Adaptation and feasibility of Many Men Many Voices (3MV), an HIV prevention intervention to reduce intersectional stigma and increase HIVST among YSMM residing in Ghanaian slums – A clustered pre-post pilot trial protocol.

Adaptation and feasibility of Many Men Many Voices (3MV), an HIV prevention intervention to reduce intersectional stigma and increase HIVST among YSMM residing in Ghanaian slums – A clustered pre-post pilot trial protocol. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Adaptation and feasibility of Many Men Many Voices (3MV), an HIV prevention intervention to reduce intersectional stigma and increase HIVST among YSMM residing in Ghanaian slums – A clustered pre-post pilot trial protocol. Gamji Rabiu Abu-Ba’are, Kwasi Torpey, LaRon Nelson, Donaldson Conserve, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4313437/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Young sexual minority men (YSMM) living in slums face high risks of contracting HIV due to poverty and limited healthcare access. Certain areas in Accra's slums have much higher HIV rates than the national average, around 7% compared to 2%. YSMM in these areas struggle to access services, have lower perceptions of HIV risk, less education, and face poverty, leading to low rates of HIV testing. These YSMM also encounter increased stigma because of where they live, like in the slum area known as "Old Fadama" or "Sodom and Gomorrah." This stigma affects their willingness to get tested for HIV and adds to other stigmas related to their sexuality and gender expression. Ghana's efforts to improve HIV testing for YSMM face challenges such as stigma, low-risk perception, and concerns about confidentiality. Introducing HIV self-testing (HIVST) offers hope to increase testing among YSMM by allowing them to test in private. However, there are challenges with implementing HIVST in Ghana, including limited knowledge and fears of stigma. Advocates suggest integrating HIVST with existing testing methods to improve access and inclusivity for YSMM in Ghana. Methods The study adapts the 3MV approach into a modified version called LAFIYA to combat intersectional stigma and enhance HIVST among young cis-gender men who have sex with men (YSMM) in Ghana. Using the ADAPTT-IT framework, the study plans to implement three aims, refining the adapted intervention, creating a manual for LAFIYA, and conducting a pilot test to assess acceptance, feasibility, appropriateness, and preliminary efficacy in reducing stigma and increasing HIVST among YSMM. Conducted within urban slum communities in Accra, the research intends to recruit 20 YSMM and 20 providers, stratified into nurses and community organization providers. The study employs a starfish sampling to recruit YSMM and purposive sampling techniques for providers. Eligibility criteria for YSMM include specific age, lack of experience with unassisted HIVST kits, identification as cis-gender men, recent engagement in sex with another man, and residency in the Greater Accra Metropolitan area within a slum community. Providers must have at least one year of experience in sexual health services and working with YSMM on HIV prevention and care within the same geographical area. Discussion The adaptation of the 3MV approach into LAFIYA aimed to tackle intersectional stigma and improve HIVST among YSMM in Ghana. The study's primary objective focused on assessing the acceptance and feasibility of this modified method in reducing stigma and increasing HIVST uptake among YSMM. Organized into three core objectives, the research evaluated the presence of stigma, transformed 3MV into LAFIYA , and rigorously examined LAFIYA 's effectiveness in reducing stigma and boosting HIVST uptake among YSMM. Following the ADAPTT-IT framework, the study systematically progressed through different stages to produce a comprehensive manual for the LAFIYA intervention. This foundational study set the groundwork for a larger-scale trial intended to assess LAFIYA' s effectiveness in reducing stigma and enhancing HIVST among YSMM. Trail registration This study is registered on clinicalTrail.gov, with identifier number NCT06238323 on 02/02/2024 https://clinicaltrials.gov/study/NCT06238323?locStr=Ghana&country=Ghana&cond=HIV&aggFilters=status:not%20rec&rank=4 Health Policy Figures Figure 1 Introduction Intersectional stigma and discrimination (ISD) significantly impact HIV testing and care among sexual minority men (SMM), gender nonconforming (GNC) men, and people living with HIV (PLHIV) in Ghana and sub-Saharan Africa (SSA) 1 – 4 . In SSA and Ghana, factors such as insufficient HIV knowledge and the association of HIV with sin and death lead to stigma against PLHIV. Stigma faced by PLHIV includes rejection, verbal abuse, violence, and denial of care 4 – 7 . SMM also face stigma due to societal opposition to same-sex acts, with a majority of Ghanaians disapproving of such relationships 5 , 8 – 14 . SMM who express in ways considered feminine in Ghana encounter ISD (multiple stigmas) related to both sexuality and gender expression, as these traits conflict with societal gender expectations for Ghanaian men 3 , 5 , 7 . ISD deters SMM from seeking HIV testing, as they avoid healthcare facilities to evade stigma associated with HIV, sexuality, and gender expression 4 . Beyond institutional and community-level ISD, interpersonal rejection and isolation are experienced by GNC SMM and SMM living with HIV within the SMM community 1 , 3 , 5 , 15 , 16 . Some individuals internalize these community-level stigmas, leading to feelings of guilt, shame, and reluctance to seek HIV testing or care in stigmatizing environments 5 , 10 , 15 – 17 . Studies indicate that over 50 to 60% of SMM delay or avoid HIV testing due to stigma, often waiting until they fall ill 3 , 10 , 17 – 19 To address ISD, Ghana aims to integrate ISD reduction strategies into interventions, recognizing the urgent need to mitigate testing avoidance, and HIV transmission among key populations like SMM and YSMM 4 , 5 , 18 , 20 . Though less than 2% of Ghana's population, SMM record an HIV prevalence of 18%, surpassing the national rate of 2% by more than eightfold. This stark contrast emphasizes the urgent need for prioritizing interventions to enhance detection and linkage to care, which is essential in curbing community spread 18 , 21 – 23 , specifically focusing on YSMM as they have increased HIV-risk behaviors and high HIV prevalence rate 24 – 27 . While limited studies focus on YSMM, the Ghana AIDS Commission estimate show that YSMM between 18 to 24 years form a sub-risk population within SMM, representing 63% of known HIV cases among SMM in Ghana 23 . Our research, alongside others focusing on a subset of YSMM within the broader SMM community, reveals that apart from facing similar challenges as older SMM, YSMM also face ISD around preventive behaviors. Many feel unable to discuss HIV prevention or even purchase or carry condoms due to societal perceptions against premarital sex among young people in Ghana 27 – 30 . The US President's Emergency Plan for AIDS Relief (PEPFAR) and the Ghana AIDS Commission have acknowledged the necessity to focus on YSMM and other priority groups 20 , 23 , 31 . Moreover, global surveillance data highlights exceptionally high HIV incidence among YSMM in SSA and globally, due to unique barriers to HIV testing, including low-risk perception, active sexual engagement, and limited testing practices within this demographic 24 , 32 , 33 . Why a focus on urban slums? Living in urban settings, particularly slums in SSA, contributes to the heightened risk of HIV infection 34 – 37 . Slum areas accommodate more than 45% of Ghana's urban population, with around 40% residing in Accra, our primary study area 38 , 39 . For instance, SMM in Accra stands notably higher at 44% compared to the national average of 18% among SMM 18 , 40 YSMM in slums face heightened vulnerability, considering these areas are documented as high-risk zones for HIV transmission due to structural challenges like poverty and limited access to healthcare, alongside predictors such as transactional sex 37 , 41 – 45 . Notably, certain slum regions within Accra report significantly higher HIV prevalence rates, averaging around 7% compared to the national average of 2% 18,46 . YSMM in these areas experience challenges accessing services, possess lower perceptions of HIV risk, face lower educational attainment, and grapple with poverty, all contributing to low rates of HIV testing 47 – 53 . Moreover, YSMM in slums may encounter escalated ISD compared to other SMM. For instance, a slum area known as "Old Fadama" or "Sodom and Gomorrah" in Accra is associated with social vices like high crime rates and the sex trade, contributing to negative stereotypes about the area 54 – 60 . Consequently, YSMM in these communities may confront not only stigma related to HIV, sexuality, and gender expression but also the stigma attached to their place of residence, potentially leading to internalization of stigma that impacts their willingness to undergo HIV testing. The spotlight on slum areas aligns with the Ghana National AIDS Control Programme and PEPFAR's strategies, focusing on redirecting HIV behavioral interventions from a generalized approach to targeting high-risk geographical areas burdened with HIV prevalence 20 , 23 , 31 . Although limited, our formative work in Ghana shows that increased ISD and apprehensions regarding confidentiality and privacy in healthcare settings act as significant barriers to testing 1 , 3 – 5 , 13 , 61 . Many SMM express the need to hide, avoid other SMM, especially those with feminine gender expression, and avoiding testing in their local community. Some were also open to testing but prefer to travel outside the community for safety reasons and hope for better environment for testing, prevention and care services. Is HIVST a possible option? The introduction of HIVST holds promise in potentially increasing testing rates among YSMM by offering the convenience of testing in preferred locations without interpersonal interactions 28 , 62 – 64 . Notably, in other contexts, HIVST has garnered higher acceptance rates, reduced stigmatization, and attracted individuals testing for the first time 65 – 68 . However, its implementation in Ghana and SSA comes with its own set of challenges, including limited knowledge about HIVST, inadequate follow-ups, and fears related to stigma and disclosure of results 28 , 63 . Therefore, it is crucial to emphasize the necessity of community-based interventions to overcome obstacles associated with the uptake of HIVST in the country 28 , 63 . Recognizing the potential of HIVST to complement Ghana's existing testing protocols conducted by nurses in facilities and homes, WHO, Ghana's HIV/AIDS Policy and community-level implementers advocate for its integration 18 , 28 , 63 , 69 . As such, the current study aims to: 1. Assess ISD and options for HIVST implementation. 2. Adapt 3MV to LAFIYA to address ISD and HIVST among YSMM. 3. Test acceptance, feasibility, appropriateness, and preliminary efficacy of LAFIYA to address ISD and increase HIVST uptake. Theoretical Underpinnings This study draws from the Health Stigma and Discrimination Framework (HSDF) perspectives and scientific evidence from Ghana and SSA to postulate that stigmatized characteristics (e.g., sexual minority, gender expression, sexual act at a young age, and place) intersect with HIV stigma to impact HIV testing among YSMM negatively 5 , 9 , 13 , 70 . The drivers and facilitators of ISD include gender norms, ignorance around HIV transmission, beliefs around morality associated with HIV, and related characteristics of persons (e.g., sexual minorities) 5 , 9 , 13 , 70 – 73 . ISD manifests through stigmatizing experiences such as social exclusion, gossip, discrimination in healthcare facilities, etc. It can also manifest at the interpersonal and intrapersonal levels, where YSMM stigmatize other YSMM for feminine expression or HIV status. YSMM can also accept negative societal perceptions about SMM, PLWHIV, or slums and begin to blame themselves, develop self-doubts, etc 5 , 9 , 13 , 70 . ISD can lead to adverse health outcomes such as increased risk behaviors and low testing, as internalizing the ISD forces YSMM to remain closeted and isolated. Thus, highlighting the importance of addressing the drivers and facilitators of stigma and manifestations of stigma and building the capacity of YSMM (Fig. 1 ) to avert adverse outcomes such as low testing 5 , 9 , 13 , 70 . The Proposed Intervention . The 3MV remains the only CDC-recommended evidenced group-based intervention focused on addressing barriers to HIV prevention, combating HIV risk and transmission, and influencing behavioral change to increase condom use and HIV/STD testing among BlacK SMM in the United States 74 – 77 . Our previously adapted 3MV addressed Ghanaian SMM contexts such as religion, sexual identity, and gender norms and expectations 6 , 28 . The previous versions do not address the ISD around age and sexual behavior or place-based factors that could increase risk or hinder testing; they did not also build capacity for HIVST and linkage to care. The proposed version, LAFIYA , will focus on building awareness of self and knowledge around ISD to reduce the interpersonal and internalized stigma experiences among YSMM (Fig. 1 ). Also, a traditional HIV testing process will require a visit to a healthcare facility where YSMM will interact with a wide range of people aside from the provider 78 – 80 . The LAFIYA intervention will alter this process by increasing YSMM's capacity for unassisted HIVST. Whereas a third component focusing on providers is necessary to ensure follow-up and connection to care, LAFIYA will focus on interpersonal and intrapersonal behavioral change capacity building so that YSMM will be self-motivated to drive their HIVST decisions. Nonetheless, unlike the previous 3MVs, healthcare providers previously trained by our team in a facility-wide stigma reduction intervention in Ghana will be engaged as part of the study to provide follow-up, confirmatory testing, and linkage to care for YSMM 4 . The focus on HIVST and slums also aligns with PEPFAR and Ghana's new commitment stipulated in its 2019 National HIV and AIDS Policy to increase HIVST among key populations and to focus on location-based intervention delivery models, especially for YSMM within slum communities 6 , 18 , 63 , 81 . Methods Study design Preliminary Studies ISD experience among SMM and YSMM . In our recent studies in Ghana 5 , 7 , 82 – 89 , we identified that SMM face various forms (e.g., experienced, anticipated, perceived, and internalized) of stigmas concerning sexual behavior or sexuality and gender expression. SMM face stigma due to the attribution of same-sex sexual acts to indiscipline, immorality, and evilness and the perception that same-sex sexual acts come from foreign cultures, not the Ghanaian culture. Also, HIV stigma continues to thrive due to the perception that contracting HIV signifies a punishment for sin and insufficient knowledge of HIV transmission. As such, SMM receive insults, gossip, avoidance, and sometimes physical violence. To circumvent stigma, many SMM avoid interacting with healthcare settings or avail themselves for HIV testing, thus providing evidence for the need to find alternative ways to combat stigma and increase testing. Feasibility of adapting 3MV for YSMM in Ghana . We previously used the ADAPT-ITT framework to modify the 3MV to address HIV prevention and testing among SMM (n = 52), including YSMM ages 18 to 25 (37%) drawn across Ghana 28 , 29 . The community partners (PORSH) recruited the SMM, with only one person dropping out of the study due to illness. We provided education on HIV and STI risk and HIV testing. Our study recorded a condom use increase of 15% for anal sex (rel. f. = 0.80–0.95) and 13% (4–17%) for HIV testing among participants in one-week post-intervention. Also, irregular testers decreased by 10% (47–37%), and 100% reported understanding the need for HIV testing. Participants in the study prepared a personal prevention menu to identify and plan ways to reduce HIV risk behaviors and engage in HIV testing. Participants reported that the intervention was acceptable to them, as it created a friendly and safe environment to express views, build social networks, and learn about HIV without prejudice 28 , 29 . Nonetheless, there is the need to adapt further to address ISD, place and age-related disadvantages, building capacity for HIVST and care, and testing our findings in a larger efficacy trial in a larger RO1. The need to address ISD, HIV risk, and testing among YSMM and YSMM in Ghanaian slums. In our recently completed formative study among YSMM in slum communities, we found that some of the YSMM have an increased risk of HIV infection, face ISD, avoid HIV testing, or even visiting HIV facilities in the community due to fear of HIV stigma. They, however, expressed willingness to try HIVST. In the qualitative interviews (n = 15), transactional sex appeared prevalent among participants for various reasons, the most prominent being poverty and challenges with food insecurity. Others assume sex work as their primary source of income or accept payments or benefits for sex if offered. All participants were not confident in going for HIV testing within healthcare facilities, especially in slum communities. Participants preferred alternatives such as organizations that provide them with care tailored through community outreach. Thus, if we combat ISD and build capacity for HIVST, there is a high chance that YSMM will use HIVST. In the quantitative data (n = 100), 60% had no specific source of income, and 70% sometimes could not afford three meals a day. Thus, our sample shows the financial challenges facing YSMM in slum communities. On HIV risk behaviors, over 49% indicated having sex with 4 to 11 sexual partners, and 41% had 1 to 3 sexual partners within the past month. 