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Guidelines for Health Education and Risk Reduction Activities



April 1995
                
Centers for Disease Control and Prevention
Atlanta, Georgia

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                         GENERAL CONSIDERATIONS 
                                REGARDING
                            HEALTH EDUCATION
                                  AND 
                        RISK REDUCTION ACTIVITIES


                               Introduction

Preventing the spread of human immunodeficiency virus (HIV) and sexually
transmitted disease (STD) requires a comprehensive strategy composed of
service delivery systems coupled with effective, sustained health education
and health promotion interventions.  These individual components of a
prevention program must not operate in isolation, but must work together
toward the well-being of the person at risk and the community as a whole. 
All education activities related to HIV/STD prevention should contribute to
and complement the overall goal of reducing high-risk behaviors.

The guidelines presented in this document are written to encourage HIV/STD
prevention programs to focus on developing programs and services that are
based on health education and health promotion strategies.  In Health
Behavior and Health Education: Theory, Research, and Practice, the authors
describe the ultimate aims of health education as being "positive changes
in behavior" (Glanz et al., 1990, p.9).  Green and Kreuter further define
health promotions as ". . . the combination of educational and
environmental supports for actions and conditions of living conducive to
health" (Green and Kreuter, 1991).  Health education is a powerful tool in
an epidemic in which the behavior of using a latex condom can make the
difference in whether or not a person becomes infected with HIV.

It is critically important that members of the populations to be served are
involved in identifying and prioritizing needs and in planning HIV/STD
education interventions.  Their involvement ensures that decisions are
made, purposes are defined, intervention messages are designed and
developed, and funds are allocated in an informed and realistic manner. 
Limited educational resources can be proactively directed to specific
populations, rather than reactively directed or directed on the basis of
guesswork or stereotyping.

Moreover, to be effective, an education intervention must be culturally
competent.  Participation of client populations throughout the process of
designing and implementing programs helps assure that the program will be
acceptable to the persons for whom it is intended.  For the purposes of
this document, cultural competence is defined as the capacity and skill to
function effectively in environments that are culturally diverse and that
are composed of distinct elements and qualities.  Cultural competence
begins with the HIV/STD professional understanding and respecting cultural
differences and understanding that the clients' cultures affect their
beliefs, perceptions, attitudes, and behaviors.  

Health departments across the country have implemented an HIV prevention
community planning process whereby the identification of a community's high
priority prevention needs is shared between the health departments
administering HIV prevention funds and representatives of the communities
for whom the services are intended.  The HIV prevention community planning
process begins with an accurate epidemiologic profile of the present and
future extent of HIV and acquired immunodeficiency syndrome (AIDS) in the
jurisdiction.  Special attention is paid to distinguishing the behavioral,
demographic, and racial/ethnic characteristics of the epidemic.   This is
followed by an assessment of HIV prevention needs that is based on a
variety of sources and is collected using different assessment strategies. 
Next, priorities are established among needed HIV prevention strategies and
interventions for specific populations.  From these priorities, a
comprehensive HIV prevention plan is developed.

Of the eight essential components of a comprehensive HIV prevention program
that are described in the community planning guidance document issued by
CDC, four relate specifically to the interventions described in these
Guidelines.  These are as follows:

  - Individual level interventions which provide ongoing health
    communications, health education, and risk reduction counseling to
    assist clients in making plans for individual behavior change and
    ongoing appraisals of their own behavior. These interventions also
    facilitate linkages to services in both clinic and community settings
    (e.g., substance abuse treatment settings) in support of behaviors and
    practices which prevent transmission of HIV, and they help clients make
    plans to obtain these services.

  - Health communications, health education, and risk reduction
    interventions for groups, which provide peer education and support, as
    well as promote and reinforce safer behaviors and provide interpersonal
    skills training in negotiating and sustaining appropriate behavior
    change.

