Description
Core Elements, Key Characteristics, and Procedures
Adapting
Resource requirements
Recruitment
Policies and Standards
Quality Assurance
Monitoring and Evaluation
Key Articles and Resources
References

Description

Healthy Relationships 1 is a 5-session, small-group intervention for men and women living with HIV/AIDS. It is not intended for persons who are not infected or living with HIV/AIDS, such as HIV-negative partners of persons living with HIV/AIDS. Healthy Relationships focuses on building skills related to problem solving, decision making, self-efficacy, and positive expectations.

Healthy Relationships has been packaged by CDC's Diffusion of Effective Behavioral Interventions project. An intervention package, training, and technical assistance are available from CDC. The intervention package will be provided only to participants of the 32-hour Healthy Relationships training conducted by CDC's training partners, the STD/HIV Prevention Training Centers. Planning and implementation information (including the starter kit, technical assistance guide) can be found at The Diffusion of Effective Behavioral Interventions (DEBI) website.

Goals

Healthy Relationships aims to build skills to reduce stress in the following 3 life areas:

• Disclosing HIV status to family and friends
• Disclosing HIV status to sex partners and needle-sharing partners
• Building healthier and safer relationships

How It Works

Healthy Relationships is intended to create a positive, engaging, and creative atmosphere that can be integrated into existing support groups or can be introduced as a new program. Conducted in 5 sessions, Healthy Relationships teaches clients decision-making and problem-solving skills to help them make informed and safe decisions about behaviors and HIV status disclosure. In each of the 3 life areas, a series of exercises is repeated to create and develop the skills. The primary exercise is viewing short clips from popular movies and then role-playing the scenarios.

Healthy Relationships is adaptable to different populations by varying the choice of movie clips and providing flexibility in role-playing to allow for cultural influences.

Theory behind the Intervention

Healthy Relationships is based on social cognitive theory. It focuses on developing skills and building self-efficacy and positive expectations about new behaviors through modeling behaviors and practicing new skills.

Research Findings

Compared with participants in a health maintenance control group, participants in the Healthy Relationships intervention group reported

• greater self-efficacy for suggesting condom use with new sex partners
• greater self-efficacy for being able to satisfy sex partners and themselves even when practicing safer sex
• intentions to consider the pros and cons of disclosing HIV status to partners
• intentions to engage in safer sex with partners of unknown HIV status

At 3-month and 6-month follow-up contacts, participants in the intervention group were significantly more likely than participants in the control group

• to have followed through on their earlier intentions
• to have considered the pros and cons of disclosing HIV status to sex partners
• to report less sexual intercourse
• to report less unprotected intercourse with partners who were not HIV infected

At the 6-month follow-up (but not the 3-month) contact, participants in the intervention group

• were significantly more likely to have refused to engage in unsafe sex (which was not true at the 3-month follow-up)
• reported
• less unprotected intercourse
• more protected intercourse
• fewer sexual contacts

Research results show that this intervention is broadly applicable across subpopulations, including persons of different sexual orientations and persons with a history of incarceration, current or past drug use, or psychiatric problems or care. The results indicate a long-term effect (up to at least 6 months) on reported behaviors and perceived self-efficacy.

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Core Elements, Key Characteristics, and Procedures

Core Elements

Core elements are those parts of an intervention that must be done and cannot be changed. They come from the behavioral theory upon which the intervention or strategy is based; they are thought to be responsible for the intervention's effectiveness. Core elements are essential and cannot be ignored, added to, or changed.

Healthy Relationships has the following 5 core elements:

• Define stress and reinforce coping skills with HIV-infected people across 3 life areas.
• Disclosing HIV status to family and friends
• Disclosing HIV status to sex partners and needle-sharing partners
• Building healthier and safer relationships
• Use modeling, role-playing, and feedback to teach and practice skills for coping with stress.
• Teach clients decision-making skills with regard to disclosing HIV status.
• Provide clients with personal feedback reports (PFRs) to motivate them to change risky behaviors and continue protective behaviors.
• Use movie-quality video clips to set up scenarios about HIV status disclosure and risk reduction to stimulate discussions and role-playing. (Note: The term clip is used, regardless whether the clip is short, long, or an entire movie.)

