MOCHA Moving Forward: Findings and Lessons Learned From Implementing a Community-Based Chronic Disease Prevention Study With Middle-Aged Black Men

Abstract

Objectives:

Black men in the United States experience disproportionately high rates of diabetes, cardiovascular disease, and prostate cancer. These conditions are closely linked to chronic stressors such as racial discrimination, economic precarity, and gender role strain. In response, the Men of Color Health Awareness (MOCHA) program was developed to address the physical, mental, social, and spiritual well-being of men of color through culturally grounded discussions on structural violence, maladaptive coping, and masculinity. The MOCHA Moving Forward study assessed the feasibility of implementing the program and compared outcomes between two intervention models: MOCHA Original (MO) and MOCHA+, the latter incorporating narrativized, culturally adapted dialogue strategies. This paper presents brief findings and key implementation lessons from this community-academic feasibility trial. While statistically significant improvements were observed among intervention completers, the study also encountered substantial attrition and logistical barriers, offering valuable insights for future community-based interventions with structurally marginalized populations.

Design:

The MOCHA Moving Forward study was a community-academic feasibility and formidability study that included 210 men aged 35–70, randomized into either the MO (standard) or MOCHA+ (enhanced) intervention groups. Both groups participated in a 10-week stress and chronic disease prevention and control program.

Results:

MO training sessions significantly reduced self-reported stress, BMI, anxiety, and depression. When analyzing the combined MO and MOCHA+ groups, reductions in stress and BMI remained statistically significant. Feasibility was challenged by high attrition and loss to follow-up, with a final retained sample of 38 participants. However, the significant program effects observed among completers indicate promise for the MOCHA program.

Conclusion:

Despite challenges with retention, findings suggest that the MOCHA program may be a supportive and effective intervention for stress and chronic disease risk reduction in men of color. The statistically significant outcomes for completers highlight the potential for MOCHA to inform future, more rigorous implementation of similar community-based programs. Future studies can explore scalable adaptations and refine culturally tailored content, ultimately strengthening MOCHA’s capacity to reach and benefit a broader population of men of color facing chronic stress and health disparities.

Introduction

Although there has been growing recognition of the health inequities experienced by Black men in the United States, few community-based interventions have been designed specifically to respond to the layered stressors they face. Namely, chronic stressors rooted in racism and discrimination, socioeconomic hardship, community disinvestment, and gendered expectations. The Men of Color Health Awareness (MOCHA) program emerged in response to these conditions through a collaboration with Black men in Springfield, Massachusetts, who co-developed a model centered on chronic stress and disease prevention. This paper draws on the implementation of the MOCHA Moving Forward study to share insights gained from testing two versions of the program. Alongside a review of outcome data, we reflect on the practical and methodological challenges of conducting this work, including recruitment, retention, and the constraints imposed by structural vulnerability, issues with critical relevance for others working at the intersection of public health, race, and gender.

Black men living in the United States have an average life expectancy of 71 years which is the shortest lifespan of all groups by race and gender apart from Native American men (Dwyer-Lindgren et. al., 2022, Woolf et. al., 2022). Black men in the US experience poor health at higher rates when compared to non-Latino White men (Heron, 2021) and face higher rates of chronic diseases, including hypertension, type 2 diabetes, cardiovascular disease, and prostate cancer, compared to their non-Latino White counterparts (Ellis et al., 2020). Alarmingly, these health conditions tend to be more severe and diagnosed at later stages, resulting in poorer outcomes and higher mortality rates for this population (Powell et al., 2019). While life expectancy in the US declined by 2.7 years between 2019 and 2021, Black men suffered declines of 4 years (Aburto et. al., 2022), and provisional data for 2022 suggest that life expectancy for Black men (69.1 years) is over 8 years lower than the average for all race and ethnic groups (77.5 years) in the US and is a stagnant 6 years lower than that of White men (75.1 years), in particular (Arias et. al., 2022). Black men in the US have higher mortality rates from heart disease (Centers for Disease Control and Prevention, 2019), specific cancers (Kaiser Family Foundation, 2022), and stroke (American Heart Association, 2020) compared to their White male counterparts. Given these significant disparities, it is crucial to advance research on the causes and effective interventions for chronic disease management in this population.

