Welcome to the Acción Mutua web-seminar:

Adaptation of Evidence-Based HIV Prevention Interventions

Before we begin, a little about our format…  Presentation by seminar speaker (approx. 40 min.)  Followed by question and answer session (approx. 20 min.) • Please press *6 on your telephone keypad to mute your line (pressing *6 again will un-mute your line) • If you are experiencing difficulty with your phone connection, dial *0 for the conferencing service operator • Questions submitted prior to the web seminar will be addressed first • For questions that arise during the presentation, please click on the “hand” button and type your question 1

Acción Mutua

is a capacity building assistance (CBA) program of

AIDS Project Los Angeles

in collaboration with the

César E. Chávez Institute

of San Francisco State University

Funded by the Centers for Disease Control and Prevention 2

Adaptation of Evidence-Based HIV Prevention Interventions

Rosemary C. Veniegas, Ph.D. & Uyen H. Kao, M.P.H.

Funded in part by NIMH grant P30 MH58107 to M. Rotheram-Borus, Ph.D.

Overview

 National context of use of EBIs  Key concepts and terms  Evidence of effectiveness and efficacy  Models of adaptation  Guidance and guidelines for adaptation 4

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National context

CDC

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REP, DEBIs, Best-evidence, promising-evidence ADAPT2 funding for 22 “ new ” EBIs

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Substance Abuse, Mental Health

  

NIDA – Principles of Effective Treatment ONDCP – Evidence-Based Principles for Substance Abuse Prevention SAMHSA – NREPP (National Registry of Evidence-based Programs and Practices)

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Health Care/Services

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AHRQ – NCI – PPIP (Put Prevention Into Practice) RTIPS (Research Tested Intervention Programs)

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CDC EBIs

(

Sharpe, Collins & Glassman, 2007)

Best-Evidence Promising Evidence ADAPT 6

CDC EBIs

(

Sharpe, Collins & Glassman, 2007)

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CDC EBIs

Compendium of HIV Interventions With Evidence of Effectiveness 24 interventions www.cdc.gov/hiv/resources/repo rts/hiv_compendium/ 8

CDC EBIs

Replicating Effective Programs, REP+ 13 interventions http://www.cdc.gov/hiv/topics/prev_ prog/rep/index.htm

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CDC EBIs

DEBIs 14 interventions www.effectiveinterventions.org

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New CDC EBIs

Best-Evidence (30 interventions) www.cdc.gov/hiv/topics/research/prs/be st-evidence-intervention.htm

Promising-Evidence Interventions (18 interventions) www.cdc.gov/hiv/topics/research/prs/pr omising-evidence-interventions.htm

Adopting and Demonstrating the Adaptation of Prevention Techniques for Persons at Highest Risk of Acquiring or Transmitting Human Immunodeficiency Virus (ADAPT, 22 interventions) grants.nih.gov/grants/guide/rfa files/RFA-PS-07-004.html

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SAMHSA EBIs

NREPP 91 substance abuse and mental health relevant interventions, Including 3 HIV/AIDS relevant interventions http://www.nrepp.samhsa.gov/ 12

Key Concepts and Terms

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Evidence-based intervention

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Adaptation & fidelity

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Bases of evidence

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Tiers of evidence

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Components of Evidence-Based Interventions

       Rotheram-Borus, 2007 Establish frame for intervention Convey issue-specific or population-specific information Use a cognitive-behavioral framework/theory to build affective, behavioral and cognitive coping skills Address environmental barriers to implementation of new behaviors Provide tools to develop ongoing sources of social support See also 17 characteristics of effective interventions sex and HIV education programs for youth by Kirby, Laris & Rolleri (2006)  http://www.etr.org/recapp/programs/SexHIVedProgs.pdf

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What is Adaptation?

(McKleroy et al., 2006; Sharpe et al., 2007)  Modifying key characteristics, activities, delivery methods without competing or contradicting core elements, theory or internal logic of the intervention  Necessary to ensure relevance in local settings, with new populations, or comply with funder  Check with your funder about what they consider appropriate adaptation 15

What is Fidelity?

(CDC, 2005)  Part of quality assurance  Maintaining the core elements, protocols, procedures, and content that made the original intervention effective  Keeping the “signature” of the intervention (Miller, 2007) 16

Adaptation Considerations

(Solomon, Card & Malow, 2006)  Adherence to intervention protocols for efficacy  Alterations to intervention for effectiveness  Benefits of adaptation  Enhance community support  Enhance client participation  Enhance program satisfaction  Enhance outcomes  Promote institutionalization 17

Adaptation Principles

(Solomon, Card & Malow, 2006)  Know the target population and community context  Select the program that best matches the population and context  Retain fidelity to the “ core program ”  Systematically reduce mismatches between the program and the new context  Document the adaptation process and evaluate the process and outcomes of the adapted intervention as implemented 18

