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Guidelines for Health Education and Risk Reduction Activities
April 1995 Centers for Disease Control and Prevention Atlanta, Georgia ***************************************************************************** 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.
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