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Lessons Learned From Field-Testing a Brief Behavioral Intervention Package for African American Women at Risk for HIV/STDs Patricia L. Jones, Jillian L. Baker, Deborah Gelaude, Winifred King and Loretta Jemmott Health Promot Pract 2013 14: 168 DOI: 10.1177/1524839912474276 The online version of this article can be found at: http://hpp.sagepub.com/content/14/2/168

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HPPXXX10.1177/15248 39912474276HEALTH PROMOTION PRACTICE / Month XXXXJones et al. / FIELD-TESTING A BEHAVIORAL INTERVENTION PACKAGE 2013

Health Education in Health Care Settings

Lessons Learned From Field-Testing a Brief Behavioral Intervention Package for African American Women at Risk for HIV/STDs Patricia L. Jones, DrPH, MPH1 Jillian L. Baker, DrPH, EdM2 Deborah Gelaude, MA1 Winifred King, PhD, MPH1 Loretta Jemmott, PhD, RN, FAAN3

This article describes how Sister to Sister, an evidencebased HIV/STD intervention for African American women in clinical settings, was prepared for national dissemination using the Centers for Disease Control and Prevention’s Replicating Effective Programs research translation process. To test the feasibility of the intervention in the “real world,” Sister to Sister’s original research team collaborated with community partners to field-test the intervention in three clinical settings. Experiences from field-testing and input from a community advisory board were used to translate research protocols into a package of user-friendly materials that could be easily adopted by frontline clinic staff throughout the nation. Process monitoring and evaluation data demonstrated that Sister to Sister could be implemented successfully by a variety of practitioners including nurses, health educators, and HIV test counselors. “Buy-in” from clinic administrators and providers was a prerequisite to the success of the intervention. Replicating Effective Programs provided a useful process that can be applied by others to successfully prepare evidence-based interventions such as Sister to Sister for national dissemination.

A

ddressing HIV risk for African American women remains a national priority. In this population, the most common modes of HIV acquisition are

1

National Institutes of Health, Bethesda, MD, USA LaSalle University, School of Nursing & Health Sciences, Philadelphia, PA, USA 3 University of Pennsylvania School of Nursing, Philadelphia, PA, USA 2

Authors’ Note: The authors would like to acknowledge the contributions of Rhondette Jones, MPH, and Susan Shewmaker, RN, MA, in reviewing the training materials. Kathie Nixon, CRNP, Daryn Eikner, MS, Shelley Miller, MS, Lynette Gueits, MS, Marcia Penn, MA, Charlotte Wroton, MA, Cathy Watson, Dr. Marisa Rogers, and Valerie Layden, CRNP, were instrumental in developing and field-testing the package of materials. We would also like to thank the 134 women who graciously agreed to participate in fieldtesting the intervention materials. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. At the time this article was developed, Dr. Patricia L. Jones was employed with the U.S. Centers for Disease Control and Prevention; she is currently employed with the National Institutes of Health.

Keywords: HIV/STD evidence-based interventions; field-testing; implementation science; knowledge translation; African American women; clinic-based prevention interventions

Associate Editors, Health Education in Health Care Settings Department

Health Promotion Practice March 2013 Vol. 14, No. 2 168–173 DOI: 10.1177/1524839912474276 © 2013 Society for Public Health Education

Melissa Gilkey, PhD, is a postdoctoral research associate at the University of North Carolina Lineberger Comprehensive Cancer Center.

Cezanne Garcia, MPH, is a consultant providing health promotion, patient safety and care strategy transformation consultation and is based in Seattle, Washington.