50% described their regular sexual partner as casual sex partners and 17% as strictly transactional sex. Whereas the majority (68%) do not know the status of their sex partners and (57%) did not disclose their HIV status to sex partners, half (50%) wish they could talk about HIV testing with partners. The majority have shown interest in discussing HIVST or using HIVST with partners (65%) if available. The findings show that despite high-risk behaviors, experiences of stigma, and impoverished conditions, YSMM are willing to learn and use HIVST kits. As a follow-up, we conducted a focus group discussion with providers (n = 9) who indicated that the main challenge in upscaling HIVST is the capacity to implement HIVST, as many who come to facilities opt for assisted testing. This finding corroborates recent publications on perspectives of HIVST among providers across Ghana that singled out the capacity to implement HIVST as a barrier to implementation, considering that it's a newly introduced technology in Ghana. Implementation science lessons for adapting HIVST to YSMM in Ghana . In our implementation science assessment of HIV testing studies in Ghana and SSA among YSMM, we established that scholars must consider several barriers and facilitators when implementing HIV testing among YSMM 6 , 81 . We found that external factors (e.g., volatile political environments and stigma) continue to affect the participation of YSMM in HIV testing. Also, access to friendly services and resources for testing remains a barrier. We also identified that although YSMM, especially in slums, remain a priority for HIV intervention, no specific studies in Ghana or West Africa were tailored to their needs; instead, they only occur as part of a larger adult population sample. Nonetheless, we note that partnering with community organizations in the recruitment and implementation of interventions facilitates an increase in reach, recruitment, and successful implementation of interventions 6 . Thus, we focus attention on YSMM to address their unique experiences with ISD and HIV testing by leveraging already existing community partners that have established trust and deliver interventions to SMM in Ghana. Another critical shortfall identified in previous interventions is the lack of follow-up to ensure linkage to care. This study will therefore involve already trained nurses in our earlier studies to follow up with YSMM after they uptake testing to ensure that those who test positive are linked to the care needed. Implementing strategies . AIM1. Assess ISD and options for HIVST implementation among YSMM. ADAPT IT, Step 1 (Assessment). The first step of the study will constitute the assessment phase, where we will conduct in-depth interviews (IDI) with YSMM and providers (trained nurses and CBOs). We aim to deepen understanding of ISD and barriers and facilitators of implementing HIVST among YSMM. Examining perspectives and experiences of stigma and HIVST among providers and YSMM will allow for a comprehensive understanding and integration of realities from both providers and YSMM to optimize the potential of the adapted intervention to address ISD and increase HIVST. We chose IDIs here based on their proven success in allowing in-depth openness from YSMM and providers about their experiences and perspectives on issues of private nature 7 , 90 , 91 . We will qualitatively examine the following. YSMM Evaluate experiences of ISD (e.g., HIV, place, gender expression, sexual) and navigating HIV testing services and how such experiences influence HIV testing decisions. Assess knowledge of HIV, prevention options, willingness to use HIVST, and preferred means of ART initiation or HIV prevention after. Identify feasible options for engaging with HIVST (home, health care setting, etc.), as some YSMM may live in shelters and face privacy challenges. Providers Assess experiences with implementing HIV testing and HIVST to YSMM Assess the role of stigma and other facilitators and challenges of HIVST implementation among YSMM Solicit recommendations for combating stigma and increasing HIVST uptake and connection to care after testing. Sampling and Recruitment Technique: To recruit YSMM , we will employ starfish sampling, which combines venue/time-based and chain referral techniques to reach hidden populations 92 . We have used both venue-based and respondent-driven strategies independently in previous studies; however, integrating both through starfish sampling will allow us to optimize reach as YSMM in Ghana remain hidden 5 , 29 . Here. PORSH will contact YSMM through their outreach services to SMM and invite them to participate in the study. We will then ask YSMM who consent to the study to refer other YSMM known to them. To recruit providers , we will use the purposive sampling technique 93 . Here. We will invite participants due to their specific abilities to provide unique and in-depth information necessary to answer the research questions. This sampling method remains best for our process, considering that YSMM in Ghana remain hidden due to criminalization and stigma. The providers' identities remain confidential and only known to the team and other SMM because of previous training and their roles around providing care to SMM in the country. We will also use stratification for providers to enable us to reach nurses in healthcare settings and providers within CBOs who offer confidential sexual health services to SMM. Sample Size . We will recruit 20 YSMM and 20 providers stratified into nurses (n = 10) and community organization providers (n = 10) or until we reach saturation. A sample size of 20 equals or exceeds other standard IDIs conducted among SSM and providers 5 , 29 , 94 . Thus, it will allow for comprehensive coverage of necessary information to reach saturation and provide enough information to inform the next stage of the study. Inclusion and exclusion criteria. YSMM To be eligible to participate in the interview, the person must be between 18 to 25 years old, have no experience using unassisted HIVST kits, do not know their HIV status or tested negative, currently identifies as cis-gender man, and have had sex with another man within six months before engaging with the recruitment team and must reside within a slum community in the Greater Accra Metropolitan area. Providers. To be eligible to participate in the interview, the person must have experience providing sexual health services such as HIV testing, counseling, and linkage to prevention and care services for at least one year. Must reside within the Greater Accra Metropolitan area and have worked with YSMM on HIV prevention and care. Data Collection . YSMM. Data collection from YSMM will be conducted by trained SMM interviewers who conducted IDIs in our previous studies with YSMM in Ghana. Providers : Data from providers will be collected by PI and Dr. Manu (Site Co-I); they both have experience researching with providers in Ghana. We will digitally record all YSMM and provider IDIs. Trained YSMM research assistants from PORSH will transcribe the data verbatim in a private space to ensure privacy. They will also translate interviews where the language is not English; the site PI will verify such translations for accuracy. The recordings will then be encrypted and uploaded to a server at the University of Rochester. Data Analysis. We will analyze the qualitative data in two phases to 1) Identify areas and content for adapting the intervention and 2) publish study findings. We will use Dedoose qualitative data and analysis software to manage and analyze the qualitative interviews. For intervention adaptation , we will use a summative analysis process, dividing the transcripts among four investigators (Abu-Ba'are, Nelson, Conserve, and Torpey) to review and provide critical summaries of key findings from the IDIs. Two investigators will review each transcript to ensure we establish the reliability of the information extracted. Nelson and Abu-Ba'are will then systematically combine the summaries by identifying major points from each summary that address the drivers and manifestations of ISD, HIV testing experiences, options for HIVST, barriers and facilitators to HIVST implementation, and recommendations for factors to be considered in the intervention to address ISD and upscale HIVST. YSMM research assistants who conducted the interviews will review the final summaries to ensure its consistent with their understanding and realities of the YSMM interviewed. For manuscript development , we will conduct a more detailed qualitative content analysis. In this procedural approach, we will categorize and review data iteratively to generate conclusions based on the text's explicit and implicit meaning. Led by Nelson, with support from Abu-Ba'are, Torpey, Conserve, and YSMM research assistants in Ghana, we will use open coding to identify categories and create a thematic codebook from the transcripts. The coders will independently apply the codebook generated to a sample of transcripts (4 each for YSMM and provider transcripts). They will meet to review line-by-line coding, discuss discrepancies, and review and update the codebook to ensure consistency in coding. They will then divide the remaining transcripts and independently code them using the finalized codebook. Code excerpts will then be exported from Dedoose for consolidation to answer the research questions. AIM2: Adapt 3MV to LAFIYA to address ISD and HIVST among YSMM ADAPTT-IT Steps 2 to 7 Step 2 Decision . Using the information gathered from AIM1 (Assessment Step). In partnership with SMM implementers and providers, the team will meet to discuss the results and identify specific intervention activities that should be modified to address ISD and HIVST. We will also look for ideas from previous interventions by conducting a review to identify evidence-based best actions to address ISD and HIVST among YSMM for consideration in our decision-making. We will then finalize the specifics of the existing intervention that needs to be adapted to ensure we fully incorporate ISD reduction and HIVST focus on the intervention. Considering that the team has diverse persons with local expertise (PI, site PI, 2 co-I, community organizations, and consultants, most of whom are SMM, we will ensure that the intervention content and adaptation meet the local context of religion, language, and HIV communication, among others. Step 3 Adaptation . We will conduct initial modifications of the intervention to reflect decisions in Step 2. We will then organize a 3-day mock workshop to administer and theatre test the intervention activities among a sample of YSMM (n = 10) and YSMM CBO intervention implementers (n = 4) who participated in the previous 3MV in Ghana. During the workshop, we will implement the activities (role plays, scenarios, discussions, presentations, games, etc.) that will tackle ISD and HIVST among YSMM. We will then collect feedback from YSMM and CBO participants on aspects of the intervention content and delivery that need amendments. Step 4 Production . A team of investigators and community partners will collate and brainstorm about the experience in the mock intervention workshop. They will review the successful parts of the training for consolidation and devise ways to address challenges or less successful areas of the interventions. We will maintain the study's focus and be consistent with the literature on HIVST, ISD, and relevance to YSMM and YSMM in slums within Ghana to ensure we produce a comprehensive yet specific manual to address ISD and increase HIVST. Step 5. Topical Expert Review . We will provide a copy of the LAFIYA manual to experts on ISD, HIVST, original 3MV, and YSMM health in Ghana and SSA for review and feedback. The experts will be asked for feedback on the consistency of the manual to address ISD and to increase HIVST among YSMM. The experts identified include Dr. LaRon Nelson, who led several studies in Ghana and is an expert in using 3MV to address HIV prevention among SMM. Dr. Kwasi Torpey has conducted several studies among HIV key populations in Ghana. Francis Boakye is a gay-identified man who founded PORSH, the civil society organization partners that work with Ghanaian SMM. Edem Zigah is a community focal person/expert in HIV prevention and care and an HIVST provider in Ghana. Dr. Donaldson Conserve is an HIVST expert with vast experience working in SSA. Gamji Rabiu Abu-Ba'are, contact PI and HIV and stigma implementation science expert among SMM in Ghana. James McMahon is an implementation science expert with a decade of experience developing HIV prevention interventions. We will also receive feedback from the Ghana AIDS Control programme on local program contents and consistency with local HIVST guidance . The topical experts will give written feedback and participate in a workshop to discuss pivotal activities and modifications to the local cultural relevance and intervention implementation. Step 6. Integration . Here, we will collate feedback from the topical experts for the investigative team and local partners to review. We will incorporate the feedback to solidify the manual, ask follow-up questions, and discuss areas where the input is unclear to the team. Step 7. Training . In consultation with the Site PI, the community partners will identify 2 facilitators to deliver the intervention. The facilitators will self-identify as SMM and experience participating in previous HIV interventions with SMM in Ghana. We expect facilitators to have cultural relatability to participants and topics and the potential anxieties and wariness of the intervention participants. The interventionists will first receive a two-day training on group facilitation skills in which they will increase their knowledge, confidence, and fluidity in group facilitation. They will then be trained on the ISD reduction intervention. The facilitators will receive training from qualified ISD reduction trainers (Drs Nelson and Abu-Ba'are) with experience implementing 3MV. Dr. Conserve and Mr. Zigah will lead the HIVST component. Zigah is a Ghanaian expert in HIVST implementation among SMM and facilitated stigma reduction in our previous studies among SMM in Ghana. Conserve developed an HIVST training which he delivered to men in Tanzania. AIM3: Test acceptability, feasibility, appropriateness, and preliminary efficacy of LAFIYA . ADAPTT-TT Step 8 (Testing) . Design . We will pilot test the LAFIYA intervention using a single arm pre-post design. We aim to adapt the intervention and preliminary test it for future full-efficacy cluster randomized control trial (CRT) 95 , 96 . Although RCT is primarily used in HIV and behavioral interventions, we find CRT better due to our place-based focus and possible sample contamination surrounding sleeping arrangements and the communal nature of slum communities. Thus, we aim to use this developmental-focused RO1 and the pre-post design as a developmental study to adapt and preliminary test LAFIYA to inform the future efficacy test using CRT. Aside from contamination, the pre-post-intervention design is less resource-intensive and is suitable for the primary focus of the intervention on acceptability and feasibility. It is also enough to show some early changes the intervention will have on the participants and prepare grounds for a more significant and more extensive efficacy CRT. Hypothesis Exposure to the LAFIYA intervention will reduce ISD and increase the capacity and uptake of HIVST among YSMM. The participants will receive the intervention and be given the option to initiate HIVST. They will also have the opportunity to collect the contacts of trained nurses for follow-up questions and confirmatory tests if needed. The nurses will visit the intervention site on the final day of training to introduce themselves and share their contacts with participants. PORSH will keep the contacts of nurses for participants' use if needed. We will collect baseline, immediate, and 3-month post-intervention surveys to examine ISD and initiation of HIVST. Sampling and recruitment We will use the starfish sampling and inclusion criteria (see AIM1) to recruit YSMM (n = 60). Per the design, all participants will receive the intervention without a control or waitlist. Research assistants who are SMM and have experience in research with YSMM in Ghana will aid in recruiting the YSMM for intervention testing. Power. For the 5-Likert acceptability and appropriateness scores, the feasible sample size of 60 will produce a two-sided 95% confidence interval (CI) with a precision of 0.32 when the standard deviation (SD) is 1.25 (estimated SD = Coefficient of variation*Assumed mean = 0.05*2.5). Also, this sample size will produce a margin error of 0.13 for proportions of satisfaction, retention, and participation in feasibility at a 5% significance level. We calculated powers to detect a pre-post change in ISD and HIV testing at three months from baseline. Based on our previous study in Ghana, we