Let's Keep Talking: An HIV risk reduction group for young gay and bisexual males

John Maxwell, AIDS Committee of Toronto
Robb Travers, Central Toronto Youth Services

Funding for this project provided through Toronto Public Health, AIDS Prevention Grants


Group Rationale

In early 1996, staff in the Lesbian, Gay and Bisexual Youth Program (LGBYP) at Central Toronto Youth Services (CTYS) noticed an increase in anecdotal stories from young men indicating that they were placing themselves at significant risk for HIV infection. We turned to the Gay Men's Health Promotion Program at the AIDS Committee of Toronto (ACT), for consultation. There, we were assured that the literature on gay men and HIV risk supported our anecdotal information.

After several more discussions, there was a commitment on the part of both agencies to investigate the possibility of providing partnership programming aimed at reducing risk for HIV infection among young gay and bisexual males. LGBYP has a solid reputation and mandate to provide supportive services to lesbian, gay and bisexual youth; ACT is widely regarded in the development of innovative HIV prevention initiatives targeted to gay and bisexual men. It was therefore decided that a joint application would be submitted to the City of Toronto, Department of Public Health -- AIDS Prevention Grants to conduct a pilot project. Our goal was to develop a psychoeducational support group model to reduce the risk of HIV transmission among these at-risk youth.

Below follows group objectives, suggested content and evaluative strategies for a twelve-week cycle of Let's Keep Talking: An HIV Risk-Reduction Group for Young Gay and Bisexual Males. What we offer is based on our experiences with young men in a number of groups in Toronto. We made many errors and found that the format below worked best for us and for the group members. This will inevitably vary depending on the community in which you live, the availability of other supports for gay youth and the ability to develop partnerships between community-based AIDS service organizations, youth serving-agencies and public health departments.



Group Goal

    • to decrease the rates of HIV infection among young gay and bisexual males



Group Objectives
    • to decrease social isolation among young gay and bisexual males
    • to increase their knowledge of HIV/AIDS
    • to change their attitudes concerning HIV
    • to increase their self-esteem
    • to decrease their HIV risk-taking behaviour



Participants

Group participants should:
    • self-identify as gay or bisexual (i.e., not appropriate for youth in the initial stages of coming out)
    • be under 25 years of age

Potential participants should be interviewed to determine whether the group is appropriate for their needs.

Interview questions could include:
    • why are you interested in a group like Let's Keep Talking?
    • are you involved with the gay community? How?
    • do you have a supportive network of gay and bisexual friends?
    • do you have concerns about your friendships? dating? intimate relationships?
    • do you worry about the future?
    • are you concerned about alcohol or drugs?
    • are you confused or concerned about safer sex?
    • have you been involved in a group before? How? When?
    • what do you think you would bring personally to a group like Let's Keep Talking?



Group Leaders

Given that this model is intended to be psychoeducational (and not solely peer support) facilitators must have significant knowledge of and experience working with sexual orientation/identity issues, HIV/AIDS, and facilitating groups.



Outreach

Extensive advertising in the lesbian/gay communities as well as among youth and young adult-serving health and social service agencies and school boards is a primary advertising strategy. A recruitment flyer (see Appendix B) can be adapted for use in your local community.



Group Format

Group participants begin the group together and new people are welcomed up until the third week. Group content should reflect the objectives, and given the short term nature of the group, a semi-structured format works best. Inevitably, the actual content and process of the group will be significantly influenced by the needs of the participants and the skills of the facilitators. However, the issues which will be covered in the four modules include:
    • developing positive peer support and friendships
    • lesbian and gay community involvement
    • the impact of HIV/AIDS on young gay and bisexual males
    • how and why HIV risk-taking behaviours occur
    • the impact of low self-esteem on HIV risk-taking behaviour
    • sexual relationships and HIV
    • substance use issues and HIV



Group Content: let's keep talking
overview of group modules



module 1: community involvement

module 2: relationships

module 3: self-esteem

module 4: HIV & safer sex




Session 1 -- Introductions


Objective
    • introduce facilitators
    • provide overview of purpose of group
    • introduction of group members
    • establish a list of topics for the group


Discussion question:

Without speaking to the person sitting next you, write on a piece of paper the following:
    • their name
    • their age
    • their occupation
    • whether they are in a relationship
    • how long they have been out
    • your assessment of how confident they are about being in this group

Have group members read aloud their answers. Each in turn should discuss what factors informed their choices.

