iTHRIVE 365: A Community-Led, Multicomponent Health Promotion Intervention for Black Same Gender Loving Men

Abstract

Although health inequities among Black same gender loving men (SGLM) are well documented (e.g., chronic psychological disorders, HIV, suicide), there are few accessible, culturally affirming, and community-led interventions designed to reduce these inequities. The present manuscript describes the process through which we developed iTHRIVE 365, a multicomponent health-promotion intervention designed by Black SGLM for Black SGLM. We utilized a community-based participatory research approach (CBPR) that included collaboration between THRIVE SS, a Black SGLM-run community-based organization, and a multisectoral team of public health, research, and digital design professionals to develop the intervention. A five-phase development process included four phases of focus groups and a technical pilot to assess community priorities and incorporate input on each feature of the intervention. Directed content analysis indicated that participants wanted a multicomponent and technology-mediated intervention that promotes health knowledge and motivation, Black SGLM social support, access to affirming healthcare, and housing and economic resources. iTHRIVE 365 combines multilevel and culturally affirming intervention features to combat the effects of oppression and ultimately promote Black SGLM’s biopsychosocial health.

INTRODUCTION

Black gay, bisexual, other same gender loving men (SGLM)^a are highly resilient¹ and practice positive health behaviors compared to their peers of other racial and sexual identities.^2–4 And yet, Black SGLM experience myriad health inequities, including those in chronic psychological disorders,⁵ HIV,⁶ and suicide.⁷ Evidence indicates that health inequities among Black SGLM are connected to experiencing high levels of social isolation,^8–12 low access to culturally affirming and effective healthcare,^8,13 and barriers to housing, transportation, and other forms of economic empowerment^13–15 linked to interpersonal,^16–19 institutional,^20,21 and structural^2,22,23 oppression. Despite this evidence, extant interventions to promote positive health outcomes among Black SGLM largely focus on individual-level approaches, such as reducing substance use and condomless sex, which do not address these root causes of health inequities facing Black SGLM.^2,3,24 Additionally, there is a need for interventions that are accessible to Black SGLM, that are developed by Black SGLM, that are rooted in and build upon the strengths and assets of Black SGLM, and respond to community-identified needs. To address this gap in the literature, the present study details a community-based participatory research (CBPR) approach to developing a multicomponent intervention called iTHRIVE 365 that builds upon Black SGLM community priorities and strengths, combats the impact of multilevel oppression, and promotes biological, psychological, and behavioral health among Black SGLM.

Theoretical Foundation

Intersectionality frameworks identify that factors operating at the social-structural level, including multiple interlocking systems of oppression (e.g., racism, heterosexism, classism), produce and exacerbate social, economic, and health inequties²⁵ at intersecting social positions (e.g., race and gender and sexual identity and socioeconomic status).^26–29 Intersectionality work from Bowleg identifies that frequently unacknowledged strengths and resiliencies empower individuals at the intersection of oppressive systems to persevere in the face of these systems, but often at the expense of health, social connections, and other important outcomes.^26,27 Accordingly, recent recommendations for best practice in public health have called for interventions that confront the multilevel and intersectional nature of oppression and build on community strengths to reduce health inequities among communities like Black SGLM.^30–33 This includes recent recommendations for best practices in HIV/AIDS treatment and prevention^34,35 that highlight evidence that the most effective interventions reduce barriers to positive health at the individual level (e.g., health information and motivation),³⁶ interpersonal/network level (e.g., social support networks),³⁴ institutional/health system level (e.g., culturally supportive environments),^37–39 and structural level (e.g., access to housing).²⁴

In line with these recommendations, an intervention that employs an integration of Information-Motivation-Behavioral Skills (IMB),^40,41 social capital,^42–44 and socioecological^45,46 theories of health to combat individual, community, institutional, and structural barriers to health for Black SGLM may be effective. The IMB model posits that individuals must possess the requisite information, motivation to change, and behavioral skills for improving their health.^40,41 Public health applications of social capital theory posit that interpersonal bonds can be essential to promoting health^42–44 as well as mitigating the negative effects of stigma.⁴⁷ HIV applications of the socioecological model identify institutional and socioeconomic structural factors as critical predictors of health, including healthcare^48,49 and housing⁵⁰ contexts, because they can affect access to care resources and, as a result, opportunities for positive health. Additionally, evidence indicates that culturally affirmative healthcare can mitigate the negative effects of stigma on HIV-relevant health outcomes.^49,51

