Developing Approaches to Reduce the Risk of HIV/AIDS Infection in Farmworkers

1. Developing Approaches to Reduce the Risk of HIV/AIDS Infection in Farmworkers Ricky Wascher-Tavares Border Health Foundation Kattrina Hancy, MPH Farmworker Justice Midwest Stream Farmworker Health Forum November, 2010

2. Learning Objectives • List three risk factors that increase farmworkers’ risk of HIV infection • Name at least two community or group level HIV prevention programs • Summarize the steps needed to effectively adapt an evidence based intervention to address the needs of migrant farmworkers • Identify technical assistance resources

3. HIV/AIDS and Farmworkers

4. HIV/AIDS and Latinos • Hispanic/Latinos are disproportionately impacted by the HIV/AIDS epidemic • 16% of the U.S. population • 18% of people living with HIV • 17% of all new infections • Rate of new HIV infections among Latino men is more that double that of white men • Rate of new HIV infections among Latina women is nearly four times that of white women. • Farmworkers are likely to have a similar profile

5. HIV/AIDS and Farmworkers • Seroprevalence rate of HIV/AIDS in farmworker communities is unknown. • The vast majority of the epidemiological data on HIV prevalence among farmworkers is based on small, local studies, the majority done more than a decade ago. • In 1992, the Centers for Disease Control and Prevention found a prevalence rate of 5% among 310 farmworkers tested in Immokalee, FL. • A few other small studies have reported rates ranging from 0.47% to 13%.

6. HIV Risk Among Farmworkers Their Circumstances Their Actions • Socioeconomically marginalized • Low wages, poverty, poor housing, lack of health insurance • Separated families • Social and geographic isolation • No or weak social support • Limited education and English/Spanish language proficiency • Lack of easy access to culturally competent health services • Immigration status • Sex with commercial sex workers • Unprotected sex with regular female partners • Multiple sex partners • Frequent alcohol use

7. Community-Level Interventions • Group-level Interventions • Group-level interventions seek to change individual behavior within the context of a group setting. • Community-level Interventions • Community-level interventions seek to change attitudes, norms, and values of an entire community/target population as well as social and environmental context of risk behaviors of the target population/community.

8. Adaptation Making Evidence-Based Interventions Work for Migrant Farmworkers

9. Key Definitions • Core Elements • Key Characteristics • Internal Logic • Re-Invention • Risk Factors • Risk Behaviors • Adaptation

10. Adaptation The modification of an intervention without competing with or contradicting its core elements or internal logic. The intervention is modified to fit the: • Cultural context in which it will be implemented • Individual determinants of risk behaviors of the target population • Circumstances of the agency and other stakeholders

11. Adaptation Adaptation may involve modifications in: • Who receives the intervention • Where it is delivered • When it is delivered • What is addressed • How the message is presented

12. The Steps (MAP) • Assess the target population, the evidence-based intervention being considered and the capacity of the implementing agency • Select the intervention that will work best for the target population and for the agency • Prepare the intervention for the new population and prepare the agency • Pilot the adapted version of the intervention • Implement the adapted intervention with fidelity Map of the Adaptation Process (MAP ) (McKleroy et al. 2006)

13. Assess • Knowing your target population (e.g., formative research - needs assessments, focus groups, stakeholder interviews, etc.) • Knowing proposed evidence-based intervention (e.g., intent, internal logic model, original population, etc.) • Considerations for agency (staff capacity, produce culturally sensitive material, develop role model stories, apply condoms, etc.) • Checking if the evidence-based intervention will work (goodness of fit chart) • Stakeholder buy-in

14. Select Make a Decision: • Decide to adopt, adapt, or select another intervention • Build capacity with subject matter and implementation skills • Consult with the community regarding the decision • Consult with staff regarding the decision

15. Select Once these decisions have been made, the agency should begin the process of seeking to increase their capacity in areas noted in the “goodness of fit chart” chart and during the assess step were they are weak and to further increase their skills with regards to the intervention

16. Prepare • Make necessary changes to the evidence-based intervention • Begin organizational preparation • Pre-Test • Adjusting the intervention

