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manner. This results in you getting what you want more often, and when not, reaching .... This chapter describes the Assert Yourself course in ASTOR format (see Hartley et al., 1999). The ...... Dodds J, Nardone A & Mercey D (1998) Gay.
Assert Yourself! Evaluating the performance of an HIV prevention intervention Ford Hickson Richard Boxford

Outcome Evaluation

Preface Writing from Florida in 1977, Heimberg and colleges observed: “Recently, we have witnessed a dramatic increase in assertion training, and today it might be conservatively be described as a ‘movement’. Unfortunately, research has not kept pace with the growing number of enthusiastic converts, and a professional innovation is now being marketed as a panacea to an unsuspecting public.”

This report does not seek to market the Assert Yourself course as an innovative solution to HIV infection during sex between men. It does seek to explore what use the course may be in the context of a strategic programme of HIV health promotion activity for gay men and bisexual men. It does this by looking at what happened when the course was implemented, and by raising questions about how we judge the value of HIV prevention activities. At Sigma, the purpose of health promotion evaluation is to enable health promoters to do what they are trying to do, better. The format of this report reflects our aspirations for the collaborative nature of outcome evaluation in HIV health promotion. The first two chapters are authored by someone involved in the commissioning, development and delivery of the intervention (Richard Boxford). These give the background to the course and a description of it. Chapters 3 and 4 are by a researcher from an independent agency (Ford Hickson). These give the evaluation design and its findings. The final chapter is co-authored by the health promoter and researcher, summing up the findings and making recommendations for future implementations of the course. In order to allow this intervention to be meaningfully compared with other interventions, the evaluation uses an ASTOR intervention description (Aim, Setting, Target, Objectives and Resources; see Hartley et al., 1999). This is a systematic way of describing HIV prevention interventions, their implementation and their outcomes. Rather than viewing the outcome of an intervention as simply a function of the method (eg. groups), ASTOR considers the ‘performance’ of the intervention as a whole. We hope this highlights the similarities and differences between Assert Yourself and other interventions. This document reports data supplied by men involved with twelve courses run in London. The evaluation also received useful data from men on two further courses, in Suffolk and Dublin. Many thanks to all the men who generously provided information and gave comments on the course. Thanks are also due to: the SWAN trainers who facilitated the courses; Dr Sharon Abrahams (Institute of Psychiatry, King’s College Hospital) for advice on the meaning of success in evaluation; James Bensley (Gay Men Fighting AIDS) and Peter Weatherburn (Sigma Research) for reading and commenting on earlier drafts of this report; David Reid who conducted the telephone interviews and Dale Brown who transcribed them (both of Sigma Research). Ford Hickson

© Sigma Research Faculty of Humanities & Social Sciences University of Portsmouth Unit 64, Eurolink Business Centre London SW2 1BZ Tel 020-7-737 6223 Fax 020-7-737 7898 www.sigma-r.demon.co.uk ISBN: 1 872956 47 5 November 1999

Contents Preface

1.

Summary

2

Key concepts in assertiveness (Richard Boxford)

4

1.1

What is assertiveness?

4

1.2

Increasing assertiveness

4

1.3

The theory of assertiveness training (AT)

5

1.4

SWAN and the Assert Yourself course

5

2.

Assert Yourself: Intervention description (Richard Boxford)

6

2.1

Aims: what is the intervention intended to change?

6

2.2

Target Group: who is the intervention intended to change?

6

2.3

Setting: how does the target encounter the intervention?

6

2.4

Objectives: what does the intervention consist of?

7

2.5

Resources: what is required to make the intervention?

9

3.

Evaluation questions and design (Ford Hickson)

10

3.1

Assertiveness and sexual HIV exposure among gay men

10

3.2

Assertiveness training in different types of health promotion interventions

11

3.3

Assertiveness and the Assert Yourself intervention

12

3.4

Self-completion questionnaires

13

3.5

Structured qualitative interviews

15

4.

Findings from the evaluation (Ford Hickson)

16

4.1

Target – who got the intervention, did they need it, who dropped out and why?

16

4.2

Setting – how was the course encountered, were the venues adequate, what difference does the course being free make?

21

Objectives – was the course well run, what was it like on the course, what was valued and why?

24

Aims – was the intervention effective, did the intended changes occur, who changed most?