anticipate a mean of 1 (SD = 0.65) for overall ISD, ranging from 0 to 3 at baseline 29 . The sample size of 60 will be able to detect the decreases of 0.25 and 0.30 ( medium effect sizes of 0.38 and 0.46) with 89% and 94% powers , respectively, in the pre-posttest at a 5% significance level. By assuming the attrition rate of about 2 to 4% from the study in Ghana, we will still have acceptable powers of 82% and 93% to detect those effect sizes with a sample of 58. As a pilot with implementation outcomes around acceptability, appropriateness, and feasibility, this study does not expect statistical significance on intervention efficacy. The sample size would be enough to estimate the intervention's preliminary effect size and measure the primary outcomes. Implementation of the intervention: Description of the intervention. The 3MV remains the only CDC-recommended evidenced group-based intervention tailored to HIV prevention among Black SMM. It was initially designed for the United States context, with seven sessions focused on addressing barriers to HIV prevention to increase understanding of HIV risk and transmission and to influence behavioral change to increase condom use and HIV/STD testing. We previously adapted it to address Ghanaian SMM contexts such as religion, sexual identity, and gender norms and expectations. Expected adaptations to the intervention. We expect our process to adapt the intervention to the context of YSMM, social vulnerability, and environmental factors that hinder HIV testing. The new intervention will also examine ISD experience around HIV, place, gender expression, sexual behavior, and the related impact on HIV testing for YSMM. We will also incorporate specific training to build capacity for using unassisted HIVST among YSMM. Table 1 Summary of 3MV and potential modified LAFIYA intervention. Current 3MV sessions Potential LAFIYA Sessions 1. Ghanaian SMM and dual identity 2. HIV/STD prevention for Ghanaian SMM: the roles and risks for tops and bottoms 3. HIV/STD risk assessment and prevention options 4. Intentions to act and capacity for change 5. Relationship issues: Partner selection, communication, and negotiation of roles for Ghanaian SMM 6. Social support and problem-solving to maintain change 7. Building bridges and community a. ISD and impact on sexual health and HIV outcomes b. HIV/STD, risk assessment, testing, and prevention options c. HIV risk assessment and testing option for YSMM in slums d. Building capacity for HIVST – Conducting an unassisted test, options, and strategies e. Intentions to act and capacity for change to adopt prevention options and HIVST f. Relationship issues: Partner selection, communication, negotiation roles, prevention, and testing options for YSMM in slums g. Social support and problem-solving to maintain change h. Building bridges and community Implementation procedure. The facilitators trained in aim 2 will receive a copy of the manual on delivering each component of the adapted intervention. PORSH will recruit the YSMM to attend a 3-day weekend retreat at a location identified by PORSH with support from the site PI and Contact PI. Considering that YSMM remain hidden, we expect to utilize places we used in previous interventions. Such locations have already been appraised and have a working relationship with the team where their security is assured. YSMM, who accept to participate in the intervention, will receive dates for the weekend intervention retreats at temporarily rented facilities. Before participating in the LAFIYA intervention, participants will attend an orientation meeting at PORSH to obtain information about the retreat's logistics and format and establish ground rules for appropriate behavior. Once participants arrive at the retreat, the LAFIYA intervention will be delivered in six consecutive 2- to 3-hour sessions. Appraisal of intervention. Data collection . Participants will complete baseline, immediate, and 3-month post-intervention surveys. Trained SMM research assistants who collected surveys in our previous studies will conduct the surveys. Data collection location will be at the designated sites (e.g., office of community partners) determined as safe for YSMM in Ghana. Such determination will be led by the community partners, the site PI, and the contact PI due to their extensive experience working with SMM on the grounds in Ghana. Measures. Demography, HIV testing, and stigma descriptive variables . We will assess important baseline characteristics for describing the sample, including age, income, gender, education, ethnicity, relationship status, religion, sexual identity, sexual behavior, HIV knowledge, HIV testing readiness, HIV testing history, and histories of intersecting stigmas, access, and utilization of health and social services, civic engagement and neighborhood. Primary implementation of the outcome we will measure our implementation primary outcome variables (acceptability, appropriateness, and feasibility) using expanded Proctors validated measures using pre-immediate and three months post-intervention surveys 97 . See sample items Table 2 Summary of primary outcome measures Measure Number of items Sample Item Wilx Acceptability 12 HIVST meets my approval .001 HIVST meets my needs. .006 I welcome use of HIVST .001 Appropriateness 9 HIVST seems reasonable. .001 HIVST seems like a good match .001 HIVST seems applicable. .001 Feasibility 9 This EBP seems easy to use .001 This EBP seems challenging. .001 This EBP seems practical .002 Secondary outcomes . At baseline and three months, we will measure the preliminary effectiveness of LAFIYA . We will measure knowledge of HIV and HIVST and willingness to receive HIVST pre- and post-intervention. Testing characteristics (testing rates, time, and mode of testing; home or in a facility). For ISD reduction, we will measure internalized and interpersonal level ISD around HIV, place, gender expression, and sexual acts at baseline and post-intervention surveys. We will also measure community-level and healthcare facility-level stigma to understand participant experiences at baseline. Table 3 Summary of secondary outcome measures Construct items Sample Item HIV self-testing/testing Rates of HIV tests in 3-months Basic Needs Satisfaction Scale 9 When I am with my friends, I feel free to be who I am? (α = 0.85–0.92) Healthcare Climate 98 , 99 . 15 I feel that my healthcare provider accepts me (α = 0.92) Brief Resilience Scale 100 6 I tend to bounce back quickly after hard times? (α = 0.80–0.91) ISD (Latent Variable) Manifest Variable: HIV Stigma Scale 121 Enacted stigma subscale 10 Has a healthcare worker not wanted to touch you because you have HIV? (α = 0.92) Vicarious stigma subscale 10 How often have you heard stories about someone with HIV being refused care? (α = 0.88) Perceived subscale 10 In your community, how many people think a person with HIV is disgusting? (α = 0.94) Internalized subscale 10 How often do you feel guilty about having HIV? (α = 0.83) Manifest Variable: Same-sex stigma scale 101 10 How often have you lost a place to live for being homosexual? (α = 0.75) Gender Non-Conformity Stigma Scale 102 10 How often have you been called names because of your feminine mannerisms? (α = 0.88) 3.9 DATA ANALYSIS. Approach. We will use the intent-to-treat (ITT) technique to analyze the baseline and post-intervention survey data using Stata software for statistical analysis. We considered other methods (e.g., per protocol approach); however, we chose ITT because it's regarded as the least biased approach since it requires all participants to be assessed regardless of whether they received the intervention assigned initially or not. Process Data collected will be exported to Stata for cleaning and further analysis. Missing patterns in the instrument will be assessed, and missing responses will be imputed when at least 70% of responses are observed. The scores of instruments will be calculated with observed and imputed responses. We will employ descriptive statistics to summarize the characteristics of participants. We will calculate a mean with a confidence interval for the variables and proportions of responses to the primary (feasibility, appropriateness, and acceptability) and secondary outcome variables (HIVST and ISD). We will run inferential statistics such as paired t-test to compare pre-and post-means, McNamar's test to compare pre-and post-proportions, and correlation analysis to examine the relationship between variables, especially differences between populations based on sociodemographic characteristics. Since this study primarily focuses on acceptability, feasibility, appropriateness, and preliminary effects, we will not conduct advanced statistical modeling. Challenges and Solutions Confirmatory testing and linkage to care after testing. Our experience working in Ghana shows that after testing for HIV, many SMM default and do not go for follow-up testing and linkage to care. The young adults in this study may need access to counseling and connection to ARV should they test positive. As such, we will identify 6 nurses with experience working with YSMM to aid in follow-up with participants when they test and need such support. The contacts of the nurses will be readily available at the CBO and given to participants as part of the information during the intervention. Recruiting the desired group of participants. In our previous study, due to stigma and fear of disclosure, we observed that some SMM who did not meet the study criteria around HIV status joined the study by following their colleagues who invited them to join. As such, we will use an already tested solution in the study, where we used concealment during recruitment to ensure we reached the right participants. Here, we will use a preloaded computer screening survey which will show at random for interested participants to fill out. Upon filling, the instrument will automatically screen them for inclusion or exclusion. We will also not let people accompany others for screening; we will reach out to every potential participant to screen them in their private space. This strategy is crucial as some participants do not ascribe to sexual orientations or do not want others to know about their sexuality until they build trust over several interactions. Retention of participants. Since we will be working with young adults and socially vulnerable persons, there is a high possibility that some of them will be mobile. As such, we will ensure we invite participants who are sure of their availability during the study period. We will also follow up periodically to check on their plans and device means to ensure continuity. Strengths and Future Directions . Strengths : the study will adapt and test the feasibility, acceptability, and appropriateness of a CDC evidence-based intervention (3MV) to address ISD and increase HIVST. Previous research highlights financial constraints, ISD, and health system challenges as critical barriers to HIV testing and ART initiation and adherence among YSMM in Ghana. This study provides an opportunity to understand YSMM's lived experiences, especially concerning their geography, HIV testing practices, HIVST awareness, and willingness to participate. The findings can inform future studies and interventions to address HIV prevention and care among YSMM within similar sociocultural contexts in Africa and elsewhere. Additionally, to surmount barriers to HIV testing, HIVST will allow YSMM to test in their private space without visiting healthcare facilities, reducing the fear of facing stigma associated with sexual minority status and being seen at an HIV care facility. In other settings, HIVST proved acceptable among users, feasible to implement, and effective in scaling testing among targeted populations. Our current focus on HIVST aligns with Ghana's new commitment stipulated in its 2019 National HIV and AIDS Policy to increase HIVST among key populations. Future Directions : Based on findings from the pilot study, we will finalize a protocol for an efficacy trial of the intervention to improve HIV testing among YSMM in Ghana. Study Period Study Activity by Quarter Y1 Y2 Y3 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 IRB submission and approval Training of project team and research assistants AIM 1: Assessment Phase Recruitment of participants In-depth Interviews Summative data analysis for intervention adaptation Data analysis for manuscript development, and dissemination AIM2: Adaptation Phase Intervention Adaptation Training of intervention ( LAFIYA ) facilitators and research assistants AIM3: Testing Phase Baseline surveys LAFIYA implementation Immediate post intervention survey 3 months post intervention survey – all participants Study field work review and closing workshop Data Analysis and Manuscript Writing Ethical considerations Ethics approval This study was approved by the institutional review board in the University of Rochester (United States) IRB STUDY00008385 on 5/26/2023, and the University of Ghana Ethic Review Committee EPRC A.9 [I 8] 2022–2023 on 5/25/2023. Process of consent/Assent. The informed consent procedure will involve several steps to ensure that participants understand and agree to participate in this study. Firstly, trained research assistants from partner organizations will conduct interviews and surveys. Participants can choose to fill out the survey themselves in person. Next, participants will receive detailed consent forms approved by the Institutional Review Board (IRB). These forms will explain the study's questions, procedures, and potential risks. Before any study intervention or procedures begin, participants must provide written consent. During the consent process, participants can read the forms themselves or have it explained by the interviewer. This discussion will take place in a private room, a secure location of the participant's choice, or via a secure online platform like Zoom. In all scenarios, written consent will be obtained. Before deciding whether to participate, participants will have enough time to review the consent form, ask questions, and talk about the study with their family members or surrogates. It will be emphasized throughout this process that participation is voluntary, and participants have the right to withdraw from the study at any time without facing any negative consequences. Participants will also receive a copy of the informed consent document for their records. Confidentiality and security of data. The researchers will take every possible measure to protect the confidentiality of the participants. Any mention of the participants in reports by the research team or partner organizations will not include their names. The data collected from the participants will be assigned unique codes for identification purposes, ensuring complete confidentiality. Personal information, including contact details, will be kept separate from other study information to further safeguard confidentiality. Participants will be referred to by titles like "key informants" or "providers" or by their assigned participant ID, rather than by their actual names. Data storage and access. The security and confidentiality of all questionnaires and data collection tools. After data capture, these materials will be stored in a locked file cabinet to prevent unauthorized access. Additionally, all data files entered into the computer will be protected with passwords, adding an extra layer of security to prevent unauthorized viewing or manipulation. These measures aim to maintain the integrity and confidentiality of the collected data throughout the research process. Data and safety monitoring plan. Participants' confidentiality will be safeguarded to the utmost extent by the researchers. Neither the research team nor any partner organization will mention participants by name in any reports. To ensure confidentiality, the data collected from participants will be assigned unique codes for identification purposes. Participants' personal information, including contact details, will be stored separately from other study information to maintain confidentiality. Participants will not be identified by their actual names but rather by titles such as "key informants" or "providers" or by their assigned participant IDs. Reporting of adverse events. The study is designed to minimize any risk, and is subject to rigorous oversight by the MPIs. MPIs are responsible for ensuring the integrity of the data, as well as conducting regular safety evaluations. If concerns arise, the MPIs have the authority to make necessary changes, pause enrollment, or terminate the study as needed. In addition, the University of Rochester and the University of Ghana (IRBs) are charged with providing additional oversight and support to ensure adherence to all protocols and maintain the safety of all participants. Management of interim results. The study will be conducted internationally with multiple sites and stages, so we will utilize a scientific leadership approach. With this approach, MPIs will ensure maximizing team science efforts to better respond to the challenges and opportunities in today's world. Our team of experts from diverse fields, including nursing, demography, public health, social work, epidemiology, and statistics, will provide oversight of the entire study, including the development and implementation of policies, procedures, and processes to ensure cultural relevance, congruence, and sensitivity throughout the process of