1 Welcome to the Acción Mutua web-seminar: Adaptation of Evidence-Based HIV Prevention Interventions Before we begin, a little about our format…  Presentation by seminar speaker (approx. 40 min.)  Followed by question and answer session (approx. 20 min.) Please press *6 on your telephone keypad to mute your line (pressing *6 again will un-mute your line) If you are experiencing difficulty with your phone connection, dial *0 for the conferencing service operator Questions submitted prior to the web seminar will be addressed first For questions that arise during the presentation, please click on the “hand” button and type your question

2 Acción Mutua is a capacity building assistance (CBA) program of AIDS Project Los Angeles in collaboration with the César E. Chávez Institute of San Francisco State University Funded by the Centers for Disease Control and Prevention

Adaptation of Evidence-Based HIV Prevention Interventions Rosemary C. Veniegas, Ph.D. & Uyen H. Kao, M.P.H. Funded in part by NIMH grant P30 MH58107 to M. Rotheram-Borus, Ph.D.

4 Overview  National context of use of EBIs  Key concepts and terms  Evidence of effectiveness and efficacy  Models of adaptation  Guidance and guidelines for adaptation

5 National context  CDC REP, DEBIs, Best-evidence, promising-evidence ADAPT2 funding for 22 “ new ” EBIs  Substance Abuse, Mental Health NIDA – Principles of Effective Treatment ONDCP – Evidence-Based Principles for Substance Abuse Prevention SAMHSA – NREPP (National Registry of Evidence-based Programs and Practices)  Health Care/Services AHRQ – PPIP (Put Prevention Into Practice) NCI – RTIPS (Research Tested Intervention Programs)

6 CDC EBIs (Sharpe, Collins & Glassman, 2007) Best-Evidence Promising- Evidence ADAPT Best-Evidence Interventions

7 CDC EBIs (Sharpe, Collins & Glassman, 2007)

8 CDC EBIs Best-Evidence Interventions Compendium of HIV Interventions With Evidence of Effectiveness 24 interventions rts/hiv_compendium/

9 CDC EBIs Best-Evidence Interventions Replicating Effective Programs, REP+ 13 interventions prog/rep/index.htm

10 CDC EBIs Best-Evidence Interventions DEBIs 14 interventions

11 New CDC EBIs Best-Evidence (30 interventions) st-evidence-intervention.htm Promising-Evidence Interventions (18 interventions) omising-evidence-interventions.htm Adopting and Demonstrating the Adaptation of Prevention Techniques for Persons at Highest Risk of Acquiring or Transmitting Human Immunodeficiency Virus (ADAPT, 22 interventions) grants.nih.gov/grants/guide/rfa- files/RFA-PS html

12 SAMHSA EBIs NREPP 91 substance abuse and mental health relevant interventions, Including 3 HIV/AIDS relevant interventions

13 Key Concepts and Terms  Evidence-based intervention  Adaptation & fidelity  Bases of evidence  Tiers of evidence

14 Components of Evidence-Based Interventions  Rotheram-Borus, 2007  Establish frame for intervention  Convey issue-specific or population-specific information  Use a cognitive-behavioral framework/theory to build affective, behavioral and cognitive coping skills  Address environmental barriers to implementation of new behaviors  Provide tools to develop ongoing sources of social support  See also 17 characteristics of effective interventions sex and HIV education programs for youth by Kirby, Laris & Rolleri (2006)

15 What is Adaptation? (McKleroy et al., 2006; Sharpe et al., 2007)  Modifying key characteristics, activities, delivery methods without competing or contradicting core elements, theory or internal logic of the intervention  Necessary to ensure relevance in local settings, with new populations, or comply with funder  Check with your funder about what they consider appropriate adaptation

16 What is Fidelity? (CDC, 2005)  Part of quality assurance  Maintaining the core elements, protocols, procedures, and content that made the original intervention effective  Keeping the “signature” of the intervention (Miller, 2007)

17 Adaptation Considerations (Solomon, Card & Malow, 2006)  Adherence to intervention protocols for efficacy  Alterations to intervention for effectiveness  Benefits of adaptation Enhance community support Enhance client participation Enhance program satisfaction Enhance outcomes Promote institutionalization

18 Adaptation Principles (Solomon, Card & Malow, 2006)  Know the target population and community context  Select the program that best matches the population and context  Retain fidelity to the “ core program ”  Systematically reduce mismatches between the program and the new context  Document the adaptation process and evaluate the process and outcomes of the adapted intervention as implemented