The purpose of this introductory session is to familiarize group participants with first impressions of each other versus actual personal characteristics. In addition, participants will have a chance to discuss the purpose of the group and provide input in developing a list of group topics.



Session 2 -- Group Guidelines & Goals


Objective
    • establish group guidelines
    • introduce concept of "check-in"
    • establish individual goals for group members


Discussion questions:

What do group members need from the group to feel welcomed and comfortable on an ongoing basis?

What would group members like to individually accomplish in this group?

The purpose of this session is to establish group guidelines (e.g., confidentiality, respect, active participation, etc.), and to have group participants decide upon individual goals. These can be recorded and submitted to the facilitators to reviewed at the last session of the group.



Session 3 -- Module 1


Objective
    • individual check-in
    • to begin a discussion about the importance of community involvement


Discussion questions:

Did you have gay or lesbian friends when you came out? In what ways was that helpful in terms of coming out and finding support?

Can your describe your coming out into the gay community. Do you feel that it is important to be part of a community?

Do you feel like you are part of the gay community? Why/why not?

How would you describe your involvement with the gay community?

Do you do volunteer work in the community?

Are you satisfied with your level of community involvement?
Are there organizations or events that you would like to become involved with?


The purpose of this session is to begin a discussion about the importance of community involvement. Key themes for discussion should include: social isolation, the importance of peers, belonging, community support and its impact on identity development and ways to become involved.



Session 4 -- Module 1


Objective:
    • individual check-in
    • to continue discussion about community involvement


Discussion questions:

What kinds of messages have you received from the community in terms of HIV/AIDS? Safer sex?

How have these messages been given to you?

Older gay men get a great deal of support form the community in terms of safer sex. Do you feel the same kind of support exists in the community for gay youth?


The purpose of this session is to begin a discussion about community norms regarding safer sex.




Session 5 -- Module 2


Objective
    • individual check-in
    • to begin discussion about relationships/friendships between gay men


Discussion questions:

What kinds of things do you value in a friendship? (prompts: trust, communication, loyalty, etc.)

What kinds of things do you value in a partner/romantic relationship?

What kinds of friendships do you actually have?

Are there differences between what you value in friendships and the people you spend time with?

How do gay men socialize with each other? Does it differ from other groups of people?

What do you find rewarding about your experiences socializing with other gay men?

What would you like to continue doing more of in your friendships with gay men?

What would you like to see change in terms of how you socialize with other gay men?


The purpose of this session is to explore the diverse ways in which gay men have friendships and intimate relationships.



Session 6 -- Module 2


Objective
    • individual check-in
    • to continue discussion about friendships/relationships between gay men.


Discussion questions:

When you consider gay male relationships, who have your role models been?

Are there differences between what you value in relationships and who you date?

Do you think heterosexual people have better quality relationships than gay men. If so, why?

Do you worry that you will never have a meaningful long-term relationship?


The purpose of this session is to explore and dispel myths surrounding gay male relationships.



Session 7 -- Module 3


Objective
    • individual check-in
    • introduce discussion re: self-esteem

Discussion questions:

What does self-esteem mean to you?

What do you think of when you hear that term?

What do you think forms self-esteem?

What does a person with low self-esteem look like? What does a person with high self-esteem look like?

What do you think informed your self esteem?

What do you think happens when people have low self-esteem? (brainstorming exercise)


The purpose of this session is to begin discussion about self-esteem including: definitions of what participants believe it is, what forms it, and to dispel the notion that a person's self-esteem can be assessed purely by personal and physical attributes.



Session 8 -- Module 3


Objective
    • individual check-in
    • continue discussion re: self-esteem


Discussion questions:

How do you think the self-esteem of young gay men compares to older gay men? Other groups? (e.g., straight youth, etc.). What accounts for the differences (if any)?

Exercise: Using the popular gay press, construct a collage of images of gay men that you think represent high self-esteem/low self-esteem. Do you see yourself in this collage? Where & why?


The purpose of this session is to have participants reflect on their own self-esteem and how it is impacted by popular media images of gay men.



Session 9 -- Module 4


Objective
    • individual check-in
    • introduce concepts of risk behaviour and risk situations


Discussion question:

Have you found yourself in situations where you felt like self-esteem was working in your favour/against you? What happens to you when you are feeling poorly about yourself? How do you act? Do you change?

