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

Description

SISTA (Sisters Informing Sisters about Topics on AIDS) is a peer-led, skill-building intervention project to prevent HIV infection in African American women. It is delivered in 5 sessions and includes discussions of self-esteem, relationships, and sexual health.

SISTA has been packaged by CDC's Diffusion of Effective Behavioral Interventions project. Information on obtaining the intervention training and materials is available at The Diffusion of Effective Behavioral Interventions (DEBI).

Goal

The goal of SISTA is to reduce sexual risk behavior by heterosexually-active African American women at highest risk for HIV.^1–3

How It Works

SISTA gives women the social and behavioral skills they need to adopt HIV risk-reduction strategies. It is composed of 5 sessions, 2 hours each, delivered by peer facilitators in a community setting. Each session is gender and culturally relevant and includes behavioral skills practice, group discussions, lectures, role-playing, a prevention video, and take-home exercises.

Theories behind the Intervention

SISTA applies 2 theories: the social cognitive theory and the theory of gender and power.

The social cognitive theory says that people need information, training in social and behavioral skills, and knowledge of norms before they will apply risk-reduction strategies. A change in behavior is dependent upon self-efficacy, self-confidence, and outcome expectations.

The theory of gender and power is a social structural theory that accounts for gender-based power differences in male-female relationships. It examines the division of labor between men and women, the distribution of power and authority within male-female relationships, and gender-based definitions of sexually appropriate conduct. In addition, the theory considers a woman's willingness to adopt and maintain sexual risk-reduction strategies within heterosexual relationships as it pertains to how much power she has, her commitment to the relationship, and her role in the relationship.

Research Findings

The original research was conducted with 128 heterosexually active African American women. W omen in the experimental group reported more condom use than did women in the control group, 1 indicating that a social skills training delivered in a community setting can increase condom use.

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Core Elements, Key Characteristics, and Procedures

Core Elements

Core elements are those parts of an intervention that must be done and cannot be changed. They come from the behavioral theory upon 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.

SISTA has the following 7 core elements:

• Conduct small-group sessions to discuss the session objectives, address the challenges and joys of being an African American woman, model skills development, and role-play women's skills acquisition. Discussions, role-playing, lectures, and skills development are included in each of the 5 sessions. SISTA was originally designed for African American women. If the target population changes, the intervention would, in essence, be reinvented. This new intervention would be based upon the theoretical framework of the original SISTA intervention. If the intervention is used with other populations, CBOs should take into account the cultural issues of the new population and keep records of any newly developed materials.
• Use a skilled facilitator to lead the group sessions because the success of SISTA depends on the skill of the facilitator. A skilled facilitator is someone who knows the target population and creates an environment conducive to learning. Specifically, the ambience is one in which clients feel valued and at ease in sharing their thoughts, beliefs, and experiences. In addition, a skilled facilitator is a listener and an observer. She prevents or manages conflict and guides group members in making quality decisions and reaching their session goals. If the CBO has the capacity, 2 cofacilitators are recommended.
• Use culture- and gender-appropriate materials to acknowledge pride and enhance self-worth with regard to being an African American woman (e.g., use poetry, artwork by African American women). The SISTA intervention includes poetry by African American women as well as discussions and role-playing scenarios that are relevant to the African American experience. It is important to use these tools and activities in order to enhance clients' experiences and encourage group discussion. Some clients may want to develop their own poems and role-playing scenarios, which can also enhance their experiences and growth. If a CBO uses SISTA with a population other than African American women, staff members need to identify and pretest culturally appropriate materials.
• Teach women sexual assertion skills so they can show that they care for their partners and negotiate safer behaviors. One session addresses developing safer-sex decision-making skills. Specifically, the session focuses on encouraging women to be assertive in sexual decision making so that if they decide to engage in sexual intercourse, they will protect themselves and their partner (e.g., by using a condom). Clients will also be encouraged to assert abstinence to their partners, particularly if their partner does not want to use condoms. If a CBO uses this intervention with a population other than heterosexually active African American women, its staff members need to understand the cultural and power dynamics of interpersonal relationships between men and women in their target population because these dynamics may differ across cultures and populations.
• Teach women proper condom-use skills, including positive attitudes and norms toward consistent condom use and knowledge of how to place condoms on a partner.
• Discuss the cultural and gender triggers that may make it challenging to negotiate safer sex. It is important that facilitators understand the cultural and gender nuances of their target population before the first session. This understanding will better equip them to lead discussions on the dynamics of male-female relationships as they relate to one's culture.
• Emphasize the importance of the partner's involvement in safer sex. The homework activities are designed to involve the male partner.