17. Prepare Things to Consider • Culture and Language • Communication • Twin Cs of Adaptation: • Competitive – if even one Core Element was compromised: STOP • Consistent – if Core elements are maintained, then all systems are GO • Logic Model Development

18. Pilot Create an Implementation Plan • Target population • Risk factors • Behavioral determinants • Risk behaviors • Core elements • Key activities • Anticipated immediate outcomes • Anticipated long-term outcomes • Schedule of Evaluation/Monitoring activities • Program’s goals • Program’s objectives • Who is responsible for what • Detailed timeline

19. Pilot Create an Evaluation Plan • Process monitoring (e.g. characteristics of population served, services provided and resources used) • Process evaluation (e.g. how the intervention was delivered, differences between the intended population and the population served, and access to the intervention) • Outcome monitoring (e.g. client outcomes before and after the intervention, such as knowledge, attitude, skills or behaviors)

20. Pilot • Make sure agency is ready • Implement intervention on a small scale with subgroups to assess adaptability, usefulness and fidelity • Each core element • Entire intervention • What do you want out of your pilot test?

21. Pilot Components of a successful pilot include: • Fidelity to core elements and internal logic of the adapted intervention • Some movement toward intermediate outcomes (intentions) • Staff implementation with quality • Participation and positive feedback from participants

22. Implement • Collect process measures on adapted intervention implementation • Conduct process monitoring and evaluation on adapted intervention implementation • Collect intervention outcome measures • Conduct outcome monitoring and evaluation • Provide routine, ongoing supervision (including quality assurance) • Make small changes as needed to staff and intervention based on process evaluation findings • Use available technical assistance

23. Group Level Interventions Safety Counts Voices/Voces

24. Safety Counts Safety Counts is: An HIV prevention intervention for out-of-treatment active injection and non-injection drug users aimed at reducing both high-risk drug use and sexual behaviors The core elements are: Group sessions 1 and 2; social events (min 2); individual counseling session (min 1); follow up contacts (min 2); counseling and testing

25. Safety Counts Program Enrollment Interview Post-Program Interview Month 1 Months 2, 3, 4 Group Session One Group Session Two Individual Counsel. Session Follow-Up Contact One Follow-Up Contact Two Social Event One Social Event Two HIV/STD Counseling and Testing Services

26. Safety Counts WHO – Drug users (within past 90 days), adults, not in treatment WHERE - Office (training room), community center, etc. WHEN - 4 months (time of day depends on clients) WHAT – HIV and viral hepatitis, risk reduction HOW – Risk reduction success stories (audio, video, written)

27. Safety Counts

28. VOICES/VOCES VOICES/VOCES is: A single-session, video-based HIV/STD prevention workshop designed to encourage condom use and improve condom negotiation skills among African-American and Latino adults. The core elements are: Viewing of culturally-specific videos; small-group skill-building sessions; condom feature education; distribution of sample condoms

29. VOICES/VOCES • WHO – Heterosexual African-American and Latino men and women • WHERE - Office (training room), community center, etc. • WHEN – 45 minutes (time of day depends on clients) • WHAT – Condom education and negotiation skills • HOW – Group discussion, condom board, culturally relevant video

30. VOICES/VOCES BHF Adaptation: • WHO – migrant farmworkers (men and women) • WHERE - Migrant housing unit • WHEN – 60 minutes/evenings • WHAT – Condom education, negotiation skills, HIV/STD information • HOW – Group discussion, condom board, culturally relevant video

31. Community Level Interventions Promotores de Salud Popular Opinion Leader

32. Roots of Promotores Programs • Community health worker/Promotores de Salud model is used widely in Mexico and other parts of Latin America, in areas where doctors are in short supply. • Borrows from popular education theories which encourage teaching adults by drawing on their life experiences in order to empower them to solve their own problems. • Many migrant farmworkers who come to the U.S. from Mexico and Central America are familiar with the Promotores model.