Have you found yourself in situations where you didn't want to be and felt that your self-esteem had something to do with it?

Have you found yourself in sexual situations where you didn't feel very confident? What happened?


The purpose of this session is to have participants explore the associations between low self-esteem and risk behaviours. Additionally, participants can discuss how risk increases in certain situations (e.g., having sex when you are felling poorly about yourself and where substances are being used).



Session 10 -- Module 4


Objective
    • individual check-in
    • to continue discussion of HIV risk and safer sex


Discussion questions:

Exercise: Each group member is given an index card with a particular sexual activity (both safer and unsafe) listed on it. Each group member is instructed to place himself along a "continuum of risk" (no risk to high risk) according to the activity that they are holding. They are not to confer with one another. In fact, there should be absolute silence.

Discuss as a group their thoughts and concerns re: risk and various sexual activities.

Ask group members:
    • how did you make your decisions in this exercise?
    • do you agree with everyone's placement on the continuum?
    • is there anything you would like to change? Why?


The purpose of this session is to discuss where participants get their information about HIV/AIDS, points of confusion, HIV antibody testing, negotiating safer sex, and friendship norms re: safer sex.



Session 11 -- Module 4


Objective
    • individual check-in
    • to continue discussion of HIV risk, safer sex and testing behaviours


Discussion questions:

Case scenario exercise:

Mark is an 18 year-old gay male from Etobicoke who believes that he is not very good looking. He came out to two of his girlfriends at high school last year and since then has told his family that he is gay. Over the summer vacation, Mark met Ken at a gay youth group meeting in Toronto. They have been dating for about three months. Recently, they had anal sex; unprotected anal sex. Mark feels upset about this but tells one of his best friends that he is "not really worried because Ken and he are both young and negative".

Discussion questions:

What do you hear from your friends or other sources about HIV testing?

What do you think about Marks' rationale for having unprotected anal sex?

The purpose of this session is to have participants reflect on a "real life" scenario of HIV risk taking and to reflect on their own HIV risk-taking behaviours.



Session 12 -- Closure


Objective:
    • individual check-in
    • group closure and evaluation


Discussion questions:

What worked for you in this group?

What was difficult?

Is there any unfinished business between group members?


The purpose of this session is to have group members provide each other and the facilitators with feedback about the group, to reflect on their individual goals set in session 2, and to discuss next steps in their lives.




Appendix A -- Literature Review


Young Gay Men and HIV: Present State of Knowledge

The incidence of new infections among young gay men is climbing at alarming rates (CDC HIV/AIDS Prevention, September, 1995; Health Canada, 1995a; Lemp, Hirozawa, Givertz, Nieri, Anderson, Lindegren, Janssen, & Katz, 1994; Vanguard Study, 1997). In the United States, the Centers for Disease Control report that the incidence of new infections among young gay men is climbing at rates 2 - 4 times higher than older groups of gay men (CDC HIV/AIDS Prevention, September, 1995). In Canada the median age of HIV infection was 29.6 years for the period 1975 - 1984; it fell to 24.5 years for the period 1985 - 1990. Of all people with AIDS in Canada, 14% are 15 - 29 year-old "men who have sex with men" (Health Canada, 1995b). It is estimated that if current infection trends continue, fifty percent of twenty year-old gay men will seroconvert in the next 25 years (Vanguard Study, 1997). Perhaps most disturbing, is that an alarmingly high number of HIV+ young gay men who have unprotected anal sex are unaware of their HIV status (Hunter, 1997; Lemp, et al.,1994).

An Amsterdam cohort study, revealed that compared to older gay men, younger gay men were more likely to "relapse" into having anal sex without condoms (de Wit & van Griensven, 1994). Up to fifty percent of young gay men report having had anal intercourse without condoms in the previous twelve months (D'Augelli, 1992; Ekstrand & Coates, 1990; Hays, Kegeles & Coates, 1990; Lemp, Hirozawa, Givertz, Nieri, Anderson, Lindegren, Janssen, & Katz, 1994; Myers, Godin, Calzavara, Lambert & Locker, 1993; Stall, Barrett, Bye, Catania, Frutchey, Henne, Lemp & Paul, 1992; Valdiserri, Lyter, Leviton, Callahan, Kingsley and Rinaldo, 1988; Vanguard Study, 1997).


