Evidence-based HIV prevention in community settings: provider perspectives on evidence and effectiveness

As part of the efforts to expand evidence-based practice (EBP) in HIV prevention at the community level, the Centers for Disease Control and Prevention (CDC) created the Diffusion of Effective Behavioral Interventions (DEBI) program. Frontline service providers, who are charged with adopting and implementing these interventions, however, have resisted and criticized the dissemination of evidence-based HIV prevention interventions. Their failure to implement the interventions with fidelity and abandonment of plans to implement interventions in which they were trained have often been discussed from the framework of ‘capacity-building’. This framework points to ‘deficits’ within community-based organizations (CBOs) that impede the uptake of EBP. This article presents the perspective of 22 frontline service providers from CBOs (n?=?8) in a Midwestern state on their experiences with the DEBI program, and illustrates the reasons providers may not implement EBP. Analysis of interview responses reveals that providers cite diverse reasons – beyond organizational capacity – for lack of implementation with fidelity. Specifically, they offer critiques of the DEBI program based on the models of evidence of effectiveness on which it is based.     

Bridging the gap between the science and service of HIV prevention: transferring effective research-based HIV prevention interventions to community AIDS service providers

OBJECTIVES: AIDS service organizations (ASOs) rarely have access to the information needed to implement research-based HIV prevention interventions for their clients. We compared the effectiveness of 3 dissemination strategies for transferring HIV prevention models from the research arena to community providers of HIV prevention services. METHODS: Interviews were conducted with the directors of 74 ASOs to assess current HIV prevention services. ASOs were randomized to programs that provided (1) technical assistance manuals describing how to implement research-based HIV prevention interventions, (2) manuals plus a staff training workshop on how to conduct the implementation, or (3) manuals, the training workshop, and follow-up telephone consultation calls. Follow-up interviews determined whether the intervention model had been adopted. RESULTS: The dissemination package that provided ASOs with implementation manuals, staff training workshops, and follow-up consultation resulted in more frequent adoption and use of the research-based HIV prevention intervention for gay men, women, and other client populations. CONCLUSIONS: Strategies are needed to quickly transfer research-based HIV prevention methods to community providers of HIV prevention services. Active collaboration between researchers and service agencies results in more successful program adoption than distribution of implementation packages alone.     

"Out-of-the-mainstream" youth as partners in collaborative research: exploring the benefits and challenges.

Forming collaborations between university-based researchers and community-based organizations (CBOs) serves to improve health promotion research and service. Unfortunately, members of the targeted populations are typically not included in such collaborations. This article describes the development and maintenance of a successful university-CBO collaboration that was formed to explore HIV-related risk rates and prevention strategies for suburban street youth and discusses the benefits and challenges of including out-of-the-mainstream youth as full collaborative partners in the research. Specific benefits included population-specific modifications of the research methods and instruments, recruitment of hard-to-reach youth, greater ease in tracking participants, and increased project acceptability and credibility. Among the challenges were issues related to boundaries, confidentiality, commitment, and burnout. Although such collaborations require increased time and commitment, the synergistic knowledge and experience of university researchers, community-based service providers, and out-of-the-mainstream youth can result in the development of unique and informative research and service programs.     

Strategies for Community/School Collaborations to Prevent Youth Substance Abuse

Within communities across the United States, collaborations have developed between community-based organizations (CBOs) and schools to plan and implement unified approaches to prevent youth substance abuse. This article describes challenges and workable strategies reported by a diverse group of 11 community-based organizations (CBOs) for developing and maintaining collaborative relationships with schools. Strategies recommended by CBOs for effective CBO/school collaborations are described within four categories: (1) establishing the collaboration; (2) maintaining cooperation with schools during program implementation; (3) addressing cultural issues; and (4) institutionalizing the collaborative programs. The need to tailor community prevention efforts to the specific context of each community is emphasized.     

Organizing community research partnerships in the struggle against AIDS.

Despite pharmaceutical advances, AIDS remains a health problem difficult to treat, leaving preventive interventions as the primary means of promoting risk avoidance. Increasing the capacity of university-based researchers to develop culturally, developmentally, and contextually appropriate AIDS prevention strategies requires the collaboration of community service and advocacy partners. To date, neither university researchers nor community providers have a great deal of partnership experience. Thus, a common language and set of experiences are yet to be developed. This article reviews the history of university-community and researcher-community collaboration for AIDS research and intervention, placing the innovative work of the University of California, San Francisco (UCSF) Center for AIDS Prevention Studies and its community and foundation partnerships among those efforts at the forefront of the community-university dialogue. It concludes with suggestions derived from the collaborative work of UCSF researchers and community service partners to strengthen efforts to develop theory, research methods, and results that are immediately useful and productive of long-term prevention research efforts.     

