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- HIV/AIDS Guidelines and Recommendations at http://www.cdc.gov/hiv/guidelines/index.html
Guidelines for Health Education and Risk Reduction Activities
April 1995 Centers for Disease Control and Prevention Atlanta, Georgia ***************************************************************************** HEALTH EDUCATION AND RISK REDUCTION ACTIVITIES Individual and Group Interventions Health education and risk reduction activities are targeted to reach persons at increased risk of becoming infected with HIV or, if already infected, of transmitting the virus to others. The goal of health education and risk reduction programs is to reduce the risk of these events occurring. Activities should be directed to persons whose behaviors or personal circumstances place them at risk. Street and community outreach, risk reduction counseling, prevention case management, and community-level intervention have been identified as successful health education and risk reduction activities. Street and Community Outreach Street and community outreach can be described as an activity conducted outside a more traditional, institutional health care setting for the purposes of providing direct health education and risk reduction services or referrals. However, before conducting any outreach activity in a community, an agency must define the specific population to be served and determine their general needs. Based on this definition and determination, an agency can then decide appropriately where to conduct intervention efforts. Street and community outreach may be conducted anywhere from a street corner to a pool hall, from a parish hall to a school room. To determine the setting, an agency need only decide that the setting is easily, readily, and regularly accessed by the designated client population. Outreach demonstrates an agency's willingness to go to the community rather than wait for the community to come to it. Often, agencies enlist and train peer educators to conduct the outreach activities. It is recommended that the content of the outreach activity be contingent upon the setting. The nature of activity varies in scope and intensity; the activity is best determined before an outreach team or individual educator goes out. Yet, flexibility is also very important. Remember, everything is not appropriate everywhere, all of the time. A street corner may be an appropriate place to conduct a brief HIV risk assessment, but it is not an appropriate place to conduct HIV counseling and testing. While street and community outreach can be complementary service components of a single agency, some agencies, based on needs assessment findings and staff capacity, may choose to provide one service and not the other. Street outreach and community outreach can also be "stand alone" pieces. Street Outreach Street outreach commonly involves outreach specialists moving throughout a particular neighborhood or community to deliver risk reduction information and materials. The outreach specialist may set up an HIV/AIDS information table on a street corner. They may supply bleach to injecting drug users at shooting galleries and condoms to commercial sex workers and their customers at the hotels or locations that they frequent. The fundamental principle of street outreach is that the outreach specialist establishes face-to-face contact with the client to provide HIV/AIDS risk reduction information and services. Effective street outreach staff: - Know the target group's language. - Have basic training and experience in health education. - Are sensitive to community norms, values, cultural beliefs, and traditions. - Have a shared identity with the population served, stemming from shared common personal experiences with the group. - Are trusted by the group they serve. - Act as role models to the clients they serve. - Advocate for the population served. - Act as liaisons between the community and the agency. - Are informed about community resources and use them. Street outreach is not simply moving standard agency operations out onto the sidewalk. A number of specific issues are unique to the delivery of services through this type of outreach and must be considered before instituting a program of street outreach. These matters are usually addressed in an agency's street outreach program plan and include the following: - Regular contact among educators, outreach specialists, and supervisors. - Observation of potential outreach areas to determine the locations, times of day, and the day of the week that are most productive for reaching the population to be served. - A written and comprehensive field safety protocol that is regularly updated. (See Figure 1 Table_Fig1.) - Establishment of and adherence to regular and consistent schedules of activities, including times and locations. (See Figure 2 Table_Fig2.) - A mechanism for measuring the use of referral services. - Creation and maintenance of a positive relationship between the agency and the local law enforcement authorities. - Identification and development of collaborative relationships with gatekeepers (key informants) in the community. - Activities for building and earning the trust and respect of the community. - Descriptions of skills-building exercises relevant to stated program objectives. - Establishment of mechanisms for maintaining client confidentiality. Community Outreach: Workshops and Presentations Workshops and presentations are typical activities of community outreach. Because they usually follow lecture formats, they can be highly structured health education and risk reduction intervention efforts. While they supply important opportunities to disseminate HIV/AIDS prevention information, their impact on behavior change is limited because they are usually single-encounter experiences. Although they provide crucial technical information that raises awareness and increases knowledge and may be a critical first step in the change process, the information alone is usually inadequate to sustain behavior change. To maximize their benefit, workshops and presentations should be planned carefully with knowledge goals and objectives specified before the individual sessions. To the extent possible, presenters should be informed about the setting where the workshop or presentation will take place, as well as the composition and knowledge level of the anticipated audience. The following are