Relationships:

Young gay men use condoms for anal sex with casual partners, but almost half of those in relationships report having anal intercourse without condoms with their partners (de Wit, Hospers, Janssen, Stroebe, & Kok, 1996). The most recent data from the American Young Men's Survey reveal a more complicated situation. Fifty percent of young men in relationships engaged in anal sex without condoms with their boyfriends, and ten percent also had anal sex without condoms with someone else other than there boyfriend in the previous two months (Hays, Kegeles & Coates, 1997). Similarly, recent Canadian data show that young gay men in relationships are more likely to have anal sex without condoms; one quarter of the young men with casual partners in this study however, also report having had anal intercourse without condoms in the last year (Vanguard Study, 1997).

Hays, Kegeles and Coates (1997) note that young men in relationships report weaker social norms favouring safer sex than single men; only 21% of single men (compared to 51% of coupled men) had anal sex without condoms; also, the young gay men in relationships who had anal sex without condoms were less likely to be involved with the gay community. The longer couples were together, the more likely they were to have anal sex without condoms (Hays, Kegeles, & Coates, 1997). Particularly alarming is that young gay men tend to be unaware of their HIV status; of the couples in one study who had anal intercourse without condoms, 42% did not know either their own or their partner's HIV status (Hays, Kegeles, & Coates, 1997).


Substance use:

Young gay men report using alcohol and drugs during sexual relations; two-thirds of the young men in the Hays, Kegeles and Coates (1990) study report using alcohol/drugs during sex in the previous 6 months. In the Vanguard Study (1997), almost one third of the 1000 cohort participants report inhaling poppers (nitrate inhalants) or using cocaine in the past year; one of the most common reasons provided by young men in this study for having anal sex without condoms, was "being drunk or stoned at the time".


Perception of risk:

Compared to young gay men who use condoms during anal sex, those who do not say they "enjoy it more", report poorer communication skills with partners, and perhaps most importantly, believe themselves to be less at risk as long as they are having sex with younger men and not older men (Hays, Kegeles & Coates, 1990). This latter finding was substantiated in another study (Gold & Skinner, 1992) where young gay men were more likely than older gay men to take risks if they could "infer from observable characteristics" that a partner was not likely to be infected.

Social factors:

Several sources of information suggest that social factors such as violence, abuse, homelessness and the societal stigmatization of homosexuality play significant roles in young gay men having sex without condoms. For example, early results from the Vanguard Study (1997) suggest that being subjected to violence is related to HIV risk-taking:

"... 11% of participants reported having been gay bashed; 18% had experienced domestic violence; and one-quarter had been sexually abused or assaulted. Preliminary results from the study suggest that men who have been victims of violence are subsequently more likely to put themselves at risk for HIV infection". (Vanguard Study, 1997)

In addition, these same researchers report that young gay men who were forced or coerced into having sex as adolescents or adults are more than twice as likely to have recently engaged in high-risk sex; these young men also report high rates of alcohol and drug use, depression, less stable housing and less formal education (Vanguard Study, 1997). Lemp et al (1994) also show that young men with a history of childhood sexual abuse (or sexual coercion at some point later in life) are more likely to have anal sex without condoms. Finally, higher rates of anal sex without condoms are found among young gay men who are street-involved (Vanguard Study, 1997).

Even in those parts of the world where it has been determined that young gay men are not at risk for HIV infection, researchers suggest that social factors play an important role. Two studies (one Australian and the other British) dispute the notion that young gay men are "at greater risk" for HIV infection by showing no differences in behavioural risk factors between younger and older gay men (Davies, Weatherburn, Hunt, Hickson, McManus, & Coxon, 1992; Van de Ven, Noble, Kippax, Prestage, Crawford, Baxter, & Cooper, 1997). The latter authors suggest the well-developed sexual identities of the young men may be related to their ability to consistently practice safer sex. Australia has been a world leader in prevention initiatives which attempt to counter the negative effects of societal prejudice and decrease social isolation by presenting positive images of gay men and through offering supportive programs like groups and workshops. The authors assert that this stands in "stark contrast with the experience of gay men, in particular gay youth, living in other Western countries" (Van de Ven, Noble, Kippax, Prestage, Crawford, Baxter, & Cooper, 1997, p. 407).