assessing ISD and developing options for HIVST, and adapting and evaluate the feasibility of 3MV to LAFIYA to address ISD and HIVST among YSMM, Test acceptance, feasibility, appropriateness, and preliminary efficacy of LAFIYA to address ISD and increase HIVST uptake, as well as the protection of human subjects. The scientific leadership in this study will ensure all institutional compliance, such as those of the NIH, University of Rochester, University of Ghana, and the Ghana and US government laws are adhered and maintained throughout the study period. Dissemination plan. The results of this research will be shared and presented in scientific conferences or in publications. Protocol modifications. All study team members have been involved in planning the project and will continue to have shared responsibility for making scientific decisions throughout the study. Suppose a question arises that requires the expertise or experience of a specific team member (such as YSMM, provider, or statistical analysis). In that case, that individual will be deferred to as the primary decision-maker. If the leadership team cannot agree on a scientific question, the investigator in charge of the relevant data collection component will have the final say. Ensuring a unified decision-making process that draws on everyone's expertise and maintains the study's scientific integrity. Payments for participation. There won't be direct monetary compensation. Instead, participants will receive tokens of appreciation in cash for their involvement. Firstly, for the assessment interview, each participant will receive 150 cedis. This token serves as recognition for their time and insights shared during this phase. Next, for engaging in the workshop and participating in both the pre- and post-intervention surveys, each participant will receive 300 cedis. This money acknowledges the commitment and valuable contributions made to the study. Lastly, three months after the interventions, there will be a follow-up survey, and participants will receive 150 cedis for their continued involvement in the study. These tokens of appreciation are offered as a gesture of gratitude for the invaluable contributions participants make toward advancing the study's objectives. Discussion The core objective of the study is to adapt the 3MV approach into a modified version termed LAFIYA, aimed at addressing ISD and bolstering HIVST uptake among young sexual minority men (YSMM). This research endeavors to comprehensively evaluate the acceptance, feasibility, appropriateness, and preliminary effectiveness of employing the 3MV approach in combating ISD while promoting HIVST among YSMM in Ghana. Structured around three pivotal aims, this study outlines a strategic framework: firstly, to evaluate ISD and explore viable options for implementing HIVST; secondly, to adapt 3MV into LAFIYA, aligning it to effectively address ISD and HIVST among YSMM; and thirdly, to rigorously test the acceptance, feasibility, appropriateness, and initial efficacy of LAFIYA in reducing ISD and enhancing HIVST uptake. Guided by the ADAPTT-IT framework, the study meticulously progresses through various steps, employing AIM1 to implement the initial phase and synthesizing outcomes from AIM1 and subsequent steps (Steps 2 to 7) to steer AIM2 towards creating a comprehensive manual for the LAFIYA intervention. The third aim marks the pilot testing phase, where assessments will be conducted to gauge the intervention's acceptance, feasibility, appropriateness (as the primary outcome), and preliminary efficacy in reducing ISD and boosting HIVST uptake (as the secondary outcome) among YSMM. This foundational RO1 study sets the stage for a larger clustered randomized trial (CRT), poised to rigorously evaluate the efficacy of LAFIYA in diminishing ISD and fostering HIVST among YSMM, thus paving the way for substantial advancements in this field. Declarations Author Contributions Conceptualization: Gamji Rabiu Abu-Ba'are 1,2,3,4,7 Data curation: Gamji Rabiu Abu-Ba'are 1,2,3,4,7 , Kwasi Torpey 5 , LaRon Nelson 6,7 , Donaldson Conserve 10 , Sangchoon Jeon 6 , James McMahon 1,2 , Adom Manu 5 , Edem Yaw Zigah 2,4 , Osman Shamrock 1,2,4, Amos Apreku 5 , Delali Dakpui 2,4 , George Rudolph Agbemedu 2,4 , Gideon Adjaka 8 Formal analysis: Gamji Rabiu Abu-Ba’are 1,2,3,4,7 , LaRon Nelson 6,7 , Sangchoon Jeon 6 , Osman Shamrock 1,2,4 , Delali Dakpui 2,4 , George Rudolph Agbemedu 2,4 , Funding acquisition: Gamji Rabiu Abu-Ba'are 1,2,3,4,7 , Adom Manu 5 , Kwasi Torpey 5 , LaRon Nelson 6,7 , James McMahon 1,2 , Donaldson Conserve 10 Investigation: Gamji Rabiu Abu-Ba'are Gamji Rabiu Abu-Ba'are 1,2,3,4,7 , Kwasi Torpey 5 , LaRon Nelson 6,7 , Donaldson Conserve 10 , Sangchoon Jeon 6 , James McMahon 1,2 , Adom Manu 5 , Edem Yaw Zigah 2,4 , Osman Shamrock 1,2,4 , Amos Apreku 5 , Delali Dakpui 2,4 , George Rudolph Agbemedu 2,4 , Gideon Adjaka 8 Methodology: Gamji Rabiu Abu-Ba’are 1,2,3,4,7 , Kwasi Torpey 5 , LaRon Nelson 6,7 , Donaldson Conserve 10 , Sangchoon Jeon 6 , James McMahon 1,2 Project administration: Gamji Rabiu Abu-Ba'are 1,2,3,4,7 , Kwasi Torpey 5 , Edem Yaw Zigah 2,4 , Amos Apreku 5 , Delali Dakpui 2,4 , George Rudolph Agbemedu 2,4 , Gideon Adjaka 8 Supervision: Gamji Rabiu Abu-Ba'are 1,2,3,4,7 , Kwasi Torpey 5 , Edem Yaw Zigah 2,4 , Adom Manu 5 , Gideon Adjaka 8 Writing – original draft: Gamji Rabiu Abu-Ba'are 1,2,3,4,7 , James McMahon 1,2 , Adom Manu 5 , Edem Yaw Zigah 2,4 , Osman Shamrock 1,2,4 , Gideon Adjaka 8 Writing – review & editing: Gamji Rabiu Abu-Ba'are 1,2,3,4,7 , Kwasi Torpey 5 , LaRon Nelson 6,7 , Donaldson Conserve 10 , Sangchoon Jeon 6 , James McMahon 1,2 , Adom Manu 5 , Edem Yaw Zigah 2,4 , Osman Shamrock 1,2,4 , Amos Apreku 5 , Delali Dakpui 2,4 , George Rudolph Agbemedu 2,4 , Gideon Adjaka 8 References Abubakari GM, Dada D, Nur J et al (2021) Intersectional stigma and its impact on HIV prevention and care among MSM and WSW in sub-Saharan African countries: a protocol for a scoping review. 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Health Place 83:103076. 10.1016/j.healthplace.2023.103076 Abu-Ba’are GR, Shamrock OW, Apreku A et al (2023) Awareness and Willingness to use Condoms and Preexposure Prophylaxis among Gay, Bisexual, and Other Cisgendered Men who Have sex with men in Slum Communities in Ghana. BSGH-004. J Int Association Providers AIDS Care (JIAPAC) 22:23259582231209650. 10.1177/23259582231209649 Shamrock OW, Abu-Ba’are GR, Zigah EY et al Family rejection of non-hetero sexuality–Sexual orientation and behavior anonymity among sexual minority men in slum communities-BSGH 001. PLOS Global Public Health 3: e0001659 doi:101371/journal.pgph0001659. Published online December 1, 2023 Abu-Ba’are GR, Zigah EY, Shamrock OW et al Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have sex with men in Ghana’s slums - BSGH-005. medRxiv . 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J Int AIDS Soc 25(S1). 10.1002/jia2.25908 GOODMAN H. In-Depth Interviews. In: The Handbook of Social Work Research Methods (2016) 10.4135/9781412986182.n17 Lucas SR (2014) Beyond the existence proof: Ontological conditions, epistemological implications, and in-depth interview research. Qual Quant 48(1). 10.1007/s11135-012-9775-3 Raymond HF, Chen YH, McFarland W (2019) Starfish Sampling: a Novel, Hybrid Approach to Recruiting Hidden Populations. J Urb Health 96(1). 10.1007/s11524-018-0316-9 Etikan I (2016) Comparison of Convenience Sampling and Purposive Sampling. Am J Theoretical Appl Stat 5(1). 10.11648/j.ajtas.20160501.11 Creswell JW, Hanson WE, Clark Plano VL, Morales A (2007) Qualitative Research Designs: Selection and Implementation. Couns Psychol 35(2). 10.1177/0011000006287390 Christie J, O’Halloran P, Stevenson M (2009) Planning a cluster randomized controlled trial: methodological issues. Nurs Res 58(2). 10.1097/NNR.0b013e3181900cb5 Calear AL, Christensen H, Mackinnon A, Griffiths KM, O’Kearney R (2009) The YouthMood Project: A Cluster Randomized Controlled Trial of an Online Cognitive Behavioral Program With Adolescents. J Consult Clin Psychol 77(6). 10.1037/a0017391 Weiner BJ, Lewis CC, Stanick C et al (2017) Psychometric assessment of three newly developed implementation outcome measures. Implement Sci 12(1). 10.1186/s13012-017-0635-3 Williams GC, Ryan RM, Rodin GC, Grolnick WS, Deci EL (1998) Autonomous regulation and long-term medication adherence in adult outpatients. Health Psychol 17(3). 10.1037/0278-6133.17.3.269 Williams GC, Cox EM, Kouides R, Deci EL (1999) Presenting the facts about smoking to adolescents: Effects of an autonomy-supportive style. Arch Pediatr Adolesc Med 153(9). 10.1001/archpedi.153.9.959 Smith BW, Dalen J, Wiggins K, Tooley E, Christopher P, Bernard J (2008) The brief resilience scale: Assessing the ability to bounce back. Int J Behav Med 15(3). 10.1080/10705500802222972 Díaz RM, Ayala G, Bein E, Henne J, Marin BV (2001) The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from 3 US cities. Am J Public Health 91(6). 10.2105/AJPH.91.6.927 Logie CH, Newman PA, Chakrapani V, Shunmugam M (2012) Adapting the minority stress model: Associations between gender non-conformity stigma, HIV-related stigma and depression among men who have sex with men in South India. Soc Sci Med 74(8). 10.1016/j.socscimed.2012.01.008 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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HIVST\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4313437/v1/74511556ca8f2872a71535f5.png"},{"id":55211301,"identity":"d5dc426d-2103-4acd-943a-47e36ffc393d","added_by":"auto","created_at":"2024-04-24 06:38:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1017988,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4313437/v1/000b9606-94de-4fbc-98ea-917d305a5b88.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eAdaptation and feasibility of Many Men Many Voices (3MV), an HIV prevention intervention to reduce intersectional stigma and increase HIVST among YSMM residing in Ghanaian slums – A clustered pre-post pilot trial protocol.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntersectional stigma and discrimination (ISD) significantly impact HIV testing and care among sexual minority men (SMM), gender nonconforming (GNC) men, and people living with HIV (PLHIV) in Ghana and sub-Saharan Africa (SSA) \u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. In SSA and Ghana, factors such as insufficient HIV knowledge and the association of HIV with sin and death lead to stigma against PLHIV. Stigma faced by PLHIV includes rejection, verbal abuse, violence, and denial of care\u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. SMM also face stigma due to societal opposition to same-sex acts, with a majority of Ghanaians disapproving of such relationships \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. SMM who express in ways considered feminine in Ghana encounter ISD (multiple stigmas) related to both sexuality and gender expression, as these traits conflict with societal gender expectations for Ghanaian men \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. ISD deters SMM from seeking HIV testing, as they avoid healthcare facilities to evade stigma associated with HIV, sexuality, and gender expression\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Beyond institutional and community-level ISD, interpersonal rejection and isolation are experienced by GNC SMM and SMM living with HIV within the SMM community \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Some individuals internalize these community-level stigmas, leading to feelings of guilt, shame, and reluctance to seek HIV testing or care in stigmatizing environments \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Studies indicate that over 50 to 60% of SMM delay or avoid HIV testing due to stigma, often waiting until they fall ill\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e To address ISD, Ghana aims to integrate ISD reduction strategies into interventions, recognizing the urgent need to mitigate testing avoidance, and HIV transmission among key populations like SMM and YSMM \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThough less than 2% of Ghana's population, SMM record an HIV prevalence of 18%, surpassing the national rate of 2% by more than eightfold. This stark contrast emphasizes the urgent need for prioritizing interventions to enhance detection and linkage to care, which is essential in curbing community spread \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, specifically focusing on YSMM as they have increased HIV-risk behaviors and high HIV prevalence rate \u003csup\u003e\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. While limited studies focus on YSMM, the Ghana AIDS Commission estimate show that YSMM between 18 to 24 years form a sub-risk population within SMM, representing 63% of known HIV cases among SMM in Ghana \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Our research, alongside others focusing on a subset of YSMM within the broader SMM community, reveals that apart from facing similar challenges as older SMM, YSMM also face ISD around preventive behaviors. Many feel unable to discuss HIV prevention or even purchase or carry condoms due to societal perceptions against premarital sex among young people in Ghana \u003csup\u003e\u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. The US President's Emergency Plan for AIDS Relief (PEPFAR) and the Ghana AIDS Commission have acknowledged the necessity to focus on YSMM and other priority groups \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Moreover, global surveillance data highlights exceptionally high HIV incidence among YSMM in SSA and globally, due to unique barriers to HIV testing, including low-risk perception, active sexual engagement, and limited testing practices within this demographic \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eWhy a focus on urban slums?\u003c/b\u003e Living in urban settings, particularly slums in SSA, contributes to the heightened risk of HIV infection \u003csup\u003e\u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Slum areas accommodate more than 45% of Ghana's urban population, with around 40% residing in Accra, our primary study area \u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. For instance, SMM in Accra stands notably higher at 44% compared to the national average of 18% among SMM \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e YSMM in slums face heightened vulnerability, considering these areas are documented as high-risk zones for HIV transmission due to structural challenges like poverty and limited access to healthcare, alongside predictors such as transactional sex \u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan additionalcitationids=\"CR42 CR43 CR44\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e. Notably, certain slum regions within Accra report significantly higher HIV prevalence rates, averaging around 7% compared to the national average of 2% \u003csup\u003e18,46\u003c/sup\u003e. YSMM in these areas experience challenges accessing services, possess lower perceptions of HIV risk, face lower educational attainment, and grapple with poverty, all contributing to low rates of HIV testing \u003csup\u003e\u003cspan additionalcitationids=\"CR48 CR49 CR50 CR51 CR52\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMoreover, YSMM in slums may encounter escalated ISD compared to other SMM. For instance, a slum area known as \"Old Fadama\" or \"Sodom and Gomorrah\" in Accra is associated with social vices like high crime rates and the sex trade, contributing to negative stereotypes about the area \u003csup\u003e\u003cspan additionalcitationids=\"CR55 CR56 CR57 CR58 CR59\" citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e. Consequently, YSMM in these communities may confront not only stigma related to HIV, sexuality, and gender expression but also the stigma attached to their place of residence, potentially leading to internalization of stigma that impacts their willingness to undergo HIV testing. The spotlight on slum areas aligns with the Ghana National AIDS Control Programme and PEPFAR's strategies, focusing on redirecting HIV behavioral interventions from a generalized approach to targeting high-risk geographical areas burdened with HIV prevalence \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Although limited, our formative work in Ghana shows that increased ISD and apprehensions regarding confidentiality and privacy in healthcare settings act as significant barriers to testing \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u003c/sup\u003e. Many SMM express the need to hide, avoid other SMM, especially those with feminine gender expression, and avoiding testing in their local community. Some were also open to testing but prefer to travel outside the community for safety reasons and hope for better environment for testing, prevention and care services.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIs HIVST a possible option?