  - Community level interventions for populations at risk for HIV
    infection, which seek to reduce risk behaviors by changing attitudes,
    norms, and practices through health communications, prevention
    marketing,(1) community mobilization/organization, and communitywide
    events.

   -    Public information programs for the general public, which seek to
        dispel myths about HIV transmission, support volunteerism for HIV
        prevention programs, reduce discrimination toward persons with
        HIV/AIDS, and promote support for strategies and interventions that
        contribute to HIV prevention in the community.

More information on the HIV prevention community planning process is
contained in the Handbook for HIV Prevention Community Planning (Academy
for Educational Development, 1994) or from the HIV/AIDS Program in  your
local health department.  All HIV health education and risk reduction
activities should complement and support the priorities established in the
HIV prevention comprehensive plan developed by the local HIV prevention
community planning group.

For the purpose of this document, communities are defined as social units
that are at least one of the following: functional spatial units meeting
basic needs for sustenance, units of patterned social interaction, or
symbolic units of collective identity (Hunter, 1975).  Communities are
selected for interventions based on their specific and identified needs and
on surveillance and seroprevalence data.

The recommendations in this document recognize that while communities may
have different approaches to HIV/STD prevention programs, certain basic
programmatic, management, and staff requirements are common to effective
health education and risk reduction activities.  These Guidelines describe
the core elements that are essential for success in a number of types of
health education and risk reduction activities -- Individual and Group
Interventions and Community-level Interventions -- and in public
information activities.

These guidelines are provided to assist program planners in enhancing their
health education and risk reduction activities.  In some cases, specific
programs of state and local health departments have advanced beyond the
basic steps outlined here.  In other instances, programs may benefit
greatly from these suggestions.  The priority activities described in this
document can be used in a variety of settings and can also be applied to
other health issues.  

(1) Prevention marketing is CDC's adaptation of social marketing in which
    science-based marketing techniques and consumer-oriented health
    communication technologies are combined with local community
    involvement to plan and implement HIV/AIDS prevention programs. 
    Essentially, Prevention marketing = social marketing + community
    involvement. 


      Core Elements of Health Education and Risk Reduction Activities

A number of core elements should be considered in health education and risk
reduction program and evaluation activities.

Effective Health Education and Risk Reduction program activities:

  - State realistic, specific, measurable, and attainable program goals and
    objectives.

  - Identify methods and activities to achieve specific goals and
    objectives.

  - Define staff roles, duties, and responsibilities.

  - Define the populations to be served by geographic locale, risk
    behavior(s), gender, sexual orientation, and race/ethnicity.

  - Assure that educational materials and messages are relevant, culturally
    competent, and language- and age-appropriate.

  - Include professional development for all program staff.

  - Include a written policy and personnel procedures that address stress
    and burnout.

  - Include written procedures for the referral and tracking of clients to
    appropriate services outside of the agency.

  - Provide for collaboration with other local service providers to assure
    access to services for clients.

  - Assure confidentiality of persons served.

Effective Health Education and Risk Reduction evaluation activities:

  - Include process evaluation. (See Appendices.)

  - Require consistent and accurate data collection procedures, including
    number of persons served, quantity and type of literature or materials
    distributed, and demographics of persons served.  A description of the
    tools to be used and definitions of various measurements (e.g., "unit
    of service" and "contact") should be outlined.

  - Include staff supervision, observation, evaluation, and feedback on a
    regular basis.  (See Appendices B-D.)

  - Include feedback from persons served.

  - Designate staff who are responsible for evaluation and quality
    assurance activities, for compiling and analyzing data, and for
    documenting and reviewing findings.

  - Define methods for assessing progress toward stated process
    goals/outcome objectives.

  - Include mechanisms for measuring the use of referral services.

  - Provide findings for program modifications.

    Core Training for Health Education and Risk Reduction Activities

Staff training is an important element in the development of a sound
program.  The suggested areas in which health education and risk reduction
staff should receive training are listed below.  Not all staff members
should receive training in all the listed areas.  The outlined training
areas provide various program and management staff with the specific
technical support necessary to implement their component of the health
education and risk reduction program.