Knowing the target population

 Solicit feedback on adaptation from a community advisory board  Conduct focus groups with the target population  Interview key informants and stakeholders 19

Select the program that best matches

 Learn the core elements of the intervention  Identify the risk factors, behavioral determinants, risk behaviors for the target population which are reflected in the intervention  Assess staffing, skills, space, costs of conducting the intervention  Review mission and vision in relation to the intervention  Pre-test or pilot activities or sessions of the intervention 20

Retain fidelity to the intervention

   Use behavior change theory to guide adaptation  If perceived vulnerability is low among gay men of color, consider increasing session content focusing on this factor Use previous experience with the intervention  If Mpowerment worked with groups composed of African American men only, consider conducting it with Asian/Pacific Islander men only Keep process evaluation data on why changes are made and what changes are made    Supervisor review of project documentation, client records, site observations, interviews, videotaped sessions Facilitator debriefing on the intervention as delivered Quality assurance or improvement efforts 21

Systematically reduce mismatches

 Identify risk factors, behavioral determinants, or risk behaviors that are the same or different between the original intervention and the new context or population  Identify necessary cultural adaptations to enhance relevance of the intervention  Draft a logic model for the intervention 22

Document the adaptation process

 Keep process evaluation data on why changes were made and what changes were made  Write, observe, record, report  Review the process data from the adapted intervention as implemented  Which changes worked? Did not work?

 Which changes enhanced the response to the intervention? Decreased the response?

 Review the outcomes of the adapted intervention and compare with the outcomes from the original intervention  Did the HIV risk behaviors decrease? Increase?

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Fidelity Considerations

(CDC, 2006)  Reinvention is a form of adaptation  Necessary for new populations/settings  Core elements have been modified (i.e., adding or dropping)  Recommendations  Rename intervention  Detail internal logic of adapted intervention (i.e., behavioral risk factors addressed)  Formally evaluate prevention outcomes  Ensure behavioral outcomes were achieved 24

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How to measure fidelity?

(Mowbray et al., 2003) Ratings by experts  Review of project documentation or client records, site observations, interviews, videotaped sessions  Surveys or interviews  Completed by those delivering the sessions or services 25

Other Ways to Measure Fidelity

 Fidelity to adapted intervention  Revised intervention materials and procedures  Debriefing forms  Completed by staff delivering the intervention  Session observations  By staff who are also trained in or familiar with the intervention  By independent observers also knowledgeable about the intervention 26

MPowerment Adaptations

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MPowerment Adaptations

(Rebchook, Kegeles, Huebner & the TRIP Research Team, 2006)

MPowerment DEBI

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Telephone interview study

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69 CBOs

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Adaptations

• • •

Delivered in different setting (75%) Different age groups targeted (49%) Single ethnic group focus (28%)

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Implemented, modified, dropped elements

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MPowerment In Los Angeles

 Locally prioritized adaptations and reinventions  Being delivered to HIV-negative and to HIV-positive individuals  Being delivered to transgender women  Being delivered to men younger than 18 29

Community Popular Opinion Leader

(Maiorana, Kegeles, Fernandez, Salazar, C áceres, Sandoval, Rosascob, Coates & NIMH Collaborative HIV/STI Prevention Trial Group, 2007)         Adapted POL to be implemented in Peru Called “Que´ te Cuentas (What’s Up)” Multi-site staff training on CPOL model and intervention Developing facilitators’ training manual with the curriculum for training the CPOLs Developing appropriate prevention messages to conduct conversations Identifying appropriate incentives Consulting and testing prevention messages with local experts and key informants part of the target populations Facilitators’ rehearsal with key informants acting the part of CPOLs.

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 

Other Examples of Adaptations and Reinventions

(Veniegas, Kao, Rosales & Arellanes, unpublished data)

Target new population Other Adaptations Reinvention

Adaptation for new target population  Include culturally appropriate language/content  Add core element to meet funder requirements Adapting to multiple populations  Changing scheduling, duration, location, order  Have open sessions with non-target group members  Integration with other services/ programs  Making adaptations which reduce the effectiveness of the intervention 31

Relevance of EBIs for local contexts

 Glasgow & Emmons, 2007  Emphasized external validity criteria for intervention developers/disseminators  Program reach and representativeness  Program or policy implementation and adaptation  Outcomes for decision making  Maintenance and institutionalization 32

CDC Bases and Tiers of Evidence

 Bases of evidence for prevention programming  CDC Evaluation Guidance Handbook, 2002  Tiers of evidence for evidence-based interventions  National HIV Prevention conference 2007 33

CDC Bases of Evidence

 Prevention programming  Data from an evaluation of their own intervention  Data from an evaluation of a similar intervention  A theoretical basis from the scientific literature  A fully articulated informal theory  Website http://www.cdc.gov/hiv/topics/evaluation/health_ depts/guidance/designing-appendix.htm