\u003c/b\u003e The introduction of HIVST holds promise in potentially increasing testing rates among YSMM by offering the convenience of testing in preferred locations without interpersonal interactions \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan additionalcitationids=\"CR63\" citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e. Notably, in other contexts, HIVST has garnered higher acceptance rates, reduced stigmatization, and attracted individuals testing for the first time \u003csup\u003e\u003cspan additionalcitationids=\"CR66 CR67\" citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e. However, its implementation in Ghana and SSA comes with its own set of challenges, including limited knowledge about HIVST, inadequate follow-ups, and fears related to stigma and disclosure of results \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e. Therefore, it is crucial to emphasize the necessity of community-based interventions to overcome obstacles associated with the uptake of HIVST in the country \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e. Recognizing the potential of HIVST to complement Ghana's existing testing protocols conducted by nurses in facilities and homes, WHO, Ghana's HIV/AIDS Policy and community-level implementers advocate for its integration \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e. As such, the current study aims to: 1. Assess ISD and options for HIVST implementation. 2. Adapt 3MV to \u003cem\u003eLAFIYA\u003c/em\u003e to address ISD and HIVST among YSMM. 3. Test acceptance, feasibility, appropriateness, and preliminary efficacy of \u003cem\u003eLAFIYA\u003c/em\u003e to address ISD and increase HIVST uptake.\u003c/p\u003e\n\u003ch3\u003eTheoretical Underpinnings\u003c/h3\u003e\n\u003cp\u003eThis study draws from the Health Stigma and Discrimination Framework (HSDF) perspectives and scientific evidence from Ghana and SSA to postulate that stigmatized characteristics (e.g., sexual minority, gender expression, sexual act at a young age, and place) intersect with HIV stigma to impact HIV testing among YSMM negatively \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e. The drivers and facilitators of ISD include gender norms, ignorance around HIV transmission, beliefs around morality associated with HIV, and related characteristics of persons (e.g., sexual minorities) \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan additionalcitationids=\"CR71 CR72\" citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e. ISD manifests through stigmatizing experiences such as social exclusion, gossip, discrimination in healthcare facilities, etc. It can also manifest at the interpersonal and intrapersonal levels, where YSMM stigmatize other YSMM for feminine expression or HIV status. YSMM can also accept negative societal perceptions about SMM, PLWHIV, or slums and begin to blame themselves, develop self-doubts, etc \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e. ISD can lead to adverse health outcomes such as increased risk behaviors and low testing, as internalizing the ISD forces YSMM to remain closeted and isolated. Thus, highlighting the importance of addressing the drivers and facilitators of stigma and manifestations of stigma and building the capacity of YSMM (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) to avert adverse outcomes such as low testing\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eThe Proposed Intervention\u003c/b\u003e. The 3MV remains the only CDC-recommended evidenced group-based intervention focused on addressing barriers to HIV prevention, combating HIV risk and transmission, and influencing behavioral change to increase condom use and HIV/STD testing among BlacK SMM in the United States\u003csup\u003e\u003cspan additionalcitationids=\"CR75 CR76\" citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e\u003c/sup\u003e. Our previously adapted 3MV addressed Ghanaian SMM contexts such as religion, sexual identity, and gender norms and expectations\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. The previous versions do not address the ISD around age and sexual behavior or place-based factors that could increase risk or hinder testing; they did not also build capacity for HIVST and linkage to care. The proposed version, \u003cb\u003eLAFIYA\u003c/b\u003e, will focus on building awareness of self and knowledge around ISD to reduce the interpersonal and internalized stigma experiences among YSMM (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Also, a traditional HIV testing process will require a visit to a healthcare facility where YSMM will interact with a wide range of people aside from the provider\u003csup\u003e\u003cspan additionalcitationids=\"CR79\" citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e\u003c/sup\u003e. The \u003cem\u003eLAFIYA\u003c/em\u003e intervention will alter this process by increasing YSMM's capacity for unassisted HIVST. Whereas a third component focusing on providers is necessary to ensure follow-up and connection to care, \u003cem\u003eLAFIYA\u003c/em\u003e will focus on interpersonal and intrapersonal behavioral change capacity building so that YSMM will be self-motivated to drive their HIVST decisions. Nonetheless, unlike the previous 3MVs, healthcare providers previously trained by our team in a facility-wide stigma reduction intervention in Ghana will be engaged as part of the study to provide follow-up, confirmatory testing, and linkage to care for YSMM\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. The focus on HIVST and slums also aligns with PEPFAR and Ghana's new commitment stipulated in its 2019 National HIV and AIDS Policy to increase HIVST among key populations and to focus on location-based intervention delivery models, especially for YSMM within slum communities \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e,\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003ePreliminary Studies\u003c/h2\u003e \u003cp\u003e \u003cb\u003eISD experience among SMM and YSMM\u003c/b\u003e. In our recent studies in Ghana\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan additionalcitationids=\"CR83 CR84 CR85 CR86 CR87 CR88\" citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e\u003c/sup\u003e, we identified that SMM face various forms (e.g., experienced, anticipated, perceived, and internalized) of stigmas concerning sexual behavior or sexuality and gender expression. SMM face stigma due to the attribution of same-sex sexual acts to indiscipline, immorality, and evilness and the perception that same-sex sexual acts come from foreign cultures, not the Ghanaian culture. Also, HIV stigma continues to thrive due to the perception that contracting HIV signifies a punishment for sin and insufficient knowledge of HIV transmission. As such, SMM receive insults, gossip, avoidance, and sometimes physical violence. To circumvent stigma, many SMM avoid interacting with healthcare settings or avail themselves for HIV testing, thus providing evidence for the need to find alternative ways to combat stigma and increase testing.\u003c/p\u003e \u003cp\u003e\u003cb\u003eFeasibility of adapting 3MV for YSMM in Ghana\u003c/b\u003e. We previously used the ADAPT-ITT framework to modify the 3MV to address HIV prevention and testing among SMM (n\u0026thinsp;=\u0026thinsp;52), including YSMM ages 18 to 25 (37%) drawn across Ghana \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. The community partners (PORSH) recruited the SMM, with only one person dropping out of the study due to illness. We provided education on HIV and STI risk and HIV testing. Our study recorded a condom use increase of 15% for anal sex (rel. f. = 0.80\u0026ndash;0.95) and 13% (4\u0026ndash;17%) for HIV testing among participants in one-week post-intervention. Also, irregular testers decreased by 10% (47\u0026ndash;37%), and 100% reported understanding the need for HIV testing. Participants in the study prepared a personal prevention menu to identify and plan ways to reduce HIV risk behaviors and engage in HIV testing. Participants reported that the intervention was acceptable to them, as it created a friendly and safe environment to express views, build social networks, and learn about HIV without prejudice\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Nonetheless, there is the need to adapt further to address ISD, place and age-related disadvantages, building capacity for HIVST and care, and testing our findings in a larger efficacy trial in a larger RO1.\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe need to address ISD, HIV risk, and testing among YSMM and YSMM in Ghanaian slums.\u003c/b\u003e In our recently completed formative study among YSMM in slum communities, we found that some of the YSMM have an increased risk of HIV infection, face ISD, avoid HIV testing, or even visiting HIV facilities in the community due to fear of HIV stigma. They, however, expressed willingness to try HIVST. In the qualitative interviews (n\u0026thinsp;=\u0026thinsp;15), transactional sex appeared prevalent among participants for various reasons, the most prominent being poverty and challenges with food insecurity. Others assume sex work as their primary source of income or accept payments or benefits for sex if offered. All participants were not confident in going for HIV testing within healthcare facilities, especially in slum communities. Participants preferred alternatives such as organizations that provide them with care tailored through community outreach. Thus, if we combat ISD and build capacity for HIVST, there is a high chance that YSMM will use HIVST.\u003c/p\u003e \u003cp\u003eIn the quantitative data (n\u0026thinsp;=\u0026thinsp;100), 60% had no specific source of income, and 70% sometimes could not afford three meals a day. Thus, our sample shows the financial challenges facing YSMM in slum communities. On HIV risk behaviors, over 49% indicated having sex with 4 to 11 sexual partners, and 41% had 1 to 3 sexual partners within the past month. 50% described their regular sexual partner as casual sex partners and 17% as strictly transactional sex. Whereas the majority (68%) do not know the status of their sex partners and (57%) did not disclose their HIV status to sex partners, half (50%) wish they could talk about HIV testing with partners. The majority have shown interest in discussing HIVST or using HIVST with partners (65%) if available. The findings show that despite high-risk behaviors, experiences of stigma, and impoverished conditions, YSMM are willing to learn and use HIVST kits. As a follow-up, we conducted a focus group discussion with providers (n\u0026thinsp;=\u0026thinsp;9) who indicated that the main challenge in upscaling HIVST is the capacity to implement HIVST, as many who come to facilities opt for assisted testing. This finding corroborates recent publications on perspectives of HIVST among providers across Ghana that singled out the capacity to implement HIVST as a barrier to implementation, considering that it's a newly introduced technology in Ghana.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplementation science lessons for adapting HIVST to YSMM in Ghana\u003c/b\u003e. In our implementation science assessment of HIV testing studies in Ghana and SSA among YSMM, we established that scholars must consider several barriers and facilitators when implementing HIV testing among YSMM \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e\u003c/sup\u003e. We found that external factors (e.g., volatile political environments and stigma) continue to affect the participation of YSMM in HIV testing. Also, access to friendly services and resources for testing remains a barrier. We also identified that although YSMM, especially in slums, remain a priority for HIV intervention, no specific studies in Ghana or West Africa were tailored to their needs; instead, they only occur as part of a larger adult population sample. Nonetheless, we note that partnering with community organizations in the recruitment and implementation of interventions facilitates an increase in reach, recruitment, and successful implementation of interventions\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Thus, we focus attention on YSMM to address their unique experiences with ISD and HIV testing by leveraging already existing community partners that have established trust and deliver interventions to SMM in Ghana. Another critical shortfall identified in previous interventions is the lack of follow-up to ensure linkage to care. This study will therefore involve already trained nurses in our earlier studies to follow up with YSMM after they uptake testing to ensure that those who test positive are linked to the care needed.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImplementing strategies\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAIM1. Assess ISD and options for HIVST implementation among YSMM.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eADAPT IT, Step 1 (Assessment).\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe first step of the study will constitute the assessment phase, where we will conduct in-depth interviews (IDI) with YSMM and providers (trained nurses and CBOs). We aim to deepen understanding of ISD and barriers and facilitators of implementing HIVST among YSMM. Examining perspectives and experiences of stigma and HIVST among providers and YSMM will allow for a comprehensive understanding and integration of realities from both providers and YSMM to optimize the potential of the adapted intervention to address ISD and increase HIVST. We chose IDIs here based on their proven success in allowing in-depth openness from YSMM and providers about their experiences and perspectives on issues of private nature\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e,\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e\u003c/sup\u003e. We will qualitatively examine the following.\u003c/p\u003e \u003cp\u003e \u003cb\u003eYSMM\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEvaluate experiences of ISD (e.g., HIV, place, gender expression, sexual) and navigating HIV testing services and how such experiences influence HIV testing decisions.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAssess knowledge of HIV, prevention options, willingness to use HIVST, and preferred means of ART initiation or HIV prevention after.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIdentify feasible options for engaging with HIVST (home, health care setting, etc.), as some YSMM may live in shelters and face privacy challenges.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eProviders\u003c/b\u003e \u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAssess experiences with implementing HIV testing and HIVST to YSMM\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAssess the role of stigma and other facilitators and challenges of HIVST implementation among YSMM\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eSolicit recommendations for combating stigma and increasing HIVST uptake and connection to care after testing.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSampling and Recruitment\u003c/h2\u003e \u003cp\u003e \u003cb\u003eTechnique: To recruit YSMM\u003c/b\u003e, we will employ starfish sampling, which combines venue/time-based and chain referral techniques to reach hidden populations \u003csup\u003e\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e\u003c/sup\u003e. We have used both venue-based and respondent-driven strategies independently in previous studies; however, integrating both through starfish sampling will allow us to optimize reach as YSMM in Ghana remain hidden \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Here. PORSH will contact YSMM through their outreach services to SMM and invite them to participate in the study. We will then ask YSMM who consent to the study to refer other YSMM known to them.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTo recruit providers\u003c/b\u003e, we will use the purposive sampling technique \u003csup\u003e\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e\u003c/sup\u003e. Here. We will invite participants due to their specific abilities to provide unique and in-depth information necessary to answer the research questions. This sampling method remains best for our process, considering that YSMM in Ghana remain hidden due to criminalization and stigma. The providers' identities remain confidential and only known to the team and other SMM because of previous training and their roles around providing care to SMM in the country. We will also use stratification for providers to enable us to reach nurses in healthcare settings and providers within CBOs who offer confidential sexual health services to SMM.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSample Size\u003c/b\u003e. We will recruit \u003cb\u003e20 YSMM and 20 providers\u003c/b\u003e stratified into nurses (n\u0026thinsp;=\u0026thinsp;10) and community organization providers (n\u0026thinsp;=\u0026thinsp;10) or until we reach saturation. A sample size of 20 equals or exceeds other standard IDIs conducted among SSM and providers \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e\u003c/sup\u003e. Thus, it will allow for comprehensive coverage of necessary information to reach saturation and provide enough information to inform the next stage of the study.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInclusion and exclusion criteria.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eYSMM\u003c/strong\u003e \u003cp\u003eTo be eligible to participate in the interview, the person must be between 18 to 25 years old, have no experience using unassisted HIVST kits, do not know their HIV status or tested negative, currently identifies as cis-gender man, and have had sex with another man within six months before engaging with the recruitment team and must reside within a slum community in the Greater Accra Metropolitan area. \u003cb\u003eProviders.