The intervention components build on each other to strengthen the couple’s relationship. The intervention incorporated Eban, a traditional concept of the Yoruba people of Africa, which means fence – a symbol of safety, security, and love within one’s family and relationships. Group sessions promoted the concept of a village that is a community protected by the fence (Eban). Group cohesion was encouraged through a variety of group activities, including: opening and closing rituals, the Talking Circle, and the setting of group rules for safety and respect. The principles of Nguzo Saba were woven into the theme and content of the sessions and used to motivate couples to use condoms consistently to protect each other and their community. Each session highlighted one to three principles of Nguzo Saba and incorporated them into the activities and discussions in the sessions. Of the seven principles, five (i.e., unity, self-determination, collective work and responsibility, purpose, and creativity) were discussed in two or more sessions, while two principles regarding cooperative economics were highlighted in Sessions 1 and 7. Multiple elements of the intervention served to build each principle of Nguzo Saba between partners and within groups of couples.
Session 1: Preparing for the Journey (group session)
The objectives of the first session were to orient the couples to the purpose of Project Eban, increase their comfort with and commitment to the study, enhance cultural and gender pride, and provide information about STDs, HIV, and safer sex practices. Facilitators introduced the purpose of Project Eban. They emphasized how HIV/AIDS and STDs are affecting the black community and highlighted the importance of couples working together to be safe. In the Talking Circle, participants sat in a circle holding an ankh and introduced themselves. After sharing their reasons for participating, they passed the ankh to the next person. The facilitators led a discussion on the meaning of this symbol. The group rules for participation were generated by participants and facilitators and were posted at each session. Each participant was asked to sign a contract of personal commitment and confidentiality. After orienting the participants, facilitators introduced the seven principles of Nguzo Saba and highlighted how they could be used as a source of cultural strength as well as a blueprint for healthy living and positive well-being. The couples discussed what the principles meant to them and related the principles to their desire to live a healthy life and protect each other and their communities from HIV/STD transmission.
The second half of this session elicited common gender-based challenges to condom use and risk reduction for women and men, and focused on enhancing the participants’ comfort with both group and couple sessions. The single-gender groups discussed and identified participants’ reasons for enrolling in the study. This discussion also focused on possible barriers to attendance and participation. During this discussion, facilitators explored how participants felt about mixed-gender group discussions in front of their partner. Facilitators led activities and discussions designed to enhance culturally-specific gender pride, focusing on the unique resilience of African American women or men as a source of motivation for HIV/STD risk reduction. The facilitators reviewed STD and HIV facts in an interactive exercise. Participants discussed a general and personal list of obstacles to condom use. The single-gender groups brainstormed strategies for overcoming these obstacles before the facilitators reconvened the couples as a village (group). Participants were given a workbook with intervention handouts and facilitators reviewed its contents and discussed the homework assignment for the next session. Participants identified what they loved about their partner and their desire to protect each other from HIV/STDs. This “Cherish Activity” was designed to enhance the couple’s motivation for risk reduction.
Session 2: Enhancing Couple Communication (couple session)
This session integrated three Nguzo Saba principles: “unity,” “purpose,” and “collective work and responsibility.” The focus was on maintaining unity in the family, community, nation, and race, preserving the legacy of ancestors, and discovering each participant’s value to the community. Through the goal-setting in this session, couples defined their “purpose” as a couple and examined how they can apply the principles of Nguzo Saba to their lives.
This session opened by welcoming the couple followed by a brief review of the major topics from prior sessions. The homework assignment from the prior session (Cherish Activity) was reviewed and discussed. Couples were reinforced for their progress on homework assignments, use of Nguzo Saba principles, and discussion about barriers to homework completion. This session introduced two core skills to be integrated in the remaining sessions (see ).
Risk Reduction Curriculum Outline
The first exercise in this session was designed to help couples to recognize common but ineffective patterns of communication. A more effective communication technique, called Talk and Listen, was introduced and demonstrated with a seven-minute video clip. Talk and Listen is a core communication skill that is designed to increase listening capacity and to slow down and clarify the process of couple communication. Training couples to provide clear communication and feedback to each other grew out of sex therapy techniques. Markman, Stanley, and Blumberg58
used the technique in efficacious couples-based HIV prevention interventions,23
and adapted it for the speaking patterns of African American Couples. Using Talk and Listen, partners gain a deeper understanding of each other’s viewpoints, and feelings about issues of potential conflict. Partners alternate being in the role of talker or listener until they have fully heard each other’s viewpoint, concerns, and feelings about a particular issue. The talking partner is asked to hold the ankh or any other meaningful symbol while talking, to be concise in communicating, and to use “I” statements when expressing concerns or feelings related to the issue. When the talker is finished, he or she passes the ankh to the other partner. The listener is asked to paraphrase the key points and feelings that the talking partner conveyed. The listener conveys his or her understanding of the talker’s communication, even if there is disagreement between them. The talker and listener reverse roles until they have completed discussing the issue.