Community-Based Participatory Research with Black SGLM

Regardless of the theoretical underpinnings, the tenets of CBPR posit that the most effective interventions are consistent with community-identified priorities and are developed by and for the communities they are meant to serve.^52–56 This includes core principles of research engagement like taking a collaborative, equitable approach that incorporates the strengths and assets of a community to coproduce sustainable community capacity. It also emphasizes that resources produced by the research process should be in line with community priorities and address the intersections of racism, heterosexism, and other forms of oppression.⁵⁷ One way to conduct CBPR is within community-based organizations (CBOs) that are run by and rooted in communities, and by involving community members as partners in the intervention development process to ensure the benefits of the intervention ultimately serve the community. In the case of developing a health empowerment intervention for Black SGLM, this can include Black SGLM community members establishing priorities, identifying means to accomplish those priorities, and leading the efforts to develop those means. In the present study, we developed an intervention by and for Black SGLM that utilizes mobile health (mHealth) to promote health education and motivation, social support, access to culturally affirming healthcare, and economic empowerment.

mHealth Interventions for Black SLGM

Recent studies have suggested that interventions that utilize mHealth technologies may be acceptable and feasible for Black SGLM and, if aligned with community priorities, may be effective tools for facilitating health equity for Black SGLM.^58,59 For example, recent evidence suggests that internet- and app-based HIV health tools may reduce the negative effects of intersectional stigma⁶⁰ by effectively providing a platform for social support among Black SGLM⁶¹ and connection to critical healthcare resources.⁶² Additionally, evidence suggests that mHealth tools may be particularly desirable and effective for Black SGLM because they provide low-cost and accessible way of reaching Black SGLM who otherwise may be experiencing practical barriers (e.g., limited funds to reach a physical clinic),⁶³ social barriers (e.g., social isolation linked to intersectional stigma),^8,63 and psychological barriers (e.g., anticipated stigma)²¹ to in-person healthcare. Also, since intersectional stigma affects daily health among Black SGLM,^64–66 daily access to mHealth support may be critical. In this study, in particular, the participating Black SGLM community served by THRIVE SS, an Atlanta-based CBO led and operated by Black SGLM for Black SGLM, was primed for an mHealth intervention given they had accessed Facebook forums for Black SGLM social connection over the previous seven years.

Present Study

The present study builds on a collaboration between leaders and members of THRIVE SS, Positive Impact Health Centers, an Atlanta-based HIV/AIDS service organization that provides medical care for people living with HIV, and Rutgers School of Public Health to develop iTHRIVE 365. Our goal in creating iTHRIVE 365 was to develop a health promotion initiative that was consistent with the priorities of Black SGLM that ultimately helps to reduce health inequities experienced by these men. As described below, this collaboration was fostered in service of the development of a multicomponent intervention that employs mHealth tools and is meant to promote the health and well-being of Black SGLM.

METHODS

Research Team and Institutional Environment

THRIVE SS is an Atlanta-based CBO that focuses on health equity for Black SGLM through cultivating peer support, advocacy, and community building. The care from THRIVE SS is based on a model that combines online support, traditional in-person support, and social support to aid Black SGLM in their health management, with a specific focus on HIV care. A key aspect of their online support has been Facebook groups that provide spaces for peer connection and empowerment. Positive Impact Health Centers is an Atlanta-based comprehensive HIV service organization that provides access to HIV testing, prevention, and care, as well as access to behavioral health, case management, and housing. The Rutgers School of Public Health team is a group of scholars with both clinical and research experience with Black SGLM and a focus on promoting health equity through community-driven and social justice-focused interventions.