\u003c/b\u003e To be eligible to participate in the interview, the person must have experience providing sexual health services such as HIV testing, counseling, and linkage to prevention and care services for at least one year. Must reside within the Greater Accra Metropolitan area and have worked with YSMM on HIV prevention and care.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eData Collection\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eYSMM.\u003c/b\u003e Data collection from YSMM will be conducted by trained SMM interviewers who conducted IDIs in our previous studies with YSMM in Ghana. \u003cb\u003eProviders\u003c/b\u003e: Data from providers will be collected by PI and Dr. Manu (Site Co-I); they both have experience researching with providers in Ghana. We will digitally record all YSMM and provider IDIs. Trained YSMM research assistants from PORSH will transcribe the data verbatim in a private space to ensure privacy. They will also translate interviews where the language is not English; the site PI will verify such translations for accuracy. The recordings will then be encrypted and uploaded to a server at the University of Rochester.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis.\u003c/h2\u003e \u003cp\u003eWe will analyze the qualitative data in two phases to 1) Identify areas and content for adapting the intervention and 2) publish study findings. We will use Dedoose qualitative data and analysis software to manage and analyze the qualitative interviews.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFor intervention adaptation\u003c/b\u003e, we will use a summative analysis process, dividing the transcripts among four investigators (Abu-Ba'are, Nelson, Conserve, and Torpey) to review and provide critical summaries of key findings from the IDIs. Two investigators will review each transcript to ensure we establish the reliability of the information extracted. Nelson and Abu-Ba'are will then systematically combine the summaries by identifying major points from each summary that address the drivers and manifestations of ISD, HIV testing experiences, options for HIVST, barriers and facilitators to HIVST implementation, and recommendations for factors to be considered in the intervention to address ISD and upscale HIVST. YSMM research assistants who conducted the interviews will review the final summaries to ensure its consistent with their understanding and realities of the YSMM interviewed.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFor manuscript development\u003c/b\u003e, we will conduct a more detailed qualitative content analysis. In this procedural approach, we will categorize and review data iteratively to generate conclusions based on the text's explicit and implicit meaning. Led by Nelson, with support from Abu-Ba'are, Torpey, Conserve, and YSMM research assistants in Ghana, we will use open coding to identify categories and create a thematic codebook from the transcripts. The coders will independently apply the codebook generated to a sample of transcripts (4 each for YSMM and provider transcripts). They will meet to review line-by-line coding, discuss discrepancies, and review and update the codebook to ensure consistency in coding. They will then divide the remaining transcripts and independently code them using the finalized codebook. Code excerpts will then be exported from Dedoose for consolidation to answer the research questions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAIM2: Adapt 3MV to\u003c/b\u003e \u003cb\u003eLAFIYA\u003c/b\u003e \u003cb\u003eto address ISD and HIVST among YSMM\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eADAPTT-IT Steps 2 to 7\u003c/h2\u003e \u003cp\u003e \u003cb\u003eStep 2 Decision\u003c/b\u003e. Using the information gathered from AIM1 (Assessment Step). In partnership with SMM implementers and providers, the team will meet to discuss the results and identify specific intervention activities that should be modified to address ISD and HIVST. We will also look for ideas from previous interventions by conducting a review to identify evidence-based best actions to address ISD and HIVST among YSMM for consideration in our decision-making. We will then finalize the specifics of the existing intervention that needs to be adapted to ensure we fully incorporate ISD reduction and HIVST focus on the intervention. Considering that the team has diverse persons with local expertise (PI, site PI, 2 co-I, community organizations, and consultants, most of whom are SMM, we will ensure that the intervention content and adaptation meet the local context of religion, language, and HIV communication, among others.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStep 3 Adaptation\u003c/b\u003e. We will conduct initial modifications of the intervention to reflect decisions in Step 2. We will then organize a 3-day mock workshop to administer and theatre test the intervention activities among a sample of YSMM (n\u0026thinsp;=\u0026thinsp;10) and YSMM CBO intervention implementers (n\u0026thinsp;=\u0026thinsp;4) who participated in the previous 3MV in Ghana. During the workshop, we will implement the activities (role plays, scenarios, discussions, presentations, games, etc.) that will tackle ISD and HIVST among YSMM. We will then collect feedback from YSMM and CBO participants on aspects of the intervention content and delivery that need amendments.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStep 4 Production\u003c/b\u003e. A team of investigators and community partners will collate and brainstorm about the experience in the mock intervention workshop. They will review the successful parts of the training for consolidation and devise ways to address challenges or less successful areas of the interventions. We will maintain the study's focus and be consistent with the literature on HIVST, ISD, and relevance to YSMM and YSMM in slums within Ghana to ensure we produce a comprehensive yet specific manual to address ISD and increase HIVST.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStep 5. Topical Expert Review\u003c/b\u003e. We will provide a copy of the \u003cem\u003eLAFIYA\u003c/em\u003e manual to experts on ISD, HIVST, original 3MV, and YSMM health in Ghana and SSA for review and feedback. The experts will be asked for feedback on the consistency of the manual to address ISD and to increase HIVST among YSMM. The experts identified include Dr. LaRon Nelson, who led several studies in Ghana and is an expert in using 3MV to address HIV prevention among SMM. Dr. Kwasi Torpey has conducted several studies among HIV key populations in Ghana. Francis Boakye is a gay-identified man who founded PORSH, the civil society organization partners that work with Ghanaian SMM. Edem Zigah is a community focal person/expert in HIV prevention and care and an HIVST provider in Ghana. Dr. Donaldson Conserve is an HIVST expert with vast experience working in SSA. Gamji Rabiu Abu-Ba'are, contact PI and HIV and stigma implementation science expert among SMM in Ghana. James McMahon is an implementation science expert with a decade of experience developing HIV prevention interventions. \u003cb\u003eWe will also receive feedback from the Ghana AIDS Control programme on local program contents and consistency with local HIVST guidance\u003c/b\u003e. The topical experts will give written feedback and participate in a workshop to discuss pivotal activities and modifications to the local cultural relevance and intervention implementation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStep 6. Integration\u003c/b\u003e. Here, we will collate feedback from the topical experts for the investigative team and local partners to review. We will incorporate the feedback to solidify the manual, ask follow-up questions, and discuss areas where the input is unclear to the team.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStep 7. Training\u003c/b\u003e. In consultation with the Site PI, the community partners will identify 2 facilitators to deliver the intervention. The facilitators will self-identify as SMM and experience participating in previous HIV interventions with SMM in Ghana. We expect facilitators to have cultural relatability to participants and topics and the potential anxieties and wariness of the intervention participants. The interventionists will first receive a two-day training on group facilitation skills in which they will increase their knowledge, confidence, and fluidity in group facilitation. They will then be trained on the ISD reduction intervention. The facilitators will receive training from qualified ISD reduction trainers (Drs Nelson and Abu-Ba'are) with experience implementing 3MV. Dr. Conserve and Mr. Zigah will lead the HIVST component. Zigah is a Ghanaian expert in HIVST implementation among SMM and facilitated stigma reduction in our previous studies among SMM in Ghana. Conserve developed an HIVST training which he delivered to men in Tanzania.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAIM3: Test acceptability, feasibility, appropriateness, and preliminary efficacy of\u003c/b\u003e \u003cb\u003eLAFIYA\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eADAPTT-TT Step 8 (Testing)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDesign\u003c/b\u003e. We will pilot test the \u003cem\u003eLAFIYA\u003c/em\u003e intervention using a single arm pre-post design. We aim to adapt the intervention and preliminary test it for future full-efficacy cluster randomized control trial (CRT) \u003csup\u003e\u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e95\u003c/span\u003e,\u003cspan citationid=\"CR96\" class=\"CitationRef\"\u003e96\u003c/span\u003e\u003c/sup\u003e. Although RCT is primarily used in HIV and behavioral interventions, we find CRT better due to our place-based focus and possible sample contamination surrounding sleeping arrangements and the communal nature of slum communities. Thus, we aim to use this developmental-focused RO1 and the pre-post design as a developmental study to adapt and preliminary test \u003cem\u003eLAFIYA\u003c/em\u003e to inform the future efficacy test using CRT. Aside from contamination, the pre-post-intervention design is less resource-intensive and is suitable for the primary focus of the intervention on acceptability and feasibility. It is also enough to show some early changes the intervention will have on the participants and prepare grounds for a more significant and more extensive efficacy CRT.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHypothesis\u003c/strong\u003e \u003cp\u003eExposure to the \u003cem\u003eLAFIYA\u003c/em\u003e intervention will reduce ISD and increase the capacity and uptake of HIVST among YSMM. The participants will receive the intervention and be given the option to initiate HIVST. They will also have the opportunity to collect the contacts of trained nurses for follow-up questions and confirmatory tests if needed. The nurses will visit the intervention site on the final day of training to introduce themselves and share their contacts with participants. PORSH will keep the contacts of nurses for participants' use if needed. We will collect baseline, immediate, and 3-month post-intervention surveys to examine ISD and initiation of HIVST.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSampling and recruitment\u003c/h2\u003e \u003cp\u003eWe will use the starfish sampling and inclusion criteria (see AIM1) to recruit YSMM (n\u0026thinsp;=\u0026thinsp;60). Per the design, all participants will receive the intervention without a control or waitlist. Research assistants who are SMM and have experience in research with YSMM in Ghana will aid in recruiting the YSMM for intervention testing.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePower.\u003c/b\u003e For the 5-Likert acceptability and appropriateness scores, the feasible sample size of 60 will produce a two-sided 95% confidence interval (CI) with a precision of 0.32 when the standard deviation (SD) is 1.25 (estimated SD\u0026thinsp;=\u0026thinsp;Coefficient of variation*Assumed mean\u0026thinsp;=\u0026thinsp;0.05*2.5). Also, this sample size will produce a margin error of 0.13 for proportions of satisfaction, retention, and participation in feasibility at a 5% significance level. We calculated powers to detect a pre-post change in ISD and HIV testing at three months from baseline. Based on our previous study in Ghana, we anticipate a mean of 1 (SD\u0026thinsp;=\u0026thinsp;0.65) for overall ISD, ranging from 0 to 3 at baseline \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. The sample size of 60 will be able to detect the decreases of 0.25 and 0.30 (\u003cb\u003emedium effect sizes\u003c/b\u003e of 0.38 and 0.46) with \u003cb\u003e89% and 94% powers\u003c/b\u003e, respectively, in the pre-posttest at a 5% significance level. By assuming the attrition rate of about 2 to 4% from the study in Ghana, we will still have acceptable powers of 82% and 93% to detect those effect sizes with a sample of 58. As a pilot with implementation outcomes around acceptability, appropriateness, and feasibility, this study does not expect statistical significance on intervention efficacy. The sample size would be enough to estimate the intervention's preliminary effect size and measure the primary outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eImplementation of the intervention:\u003c/h2\u003e \u003cp\u003e \u003cb\u003eDescription of the intervention.\u003c/b\u003e The 3MV remains the only CDC-recommended evidenced group-based intervention tailored to HIV prevention among Black SMM. It was initially designed for the United States context, with seven sessions focused on addressing barriers to HIV prevention to increase understanding of HIV risk and transmission and to influence behavioral change to increase condom use and HIV/STD testing. We previously adapted it to address Ghanaian SMM contexts such as religion, sexual identity, and gender norms and expectations.\u003c/p\u003e \u003cp\u003e \u003cb\u003eExpected adaptations to the intervention.\u003c/b\u003e We expect our process to adapt the intervention to the context of YSMM, social vulnerability, and environmental factors that hinder HIV testing. The new intervention will also examine ISD experience around HIV, place, gender expression, sexual behavior, and the related impact on HIV testing for YSMM. We will also incorporate specific training to build capacity for using unassisted HIVST among YSMM.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of 3MV and potential modified \u003cem\u003eLAFIYA\u003c/em\u003e intervention.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent 3MV sessions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotential \u003cem\u003eLAFIYA\u003c/em\u003e Sessions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Ghanaian SMM and dual identity\u003c/p\u003e \u003cp\u003e2. HIV/STD prevention for Ghanaian SMM: the roles and risks for tops and bottoms\u003c/p\u003e \u003cp\u003e3. HIV/STD risk assessment and prevention options\u003c/p\u003e \u003cp\u003e4. Intentions to act and capacity for change\u003c/p\u003e \u003cp\u003e5. Relationship issues: Partner selection, communication, and negotiation of roles for Ghanaian SMM\u003c/p\u003e \u003cp\u003e6. Social support and problem-solving to maintain change\u003c/p\u003e \u003cp\u003e7. Building bridges and community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ea. ISD and impact on sexual health and HIV outcomes\u003c/p\u003e \u003cp\u003eb. HIV/STD, risk assessment, testing, and prevention options\u003c/p\u003e \u003cp\u003ec. HIV risk assessment and testing option for YSMM in slums\u003c/p\u003e \u003cp\u003ed. Building capacity for HIVST \u0026ndash; Conducting an unassisted test, options, and strategies\u003c/p\u003e \u003cp\u003ee. Intentions to act and capacity for change to adopt prevention options and HIVST\u003c/p\u003e \u003cp\u003ef. Relationship issues: Partner selection, communication, negotiation roles, prevention, and testing options for YSMM in slums\u003c/p\u003e \u003cp\u003eg. Social support and problem-solving to maintain change\u003c/p\u003e \u003cp\u003eh. Building bridges and community\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eImplementation procedure.\u003c/b\u003e The facilitators trained in aim 2 will receive a copy of the manual on delivering each component of the adapted intervention. PORSH will recruit the YSMM to attend a 3-day weekend retreat at a location identified by PORSH with support from the site PI and Contact PI. Considering that YSMM remain hidden, we expect to utilize places we used in previous interventions. Such locations have already been appraised and have a working relationship with the team where their security is assured. YSMM, who accept to participate in the intervention, will receive dates for the weekend intervention retreats at temporarily rented facilities. Before participating in the \u003cem\u003eLAFIYA\u003c/em\u003e intervention, participants will attend an orientation meeting at PORSH to obtain information about the retreat's logistics and format and establish ground rules for appropriate behavior. Once participants arrive at the retreat, the \u003cem\u003eLAFIYA\u003c/em\u003e intervention will be delivered in six consecutive 2- to 3-hour sessions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAppraisal of intervention.