 Emphasis on effectiveness 34

CDC Tiers of Evidence

 http://www.cdc.gov/hiv/to pics/research/prs/tiers of-evidence.htm

 Emphasis on efficacy 35

Tiers

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Models of Adaptation

 Technology Transfer Model  Replicating Effective Programs  Map of Adaptation Process 39

Models of Adaptation

 Technology Transfer Model  Replicating Effective Programs  Map of Adaptation Process 40

Technology Transfer Model

    Kraft, Mezoff, Sogolow, Neumann & Thomas, 2000 Pre-implementation     Review prevention needs Acquire information Assess fit Prepare organization/staff Implementation   Secure technical assistance Conduct process evaluation Maintenance and Evolution   Support staff; organization change and institutionalization Conduct process, outcome, and cost evaluations 41

Technology Transfer of Multiple EBIS

(Veniegas, Kao, Rosales & Arellanes in press)

Activity Strategy used by CBO Challenge experienced by CBO

Assess fit Prepare organization and Staff Secure technical Assistance (TA) for intervention selection   Review existing client and program data with intervention requirements  Modify key characteristics of EBI  Poor fit between the intervention and the population CBO was funded to serve Funder required major modifications to EBI   Seek TA from external consultant Seek TA from CBA provider  Few TA resources available 42

Replicating Effective Programs (REP) Model

      Kilbourne, Neumann, Pincus, Bauer, & Stall, 2007 Model for packaging interventions for use by CBOs Pre-conditions  identify need, target population, intervention Pre-implementation  develop intervention package, seek community input Implementation  disseminate, train, technical assistance, evaluate Maintenance and evolution  prepare for sustainability 43

REP Model

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Map of Adaptation Process

(McKleroy, Galbraith, Cummings, Jones, Harshbarger, Collins, Gelaude, Carey, & the ADAPT Team, 2006)

A S

ssess elect

P

repare

P

ilot

I I

mplement             Target population Interventions Goodness of fit Stakeholders Organizational capacity Decide to adopt, adapt, or select another intervention Make necessary changes to EBI Prepare agency Pre-test materials Implementation plan Successful pilot of adapted intervention Implement adapted EBI

(Adapted from McKleroy

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Map of Adaptation Process

(McKleroy, Galbraith, Cummings, Jones, Harshbarger, Collins, Gelaude, Carey, & the ADAPT Team, 2006) 46

Guidelines and Guidance

 HIV Prevention Plans  Provisional Procedural Guidance  CRIS at CDC  Other Adaptation Guidance 47

HIV Prevention Plans

     Website of CPGs http://hivinsite.ucsf.edu/InSite?page=li-07-12 Required for each CDC funded jurisdiction Details HIV prevention priorities and populations  In Los Angeles use of the “hard core 4” drugs heroin, cocaine, crack and methamphetamine is a primary HIV risk factor  In Florida Black Heterosexuals are a priority population for HIV prevention Identifies interventions for priority populations Provides guidance on recommended interventions for the region 48

CDC Provisional Procedural Guidance for CBOs

   http://www.cdc.gov/hiv/topics/prev_prog/AHP/resources/ guidelines/pro_guidance.htm

Covers core elements, resource requirements, quality assurance, monitoring and evaluation Policies and standards for        Confidentiality Cultural competence Data security Informed consent Legal and ethical policies Referrals for additional client services Liability insurance and applicability of workers’ compensation for volunteers 49

CDC Provisional Procedural Guidance for CBOs

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Capacity Building Request Information System (CRIS) for Directly Funded CBOs

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Other Adaptation Guidance

 Weaving Science and Practice Project (ETR & Healthy Teen Network) http://www.healthyteennetwork.org/vertical/Sites/%7BB4 D0CC76-CF78-4784-BA7C 5D0436F6040C%7D/uploads/%7BC4AC9F3C-F7C5 4F72-BF6A-867A953849A6%7D.PDF

 Adapting Efficacious Interventions (PROCEED, Inc.) http://www.proceedinc.com/downloads/NCTSTA Publications/Adapting%20Efficacious%20Interventions% 20-%20Article%204%20-%20CH%20-%20PDF.pdf

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Other Adaptation Guidance

   Adaptation and Tailoring (ETR) http://www.etr.org/tabono/Images/FILES/Web%20Adapt%20&%20Ta ilor.doc

Implementation and Fidelity of Evidence-Based Behavioral Interventions (Galbraith et al. 2008) http://heb.sagepub.com/cgi/rapidpdf/1090198108315366v1.pdf

UNAIDS Guidance on HIV Counseling and Testing Adaptation http://libdoc.who.int/publications/2007/9789241595568_eng.pdf

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iGracias ~ Thank You!

Questions & Comments

Thanks for Your Participation

For more information or to learn how to receive CBA services, contact us at:

213.201.1345

www.accionmutua.org

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