Chronic stress stands out as a significant risk factor for chronic disease development and can act as a bridge between larger socio-structural forces (e.g., racism, socioeconomic instability, gender role strain) and individual behaviors (such as poor dietary choices, substance misuse, and violence), resulting in adverse health outcomes like diabetes, stroke, liver disease, and COPD (Buchanan et al., 2018; Mullany et al., 2021). Chronic stress rooted in racial discrimination, economic disparities, and enduring social inequality has been associated with various chronic diseases, including cardiovascular disease, diabetes, and mental health disorders (Bey et al., 2018; Powell-Wiley et al., 2022). Those enduring chronic stress have an elevated risk of atherosclerosis (Powell-Wiley et al., 2022), insulin resistance and impaired glucose metabolism (Oguntibeju, 2019), as well as depression and anxiety - all recognized as risk factors for chronic disease (Greer & Cavalhieri, 2019).

Over the past decade, several promising, evidence-based interventions have been developed to address chronic disease prevention among Black men. For instance, the Black Barbershop Health Outreach Program (Releford et al., 2010) leverages community spaces to provide accessible health screenings, while ‘Men on the Move’ (Griffith et al., 2014) offers a tailored approach that emphasizes physical activity as a pathway to improved health outcomes. Additionally, faith-based initiatives like the prostate cancer program (Saunders et al., 2013) tap into trusted networks to increase health awareness and early detection. Despite the success of these initiatives, disparities in health outcomes for Black men remain significant. This underscores a critical need to advance this work by developing interventions that not only replicate these models but also deepen their cultural relevance, address systemic social and economic challenges, and engage Black men in ways that empower sustainable lifestyle changes. Continued research should focus on adapting these promising frameworks to meet the diverse and nuanced needs within Black male communities, ultimately working toward greater equity in health outcomes.

In a community-academic effort to meet the needs of the Black community in Springfield, MA, the Men of Color Health Awareness (MOCHA) movement has historically brought together cohorts of low- and no-income Black men to improve health outcomes. In partnership with researchers from the University of Massachusetts: Amherst (LV, JM, JM, SP, DR and DB), MOCHA leaders developed a chronic disease prevention curriculum that addresses gender role strain, stress, coping, and chronic disease self-management. The current work, the MOCHA Moving Forward study (NIMHD: R01MD010618.), employs a Community-Based Participatory Research (CBPR) approach to evaluate the feasibility and formidability of two versions of the MOCHA program in reducing stress and chronic disease risk (Valdez et al., 2021). This article reports on the feasibility and expected effectiveness (formidability) of the MOCHA+ and MOCHA Original (MO) interventions in decreasing self-reported stress and associated risk factors, while also discussing lessons learned from unforeseen implementation challenges.

Materials and Methods

Building on the foundational goals of the MOCHA program, which emerged from community-driven efforts to reduce chronic stress and disease among Black men, the current study represents the next phase in a longstanding collaboration between community members, MOCHA leadership, and academic partners. A series of community conversations informed the further refinement of the MOCHA Original intervention, incorporating a narrative component developed through 42 individual interviews, 14 life-course interviews, and four digital storytelling (DST) sessions with 36 participating men (Buchanan et al, 2018; Gubrium, 2020). These sessions generated a library of digital stories and revealed key narrative strategies with potential to deepen participant engagement and reflection. The insights and materials derived from this formative work were then used to enhance intervention strategies, educational content, and facilitation approaches (Valdez et al., 2021). With ongoing input from the MOCHA Steering Committee, each weekly module of the original curriculum was reviewed and tailored, ultimately resulting in two intervention arms: the MOCHA Original (MO), which preserved the program’s foundational structure and pedagogy, and MOCHA+, which integrated narrativized content to further contextualize stress and health experiences among Black men.

Description of the intervention: MOCHA Original and MOCHA+

The MOCHA Moving Forward study employed a delayed-start, wait-list crossover design in which participants served as their own controls. Eligible individuals underwent a screening process and an informational session where informed consent was obtained. After completing a baseline questionnaire, participants entered a three-month waiting period with limited program contact, this constituted the “control phase” and was implemented in response to community partner objections to a no-treatment control group. This approach ensured all participants received the intervention but also unexpectedly contributed to high attrition, as some participants disengaged before program initiation. Following the control phase, participants completed a pre-intervention questionnaire, enrolled in the 10-week program (either MOCHA Original or MOCHA+), and then completed post-intervention and three-month follow-up assessments. The total study period spanned approximately nine months. The study was approved by the University of Massachusetts - Amherst Institutional Review Board (IRB Protocol ID: 2016–3257). Primary outcomes included self-reported stress, while secondary outcomes included BMI, blood pressure, anxiety, and depression.

