States and cities have effectively used community-level intervention projects to reduce cigarette smoking and other risk behaviors associated with chronic disease (1-3); similar strategies have been introduced to prevent human immunodeficiency virus (HIV) infection in men who have sex with men and who identify themselves as homosexual or bisexual (4,5). Many of these projects used community volunteers to deliver interventions (2,4,5). An important concern for community-level intervention projects that rely on volunteers is the need to address the recruitment and retention of these volunteers. CDC AIDS Community Demonstration Projects have developed and maintained volunteer networks among hard-to-reach populations for HIV prevention. This report summarizes methods used by demonstration projects in five cities* to develop and maintain volunteer networks during 1991-1992. Development of Volunteer Networks

The projects have used community-level campaigns to promote HIV prevention among hard-to-reach persons at risk for HIV infection (6), including 1) men who have sex with men but who do not self-identify as homosexual; 2) injecting-drug users (IDUs) not in treatment; 3) female sex partners of IDUs; 4) prostitutes; and 5) youth in high-risk situations. The intervention objective has been to increase condom use and bleach use (for disinfecting needles) among persons at risk by changing the attitudes, perceived risk, self-efficacy **, and social norms of these groups. Community volunteers have distributed and discussed materials and served as trainers, role models, or opinion leaders in the targeted communities (4-8).

Before intervention efforts began, outreach workers from local health departments made contact with the selected groups to recruit volunteers during the first year of the intervention. Businesses were recruited to act as additional sites for distribution of materials.

Volunteers included peers (i.e., persons who shared the culture and some of the behaviors of the target groups) and interactors (members of the community who had frequent contact with persons in the target groups [e.g., shopkeepers, housing project managers, and social- and health-service providers]). During training sessions, volunteers were introduced to the project, provided with basic education about HIV and AIDS, and engaged in role playing. Volunteers disseminated media materials (e.g., brochures and posters) along with condoms and bleach to high-risk, hard-to-reach persons within the same community. Volunteers focused the attention of recipients on the role-model stories contained in the brochures, reinforced any reported positive behavior change, and sometimes acted as role models (6). Assessment of Volunteer Networks

Because of the relatively small numbers of volunteers working with each risk group and at each site, this assessment has combined the number of active volunteers during the first 12 months of operation at each site (June 1991-August 1992). During the first 12 months, the number of active volunteers for all sites increased 82.6% (from 138 to 252). Of the 138 volunteers who were recruited during the first month of the intervention, 101 (73%) remained active in the sixth month; of these, 85 (61% of the total) remained active at 12 months.

Project staff at each site conducted debriefing interviews and focus groups with volunteers to determine reasons for volunteering and methods for maintaining and improving the networks. Reasons for volunteering included an appreciation of the emotional rewards of volunteering and incentives, satisfaction with the social aspects of volunteering, and self-perception of making a substantive contribution to prevent AIDS.

Based on these efforts, each site developed means for maintaining and improving the volunteer networks, including 1) offering incentives that provide volunteer recognition (e.g., prizes and media coverage); 2) increasing team-building opportunities for volunteers; 3) informing volunteers of the progress of the project and reinforcing their role; 4) maintaining frequent contact between outreach workers and volunteers; and 5) providing skills during volunteer training sessions for coping with rejection.

Reported by: C Guenther-Grey, MA, S Tross, PhD, National Development and Research Institute, New York City. A McAlister, PhD, Univ of Texas, Austin; A Freeman, MPH, Dallas County Health Dept, Dallas. D Cohn, MD, Denver County Health Dept, Denver. N Corby, PhD, Long Beach Health Dept, California. R Wood, MD, Seattle-King County Dept of Public Health, Seattle. M Fishbein, PhD, Univ of Illinois, Urbana-Champaign, Illinois. Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The findings in this report suggest that community projects for HIV prevention can recruit and retain active volunteers to intervene within hard-to-reach groups and provide HIV-prevention messages in their communities. The retention rate for these project volunteers, who generally are from low socioeconomic and disenfranchised backgrounds, was higher at 12 months (61%) than that for volunteers who actively sought out the volunteer role at mainstream AIDS-service organizations (50%) (9). In addition, the distribution of intervention materials by trained volunteers increased exposure to the intervention, particularly among hard-to-reach persons in high-risk groups who infrequently attended clinics.

The findings in this report are subject to at least two limitations. First, this assessment is based on a descriptive review of information rather than on a rigorous experimental design to evaluate the strategies used to recruit and maintain a volunteer network. Second, because the methods to recruit and retain volunteers were combined by site and target group for the total intervention period, it was not possible to determine which strategies were most successful.

These preliminary findings from the projects do not address whether the intervention delivered by volunteers has changed HIV-risk behavior among these hard-to-reach populations. The impact of using volunteers in community-level interventions to change risk behaviors among targeted groups requires further evaluation. Therefore, AIDS community demonstration projects in these five cities are continuing to evaluate the impact of disseminating intervention materials through community volunteers to hard-to-reach populations regarding condom use and the use of bleach to disinfect needles (6). This report suggests that focus groups and interviews with volunteers may be useful as methods to improve this intervention.

References

1. Farquhar JW, Fortmann SP, Maccoby N, et al. The Stanford five-city project: design and methods. Am J Epidemiol 1985;122:323-34.

2. Puska P, Nissinen A, Tuomilehto J, et al. The community-based strategy to prevent coronary heart disease: conclusions from the ten years of the North Karelia project. Ann Rev Public Health 1985;6:147-93.

3. Carlaw RW, Mittlemark MB, Bracht N, Luepker R. Organization for a community cardiovascular health program: experiences from the Minnesota heart health program. Health Educ Q 1984;11:243-52.

4. Kelly J, St. Lawrence J, Diaz Y, et al. HIV risk behavior reduction following intervention with key opinion leaders of the population: an experimental analysis. Am J Public Health 1991;81:168-71.

5. Kegeles SM, Hays RB, Coates TJ. A community-level risk reduction intervention for young gay and bisexual men. Presented at the Annual Convention of the American Psychological Association, Washington, DC, August 14-18 1992.

6. O'Reilly K, Higgins D. AIDS community demonstration projects for HIV prevention among hard-to-reach groups. Public Health Rep 1991;106:714-20.

7. Puska P, Koskela K, McAlister A, et al. Use of lay opinion leaders to promote diffusion of health innovations in a community programme: lessons learned from the North Karelia project. Bull WHO 1986;64:437-46.

8. McAlister A. Population behavior change: a theory-based approach. J Public Health Policy 1991;12:345-61.

9. Snyder M, Omoto AM. Volunteerism and society's response to the HIV epidemic. Current Directions in Psychological Science 1992;1:113-6.

• Dallas; Denver; Long Beach, California; New York City; and Seattle. ** Confidence that one can practice a new behavior even in difficult circumstances, for example, practicing safer sexual behavior when under the influence of drugs or alcohol or in the company of a new sex partner.

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