Experiences of peer navigators implementing a bilingual multilevel intervention to address sexually transmitted infection and HIV disparities and social determinants of health

Abstract Introduction Sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) disproportionately affect young gay, bisexual and other men who have sex with men (GBMSM) and transgender women of colour. We explored the experiences of community‐based peer navigators (‘Community Navigators’) who participated in Impact Triad, a bilingual multilevel intervention developed by our community‐based participatory research partnership to reduce STIs and HIV and address social determinants of health (e.g., employment, education, social support and discrimination) among young GBMSM and transgender women of colour. Methods Individual in‐depth interviews were conducted with 15 Community Navigators who participated in Impact Triad. Themes were identified through constant comparison. Results Community Navigators' mean age was 31.4 years. Seven were self‐identified as African American/Black, 5 as Latine, 2 as multiracial/multiethnic, 1 as Asian American, 10 as cisgender men, 4 as transgender women and 1 as gender nonbinary. Thirteen themes emerged in three domains: (1) key aspects of the Community Navigator role (e.g., desire to serve as a community resource, the importance of being part of the communities in which one was working, the value of having an official role, being connected to other Community Navigators to problem‐solving and sustaining intervention aspects long‐term); (2) experiences implementing Impact Triad (e.g., engaging community members, meeting prioritized needs, building trust, using social media, increasing awareness and knowledge and challenges related to COVID‐19) and (3) lessons learned for future interventions (e.g., facilitating access to broader resources, building additional skills and increasing interactions among Community Navigators). Conclusion Interviews identified important learnings about serving as Community Navigators and implementing Impact Triad that can guide future efforts to address STI/HIV disparities and social determinants of health through community‐based peer navigation. Patient or Public Contribution Throughout this intervention trial, our partnership worked collaboratively with a study‐specific community advisory board (CAB) comprised primarily of young GBMSM and transgender women of colour. Members of this CAB participated in all aspects of the trial including trial design, intervention development, recruitment and retention strategies, data collection and analysis, interpretation of findings and dissemination.


| Sexually transmitted infection (STI) and human immunodeficiency virus (HIV) disparities
There is an urgent need to address disparities related to STIs and HIV in the United States. STI and HIV rates are highest among young persons, 1,2 and gay, bisexual and other men who have sex with men (GBMSM) and transgender women, and particularly those who are persons of colour, also carry a disproportionate burden of STIs and HIV. For example, GBMSM comprise approximately 4% of the US adult male population but 43% of all syphilis cases in the country and 86% of all HIV diagnoses among men, [2][3][4] and if current rates persist, one in two African American/Black and one in four Latine GBMSM may be diagnosed with HIV during his lifetime. 5

(The term
'Latine' uses a gender-neutral 'e', which replaces the gendered endings 'a' and 'o' as in 'Latina' and 'Latino', and is similar to 'Latinx'; this term is increasingly used within Latine LGBTQ communities). It is estimated that 14% of transgender women in the country are living with HIV, with prevalence rates as high as 44% among African American/Black and 26% among Latine transgender women. 6 Furthermore, the US South has high STI rates compared to other regions of the country 1,7 and has been referred to as the 'new' and 'latest' US HIV epicentre. 8

| Social determinants of health
The issues contributing to STI and HIV disparities experienced by young GBMSM and transgender women of colour are complex. Social determinants that influence the health of these communities include individual, sociocultural, environmental, system and policy factors. For example, GBMSM and transgender women, particularly those who are persons of colour, are more likely than heterosexual and cisgender counterparts to experience limited access to employment and education and face high rates of discrimination in a range of settings including health care, workplaces and schools. [9][10][11][12] In addition, employment status, education level and related factors such as poverty, income and health insurance coverage have been associated with STI and HIV incidence and outcomes. 13,14 There has been a call to broaden the focus of STI and HIV prevention efforts to address these 'upstream' factors that profoundly impact sexual health, in addition to individuallevel factors such as increasing correct and consistent condom use and STI and HIV screening. 15,16 1.3 | Community-based participatory research (CBPR) and community-based peer navigation CBPR, which engages community members and community organizations as partners in all phases of the research process, 17 has been identified as an important approach to understanding and reducing disproportionate STI and HIV burdens. 18,19 Community-based peer navigation leverages natural helping within existing social networks and has been used in STI and HIV prevention efforts with promising results. [20][21][22][23][24] There is a need for further development and evaluation of community-based peer navigation interventions to address STIs and HIV as well as contributing social determinants using CBPR.