Effective training plans for Health Education and Risk Reduction staff:

  - Provide basic HIV, STD, and tuberculosis (TB) health education
    information.

  - Provide bleach use instruction.

  - Increase knowledge of substance use/abuse.

  - Provide orientation to human sexuality, including diverse lifestyles
    and sex practices.

  - Enhance sensitivity to issues for persons living with HIV/AIDS and
    STDs.

  - Recognize cultural diversity and enhance cultural competence.

  - Provide an orientation to the agency, community, and available
    community resources.

  - Include ongoing professional development for staff.

  - Provide opportunities for role play, observation, and feedback,
    including the use of video replay where possible.

  - Provide training in the dynamics of community and agency collaboration.

  - Enhance basic health education concepts.

  - Provide orientation to community resources.

  - Identify additional sources for updated information.

  - Build communication skills (e.g., active and reflective listening,
    clear speaking).

  - Provide for regular updates on analyses and programmatic
    interpretations of data.

  - Provide training on program planning, operations, and supervision.
    
  - Provide orientation to safer sex guidelines.

  - Provide training on developing HIV/AIDS publications and resources.

  - Enhance basic knowledge of family planning and contraception.

  - Increase knowledge of treatment and therapy for people living with HIV
    and AIDS.

  - Provide training on crisis intervention.

  - Provide training on street and community outreach.

  - Provide ongoing discussion on grief and bereavement.

  - Provide training on confidentiality and privacy.

                        Community Needs Assessment

The HIV prevention community planning process requires an assessment of HIV
prevention needs based on a variety of sources and different assessment
strategies.  This assessment serves as the basis for the development of a
comprehensive HIV prevention plan.  In addition, more targeted needs
assessment may be needed for effective health education program planning
for health departments and non-governmental organizations (NGOs).  Tailored
needs assessments enable the program planner to make informed decisions
about the adequacy, availability, and effectiveness of specific services
that are available to the target audience.

For the purposes of developing specific health education and risk reduction
activities, a targeted needs assessment assists in the following:

  - Establishing appropriate goals, objectives, and activities.
  - Defining purpose and scope.
  - Identifying social/behavioral attitudes, behaviors, and perceptions of
    the target community.
  - Providing the basis for evaluation as part of formative and summative
    studies of interventions.
  - Establishing community-based support for the proposed activities.

The needs assessment may be informal or formal.  An informal needs
assessment may occur through frequent conversations and personal
interactions with colleagues and clients.  Staff and clientele interact
with each other when services are being delivered; therefore, clients may
inform them about services they find useful or unsatisfactory.  Also, staff
meetings are a vehicle for sharing and transferring information among
colleagues.  Through both of these processes, staff can usually determine
whether there are gaps in services.  

A formal needs assessment involves a systematic collection and analysis of
data about the client population.  This process may uncover needs that may
not be identified through an informal process.

A formal needs assessment requires the program planner to do the following:

  - Identify questions that need to be answered.
  - Determine how the information will be collected and from whom.
  - Identify existing sources of data, e.g., needs assessment data from the
    HIV prevention community planning group.
  - Collect the data.
  - Conduct a comprehensive analysis of the data.

The program staff should review data from the HIV prevention community
planning needs assessment to determine what additional information is
needed.  A variety of information would be useful in developing program
activities, including the following:

  - Socioeconomic and demographic status of the overall community and the
    specific populations being targeted.
  - Current statistics and trends involving HIV/STD disease.
  - Existing gaps in HIV/STD programs and services.
  - Social indicator data to examine significant and relevant factors that
    influence prevalence of HIV/STD disease, e.g., substance abuse, teenage
    pregnancy.
  - Identification of other programs and resources that focus on the same
    target audience.