The collaboration began in 2019 given the shared goal across the teams to support community-developed interventions that promote health equity for Black SGLM. The groups specifically focused on meeting a community-identified need for THRIVE SS to transition away from Facebook group forum spaces for their online support. This need to transition to an alternate online support platform arose from security, privacy, and accessibil‐ ity problems with Facebook forums that included THRIVE SS participants being unduly restricted from using the platform, lacking a way to protect members’ personal data, and having membership information erased. In 2021, to design and develop the app-component of what was eventually referred to as the iTHRIVE 365 intervention, THRIVE SS connected with CorporateLounge, a certified Black woman-owned company that delivers technological design and development, compliance, and project management services. CorporateLounge had partnered with THRIVE SS for three years prior, supporting their website, cloud apps, and power platform services. Throughout 2021, members of CorporateLounge also started attending weekly meetings to discuss the app development process and necessary back-office processes for iTHRIVE 365 success.

Procedures

From August 2020 to August 2021 THRIVE SS, Positive Impact Health Centers, Rutgers School of Public Health, and later CorporateLounge study teams met weekly to plan data collection for this CBPR project. We have decided to structure our community-informed intervention development in five phases: four rounds of qualitative focus groups and a functional pilot (Figure 1). We recruited cisgender and transgender Black SGLM participants from inside and outside of THRIVE SS for both the interviews and the pilot, though the five participants in the functional pilot only included cisgender men. In the different phases, we sought feedback including: 1) initial perspectives on community priorities for an online platforms; 2) feedback on the introduction page, registration process, profile and linkage to care process, calendar and community pages, and additional general feedback on the style and substance of the intervention; 3) feedback on the forums, introduction video, health maintenance reminders, and other app-based content; 4) perspectives on the content provided in the app homepage, including health information and Black LGBTQ community news/information; and 5) feedback on the functionality and performance of the entire intervention. Participants received $20 for their participation in 30–45 minute focus groups described below and $93 for participation in the 14 day pilot. We obtained written consent from all participants prior to participation. All procedures were reviewed and approved by the Rutgers School of Public Health Institutional Review Board (Pro2020002582, Pro2021001082).

Figure 1.

iTHRIVE 365 development process.

Focus Group Process.

We conducted the first three focus group phases with 4–6 groups of 3–6 participants each phase in an online Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant WebEx supported platform. The participants consisted of Black SGLM from THRIVE SS as well as Black SGLM from another CBO in New Jersey named Hetrick-Martin Institute: New Jersey (HMI:NJ). HMI:NJ was focused on supporting and empowering LGBTQ youth of color throughout New Jersey. We incorporated feedback from HMI:NJ to ensure the intervention was appealing to Black SGLM communities broadly and to enable THRIVE SS to more easily scale it to serve communities outside of Atlanta in the future. We stratified the first three focus group phases by age, with participants age 25 and younger together and participants over age 25 together. We did so to ensure that intervention content appealed to relatively younger and older Black SGLM. The fourth phase of focus groups and pilot were only conducted with a group of THRIVE SS participants given HMI:NJ permanently ceased operations during the COVID-19 pandemic.

All focus groups were semistructured and encouraged participants to discuss preferences and perspectives on potential, and later actual, intervention features. The semistructured format provided interviewers with the flexibility to utilize probes to further discuss relevant topics that emerged during the interview.⁶⁷ We chose to utilize focus groups, because we were most interested in measuring consensus opinions and perspectives among Black SGLM.⁶⁸ The focus group facilitators were administrators at THRIVE SS and HMI:NJ who were experienced in conducting semistructured focus groups with their members. Both facilitators are service providers for Black SGLM and identify as a Black gay man and a Filipina lesbian woman. In this focus groups, and throughout the process, we were intentional about maximizing racial and sexual identity concordance between research staffand research participants, in keeping with best practices of community engagement.⁶⁹

Focus Group Content.

