Adapting behavioral interventions is complex
Adapting behavioral interventions is complex
Myriad factors complicate process
HIV-prevention researchers describe many frustrations with the process of adapting community-based intervention work to fit into the mold of one of the available evidence-based HIV interventions.
Increasingly, states are awarding HIV prevention grants only to community-based organizations (CBOs) that base their prevention work on one of the dozen HIV interventions sanctioned by the CDC and included on the Diffusion of Effective Behavioral Interventions (DEBI) list. This has increased demand for strategies in adapting a local organization’s resources, experience, and target population to fit a DEBI, experts say.
However, behavioral scientists say this adaptation is difficult to do well, even when there are ample resources. A variety of factors may impact the translation of an evidenced-based prevention program, but among these are important factors regarding the capacity of the organization that will be using the intervention, says Bart Aoki, PhD, associate director of the Universitywide AIDS Research Program, University of California, Office of the President, in Oakland. According to Aoki, these factors include the following:
- The strength and maturity of the service systems within a specific organization, including how long the CBO has existed and how strong the CBO is in terms of consistency of staffing and having procedures in place for delivering services.
- The overall climate for implementation of innovation within a particular community or organization, such as how open the organization is to change and adopting new ideas, and what incentives and processes are in place to reinforce or support the change.
- The organizational capacity and fitness of an organization to reflect community values, because if what’s developed fits within the values of an organization, it’s more likely to be implemented.
Other problems with translating evidenced-based interventions is that researchers and public health policy-makers do not yet know how much an intervention may be tailored and still remain effective, Aoki says.
Are DEBIs really the future?
Some those working in the trenches of HIV prevention express skepticism that adaptation of DEBIs is the best way to achieve prevention results.
"The fact that DEBI models may have been tested successfully once or twice does not automatically make them the future of HIV prevention as we know it," says Mark Bond-Webster, an outreach worker at Perception Programs in Willimantic, CT. The 35-year-old CBO was one of the few in Connecticut to receive an increase in funding for the implementation of two DEBI programs this year.
"I have a real concern that agencies are going to be funded to do DEBIs without necessarily having the resources and skill sets to implement those DEBIs correctly, so what you’re going to get are poorly-implemented DEBIs to replace the previously effective interventions," he says.
A CDC official acknowledges the challenges CBOs and researchers now face in adapting prevention programs to fit the DEBI list, but he says is to be expected during a transition period.
"When we’re trying to build national capacity to move science into practice, we’re in a catch-up game here," says Charles Collins, PhD, supervisor health scientist and science application team leader with the CDC.
He compares the move from what the work CBOs traditionally have done, which he says was mainly HIV prevention outreach intervention and handing out condoms, to evidence-based interventions, to the theory, described in the 1995 book Diffusion of Innovations, written by Everett Rogers.
Rogers had explained an experiment of trying to convince Western farmers to switch to a new type of corn that would produce better crops, Collins says.
After launching a big diffusion effort to educate farmers, researchers found that in the first year farmers had planted half their field with the new corn and half with the old corn, he explains.
"Now I think there’s a very important message for HIV in that," Collins says. "The message is that CBOs have a role in protecting their communities, and they have a role in making sure these are culturally competent and effective interventions."
Still, in the first few years that they try the evidence-based interventions they will mix old prevention practices with the new prevention practices, just as the farmers mixed old seed corn with new seed corn, he adds.
"So when I hear a CBO is doing the Mpowerment intervention and they’re only doing half of it, instead of thinking they’re 50% noncompliant, I think it’s better to think they are showing 50% trust in us, and they’re willing to try it," Collins says.
Eventually, CBOs will master the new interventions, just as the farmers finally had switched entirely to the new corn, he notes.
However, even when CBOs more fully embrace evidence-based interventions, some significant challenges will remain in order for these to work in very different situations.
"The basic argument advanced is the kind of model that is dominant right now in disseminating prevention programs is problematic in multiple respects," says Robin Lin Miller, PhD, associate professor at Michigan State University in East Lansing.
"One way in which it’s problematic is there is often a real mismatch between what gets designed and tested in these demonstrations and what communities have the capacity to implement," Miller says. "It’s not just the issue of financial costs, there are a whole host of things that go into capacity of the organization to carry out a program, and I think we don’t understand enough about that."
Also, there is a bias in the HIV prevention field that the evidence-based programs are better than what they might replace, and that hasn’t been proven, Miller says.
"While it is the case that CBOs don’t have evidence to support their practice, that isn’t the same thing as saying their practice is of no benefit," Miller explains.
So while there is evidence the DEBIs have been reliable to produce a small effect, investigators have no idea how that effect would compare to a range of programs in a particular community with which they might be evaluated, Miller says.
"There are many cases where the DEBIs might be better, but also there might be cases where they might not be," Miller adds.
"The process of tailoring requires more study and guidance," Aoki says.
How much can be modified?
"Do you need to replicate an intervention with 100% accuracy or 80%?" asks Aoki. "What aspect of it must be retained to enable you to benefit from the innovation that’s inherent in that particular program?"
An analysis of 50 projects showed that there were many factors that contributed to sound scientific interventions, he reports. "But one that seemed most prominent is whether there was a history of prior collaboration between community service organizations and evaluators and researchers," Aoki says. "So it looks like, and this is something we’ve been trying to encourage, is a culture of collaboration between academics and the community."
More money needed
The reality of HIV prevention work is that too little funding is available to develop these types of collaborations and careful tailoring, prevention researchers say.
Meantime, some states are stepping up the pressure for DEBI use, despite the challenges inherent in making these interventions work in populations for which they were not designed.
For example, one of the only DEBIs designed specifically to target a Latino population of men and women is the VOICES/VOCES intervention, which stands for Video Opportunities for Innovative Condom Education & Safer Sex.
It was designed to increase condom use among heterosexual African Americans and Latinos who visit sexually transmitted disease (STD) clinics. If a CBO decides to use this intervention for a population of heterosexual Mexican farm workers, who have very limited access to health care clinics and live in rural migrant camps, there may be a problem finding an appropriate video because the ones designed for the initial intervention are suited for an urban Latinos who can watch the video in an STD clinic, says Scott Rhodes, PhD, an assistant professor in the department of public health sciences at Wake Forest University School of Medicine in Winston Salem, NC.
"So we say we’ll implement VOCES, but since we don’t have an appropriate video, we’ll come up with a skit, and all of a sudden the funders say, You’re not doing a DEBI,’" he says. "But the CBO says, In these farm camps there is not good video access, and the videos developed are not appropriate, and we don’t have the knowledge to develop a good video, but we can train three people to act it out at the camp site.’"
Although the CBO’s goal to improve condom use is the same as the DEBI’s goal, and although the same type of prevention message would be given out in the skits as would be in videos, the funding entity says that because a video wasn’t used, there would be no funding for the intervention, Rhodes adds.
It’s that type of hypothetical situation that has occurred in North Carolina and elsewhere as some states have created stringent and sometimes arbitrary criteria for what has to be included in DEBI adaptation, Rhodes and other researchers say.
"All of these DEBI interventions offer good empirical evidence that behavior can be changed, and we can do something useful, but they’re not necessarily perfect for the communities we’re working with," Rhodes says. "We are creating a standard, but I’m not sure we know whether the standard we’re creating is the right standard and will be effective across the board."
HIV-prevention researchers describe many frustrations with the process of adapting community-based intervention work to fit into the mold of one of the available evidence-based HIV interventions.Subscribe Now for Access
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