A national,geographic database of CDC-funded HIV prevention services: development challenges and potential applications

Background  

From 2000–2002, the Centers for Disease Control and Prevention (CDC) funded a study that was designed to improve the information available to program planners about the geographic distribution of CDC-funded HIV prevention services provided by community-based organizations (CBOs). Program managers at CDC recognized the potential of a geographic information system (GIS) to organize and analyze information about HIV prevention services and they made GIS a critical component of the study design. The primary objective of this study was to construct a national, geographically-referenced database of HIV prevention services provided by CDC-funded CBOs. We designed a survey instrument to collect information about the geographic service areas where CBOs provided HIV prevention services, then collected data from CBOs that received CDC funding for these services during fiscal year 2000. We developed a GIS database to link questionnaire responses with GIS map layers in a manner that would incorporate overlapping geographies, risk populations and prevention services. We collected geographic service area data in two formats: 1) geopolitical boundaries and 2) geographic distance.     

Technical assistance for the evaluation of community-based HIV prevention programs.

Funding agencies are using technical assistance (TA) to strengthen the evaluation capacity of community-based organizations (CBOs) engaged in HIV prevention efforts. The authors used qualitative methods to identify the types of evaluation TA needed by CBOs, to understand CBOs' past experiences with evaluation TA, and to elicit ideas for optimal delivery of evaluation TA. Assistance in developing evaluation tools and data analysis were the most commonly cited needs. Preferred TA providers were characterized as having practical expertise, accessibility, cultural competence, communication skills, and collaboration skills. Critical elements of an ideal TA system were adequate funding, program-specific TA, and extensive interaction between TA providers and CBO staff. Study data were used to generate a set of recommendations for health educators and others who may provide CBOs with TA for evaluating prevention programs.     

Promovision: designing a capacity-building program to strengthen and expand the role of promotores in HIV prevention

This article describes the development of Promovisión, a program based on the utilization of promotores in community-based organizations (CBOs) to improve the provision of HIV prevention services to recent immigrants and Latinos who are less acculturated. Promovisión aims to demonstrate the contribution of promotores as a cost-effective strategy in HIV prevention efforts, and how promotores facilitate the formation of community, regional, and national CBO networks working collaboratively to prevent the spread of HIV in Latino communities. In addition, this article examines the interpersonal, organizational, community, and sociocultural dimensions that facilitate or hinder community mobilization, and coalition formation and growth, and how these findings shaped the final design of the program. Finally, the Promovisión program seeks to demonstrate that a promotor-based program is a culturally appropriate model for HIV prevention and care, which can be successfully implemented in community and clinical settings among ethnic populations with limited English proficiency.     

Sampling for evaluation. Issues and strategies for community-based HIV prevention programs

Sampling methods are an important issue in the evaluation of community-based HIV prevention initiatives because it is through responsible sampling procedures that a valid model of the population is produced and reliable estimates of behavior change determined. This article provides an overview on sampling with particular focus on the needs of community-based organizations (CBOs). As these organizations continue to improve their capacity for sampling and program evaluation activities, comparisons across CBOs can become more rigorous, resulting in valuable information collectively regarding the effectiveness of particular HIV prevention initiatives. The author reviews several probability and non-probability sampling designs; discusses bias, cost, and feasibility factors in design selection; and presents six guidelines designed to encourage community organizations to consider these important sampling issues as they plan their program evaluations.     

云南省社会组织参与艾滋病综合防治示范区HIV筛查检测现状分析

目的 了解云南省第三轮全国艾滋病综合防治示范区社会组织提供人类免疫缺陷病毒（human immunodeficiency virus,HIV）筛查检测服务的现状,为社会组织提供HIV筛查检测服务提供建议。方法 采用网络问卷调查收集信息,利用SPSS 19.0进行数据汇总和分析。结果 云南省第三轮全国艾滋病综合防治示范区有50个社会组织参与示范区艾滋病防治工作,100.0%（50/50）的社会组织均提供HIV动员检测服务,64.0%（32/50）的社会组织提供HIV筛查检测服务,血HIV快速检测服务占81.3%（26/32）,唾液检测服务占53.1%（17/32）。100.0%（32/32）的社会组织接受过HIV快速检测技术培训。40.0%（20/50）的社会组织可直接提供HIV快速检测服务。卫生行政部门、疾病预防控制中心以及医院对其开展HIV筛查检测服务的态度差异有统计学意义（χ2=15.309,P=0.004）。结论 社会组织在提供HIV筛查检测和发现HIV感染者有重要作用,云南省第三轮全国艾滋病综合防治示范区应充分发挥社会组织提供HIV筛查检测服务的优势,结合外展干预服务提供HIV筛查检测服务,扩大HIV检测覆盖面。     

