Table 3.

Illustrative quotations for mechanisms of actions from post-workshop and post-PEACHES surveys and interviews among healthcare providers

Mechanisms of action	Illustrative Quotations
Knowledge Awareness of anal pleasure and health acquired as a result of PEACHES	“Knowing some do’s and don'ts, knowing that it doesn’t have to be painful, and it should be pleasurable to the person… a lot of times when you grow up and then you're, especially if you’re growing up a young gay person especially within the Black community, talking about sex, it’s not spoken about. And so, you honestly learn everything on your own…when you don’t know any better, you get information from people who also don’t know any better.”—Participant 2—Post-Workshop “My verbiage with talking to them about certain things, pertaining to the ones that are having anal sex, so just being able to talk a little bit more about what I learned has helped a whole lot. So, that has been a huge help for me, because now I’m not afraid to have those conversations with them.”—Participant 36—Post-PEACHES “I feel like a lot of the times when I spoke to people beforehand, they were from those ‘little t’ truths. From those personal experiences. Now, I feel like I can give them a ‘big T’ truth because it’s pushed by and backed by some hardcore information and hardcore research that I personally didn’t know was out there.”—Participant 58—Post-PEACHES
Skills Increased ability or proficiency to perform either Target Behavior 1 or 2 acquired through PEACHES	“So, I can tell you prior to that workshop I didn’t ask somebody, ‘Is your anal sex enjoyable?’ I didn’t really honestly want to know, because I was like my patients share a lot of stuff, and I would just be like no, I don’t want to. But now I feel like when I learned how to do PrEP [pre-exposure prophylaxis for HIV], I feel like I have a lot more knowledge to open up that conversation. Whether they want to have it or not, it’s okay, but at least I feel like I can open it and ask them and be able to share information if I say, ‘Is your sex pleasurable?’”—Participant 55—Post-Workshop “Again, like the ask-offer-ask [from motivational interviewing], asking what they know and then giving them the chance to respond. And then, you know, like asking them would they care to know what I know, and then sharing that with them as well. And then, again, going into the conversation just sharing that anal sex does not have to be painful. It can be 100% painless and pleasurable for those who are engaging. And just letting them know that it’s practiced by a lot of people, just basically destigmatizing anything or like most of the common things that people in our community hear about it before going into their concern.”—Participant 14—Post-Workshop “[After PEACHES,] I like to make sure that people are more comfortable talking about their booty hole and their bottom. It’s definitely – it’s so silly – but one of my rectal swabs that I collect, I like to remind people now that, ‘Hey, this is your anus and your rectum. It’s meant to do a certain thing which is push out poop or fecal matter, and that means when you get this swab for me it might have a little poop on it, and that’s okay.’ And that was not a conversation I was maybe as comfortable having before this thing, which you think as a nurse I would be but it just, that’s another seed I plant. It’s like, ‘Hey, we're going to be comfortable with fact that there's poop on this swab.’”—Participant 33—Post-PEACHES
Empathy/attitudes Understanding and acceptance of the feelings and behaviors of people who engage in anal sex, acquired as a result of PEACHES	“When I look at things, I like to know the science behind everything. And I really enjoyed that we learned the science behind it. Because once you kind of know how everything works together, you understand why other people enjoy anal pleasure and things like that. And you it kind of just takes out all the judgment because you now know the physiology behind everything.”—Participant 4—Post-Workshop “It just made me more knowledgeable of why people enjoy things, whether it’s men, heterosexual men or even women. It just showed me the part why they do it, why they choose to do it because it is pleasure for them. It’s not always pain.”—Participant 11—Post-Workshop
Beliefs about consequences Perceptions about positive results or what will be achieved from undertaking Target Behavior 1 or 2	“I get to bring this information back, not only to my patients, but also to people in my community and friend group, who honestly need this information. I think that they can share that information with their friends and their community, just like I talked about I was going to do with my friends and my husband’s friends. It gets it all out there when it’s needed because let’s face it, you're not talking to your doctor about these things. You're talking to your friends. If one of your friends in the room knows the information, it’s golden. It’s the best thing.”—Participant 33—Post-Workshop “These young men, they feel very defeated. They feel like it’s hopeless. They feel very hopeless, and it’s like, ‘Well, it doesn’t matter, I’m going to get HIV anyway’…They feel like, ‘Well, there’s nothing I can do anyway. I’ll probably just get it’, so they don’t take any kind of precautions. So, if you approach them, I think, from this angle, I think it would be a lot more beneficial."—Participant 8—Post-Workshop “This workshop taught me that if I teach people how to safely engage in anal sex and, like, incorporate the pleasure, like they could naturally prevent themselves from getting certain STIs or STDs, prevent themselves from, like, tearing and hurting themselves. It’s not always about, like, HIV prevention. Like that’s not the main topic. The main topic is, ‘Hey, come and engage in these, or use these tips and tricks to up your pleasure’, and you’re secretly also benefiting from, I guess, like harm reduction-style methods as well.”—Participant 9—Post-Workshop