33. Need for Promotores Promotores de Salud can play a critical role: • Bringing underserved populations important health messages and information about available health services • Connecting people to health care who have not had ready access to or felt comfortable utilizing health care services • Increasing the availability of culturally and linguistically competent health services

34. Activity: La Mano 5 things I know about promotores

35. Characteristics of Promotores Promotores… • Are usually drawn from the target population, sharing the same language, culture and customs as those they are willing to reach • Are often willing to work evenings or weekend hours • Can reach out to community members wherever they are located and they normally gather • Are trained to communicate health specific messages in a manner the target community can understand • Readily develop relationships of trust with the community.

36. Development of a PdS Program • Planning • Formative research • Materials development • Field testing • Evaluation and follow-up

37. Development Process • Planning: Identifying areas of interest/need in the community, and assess agency resources • Formative Research: Literature review, focus group discussions, in-depth interviews • Materials Development: Use formative research findings to develop materials for use by promotores. Pre-test the materials with community members, and modify materials based on feedback.

38. Implementation and Evaluation Process • Fielding Testing: Capacity building with promotores de salud to implement project, monitor and provide support. • Evaluation and Follow-up: Develop evaluation tools at the beginning of process, train promotores on the importance of evaluation and how to implement the tool with the community, and disseminate evaluation findings.

39. Promotores Program Materials • Training curriculum • Manual for Promotores • Materials to distribute • Evaluation materials

40. Popular Opinion Leader (POL) • An effective behavioral intervention currently being promoted in the CDC DEBI project • Originally implemented with gay men in Mississippi in the 1980s • How it works: Friends influence friends to instill a risk reduction norm among themselves • Has been widely adapted with new target populations, including with farmworkers

41. Young Latino Promotores Project (YLP) • Based on POL intervention • YLP targeted young, migrant, Latino Men Who Have Sex With Men (MSM) • Incorporated concepts from the promotores de salud model • Took place in Vista, CA and McAllen, TX • Vista Community Clinic and Valley AIDS Council were Farmworker Justice’s local partners

42. Considerations for Adapting POL for Migrant Latino MSM • Project Staff • Language and Literacy • HIV Knowledge • Sexual Orientation • Other Considerations

43. Project Staff and Volunteers • Familiar with local Latino issues and norms • Comfort working with migrant community • Bilingual in Spanish and English • Latino MSM served as project coordinators

44. Adaptation: Language and Literacy • Surveys in Spanish and English • POL training sessions and materials in English and Spanish • Activities and lessons were designed to accommodate people with low literacy skills • Focused on communication skills with Latino audiences and changed role play situations • Presented underlying theory briefly and in simple terms

45. Adaptation: HIV Knowledge • Community discovery process revealed low HIV knowledge, requiring certain curriculum modifications: • Expanded module on HIV • Addressed prevailing and persistent myths about HIV in the community

46. Adaptation: Sexual Identity • Added session on sexual identity and sexual orientation • Addressed stigma and discrimination associated with behaviors • Sexual • Communicative • Adapted module on sexual health • More information on other STIs

47. Young Latino Promotores Project • Initial community surveys showed that more than 60% of the target group engaged in unprotected sex • Results after 2 and 3 years: • Increases in frequency of condom use in receptive anal sex • Myths about HIV transmission were reduced

48. Capacity Building Assistance What is Capacity Building Assistance Technical Assistance Contact Us!

49. What is Capacity Building Assistance A way of providing organizations with additional skills, training, or technical assistance to enable them to improve delivery of services. Capacity Building Assistance (CBA) is available free to any organization interested in implementing an evidence-based HIV prevention program or promotores de salud program, who would like additional help getting that program off the ground.

50. Technical Assistance • AIDS Education and Training Centers • Centers across the country with specialists for rural providers • Prevention Training Centers • Regional centers in Berkeley, CA; Rochester, NY; Denver, CO; and Dallas, TX. • CDC Capacity Building Branch • Funds CBA providers nationwide to help organizations develop, implement, and evaluate effective HIV prevention programs • Farmworker Justice and Border Health Foundation are organizations funded by CDC to provide CBA