The intent of phase one focus groups was to focus on community priorities for an online intervention. To accomplish this goal, questions from the semistructured interview focused on the need for an intervention that integrates online tools to reduce the impact of discrimination (e.g., “THRIVE SS has Facebook groups where Black SGLM are able to connect with one another. Do you think that has helped (or would help) in dealing with discrimination? Tell me how.”) and to ask about what they would want to include in an intervention with online tools (e.g., “What do you think an app like this should include? How else might an app like this help you stay healthy and feeling good?”). As reviewed in the Results section, there was a relatively universal positive evaluation of a potential intervention that utilizes mHealth tools. Based on the initial feedback from focus group participants, the experience and expertise of THRIVE SS leadership, and the app-development expertise at CorporateLounge, we developed an initial draft of the intervention. This included an introduction page, known as a splash page, a registration page, a welcome page, a linkage to care page, and a profile page.

In the next three focus group phases, participants provided feedback on the design and development of different functions of the app portion of the intervention recommended by participants and THRIVE SS leadership. In phase 2, this included the registration and sign-in process, profile functionality, and medication reminder functionality (e.g., “How was the registration process?” [registration process], “Are you comfortable putting in personal information? Would you use this for linkage to care and other resources? Why or why not?” [profile feature], “What services would THRIVE SS be able to offer BSLGM through the app?” [linkage feature]). In phase 3, we asked for feedback on the community calendars and forums, interpersonal chat, and health reminders (e.g., “What are your thoughts on navigating the community and calendar features?” [community calendar], “What do you think about the format of the chat feature?” [interpersonal chat]). In phase 4, we asked for feedback on intervention content, the relationship between app features, and overall functionality (e.g., “What additional content or information you would like to have in this section?” [content]; “What do you think about the placement of the content in the scrolling rotating panel?”). We transcribed all audio recordings of the focus groups following their recording. In the small functional pilot, we examined the daily functionality of the entire app with five SGLM connected to THRIVE SS accessing the intervention for one week to provide feedback on its performance.

ANALYTIC APPROACH

We analyzed the qualitative data using a directed content analysis approach⁷⁰ within NVivo software. In this coding, the second author, a Black queer man and the cofirst author, a White primarily heterosexual man, focused on semantic codes that pertained to concrete recommendations from the participants for intervention priorities based on the opinions participants expressed about the intervention features. For each phase, the collaborators at Positive Impact Health Centers and Rutgers School of Public Health summarized the results for the THRIVE SS team, which considered costs and benefits, including financial constraints, and institutional expertise and priorities, of each potential intervention feature. THRIVE SS then provided CorporateLounge directives for additions and revisions based on the available development tools. Subsequently, THRIVE SS would engage in a weekly iterative process with CorporateLounge to produce updated versions of the intervention (Figure 1). As such, THRIVE SS maintained autonomy in decision-making for intervention features.

RESULTS

Demographic information for focus group and small pilot participants is included in Table 1.

TABLE 1.

Demographic Characteristics of Participants in Focus Groups and Pilot

Demographic characteristics	N	%
Age
16–20	5	16.7
21–25	11	36.6
29–40	5	16.7
41–52	4	13.3
53–72	5	16.7
Sexual Identity
Gay	20	66.7
Bisexual	5	16.7
Same Gender Loving	2	6.7
Queer	1	3.3
Other	2	6.7
Race
Black/African American only	27	90.0
Black/African American and American Indian/Alaskan Native	2	6.7
Black/African American and Asian	1	3.3
Affiliated CBO
HMI:NJ	7	23.3
THRIVE SS	23	76.7

iTHRIVE 365 Strategies and Elements

Based on the initial feedback from focus group participants, the experience and expertise of THRIVE SS leadership, and the options available through the app-development technology at CorporateLounge, the team identified four primary community priorities to promote health and combat intersectional oppression in the intervention: 1) promote health knowledge and motivation; 2) foster a sense of community and positive social connections among BMSM; 3) connect BMSM to affirming healthcare, including HIV treatment and mental healthcare; and 4) provide resources for housing, transportation, and other economic empowerment. To accomplish these priorities, and in line with best practices for mHealth intervention approaches,^71,72 we identified intervention elements to accomplish intervention strategies matching the community priorities. Intervention elements included: 1) weekly HIV and psychological information and motivation content and daily health notifications; 2) online moderated forums, interpersonal chat, and community calendars; 3) linkage to healthcare via THRIVE SS’s network of BMSM-affirming providers; and 4) housing and economic resources through THRIVE SS’s direct support and referral network (Figure 2). Example qualitative themes, quotes, and corresponding intervention strategies and elements are provided in Table 2. Revisions from phase 2–4 focus groups are available in Table 3. The functional pilot yielded feedback on streamlining the registration process for users and adding more Black SLGM to the online space to create the feeling of community within the app. Overall, the feedback from these phases led to the development of the intervention element content described below.

