of Nia, word of mouth from past participants can be an effective marketing method. The community advisory board is also a valuable marketing resource. Members can advise on where to place the marketing materials and how to identify other ways to engage the community.

Agencies may choose to interview potential participants as part of the recruitment process. Some barriers to participation might be addressed during the interview. By meeting a few basic client needs, agencies can make it possible for someone to participate fully in Nia, but removing barriers to attendance is not the same as providing financial incentives to motivate attendance. For instance, providing child care could make it possible for a single father to attend Nia. Child care or other types of services may help keep participants involved in the group sessions.

A generic marketing tool can be adapted for recruiting the target population, with the assistance of the community advisory board as well as additional information on adapting marketing materials available in the facilitator’s guide.

Before a CBO attempts to implement Nia, the following policies and standards should be in place to protect clients, the CBO, and the Nia intervention team.

Confidentiality
A system must be in place to ensure that confidentiality is maintained for all participants in the program. Before sharing any information with another agency to which a client is referred, signed informed consent from the client must be obtained.

Cultural Competence
CBOs must strive to offer culturally competent services by being aware of the demographic, cultural, and epidemiologic profile of their communities. CBOs should hire, promote, and train all staff to be representative of and sensitive to different cultures. In addition, they should offer materials and services in the preferred language of clients, if possible, or make translation available, if appropriate. CBOs should facilitate community and client involvement in designing and implementing prevention services to ensure that cultural issues are incorporated. The Office of Minority Health of the Department of Health and Human Services has published the National Standards for Culturally and Linguistically Appropriate Services in Health Care, which should be used as a guide for ensuring cultural competence in programs and services. (Please see Ensuring Cultural Competence in the Introduction of this document for standards for developing culturally and linguistically competent programs and services.)

Data Security
To ensure data security and client confidentiality, data must be collected and reported according to CDC requirements.

Informed Consent
CBOs must have a consent form that carefully and clearly explains (in appropriate language) the CBO’s responsibility and the clients’ rights. Individual state laws apply to consent procedures for minors; at a minimum, consent should be obtained from each client. Participation must always be voluntary, and documentation of this informed consent must be maintained in the client’s record.

Legal and Ethical Policies
By virtue of participation in Nia, clients living with HIV/AIDS may learn of or disclose their HIV status. CBOs must know their state laws regarding disclosure of HIV status to sex partners and needle-sharing partners; CBOs are obligated to inform clients of the organization’s responsibilities if a client receives a positive HIV test result and the organization’s potential duty to warn. CBOs also must inform clients about state laws regarding the reporting of domestic violence, child abuse, sexual abuse of minors, and elder abuse.

Referrals
CBOs must be prepared to refer clients as needed. For clients who need additional assistance in decreasing risk behavior, providers must know about referral sources for prevention interventions and counseling, such as comprehensive risk counseling and services, partner counseling and referral services, and other health department and CBO prevention programs. For potential clients who are experiencing severe violence in their relationship, providers must be prepared to refer them to intimate partner violence help.

Volunteers
If the CBO uses volunteers to assist with or conduct this intervention, then the CBO should know and disclose how their liability insurance and worker’s compensation applies to volunteers. CBOs must ensure that volunteers also receive the same training and are held to the same performance standards as employees. All training should be documented. CBOs must also ensure that volunteers sign and adhere to a confidentiality statement.

The following quality assurance activities should be in place when implementing Nia.

Facilitators
Training
Both Facilitators should complete a training workshop, including review of the intervention theories and materials and participate in practice sessions with one another in advance of conducting a session. Doing so will allow them to deliver the session content with ease and properly describe and facilitate the movie clips in each session

Session review
CBOs should have in place a mechanism to ensure that all session protocols are followed as written. Quality assurance activities can include observation and review of sessions by key staff and supervisors involved with the activity. This review should focus on adherence to session content, use of correct videos and adequate facilitation of discussions, accessibility and responsiveness to expressed client needs, and process elements (e.g., time allocation, clarity).

Record review
Selected intervention record reviews should focus on assuring that consent forms (signed either by the client, if older than 18 or emancipated, or by a legal guardian) are included for all participants and that session notes are of sufficient detail to document that clients are participating actively.

Clients
Clients’ satisfaction with the intervention and their comfort should be assessed at each session.

Specific guidance on the collection and reporting of program information, client-level data, and the program performance indicators will be distributed to agencies after notification of award.

General monitoring and evaluation reporting requirements for the programs listed in the procedural guidance will include the collection of standardized process and outcome measures.  Specific data reporting requirements will be provided to agencies after notification of award. For their convenience, grantees may utilize PEMS software for data management and reporting.  PEMS is a national data reporting system that includes a standardized set of HIV prevention data variables, web-based software for data entry and management. CDC will also provide data collection and evaluation guidance and training and PEMS implementation support services.

Funded agencies will be required to enter, manage, and submit data to CDC by using PEMS or other software that transmits data to CDC according to data requirements.  Furthermore, agencies may be requested to collaborate with CDC in the implementation of special studies designed to assess the effect of HIV prevention activities on at-risk populations.

CDC. Draft CDC technical assistance guidelines for CBO HIV prevention program performance indicators. Atlanta, GA: US Department of Health and Human Services; 2003.

Office of Minority Health. National standards for culturally and linguistically appropriate services in health care. Washington, DC: US Department of Health and Human Services; 2001.

An intervention package, training, and technical assistance on the Nia intervention are available from CDC.

1. Kalichman SC, Cherry C, Browne-Sperling F. Effectiveness of a video-based motivational skills-building HIV risk-reduction intervention for inner-city African American men. Journal of Consulting and Clinical Psychology. 1999;67(6):959–966.
2. Fisher JD, Fisher WA. Changing AIDS-risk behavior. Psychological Bulletin. 1992;111:455–474.
3. Miller WR, Zweben A, DiClemente C, Rychtarik R. Motivational enhancement therapy manual (DHHS Publication No. ADM 92-1894). Washington, DC: US Government Printing Office; 1992.
4. Carey MP, Maisto SA, Kalichman SC, Forsyth A, Wright L, Johnson BT. Enhancing motivation to reduce risk for HIV infection for economically disadvantaged urban women. Journal of Consulting and Clinical Psychology. 1997;65:531-541.

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