The intervention was grounded in a formative framework adapted from the minority stress model (Meyer, 1995; 2003; Frost & Meyer, 2023), which was expanded through qualitative research to account for intersecting stressors disproportionately affecting Black men specifically, including racism and discrimination, internalized stigma, and gender role strain. Building on this model, the intervention emphasized psychoeducation on chronic stress, coping strategies, community-building, and advocacy for systemic change (Valdez et, a, 2022). The resulting program, MOCHA Original (MO), combined an existing YMCA fitness model with weekly discussion sessions shaped by community focus groups. Each cohort participated in ten weeks of programming, with two hours of group discussion and two one-hour aerobic exercise sessions each week, led by trained MOCHA mentors.

MOCHA+ retained the core elements of MO but introduced two key adaptations. First, the discussion component was restructured to prioritize storytelling and narrative-based pedagogy over direct instruction. Second, the physical activity component shifted from structured, gym-based exercise to one self-directed session per week and one project-led outing focused on applying intervention themes, such as grocery shopping with a nutrition lens to practice label reading and meal planning. These additions were designed to enhance social connectedness and real-world application of knowledge.

Storytelling served as the central pedagogical strategy in MOCHA+. Each session began with a digital story or personal narrative derived from earlier formative research (Buchanan et al, 2018; Gubrium et al, 2020). Narratives were presented via video or read aloud by facilitators and followed by structured reflection using a facilitation guide developed with community stakeholders. Prompts encouraged connections to themes like stress, masculinity, and coping, and although facilitators created space for organic conversation, sessions maintained a structured format to ensure alignment with behavioral goals and group cohesion.

All sessions were led by trained MOCHA mentors, with additional training for MOCHA+ facilitators on trauma-informed facilitation and narrative methods. While the mentors were experienced with the original curriculum, the introduction of storytelling required new skills in holding space, fostering emotional safety, and linking personal stories to broader social determinants of health. This shift in facilitation style was supported by a shared guide but still required facilitators to adapt to emergent group dynamics while staying focused on thematic objectives. Please see Valdez et al. (2021) for in-depth details of the intervention development and implementation protocol.

Participants, randomization, and blinding

Participants were recruited through a multi-pronged community engagement strategy led by MOCHA staff and partners. Recruitment took place at prominent cultural and community events in Springfield, MA, such as the Stone Soul Picnic and an Annual Jazz Festival, as well as at trusted institutions serving the local Black community, including the Mason Square Health Center and the Deborah Hunt Community Center (Graham et al., 2018). In alignment with MOCHA’s mission to reach those most marginalized, targeted outreach was also conducted at homeless shelters, halfway houses, soup kitchens, and similar sites.

Eligible individuals met the following inclusion criteria: (1) self-identification as a Black, African American, or biracial man including Black heritage; (2) age between 35 and 70 years; (3) self-defined as having insufficient or low income; and (4) residency in the Springfield area for at least the previous six months. After attending an informational session on the study and human subjects’ protections, individuals who consented to participate completed a baseline questionnaire and were enrolled into the study.

Randomization was conducted by the study statistician (SP) using a permuted block design to ensure equal allocation across study arms. Blocks of varying sizes were randomly ordered to maintain allocation concealment, and assignments were generated via a pseudo-random number generator based on a uniform distribution algorithm. The research team remained blinded to the randomization process to minimize allocation bias.

Following randomization, participants were assigned to either the MOCHA Original or MOCHA+ program. Each participant was issued a unique project ID number, which was used to anonymously link their data across self-report questionnaires, biological measures (e.g., fingernail cortisol – findings not reported here), and physiological assessments (e.g., blood pressure and BMI) at each data collection point.

To minimize barriers to participation and enhance retention, compensation and additional supports were carefully developed in collaboration with the MOCHA Steering Committee, drawing from community feedback and prior MOCHA cohorts. Participants received a total stipend of $300, disbursed in four increments: $25 for completing the baseline questionnaire, $40 for the pre-intervention assessment, $100 for attending all ten sessions, $60 for the post-intervention survey, and $75 for completing the three-month follow-up. In addition to financial compensation, participants received transit passes, refreshments at in-person sessions, and referrals to local resources such as mental health, housing, and employment services. These supports were designed in consultation with community partners to ensure cultural alignment and relevance, though resource limitations ultimately constrained the breadth of services available.