Perceptions of evidence-based programs among community-based organizations tackling health disparities: a qualitative study

Dissemination of prevention-focused evidence-based programs (EBPs) from research to community settings may improve population health and reduce health disparities, but such flow has been limited. Academic-community partnerships using community-based participatory research (CBPR) principles may support increased dissemination of EBPs to community-based organizations (CBOs). This qualitative study examined the EBP-related perceptions and needs of CBOs targeting underserved populations. As part of PLANET MassCONECT, a CBPR study, we conducted six key informant interviews with community leaders and four focus groups with CBO staff members in Boston, Worcester and Lawrence, Massachusetts, in 2008. Working definitions of EBPs among CBO staff members varied greatly from typical definitions used by researchers or funders. Key barriers to using EBPs included: resource constraints, program adaptation challenges and conflicts with organizational culture. Important facilitators of EBP usage included: program supports for implementation and adaptation, collaborative technical assistance and perceived benefits of using established programs. This exploratory study highlights differences among key stakeholders regarding the role of evidence in program planning and delivery. An updated perspective should better incorporate CBO perspectives on evidence and place greater, and much needed, emphasis on the impact of context for EBP dissemination in community settings.     

Encouraging survey participation among individuals seeking HIV prevention services: does a community identity match help or hurt?

Understanding the behaviors and attitudes of at-risk populations is fundamental to controlling the spread of HIV, the virus that causes AIDS. The problem of nonresponse among these populations, however, plagues survey research designed to address these issues. Previous work undertaken to map out the dynamics of nonresponse--both noncontacts and refusals--have primarily focused on exploring the effectiveness of a single method of outreach. This analysis improves on this prior research by comparing the effectiveness of two types of outreach strategies in a follow-up face-to-face survey of individuals seeking HIV prevention services in New Jersey during the period 1999-2001. Case workers from community-based organizations (CBOs) attempted to contact one set of respondents, whereas "outsider" researchers attempted to contact the second set. In brief, the authors find that in contrast to a CBO research affiliation, an outsider researcher status is associated with higher survey response rates.     

Extra Federal aid for minorities presents challenges for CBOs

Congress awarded $156 million to deal with the HIV epidemic among African-Americans and other minorities. AIDS service providers welcomed the money but said that much more needs to be done. Community-based organizations (CBOs) serving minority populations are relatively new, and many need improved accounting and auditing procedures, information technology, and leadership development systems if they are to be productive. Hurdles faced by CBOs include competing for funding, recruiting volunteers, educating minority physicians, and planning community responses. The opinions of two former U.S. Surgeon Generals regarding this new funding and how it should be used are discussed.     

Adapting efficacious interventions: advancing translational research in HIV prevention

The Human Immunodeficiency Virus (HIV) has infected approximately 1.5 million people in the United States. Type 1 translation research (basic research, methods development, and efficacy trials) has yielded multiple efficacious behavioral HIV prevention programs. Type 2 translation research (dissemination and effectiveness studies) has been less prevalent or successful. Adaptation of efficacious interventions for culturally diverse populations has received increasing researcher attention, and empirical validation of adaptation procedures promises to help bridge the gap between Type 1 and Type 2 studies. In this article, the authors briefly discuss the development, testing, and dissemination of efficacious HIV prevention programs and then focus on research-based principles and processes that can guide researchers'adaptation efforts and steps that researchers can take to help empower practitioners to conduct science-based adaptation. Greater collaboration between researchers and service providers to test adaptation frameworks promises to benefit both research and practice.     

Stärkung von Gemeinschaften: Partizipative Forschung zu HIV-Prävention mit Migrant/innen

Background

Communities play a key role in health promotion, in the concept of structural prevention and also in participatory health research. Community-Based Participatory Research (CBPR) aims to equitably involve community partners in investigating problems, identifying resources and developing solutions in order to improve community health. The participating communities are supposed to benefit from the research collaboration. However, whether this aim is actually realized in practice is only rarely analyzed.

Aim

This article explores how the community partners benefited from participating in a CBPR study on HIV prevention with migrant communities in Germany (PaKoMi).