examples of issues the presenter might consider before conducting a presentation or workshop: - Where will the workshop or presentation be held? - What is the age range of the participants/audience? - What is the language(s) of the participants/audience? - What audiovisual equipment is available? A well-planned, detailed outline, which allows flexibility, can prove useful and beneficial to the presenter and the participants/audience. Such an outline helps keep the presentation on track and focused. If a pretest evaluation is to be used, an outline can ensure that all relevant material will be covered in the lecture. In a workshop or presentation, audience participation is to be strongly encouraged. Time must be allotted, usually at the end of the presentation, for a question and answer session. However, some questions may be so pressing, or some participants so persistent, that the presenter will have to address some questions and concerns during the presentation. The presenter should answer the questions succinctly and return to the original order of the presentation. To increase the number of workshops and presentations they are able to provide, some agencies will elect to develop speaker's bureaus to augment their paid staff. Recruitment, training, and retention of volunteers present complex programmatic questions and are not to be undertaken lightly. Several references related to volunteers are provided at the end of this document and should be reviewed carefully. A more detailed list of important points to consider for workshops and presentations is contained in Appendix C. The points below are relevant to agencies providing workshops and presentations either by paid staff or by volunteers in a speaker's bureaus. Effective presenters: - Possess organizational and public speaking skills. - Are well informed and comfortable talking about the subject. - Ensure that the presentation is linguistically appropriate for the audience. - Elicit and encourage audience participation. - Are adaptable to logistics and audience needs. - Are non-judgmental. - Assess the nature of questions to make appropriate responses, i.e., whether better answered in private. - Seek accurate answers to difficult questions and provide information in a timely manner. A few items specifically needed in a Community Outreach Program Plan are listed below. - A comprehensive workshop/presentation curriculum. (See Appendix C.) - Assurance that curricula provide for discussion of related issues. - Detailed workshop/presentation outlines. - Logistical guidance for workshops/presentations (e.g., time and location, room arrangement, number of participants, number of facilitators). - Methods to assure that the audience is informed about workshop/ presentation goals and objectives and that discussion of subject matter is facilitated. - Descriptions of skills-building exercises relevant to stated program objectives. - Training in the operation of audiovisual equipment and the use of diverse forms of audiovisual equipment. - Recruitment of staff with organizational and public speaking skills. Peer Educators Agencies that provide street and community outreach will frequently engage peer educators to conduct intervention activities. Peer education implies a role-model method of education in which trained, self-identified members of the client population provide HIV/AIDS education to their behavioral peers. This method provides an opportunity for individuals to perceive themselves as empowered by helping persons in their communities and social networks, thus supporting their own health enhancing practices. At the same time, the use of peer educators sustains intervention efforts in the community long after the professional service providers are gone. Effective peer educators: - Have a shared identity with the targeted community or group. - Are within the same age range as the targeted community or group. - Speak the same "language" as the community or group. - Are familiar with the group's cultural nuances and are able to convey these norms and values to the agency. - Act as an advocate, serving as a liaison between the agency and the targeted community or group. Peer education can be very powerful, if it is applied appropriately. The peer educator not only teaches a desired risk reduction practice but s/he also models it. Peer educators demonstrate behaviors that can influence the community norms in order to promote HIV/AIDS risk reduction within their networks. They are better able to inspire and encourage their peers to adopt health seeking behaviors because they are able to share common weaknesses, strengths, and experiences. Agencies often recruit and train peer educators from among their client populations. However, not everyone is an educator. The model client does not necessarily make the model teacher, no matter how consistently s/he practices HIV/AIDS risk reduction or is liked by agency staff. Peer educators should be instinctive communicators. They should be empathetic and non-judgmental. They should also be committed to client confidentiality. Peer educators will not replace an agency's professional health educators, but they can complement the intervention team and enhance intervention efforts. Peer educators may act as support group leaders or street outreach volunteers who distribute materials to friends. They may be members of an agency's speaker's bureau and give workshop presentations. They may run shooting galleries, keeping bleach and clean water readily available to other (IDUs). They may be at-risk adolescents who model responsible sexual behaviors. The role of the peer educator is determined by the intervention need of the client population and the skill of the peer educator. Although some agencies will hire peer educators as paid staff, others will not. As in the case of speaker's bureaus, engaging volunteer peer educators also involves issues of volunteer recruitment, training, and retention. Several references in the list of publications included at the end of this document provide more information on this issue. In addition to the core elements identified for health education and risk reduction activities, an effective peer education program plan contains the following: - A written and comprehensive field safety protocol. (See Figure 1 Table_Fig1.) - Establishment of and adherence to regular and consistent schedules of activities, including times and locations. (See