Problem-solving skills were taught through FENCE, an acronym representing cognitive skills needed for communication regarding risk reduction. Couples were encouraged to conceptualize this skill as a way of creating a FENCE of safety around themselves and the community. “F” represented finding out what is going on, which helps define the problem or issue. “E” represented exploring each partner’s feelings, which facilitates understanding of the issue and provides an opportunity to validate each partner’s feelings. “N” represented naming and discussing the couple’s options. “C” represented choosing the best option to solve a problem, and “E” represented executing the plan and monitoring progress.
Couples practiced using FENCE and facilitators provided guidance, praise, and constructive feedback. Through repeated guided practice in the remainder of the sessions, couples developed competence in these two skills. They were encouraged to use Talk and Listen to ensure that they fully understood each other’s viewpoint, and to use FENCE to problem solve the issue together.
In the next activity, couples identified risky behaviors they engaged in as a couple and the level of HIV/STD risk for each behavior. Finally, they set two goals to accomplish in the next seven weeks: one related to reducing HIV/STD risk behavior and one involved with improving their relationship.
For homework, the couples were asked to select which strategies they would use over the next week (HIV risk and relationship) using the Talk and Listen and FENCE techniques to discuss their goals (Practice Skills Learned).
Session 3: Tools for the Journey (couple session)
The Nguzo Saba principle of “purpose” was implemented by couples acquiring the knowledge and skills necessary to protect themselves. The concept of creativity was also integrated into this session to highlight participants’ talent and imagination to build harmony and beauty in their community. The intervention also emphasized how knowledge, wisdom, and creativity have historically been emphasized in African culture and societies.
The homework (Practice Skills Learned) from the previous session was reviewed. Couples recorded their progress on goals of practicing Talk and Listen and FENCE on a Couple Goal Form and rewarded themselves for progress. Alternative methods of managing situations that arose in the homework were discussed and practiced in role plays.
After reviewing the homework, the co-facilitators reviewed male and female reproductive anatomy using pictures and anatomical models, described in detail how HIV/STD transmission may occur, and also discussed common sexual problems that couples experience (e.g., erectile difficulties, inorgasmia and vaginal dryness) that may influence their ability to use condoms. Couples were asked to use Talk and Listen to discuss how to improve their sex life and relationship. Co-facilitators demonstrated how to use both male and female condoms correctly. Both partners were asked to practice correct use of condoms using anatomical models. Co-facilitators reviewed which lubricants were safe to use with condoms as well as how to eroticize condom use. Oral sex, anal sex, and mutual masturbation were defined, and safer sex practices for each were identified (e.g., use of dental dams). Finally, couples learned ways to enhance safer sexual techniques to make sex more enjoyable using the Eban Café exercise (see ). The Eban Cafe is a menu of safer sex activities from which couples “order” to select enjoyable behaviors using communication about sexual activities and safer sex practices. Co-facilitators guided the couple in practicing how to order from the Eban Café, emphasizing the need to choose behaviors that both partners would prefer to engage in. Co-facilitators also worked with couples to review progress on their goals.
For homework, couples were asked to plan a date night and use their creativity to find exciting ways to incorporate condoms and other safer sex methods (Date Night). They were provided a bag of “condom-ments” to take home to promote safer sex behaviors when ordering from the Eban Café Menu. Couples were also referred to a handout that listed what they could do on a date for under $20.
Session 4: Sharing the Load (couple session)
The Nguzo Saba principles of unity, collective work, and responsibility emphasize how the decisions couples make affect their health. The relationship between individual risk and heightened risks to the relationship, family and larger community were discussed in this session. If one member of the couple increased the risk of their partner, there were costs and potential consequences to the children and family as well as the larger community.
During homework review (Date Night), couples discussed their date, including whether they used condoms or other methods to reduce sex-related risk. Any difficulties with using safer sex practices were addressed using the Talk and Listen techniques to understand each person’s perspectives on an issue and then using FENCE to problem-solve it.