19 Knowing the target population  Solicit feedback on adaptation from a community advisory board  Conduct focus groups with the target population  Interview key informants and stakeholders

20 Select the program that best matches  Learn the core elements of the intervention  Identify the risk factors, behavioral determinants, risk behaviors for the target population which are reflected in the intervention  Assess staffing, skills, space, costs of conducting the intervention  Review mission and vision in relation to the intervention  Pre-test or pilot activities or sessions of the intervention

21 Retain fidelity to the intervention  Use behavior change theory to guide adaptation If perceived vulnerability is low among gay men of color, consider increasing session content focusing on this factor  Use previous experience with the intervention If Mpowerment worked with groups composed of African American men only, consider conducting it with Asian/Pacific Islander men only  Keep process evaluation data on why changes are made and what changes are made Supervisor review of project documentation, client records, site observations, interviews, videotaped sessions Facilitator debriefing on the intervention as delivered Quality assurance or improvement efforts

22 Systematically reduce mismatches  Identify risk factors, behavioral determinants, or risk behaviors that are the same or different between the original intervention and the new context or population  Identify necessary cultural adaptations to enhance relevance of the intervention  Draft a logic model for the intervention

23 Document the adaptation process  Keep process evaluation data on why changes were made and what changes were made Write, observe, record, report  Review the process data from the adapted intervention as implemented Which changes worked? Did not work? Which changes enhanced the response to the intervention? Decreased the response?  Review the outcomes of the adapted intervention and compare with the outcomes from the original intervention Did the HIV risk behaviors decrease? Increase?

24 Fidelity Considerations (CDC, 2006)  Reinvention is a form of adaptation  Necessary for new populations/settings  Core elements have been modified (i.e., adding or dropping)  Recommendations Rename intervention Detail internal logic of adapted intervention (i.e., behavioral risk factors addressed) Formally evaluate prevention outcomes Ensure behavioral outcomes were achieved

25 How to measure fidelity? (Mowbray et al., 2003)  Ratings by experts Review of project documentation or client records, site observations, interviews, videotaped sessions  Surveys or interviews Completed by those delivering the sessions or services

26 Other Ways to Measure Fidelity  Fidelity to adapted intervention Revised intervention materials and procedures  Debriefing forms Completed by staff delivering the intervention  Session observations By staff who are also trained in or familiar with the intervention By independent observers also knowledgeable about the intervention

27 MPowerment Adaptations

28 MPowerment Adaptations (Rebchook, Kegeles, Huebner & the TRIP Research Team, 2006)  MPowerment DEBI Telephone interview study 69 CBOs Adaptations Delivered in different setting (75%) Different age groups targeted (49%) Single ethnic group focus (28%) Implemented, modified, dropped elements

29 MPowerment In Los Angeles  Locally prioritized adaptations and reinventions  Being delivered to HIV-negative and to HIV-positive individuals  Being delivered to transgender women  Being delivered to men younger than 18

30 Community Popular Opinion Leader (Maiorana, Kegeles, Fernandez, Salazar, Cáceres, Sandoval, Rosascob, Coates & NIMH Collaborative HIV/STI Prevention Trial Group, 2007)  Adapted POL to be implemented in Peru  Called “Que´ te Cuentas (What’s Up)”  Multi-site staff training on CPOL model and intervention  Developing facilitators’ training manual with the curriculum for training the CPOLs  Developing appropriate prevention messages to conduct conversations  Identifying appropriate incentives  Consulting and testing prevention messages with local experts and key informants part of the target populations  Facilitators’ rehearsal with key informants acting the part of CPOLs.

31 Other Examples of Adaptations and Reinventions (Veniegas, Kao, Rosales & Arellanes, unpublished data) Target new population Other AdaptationsReinvention  Adaptation for new target population  Include culturally appropriate language/content  Add core element to meet funder requirements  Adapting to multiple populations  Changing scheduling, duration, location, order  Have open sessions with non-target group members  Integration with other services/ programs  Making adaptations which reduce the effectiveness of the intervention

32 Relevance of EBIs for local contexts  Glasgow & Emmons, 2007  Emphasized external validity criteria for intervention developers/disseminators Program reach and representativeness Program or policy implementation and adaptation Outcomes for decision making Maintenance and institutionalization