Instruments

Socio-demographics and Outcome Measures

In addition to standard demographic indicators (age, race, level of education, etc.) the primary outcome, reduction in stress, was measured through self-report using the Depression Anxiety Stress Scale 21 (DASS-21), which consists of three scales designed to measure depression, anxiety, and stress (Brown et al., 1997). These scales have demonstrated high internal consistency and meaningful distinctions in various settings (Osman et al., 2012). Secondary goals included lowering BMI, blood pressure, and addressing anxiety and depression.

Physiological measures

Physiological measures of blood pressure, height, weight, and Body Mass Index (BMI) were collected at all four data collection points by a licensed nurse delegated to the project by the Springfield Health Department in support of the research.

Assessing Feasibility and Formidability

We elected to assess the feasibility of our program using our recruitment, randomization, and retention data. Assessing feasibility through retention is crucial in understanding how responsive to the contextual realities of participants an intervention is, as high retention rates can indicate that participants find value in the program, suggesting that the intervention is not only acceptable but also aligns with participant needs and preferences (Teresi, Yu, Stetwart, & Hays, 2022). Further, this metric can serve as an indicator of the intervention’s relevance and practicality within our target community and provides insights into participant’s engagement levels which can inform future adjustments to enhance program delivery and content.

We also sought to explore the formidability of the intervention program as a whole and to compare the pre-existing MOCHA Original (MO) chronic disease prevention program with the newly developed MOCHA+ version. Thus, we randomized participants into three arms: MO, MOCHA+, and wait-list control. The study was designed so that each person served as their own control. That is, at the time of enrollment, all participants completed the full complement of measures, but they did not begin the intervention until three-months later. After the wait-list control period, they were then randomized to the MO or MOCHA+ interventions. Based on this design, paired t-tests were used to assess overall change and differences of differences to assess changes in MO vs. MOCHA+. Study statisticians used SAS 9.4 for data analysis.

Adapting to the Impacts of COVID-19

The MOCHA Moving Forward research project, like clinical trials nationwide, faced disruptions due to the COVID-19 pandemic. Following UMass IRB directives, all in-person recruitment, data collection, and intervention activities paused from mid-March 2020 to March 2021. Research resumed after adapting field procedures for a virtual environment and securing IRB approval. Recruitment shifted from in-person events to paid Facebook advertisements (Meta Platforms). Data collection transitioned to REDCap (Research Electronic Data Capture, Vanderbilt University) on tablets. The MOCHA curricula (MOCHA Original and MOCHA+) were adapted for Zoom (Zoom Video Communications, Inc.). An Administrative Supplement request to compensate for lost time was not approved.

Results

We begin with a brief description of socio-demographic characteristics of the study population and information on the rate of attrition over the four data collection points during the nine-month period of enrollment. The report on the tests of primary outcome hypotheses for the research population, and then, broken out for each program, MOCHA Original or MOCHA+, follows.

Study Recruitment and Retention

As illustrated in Figure 1. A total of 261 individuals were assessed for eligibility and 257 were consented and randomized. It is important to note most participants (80.4%) self-identified as Black while the remaining participants were Latinx. Latinx participants were included in the intervention process because it is a tenet of MOCHA to not deny participation in the MOCHA program to anyone, nevertheless, because the MO and MOCHA+ programs were normed by and for the Black community, inclusion of Latinx participants was a supplement to the original objectives of this work. Thus, for the purposes of this report, the Latinx population was excluded from tests of the primary hypotheses, resulting in a final total of 210 Black participants at baseline. Nevertheless, the attrition rate was considerably higher than anticipated. As shown in Table 2, of the 210 randomized Black male participants, only 113 were present at T2, 65 at T3 and 38 at T4 follow-up. Data describing reasons for loss to follow-up were not collected and as such are not reported here.

Figure 1. MOCHA Moving Forward CONSORT Diagram.

*Data on reasons for loss to follow up were not collected and as such, not reported here.