The co-facilitators introduced the first main topic, specifically identifying the top three triggers (events and circumstances) that could lead to unsafe sex. Couples practiced their problem-solving skills, using FENCE, to address one of these triggers. In the next activity, the co-facilitators discussed how issues associated with the balance of power and gender roles in their relationship could influence decisions related to engaging in risky behaviors and using condoms. The curriculum highlighted how a history of childhood sexual abuse or partner violence could heighten risky sexual or drug-related behaviors, as well as depression or post-traumatic stress. Facilitators provided examples of how past experiences could affect current sexual decision-making. The Talk and Listen technique along with cognitive strategies to disclose and separate abusive experiences and their subsequent psychological effects from current decisions were recommended for couples to further discuss these issues. Referrals for counseling services that specialized in abuse-related trauma and HIV risk practices were also offered. Thus, participants were not required to disclose their past experiences to partners but were provided with information to assist them in making decisions about seeking counseling to further discuss trauma-related events in their lives.
In the next activity, couples discussed other issues (e.g., use of alcohol or drugs) in their relationship that may have affected their sexual risk-taking behaviors. A game called the “Wheel of Relationship Issues” was introduced, in which couples spin the wheel to select a common issue for serodiscordant partners and then use FENCE to problem-solve it. The next two activities provided opportunities to practice the FENCE technique to discuss medication adherence, if applicable, and other decisions about their sexual relationships. Facilitators prepared couples for the next session and re-introduction into the group of couples known as the “village.” As homework, couples were asked to exchange Couple Connection Coupons to request non-sexual love and affection from each other (e.g., 30 minutes of cuddling).
Session 5: It Takes a Village (group session)
The Nguzo Saba principles of self-determination and unity were integrated into this session. While acknowledging the value of relationships, self-determination involved self-definition rather than being defined by others. Couples were encouraged to make their own decisions about how to stay safe and healthy, despite the perceived racism, ostracism and stigma that they experienced in the outside world. The connection between practicing safer sex and restoring the African American community’s health was highlighted by the process of Reality Construction.51
This process focused on exploring the different ways in which social injustice, fear, and perceived racism may inhibit couples from acknowledging that prevention efforts are not a method to “control behavior.” Reducing risks and engaging in safer sex practices was the primary focus. The importance of knowing the history of health, and educational disparities was emphasized as a way to better appreciate the resilience of African Americans who have confronted social injustice, fear and perceived racism with strategies for social activism.36
The need for social support, a cornerstone of unity, was highlighted in this session. This information was designed to build and strengthen ethnic pride and promote individual and partner self-protection by overcoming perceived racism and stigma regarding HIV/AIDS.
Co-facilitators re-introduced the concept of the group as a village where couples can unite in a safe, respectful, and protected space and gain support. Group rules for participation, including confidentiality, and homework from the last session were reviewed.
Objectives of this session included: identifying strengths of African American communities to make changes and cope with HIV/AIDS; practicing the FENCE techniques to problem-solve barriers to safer sex; and learning to identify and build social networks that promote safer sex. Each participant was asked to describe what pride in their ethnic and cultural group meant to them. Maya Angelou’s poem “Still I Rise” was used to illustrate resilience and inspire couples to overcome obstacles and protect each other in the process. Each couple was asked to use the cognitive strategy FENCE to address a situation that they had experienced in which negative judgments about people with HIV interfered with a serodiscordant couple’s ability to practice safer sex. The desire to avoid reminders of HIV was used as an example of how stigma promotes HIV risk practices.
In the next activity, couples discussed the pros and cons of disclosing their HIV status to people in their support system, and benefits and consequences of non-disclosure.
Single-gender groups discussed obstacles to condom use and brainstormed different strategies for working through these barriers. The mixed-gender group reconvened and shared issues discussed in the single-gender groups.
For homework, couples were encouraged to continue to work on their goals and to share Couple Connection Coupons. They were also asked to complete a worksheet to help them assess their sources of social support and to strengthen their connection to at least one person in their social network. Finally, for the Eban Closing Circle ritual, the group concluded with a Talking Circle in which each person shared what they had learned.
Session 6: Strengthening the Village (group session)
This session integrated principles of collective work and responsibility. Couples discussed living with HIV and participated in the Eban Fence of Safety activity, garnering support from the group or village. Couples were supported in making decisions to protect and support each other from HIV/STD transmission.
During review of the homework, couples shared their experiences with building their social network and their progress on their risk-reduction goals.