Informational resources/patient-facing materials changes in a person’s physical or social surroundings resulting from PEACHES that encourage target behavior 1 or 2	“I like the website because it gives the patients ways to engage with their provider as far as, like, feeling comfortable to ask their provider questions? Like before, I think it’s a conversation piece that’s hard for them to talk to their provider. So, now when I give this information to them, especially the person who visited the website, he’s able to come back and have a conversation around anal pleasure. And feels like he’s able to talk about it instead of not saying anything at all. Just coming for the follow-up appointment, he’s able to talk about his issue or questions he might have involving anal sex.”- Participant 27—Post-PEACHES “The palm cards are also a very useful tool to handout to patients. They offer an alternative to providers who might not have the comfort level with anal health but still want to educate their patients.”—Participant 7—Post-PEACHES
Organizational context and resources changes in a person’s physical or social surroundings resulting from PEACHES that encourage target behavior 1 or 2	“I think that the two-day workshop was like an amazing first step. And it definitely got everyone in my practice’s wheels thinking about it. But the whole three and a half months where we’ve had support, working out some of these processes that we started thinking about at the workshop, that’s really solidified for our organization how we do it, why we’re doing it, and the best practices that we can take for these changes.”—Participant 3—Post-PEACHES
Self-Efficacy/ Confidence Increased belief In one’s ability to successfully carry out target behavior 1 or 2 as a result of PEACHES	“It gave me the confidence and the comfortability to be able to kind of talk about these things rather than completely ignoring them and putting up a wall to them, which is what I would have done before when I felt uneducated. Now I feel like I can plant some seeds, and as I work with my patients more when they come back, I can ask these questions and talk to them about these things without a lot of fear and anxiety.”—Participant 33—Post-PEACHES "After the workshop, I realized pleasure and health go hand-in-hand and, in fact, centering pleasure is how we can help people practice harm reduction and engage in safer behaviors. I am now confident that anal pleasure and health can be integrated into settings/environments that are largely conservative, like Alabama.”—Participant 53—Post-Workshop
Comfort and positive & negative emotions feelings of being at ease, comfortable, relaxed with the topic of anal pleasure and health, acquired as a result PEACHES	“I just had some personal stigma around anal pleasure and health, and just maybe living in the part of the country where I do, I was kind of nervous about approaching that subject. So, I think that what, the most powerful thing that the workshop did is it kind of helped with my own personal feelings, allowing me to then be able to broach the subject with clients and not get bogged down by my own maybe personal insecurities or questions or shame or stigma about the subject.”—Participant 3—Post-Workshop “I think feeling more comfortable because beforehand, one, I came in not knowing that much ‘cause I don’t come from like a clinical biological background. So, I think having those resources to interact with, it’s just has built my comfortability and confidence with discussing things like this because even if I get stumbled, I have a resource that I can refer people to. So, I think just me being comfortable in, one, talking about the topic and like I said, my confidence and being able to answer people’s questions and refer them to the information on the website.”—Participant 43—Post-PEACHES
Intentions The conscious decision to perform target behavior 1 or 2 in the future, as a result of PEACHES	“By ourselves or with people that we’re close with, maybe anal sex isn’t a big deal, but one of the points I feel of this workshop is you are now having to talk about something that you might not be used to talking about in a more public setting… which was just a little bit of that social push within my community to say, ‘Anal sex is normal, it’s okay. And look, I’m in this group of other people who work in my city, and we are all learning about it together and addressing it as professionals.’”—Participant 3—Post-Workshop “I definitely think that the study and the client-facing materials all sort of put into perspective that people are having these conversations, maybe not within our walls, but we have to meet people where they are. And if this is what people want, this is what people want. So, I definitely think it showed that we have to meet the mark, so to speak.”—Participant 35—Post-PEACHES “One thing about our organization is we want to be able to, of course, assist our clients in whatever area they may need. I think this brought up an area that we may have missed, per say. But, now that we are trained in being able to have conversations about anal pleasure, it helps make up an area where we may have fallen short.”—Participant 54—Post-PEACHES