Figure 2.

iTHRIVE 365 intervention strategies and elements.

TABLE 2.

Exemplar Themes, Quotes, and Corresponding Intervention Strategies and Elements Identified in Round 1 Qualitative Focus Groups

Theme	Definition	Illustrative quote	iTHRIVE 365 strategy	iTHRIVE 365 element
1. Health education	Interest in having the app to teach more about HIV, medications, treatments, safe sex tips, and health outside of HIV (e.g., mental health)	“I think a link to educational stuff as far as even just a basics of HIV, the basics of knowledge, or like a link or some type of… where to get knowledge on STDs or STIs. And educate themselves because some people are still embarrassed on asking the signs of certain diseases.”	Increase health knowledge	HIV and mental health education
2. Health reminders	A desire for health reminders to motivate them to maintain positive health practices like exercise and doctor appointments	“It can remind me about my appointments…A lot of us, we have good intentions on making our appointments, but… it goes out of our memory, you know, so reminders and every phone has it.”	Increase health motivation	Daily health maintenance reminders
3. Connection through shared experiences	The need to feel safe and validated through shared connections with others. While multiple participants identified being part of a community (e.g., neighborhood, school), they acknowledged the difficulty of finding people with similar experiences (e.g., Black SGLM-affirming churches)	“it’s been really hard to meet like gay people in person. Like it’s really hard. I don’t know why I’m, so it’d be really cool to like, be able to meet. Um, or like, know that, that there’s like people around that are like, like me, cause it’s like, I don’t really see any of that for the most part.”	Increase social support	Moderated forums and interpersonal chat
4. Calendar of events and social activities	Interest in using an app to see an active calendar of Black SGLM outreach events and social activities	“I definitely would add a calendar of events to where it allows all of us to see in one place, you know what I mean? Without having to go to a specific link, it’s just, here’s the calendar…”	Increase social support	Community calendar
5. Directory and connection to a variety of healthcare providers	The importance of being able to locate different types of providers that span: HIV providers, mental health practitioners, primary care providers, gender affirmation providers, and other LGBTQ-affirming providers	“[I want] an app that would tell you what doctors are in your immediate area that offer things like PrEP based on your location and how you can go about setting up your counseling and the things that you need to get that started.”	Increase access to affirming healthcare	Connect clients to Black SGLM-affirming healthcare
6. Multilevel support	Participants would like the intervention to have supports for: finances, housing, preparing for retirement, finding employment, and adoption	“I would add in different resources like… connections to how to purchase a home and not be a renter all your life. Information I think that a lot of people in our community miss, and we miss a lot of times because we don’t think it’s attainable…”	Increase access to housing and economic resources	Provide resources for housing, transportation, and other economic empowerment

TABLE 3.

Exemplar Applications of Rounds 2–4 Qualitative Data to iTHRIVE 365 Intervention Features

Focus group round	Theme	Illustrative quote	Relevant intervention feature	Intervention additions/ Revisions
Round 2	LGBTQ+Friendly	“It says it’s for like gay black men, so you would expect it to be for that demographic only.”	Splash screen	Using Black SGLM as terminology instead of Black gay men to include the larger Black Queer community
Round 3	Safety	“Creating community guidelines for when users do not feel safe and need to report such behavior and a page in the app where users could learn more about THRIVE SS.”	Community Forums	The creation of a “Community Forums Guidelines” notice with parameters of acceptable communication within community forums
Round 4	Adding content to promote interaction in the app	“I think we could utilize this [article] as an opportunity for dialogue to happen in a separate setting.”	Content	Featuring opportunities in the community forums section for users to comment on featured articles

iTHRIVE 365 Content

Sample screenshots of intervention content are available in Figure 3.