Before conducting a needs assessment, program staff should consult with
community leaders from the client or target populations.  This is important
in order to determine the leaders' perceptions of their communities' needs,
to discuss the agency's plan for conducting the assessment, and to begin to
cultivate a working relationship with the leaders in order to attain
community support for the proposed avtivities.

How to Conduct a Needs Assessment

  - Identify sources of information and data.
  - Review existing literature on the specific problem.
  - Survey other agencies/organizations in the community to avoid
    unnecessary overlap in program activities and to identify emerging
    issues and new resources.
  - Interview key informants and community members who have knowledge of or
    experience with the problem.
  - Consult with national/state agencies where specific data, literature,
    or experience are deficient.

How Needs Assessments Affect Program Evaluation

A needs assessment is a component of program evaluation.  Each element of a
needs assessment plays a significant role in the planning, implementation,
and management of effective education programs.  If a program is to be
evaluated, the degree to which the program addresses the needs of the
target audiences must be examined.

Both qualitative and quantitative methods of data collection and evaluation
are useful.  Qualitative methods afford the target audiences an opportunity
to express their thoughts, feelings, ideals, and beliefs.  Examples of
qualitative methods include informal interviews, focus groups, and public
forums.  These methods are designed to assist the program staff in
identifying problems or gaps that the agency may not have recognized, e.g.,
barriers to service delivery and client dissatisfaction.

Quantitative methods render statistical information.  Examples include
questionnaires and surveys, results of studies of the client populations'
attitudes and beliefs about HIV/STD disease, and information derived from
program activities, e.g., number of condoms distributed and documented
requests for services.

Note: For further reading on needs assessment, see "Chapter 5: Assessing
and Setting Priorities for Community Needs," Handbook for HIV Prevention
Community Planning, Academy for Education Development, April 1994.

                     Collaborations and Partnerships
                                    
The HIV prevention community planning process calls for health departments
and affected communities to collaboratively identify the HIV prevention
priorities in their jurisdictions.  However, some members of these affected
communities distrust health departments.  They  may feel that government
officials have not traditionally reached out to them until certain health
issues have also threatened the greater public health, i.e., the majority
community.  Sexually transmitted diseases, other communicable diseases, and
substance abuse have long been problems in disadvantaged and
disenfranchised communities.  Injecting drug users (IDUs) were dying of
endocarditis, hepatitis B, and drug overdose long before AIDS.  For years,
the tuberculosis epidemic persisted in poor African American and Hispanic
neighborhoods, while prevention and treatment resources dwindled. 
Consequently, developing collaborative working relationships with affected
communities for the purpose of HIV prevention may pose special challenges
to many state and local health departments.  

In the United States, public health officials frequently underestimate the
strengths and resourcefulness of affected communities.  As a result, state
and local health departments and communities have seldom come together in
partnership.  In many instances, state and local health departments have
not sought the support of, or consulted with, community members before
designing and implementing community intervention efforts.  At times,
public health officials may have inadvertently stigmatized communities in
their attempts to intervene and promote public health.  

Affected communities are acutely aware of the peculiarities of public
health as it relates to them.  Some have asked, "Is this a war on drugs or
on us?"  or "Why do you care?"  Despite government support for community-based organizations (CBOs), national and regional minority  organizations,
and HIV prevention community planning, many communities remain wary of
public health programs as they have been implemented by officials in their
communities.

As if this lack of confidence were not challenging enough to state and
local health departments, many communities genuinely suspect conspiracy
when health officials implement programs for them.  Many disadvantaged,
disenfranchised persons not only distrust the government, but they may also
fear it.  For African Americans, the Tuskegee Study continues to cast its
own specter of doubt as to whether or not public health officials are truly
committed to ensuring the public's health.   Hispanic farm workers continue
to struggle with government pesticide regulators who seem indifferent to
the dangers that farm workers face in the workplace.  For Native Americans
living on reservations, the quality of health is chronically poor, and life
expectancy is diminished.  Within many communities, there is a pervasive
belief that the government "does not care," or worse, that it "will
experiment on them."