Table 2:

Number of participants at each data collection point

T1 – Baseline	T2 – Pre-test	T3 – Post-test	T4 – 3-month Follow-up
210	113	65	38

Demographic Characteristics at Baseline

As shown in Table 1, the mean of participants was 51.4 (SD 12.4 years and ranged from 35 – 70 years. As noted above, the MOCHA mentors responsible for conducting outreach intentionally tried to reach those most in need, such as men residing in homeless shelters and halfway houses. These characteristics are reflected in the levels of education and employment of the study population. Almost one in five men (15.5%) did not finish high school, while 21.8% reported some college training. In terms of employment, only 8.6% reported have a full-time job and another 11% reported working part-time.

Table 1:

Demographic characteristics of sample population at baseline (N = 210)

Characteristic	% (N)
Age (Mean, SD)	51.4 (12.4)
Gender (% male)	100 (210)
Race/Ethnicity: Black	100 (210)
Education: less than high school	15.5 (30)
High school graduate	33.7 (65)
Certificate or training completion	6.7 (13)
Some college	21.8 (42)
Trade school or Associate’s degree	11.9 (23)
Undergraduate degree	6.2 (12)
Graduate degree	4.2 (8)
Employment: Full-time	8.6 (18)
Part-time	11 (23)

Reduction of Stress and Chronic Disease Risk Factors

Because of our use of the wait-list control study design, we began the analysis by examining whether there were any significant differences between Baseline and Pre-Test. In Table 2, we present the change in outcomes over time from pre-test to post-test and then pre-test to 3-month follow-up for participants of both MO and MOCHA+ conditions. We found no statistically significant differences, except for a slight increase in Systolic blood pressure (from 133.6 mmHg to 139, p <0.03).

We then conducted paired t-test analyses comparing the pre-test and post-test results for the combined groups and then by intervention type, as shown in Tables 3 - 5. Of note, as illustrated in Table 3 our findings suggest that men in the study (MO and MOCHA+ combined) experienced significant reductions in self-reported stress (1.4 points, p=0.04) and BMI (1.6 kg/m², p=0.02) from pre-test to post-test. However, it also is important to mention the lack of significant self-reported stress reduction, except for systolic blood pressure, from pre-test to 3-month follow-up.

Table 3:

Change in Outcomes Over Time: Pre-test vs. Post-test and Pre-test vs. 3 Month Follow-up. Combined groups, all participants

	Pre-Test			Post-test			3 Mo Follow-up			Pre - Post				Pre – 3 Mo-Follow-up
Measure	Mean	SD	N	Mean	SD	N	Mean	SD	N	Mean	SD	N	p-val	Mean	SD	N	p-val
Primary Outcomes
Stress	13.6	4.7	109	12.4	4.6	61	13.6	3.4	38	1.6	4.1	55	0.003	0.5	3.9	32	0.39
BMI	28.5	7.0	112	28.0	6.1	61	29.3	6.5	33	1.4	5.0	54	0.041	1.1	8.1	29	0.44
Systolic BP	140.6	19.7	98	140.1	21.2	57	134.6	19.3	38	2.7	18.8	49	0.31	8.9	20.0	30	0.020
Diastolic BP	85.8	13.1	98	85.9	14.4	58	83.6	11.6	38	1.1	12.7	50	0.52	4.5	14.2	30	0.88
Secondary Outcomes
Anxiety	11.1	4.5	109	10.5	4.0	61	12.1	4.2	38	0.8	3.5	55	0.09	−0.4	3.6	32	0.53
Depression	12.4	4.5	109	11.2	3.8	61	13.1	3.6	38	1.2	3.9	55	0.02	−0.3	4.4	32	0.66

Table 5:

Change in Outcomes Over Time: Pre-test vs. Post-test and Pre-test vs. 3 Month Follow-up MOCHA+ Condition