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eData collection\u003c/b\u003e. Participants will complete baseline, immediate, and 3-month post-intervention surveys. Trained SMM research assistants who collected surveys in our previous studies will conduct the surveys. Data collection location will be at the designated sites (e.g., office of community partners) determined as safe for YSMM in Ghana. Such determination will be led by the community partners, the site PI, and the contact PI due to their extensive experience working with SMM on the grounds in Ghana.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMeasures.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eDemography, HIV testing, and stigma descriptive variables\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eWe will assess important baseline characteristics for describing the sample, including age, income, gender, education, ethnicity, relationship status, religion, sexual identity, sexual behavior, HIV knowledge, HIV testing readiness, HIV testing history, and histories of intersecting stigmas, access, and utilization of health and social services, civic engagement and neighborhood.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePrimary implementation of the outcome\u003c/strong\u003e \u003cp\u003ewe will measure our implementation primary outcome variables (acceptability, appropriateness, and feasibility) using expanded Proctors validated measures using pre-immediate and three months post-intervention surveys \u003csup\u003e\u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e97\u003c/span\u003e\u003c/sup\u003e. See sample items\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of primary outcome measures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample Item\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWilx\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAcceptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHIVST meets my approval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHIVST meets my needs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI welcome use of HIVST\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAppropriateness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHIVST seems reasonable.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHIVST seems like a good match\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHIVST seems applicable.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFeasibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThis EBP seems easy to use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThis EBP seems challenging.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThis EBP seems practical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSecondary outcomes\u003c/b\u003e. At baseline and three months, we will measure the preliminary effectiveness of \u003cem\u003eLAFIYA\u003c/em\u003e. We will measure knowledge of HIV and HIVST and willingness to receive HIVST pre- and post-intervention. Testing characteristics (testing rates, time, and mode of testing; home or in a facility). For ISD reduction, we will measure internalized and interpersonal level ISD around HIV, place, gender expression, and sexual acts at baseline and post-intervention surveys. We will also measure community-level and healthcare facility-level stigma to understand participant experiences at baseline.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of secondary outcome measures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstruct\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eitems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample Item\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIV self-testing/testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRates of HIV tests in 3-months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasic Needs Satisfaction Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhen I am with my friends, I feel free to be who I am? (α\u0026thinsp;=\u0026thinsp;0.85\u0026ndash;0.92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare Climate \u003csup\u003e\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e,\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI feel that my healthcare provider accepts me (α\u0026thinsp;=\u0026thinsp;0.92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrief Resilience Scale\u003csup\u003e\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI tend to bounce back quickly after hard times? (α\u0026thinsp;=\u0026thinsp;0.80\u0026ndash;0.91)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eISD (Latent Variable)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eManifest Variable: HIV Stigma Scale\u003c/b\u003e\u003csup\u003e121\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnacted stigma subscale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHas a healthcare worker not wanted to touch you because you have HIV? (α\u0026thinsp;=\u0026thinsp;0.92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVicarious stigma subscale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHow often have you heard stories about someone with HIV being refused care? (α\u0026thinsp;=\u0026thinsp;0.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived subscale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIn your community, how many people think a person with HIV is disgusting? (α\u0026thinsp;=\u0026thinsp;0.94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternalized subscale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHow often do you feel guilty about having HIV? (α\u0026thinsp;=\u0026thinsp;0.83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManifest Variable: Same-sex stigma scale \u003csup\u003e\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHow often have you lost a place to live for being homosexual? (α\u0026thinsp;=\u0026thinsp;0.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender Non-Conformity Stigma Scale \u003csup\u003e\u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e102\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHow often have you been called names because of your feminine mannerisms? (α\u0026thinsp;=\u0026thinsp;0.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e3.9 DATA ANALYSIS.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eApproach.\u003c/b\u003e We will use the intent-to-treat (ITT) technique to analyze the baseline and post-intervention survey data using Stata software for statistical analysis. We considered other methods (e.g., per protocol approach); however, we chose ITT because it's regarded as the least biased approach since it requires all participants to be assessed regardless of whether they received the intervention assigned initially or not.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eProcess\u003c/strong\u003e \u003cp\u003eData collected will be exported to Stata for cleaning and further analysis. Missing patterns in the instrument will be assessed, and missing responses will be imputed when at least 70% of responses are observed. The scores of instruments will be calculated with observed and imputed responses. We will employ descriptive statistics to summarize the characteristics of participants. We will calculate a mean with a confidence interval for the variables and proportions of responses to the primary (feasibility, appropriateness, and acceptability) and secondary outcome variables (HIVST and ISD). We will run inferential statistics such as paired t-test to compare pre-and post-means, McNamar's test to compare pre-and post-proportions, and correlation analysis to examine the relationship between variables, especially differences between populations based on sociodemographic characteristics. Since this study primarily focuses on acceptability, feasibility, appropriateness, and preliminary effects, we will not conduct advanced statistical modeling.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eChallenges and Solutions\u003c/h2\u003e \u003cp\u003e \u003cb\u003eConfirmatory testing and linkage to care after testing.\u003c/b\u003e Our experience working in Ghana shows that after testing for HIV, many SMM default and do not go for follow-up testing and linkage to care. The young adults in this study may need access to counseling and connection to ARV should they test positive. As such, we will identify 6 nurses with experience working with YSMM to aid in follow-up with participants when they test and need such support. The contacts of the nurses will be readily available at the CBO and given to participants as part of the information during the intervention.\u003c/p\u003e \u003cp\u003e\u003cb\u003eRecruiting the desired group of participants.\u003c/b\u003e In our previous study, due to stigma and fear of disclosure, we observed that some SMM who did not meet the study criteria around HIV status joined the study by following their colleagues who invited them to join. As such, we will use an already tested solution in the study, where we used concealment during recruitment to ensure we reached the right participants. Here, we will use a preloaded computer screening survey which will show at random for interested participants to fill out. Upon filling, the instrument will automatically screen them for inclusion or exclusion. We will also not let people accompany others for screening; we will reach out to every potential participant to screen them in their private space. This strategy is crucial as some participants do not ascribe to sexual orientations or do not want others to know about their sexuality until they build trust over several interactions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRetention of participants.\u003c/b\u003e Since we will be working with young adults and socially vulnerable persons, there is a high possibility that some of them will be mobile. As such, we will ensure we invite participants who are sure of their availability during the study period. We will also follow up periodically to check on their plans and device means to ensure continuity.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and Future Directions\u003c/b\u003e. \u003cb\u003eStrengths\u003c/b\u003e: the study will adapt and test the feasibility, acceptability, and appropriateness of a CDC evidence-based intervention (3MV) to address ISD and increase HIVST. Previous research highlights financial constraints, ISD, and health system challenges as critical barriers to HIV testing and ART initiation and adherence among YSMM in Ghana. This study provides an opportunity to understand YSMM's lived experiences, especially concerning their geography, HIV testing practices, HIVST awareness, and willingness to participate. The findings can inform future studies and interventions to address HIV prevention and care among YSMM within similar sociocultural contexts in Africa and elsewhere. Additionally, to surmount barriers to HIV testing, HIVST will allow YSMM to test in their private space without visiting healthcare facilities, reducing the fear of facing stigma associated with sexual minority status and being seen at an HIV care facility. In other settings, HIVST proved acceptable among users, feasible to implement, and effective in scaling testing among targeted populations. Our current focus on HIVST aligns with Ghana's new commitment stipulated in its 2019 National HIV and AIDS Policy to increase HIVST among key populations. \u003cb\u003eFuture Directions\u003c/b\u003e: Based on findings from the pilot study, we will finalize a protocol for an efficacy trial of the intervention to improve HIV testing among YSMM in Ghana.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStudy Period\u003c/h2\u003e \n\u003ctable style=\"width: 5.0e+2pt;border-collapse:collapse;border:none;margin-left:6.75pt;margin-right: 6.75pt;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eStudy Activity by Quarter\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 106.45pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eY1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 108.25pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eY2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 104.3pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eY3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eQ1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eQ2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eQ3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eQ4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eQ1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eQ2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eQ3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eQ4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eQ1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eQ2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eQ3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eQ4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eIRB submission and approval\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n 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style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eTraining of project team and research assistants\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"13\" style=\"width: 499.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eAIM 1: Assessment Phase\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eRecruitment of participants\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eIn-depth Interviews\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eSummative data analysis for intervention adaptation\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eData analysis for manuscript development, and dissemination\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;background:yellow;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;background:yellow;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"13\" style=\"width: 499.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eAIM2: Adaptation Phase\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eIntervention Adaptation\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eTraining of intervention (\u003cem\u003eLAFIYA\u003c/em\u003e) facilitators and research assistants\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"13\" style=\"width: 499.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eAIM3: Testing Phase\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eBaseline surveys\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 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style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 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style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eLAFIYA implementation\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 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Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eImmediate post intervention survey\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003e3 months post intervention survey \u0026ndash; all participants\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New 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style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;background:yellow;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eStudy field work review and closing workshop\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 10.25pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180.25pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;color:black;'\u003eData Analysis and Manuscript Writing\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.25pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(251, 228, 213);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(180, 198, 231);padding: 0in 5.4pt;height: 9.7pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:12px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003c/br\u003e\n\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section4\"\u003e \u003ch2\u003eEthics approval\u003c/h2\u003e \u003cp\u003e This study was approved by the institutional review board in the University of Rochester (United States) IRB STUDY00008385 on 5/26/2023, and the University of Ghana Ethic Review Committee EPRC A.9 [I 8] 2022\u0026ndash;2023 on 5/25/2023.\u003c/p\u003e \u003cp\u003e \u003cb\u003eProcess of consent/Assent.\u003c/b\u003e The informed consent procedure will involve several steps to ensure that participants understand and agree to participate in this study. Firstly, trained research assistants from partner organizations will conduct interviews and surveys. Participants can choose to fill out the survey themselves in person. Next, participants will receive detailed consent forms approved by the Institutional Review Board (IRB). These forms will explain the study's questions, procedures, and potential risks. Before any study intervention or procedures begin, participants must provide written consent. During the consent process, participants can read the forms themselves or have it explained by the interviewer. This discussion will take place in a private room, a secure location of the participant's choice, or via a secure online platform like Zoom. In all scenarios, written consent will be obtained. Before deciding whether to participate, participants will have enough time to review the consent form, ask questions, and talk about the study with their family members or surrogates. It will be emphasized throughout this process that participation is voluntary, and participants have the right to withdraw from the study at any time without facing any negative consequences. Participants will also receive a copy of the informed consent document for their records.