| Centers for Disease Control and Prevention (CDC) Community Approaches to Reducing Sexually Transmitted Diseases (CARS) initiative and the Impact Triad intervention
CARS is a unique initiative of the US CDC that promotes the use of community engagement to increase STI and HIV prevention, ROBLES ARVIZU ET AL. | 729 screening and treatment and address related social determinants of health within communities disproportionately affected by STIs and HIV. The initiative focuses on identifying and implementing innovative community-driven strategies that leverage community assets. 25 As part of the CARS initiative, our CBPR partnership developed and tested Impact Triad, a bilingual (English and Spanish), multilevel intervention designed to reduce STIs and HIV and improve social determinants of health among young GBMSM and transgender women of colour in a high-incidence community within the US South.

| Purpose
A better understanding of the implementation of community-based peer navigation interventions is essential to strengthening future STI and HIV prevention efforts among communities facing health disparities. As a component of the process evaluation of Impact Triad, we qualitatively explored the experiences of community-based peer navigators within the intervention, using individual in-depth interviews.

| Development of Impact Triad
The Impact Triad intervention trial was conducted by the North Carolina Community Research Partnership. This partnership is a longstanding CBPR partnership comprised of community members, community organization and clinic representatives and academic researchers. 18 Throughout this trial, our partnership worked collaboratively with a 15-member community advisory board (CAB) comprised primarily of young GBMSM and transgender women of colour.
We first conducted a community-driven needs assessment to identify and better understand needs and priorities related to STI and HIV prevention, screening and treatment and social determinants of health among young GBMSM and transgender women of colour locally, as well as existing community assets. Through this process, the CAB and CBPR partnership prioritized four social determinants of health as particularly salient for young GBMSM and transgender women of colour and their risk for STIs and HIV: employment, education, social support and discrimination. Based on needs assessment findings, the CAB and CBPR partnership developed intervention strategies to reduce STIs and HIV and improve these social determinants of health and integrated these strategies into the Impact Triad intervention, the details of which are described elsewhere. 26 Briefly, Impact Triad includes three primary multilevel strategies: community-based peer navigation, use of social media and antidiscrimination trainings for community organization staff. The intervention involved training young GBMSM and transgender women of colour as community-based peer navigators, known as 'Community Navigators' in English and 'Navegantes Comunitarios' in Spanish, to carry out helping activities with members of their social networks in the community within the context of their daily lives. In addition to oneon-one and group-level in-person helping to share information and resources related to STI and HIV prevention, screening and treatment and prioritized social determinants of health, Community Navigators created and updated intervention-related social media accounts (e.g., Facebook and Instagram) and used their own social media accounts for messaging with social network members. Community Navigators were also involved in the development of brief online video testimonials designed to raise consciousness among community organizations about the challenges and barriers young GBMSM and transgender women of colour face when accessing services related to STIs and HIV and social determinants of health and ways to facilitate access (https:// www.youtube.com/channel/UCd7gOGhBerT0w1CTq5BwMcQ).