	Pre-Test			Post-test			3 Mo Follow-up			Pre - Post				Pre – 3 Mo-Follow-up
Measure	Mean	SD	N	Mean	SD	N	Mean	SD	N	Mean	SD	N	p-val	Mean	SD	N	p-val
Primary Outcomes
Stress	13.6	5.3	56	12.5	3.4	33	13.4	3.2	22	0.8	3.9	29	0.22	0.7	3.8	18	0.40
BMI	28.6	6.3	62	28.9	6.5	36	29.7	6.5	22	1.1	5.2	31	0.24	2.5	9.1	19	0.24
Systolic BP	141.5	21.5	53	143.3	23.1	32	136.0	16.9	22	0.2	18.1	27	0.94	8.1	21.8	18	0.13
Diastolic BP	86.3	13.8	45	86.9	16.0	33	85.7	11.1	22	0.5	13.3	28	0.82	4.1	14.8	18	0.25
Secondary Outcomes
Anxiety	11.0	4.6	56	10.5	3.0	33	12.2	3.9	22	0.1	3.3	29	0.86	−1.3	3.5	18	0.11
Depression	12.4	5.0	56	11.4	2.8	33	12.3	2.8	22	0.7	4.0	29	0.34	0.1	4.0	18	0.86

We also used paired t-tests to highlight differences over time within each condition. As shown in Table 4, we observed several significant changes between pre-test and post-test in the MO arm. Of note, participants of the MO condition experienced statistically significant reductions in self-reported stress (2.6 points, p=0.005), self-reported anxiety (1.7 points, p=0.025), and self-reported depression (1.9 points, p=0.018). Importantly, according to the scoring manual developed by Gomez (n.d.), a 2.7-point (13%) reduction in self-reported stress levels marks a clinically significant shift from severe to moderate levels of stress. In Table 5 findings indicate that we observed no statistically significant changes between pre-test to post-test in the MOCHA+ condition.

Table 4:

Change in Outcomes Over Time: Pre-test vs. Post-test and Pre-test vs. 3 Month Follow-up. MOCHA Original (MO) condition

	Pre-Test			Post-test			3 Mo Follow-up			Pre - Post				Pre – 3 Mo-Follow-up
Measure	Mean	SD	N	Mean	SD	N	Mean	SD	N	Mean	SD	N	p-val	Mean	SD	N	p-val
Primary Outcomes
Stress	13.7	4.1	50	12.2	5.4	29	13.9	3.8	16	2.6	4.3	25	0.005	0.3	4.0	14	0.74
BMI	28.4	7.8	50	26.6	5.1	25	28.4	6.5	11	1.8	4.9	23	0.083	−1.4	5.0	10	0.388
Systolic BP	139.6	17.4	45	136.0	18.1	25	132.7	22.7	16	5.8	19.6	22	0.17	10.1	17.8	12	0.074
Diastolic BP	85.3	12.4	45	84.6	12.0	25	80.6	11.9	16	1.9	12.1	22	0.47	5.2	13.8	12	0.21
Secondary Outcomes
Anxiety	11.4	4.3	50	10.3	5.2	26	12.0	4.8	16	1.7	3.6	25	0.025	0.8	3.5	14	0.37
Depression	12.5	4.1	50	11.1	5.0	26	14.1	4.3	16	1.9	3.7	25	0.018	−1.0	4.9	14	0.46

In sum, these results demonstrate that the MOCHA intervention was effective in reducing stress and stress-adjacent BMI for all participants in a combined analysis. The results also show that the MOCHA Original intervention, in particular was effective in reducing the primary outcomes of stress and BMI, while also alleviating the secondary outcomes of anxiety and depression. Finally, contrary to the stated hypotheses, study findings show that the MOCHA+ intervention did not produce the desired effects, showing no statistically significant differences. Hence, we conclude that the narrativized MOCHA+ intervention was less effective than its MOCHA Original counterpart.

Discussion and Conclusions

The MOCHA Moving Forward study contributes to the growing body of literature on gender-responsive, community-based health interventions for Black men, particularly those addressing stress, structural vulnerability, and chronic disease risk. While significant reductions in stress, anxiety, depression, and BMI were observed among completers of the MOCHA Original program, the broader significance of this study lies in the implementation challenges and contextual factors that shaped its outcomes. This discussion draws from both empirical findings and critical lessons learned, with implications for the design and sustainability of future interventions targeting minoritized populations

Study Design Trade-Offs: Ethics vs. Rigor

The use of a delayed-start, wait-list crossover design in this study was shaped by community-based participatory research (CBPR) principles. Our community partners expressed clear objections to a placebo or no-treatment control, emphasizing the ethical imperative that all participants have access to the MOCHA program. This is particularly the case, given its prior community-validated benefits. This also is consistent with CBPR standards, which resist extractive research designs (Minkler & Wallerstein, 2008; Wallerstein et al., 2017). However, the resulting three-month delay between enrollment and intervention led to higher-than-anticipated attrition, particularly between baseline and pre-test. This mirrors challenges documented in other community-engaged trials with marginalized populations and underscores a key tension in equity-focused intervention research: balancing ethical access with research rigor and retention.