Figure 3.

Screenshots of iTHRIVE 365 mHealth App, highlighting the home screen and linkage to care features

Health Knowledge and Motivation Content.

This content includes a health maintenance notification system and weekly posts covering HIV and psychological health content tailored to Black SGLM (Table 2, rows 1–2). The health maintenance notification system allows users to input the timing and dosage of medications or health practices (e.g., mindfulness meditation), so they receive push notifications based on their needs.

The HIV health content includes educational and motivational material developed by THRIVE SS and Rutgers School of Public Health that is consistent with evidence-based HIV treatment approaches.^73,74 For example, one exercise guides users through considering barriers (e.g., intersectional stigma toward Black SGLM), solutions, and plans to engage in a positive HIV-related behavior. Another exercise provides information on Undetectable = Untransmittable and guides users through considering their experiences with HIV, including what is colloquially known among Black SGLM at THRIVE SS as a seroversary (i.e., anniversary of seroconversion).

The psychological health content includes psychoeducation and exercises that are consistent with participants feedback of wanting positive content (e.g., “There has to be…something that is bright, something that is going to bring happiness out”) and THRIVE SS’s approach to empowering Black SLGM with an assets- and resilience-focused approaches to combat negative, stigmatizing messages directed at Black SLGM in U.S. society. Accordingly, we adapted psychoeducation and exercises for Black SGLM from positive psychology (PPI),⁷⁵ cognitive behavioral therapy (CBT),⁷⁶ and dialectic behavioral therapies (DBT; Table 1)⁷⁷ that aim to foster a positive framing, acceptance, self-reflection, and interpersonal efficacy. Positive psychology content focuses on building strengths and enhancing well-being through gratitude, forgiveness, and positive visualization exercises. For instance, one article includes a daily affirmation journal with prompts for positive reflections (e.g., “Today I am grateful for…”), which features a Black SGLM couple and other positive images of Black SGLM from THRIVE SS’s past BGLM affirmation work (https://thrivess.org/ithrive-gallery/).

CBT content⁷⁸ includes cognitive restructuring exercises, engaging in emotional reflection, effectively expressing emotions, and behavioral activation. For example, one behavioral activation exercise focuses on the link between desirable activities and positive mood and helps users to develop a plan to engage in those activities. We tailored this for Black SGLM to include culturally relevant examples of desirable behaviors (e.g., connecting with the Silver Linings Project [a supportive space for older Black SLGM]). The DBT content provides participants with information and practice in DBT skills such as wise mind, mindfulness, and effective communication.⁷⁷ For example, one article provides psychoeducation on flight-or-fight responses to stress for Black SGLM (e.g., racism, heterosexism) and guides users through a progressive muscle relaxation exercise.

Social Support Content.

This includes a community calendar that provides up-to-date information on THRIVE SS-led and other Black SGLM community events in the Atlanta area and provides the opportunity for users to receive reminder push notifications about them (Table 2, rows 3–4). The social support content also includes a moderated forum with discussions on topics generated by THRIVE SS staffand/or proposed by users and approved by staff. Moderated forums have supported discussions on popular topics like Black SGLM confronting intersectional stigma, HIV medication side effects, shared interests, and popular culture. Consistent with the feedback from phase one focus groups (Table 2, row 5), the forums support conversation around more than just health, including finances, music, pop culture, and include articles on Black SLGM-relevant topics in iTHRIVE 365’s CSS news feed and sex positive short stories. Forums include community guidelines that require users to refrain from personal attacks, hateful language, and other forms of communication that may cause forums to be unsafe for users. Forum moderators are Black SGLM THRIVE SS staffwho identify violations of community guidelines and remediate those violations. The interpersonal chat is a private chat between two users. The private chat is only restricted if a user reports a violation of community guidelines.

Linkage to Affirming Healthcare.