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.

SISTA has the following key characteristics:

• Adapt the flexible intervention to different populations of African American women (e.g., women in substance abuse treatment facilities, incarcerated women, women residing in shelters, and sex workers).
• Be passionate. Deliver the intervention with conviction and purpose. The facilitator should be able to connect with clients on intellectual and emotional levels. The facilitator should be a peer with whom the clients can identify in terms of gender, race, ethnicity, and age.
• Reflect cultural competency (SISTA was developed by African American women for African American women). The poetry and activities included in the intervention are relevant to African American women and the African American experience. The facilitator should be a peer who is familiar with the lifestyle of the target population. If a CBO is using the intervention with a target population of mixed race and ethnicity, whereby most clients are African American, it is important to use all of the materials within the intervention. If the race and ethnicity of the target population is other than African American, the CBO must adapt the activities included in the intervention. If all of the intervention activities are adapted, this would constitute a culturally appropriate reinvention.
• Discuss many topics in addition to HIV prevention (e.g., relationships, dating, and sexual health). Discussions may also include information on other sexually transmitted diseases.

Procedures

Procedures are detailed descriptions of some of the above-listed elements and characteristics.

The SISTA Project consists of 5 weekly sessions, 2 hours each. Each of the sessions has a specific goal and objectives. It is important to conduct all 5 sessions. Depending upon the clients, the sessions may last 2 hours or longer. At times, the sessions may be shorter. If possible, 1 session should be held per week for 5 weeks. This allows time for clients to discuss homework with their partner or family. However, it is acceptable to conduct more than 1 session per week (e.g., Session 1 on Monday, Session 2 on Wednesday).

Homework should be completed by all clients and their partners because it serves as a mechanism to begin discussions about safer sex. However, if there are challenges in completing the homework, or if the client does not have a partner, the client can talk with a friend, family member, or another client in the class. Clients are not graded on the homework.

Session 1: Ethnic/Gender Pride
Goal: Generate a discussion about being African American and female, having pride in oneself, and valuing oneself.

• Open by handing out and reading a poem. (P oems are included in the intervention kit. However, women may write a poem or bring their favorite poem to read.)
• Introduce
• the facilitators to the women
• the intervention to the women
• the women to each other
• Encourage the women to develop ground rules and expectations.
• Lead a discussion about the positive qualities of African American women and how these qualities can be used as a source of strength and pride and about values, asking the women to prioritize their personal values.
• Encourage the women to complete a simple homework exercise.
• Distribute anonymous evaluation forms to assess session 1.
• Close by handing out and reading a poem and reciting the SISTA motto with the women.

Session 2: HIV/AIDS Education

Goal: Provide factual and statistical information on HIV/AIDS and other sexually transmitted diseases, correct misconceptions about HIV/AIDS, and discuss the importance of protecting oneself.

• Open by handing out and reading a poem.
• Review ground rules and expectations.
• Review the key concepts of session 1 and discuss the homework exercise from session 1.
• Hand out information on HIV/AIDS and initiate discussions about the information.
• Engage the women in a card swap game to demonstrate how people get HIV and spread it to other people.
• Show and discuss a 30-minute video. The SISTA video is called ,“It's Like This” and is used to begin discussions about HIV prevention. CBOs may substitute a different video that also serves as a catalyst to discuss HIV, prevention, transmission, and relationships. The video selected should have actors that reflect the population served. In addition, the video should not endorse nonoxynol 9 when discussing condoms. CBOs should inform their project officer of the video they decide to use.
• Distribute homework assignments.
• Distribute anonymous evaluation forms to assess session 2.
• Recite the SISTA motto with the women.

Session 3:Assertiveness Skills Training

Goal: Teach women how to differentiate between assertive, aggressive, and nonassertive behaviors, and teach skills for initiating assertive qualities.

• Open by handing out and reading a poem.
• Review the key concepts of session 2 and discuss the homework exercise from session 2.
• Lead a discussion on the difference between assertion, non-assertion (passivity) and aggression.
• Hand out information about various realistic situations; ask the women to provide examples and consequences of assertive, aggressive, and nonassertive responses to the situations; discuss steps in the decision-making process.
• Distribute homework assignments.
• Distribute anonymous evaluation forms to assess session 3.
• Close by handing out and reading a poem and reciting the SISTA motto with the women.