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Health Education in Health Care Settings high-risk heterosexual contact and injection drug use (Centers for Disease Control and Prevention [CDC], 2007), and key prevention-related challenges include lack of awareness of HIV serostatus (for women and for their sexual partners), high rates of substance use, inadequate condom negotiation skills, and inconsistent condom use (CDC, 2010). To address these challenges, behavioral interventions are needed within venues such as primary care settings, where it is possible to reach a wide range of women, including those who may not actively seek HIV-/sexually transmitted disease (STD)–specific services. Given the constraints of the clinical encounter, such interventions must be brief. However, despite time limitations, research shows that effective HIV prevention interventions can be successfully integrated into existing clinic services (Exner et al., 2011) and HIV care and treatment (Myers et al., 2010; Richardson et al., 2004). A critical prevention activity for those working to stymie the HIV/AIDS epidemic in African American women is translating these evidence-based interventions into user-friendly prevention materials that can be readily disseminated for widespread adoption in practice settings. Over the past decade, the CDC has applied a threestep research-to-practice model for identifying, packaging, and disseminating evidence-based behavioral interventions for use by state and local health departments, community-based organizations, and other frontline HIV prevention providers (Galbraith et al., 2011). First, the Prevention Research Synthesis project identifies and synthesizes HIV/STD interventions proven to be effective through rigorous evaluation. Next, the Replicating Effective Programs (REP) project translates protocols and marketing materials used in the original trials into user-friendly materials for dissemination. Last, the Diffusion of Effective Behavioral Interventions project uses materials developed by the REP to help train the HIV prevention workforce in how to deliver evidence-based interventions most effectively (Eke, Neumann, Wilkes, & Jones, 2006). This article focuses on REP, the second stage of the research-to-practice model, which will be explored using a case study of the Sister to Sister intervention.

SISTER TO SISTER >>

AND THE REP PROJECT

Sister to Sister: Respect Yourself, Protect Yourself, Because You Are Worth It (known as Sister to Sister) is a 20- to 30-minute, one-on-one behavioral intervention for HIV/STD prevention. The intervention was devel-

oped specifically for urban African American women 18 to 45 years old attending primary care clinics (Jemmott, Jemmott, & O’Leary, 2007). Using culturally and gender-appropriate posters, videos, and local HIV/ AIDS statistics, Sister to Sister personalizes HIV/STD risk and teaches women how to correctly use condoms and negotiate condom use with sexual partners. One defining goal of Sister to Sister is instilling in women the confidence and enthusiasm needed to protect themselves from HIV/STD transmission. To do this, Sister to Sister reframes commonly held beliefs about condom use (e.g., that a condom interferes with sexual pleasure) and reinforces knowledge that condoms prevent HIV/STDs. Concepts of self-respect, family and community responsibility, and self-efficacy are reinforced throughout the intervention. For example women use mirrors to affirm their self-worth, value, and commitment to safer sex, and facilitators demonstrate that they care about the women through an intimate conversational and nonjudgmental style, which is echoed in the intervention motto: “Respect Yourself! Protect Yourself! Because You Are Worth It!” Intervention activities also promote skills acquisition. For example, women practice correctly applying a condom and learn negotiation techniques for using condoms with resistant partners. Through demonstration and role play, facilitators model the relevant skills for the participant before asking her to do them herself. A take-home brochure is provided to the participant that is both a reference tool and a conversation starter for women to use with their sexual partners. Evidence for Sister to Sister comes from a randomized controlled trial, which assessed the efficacy of a brief, nurse-delivered intervention for inner-city African American women in primary care clinics. At 12-month follow-up, women who participated in this intervention were significantly less likely to test positive for an STD as compared with women in the control group (p = .03). In addition, a marginally significant intervention effect was reported for increasing condom use at most recent sexual intercourse (p = .07; Jemmott et al., 2007). Based on the success of the intervention, the original researcher was funded by the CDC to translate Sister to Sister through the REP Project. The REP process provides steps for developing several interrelated products (Figure 1). The first step in the process involves the development of written and audiovisual intervention materials used for patient education, outreach, or other intervention activities. These materials are then rigorously field-tested in real-world settings by community-based partners known as “case

Jones et al. / FIELD-TESTING A BEHAVIORAL INTERVENTION PACKAGE 169


Establish/convene Community Advisory Board to consult on translating protocol into user-friendly package

Identify original intervention protocols & recruitment materials

Develop Training Curriculum

Pilot/refine Training Curriculum

Conduct Actual Training of Facilitators using translated materials

Refine training materials based on training experience

Field Test complete package of materials in “real world” clinics

Collect process monitoring/evaluation data from each site during field testing phase

Analyze/distill process monitoring/evaluation data and incorporate lessons in final package of materials

Hand-off final package of materials to Capacity Building Branch for national dissemination, training, and support

FIGURE 1 REP Project’s Research Translation Process Flowchart NOTE: REP = Replicating Effective Programs.

study agencies” (Eke et al., 2006). Next, developers use the lessons learned from field-testing to refine these materials and to create a Technical Assistance Guide, which can be used to train clinicians and other prevention specialists in how to properly implement the program. The third step in the REP process involves the development of a Training of Facilitators curriculum, which is used to prepare the national trainers who introduce and teach the intervention to local and regional audiences.

