Staff focus group
Our staff focus group yielded three main findings regarding the language, structure, and presentation of the intervention. First, staff recommended we change certain wording (e.g., say “unprotected sex” instead of “risky sex”; query about oral sex in additional to vaginal and anal sex) to enhance resident understanding and engagement. Second, staff had mixed reactions about when we should start the intervention. Some recommended starting the first session 4 weeks or more after residents enter housing instead of within 2 weeks because they were worried that residents would not be honest about their risk behaviors, while other staff thought it may be easier to recruit clients to the study early on when they were motivated to enter housing. They recommended we clearly outline our rules about confidentiality to encourage honest reporting. Finally, staff had several positive comments about the visualizations stating they liked the colors of the nodes and the sizes of the circles to distinguish different people in their network. They stated that the visualizations may lower any defensiveness naturally engendered when discussing their substance use and sexual risk behaviors. They also recommended that we use computers versus tablets to deliver the intervention because the visualizations may be easier to see on a larger monitor. They recommended bigger fonts and surface area to see the intervention visualizations and the need to have a backup if internet connectivity was not available. Finally, staff recommended that we beta-test our intervention with long-term residents who were also peer advocates in addition to new residents because of their relevant experiences.
Residents
We group the themes from both the long-term residents and new residents together because their feedback was similar. The three themes that emerged were that the intervention was helpful in discussing their social network, that seeing the visualizations was more impactful than just talking about their network, and that the intervention prompted thoughts about changing their AOD use and HIV risk networks. Each theme is described below. Table
1 elaborates on each theme by providing additional participant quotes.
Table 1
Themes from resident interviews
Intervention was helpful in examining their social network | I thought it was awesome |
It was helpful to me also to stay motivated and stay positive |
It showed me the connection that one must have in order to stay focused. You can be connected to an awesome network, people that’s moving forward…and also you can be connected to a network that’s dying. So it is a network whether it’s good or bad…it’s just which one you choose to be connected to |
It helps you see who really around you is helping you, who is your support system, and how do you feel about your support system, and whether or not you’re going to change your daily behavior and/or interactions |
Seeing the visualizations is more impactful than just talking about their network | Well, actually I see my support system. Visually I can see it. It’s different between thinking it and all that, but seeing it lets me know that this is correct |
It makes you see the pattern of your own life, and you visualize it, you know what I mean, it’s not just in your mind |
With a case manager you set goals, but this is better. It shows... your activities. You know, I can see who’s bad for me and who’s not bad for me |
Seeing it is different than just somebody telling you or talking about it. Seeing it makes it easier to understand |
Intervention prompted thoughts about changing their AOD use and HIV risk networks | I need to not be up in their face, I need them not to be up in mine, because if I could stop smoking cocaine, I know I could slow down on my drinking. But it’s the environment that I be around, the environment that I be around, the people that be in my circle, and I be in their circle, I need to change that |
So as far as not drinking, I haven’t been going to see my friends who drink. And I’ve been meeting new friends, and hoping, you know, like non-drinking, and if I go for information, I call individuals that are in AA. I’m getting closer to that also |
If I surround myself with people that have my old mentality, it’s just going to keep me trapped in my same situation bringing me no type of change. So if I expand my surroundings, expand the people that I deal with, and cut out people that I know that I shouldn’t be dealing with, or that aren’t really beneficial to me |
The first theme that participants frequently mentioned was how helpful the intervention was in discussing and examining the people currently in their lives. For example, one respondent said, “It made me think about who is in my life…who I interact with” and “It kind of shows you who you need to be with and who you don’t need to be with.” Some commented on how this insight helped them understand their own behaviors. For example, “I also see what I gravitate to more…which is good, because I can see what I’m doing.”
There were some negative comments in the early stages of the beta testing regarding the number of alters and type of alters that participants were being asked to name. As a result, we changed the instructions to add flexibility to the number of alters that participants are asked to name, as the participants indicated it may be challenging for some residents to generate 20 people that they had interacted with in the past 2 weeks and others suggested that 10 names might be too few to identify important relationships. Also, participants expressed concern that the instructions were too ambiguous and that they may name children that would not be relevant to their AOD and HIV risk behavior. For example, one participant said, “because if I had named ten other different people, you would have got a totally different read, a totally different understanding. So I guess that’s why I was kind of confused because I didn’t know what direction you was going, what basically you were trying to find out, what were you trying to find out about?” Therefore, we modified the instructions so that participants were prompted to mention at least 10 adults (up to 15) that they had interacted with in the past 2 weeks.
Second, when asked about their feedback about the visualizations, the majority of participants felt that seeing their networks was much different and more beneficial than merely talking about the people in their life. For example, one participant stated, “it’s easy to talk about, but when I see who I should be with, who I shouldn’t be with, it’s a different issue, so it makes more sense”, and another participant stated that they realized after seeing the visualization that “this [social network] circle is not going to work for me. You know, hearing about it is one thing, but seeing it is another.” Some participants also commented that the visualizations were easy to understand. One participant stated, “it’s a concrete way to see the big green circles are good, the big red ones are bad” and another participant stated, “The big circle I know for a fact there’s unprotected sex there”. Overall, the participants appeared to understand the purpose of using the visualizations to talk about social network change.
Finally, some residents who completed two sessions discussed how the session information helped them explore changes to their networks and/or their AOD or sexual risk behaviors. For example, one participant stated: “it showed me which ones I should be with, in case I need to, you know, if I’m trying to stop smoking, stop drinking, stop drugs, it kind of shows you who you need to be with and who you don’t need to be with". Another participant stated, “I see sobriety in the smallest circles, I see social [drinkers] in the medium circles…and then I see loss of control in the larger circles, and that’s why the [larger circles are] falling away from my network.” While we cannot conclude whether these changes were a result of the intervention itself, participants who reported change to their AOD and HIV risk behaviors consistently noted changes to their social networks. One participant talked about his network composition and how he “cut a lot of people out” and added “replacements” for the AOD-using individuals so that he could build a stronger support system. Another participant used the visualizations of her network structure to build her self-efficacy when stating, “…and by looking at having unprotected sex, how if a couple more lines would have been more connected, I would have been a little more scared, because I don’t know who’s sleeping with who. So two more lines and I’d have to run to the clinic.”
Satisfaction survey
Participants rated the sessions very highly as ratings were between a 4 (agree) and 5 (strongly agree; 1-5 Likert scale) in all 4 domains. Participants were highly satisfied with the overall session. On average, they agreed or strongly agreed that they had left the session with a specific goal in mind about changing their AOD use habits, as well as their social networks, and had found the session activities helpful. Participants also highly rated the social network visualizations, reporting they agreed or strongly agreed that the pictures showing their interaction, social support, alcohol and drug use, and sex and condom use were helpful. They also agreed or strongly agreed that the facilitators were well trained, valued and respected the respondent’s opinions, and were helpful throughout the session. Finally, participants also thought the session would positively impact new residents.