Key Characteristics

Key characteristics are those parts of an intervention (activities and delivery methods) that can be adapted to meet the needs of the CBO or target population.

Healthy Relationships has the following key characteristics:

• Have clients meet in small groups (5 to 12 people), similar to support groups. New members cannot join once the series of sessions has begun.
• Have clients sit face to face in a circle.
• Have clients meet for at least 5 sessions, 2 hours each.
• Ensure that groups contain members of the same gender and sexual orientation.
• Have 2 facilitators per group.
• Ensure that facilitators have the following characteristics, which bring immediate credibility and rapport with clients:
• One facilitator should be male and the other female.
• At least 1 facilitator should be an experienced and skilled counselor, preferably a mental health professional. This facilitator may or may not be HIV infected.
• At least 1 facilitator should be HIV infected.
• At least 1 should be the same ethnicity as most clients.
• Both should have the personal characteristics and group skills needed to be effective facilitators.

Procedures

Procedures are detailed descriptions of some of the above-listed elements and characteristics.

Procedures for Healthy Relationships are as follows:

Making Sessions Interactive

Healthy Relationships is based on interactive sessions that educate and engage clients. They are not classes, lectures, or forums. These sessions create a context where people can interact, examine their risks, develop skills to reduce their risks, and receive feedback from others. Groups consist of 5 to 12 people of similar backgrounds. Clients sit in a circle so that they can easily see each other, share experiences, practice new skills, and receive feedback from their peers. Facilitators use easel chart guides to lead clients through the Healthy Relationships content.

Creating Personal Feedback Reports

Each client completes an initial assessment survey. From this survey, 3 PFR forms are created for each client. These PFR forms are designed to reinforce clients' motivation to change by helping them identify their behaviors, as well as determine which behaviors they want to change and which they want to maintain. The PFR forms are distributed in 3 different sessions, each tied to 1 of the life areas mentioned in the first core element.

Conducting Exercises

After each PFR is distributed and discussed, 3 risk continuum exercises are done. The continuum exercises use a long banner with a double-ended arrow labeled from high to low. Clients are given cards according to their personal evaluation of the stress or risk involved. The cards and the banner have corresponding pieces of Velcro on the back. Clients stick these cards along the appropriate place on the banner.

The continuum banner is used in 3 of the sessions, each time with a different set of cards. These exercises focus on how the clients view each of the following:

• Exercise 1 Risk and stress of HIV status disclosure to family and friends
• Exercise 2 Risk and stress of HIV status disclosure to sexual partners
• Exercise 3 Risk of various sexual behaviors

Showing Videos

A variety of videos and movie clips are shown in the 5 sessions of Healthy Relationships.

• Personal statements
• HIV/AIDS information
• Condom demonstration
• Segments from popular movies (most important)

Describing Scenarios

Facilitators give brief descriptions or scenarios to introduce clips while tying them to the objectives of the session. Correctly setting up the scenarios facilitates both role-playing and discussion. These scenario descriptions are also used on many of the easel chart guides.

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Adapting

Healthy Relationships is highly adaptable for many subgroups of persons living with HIV by varying the choice of movie clips and providing flexibility in role-playing to allow for cultural influences. CBOs are encouraged to select movie clips in which the race and ethnicity of the characters match that of most clients. CBOs are also encouraged to use a different set of a movie clips for each type of group conducted (e.g., movies clips for a Latina group, for an African American MSM group, or for a Latino heterosexual men's group). CBOs should consult the Clip Essence tables found in Appendix VI of the Healthy Relationships implementation manual to obtain the purpose and the essential ingredients of the each movie clip. Healthy Relationships may be adapted for several settings and has been used successfully in clinical as well as community-based settings.