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PREPARING PRODUCTS FOR THE SISTER >> TO SISTER PACKAGE: THE ROLE OF THE COMMUNITY ADVISORY BOARD

One of the first steps in the Sister to Sister REP project involved establishing a community advisory board to guide the translation of original research materials into a user-friendly package that could be shared with practitioners. Sister to Sister’s community advisory board comprised several types of stakeholders,

HEALTH PROMOTION PRACTICE / March 2013


Health Education in Health Care Settings

TABLE 1 Description of Sister to Sister Products Developed Through REP Project Package Materials Implementation manual Facilitator’s guide Training of facilitator’s curriculum Participant’s guide Wall chart Participant education videos Monitoring and evaluation guide Technical assistance guide

Intended Use Provides detailed summary of the science behind the intervention and processes clinics may consider before, during, and after adopting the intervention Step-by-step instructions for implementing the intervention with fidelity An instructional curriculum validated through pilot testing that is used by CDC-funded training agencies to prepare HIV/STD prevention workforce on implementing the intervention with fidelity Local HIV/STD epidemiological data by zip code and local resources Visual aid conveying acronym used for communication skills used to negotiate condom use Video clips illustrating (a) a woman’s personal vulnerability to HIV/STD and (b) and example of a woman initiating condom negotiation An overview of monitoring and evaluation activities relevant to CDC requirements for awardees funded to implement intervention A summary of implementation successes and challenges collected during the field-testing period that can make implementation more efficient

NOTE: REP = Replicating Effective Programs; CDC = Centers for Disease Control and Prevention.

including clinic staff familiar with the target population, nurse training staff familiar with developing curricula for clinic personnel, and research staff familiar with translating scientific information into prevention programs. Drawing from their various areas of expertise, board members met throughout the 2-year project to provide feedback on intervention materials, such as wall charts and patient education videos, as well as on manuals related to implementation and training (Table 1). One of the community advisory board’s most important roles was to help identify Sister to Sister’s “core elements” and “key characteristics.” Core elements is the CDC’s term for critical features of an intervention’s intent and design thought to be responsible for its efficacy; these are features that must be implemented regardless of where the intervention takes place. By contrast, key characteristics are the features of the intervention that can be adapted for different populations or settings without altering the efficacy of the intervention. In the case of Sister to Sister, the community advisory board identified features such as the condom demonstration and the condom negotiation video as core elements, whereas features such as who delivered the program (e.g., nurses vs. health educators) were deemed key characteristics. Such criteria were critical to the subsequent development of imple-

mentation and training manuals. In addition to these conceptual contributions, the community advisory board also provided oversight at a more technical level, giving guidance on topics such as how to update educational videos and even how to design the intervention package to be appealing to end users in terms of color and logo selection.

FIELD-TESTING SISTER TO SISTER IN >>

THE REAL WORLD: THE ROLE OF CASE STUDY AGENCIES

To field-test the Sister to Sister materials, the intervention was implemented in three clinics selected with an eye toward testing the intervention in different settings and with different types of health professionals. In terms of settings, two family planning clinics in Philadelphia, Pennsylvania, and one public health clinic in Baltimore, Maryland, served as case study agencies. At these three sites, five health care providers were identified as facilitators to deliver the intervention, including two health educators, two HIV test counselors, and one nurse. Prior to field-testing, a researcher from the original Sister to Sister study team conducted a 1-day, 8-hour training session with facilitators using a pretested curriculum. Trainers from a community clinic setting assisted in delivering the