| Community Navigator recruitment and training
Fifteen young GBMSM and transgender women of colour identified as informal leaders among their communities were recruited and trained to serve as Impact Triad Community Navigators. To be eligible to serve as a Community Navigator, a participant was 18 years of age or older; self-identified as a person of colour; self-identified as a man or as a transgender woman; reported sex with men and provided informed consent.
Community Navigators completed four 4-h training sessions, in two cohorts of seven to eight Community Navigators each. They were trained to serve as (1) health advisors to provide information to social network members to meet needs and priorities related to STI and HIV prevention (e.g., condom and pre-exposure prophylaxis [PrEP] access and use), screening and treatment, as well as social determinants of health (e.g., employment and education), offering guidance on where and how to access available services; (2) opinion leaders to bolster healthy and reframe unhealthy norms and expectations related to STIs and HIV or social determinants of health (e.g., social support) and (3) community advocates to bring the voices of young GBMSM and transgender women of colour to local community organizations by sharing feedback for improvement based on the perspectives of social network members. Community Navigators were trained to use an adapted version of the 'ask-adviseassist' model, 27 represented by the acronym 'IMPACT' in English or 'IMPACTO' in Spanish with each letter representing a step in the natural helping process. A low-literacy wallet-sized reminder card was developed to serve as a 'cheat sheet' for Community Navigators outlining these steps to support others. 26 Upon graduation, Community Navigators received a framed certificate of training completion, an identification badge, a t-shirt and bag with the Impact Triad intervention logo and intervention materials (e.g., condoms, penis models and informational brochures) to carry out their work within their social networks and communities of young GBMSM and transgender women of colour. Community Navigators worked informally and formally with members of their social networks for 12 months and met monthly as a group with one another and with members of the CBPR partnership in convenient locations within trusted community organizations to plan, coordinate and evaluate their activities.
Community Navigators were provided a $50 stipend for each training session and each month of the 12-month intervention implementation. They also were provided $50 per month to compensate for transportation costs.

| Qualitative interviews
After the conclusion of intervention implementation, individual indepth interviews were conducted with all 15 Impact Triad Community Navigators. Standardized interview guides were developed in English and Spanish with careful consideration of wording, sequence and content to explore experiences with the intervention and current issues affecting the health of young GBMSM and transgender women of colour. Abbreviated sample items from the guide are outlined in Table 1.
Because of the COVID-19 pandemic, interviews were con- When you became a Community Navigator, was your role how you thought it would be? What was different than you expected?
What did you like about being a Community Navigator?
What was hard about being a Community Navigator?

Training
How well prepared were you to serve as a Community Navigator? What other training would have helped you?
What suggestions for other topics should we have included?
How new for you was the information you received?

Recruitment
Tell me how you recruited the young gay and bisexual men and transgender women of colour who are part of your social network to participate in Impact Triad.

Community Navigator experience
What are some challenges that you faced as you began working with other young gay and bisexual men and transgender women of colour in your community?
What were some of the things that made it easier to talk to other young gay and bisexual men and transgender women of colour about sexual health? To talk about social determinants of health, such as employment, education, social support and discrimination? What were some of the things that made it difficult?
What were the most popular topics that young gay and bisexual men and transgender women wanted to discuss? What topics did they not seem comfortable talking about?
How did you use social media to work with young gay and bisexual men and transgender women of colour?
What do you think worked well with social media?
What challenges did you have using social media? Were you able to work them out?
Think back to before Impact Triad started. Are the topics that you and your friends talk about now any different? How have the ways your friends provide support to one another changed?
How were the monthly meetings with the Impact Triad coordinators and the other Community Navigators?

PrEP
How do the people who were part of your group feel about PrEP?
How interested are they in PrEP?
What barriers do they face to using PrEP?
Alcohol and drug use How common is alcohol use among the people who were part of your group? Among other young gay and bisexual men and transgender women of colour?
How about drug use? What types of drugs do they use?
How common is it to use alcohol when having sex?
How common is it to use drugs when having sex? What drugs are used during sex?
What does alcohol and drug use have to do with risky sexual behaviours?

Social determinants of health
In Impact Triad, we focused on employment, education, social support and discrimination as social determinants of health. What else affects the health and well-being of young gay and bisexual men and transgender women of colour?
How big of an issue is housing for young gay and bisexual men and transgender women of colour? How big of an issue is access to food? How do these issues affect their health?