The objectives of this session were to enhance identification with the group or village as well as to identify and problem-solve barriers to practicing safer sex. In the first activity of the session, participants were asked to take part in a group-within-a-group exercise called the Eban Fence of Safety (see Formative Study to Develop the Eban Treatment and Comparison Interventions for Couples). During this exercise, the HIV-positive partners formed an inner circle and shared how HIV affects their lives, while the HIV-negative partners listened as part of a protective outer circle. After discussion, the groups changed places, and the HIV-negative partners shared their feelings while the HIV-positive partners listened. This activity was intended to help break through feelings of alienation and to enhance empathy for the challenges each partner faced.
The next activity provided several opportunities to practice the FENCE technique by problem-solving couple-specific triggers to risky behaviors. Facilitators led the group in a discussion about how: 1) condoms could be incorporated into their sex life in an erotic and enjoyable way; 2) couples can be prepared to use condoms to avoid unpleasant interruptions during sexual intimacy; and 3) couples could be intimate with their partner while still protecting each other. Self-talk involving positive, motivating messages were discussed as another strategy for addressing triggers to risks and barriers to being healthy sex partners.
The couples homework (Practice Planning Ahead for Safer Sex) included practicing the skills they learned by developing a plan to address their triggers to risky behaviors and increase safer sex. Couples were also encouraged to continue sharing the Couple Connection Coupons and to use Talk and Listen to discuss the reality of living with HIV.
Session 7: Expanding the Village (group session)
The primary Nguzo Saba principle underlying this session was purpose. Throughout this session, facilitators reviewed how each activity involved the shared purpose of keeping one’s self, partner, family, and community safe.
For homework (Practice Planning Ahead for Safer Sex), co-facilitators asked couples to share their progress on their risk reduction and relationship goals, particularly any examples in which they utilized Talk and Listen, FENCE techniques, or other skills learned. The group offered ideas and support to couples who encountered difficulties in achieving their goals.
Objectives included reviewing skills and information, enhancing sexual communication as well as self-assertiveness skills, and developing strategies to stay connected to the other couples. A game called Safer Sex Jeopardy reviewed and summarized key components of the intervention: how to put on condoms correctly, HIV/STD facts, condom facts, safer sex techniques, communication and problem-solving skills, and Nguzo Saba principles. The next activity involved modeling and role playing how to say “no” to unsafe sex in a loving way, using Talk and Listen and assertive communication. During this activity, couples learned how to consider using condoms as an intimate act of love and protection rather than symbol of mistrust or casual sex. Couples were also encouraged to use the FENCE technique to resolve situations where there might be disagreement about safer sex practices. In addition, couples were provided with Safety and Protection Cards with messages to remind themselves and each other about their commitment to safer sex and to protecting themselves, their families, and communities.
The couples’ homework included creating additional personal Safety and Protection Cards to develop a message that was most meaningful to them in promoting safer sex behaviors. Because this session was the final group session, the facilitators discussed the possibility of couples exchanging contact information, if they wished to keep in touch with each other. The session ended with the Talking Circle and the Eban Closing Circle.
Session 8: Celebrating our Relationship (couple session)
This session reviewed all the Nguzo Saba principles but focused on self-determination, unity, and purpose to identify how to address triggers to risky behaviors, avoid relapse, and maintain safer sex behavior. While the intervention was designed to empower couples with knowledge and skills to reduce the risk of HIV and STD transmission, the facilitators emphasized that each couple had to decide how they would use these skills to keep each other safe.
During homework review, couples shared their experiences with the Safety and Protection Cards and the Couple Connection Coupons and then reviewed progress with their couple goals. Each partner rated his or her progress on a scale from 1 to 10. The co-facilitators reviewed the couple’s progress in learning the various skills taught in Eban (e.g., Talk and Listen, and FENCE) and praised them for specific achievements in using skills and accomplishing their goals.
Objectives included reinforcing safe sex communication and problem-solving skills, developing relapse prevention strategies, re-committing to staying safe and bringing closure to the program. Couples were prepared for possible slips by identifying situations that might trigger a relapse to unsafe sexual behaviors. They were asked to role play how to handle these potential relapse situations using the Eban skills of FENCE, Talk and Listen, and self-talk. Couples were reminded to reward themselves when they met their goal of practicing safer sex and to acknowledge any progress they achieved, in order to build confidence in their abilities to protect themselves consistently. Examples of rewards were identified, including rewarding self-statements and engaging in safer sexual or recreational activities that both partners enjoyed. In order to reaffirm their commitment to practicing safer sex, participants wrote letters to themselves about the promise they made to use what they learned from the Eban Project to protect themselves and their partners from HIV and STDs. These letters were later mailed to participants to remind them of what they accomplished. The session ended with praise and recognition for the work each couple had completed and with an affirmation that focused on making healthy choices. Participants were also given Certificates of Completion and condoms.