Attrition and Structural Vulnerability

We originally anticipated a 20% attrition rate based on previous MOCHA implementation; actual rates exceeded 50%. Attrition was influenced by several factors, including unstable housing, inconsistent phone access, and lack of reliable transportation, even with supports like bus passes. Participants frequently moved between shelters, halfway houses, and other unstable environments, which disrupted follow-up. These conditions echo findings by Newton et al. (2014), McKenzie et al. (2018), and Wippold et al. (2022), who stress that high attrition in interventions with low-income Black men is less a reflection of disengagement than of systemic precarity.

Retention efforts, including outreach talks and health education during the wait period, were further disrupted by the COVID-19 pandemic, which severely impacted both recruitment and program delivery. These dynamics reinforce the need for adaptive, crisis-resilient designs that can flex in response to public health emergencies and point to the structural fragility faced by the communities MOCHA seeks to serve.

MOCHA+ Delivery and Fidelity Challenges

MOCHA+ was developed to integrate narrativized content into the existing MOCHA framework, building on participatory research and digital storytelling literature (Davidson & Gubrium, 2021; Bell et al., 2023). However, the modified version yielded weaker outcomes than the original model. This may be attributable to multiple factors. First, although MOCHA+ narratives were drawn from men demographically aligned with participants (Gubrium et al., 2020; Valdez et al., 2021), not all men saw their experiences reflected. Narratives risk overgeneralizing, and even well-crafted stories may not align with all participants’ lived experiences, values, or learning preferences.

Second, trainers were deeply familiar with the MOCHA Original model, having delivered it for years, while the narrative approach required a pedagogical shift. Despite shared development of the MOCHA+ content, trainers may have lacked full confidence and fluency in the new facilitation style. Toomey et al. (2020) emphasize that fidelity is both a technical and cultural issue; it requires not just adherence to protocol but deep integration of delivery methods. The use of different facilitators for each condition (to avoid cross-contamination) may have also introduced unintended differences in delivery. A more rigorous fidelity protocol, along with extended trainer support, would strengthen future adaptations.

Social Connectedness as a Mechanism of Change

Although social connectedness was not formally measured as an outcome in this trial, participant feedback, facilitator notes, and observational data point to its centrality. Social connectedness is increasingly recognized as a critical determinant of health, with implications for psychological well-being, blood pressure, immune functioning, and mortality (Holt-Lunstad, 2018, 2022; Holt-Lunstad et al., 2017; Berkman, 1986). It also serves as a key buffer against stress (Aslund et al., 2014; Pantell et al., 2013; McKenzie, 2018), particularly among Black men who face layered oppressions related to race, class, and gender (Griffith et al., 2011; 2013).

Weekly group sessions may have functioned as low-intensity, peer-based mental health support, even in the absence of clinical staff, by offering space for reflection, validation, and shared storytelling. Programs like MOCHA may thus improve health not just through education or behavior change, but by fostering relational solidarity. Future evaluations should integrate validated measures of social connectedness and consider its mediating role in chronic disease prevention.

Understanding the Decline at Follow-Up

The loss of statistical significance at the three-month follow-up was not unexpected. Without sustained social contact and structural supports, participants returned to the same environments that generated stress in the first place. This may reflect regression to the mean (Barnett, Van Der Pols, & Dobson, 2005), but it also reinforces that short-term programs are unlikely to produce long-term gains without broader structural change. Booster sessions or quarterly follow-ups might offer a cost-effective way to sustain impact and maintain relational continuity.

Implications for Practitioners

Findings and the lessons learned from the implementation of this iteration of the MOCHA program have practical implications for practitioners working with parallel populations. Firstly, MOCHA demonstrates the importance of an intersectional approach to tailoring interventions to be culturally and gender-responsive while considering the social contexts in which they are being delivered. That is, MOCHA was specifically designed to meet the needs of men of color who exist at the socioeconomic margins, shedding light on the impacts of gender role strain, structural violence, and chronic stressors that disproportionately affect their physical, mental, and social well-being. By addressing these intersecting challenges, MOCHA creates a culturally relevant and supportive space that empowers men to navigate and overcome the barriers imposed by societal expectations and systemic inequalities.

