Background

Acceptance and Commitment to Empowerment (ACE) Intervention: Reducing HIV Stigma and Promoting Community Resilience Through Capacity Building

HIV stigma is a priority issue that negatively affects people living with HIV (PLHIV) or vulnerable to HIV, especially in terms of accessing HIV and mental health care. The Project ACE intervention program consists of evidence-based trainings in reducing stigma at the individual and collective levels.

Our Project is carried out in six local sites across Canada: Alberta (Calgary, Edmonton), and Ontario (Greater Toronto Area (GTA), London, Niagara & Ottawa)

Our program is built on evidence generated from recent research completed by our team. Between 2011 and 2015, our team worked closely with the Black, Latino and Asian communities in Toronto to design and pilot the Community Champions HIV/AIDS Advocates Mobilization Project (CHAMPs) funded by CIHR. The CHAMP study engaged PLHIV and non-PLHIV community leaders from faith-based, media, and social justice sectors to address HIV stigma and promote social justice.

We evaluated the effectiveness of two evidence-based trainings in reducing stigma at the individual and the collective level:
(1) Acceptance and Commitment Therapy (ACT) — an intervention that promotes psychological flexibility through mindfulness-based exercises and experiential activities that are underpinned by six core processes: defusion (observing thoughts as thoughts), acceptance (of experiences of emotions and feelings), contact with the present moment (mindfulness), self-as-context (awareness and self-perspective), values (being clear about what matters), and committed action (based on values); and
(2) Social Justice Capacity Building (SJCB) – an empowerment education that promotes a critical understanding of stigma in the context of power relations in society and how to tap into lived experiences and community strengths to take action to reduce stigma. SJCB consists of four core concepts: empathy/compassion, interdependence, collective empowerment, and social justice/equity; and four core processes: experiential learning, critical reflection, collaborative learning, and critical dialogue.

In the CHAMP Study, a total of 66 participants completed the 4-day in person CHAMP training. Study results indicated that ACT and SJCB were effective in reducing stigma. There was a statistically significant decrease in stigma, increase in value-action consistency, and increase in readiness to work together to address stigma and advocate for social justice. Since then, the CHAMPs interventions have been adapted for use with diverse ethno-racial communities to reduce health disparities and promote health. In the Strength In Unity Study, 2014-2017), the interventions were evaluated for their effectiveness in reducing stigma of mental illness among Asian men in Calgary, Toronto and Vancouver, Result of this study with over 1100 Asian Canadian men confirmed that ACT was effective in addressing internalized stigma, and empowerment education addressed more broadly social stigma and collective action.
Based on these findings, our core intervention team has integrated ACT and SJCB into a comprehensive model–Acceptance and Commitment to Empowerment (ACE), which is now being scaled up with service providers and university students in a Global Alliance for Chronic Diseases (GACD) partnership project in Jinan, China to reduce mental illness stigma and promote mental health literacy

Insights from program evaluation indicated that multi-day in-person training posed logistic challenges and access barriers for some participants, limiting its scale up and utilization for broader community access. Existing research show that while online interventions are more costly to develop, deployment can be cost-effective.^, In Fall 2019, we adapted ACE into a pilot online gender-specific intervention (WE-CARE) for use with women temporary foreign workers, hired as live-in caregivers in Toronto, to reduce mental health stress and promote resilience. Making WE-CARE available online enabled participation access since they worked 12-14 hours per day, with little time for self-care or learning activities. WE-CARE participants, 6-week post-training, reported increased and improved sleep, reduced stressed and increased social support.
The COVID-19 pandemic highlighted the importance of virtual programming in health promotion. In 2020, our core intervention team responded to the unprecedented COVID-19 related mental health needs among frontline health care providers and members of affected communities. We applied our ACE model and developed and implemented the online Pandemic Acceptance and Commitment to Empowerment Response (PACER) Training. To date, we have engaged over 400 frontline health care providers and community leaders/volunteers. Our preliminary results showed significant improvement in reducing mental distress, and promoting psychological flexibility, resilience, and empowerment (p <0.001), with a significant moderate effect size.

Study Purpose

We aim to study the efficacy, satisfaction, and cost-effectiveness of online ACE training at 6 project sites in Alberta (Calgary, Edmonton) and Ontario (Greater Toronto Area (GTA), London, Niagara & Ottawa).

Methods

The ACE program consists of: (a) six weekly self-directed learning modules with experiential and reflective learning activities; and (b) six weekly online group debriefing sessions in which the facilitators debrief the learning activities and participants can share their insights.

Applying the integrated ACE model, and using a similar online format as WE-CARE and PACER,

The modules are underpinned by the values and principles of social justice and equity, empathy and compassion, collective empowerment, and recognition of our interdependence.

The learning strategies are collaborative and informed by Freirean pedagogy of critical dialogue and reflection.

The learning modules also promote skills and capacity through six psychological emancipatory processes as described above under the explanation of ACT and SJCB:

defusion (observing thoughts as thoughts)
acceptance (of experiences of emotions and feelings)
contact with the present moment (mindfulness)
self-as-context (observer self, interconnectedness, and self-perspective)
values (being clear about what matters)
committed action (taking action based on values)

Project Activities

Phase One

Contextual Assessment and application

The purpose of the contextual assessment is to explore and identify the local sociocultural contexts and existing responses in the affected communities. We will engage service providers, community leaders and members of affected communities in focus groups to explore their experiences and/or perspectives on HIV stigma, existing community strategies or gaps in reducing HIV stigma, and access to relevant support. The results of Phase One will be used to inform the refinement of the ACE online intervention learning activities to promote local and community-specific relevance and increase effectiveness.

Phase Two

ACE Train-the-Trainer Community Capacity Building

We will engage and build capacity among service providers and community leaders using a “train-the-trainer” capacity-building approach. ACE graduates from Phase Two will be mentored to become ACE facilitators and facilitate intervention groups of community members of the affected communities. These trained service providers and community leaders will collaborate in small teams of 4-5 members and be mentored by the principal investigators to facilitate the ACE intervention for community members in Phase Three.

Phase Three

ACE Training with Community Members

We will recruit about 280-300 community participants living with, affected by, or vulnerable to HIV to take part in the ACE online training to reduce stigma and promote collective resilience.

Expected Outcomes

Knowledge gained from this study will inform HIV stigma reduction in affected communities. It will advance our understanding of the factors, processes, contexts and costs that influence the adoption of evidence-based interventions in different settings. The online version of ACE offers access flexibility and potential integration or scaled up across Canada.