Individual perceptions and empowerment
What do you think healthy sexuality means to young gay and bisexual men and transgender women of colour in our local community? Have your ideas of what healthy sexuality looks like changed since participating in Impact Triad?
What do you think would be good ideas or ways to prevent STIs and HIV among young gay and bisexual men and transgender women of colour living in your community? What do you think would be good ideas or ways to improve social determinants of health?
Do you think you will continue your work as a Community Navigator? Why?
ROBLES ARVIZU ET AL.

| Data analysis and interpretation
All interviews were digitally recorded and transcribed. Constant comparison, an approach to grounded theory, was used to analyse interview data. Constant comparison combines qualitative coding with simultaneous comparison; initial observations are continually refined throughout data collection and analysis. 28 Three analysts read and reread interview transcripts, compared and contrasted content categories based on each analyst's interpretation of the data and identified emerging themes. After preliminary themes were developed, analysts came together with other CBPR partnership members via WebEx (a videoconferencing platform) in multiple meetings to discuss and reconcile final themes using an iterative process. Themes were also presented to the CAB in a meeting via WebEx for refinement and validation; CAB members were invited to respond to the themes and offered insights regarding themes that resonated with their own experiences and themes that they considered priorities for informing future efforts to improve the health of young GBMSM and transgender women of colour. At each stage in the analysis and interpretation process, a consensus approach was used, resolving discrepancies through discussion.

| Community Navigator characteristics
Key characteristics of the Impact Triad Community Navigators at the time of enrolment in the intervention trial are presented in Table 2.

| Qualitative findings
Thirteen themes emerged from the interviews and were organized into three domains: (1) key aspects of the Community Navigator role, (2) experiences implementing the Impact Triad intervention and (3) lessons learned for future interventions.

| Key aspects of the Community Navigator role
Community Navigators identified several important aspects of fulfilling their role within Impact Triad. These themes, along with selected quotations, are presented in Table 3.

Desire to serve as a community leader
Community Navigators expressed that they valued serving as leaders and as resources to address social determinants of health within their communities. Among the Community Navigators, there was a common sense of intrinsic motivation to engage, be involved with and help their communities of identity-LGBTQ communities and communities of colour. Community Navigators reported that they were drawn to the Impact Triad intervention because of the opportunity to gain knowledge to share within their social networks and because they recognized the importance of both promoting sexual health and addressing social determinants that can make it Asian American 1 (7) Gender Cisgender man 10 (67) Transgender woman 4 (27) Gender nonbinary 1 (7) Sexual orientation Gay 10 (67) Heterosexual 4 (27) Bisexual 1 (7) Education level Less than a high school diploma or equivalent 1 (7) High school diploma or equivalent 3 (20) Some college 5 (33) 2-year degree 1 (7) 4-year degree 4 (27) Master's degree, professional degree or more difficult for community members to take care of their health.
Community Navigators also appreciated that they made a genuine impact, which furthered their desire to continue being leaders within their social networks and communities. They felt pride in their roles as Community Navigators, saw themselves as fulfilling a need for social support within their communities, enjoyed building leadership skills that could potentially create opportunities for future careers (e.g., public speaking skills) and demonstrated a desire to continue utilizing the knowledge and training they received postintervention.
Importance of being part of the communities in which one was working Community Navigators emphasized that being members of the communities in which they worked was fundamental to trust building and successful intervention implementation. Community Navigators had shared experiences and identities and felt a sense of belonging with others in their communities and were known and seen as leaders in their communities before becoming involved with Impact Triad. These connections led to increased initial levels of rapport with community members within Community Navigators' social networks, facilitated the process of recruiting social network members to participate in the intervention and were helpful for further building trust to have conversations about a wide array of health-related topics.

Value of having an official role
Community Navigators reported that having official titles and roles that were linked to well-known and well-respected institutions (i.e., Wake

Connections built with other Community Navigators
Community Navigators shared that being connected to the other Community Navigators across gender identities, sexual orientations and racial/ethnic identities increased a sense of belonging, Having official titles and roles contributed to Community Navigators' self-assurance and validated their work in communities.
Podíamos hablar de temas de sexualidad sin que fuera tabú. Y era más fácil teniendo el respaldo de una institución y un programa para resolver algunas de las preguntas que tenían algunos de mis amigos y les daba pena hacer. [We were able to discuss topics about sexuality without it being taboo. It was also easier having the backing of an institution and program to assist in answering the questions that some of my friends had but were shy to ask.] (P1) I was extremely well prepared and was ready to become a Community Navigator for all the good, the bad, ugly, and different. We all prepared for everything no matter what happens. (P11)