A recent Health Canada review of the literature addressing gay male youth also theorizes that systemic prejudice against gay male youth impacts self-esteem:

Suffering is often associated with the self-discovery of a gay identity. "Coming out" many times... is a stressful and tenuous lifelong experience. Gay youth's self-esteem is in jeopardy in a society that largely does not acknowledge homosexuality... The detrimental effects of homophobia and heterosexism on gay youth are substantial. (Health Canada, 1996, pp. 3 & 17)

Similarly, according to Savin-Williams (1990), young gay men learn they are among the most despised people in society which contributes to low self-esteem and impacts on health:
... gay adolescents must confront a hostile audience which disbelieves that one can be homosexual during adolescence. [The] psychosocial stresses that result from this denial may have profound medical consequences in the current reality of the AIDS epidemic. (p. 75).

Both the Health Canada report and Savin-Williams argue that social factors such as societal stigmatization of homosexuality account for low self-esteem which can result in young gay men having anal sex without condoms. Given the current state of knowledge concerning young gay men and HIV risk-taking behaviour, however, we must contend with the fact that this is a theory and has yet to be empirically determined. Nonetheless, the theory represents a recognition on the part of researchers that sexual behaviours do not occur in a social vacuum; they occur in a social context.


References:

CDC HIV/AIDS Prevention, (September, 1995). HIV/AIDS among young gay and bisexual men. Atlanta: Centers for Disease Control, US Department of Health and Human Services.

D'Augelli, A.R. (1992). Sexual behavior patterns of gay university men: Implications for preventing HIV infection. JACH, 41, 25-28.

Davies, P.M., Weatherburn, P., Hunt, A.J., Hickson, F.C.I., McManus, T.J. & Coxon, A.P.M. (1992). The sexual behaviour of young gay men in England and Wales. AIDS Care, 4, 259-272.

de Wit, J.B.F. & van Griensven, G.J.P. (1994). Time from safer to unsafe sexual behaviour among homosexual men. AIDS, 8, 123-126.

de Wit, J., Hospers, H., Janssen, M., Stroebe, W., & Kok, G. (1996). Risk for HIV-infection among young gay men: Sexual relations, high risk behavior, and protection motivation. Paper presented at the XI International Conference on AIDS, Vancouver, July, 1996.

Ekstrand, M., & Coates, T.J. (1990). Maintenance of safer sex behaviors and predictors of risky sex: The San Francisco Men's Health Study. American Journal of Public Health, 80, 973-977.

Gold, R.S., & Skinner, M.J. (1992). Situational factors and thought processes associated with unprotected intercourse in young gay men. AIDS, 6, 1021-1030.

Hays, R.B., Kegeles, S.M., & Coates, T.J. (1997). Unprotected sex and HIV risk taking among young gay men within boyfriend relationships. AIDS Education and Prevention, 9, 314-329.

Health Canada, (1995a). Recent trends: Canadian HIV epidemics. Ottawa: Division of HIV/AIDS Epidimiology, Laboratory Centre for Disease Control, Health Canada, 1995.

Health Canada, (1995b). AIDS in Canada: Quarterly surveillance update. Ottawa: Division of HIV/AIDS Epidemiology, Laboratory Centre for Disease Control, Health Canada, Table 1, AIDS Cases Reported in Canada, July 1995.

Health Canada. (1996). The experiences of young gay men in the age of HIV. Ottawa: Minister of Supply and Services Canada.

Hunter, J. (1997). It's beginning to rain: Lesbian/gay/bisexual adolescents and AIDS. In M. Schneider (Ed.), Pride and prejudice: Working with lesbian, gay and bisexual youth. Toronto: Central Toronto Youth Services.

Lemp,G.F., Hirozawa, A.M., Givertz, D., Nieri, G.N., Anderson, L., Lindegren, M.L., Janssen, R.S., & Katz, M. (1994). Seroprevalence of HIV and risk behaviors among young homosexual and bisexual men: The San Francisco/Berkeley Young men's Survey. JAMA, 272, 449-454.

Myers, T., Godin, G., Calzavara, L., Lambert, J., & Locker, D. (1993). The Canadian survey of gay and bisexual men and HIV infection: Men's survey. Ottawa: Canadian AIDS Society.