This feature allows users to request THRIVE SS institutional support including linkage to medical care, psychotherapy, HIV care, peer support groups, and COVID-related care (Table 2, row 5). THRIVE SS draws on a network of Black SGLM-affirming healthcare providers in the Atlanta metro area (e.g., AboluteCare, AHF Health Centers). This network was developed and vetted by THRIVE SS over the last 10 years through site visits and qualitative evaluations from THRIVE SS staff and members that assess aspects of affirming contexts such as ease of access, patient comfort, and provider cultural humility.

Housing and Economic Empowerment Resources.

This feature allows users to request cost-free transportation, food assistance, culturally appropriate clothes, and connection to housing support (Table 2, row 6). Transportation costs are covered through paid transit passes and direct cash assistance. Clothes and food assistance are provided onsite at THRIVE SS’s Atlanta location and through THRIVE SS partner organizations (e.g., Feed Thee Inc., Midwest Food Bank). Housing support is provided by THRIVE SS case workers and includes connection to transitional housing at a THRIVE SS-owned transitional home that provides housing for up to five months for those seeking a permanent residence and referrals to housing vouchers, rental assistance, and other housing support in THRIVE SS’s network (e.g., Partners for Home).

Both healthcare and economic resources linkage requests are managed by a THRIVE SS case worker. Case workers respond to all linkage requests within 48 business hours and maintain contact with users until connection with the provider occurs. Providers are identified from THRIVE SS’s 20 Atlanta-area partner organizations.⁷⁹

DISCUSSION

iTHRIVE 365 is a multicomponent, technology-mediated intervention that promotes health knowledge and motivation, Black SGLM social support, access to affirming healthcare, and housing and economic resources to address barriers to health at multiple socioecological levels faced by Black SGLM. We developed the intervention to meet a Black SGLM community priority identified by THRIVE SS and their members for a secure, community-run online space, and resources to combat intersectional oppression and other barriers to health at the individual, community, institutional, and structural levels. The development of iTHRIVE 365 was informed by several rounds of focus groups with Black SGLM from two CBOs and all decisions for the inclusion of intervention content were made by THRIVE SS, with consultation from CorporateLounge (app developer), Positive Impact Health Centers (community-based HIV healthcare and case management provider), and Rutgers School of Public Health (scientific partner) teams. As such, iTHRIVE 365 is a novel health promotion intervention for Black SGLM, developed by Black SGLM, in line with the priorities identified by Black SLGM, and with the assistance of a multisectoral team.

Our research extends previous work to develop mHealth technologies to address HIV among Black SGLM as we developed iTHRIVE 365 using a CBPR framework to guide the development and implementation of the intervention.²⁴ As a technological tool that was built to meet a community-identified priority within THRIVE SS’s membership base, a community that already exists within an online digital environment, iTHRIVE 365 has a built-in user base. The community-driven development and implementation of iTHRIVE 365 suggest that the intervention will have sustainability beyond the end of research studies and/or grants. For example, THRIVE SS plans to continue to administer and refine iTHRIVE 365 in the coming years based on community feedback (e.g., improving chat features and bolstering accessibility features). This is critical given the history of interventions to address HIV among Black SGLM being discontinued after research grant cycles end, even if the interventions are found to be efficacious. Additionally, as an intervention developed within a CBPR framework, THRIVE SS had the final determination on the elements that are integrated into the iTHRIVE 365 app. THRIVE SS is an organization led by Black SGLM, and as a function of being founded in, and run by, the community, has the trust and respect of the community. This process also facilitates rapid dissemination of lessons learned from the intervention back into THRIVE SS for its staff and members to integrate into other programmatic activities. Further, by working with CorporateLounge, a Black woman-owned technology company, we prioritized equity by investing resources in historically marginalized communities throughout the intervention development process itself.