Session 4:Behavioral Self-Management

Goal: D ecrease clients' anxiety about condom use, demonstrate and role-play how to use condoms, and discuss reasons that women do not insist on using condoms.

• Open by handing out and reading a poem.
• Review the key concepts of session 3 and discuss the homework exercise from session 3.
• Lead a discussion about why people do not use condoms, and develop a strategy for overcoming the stated obstacles.
• Distribute condom packets and lubricant.
• Engage the women in a condom-card line-up activity to assess their knowledge of putting a condom on their partner.
• Demonstrate how to put on a condom, using anatomical models.
• Role-play negotiation exercises.
• Distribute homework assignments.
• Distribute anonymous evaluation forms to assess session 4.
• Close by handing out and reading a poem and reciting the SISTA motto with the women.

Session 5: Coping Skills

Goal: Initiate discussion about coping with life experiences, including the link between alcohol and AIDS, coping with alcohol and sex, and coping with negative responses. This session also serves as a review of the previous sessions.

• Open by handing out and reading a poem.
• Review the key concepts of session 4 and discuss the homework exercise from session 4.
• Review the handouts from previous sessions.
• Discuss what coping is and its relationship to alcohol.
• Distribute a handout on coping situations.
• Inform the group of the booster sessions.
• Distribute anonymous evaluation forms to assess session 5.
• Close by handing out and reading a poem and reciting the SISTA motto with the women.

Booster Sessions

The booster (refresher) sessions are offered after the project is completed. Each session lasts 2 hours. These booster sessions provide an opportunity for clients to ask more questions and provide peer support. Although 2 booster sessions are recommended, they are not required.

The first booster session is held 2 months after the last session of the intervention. The women will begin designing their graduation ceremony. The facilitator will lead discussions about

• how the intervention could be strengthened
• whether the clients are using their newly developed skills
• any challenges that the clients have encountered

The second booster session is held 4 months after the intervention. During this session

• additional questions are answered
• the graduation ceremony is held
• certificates of accomplishment are given to each client

It is recommended that the graduation party be held at the close of the second booster session. However, is can be held after Session 5 (Coping).

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Adapting

SISTA activities were designed specifically for African American women. However, at times, CBOs may find that they will conduct the intervention with groups of clients of mixed race and ethnicity. CBOs that wish to adapt SISTA to populations other than African American women are advised to go back to the original theoretical foundations for SISTA and build an intervention appropriate for the women they serve. They should ask whether the women they will reach live in communities where men are given more power than women regarding condom use during intercourse. If so, then adapting SISTA is appropriate. However, the process of adapting is more than replacing African-inspired poems and proverbs with other race-specific poems and proverbs. It may involve offering new activities and discussions that are not included in SISTA so as to make the intervention culturally relevant to the new population of women. This is called reinvention because core elements are added or deleted. Reinvention is not a bad thing if done carefully with the needs of the new target population of women clearly in mind as the adaptation process takes place.

CBOs that reinvent SISTA for their specific target population can rename the program. This intervention would be based upon SISTA.

Before a CBO attempts to adapt SISTA for a population other than African American women, it will need to perform the following activities.

1. Interview key stakeholders.  
2. Conduct a focus group with the target population.  
3. Design a logic model (to assess risk determinants).  

After the training, it will be necessary to pretest intervention materials (with a small target group) and pilot test the intervention (also with a small target group).

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Resource Requirements

People

In addition to having a project coordinator, it is recommended that 2 persons cofacilitate SISTA. This is because issues among clients may arise within a session, and 1 facilitator may need to remove a client from the class to address the issue while the other facilitator can continue moving the class along. However, CBO capacity to hire 2 facilitators should be taken into consideration; and, if necessary, 1 facilitator can be used. A skilled facilitator is the key to ensuring this intervention is effective.

Facilitators should

• be of the same race and ethnicity as the target population (African American women)
• speak the same language and dialect as the target population
• be able to create a culturally sensitive environment
• be knowledgeable about HIV transmission and prevention
• have a nonjudgmental attitude toward persons living with HIV/AIDS

Space

SISTA needs a place to hold the sessions. It must be

• large enough for 10 to 12 people
• easy to get to using public transportation
• private and secure, so that confidentiality can be maintained
• quiet and without interruptions (such as people entering and exiting the room or outside noise)

Supplies

SISTA needs

• anatomical models (male and female)
• incentives (e.g., transportation tokens, toiletry items, food, money, child care while the woman participates in the sessions, phone cards, gift certificates, and food)
• printer or photocopier
• training materials
• condoms

The SISTA intervention kit provides materials. CBOs will need to copy these materials and purchase incentives. CBOs may need to locate agencies willing to partner.