training session. Facilitator training is an important part of the REP process because such training helps ensure proper program implementation while at the same time informing the development of training manuals. Once the initial training was complete, the three case study agencies integrated the intervention into their routine clinical practice from October 2007 to January 2008. In a 3-month period, 134 clients, who were screened and determined to be eligible, received the Sister to Sister session, the largest number of sessions conducted during an REP field-testing process at the time the data were reported. Approximately 99% of the clients were African American, 68% were between the ages of 20 to 29 years, and 17% were 19 years old and younger. Ongoing technical assistance provided to the facilitators by the development team enhanced facilitators’ ability to deliver the intervention with confidence and fidelity. During these sessions, facilitators practiced following the script required to effectively conduct a variety of skills-building activities (e.g., role-plays, condom demonstrations, etc.). Facilitators also developed their ability to recruit and communicate with participants as well as to manage time spent with clients and the overall clinic flow. In all, 22 technical assistance sessions were provided via face-to-face meetings and telephone calls. At the end of the fieldtesting period, a technical assistance guide was developed containing all of the information collected from the sessions.

EVALUATING THE SISTER TO SISTER >> FIELD-TESTING PROCESS

The REP process relies on rigorous process evaluation to capture lessons learned during field-testing. For Sister to Sister, process measures included the following: the utility of the training of facilitators curriculum for preparing facilitators and their supervisors, the extent to which facilitators completed intervention activities with fidelity, facilitators’ use of and satisfaction with the intervention materials during the fieldtesting period, any adaptations made to the materials during the field-testing period, and analysis of issues addressed through technical assistance provided during the field-testing process. Process evaluation data were collected from October 2007 and January 2008 through surveys that included both multiple-choice and open-ended questions that were administered to facilitators and their supervisors throughout the implementation process. Completed reports were submitted weekly to the package developers, and a technical

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assistance plan was established based on the information reported. Of particular importance were “adopter forms,” a tool used to capture features of the intervention the facilitators implemented with fidelity to the training manuals. With regard to core elements, the process evaluation found that all five facilitators were able to implement Sister to Sister with fidelity. Of 134 individual sessions evaluated, the majority included each of the key activities outlined by evaluators, and 80% of the sessions included all core elements. Facilitators implemented the following components of the brief intervention— (a) introduction (98%), (b) sex and drug risk assessment tool and videos (90% to 96%), (c) dispelling myths concerning HIV transmission (83%), (d) promoting consistent and correct condom use (82% to 90%), (e) building communication and negotiation skills (72% to 83%), and (f) addressing injection drug use risks (82%)—and summarized key messages and skills (80%). Furthermore, facilitators reported that in 87% of the sessions delivered, they did not add content that was not from Sister to Sister. At the conclusion of the 3-month field-testing period, facilitators were further surveyed to identify key barriers to program implementation. Barriers reported by clinic staff included the following: (a) the challenge of transitioning from a didactic, information-only delivery style to an interactive, skills-building, client-focused approach; (b) the difficulty of delivering the intervention in light of competing demands for patients’ time; and (c) the challenges of communicating with other providers and clinic staff. Respondents noted that technical assistance and experience in delivering the intervention helped them overcome these barriers. To encourage the field-testing clinic sites to continue using the Sister to Sister intervention once REP funding ended, package developers provided each clinic with a final copy of the intervention materials and conducted follow-up meetings with the administrators and facilitators of each clinic site. The meetings were focused on providing technical assistance to address implementation barriers and maximize sustainability. All of the clinics reported interest in continuing to offer the Sister to Sister intervention.

CONCLUSIONS AND LESSONS LEARNED >> FROM TRANSLATING THE SISTER TO SISTER INTERVENTION

By the end of the REP process, project partners had successfully delivered the intervention in three clinics and developed a package of materials to support the implementation of Sister to Sister in clinic settings