33 CDC Bases and Tiers of Evidence  Bases of evidence for prevention programming CDC Evaluation Guidance Handbook, 2002  Tiers of evidence for evidence-based interventions National HIV Prevention conference 2007

34 CDC Bases of Evidence  Prevention programming  Data from an evaluation of their own intervention  Data from an evaluation of a similar intervention  A theoretical basis from the scientific literature  A fully articulated informal theory  Website depts/guidance/designing-appendix.htm depts/guidance/designing-appendix.htm  Emphasis on effectiveness

35 CDC Tiers of Evidence  pics/research/prs/tiers- of-evidence.htm pics/research/prs/tiers- of-evidence.htm  Emphasis on efficacy

36 Tiers

37

38

39 Models of Adaptation  Technology Transfer Model  Replicating Effective Programs  Map of Adaptation Process

40 Models of Adaptation  Technology Transfer Model  Replicating Effective Programs  Map of Adaptation Process

41 Technology Transfer Model  Kraft, Mezoff, Sogolow, Neumann & Thomas, 2000  Pre-implementation Review prevention needs Acquire information Assess fit Prepare organization/staff  Implementation Secure technical assistance Conduct process evaluation  Maintenance and Evolution Support staff; organization change and institutionalization Conduct process, outcome, and cost evaluations

42 Technology Transfer of Multiple EBIS (Veniegas, Kao, Rosales & Arellanes in press) ActivityStrategy used by CBOChallenge experienced by CBO Assess fit  Review existing client and program data with intervention requirements  Poor fit between the intervention and the population CBO was funded to serve Prepare organization and Staff  Modify key characteristics of EBI  Funder required major modifications to EBI Secure technical Assistance (TA) for intervention selection  Seek TA from external consultant  Seek TA from CBA provider  Few TA resources available

43 Replicating Effective Programs (REP) Model  Kilbourne, Neumann, Pincus, Bauer, & Stall, 2007  Model for packaging interventions for use by CBOs  Pre-conditions identify need, target population, intervention  Pre-implementation develop intervention package, seek community input  Implementation disseminate, train, technical assistance, evaluate  Maintenance and evolution prepare for sustainability

44 REP Model

45 Map of Adaptation Process (McKleroy, Galbraith, Cummings, Jones, Harshbarger, Collins, Gelaude, Carey, & the ADAPT Team, 2006)

46 Map of Adaptation Process (McKleroy, Galbraith, Cummings, Jones, Harshbarger, Collins, Gelaude, Carey, & the ADAPT Team, 2006)

47 Guidelines and Guidance  HIV Prevention Plans  Provisional Procedural Guidance  CRIS at CDC  Other Adaptation Guidance

48 HIV Prevention Plans  Website of CPGs  Required for each CDC funded jurisdiction  Details HIV prevention priorities and populations In Los Angeles use of the “hard core 4” drugs heroin, cocaine, crack and methamphetamine is a primary HIV risk factor In Florida Black Heterosexuals are a priority population for HIV prevention  Identifies interventions for priority populations  Provides guidance on recommended interventions for the region

49 CDC Provisional Procedural Guidance for CBOs  guidelines/pro_guidance.htm guidelines/pro_guidance.htm  Covers core elements, resource requirements, quality assurance, monitoring and evaluation  Policies and standards for Confidentiality Cultural competence Data security Informed consent Legal and ethical policies Referrals for additional client services Liability insurance and applicability of workers’ compensation for volunteers

50 CDC Provisional Procedural Guidance for CBOs

51 Capacity Building Request Information System (CRIS) for Directly Funded CBOs

52 Other Adaptation Guidance  Weaving Science and Practice Project (ETR & Healthy Teen Network) D0CC76-CF BA7C- 5D0436F6040C%7D/uploads/%7BC4AC9F3C-F7C5- 4F72-BF6A-867A953849A6%7D.PDF  Adapting Efficacious Interventions (PROCEED, Inc.) Publications/Adapting%20Efficacious%20Interventions% 20-%20Article%204%20-%20CH%20-%20PDF.pdf

53 Other Adaptation Guidance  Adaptation and Tailoring (ETR) ailor.doc  Implementation and Fidelity of Evidence-Based Behavioral Interventions (Galbraith et al. 2008)  UNAIDS Guidance on HIV Counseling and Testing Adaptation

Questions & Comments iGracias ~ Thank You!

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