Regarding its place within the theoretical literature, iTHRIVE 365 incorporates community-identified priorities that are consistent with Information-Motivation-Behavioral (IMB) skills,^40,41 social capital,^42–44 and socioecological^45,46 models of health behavior. In line with IMB model,^40,41 iTHRIVE 365 offers daily health maintenance reminders (e.g., customized pill reminders) and weekly health education and motivation content to promote health knowledge and motivation to maintain HIV-related and psychological health. In line with social capital theories of health,^42–44 iTHRIVE 365 provides online moderated community forums and calendars and an interpersonal chat aimed at reducing social isolation and promoting social support among Black SGLM. In line with the socioecological models of health,^45,46 to address institutional barriers to health, iTHRIVE 365 provides linkage to culturally affirming biopsychosocial healthcare for Black SGLM through THRIVE SS’s network of Black SGLM-affirmative healthcare (e.g., primary care, HIV care, mental healthcare) providers. And to address barriers to housing and economic empowerment, iTHRIVE 365 provides connections to housing assistance and other forms of economic empowerment like food and transportation assistance that are foundational services for THRIVE SS. Thus, iTHRIVE 365 combines an mHealth health app and institutional support from THRIVE SS, consistent with the public health and mobile app industry best practices for maintaining community engagement and impact.^71,79

Regarding its place in the empirical literature, iTHRIVE 365 is consistent with best-practices in mHealth intervention as it employs community-developed intervention elements to serve intervention strategies to reach community-identified intervention aims.^71,72 In providing connections to psychological healthcare, housing, and economic empowerment resources, iTHRIVE 365 fills a gap in intervention research that tends to focus on individual-level health behaviors without addressing institutional and structural barriers that drive health inequities among Black SLGM.^3,24,80 Additionally, many of the iTHRIVE 365 features are consistent with evidence-based health promotion approaches including the Black SGLM-tailored psychological and HIV health information,^73–77 the maintenance notification system with automated push notifications for health practices,^82–84 and moderated Black SGLM community forums.^47–52 Critically, iTHRIVE 365 employs community-developed strategies that promote social capital^42–44 and affirming healthcare,^48,49 and that have been found to mitigate the negative impact of intersectional stigma on Black SLGM’s HIV-related and psychological health.^{13,47,51,61,85–89}

While ITHRIVE 365 is a novel and innovative intervention, there are some limitations that are worth noting. First, although the intervention provides support to reduce the impact of barriers at multiple levels of the social ecological model, it is limited because it is only delivered at the individual and community levels (i.e., within individuals and groups of THRIVE SS members). To truly eliminate health inequities for Black SGLM, we must rectify the multilevel drivers of these inequities, such as inequalities in wealth, housing, education, and incarceration through robust and intersectional policy intervention (e.g., increasing affordable housing for Black SGLM).⁹⁰ Second, there were several priorities identified by participants that THRIVE SS was not able to include in the intervention as a result of funding and technological limitations (e.g., geomapping to locate where healthcare and community sites are within the Atlanta area). With additional resources, the team will consider adding these features. Finally, in future research, we need to examine the feasibility, acceptability, and efficacy of iTHRIVE 365 to examine if the ways in which we incorporated community perspectives translated into an engaging and impactful intervention.

CONCLUSION

iTHRIVE 365 can serve as a model for future interventions aiming to reduce health inequities among Black SGLM. By integrating the use of an mHealth tool into an already existing support network of Black SGLM, iTHRIVE 365 has the potential to transform the healthcare landscape for Black SGLM by offering a readily accessible portal to support the physical and mental health of Black SGLM. We were intentional about the partnerships forged in the development of the intervention, with the goal of ensuring that Black SGLM are leading throughout every step of the process, putting into practice the notion that Black SGLM ourselves should guide the efforts to develop interventions to support the health and well-being of our own communities. This type of sustained investment and leadership from Black SGLM is needed to end psychological, HIV, and other health inequities we face.

Statement of Public Health Significance:

Given the continued devastating impact of HIV, mental health, and other health inequities facing Black same gender loving men (SGLM), there is an urgent need for interventions that address the multilevel drivers of these inequities. The iTHRIVE 365 intervention helps to meet that need as a technology-mediated, multicomponent intervention developed by Black SGLM for Black SLGM that promotes health knowledge and motivation, Black SGLM social support, access to affirming healthcare, and housing and economic resources.