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Resource requirements

People

Healthy Relationships needs

• 1 full-time paid, experienced counselor or mental health professional
• 1 part-time (25% of time) HIV-infected peer group facilitator (volunteer or paid) for each group of clients (e.g., women, heterosexual men, men who have sex with men).
• 1 part-time (25% of time) program manager to do quality assurance and evaluation

The facilitators should meet the criteria described under Key Characteristics. Each group facilitator is strongly recommended to attend the 32-hour Healthy Relationships training conducted by CDC's training partners, the STD/HIV Prevention Training Centers. Program Coordinators/Managers, who oversee the intervention and supervise the group facilitators, are encouraged to attend the 32-hour Healthy Relationships training. Program Coordinators/Managers and those interested in learning more about the intervention are encouraged to read the Healthy Relationships starter kit found at www.effectiveinterventions.org.

A CBO will need from 40 to 60 hours to find and assemble 13 movie clips to use during the sessions. The 13 movie clips will not be provided by CDC or as part of the intervention package. The actual number of hours and costs for assembling the clips depends on

• staff knowledge of movies and appropriate clips
• equipment availability and staff skill for assembling clips on a VCR tape or DVD disk (or a contract for these services)
• the number of populations of clients who will be receiving the intervention (most of the selections are population specific)

Space

Healthy Relationships needs space that is

• private and secure, so that confidentiality of clients can be assured
• discrete (for clients who are uncomfortable with others knowing their HIV status)
• quiet and without interruptions (such as people entering and exiting the room or outside noise)

Supplies

The Healthy Relationships package comes with generic marketing tools, such as a video and printed promotional literature, which can modified for specific populations. Healthy Relationships will also require

• a TV and VCR or a DVD player with a remote control
• an easel, easel chart paper, and markers
• small incentives
• 1 small prize to give away through a random drawing at the end of each session

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Recruitment

CBOs are encouraged to screen potential clients to determine whether they are appropriate for the group-level intervention. The Healthy Relationships package (Appendix IV of the Healthy Relationships implementation manual) includes a list of questions that can be used to determine the appropriateness of potential clients.

The following recruitment strategies can be used to reach persons living with HIV:

• Recruit from existing programs and services for persons living with HIV, such as HIV support groups, comprehensive risk counseling and services, and HIV primary care settings.
• Use the generic marketing materials in the Healthy Relationships package.
• Send press releases to local radio and television stations.
• Advertise in local newspapers, including gay and alternative papers.
• Post announcements on the Internet.

Review Recruitment in this document to choose a recruitment strategy that will work in the setting in which the CBO plans to implement Healthy Relationships.

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Policies and Standards

Before a CBO attempts to implement Healthy Relationships, the following policies and standards should be in place to protect clients, the CBO, and the Healthy Relationships intervention team:

Confidentiality

A system must be in place to ensure that confidentiality is maintained for all participants in the program. Before sharing any information with another agency to which a client is referred, signed informed consent from the client or his or her legal guardian must be obtained.

Cultural Competence

CBOs must strive to offer culturally competent services by being aware of the demographic, cultural, and epidemiologic profile of their communities. CBOs should hire, promote, and train all staff to be representative of and sensitive to these different cultures. In addition, they should offer materials and services in the preferred language of clients, if possible, or make translation available, if appropriate. CBOs should facilitate community and client involvement in designing and implementing prevention services to ensure that important cultural issues are incorporated. The Office of Minority Health of the Department of Health and Human Services has published the National Standards for Culturally and Linguistically Appropriate Services in Health Care, which should be used as a guide for ensuring cultural competence in programs and services. (Please see Ensuring Cultural Competence in the Introduction of this document for standards for developing culturally and linguistically competent programs and services.)

Data Security

To ensure data security and client confidentiality, data must be collected and reported according to CDC requirements.