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConfidentiality and security of data.\u003c/b\u003e The researchers will take every possible measure to protect the confidentiality of the participants. Any mention of the participants in reports by the research team or partner organizations will not include their names. The data collected from the participants will be assigned unique codes for identification purposes, ensuring complete confidentiality. Personal information, including contact details, will be kept separate from other study information to further safeguard confidentiality. Participants will be referred to by titles like \"key informants\" or \"providers\" or by their assigned participant ID, rather than by their actual names.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData storage and access.\u003c/b\u003e The security and confidentiality of all questionnaires and data collection tools. After data capture, these materials will be stored in a locked file cabinet to prevent unauthorized access. Additionally, all data files entered into the computer will be protected with passwords, adding an extra layer of security to prevent unauthorized viewing or manipulation. These measures aim to maintain the integrity and confidentiality of the collected data throughout the research process.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData and safety monitoring plan.\u003c/b\u003e Participants' confidentiality will be safeguarded to the utmost extent by the researchers. Neither the research team nor any partner organization will mention participants by name in any reports. To ensure confidentiality, the data collected from participants will be assigned unique codes for identification purposes. Participants' personal information, including contact details, will be stored separately from other study information to maintain confidentiality. Participants will not be identified by their actual names but rather by titles such as \"key informants\" or \"providers\" or by their assigned participant IDs.\u003c/p\u003e \u003cp\u003e \u003cb\u003eReporting of adverse events.\u003c/b\u003e The study is designed to minimize any risk, and is subject to rigorous oversight by the MPIs. MPIs are responsible for ensuring the integrity of the data, as well as conducting regular safety evaluations. If concerns arise, the MPIs have the authority to make necessary changes, pause enrollment, or terminate the study as needed. In addition, the University of Rochester and the University of Ghana (IRBs) are charged with providing additional oversight and support to ensure adherence to all protocols and maintain the safety of all participants.\u003c/p\u003e \u003cp\u003e \u003cb\u003eManagement of interim results.\u003c/b\u003e The study will be conducted internationally with multiple sites and stages, so we will utilize a scientific leadership approach. With this approach, MPIs will ensure maximizing team science efforts to better respond to the challenges and opportunities in today's world. Our team of experts from diverse fields, including nursing, demography, public health, social work, epidemiology, and statistics, will provide oversight of the entire study, including the development and implementation of policies, procedures, and processes to ensure cultural relevance, congruence, and sensitivity throughout the process of assessing ISD and developing options for HIVST, and adapting and evaluate the feasibility of 3MV to LAFIYA to address ISD and HIVST among YSMM, Test acceptance, feasibility, appropriateness, and preliminary efficacy of LAFIYA to address ISD and increase HIVST uptake, as well as the protection of human subjects. The scientific leadership in this study will ensure all institutional compliance, such as those of the NIH, University of Rochester, University of Ghana, and the Ghana and US government laws are adhered and maintained throughout the study period.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDissemination plan.\u003c/b\u003e The results of this research will be shared and presented in scientific conferences or in publications.\u003c/p\u003e \u003cp\u003e \u003cb\u003eProtocol modifications.\u003c/b\u003e All study team members have been involved in planning the project and will continue to have shared responsibility for making scientific decisions throughout the study. Suppose a question arises that requires the expertise or experience of a specific team member (such as YSMM, provider, or statistical analysis). In that case, that individual will be deferred to as the primary decision-maker. If the leadership team cannot agree on a scientific question, the investigator in charge of the relevant data collection component will have the final say. Ensuring a unified decision-making process that draws on everyone's expertise and maintains the study's scientific integrity.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePayments for participation.\u003c/b\u003e There won't be direct monetary compensation. Instead, participants will receive tokens of appreciation in cash for their involvement. Firstly, for the assessment interview, each participant will receive 150 cedis. This token serves as recognition for their time and insights shared during this phase. Next, for engaging in the workshop and participating in both the pre- and post-intervention surveys, each participant will receive 300 cedis. This money acknowledges the commitment and valuable contributions made to the study. Lastly, three months after the interventions, there will be a follow-up survey, and participants will receive 150 cedis for their continued involvement in the study. These tokens of appreciation are offered as a gesture of gratitude for the invaluable contributions participants make toward advancing the study's objectives.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe core objective of the study is to adapt the 3MV approach into a modified version termed LAFIYA, aimed at addressing ISD and bolstering HIVST uptake among young sexual minority men (YSMM). This research endeavors to comprehensively evaluate the acceptance, feasibility, appropriateness, and preliminary effectiveness of employing the 3MV approach in combating ISD while promoting HIVST among YSMM in Ghana. Structured around three pivotal aims, this study outlines a strategic framework: firstly, to evaluate ISD and explore viable options for implementing HIVST; secondly, to adapt 3MV into LAFIYA, aligning it to effectively address ISD and HIVST among YSMM; and thirdly, to rigorously test the acceptance, feasibility, appropriateness, and initial efficacy of LAFIYA in reducing ISD and enhancing HIVST uptake. Guided by the ADAPTT-IT framework, the study meticulously progresses through various steps, employing AIM1 to implement the initial phase and synthesizing outcomes from AIM1 and subsequent steps (Steps 2 to 7) to steer AIM2 towards creating a comprehensive manual for the LAFIYA intervention. The third aim marks the pilot testing phase, where assessments will be conducted to gauge the intervention's acceptance, feasibility, appropriateness (as the primary outcome), and preliminary efficacy in reducing ISD and boosting HIVST uptake (as the secondary outcome) among YSMM. This foundational RO1 study sets the stage for a larger clustered randomized trial (CRT), poised to rigorously evaluate the efficacy of LAFIYA in diminishing ISD and fostering HIVST among YSMM, thus paving the way for substantial advancements in this field.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: Gamji Rabiu Abu-Ba\u0026apos;are\u003csup\u003e1,2,3,4,7\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eData curation: Gamji Rabiu Abu-Ba\u0026apos;are\u003csup\u003e1,2,3,4,7\u003c/sup\u003e, Kwasi Torpey\u003csup\u003e5\u003c/sup\u003e, LaRon Nelson\u003csup\u003e6,7\u003c/sup\u003e, Donaldson Conserve\u003csup\u003e10\u003c/sup\u003e, Sangchoon Jeon\u003csup\u003e6\u003c/sup\u003e, James McMahon\u003csup\u003e1,2\u003c/sup\u003e, Adom Manu\u003csup\u003e5\u003c/sup\u003e, Edem Yaw Zigah\u003csup\u003e2,4\u003c/sup\u003e, Osman Shamrock\u003csup\u003e1,2,4,\u0026nbsp;\u003c/sup\u003eAmos Apreku\u003csup\u003e5\u003c/sup\u003e, Delali Dakpui\u003csup\u003e2,4\u003c/sup\u003e, George Rudolph Agbemedu\u003csup\u003e2,4\u003c/sup\u003e, Gideon Adjaka\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eFormal analysis: Gamji Rabiu Abu-Ba\u0026rsquo;are\u003csup\u003e1,2,3,4,7\u003c/sup\u003e, LaRon Nelson\u003csup\u003e6,7\u003c/sup\u003e,\u003csup\u003e\u0026nbsp;\u003c/sup\u003eSangchoon Jeon\u003csup\u003e6\u003c/sup\u003e, Osman Shamrock\u003csup\u003e1,2,4\u003c/sup\u003e, Delali Dakpui\u003csup\u003e2,4\u003c/sup\u003e, George Rudolph Agbemedu\u003csup\u003e2,4\u003c/sup\u003e,\u003c/p\u003e\n\u003cp\u003eFunding acquisition: Gamji Rabiu Abu-Ba\u0026apos;are\u003csup\u003e1,2,3,4,7\u003c/sup\u003e, Adom Manu\u003csup\u003e5\u003c/sup\u003e, Kwasi Torpey\u003csup\u003e5\u003c/sup\u003e, LaRon Nelson\u003csup\u003e6,7\u003c/sup\u003e, James McMahon\u003csup\u003e1,2\u003c/sup\u003e, Donaldson Conserve\u003csup\u003e10\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInvestigation: Gamji Rabiu Abu-Ba\u0026apos;are Gamji Rabiu Abu-Ba\u0026apos;are\u003csup\u003e1,2,3,4,7\u003c/sup\u003e, Kwasi Torpey\u003csup\u003e5\u003c/sup\u003e, LaRon Nelson\u003csup\u003e6,7\u003c/sup\u003e, Donaldson Conserve\u003csup\u003e10\u003c/sup\u003e, Sangchoon Jeon\u003csup\u003e6\u003c/sup\u003e, James McMahon\u003csup\u003e1,2\u003c/sup\u003e, Adom Manu\u003csup\u003e5\u003c/sup\u003e, Edem Yaw Zigah\u003csup\u003e2,4\u003c/sup\u003e, Osman Shamrock\u003csup\u003e1,2,4\u003c/sup\u003e, Amos Apreku\u003csup\u003e5\u003c/sup\u003e, Delali Dakpui\u003csup\u003e2,4\u003c/sup\u003e, George Rudolph Agbemedu\u003csup\u003e2,4\u003c/sup\u003e, Gideon Adjaka\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eMethodology: Gamji Rabiu Abu-Ba\u0026rsquo;are\u003csup\u003e1,2,3,4,7\u003c/sup\u003e, Kwasi Torpey\u003csup\u003e5\u003c/sup\u003e, LaRon Nelson\u003csup\u003e6,7\u003c/sup\u003e, Donaldson Conserve\u003csup\u003e10\u003c/sup\u003e, Sangchoon Jeon\u003csup\u003e6\u003c/sup\u003e, James McMahon\u003csup\u003e1,2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eProject administration: \u0026nbsp;Gamji Rabiu Abu-Ba\u0026apos;are\u003csup\u003e1,2,3,4,7\u003c/sup\u003e, Kwasi Torpey\u003csup\u003e5\u003c/sup\u003e, Edem Yaw Zigah\u003csup\u003e2,4\u003c/sup\u003e, Amos Apreku\u003csup\u003e5\u003c/sup\u003e, Delali Dakpui\u003csup\u003e2,4\u003c/sup\u003e, George Rudolph Agbemedu\u003csup\u003e2,4\u003c/sup\u003e, Gideon Adjaka\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSupervision: Gamji Rabiu Abu-Ba\u0026apos;are\u003csup\u003e1,2,3,4,7\u003c/sup\u003e, Kwasi Torpey\u003csup\u003e5\u003c/sup\u003e, Edem Yaw Zigah\u003csup\u003e2,4\u003c/sup\u003e, Adom Manu\u003csup\u003e5\u003c/sup\u003e, Gideon Adjaka\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; original draft: Gamji Rabiu Abu-Ba\u0026apos;are\u003csup\u003e1,2,3,4,7\u003c/sup\u003e, James McMahon\u003csup\u003e1,2\u003c/sup\u003e, Adom Manu\u003csup\u003e5\u003c/sup\u003e, Edem Yaw Zigah\u003csup\u003e2,4\u003c/sup\u003e, Osman Shamrock\u003csup\u003e1,2,4\u003c/sup\u003e, Gideon Adjaka\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; review \u0026amp; editing: Gamji Rabiu Abu-Ba\u0026apos;are\u003csup\u003e1,2,3,4,7\u003c/sup\u003e, Kwasi Torpey\u003csup\u003e5\u003c/sup\u003e, LaRon Nelson\u003csup\u003e6,7\u003c/sup\u003e, Donaldson Conserve\u003csup\u003e10\u003c/sup\u003e, Sangchoon Jeon\u003csup\u003e6\u003c/sup\u003e, James McMahon\u003csup\u003e1,2\u003c/sup\u003e, Adom Manu\u003csup\u003e5\u003c/sup\u003e, Edem Yaw Zigah\u003csup\u003e2,4\u003c/sup\u003e, Osman Shamrock\u003csup\u003e1,2,4\u003c/sup\u003e, Amos Apreku\u003csup\u003e5\u003c/sup\u003e, Delali Dakpui\u003csup\u003e2,4\u003c/sup\u003e, George Rudolph Agbemedu\u003csup\u003e2,4\u003c/sup\u003e, Gideon Adjaka\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbubakari GM, Dada D, Nur J et al (2021) Intersectional stigma and its impact on HIV prevention and care among MSM and WSW in sub-Saharan African countries: a protocol for a scoping review. 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Soc Sci Med 74(8). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.socscimed.2012.01.008\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2012.01.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Fogarty International Center of the National Institute of Health","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4313437/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4313437/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYoung sexual minority men (YSMM) living in slums face high risks of contracting HIV due to poverty and limited healthcare access. Certain areas in Accra's slums have much higher HIV rates than the national average, around 7% compared to 2%. YSMM in these areas struggle to access services, have lower perceptions of HIV risk, less education, and face poverty, leading to low rates of HIV testing. These YSMM also encounter increased stigma because of where they live, like in the slum area known as \"Old Fadama\" or \"Sodom and Gomorrah.\" This stigma affects their willingness to get tested for HIV and adds to other stigmas related to their sexuality and gender expression. Ghana's efforts to improve HIV testing for YSMM face challenges such as stigma, low-risk perception, and concerns about confidentiality. Introducing HIV self-testing (HIVST) offers hope to increase testing among YSMM by allowing them to test in private. However, there are challenges with implementing HIVST in Ghana, including limited knowledge and fears of stigma. Advocates suggest integrating HIVST with existing testing methods to improve access and inclusivity for YSMM in Ghana.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study adapts the 3MV approach into a modified version called LAFIYA to combat intersectional stigma and enhance HIVST among young cis-gender men who have sex with men (YSMM) in Ghana. Using the ADAPTT-IT framework, the study plans to implement three aims, refining the adapted intervention, creating a manual for LAFIYA, and conducting a pilot test to assess acceptance, feasibility, appropriateness, and preliminary efficacy in reducing stigma and increasing HIVST among YSMM. Conducted within urban slum communities in Accra, the research intends to recruit 20 YSMM and 20 providers, stratified into nurses and community organization providers. The study employs a starfish sampling to recruit YSMM and purposive sampling techniques for providers. Eligibility criteria for YSMM include specific age, lack of experience with unassisted HIVST kits, identification as cis-gender men, recent engagement in sex with another man, and residency in the Greater Accra Metropolitan area within a slum community. Providers must have at least one year of experience in sexual health services and working with YSMM on HIV prevention and care within the same geographical area.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe adaptation of the 3MV approach into \u003cem\u003eLAFIYA\u003c/em\u003e aimed to tackle intersectional stigma and improve HIVST among YSMM in Ghana. The study's primary objective focused on assessing the acceptance and feasibility of this modified method in reducing stigma and increasing HIVST uptake among YSMM. Organized into three core objectives, the research evaluated the presence of stigma, transformed 3MV into \u003cem\u003eLAFIYA\u003c/em\u003e, and rigorously examined \u003cem\u003eLAFIYA\u003c/em\u003e's effectiveness in reducing stigma and boosting HIVST uptake among YSMM. Following the ADAPTT-IT framework, the study systematically progressed through different stages to produce a comprehensive manual for the \u003cem\u003eLAFIYA\u003c/em\u003e intervention. This foundational study set the groundwork for a larger-scale trial intended to assess \u003cem\u003eLAFIYA'\u003c/em\u003es effectiveness in reducing stigma and enhancing HIVST among YSMM.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrail registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is registered on clinicalTrail.gov, with identifier number NCT06238323 on 02/02/2024\u003c/p\u003e\n\u003cp\u003ehttps://clinicaltrials.gov/study/NCT06238323?locStr=Ghana\u0026amp;country=Ghana\u0026amp;cond=HIV\u0026amp;aggFilters=status:not%20rec\u0026amp;rank=4\u003c/p\u003e","manuscriptTitle":"Adaptation and feasibility of Many Men Many Voices (3MV), an HIV prevention intervention to reduce intersectional stigma and increase HIVST among YSMM residing in Ghanaian slums – A clustered pre-post pilot trial protocol.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-24 06:30:33","doi":"10.21203/rs.3.rs-4313437/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d573235-4bc4-4eb9-8cdc-b46b8cdda1a7","owner":[],"postedDate":"April 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":31067762,"name":"Health Policy"}],"tags":[],"updatedAt":"2024-04-24T06:30:33+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-24 06:30:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4313437","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4313437","identity":"rs-4313437","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}