Although the AIDS epidemic has illustrated the real value of developing
partnerships among local and state health departments and communities,
achieving communication, collaboration, and cooperation with these
communities and maintaining the relationships in a climate of distrust,
apathy, and even fear is daunting.  Such a task will surely require
cultural sensitivity, competency, respect, and the most critical of all
elements, time.  

In particular, for an effective HIV prevention community planning process,
state and local health departments must develop strong linkages and
collaborations with affected communities.  A working definition of
collaboration is the process by which groups come together, establishing a
formal commitment to work together to achieve common goals and objectives. 
Collaborative relationships are also referred to as coalitions or
partnerships.  Regardless of the term, the concept is a crucial one.

To facilitate the formation of effective community planning groups and
other partnerships, health departments need to understand not only the
knowledge and behaviors of their client populations, but also their
attitudes toward and beliefs about their own communities, the government,
and public health.  Health departments will want to assess these same
issues among their own employees.  In addition to this understanding, to
fully achieve cultural competence, to have the capacity and skills to
effectively function in environments that are culturally diverse and
composed of distinct elements and qualities, health department
professionals must also develop a respect for cultural differences.  They
must appreciate how culture and history affect their clients' perceptions,
beliefs, attitudes, and behaviors, as well as their own. 

For many health departments and community organizations, responding to the
AIDS epidemic means long-term institutional change.  Simply channeling HIV
resources to affected communities through community-based and national non-governmental organizations is not enough.  The epidemic compels the
formation of real working relationships among partners who perceive each
other as equal.  The community planning process addresses these issues by
emphasizing the importance of assuring representation, inclusion, and
parity in the planning process.  

An important program objective for health departments may be to gain
acceptance and credibility in the communities they seek to serve.  To
assume that these will come automatically or even easily may demonstrate
cultural insensitivity and incompetence.  Respect and regard for the
perceptions of those being served will help eliminate barriers to HIV
prevention and will build the bridges to better health. 

How Can Collaborations Help?

Collaborations can:

  - Facilitate strategic planning.
  - Help prevent duplication of cost and effort.
  - Maximize scarce resources.
  - Integrate diverse perspectives to create a better appreciation and
    understanding of the community.
  - Provide comprehensive services based on the client's needs.
  - Increase client accessibility to health services.
  - Improve communication between the health department and its
    constituents.
  - Provide liaison for clients unwilling to seek services from government
    organizations. 

At the same time, public health agencies must be aware of some of the
difficulties inherent in collaborative relationships:

  - Organizations and individuals may have hidden agendas.
  - Intra-agency trust may be difficult to develop.
  - Decision-making processes may become complicated.
  - Organizations have to collectively take the responsibility for program
    objectives, methods, and outcomes.
  - The group may lack a clear sense of leadership and direction.
  - The group may lack a clear sense of its tasks and responsibilities.

What Influences the Success of a Collaborative Effort?

Many factors influence the success of a collaborative effort; however, the
following factors are vital:

  - The group must develop a sense of mutual respect, trust, purpose, and
    understanding.

  - There must be an appropriate representation of groups from all segments
    of the community for whom the activities will have an impact.

  - All members must "buy into" and develop ownership in the development
    and outcome of the process.

  - Effective communication among members must be constant and ongoing.

  - The group must position itself as a leader in the community, eager to
    work with persons from all communities in developing effective
    prevention strategies.

  - The group must be willing to try non-traditional strategies.

The development and maintenance of collaborative relationships are
challenging and rewarding tasks.  Collaborations can make positive,
significant changes in communities, if they are developed in a way that is
culturally competent and respectful of the people for whom interventions
will be developed.  Health departments must also consider whether efforts
are cost-efficient, appropriate, duplicative, and accessible; they must
determine where community-based organizations fit into the overall realm of
prevention activities.  Collaborations should be structured with long-term
results in mind.  They should serve as a bridge to better relations between
state and local health departments and the community, ultimately effecting
better health in the community.