Figure 2 Table_Fig1.) - A description of skills-building exercises relevant to the stated program objectives. Risk Reduction Counseling The purpose of risk reduction counseling is to provide counseling and health education interventions to persons who are at high risk for HIV infection. The interventions promote and reinforce safe behavior. The participants may range from a single individual to couples, families, groups, or entire communities. Risk reduction counseling is interactive. Such counseling assists clients in building the skills and abilities to implement behavior change. These programs offer training in the interpersonal skills needed to negotiate and sustain appropriate behavior changes. For example, sessions could concentrate on delaying the initiation of sexual activity, on methods for avoiding unsafe sex and negotiating safer sex, and on techniques to avoid sharing injecting drug paraphernalia. Risk reduction may be implemented in a variety of formats. The interventions may take the form of role plays, safer sex games, small group discussion, individual counseling, or group counseling. Effective risk reduction counseling sessions: - Emphasize confidentiality. - Begin with an assessment of the specific HIV/STD prevention needs of the client(s). - Identify, with the group or individual, the appropriate goals/ objectives (e.g., condom use negotiation skills for female sex partners of IDUs). - Use skills-building exercises designed to meet the specific needs of the client(s). - Include negotiations with the client(s) on suggestions and recommendations for changing and sustaining behavior change as appropriate to their situation. - Enable/motivate participants to initiate/maintain behavior change independently. - Enhance abilities of the participant(s) to access appropriate services (e.g., referrals to drug treatment). Risk Reduction Program Plans An effective risk reduction program plan includes the following: - Protocols and procedures specific to each activity and logistical check lists for implementation. - Development of innovative behavior modification strategies. - Provision for regular updates in techniques for skills building. - Provisions for updates on client-focused approaches to risk reduction activities. - Provision for updates in techniques for increasing facilitators' skills in managing group or one-on-one dynamics. Conducting Groups Groups can provide significant informational and therapeutic HIV risk reduction interventions to individuals who are ready to initiate and/or maintain specific health promoting behaviors. Groups are usually formed around common issues or problems. Some groups, originally established to provide information and skills training, may evolve into support groups, which encourage maintenance of newly acquired behaviors. Utilizing groups suggests a systems approach to intervention. Groups provide access to social networks that enable and reinforce health enhancing behavior change through peer modeling and peer support. Although open-ended groups (e.g., support groups) may have less structure than the more close-ended kinds of groups (e.g., educational or skills-building), both types should have clearly defined goals/objectives and specifically defined processes. The structure of a group should be determined based upon the needs of the members. At times, the open-ended group with its open enrollment and extended life is more suited to members' needs. By being open-ended, potential members are able to drop in when they need to and thus avoid the wait for new groups to form. This type of group is likely to appeal to the individual whose commitment to the group's process is initially limited. In the open-ended group, members determine their own topic of discussion at each meeting. For this reason, an open-ended model, that encourages drop-ins, is perhaps less amenable to instructional sessions which usually need to build on information presented at earlier meetings. The open model, because of its unpredictable structure and enrollment, may be more amenable to process evaluation (i.e., percentage of agency's clients attending a determined number of sessions). The close-ended model will have a defined lifespan and is also likely to set membership limits. The closed group allows for important continuity and facilitating the development of trust among members, as they get to know each other over time. Members can expect the same individuals to be present each week, which can aid in building significant, supportive relationships. The closed group model is more suitable to the establishment of client-specific outcome objectives that can be monitored over time (i.e., self-reported reduction in number of sex partners at the end of 8 weeks of group attendance). There are significant advantages to both open and closed models, and determination of which model to employ is based on the needs of an agency's clients and on an agency's capacity to implement the model. Whatever the model selected, the size of the group is an important consideration. Group facilitation is not crowd control. Smaller groups can be more manageable and result in enhanced group dynamics. Group facilitators or instructors may be peers or professionals; in some instances, they may be both. They should be skilled at promoting effective group dynamics, encouraging reticent members to speak up and guiding the dominant ones. Skilled facilitators and instructors are astute observers. They not only listen to what is being said, but they also note nonverbal cues. Good observation skills are especially critical for support or therapeutic group facilitators. Skilled facilitators and instructors are able to see changes in body language, hear sighs, and catch subtle changes in facial expressions. Groups are a naturally occurring phenomenon. People come together for a variety of reasons and left to themselves, they will develop informal but powerful supportive networks. Proactive HIV risk reduction programs can tap into this resource and enhance program effectiveness. HIV Prevention Case Management HIV Prevention Case Management (PCM) is a one-on-one client service designed to assist both uninfected persons and those living with HIV. PCM provides intensive, individualized support and prevention counseling to assist persons to remain seronegative or to reduce the risk for HIV transmission to others by those who are seropositive. PCM is intended for