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Recruitment

The population recruited for SISTA is African American women at very high risk for HIV.

To encourage participation, SISTA should be publicized as a program for African American women; a program developed by African American women; and a program that discusses dating, relationships, healthy sex practices, and works at improving women's ability to effectively communicate with sex partners.

Women may be recruited from shelters, juvenile court systems, bars, focus groups, jails and prisons, sexually transmitted disease clinics, or community organizations. Specific cultural needs should be addressed.

If you are not using SISTA with the intended population, the intervention should be publicized as a behavioral change intervention that includes discussions on dating, relationships, and healthy sexual practices and works at improving women's ability to effectively communicate with sex partners.

Review the Recruitment strategy that will work in the setting in which the CBO plans to implement SISTA.

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Policies and Standards

Before a CBO attempts to implement SISTA, the following policies and standards should be in place to protect clients, the CBO, and the facilitators:

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 or her legal guardian 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 these 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 important 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; but at a minimum, consent should be obtained from each client and, if appropriate, a legal guardian if the client is a minor or unable to give legal consent. Participation must always be voluntary, and documentation of this informed consent must be maintained in the client's record.

Legal and Ethical Policies

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.

Linkage of Services

Recruitment and health education and risk reduction must link clients whose HIV status is unknown to counseling, testing, and referral services and persons living with HIV to care and prevention services. CBOs must develop ways to assess whether and how frequently the referrals made by their staff members were completed.

Personnel Policies

CBOs conducting recruitment, outreach, and health education and risk reduction must establish a code of conduct. This code should include, but not be limited to, the following: do not use drugs or alcohol, do use appropriate behavior with clients, and do not loan or borrow money.

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 partner counseling and referral services and other health department and CBO prevention programs.

At times, personal issues among clients may arise whereby they may need immediate referral attention. If there is only 1 facilitator, that facilitator may need to call a “time out” to individually address the client's issue.

Safety

CBO policies must exist for maintaining the safety of workers and clients. Plans for dealing with medical or psychological emergencies must be documented.

Selection of Target Populations

CBOs must establish criteria for, and justify the selection of, the target populations. Selection of target populations must be based on epidemiologic data, behavioral and clinical surveillance data, and the state or local HIV prevention plan created with input from state or local community planning groups.

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.

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Quality Assurance

The following quality assurance activities should be in place when implementing SISTA:

CBOs

• Facilitators should have extensive knowledge of HIV transmission and of local and national HIV/AIDS surveillance data.
• Facilitators must reflect the target population in race and gender and are expected to deliver the information in a non-threatening and culturally relevant manner.
• CBOs should have in place a mechanism to ensure that all sessions and core elements are implemented.
• Quality assurance activities can include direct observation and review of sessions by staff. The review could focus on the quality of the sessions, how well they adhere to content, and the responsiveness and openness of the women to the facilitator.
• Facilitators should collect all evaluation forms after each session and ensure client confidentiality.
• Facilitators should ensure that all clients are actively involved in each of the sessions.
• Facilitators should meet with supervisors twice a month to discuss progress and opportunities for change.

Clients

The clients' satisfaction with the intervention and their comfort should be assessed during each session. CBOs can use the evaluation forms provided in the intervention box or can develop their own.

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Monitoring and Evaluation

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.

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Key Articles and Resources

• Wingood GM, DiClemente R J. The effects of an abusive primary partner on the condom use and sexual negotiation practices of African-American women. American Journal of Public Health. 1997; 87:1016–1018.
• Wingood GM DiClemente RJ. Child sexual abuse, HIV sexual risk, and gender relations of African-American women. American Journal of Preventive Medicine. 1997;13(5):380–384.

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References

1. DiClemente RJ, Wingood GM. A randomized controlled trial of an HIV sexual risk reduction intervention for young African American women . Journal of the American Medical Association. 1995;274:1271–1276.
2. Wingood GJ, DiClemente RJ. Partner influences and gender-related factors associated with noncondom use among young adult African American women. American Journal of Community Psychology. 1998;26:29–49.
3. Wingood GM, DiClemente RJ. Application of the theory of gender and power to examine HIV-related exposures, risk factors, and effective interventions for women. Health Education & Behavior. 2000;27:539–565.

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