Contracting With Community-Based Organizations

Request for Proposals
    
In many cases, a health department may determine that the best approach for
reaching affected populations is by contracting with community-based
organizations that have experience serving specific populations.  In these
situations, the health department may issue a Request for Proposals (RFP)
from community-based organizations.  The RFP should be clear and directive
to assure that proposals will address the areas that have been identified
as priorities.  The RFP might require the following:

  - Specific, time-phased, and measurable program objectives and program
    plans that target populations whose behaviors place them at high risk
    for HIV, STD, and tuberculosis (TB). 

  - Interventions that are:

     -- culturally competent (function effectively in environments that are
        culturally diverse and composed of distinct elements and
        qualities);
            
     -- sensitive to issues of sexuality and sexual identity;
            
     -- developmentally appropriate (provided at a level of comprehension
        that is consistent with the learning skills of persons to be
        served);
            
     -- linguistically specific (presented in dialect and terminology
        consistent with the target population's native language and style
        of communication); and 
            
     -- educationally appropriate.

  - Coordination and collaboration with other organizations and agencies
    involved in HIV/STD prevention programs, particularly those targeting
    the same populations.

  - An evaluation plan.

The RFP also should be clear in outlining the eligibility requirements.  A
CBO may be defined as:
    
  -     A tax-exempt organization.
    
  -     An organization with a significant number of the affected
        populations in key program positions.
 
  -     An organization with an established record of service to affected
        communities.

The following additional points should be considered in the RFP process:

  - RFPs should be disseminated widely.

  - The initial award should be competitive; multi-year assistance is
    allowable only after an initial competitive award.

  - A procedure should  be in place to assure that funds are awarded to
    CBOs in a timely manner, no longer than 90 days.

  - The RFP should provide details on the application procedures and how
    eligible applicants can obtain technical assistance in the application
    process, including a contact person and phone number.  

Review Process
    
A review panel should judge applications strictly against the criteria
outlined in the RFP. Members of the review panel should include qualified
persons representing the target communities who do not have a conflict of
interest in reviewing proposals.  Other criteria for membership to the
review panel should include the following:
    
  -     Members who reflect the characteristics of the epidemic in the
        population.

  - Members who have expertise in understanding and addressing the specific
    HIV prevention needs of the populations they represent.
  
Technical Assistance

A person or organization (on staff or through contract) should be
designated as the health department resource for technical assistance (TA)
to CBOs.

Types of technical assistance should include the following:

  - Assessing current and projected needs for HIV/STD prevention and early
    medical intervention.

  - Developing strategies for meeting identified needs.

  - Developing strategies for overcoming barriers to prevention. 

  - Planning, implementing, and evaluating prevention programs.

  - Providing program management.

  - Establishing a protocol for active monitoring and quality assurance
    (QA) of CBO activities.

As previously stated, linkages and coordination among organizations
providing HIV/STD prevention activities are essential.  This is
particularly important among funded CBOs and health departments to avoid
gaps in services and duplication of services.  The HIV prevention community
planning process plays a major role in assessing needs and identifying
overlapping services.  

In addition to contracting with CBOs, many health departments have 
full-time staff whose primary responsibility is to provide health education
and risk reduction services to affected populations.  The criteria outlined
in these Guidelines apply consistently to services provided directly by
health department staff as well as those provided through a contract with a
community-based organization.  


Note: For further reading on collaborations and partnerships see Chapters
1-3, "Handbook for HIV Prevention Community Planning," Academy for
Educational Development, April 1994.  For further reading on contracting
with CBOs, see Cooperative Agreements for Human Immunodeficiency Virus
(HIV) Prevention Projects Program Announcement and Notice of Availability
of Funds for Fiscal Year 1993.



This page last reviewed: Monday, February 01, 2016
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