persons who are having or who are likely to have difficulty initiating and sustaining safer behavior. The client's participation is always voluntary, and services are provided with the client's informed consent. Prevention Case Management involves the assessment of HIV risk behavior and the assessment of other psychosocial and health service needs in order to provide risk reduction counseling and to assure psychosocial and medical referrals, such as housing, drug treatment, and other health and social services. PCM provides an ongoing, sustained relationship with the client in order to assure multiple-session HIV risk reduction counseling and access to service referrals. PCM should not duplicate Ryan White CARE Act case management services for persons living with HIV. Case managers work with clients to assess their HIV risk and psychosocial and medical needs, develop a plan for meeting those needs, facilitate the implementation of the PCM plan through referral and follow-up, provide ongoing HIV risk-reduction counseling, and advocate on behalf of the client to obtain services. HIV Prevention Case Management creates bridges to assist clients in obtaining services with which they are unfamiliar or that pose special barriers to access. Clients are active participants in developing their PCM plan for risk reduction. Prevention Case Management may be carried out in a variety of settings, including the client's home, a community-based organization's office or storefront, clinics, or institutional settings. Referral services may include HIV counseling and testing services (CT), psychosocial assessment and care, other HIV health education and risk reduction programs, medical evaluation and treatment, legal assistance, substance abuse treatment, crisis intervention, and housing and food assistance. Additionally, HIV PCM services should assist the client in obtaining STD prevention and treatment services, women's health services, TB testing and treatment, and other primary health care services. A strong relationship with STD clinics, TB testing sites, HIV counseling and testing clinics, and other health service agencies may be extremely beneficial to successfully recruiting persons at high risk who are appropriate for this type of intervention. PCM services are not intended as substitutes for medical case management, extended social services, or long-term psychological care. The case manager needs a thorough knowledge of available community social and medical services as well as HIV prevention, treatment, and related services. This includes specific knowledge of the scope of services available, the protocol for accessing these services, and contact persons working with local agencies. Case managers are usually skilled in providing individual or couples' HIV risk-reduction counseling on an ongoing basis. Case managers usually have an academic background or special training in psychosocial assessment and counseling (e.g., social work, drug and alcohol treatment counseling, nursing, health education). Prevention Case Management supervisors need the academic training and/or experience to adequately develop PCM protocols, case documentation, and policies. The following provides further information on counseling and testing issues: HIV Counseling, Testing, and Referral: Standards and Guidelines, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, May 1994. Staff Characteristics of the Prevention Case Manager Effective case managers are: - Non-judgmental in addressing the needs of the client. - Empathetic and critical listeners. - Skilled in dispute mediation. - Skilled in individual and relationship counseling. - Skilled in conducting a thorough behavioral risk assessment and psychosocial assessment at client intake and skilled in developing an individualized case plan. - Comfortable working in the home environments of their clients as well as in street settings, if necessary. - Continually concerned about the protection of the client's rights, including confidentiality, and always respectful of guidelines in the agency protocol document. - Sensitive to the client's ability to read literature and comprehend oral presentations. - Responsive to the financial resources of clients in regard to case planning and referrals. Additionally, case managers: - Maintain communication with case managers from other agencies working with the client to assure a coordinated treatment plan. - Identify resources and services for the client and assist them in accessing service needs. - Take into account and provide for cognitive impairments that may be related to the health status of the client. - Reinforce behavioral change accomplished by the client at all opportunities. - Troubleshoot episodes of client's unsafe behavior and relapse to identify barriers to practicing safer behavior and provide support and skills-building counseling. - Establish a rapport with clients and maintain open communication with them and their partner(s). - Act as an advocate in gaining access to services for clients. Characteristics of the Prevention Case Management Program Plan: - Includes specific, measurable, realistic, and time-phased program objectives. - Assures that all services in the plan conform to agency policies and local, state, and Federal laws (for example, confidentiality of information). - Assures the development of a written, formal PCM protocol for service delivery. - Provides for the development of specific, measurable, realistic, and time-phased objectives in each client's case plan. - Provides for regular meetings with each client to assess changing needs, monitor progress, and revise the service plan accordingly. - Assures that each case manager negotiates a risk reduction plan with the client, referring to the plan at each session in order to assess progress. - Assures the development and use of a comprehensive HIV risk assessment instrument to assess the behavioral variables influencing the client's risk taking. - Assures the development and use of a comprehensive psychosocial assessment instrument to assess psychosocial and medical service needs of the client as well as financial resources, language preferences, barriers to accessing these services, etc. - Assures that prevention case managers and their supervisors meet frequently for case presentations and supervision. - Defines collaboration with other local service providers through memoranda of agreement and regular meetings