32

Resources – was the intervention efficient?

38

4.3 4.4 4.5 5.

Conclusions & recommendations (Ford Hickson & Richard Boxford)

39

5.1

Conclusions from the evaluation research

39

5.2

Recommendations for future implementations

39

References

41

Appendix

42

SUMMARY: INTERVENTION DESCRIPTION AND OUTCOMES DESCRIPTION

OUTCOMES

Setting Advertising – The course was advertised in the gay press, and internally at Gay Men Fighting AIDS (an HIV health promotion volunteering organisation), and with a direct invitation to men on a health promotion mailing list.

How did men hear about the course? 59% in the gay press; 13% by word of mouth; 8% through Gay Men Fighting AIDS; 7% in a direct mailing; 14% through other or multiple sources.

Location – The courses reported on all took place in London, at the University of London Student’s Union, the FACTS Centre and the Immune Development Trust. All took place at weekends.

No evidence that demographic groups access the course through different routes. ■ ■

Target Group The course is for gay men and bisexual men who want to be more assertive and confident in their everyday lives.

91% felt that the directions to the building were clear. 87% felt that the room was easy to find in the building.

Who got it and did they need it? Course completers are similar to other gay community recruited samples of men resident in London, but a much higher proportion were single. Before the course (need) ■ 32% had a ‘low’ assertiveness score. ■ 41% agreed they find it hard to say ‘no’to sex they do not want. ■ 54% disagreed they can usually tell their partners what they like to do sexually. Attrition ■ 53% of men booking a place completed the course. ■ 68% of men attending Day One completed the course. No evidence for an association between attrition and either demographics or indicators of need.

Objectives Four 6 hour meetings (2 days on, 19 off, 2 on) with 12-14 men and 2 trained facilitators + Reflection and communication on change one month after course finishes. During Day One, men set their own goals for the course using a personal programme, identifying situations which they would like to be more assertive in. The course provides a space to share ideas about solutions to these situations and an introduction to assertive techniques for dealing with them. Group discussion in a relaxed and safe environment allows men to: ■ explore the relationship between feelings, thoughts and behaviours. ■ acquire an increased awareness of rights and responsibilities. ■ explore barriers to choice, change and communication. ■ practise skills through role play. ■ experience personal power through use of assertiveness in controlled supportive environment.

2

What happened? Courses started with approximately 13 men and lost an average of four before the end. ■ 5% felt the waiting time for a place on the course was unreasonable. ■ 88% felt the organisation of the course was good.

■ 25% would have liked more information about the course beforehand.

93% felt the course leaders listened carefully to what they said. 93% felt they were treated with courtesy and respect. ■ 91% felt the course leaders knew what they were doing. ■ ■

• •

The quality of the course administration & its delivery was high. The course provides is a safe and supportive environment for the majority of men.

ASSERT YOURSELF!

Aims To increase men’s ability to choose who they have sex with and what kind of sex they have, and to ensure men are equipped and competent to negotiate sex. The personal resources and interpersonal skills needed to negotiate sex are not specific to sexual situations but are general life skills.The aims of the intervention are therefore not sex specific.They are: 1. Increased ability to recognise choices. 2. Increased communication skills (eg. ability to: make requests; say ‘No’; negotiate compromise; express feelings; give and receive compliments). 3. Increased ability to instigate change (eg. ability to: make assertive challenges; give and receive constructive criticism).

Is it effective? Because of the course (N=84 course completers): ■ 82% felt they were able to recognise more clearly the choices they have in everyday life. ■ 72% felt they were more able to express themselves. ■ 72% felt saying ‘no’ had become easier – less common among men in long term relationships. ■ 68% felt they were more able to make everyday requests. ■ 61% felt they had increased the value they placed on being gay – particularly older men and those not diagnosed HIV positive. ■ 2% felt the course was a complete waste of their time. ■ 94% would recommend the course to other gay men who wanted to be more assertive.



The majority of men felt the course worked for them.

After the course (need among course completers) 6% had a ‘low’ assertiveness score (32% before) ■ 12% agreed they find it hard to say ‘no’ to sex they do not want (41% before) ■ 21% disagreed they can usually tell their partners what they like to do sexually (54% before) ■ Mean assertiveness score was significantly higher after than before the course (p