Methods

The PaKoMi-Project was a 3-year participatory research project which aimed to improve the involvement of migrant communities in HIV research and prevention services. It was conducted by the national association of community-based AIDS service organisations (Deutsche AIDS-Hilfe e. V.) in collaboration with partners from different immigrant communities, AIDS service providers and researchers from the Social Science Research Center Berlin (WZB). Community members were trained as peer researchers and supported to conduct local CBPR-projects (case studies) in four cities. In the final evaluation, the partners stated what they gained from collaborating in the project. The current analysis focuses on the benefits for the participating partners, their communities and the field of HIV prevention.

Results

Competences were developed by the participating individuals and community capacities were strengthened, for example by developing networks, peer-based initiatives and migrant self organisations. Concepts, tools and recommendations for improving HIV prevention services for migrants were developed.

Conclusions

The PaKoMi-project shows how communities can benefit from participatory research.     

Assessing HIV prevention provider knowledge of behavior science theory: building on existing intuitive experience

Behavioral science theory is recommended as a basis for prevention programs, yet many STD/HIV prevention providers have little academic background in this area and see no relevance of theory to their work. This study assessed STD/HIV prevention providers' intuitive insight about behaviors. Comparisons of behavioral determinants from providers "common sense" theories with determinants identified in formal theories are made through the use of Theoretical Domains, a teaching tool designed to enhance the understanding and use of behavioral science in planning and implementing interventions. Understanding how to effectively apply behavior change concepts, combined with prevention providers' basic, intuitive knowledge can enhance understanding, communication, and skills exchange between providers and researchers. Building capacity in local communities begins with a participatory process of community members, prevention providers, and researchers working together as equal partners. Better translation of research into practice using theory-based interventions will benefit the field of STD/HIV prevention.     

Cross-cultural considerations in the conduct of community-based participatory research

This article explores cross-cultural challenges that arise when university and community members collaborate in community-based participatory research. As part of a project for primary prevention of human immunodeficiency virus (HIV) infection, researchers trained community leaders to jointly develop a research question and conduct a pilot qualitative study in a Puerto Rican community in Massachusetts. Different priorities of the community and university members about HIV as a research topic underscored the need to continuously reflect on developing a research question in community-based participatory research. Recognizing the cultural assumptions of both university and community members is an important component of capacity building among collaborative research teams.     

Peer Relationships Among Community-Based Organizations (CBO) Providing HIV Prevention Services

Community-based organizations (CBOs) play a vital role in the provision of HIV prevention services across the country. Little is known about how CBOs interact to share prevention ideas and implement prevention activities. In this qualitative study we examine the ways in which CBOs share with one another prevention-related resources and ideas, and produce prevention programs. Utilizing a grounded theory approach to analysis, we develop a model to explain CBOs' relationships with their peers. Implications for working with CBOs are discussed.     

A Network Assessment of Community-Based Participatory Research: Linking Communities and Universities to Reduce Cancer Disparities