between agencies to facilitate access to other social and health services as well as to discuss and coordinate treatment plans for individual clients. - Assures that the memoranda of understanding among agencies are periodically updated, accurately reflecting collaborative activities. - Assures that the assessment of progress in meeting the case plan is communicated to the client for review and comment. - Assures that case records include documentation that acknowledges voluntary client participation and mutually satisfactory case plans. - Assures that an updated written or computerized database of service referrals and a system for documenting successful referrals are maintained. - Assures that regularly scheduled staff meetings are held to discuss challenges, successes, and barriers encountered by case managers; adequate time must be allocated for staff to share concerns, frustrations, grief, and other emotions experienced through the close work with persons at risk or with persons living with HIV. PCM staff training plans usually include the following: - Staff training in established PCM protocols, agency policies, and referral mechanisms. - Periodic training addressing the local services available for client referral. - Skills training to improve the HIV risk reduction counseling provided to clients. - Training that addresses how to effectively intervene with clients who are in extreme states, such as persons who are combative, in emotional crisis, mentally ill, or under the influence of drugs and/or alcohol. Community Level Intervention Community Level Intervention combines community organization and social marketing -- a strategy that takes a systems approach. Its foundation is an assumption that individuals make up large and small social networks or systems. Within these social networks or systems, individuals acquire information, form attitudes, and develop beliefs. Also, within these networks, individuals acquire skills and practice behaviors. The fundamental program goal of Community Level Intervention is to influence specific behaviors by using social networks to consistently deliver HIV risk reduction interventions. Although the intervention strategy is community-based, Community Level Interventions target specific populations -- not simply the community in general. The client populations have identified shared risk behaviors for HIV infection and also may be defined by race, ethnicity, gender, or sexual orientation. In order to influence norms that support HIV risk reduction behavior, Community Level Interventions are directed at the population, rather than at the individual. The primary goal of these interventions is to improve health status by promoting healthy behaviors and changing those factors that negatively affect the health of a community's residents. A specific intervention may take the form of persuasive behavior change messages, or it may be a skills-building effort. Whatever its form, an intervention achieves reduced HIV risk by changing group norms to improve or enhance the quality of health for members of the client population. These norms may relate to condom use, contraceptive use, or needle-sharing. They may also focus on diagnosis and treatment of sexually transmitted diseases or HIV-antibody counseling and testing. It takes time to change social norms. Social norms cannot be changed quickly or at the same rate that knowledge acquisition or skills development can occur. Change occurs as a result of sustained, consistent intervention efforts over time. The intervention must be implemented thoroughly throughout the social networks. A firm grounding in behavioral theory is essential to the development and implementation of Community Level Interventions. Community-based needs assessment is critical to the development and implementation of Community Level Interventions. This phase is important for identifying and describing structural, environmental, behavioral, and psychological facilitators and barriers to HIV risk reduction. To successfully conduct this intervention, a program must identify the sources for and patterns of communication within a social network. Peer networks must be defined and described. Note: Community Level Intervention is referred to as Community Intervention Programs in Program Announcement #300. The following questions should be considered in designing community level interventions: - Who are the gatekeepers to the client population? - What are the important points of access? - What are the appropriate and relevant risk-reduction messages, methods, and materials? - What are the linguistic and literacy needs of the client population? A needs assessment should yield this vital information. For further reading on the developmental steps of Community Level Intervention, see Cooperative Agreement for Human Immunodeficiency Virus (HIV) Prevention Projects Program Announcement and Notice of Availability of Funds for Fiscal Year 1993. A variety of methods exists for collecting the answers to these questions. It is recommended that programs select the method that is most appropriate for their professional orientation (e.g., social work, health education). Whatever method is chosen, it is critical that the formative activity be community-based and as collaborative as possible with the client population. The information gathered during the formative phase provides the foundation on which an effective program can be built. Completing this activity should result in culturally competent, developmentally appropriate, linguistically specific, and sexual-identity-sensitive interventions that promote HIV risk reduction. Members of existing and relevant social networks can be enlisted to deliver the interventions. Other peer networks may also be created and mobilized to provide intervention services. This, of course, means volunteer recruitment and management. Community Level Intervention strategies offer opportunities for peers to acquire skills in HIV risk reduction and, in turn, reinforce these abilities when the peers become the teachers of these same skills to others. In this manner, Community Level Interventions become community-owned and operated; thus, they are more likely to be sustained by the community when the program activity is completed. Social norms changed in this way are likely to have a long-lasting and effective impact upon HIV risk reduction.
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