Relatedly, a holistic approach is essential for practitioners working with men of color, as it acknowledges the interconnectedness of physical, mental, social, and spiritual health. This comprehensive perspective is particularly relevant in programs like MOCHA, where the impacts of chronic stress, gender role strain, and structural violence cannot be addressed in isolation. By considering the full spectrum of an individual’s lived experiences, practitioners are better equipped to design interventions that resonate with participants and address the root causes of health disparities. A holistic approach also fosters a more inclusive and empowering environment, where men feel validated in exploring the multiple facets of their identity and health. For practitioners, this means creating and delivering programs that go beyond surface-level solutions, incorporating strategies that support emotional well-being, community connection, and personal growth, which are all critical for sustainable change among men of color facing complex societal challenges

Further, community involvement in the design and implementation of interventions is a vital component for achieving meaningful and sustainable outcomes, especially in programs targeting men of color. When community members actively participate in shaping the program, it ensures that the intervention is culturally relevant, responsive to local needs, and grounded in lived experiences. This approach fosters a sense of ownership and empowerment, which enhances engagement and long-term impact. MOCHA’s emphasis on peer-to-peer delivery within this community-driven model further strengthens the intervention’s effectiveness by leveraging the shared experiences, cultural understanding, and credibility of peers. This dynamic creates an environment where men feel more comfortable discussing sensitive topics and are more likely to adopt positive health behaviors. For practitioners, integrating community involvement and peer-led delivery is not only a best practice but also a strategy that ensures interventions are both authentic and effective in addressing the unique challenges faced by men of color (Wippold, Frary, Abshire, & Wilson, 2022).

Despite the significant benefits, the high attrition rates indicate a need for strategies to improve retention in health interventions for this population. Practitioners should consider incorporating flexible engagement strategies, ongoing support, and addressing barriers to participation to maintain engagement throughout the program.

Given the positive outcomes observed in MOCHA, similar culturally adapted interventions could be considered for other health disparities affecting men of color. Practitioners should explore ways to adapt and apply these findings in different health contexts and populations.

Limitations and Future Directions

The MOCHA Moving Forward study encountered a few limitations that warrant consideration. Our sample reflects the experiences of Black men in a specific region of New England. Thus, our findings, and the assertions that are made need to be interpreted with caution as they may not directly reflect the experiences of Black men in other areas of the country. Another key issue was the unexpectedly high attrition rate and loss to follow-up, which reduced the final sample size, limiting the generalizability of the findings. Additionally, the reliance on self-reported data for stress and other outcomes introduces potential bias, as self-assessments can be subjective and may not accurately reflect true changes. Importantly, limitations also arose from the relatively short follow-up period, which may not capture the long-term sustainability of the observed reductions in stress and chronic disease risk factors.

Future research should focus on expanding the sample size to include more diverse participants, thereby enhancing the generalizability of the findings to a broader population of Black men. Long-term follow-up studies are essential to evaluate whether the positive effects of the intervention, such as reductions in stress and BMI, can be maintained over time. Moreover, addressing the high attrition rates through improved retention strategies—such as flexible program delivery models and increased participant engagement—will be critical in ensuring the feasibility and scalability of future interventions.

Lastly, incorporating a mixed methods design would have enriched our understanding of both attrition and participant experience. While we initially relied on internal discussions among program staff and steering committee members to reflect on challenges, systematic qualitative follow-up with both participants and dropouts could have provided valuable data. This omission reflects the resource constraints and rapid adaptation required during the COVID-19 pandemic but highlights a critical area for future study design improvements.

Conclusion

This study aimed to evaluate MOCHA’s impact on reducing stress, hypertension, and BMI, significant risk factors for chronic diseases. Additionally, it explored the potential of narrative communication strategies in the MOCHA+ curriculum to enhance its efficacy. While the results did not show a significant positive influence of the narrative approach on stress and chronic disease risk, they do suggest promise for such interventions, warranting further investigation.

Working with socially and economically marginalized populations presents challenges but offers valuable insights to improve future implementations. Despite the encountered difficulties, the findings highlight a statistically and clinically significant program effect for those who completed it—an important achievement. Recognizing this qualification, it is crucial to note that the MOCHA program has empirically demonstrated clear benefits for low/no-income middle-aged Black men who chose to participate.