d-up: Defend Yourself! A Community-level Intervention for Black MSM

The Research

The Science Behind the Package

d-up: Defend Yourself! is a cultural adaptation of the Popular Opinion Leader (POL) intervention. d-up! is designed to promote condom use and self-worth social norms and perceptions among black men who have sex with men (MSM). The intervention uses opinion leaders to reduce risky sexual norms and behaviors in their own social networks. The program is based on two theories. The first is the diffusion of innovation/social influence principles, which states that trends and innovations are often initiated by a relatively small segment of opinion leaders in a population. Once innovations are visibly modeled and accepted, they then diffuse throughout a population, influencing others. The second theory is preparation for bias (also called race-related socialization). This theory refers to strategies used to promote positive identification with one’s own racial or ethnic group to prepare persons to succeed in the face of racial bias.

Target Population
Black MSM who are in social networks with other black MSM

Intervention
Intervention staff select a social network that regularly meets in an accessible venue. Staff identify and recruit people in that network whose advice is respected and trusted by their peers. These opinion leaders are trained to have conversations with their friends and acquaintances that promote the benefits of consistent condom use and increase feelings of positive self-worth. These friends and acquaintances are an opinion leader’s friendship group within the larger social network. Opinion leaders also identify new opinion leaders within their friendship groups.

Over time, more opinion leaders have more conversations with more people in their friendship group. Once >15% of the members in each friendship group actively endorses condom use and self-worth, safer sex practices will become accepted as the norm within the social network.

Research Results
The following changes in risk behaviors were observed among targeted social networks of black MSM during a one year study in three North Carolina cities implementing the d-up! intervention:

• Percentage of black MSM reporting unprotected insertive anal sex decreased 35.2%.
• Percentage of black MSM reporting unprotected receptive anal sex decreased 44.1%.
• Percentage of black MSM reporting always using condoms for insertive anal sex increased 23.0%.
• Percentage of black MSM reporting always using condoms for receptive anal sex increased 30.3%.
• The average number of partners for unprotected receptive anal sex decreased by 40.5%.

For Details on the Research Findings
Jones KT, Gray P, Whiteside YO, Wang T, Bost D, Dunbar E, Foust E, and Johnson W.D. (2008). Evaluation of an HIV prevention intervention adapted for Black men who have sex with men. American Journal of Public Health 98(6):1043–1050.

The Intervention

A Package Developed from Science
Replicating Effective Programs (REP) is a CDC-initiated project that supports the translation of evidence-based HIV/AIDS prevention interventions into everyday practice, by working with the original researchers in developing a user-friendly package of materials designed for prevention providers. d-up! is one of the REP interventions. The d-up! intervention package is the product of extensive collaboration between the original researchers who developed and evaluated the intervention and the AIDS service organizations who implemented it. The package has been field tested by community-based organizations using their own facilitators.

Core Elements
Core elements are intervention components that must be maintained without alteration to ensure program effectiveness.

The core elements of d-up! include:

1. Direct d-up! to an identified at-risk target population in well-defined community venues where the sizes of the population’s social networks and number of friendship groups can be estimated
2. Use key informants and systematic observation to identify the selected social network’s friendship groups and to identify the most respected, credible, trustworthy, listened to, empathetic to friends, and self-confident persons in each friendship group.
3. Over the life of the program, recruit and train as opinion leaders 15% of the persons from each friendship group in the social network that is found in the intervention venue.
4. Raise opinion leaders’ awareness of how negative social and cultural factors impact black MSM’s sexual risk behavior in order to promote a norm of positive self-worth in their social networks and to address these biases in their conversations, as needed.
5. Teach opinion leaders skills for putting risk reduction endorsement messages into everyday conversations with friends and acquaintances.
6. Teach opinion leaders the elements of effective behavior change messages that target attitudes, norms, intentions, and self-efficacy related to risk. Train opinion leaders to personally endorse the benefits of safer sex in their conversations and to offer practical steps to achieve change.
7. Hold weekly sessions for small groups of opinion leaders to help them improve their skills and gain confidence in giving effective HIV prevention messages to others. Instruct, model, role-play, and provide feedback during these sessions. Make sure that all opinion leaders have a chance to practice and shape their communication skills and get comfortable putting messages into conversations.
8. Have opinion leaders set goals to hold risk reduction conversations with at-risk friends and acquaintances in their own social network between weekly sessions.
9. Review, discuss, and reinforce the outcomes of the opinion leaders’ conversations at later training sessions.
10. Use logos, symbols, or other items as “conversation starters” between opinion leaders and others.

Package Contents

• Implementation manual that guides agencies through planning, implementation, maintenance, and program evaluation
• Facilitators guide that directs agencies how to conduct the opinion leader training
• Opinion leader handbooks and other training materials

Timeline for Availability
The package is available from CDC along with training on program implementation and technical assistance.

For More Information on the d-up! Intervention Package
To find out more about future trainings, please visit Effective Interventions.