Moving from practice evaluation to intervention research: Group services to improve body image and nutrition among HIV-positive

men who have sex with men (MSM)

Matthew Feldman, Ph.D., MSW Jenny Torino, M.S., R.D. Gay Mens Health Crisis

Overview
Overview of program evaluation at GMHC Creation, implementation, and evaluation of a group to help MSM living with HIV/AIDS adopt healthy nutritional habits by improving body image Process of moving from program evaluation to intervention research

Program Evaluation at GMHC

Process Evaluation

Are service goals being met?

Is a service being used? Is the target population for a service being reached?

Outcome Evaluation
Are there improvements in the target behavior?

Program Evaluation Resources at GMHC

Department of Health Informatics Program Services Evaluation Committee

Recent Evaluation Projects

Process Evaluation
Rapid Response System Care Coordination deliverables

Outcome Evaluation
Art therapy Body Image Group

Body image among people living with HIV/AIDS

Three main spheres of influence on body image1 Physical Psychological Social

1Chapman,

1998

Physical aspects of body image

Physical changes impact how we feel about our bodies Illness increases awareness of the body
Anti-contagion measures Regular CD4 count and viral loads Bodily changes due to side effects from medications

Psychological aspects of body image

Anxiety Fear Frustration Uncertainty about the cause of bodily changes and declining health

Social aspects of body image

Five dimensions of stigma1
Concealability Course/predictability Peril Disruptiveness Origin

1Jones

et al., 1984

Body Image among men living with HIV/AIDS

31% of HIV-positive or at-risk men reported negative body image1 Current perception of body image was less than prior to HIV infection and greater than their perception of how others view people with HIV.2

1Sharma

et al., 2007 2Martinez et al., 2005

Body Image among men living with HIV/AIDS

Body image dissatisfaction is associated with depression, anxiety, stress, poor self-reported health, and a lack of social support among people living with HIV/AIDS (PLWHA).1,2 HIV-positive men may engage in potentially harmful behaviors to attempt to control bodily changes, including taking steroids and unhealthy nutritional habits.3-5
1Fingeret

et al., 2007 2Sharma et al., 2007 3Halkitis et al., 2004 4Power et al., 2003 5Reynolds et al., 2006

Body image among MSM

MSM are more likely than heterosexual men to:
Have an eating disorder diagnosis1-3 Experience body image dissatisfaction4-12 Be more preoccupied with their weight13,14 Report lower ideal weights and desire to be thinner6,15,16
9Siever,1994 10Silberstein

1Carlat

et al., 1997 2Feldman & Meyer, 2007 3Herzog et al., 1984 4Beren et al., 1996 5Conner et al., 2004 6Kaminski et al., 2002 7Lakkis et al., 1999 8Russell & Keel, 2002

et al.,1989 11Yager et al., 1988 12Yelland & Tiggemann, 2004 13Brand et al., 1992 14Gettelman & Thompson, 1993 15Brand et al., 1992 16Herzog et al., 1991

Body image among MSM living with HIV/AIDS

Themes1
Weight loss as a visible sign of HIV/disease progression Avoiding social and sexual activities to pre-empt self consciousness Experience food as a chore History of body image dissatisfaction pre-dating HIV Pervasiveness of gay bodily ideals Feeling let down by the body Not knowing when/where weight loss will stop
1Tate

& George (2001)

Nutrition and HIV

Malnutrition Metabolic Complications
High Cholesterol High Blood Sugar High Triglycerides

Body image dissatisfaction and health behaviors

Dietary Restraint Overeating Misuse of vitamin, mineral and herbal supplements Over exercising Eating Disorders

Nutritional Interventions
Nutrition counseling positively impacts weight, calorie intake, CD4 count and quality of life in PLWHA.1-5 Nutrition and exercise interventions are successful in improving serum lipids and blood sugar levels.6-8
1Chlebowski

et al., 1995 2Rabeneck et al., 1998 3Schweck et al., 1999 4Tabi et al., 2006 5Topping et al., 1995 6 Barrios et al., 2002 7Thoni et al., 2002 8Yarasheski et al., 2001

Interventions with mental health and nutritional elements Nutritional Components: Diet and exercise education and/or counseling1-3 Mental Health Components: Support groups1 Stress management1,2 Behavior therapy2,3 Motivational Interviewing3
1Kaiser

et al., 1996 2Segal-Issacson et al., 2006 3Reid & Courtney, 2007

Interventions with mental health and nutritional elements

Interventions focusing on mental health and nutrition have been successful in improving:
Quality-of-life1-2 CD4 counts1 Dietary patterns3

1Kaiser

et al., 1996 2Reid & Courtney, 2007 3 Segal-Isaacson et al., 2006

Behavioral mediation of the relationship between psychosocial factors and disease progression
HIV Disease Progression - CD4 decline - Viral Load Increase - AIDS diagnosis - AIDS defining illness

Psychosocial Factors -Body Image Dissatisfaction

Behavioral Mechanisms - Poor nutritional habits

Gore-Felton & Koopman, 2008

Study Aims
To evaluate the effectiveness of a 14-week group Intervention in improving nutritional habits and body image among MSM living with HIV/AIDS.

Recruitment and data collection

Recruited clients through open houses at GMHCs dining room Group members completed measures at baseline and at a 3-month reassessment point

Intervention
14 weeks Weekly 90 minute sessions Transportation and healthy snacks provided Group closed to new members after the third session

Intervention Curriculum
1. Nutrition and Exercise Education 2. Stress and Coping 3. Media Literacy

Measures
Nutritional measures
Rapid Eating Assessment for Participants-Short Version (REAP-S, Segal-Isaacson et al., 2004) Nutrition knowledge test

Body Image measures

Body Image Scale (BIS; Martinez et al., 2005) Eating Attitudes Test (EAT-26; Garner et al., 1982)

Sample description (n=10)

Mean age: 48 years-old (SD= 1.91; Range= 38-61 years) African American: 60%; Latino: 40% Gay/bisexual: 80% At least some high school: 40%

Results
Baseline M (SD) Nutritional outcomes Nutrition Knowledge Test REAPS Sugar Subscore Fat Subscore Body image outcomes Body Image Scale EAT-26
*

3 months M (SD) 6.6 (1.17) 23.2 (4.21) 3.1 (1.37) 6.4 (1.71)

6.3 (.948) 26 (3.91) 3.8 (1.22) 7.7 (1.56)

t= -.709 t= 2.35* t= 1.76 t= 2.75*

25.8 (9.08) 13.1 (12.16)

23.3 (7.13) 13.9 (12)

t= 1.03 t= -.287

p < .05

Discussion
Strengths Psychoeducation modality Men of color High rate of participation Limitations Small sample Lack of strict eligibility Criteria Low literacy

Potential changes for future group cycles

Stricter eligibility criteria Additional tools to measure body image, quality of life Revised Nutrition Knowledge Test Revising content of intervention Womens Body Image Group

Moving towards intervention research: Progress and opportunities

Submitted paper summarizing evaluation to AIDS Care Designing quantitative study to assess the prevalence of body image dissatisfaction among MSM living with HIV/AIDS Conference call with NIMH project officer to discuss next steps in applying for a grant to support further development and testing of this intervention

Moving towards intervention research: Challenges

Ethical challenges of more rigorous research designs in the context of community-based organizations Thin line between research and evaluation: When is consultation with an IRB necessary?