Informed Consent

CBOs must have a consent form that carefully and clearly explains (in appropriate language) the CBO's responsibility and the clients' rights. Individual state laws apply to consent procedures for minors; but at a minimum, consent should be obtained from each client and, if appropriate, a legal guardian if the client is a minor or unable to give legal consent. Participation must always be voluntary, and documentation of this informed consent must be maintained in the client's record.

Legal and Ethical Policies

By virtue of participation in Healthy Relationships, clients will be disclosing their HIV status. CBOs must know their state laws regarding disclosure of HIV status to sex partners and needle-sharing partners; CBOs are obligated to inform clients of the organization's responsibilities if a client receives a positive HIV test result and the organization's potential duty to warn. CBOs also must inform clients about state laws regarding the reporting of domestic violence, child abuse, sexual abuse of minors, and elder abuse.

Referrals

CBOs must be prepared to refer clients as needed. For clients who need additional assistance in decreasing risk behavior, providers must know about referral sources for prevention interventions and counseling, such as comprehensive risk counseling and services, partner counseling and referral services, and other health department and CBO prevention programs.

Volunteers

If the CBO uses volunteers to assist with or conduct this intervention, then the CBO should know and disclose how their liability insurance and worker's compensation applies to volunteers. CBOs must ensure that volunteers also receive the same training and are held to the same performance standards as employees. All training should be documented. CBOs must also ensure that volunteers sign and adhere to a confidentiality statement.

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Quality Assurance

The following quality assurance activities should be in place when implementing Healthy Relationships:

Facilitators

Training

Facilitators should

• complete a training workshop, including review of the intervention theory and materials
• participate in practice sessions
• observe cofacilitation of groups, including practicing mock intervention sessions

Session Review

CBOs should have in place a mechanism to ensure that all session protocols are followed as written. Quality assurance activities can include observation and review of sessions by key staff and supervisors involved with the activity. This review should focus on

• adherence to session content
• use of appropriate videotapes with adequate facilitation of discussions
• accessibility and responsiveness to expressed client needs
• important process elements (e.g., time allocation, clarity)

Record Review

Selected intervention record reviews should focus on assuring that consent forms (signed either by the client, if older than 18 or emancipated, or by a legal guardian) are included for all participants and that session notes are of sufficient detail to assure that clients are participating actively.

Clients

Clients' satisfaction with the intervention and their comfort should be assessed at each session.

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Monitoring and Evaluation

Specific guidance on the collection and reporting of program information, client-level data, and the program performance indicators will be distributed to agencies after notification of award.

General monitoring and evaluation reporting requirements for the programs listed in the procedural guidance will include the collection of standardized process and outcome measures. Specific data reporting requirements will be provided to agencies after notification of award. For their convenience, grantees may utilize PEMS software for data management and reporting. PEMS is a national data reporting system that includes a standardized set of HIV prevention data variables, web-based software for data entry and management. CDC will also provide data collection and evaluation guidance and training and PEMS implementation support services.

Funded agencies will be required to enter, manage, and submit data to CDC by using PEMS or other software that transmits data to CDC according to data requirements. Furthermore, agencies may be requested to collaborate with CDC in the implementation of special studies designed to assess the effect of HIV prevention activities on at-risk populations.

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Key Articles and Resources

CDC. Draft CDC Technical Assistance Guidelines for CBO HIV Prevention Program Performance Indicators. Atlanta, GA: US Department of Health and Human Services, CDC; November 2003.

US Department of Health and Human Services, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care. Washington, DC: US Department of Health and Human Services; 2001.

An intervention package, training, and technical assistance on the Healthy Relationships intervention is available from CDC.

CDC would like to acknowledge and thank the faculty and staff of the Dallas STD/HIV Prevention Training Center for their assistance in compiling this Procedural Guidance for Implementation of Healthy Relationships.

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References

1. Kalichman SC, Rompa D, Cage M, et al. Effectiveness of an intervention to reduce HIV transmission risks in HIV-infected people. American Journal of Preventive Medicine. 2001;21(2):84–92.

Many Men, Many Voices