HEALTH PROMOTION PRACTICE / March 2013


Health Education in Health Care Settings nationally. Updating the program materials to reflect current fashion, language, and HIV/STD information made the intervention more relevant and easier for clinics to integrate into routine care. At the same time, expanding the type of facilitator to include not only nurses but also health educators and HIV test counselors simulated “real-world” task-shifting decisions likely to be made in clinics. Fortunately, the process evaluation showed that these modifications to key characteristics could be made without compromising intervention fidelity. Several lessons emerged from field-testing the Sister to Sister intervention package that may be applicable to other HIV/STD prevention programs. Most important, identifying and engaging key stakeholders within each agency early in the planning phase for field-testing promoted a strong partnership between the package developers and case study agencies. Case study agencies were screened and selected during the first year and regular in-person meetings and conference calls were convened by the package developers to better understand the unique characteristics each site contributed to the field-testing process. By the time field-testing began in the middle of the second year, the package developers had secured “buy-in” from key stakeholders. Obtaining “buy-in” and input from key clinic personnel throughout the project was critical for effective integration of Sister to Sister in the clinics. Without the support of clinic administrators and first-line managers, clinic staff would likely not have been able to deliver the intervention to the targeted number of clients per day or to complete process evaluation activities. “Buy-in” also allowed administrators to plan ahead for the resource allocation needed to sustain the program. The package developers applied these lessons learned to Sister to Sister’s technical assistance guide as well as to the development of new programs targeting other at-risk groups, such as inner-city adolescent girls. In conclusion, Sister to Sister packaging and fieldtesting efforts demonstrate the value of using REP as a framework for preparing evidence-based interventions for widespread dissemination. Drawing on the expertise of researchers, frontline health care providers, and other community partners, the REP process is designed to identify core components that constitute the heart of

the intervention as well as key characteristics that can be tailored to local audiences. In this way, interventionists can strike a balance between the sometimes competing needs of fidelity and relevance. Because HIV and other STDs continue to disproportionately affect African American women, packaging and disseminating evidence-based prevention interventions such as Sister to Sister is essential for eliminating health disparities, and the REP project provides a model for guiding this important work. REFERENCES Centers for Disease Control and Prevention. (2007). HIV/AIDS fact sheet: HIV/AIDS among women. Retrieved from http://www .cdc.gov/hiv/topics/women/resources/factsheets/women.htm Centers for Disease Control and Prevention. (2010). HIV among African Americans. Retrieved from http://www.cdc.gov/hiv/ topics/aa/ Eke, A. N., Neumann, M. S., Wilkes, A. L., & Jones, P. L. (2006). Preparing effective behavioral interventions to be used by prevention providers: The role of researchers during HIV prevention research trials. AIDS Education and Prevention, 18(4 Suppl. A), 44-58. doi:10.1521/aeap.2006.18.supp.44 Exner, T. M., Mantell, J. E., Hoffman, S., Adams-Skinner, J., Stein, Z. A., & Cheng-Suen, L. (2011). Project REACH: A provider-delivered dual protection intervention for women using family planning services in New York City. AIDS Care, 23,467-475. doi:10.1080/09540121.2010.516335. Galbraith, J., Herbst, J. H., Whittier, D. K., Jones, P. L., Smith, B. D., Uhl, G., & Fisher, H. H. (2011). Taxonomy for strengthening the identification of core elements for evidence-based behavioral interventions for HIV/AIDS prevention. Health Education Research, 26, 872-885. doi:10.1093/her/cyr030 Jemmott, L. S., Jemmott, J. B., III, & O’Leary, A. (2007) Effects on sexual risk behavior and STD rates of brief HIV/STD prevention interventions for African American women in primary care settings. American Journal of Public Health, 97, 1034-1040. doi:10.2105/AJPH.2003.020271 Myers, J. J., Shade, S. B., Rose, C. D., Koester, K., Maiorana, A., Malitz, F. E., & Morin, S. F. (2010). Interventions delivered in clinical settings are effective in reducing risk of HIV transmission among people living with HIV: Results from the Health Resources and Services Administration (HRSA)’s Special Projects of National Significance Initiative. AIDS Behavior, 14, 483-492. doi:10.1007/s10461-010-9679-y Richardson, J. L., Milam, J., McCutchan, A., Stoyanoff, S., Bolan, R., Weiss, J., & Marks, G. (2004). Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: A multi-clinic assessment. AIDS, 18, 1179-1186. doi:10.1097/01.aids.0000125965.01259.5f