Savin-Williams, R.C. (1990). AIDS prevention among gay and lesbian youth. In D.G. Ostrow, (Ed.), Behavioral aspects of AIDS. New York: Plenum.

Valdiserri, R.O., Lyter, L.D., Leviton, C.M., Callahan, C.L., Kingsley, C.L., and Rinaldo, C.R. (1988). Variables influencing condom use in a cohort of gay and bisexual men. American Journal of Public Health, 78, 801-805.

Van de Ven, P., Noble, J., Kippax, S., Prestage, G., Crawford, J., Baxter, D., and Cooper, D. (1997). Gay youth and their precautionary sexual behaviors: The Sydney Men and Sexual Health Study. AIDS Education and Prevention, 9, 395-410.

Vanguard Study. (1997). The Vanguard Project. Vancouver: British Columbia Centre for Excellence in HIV/AIDS.



Appendix B -- Recruitment Flyer



CAN WE TALK?

Ever feel lonely, isolated or depressed? Having trouble making or keeping friends? Worried about what guys think about you? Feeling detached from the community?
Worried about what the future holds for you? Concerned about alcohol or drugs?
Confused about safer sex? Worried about HIV/AIDS?

Gay or bisexual male youth 19 to 25

LET'S KEEP TALKING!
A NEW DISCUSSION GROUP

A chance to make friends
A chance to fit in
A chance to talk about being young and gay
A chance to feel better about yourself
A chance to talk about relationships and safer sex

for information call:

CENTRAL TORONTO YOUTH SERVICES
and say you'd like to find out more about the
let's keep talking group

(416) 924 2100, MONDAY TO FRIDAY, 9-5


A JOINT PROJECT OF THE AIDS COMMITTEE OF TORONTO AND CENTRAL TORONTO YOUTH SERVICES




Appendix C
Let's Keep Talking
Evaluation of Group

This is a list of the objectives of the Let's Keep Talking Group. For each one, mark an X to indicate where you were before you came into the group, an O to indicate where you are now.

1.) increase knowledge of HIV
*..................................*...............................*...............................*.................................*..................................*
no knowledge change..................................................................................................... knowledge significantly increased



2.) increase in self-esteem
*..................................*...............................*...............................*.................................*..................................*
no change in feelings about self ............................................................ significant increase in positive feelings about self


3.) contact with other young gay and bisexual men
*..................................*...............................*...............................*.................................*..................................*
little or no contact .................................................................................................................................... lots of contact


4.) information about the gay communities
*..................................*...............................*...............................*.................................*..................................*
very little information ...........................................................................................................................lots of information


5.) change your attitudes towards HIV
*..................................*...............................*...............................*.................................*..................................*
no change in attitude.............................................................................................................. significant change in attitude


6.) change in risky sexual behaviour
*..................................*...............................*...............................*.................................*..................................*
no change in behaviour.......................................................................................................... positive change in behaviour



Let's Keep Talking
Evaluation of Group Topics

Favourite Session or Topic:

During the course of the group, the following topics or issues were discussed. Using a number from 1 to 6, indicate which was your most favorite topic (1), and do this until number 6, which would be your least favorite topic. If you did not attend a session, mark it with an X.
    • discussions about self-esteem
    • images of gay males collage exercise
    • discussions about intimate relationships
    • discussions about friendships
    • safer sex/risk continuum exercise
    • discussions about community involvement
    • case scenario (HIV risk-taking in a relationship) exercise

Other favourite topic or session:_____________________________________________


Most Important Session or Topic

During the course of the group, the following topics or issues were discussed. Using a number from 1 to 6, indicate which was the most important topic for you (1), and do this until number 6, which would be the least important topic for you. If you did not attend a session, mark it with an X.
    • discussions about self-esteem
    • images of gay males collage exercise
    • discussions about intimate relationships
    • discussions about friendships
    • safer sex/risk continuum exercise
    • discussions about community involvement
    • case scenario (HIV risk-taking in a relationship) exercise

Other most important topic for you: __________________________________________




Appendix D -- Goal Attainment Measure

Goal Number 1

How Will I Know My Goal is Attained?

Was Goal Attained/Comments?

( yes ................................ ( no



Goal Number 2

How Will I Know My Goal is Attained?

Was Goal Attained/Comments?

( yes ................................ ( no



Goal Number 3

How Will I Know My Goal is Attained?

Was Goal Attained/Comments?

( yes................................( no