Connections built with other Community Navigators
Being connected to the other Community Navigators across gender identities, sexual orientations and racial/ethnic identities increased a sense of belonging, resource sharing, creativity and problem solving. Sustaining intervention aspects long-term Community Navigators sustained aspects of the intervention after implementation officially ended.
I will continue work as a Community Navigator because it isn't a job but is something that needs to be done, even if I am not paid for it. It just needs to be done. (P10) I think I will always be a Community Navigator, formally or informally, because I know something that I can always use and I will always be involved doing something to help others.

| Experiences implementing the Impact Triad intervention
Another set of themes related to Community Navigators' experiences implementing Impact Triad. These themes and selected quotations are presented in Table 4.

Engaging community members
Community Navigators shared that they had identified effective and innovative strategies to engage community members. Community Navigators utilized various strategies to reach the individuals within their social networks. At the beginning of intervention implementation, Community Navigators focused their recruitment efforts on social network members who they perceived as being more vulnerable or at risk and as needing social support and emphasized to these social network members the benefits of their participation.
Through this process, Community Navigators were able to reach a broad range of individuals, including engaging nongay identifying T A B L E 4 Community Navigator experiences implementing the Impact Triad intervention (qualitative themes with select quotations from in-depth interviews) Engaging community members Community Navigators identified effective and innovative strategies to engage community members.  The COVID-19 pandemic hindered implementation and social media became the main strategy to reach social network members. La pandemia afectó a mi red social mucho porque nos dejamos de reunir, y la intimidad y el espíritu del grupo de estar reunidos en un solo lugar, la convivencia y la confianza que se crea en el grupo, se pierde y se vuelve más individual. [The pandemic affected my social network a lot since we stopped getting together, and the intimacy and group spirit from gathering in the same place, the atmosphere of trust that was created within the group, this was all lost and everything became more topics such as how to correctly use condoms when they could not carry out these activities in person. However, Community Navigators were resilient and adapted quickly to utilizing social media to continue to maintain relationships with participants and engage and teach them.

| Lessons learned for future community navigation interventions
Finally, Community Navigators highlighted learnings to inform future similar interventions. Related themes and selected quotations are presented in Table 5.
T A B L E 5 Lessons learned for future community navigation interventions (qualitative themes with select quotations from in-depth interviews) Facilitating access to broader resources The Impact Triad intervention should be expanded to facilitate access to a wider range of resources.   32 In some ways, these changes increased accessibility, allowing Community Navigators to overcome logistical barriers to engagement based on locations, schedules and work demands; these learnings could also greatly benefit research efforts in rural and other more isolated communities. However, restrictions due to COVID-19 did affect camaraderie among Community Navigators and members of their social networks. Community Navigators noted that there was a personal aspect of face-to-face contact that social media could not replicate. Nonetheless, our findings demonstrate that the versatility of social media is a major asset in conducting intervention research. Other intervention studies in recent years have reported making similar adaptations due to COVID-19, [33][34][35] and future studies should continue to explore ways to achieve the connection typically built and reinforced through inperson interaction in a virtual setting.
Interviews also identified implications for future iterations of the Impact Triad intervention to seek to further address and improve the

| Limitations
It is possible that social desirability bias could have influenced Community Navigators' responses to interview items. Given that interview data were collected and analysed by members of our CBPR partnership that had developed and implemented the Impact Triad intervention, Community Navigators may have felt inclined to describe Impact Triad and their experiences with the intervention in ways that were positive and less comfortable sharing constructive criticism or difficulties they had faced as part of Impact Triad. We tried to mitigate this possibility and encourage open and honest responses by ensuring confidentiality and emphasizing that there were no right or wrong answers and that Community Navigators were experts in their own experiences. Furthermore, interviews were conducted by CBPR partnership members who were not directly responsible for training and supporting the Community Navigators.

| CONCLUSIONS
These interviews identified important learnings about serving as Community Navigators and implementing Impact Triad and provided information to guide future efforts to address STI and HIV disparities and critical social determinants of health through community-based peer navigation. Further research is warranted given that communitybased peer navigation remains an understudied yet promising approach to health promotion and disease prevention among communities and populations experiencing health disparities.