Objectives. We sought to determine whether a community-based initiative designed to reduce cancer disparities among Pacific Islanders in Southern California increased communications between community-based organizations and university researchers.Methods. We conducted network analysis among 11 community-based organizations (CBOs) and 5 universities by interviewing 91 and 56 members of these organizations, respectively, at 2 points in time. We estimated random effects probit regression and stochastic actor-oriented network dynamic models.Results. We found that, during the 2-year study period, CBOs increased their connectedness with one another (b= 0.44; P < .05) and to the universities (b = 0.46; P < .05), but that university researchers did not increase their connectedness to each other or to CBOs.Conclusions. Cancer awareness, cancer education, and access to cancer services are low among Pacific Island groups, and this study provides an initial attempt to reduce these disparities. Community-based initiatives can strengthen a CBO network, creating the potential for increased community-informed cancer research and improved community access to cancer research resources.Community-based participatory research (CBPR) is increasingly viewed as a promising approach to cancer health disparities research that can bridge the enduring divide between scientific discovery and community impact.¹ Although CBPR methodologies vary, at their core they promote translational research by forging ties between community members and university researchers throughout the research development, implementation, and translation processes.^2–4 Additionally, such processes yield longer-term benefits to CBPR partners, including the creation of communities that can effectively advocate their needs and create institutional changes that can reduce community cancer health disparities.⁵ As the CBPR field has grown, so, too, has the number of empirical studies on various aspects of its conduct and impacts⁶; however, there remains a dearth of studies evaluating the effectiveness of CBPR programs.We report the results of the Weaving an Islander Network for Cancer Awareness Research and Training (WINCART) initiative designed to reduce cancer disparities among Pacific Islanders in Southern California.⁷ The WINCART initiative was created as a forum for university researchers and Pacific Islander community leaders to meet and establish linkages and has involved both a scientific advisory board (SAB; comprised of cancer-related researchers from 5 universities) and a community advisory board (CAB; comprised of representatives from 11 community-based organizations [CBOs]) to guide WINCART''s collaborative activities. A stated objective of the WINCART initiative is to create linkages between CBOs and academic institutions conducting cancer education, research, and training.⁸The CBOs are all nonprofit entities that conduct health and social service programs for Pacific Islanders in Southern California. The linkages created by WINCART would enable CBOs to disseminate information about cancer prevention, early detection, research, and treatment developments to their constituents. At the same time, WINCART was designed to create linkages from cancer researchers in 5 academic institutions (3 of which have comprehensive cancer centers) to CBOs so that cancer research, education, and training would be more community-informed. Public health researchers and advocates have long recognized that health disparities research often is not informed by community partners, and the gap between the academy and community persists today.Since its inception in May 2005 (with $2.5 million in funding over 5 years from the National Cancer Institute''s Center to Reduce Cancer Health Disparities), WINCART has conducted many activities to bridge the gaps between community and academy. Some of these activities have included bimonthly trainings of community leaders (usually by SAB members), retreats in which community and university researchers have focused on collaboration-building exercises and discussions, and events where community and university researchers have shared research activities and findings. Behind the scenes, WINCART has also facilitated relationship-building between community and university network members with mutual research interests, resulting in 6 National Cancer Institute–funded research projects on cancer epidemiology, prevention (nutrition and physical activity), and survivorship issues.Several activities were initiated by core WINCART staff to promote collaboration between university and community partners. With regard to education, 3 researchers in the network were asked to train CAB members on the topics of “cancer 101,” physical activity, and cancer survivorship. These training sessions helped increase the capacities of CAB members to provide cancer-related outreach education to their communities, which, for the first year, included a total of 223 events that educated 27 886 individuals. With regard to research, SAB and CAB members attended 2 all-day meetings on networking and collaboration, including the annual WINCART fall event that reviewed the network''s yearly activities and progress and an SAB orientation that introduced university researchers to the network''s mission and to potential community collaborators.We used social network analysis to evaluate the effectiveness of these activities. The stated goal of the project was to increase connections among and between CBOs and university organizations; thus, social network analysis was a logical methodology to use. Social network analysis is a set of theories, methods, and models for understanding how connections and relationships among entities are formed, evolve, and influence behaviors and actions.^3,9–11 There have been several notable prior network studies of interorganizational relations in the public health and health care delivery fields.^3,9,12–14 Generally these studies measure the degree of communication, collaboration, client referral, and formal agreements among organizations. The connections are mapped with specialty software and individual and network-level indicators are calculated (UCINET for Windows; Analytic Technologies, Lexington, KY).^9,15This study was designed to determine whether community-based outreach activities can increase cancer-related networks connecting CBOs and university researchers. Specifically, we expected networks to become denser overall and more heterogeneous such that communications between CBOs and universities show an increase over time. To test this hypothesis, we collected network data at 2 time points and employed several statistical modeling techniques.     

Strengthening community-based care for vulnerable children in Ethiopia: A mixed-method evaluation of program reach and community capacity development

Ethiopian children face serious challenges resulting from the HIV/AIDS pandemic. In response to these challenges, the Positive Change: Children, Communities and Care (PC3) program mobilized local communities to address them in seven regions of Ethiopia. This study aims to evaluate the PC3 program reach including the scale of services provided and the extent to which the provided care corresponded to the identified needs. It also assesses whether and how the program enhanced the capacity of local community-based organizations (CBOs) to respond to the needs of vulnerable children. The study team employed a mixed-method approach, assessing program reach through record review of services provided to children (n = 247,461), and assessing community capacity development through 11 in-depth, semi-structured interviews with leaders from four randomly selected local nongovernmental organizations (NGOs) and seven CBOs. Of all children included in the program, 88% needed at least one service and 97% of these children received at least one, whereas 55% had at least one un-met need. Further, 29% of children received services for needs which were not identified. Interviews indicated that the PC3 program mobilized and transformed local communities to address multiple needs of children. Community involvement and ownership of the program helped leverage partner resources to meet the needs of children in their communities. The PC3 program can provide a model for other communities in Sub-Saharan African countries with similar challenges. The impact of the PC3 program may have been understated due to underreporting. The research indicated that the program underutilized program data for the purposes of program management, assessment, and improvement. Improvement in this area would have enhanced this highly effective community mobilization model.