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CHAPTER 2The Southern California Border HIV/AIDS Project: An Innovative Approach
to HIV Outreach, Primary Care, and Cross-Border Linkages at the California–Baja
California Border
|
D |
---|
The Southern California Border HIV/AIDS Project proposed to use innovative approaches to increase HIV/AIDS outreach, primary care services, and cross-border linkages for people who live or work in the San Diego or Imperial County border region. The project targeted underserved, hard-to-reach, minority populations, particularly Latinos. To address the diverse nature of Latino populations, each partner site was asked to designate its target population based on its organization’s geographical area and unique service population. Target populations collectively included:
The categories were not mutually exclusive, although they represented distinct populations for each region. Initially, one target population was male Latino youth sex workers; however, because of an inability to identify that population in a consistent manner, the youth sex worker population was integrated into the Latino MSM category.
The Southern California Border HIV/AIDS Project had three main goals:
The service delivery model implemented at each partner site was based on the service model developed at SYHC (Figure 2.1). The SYHC model identified five categories of primary HIV services (i.e., core services) that are necessary to reach and adequately serve Latinos:
Three partner sites agreed to implement the SYHC HIV service delivery model, given demonstrated success observed at SYHC. The fourth site, Comprehensive Health Centers, was contracted to provide technical assistance to other partner sites for the development of culturally and linguistically appropriate treatment adherence counseling. Figure 2.2 depicts the patient flow at SYHC.
Providing HIV primary medical care was considered a basic service for meeting the needs of HIV-positive Latinos, but the case management component was essential to the success of SYHC’s service delivery model. All partner sites were required to have bilingual case management services. The case manager became the primary access point for helping HIV-positive Latinos access and stay in care.
The initial logic model for the Southern California Border HIV/AIDS Project was found to not accurately reflect the planned intervention or realistically capture the evaluation measures proposed to assess the intervention. Minor changes in model language and target population contact estimates were made through partner consensus and approved by HRSA. The logic model is shown in Appendix 2.A.
SYHC’s initial target population was transborder Latino MSM; the target population was modified to include all transborder Latinos because of the lack of MSM outreach sites in the South Bay region. As indicated earlier, a partner site, FHCSD, had to expand its initial target population of Latino youth sex workers to encompass Latino MSM as a result of similar participant recruitment problems. The proposed project plan remained essentially the same throughout the 5-year SPNS initiative. The evaluation plan for the Southern California Border HIV/AIDS Project used both process and outcome evaluation measures.
Implementation of a new service delivery structure at partner sites was challenging. Most sites had established HIV services to various degrees. The longer the history of HIV services at a site, the harder it was to implement a new service delivery model and train staff in using that model.
A key to the success of the Southern California Border HIV/AIDS Project was the collaboration among the four partner sites and the local UCSD evaluation team from the outset. The successful collaboration was attributable to excellent communication established during the planning phase. Regular monthly meetings were forums to discuss project progress and problems. The monthly meetings also served as a support system for project staff and contributed to staff buy-in. Each site submitted monthly reports that provided the lead agency with regular updates on progress toward the project objectives. In addition to reports and meetings, the lead agency and evaluation team made annual site visits to provide consultation and assess progress.
The
Centro de Evaluación (see Chapter 1) provided technical support
on various aspects of program evaluation. For example, it helped create
TeleForm versions of two local HIV measurement instruments. TeleForm
versions made it possible for local data to be entered online through
the University of Oklahoma server and integrated with other multisite
data using unique record numbers (URNs).
D |
---|
During annual site visits, the leadership of the Centro de Evaluación
provided support and guidance when needed on evaluation-related activities.
The visits proved useful for the project evaluation activities in general.
The UCSD evaluation team met with the Pacific AETC director during the
first project months. Her participation in monthly meetings helped identify
individual site training needs and provide a source of additional funding
to support staff development and education.
CASE STUDY “José” was an at-risk, Spanish-language-dominant, Latino MSM contacted by a female outreach worker at a local trolley station. He was given a test location card with information on where to go for an HIV test. José presented for HIV testing at the clinic the following week, where he received an incentive to return for results. The incentive was a $10 gift certificate to a local grocery store. On the day of his test, he was invited to become a participant in the SPNS study. The HIV test counselor explained the purpose and conditions of the study, read the voluntary consent statement, enrolled him in the study, and administered two data collection instruments: a demographic survey and an HIV risk assessment survey. The HIV test was performed, and José was asked to return in 5 days for his HIV test results. When José returned for his test results, he learned that he was HIV positive. He was immediately assigned a bilingual case manager. José’s first appointment with the case manager took place within 48 hours of learning his HIV status. During that first meeting, the case manager asked questions to assess José’s psychosocial needs and described the HIV medical care services. The data collection instruments used for program evaluation were completed during the initial assessment meeting. The surveys (i.e., the multisite modules) became part of José’s case management record. José agreed to enroll in medical care and was given information on other clinic services. José continues to seek medical care and case management services at the clinic. He also sees the bilingual mental health counselor and participates in the weekly support group. |
Two consumer focus groups were used to obtain feedback on barriers to accessing HIV services. From those groups, it was learned that both men and women wanted improved access to clinical trials. This information was used for a pilot study funded by the National Institutes of Health, Center on Minority Health and Health Disparities, to explore barriers to HIV clinical trials for Latinas living with HIV.
Based on data from the study, UCSD sought to continue collaborating with SYHC to expand the study to include Latinos and HIV service providers and has since been awarded a 5-year grant5 from the National Institutes of Mental Health to improve understanding of barriers to HIV clinical trials and issues related to access to care.
The evaluation coordinator trained personnel at each site during first year of the project. The SYHC project coordinator met monthly with partner site representatives to discuss implementation challenges. Staff understanding of the project was critical to their buy-in, and it contributed to program stability at the sites throughout the grant period. Significant staff turnover occurred at only one partner site.
Outreach to populations at risk for HIV varied by the type of population served. For example, at VCC and CSP, promotores (bilingual lay health workers) conducted outreach activities with farmworkers. Initially, CSP promotores were inexperienced in the field of HIV/AIDS and were hesitant to ask personal questions involving sexual practices and orientation. The evaluation team provided peer-based training for new rural promotores in which experienced urban outreach workers taught effective HIV/AIDS outreach strategies. In addition, the AETC arranged for a promotor specialist from Arizona to train the CSP promotores. Training improved their HIV/AIDS outreach activities and services.
Community outreach workers trained specifically to conduct HIV/AIDS outreach performed outreach activities at SYHC and FHCSD. The enhanced HIV/AIDS outreach training helped in the data collection process for the project.
Four local evaluation measures were used in this project (Table 2.1). The HIV Test Demographic Survey developed in Year 2 used items from the multisite demographic and risk factor instruments (Modules A and D, respectively; see Chapter 1 in this volume for additional information). The Treatment Adherence Counseling Form was developed in Year 3 to study the relationship of psychosocial factors to HIV medication adherence. The instrument was developed collaboratively by the UCSD Evaluation Unit and the treatment education staff at Comprehensive Health Centers. Quality of care was measured using Module G (see Chapter 1), a multisite instrument designed to measure patient satisfaction with the care services provided. In addition, two focus groups were created in 2002 to explore patient perceptions about access to care and related issues.
Patients were read an informed consent form that outlined the risks and benefits of project participation. Participants received an incentive (a $10 grocery store voucher) when they returned for HIV test results. Clinic staff administered local modules at testing, so HIV-negative participants were enrolled in the study as well.
The UCSD Human Research Protections Program (HRPP), the university’s institutional review board, oversees protection of study participants, adherence to university and Federal standards of research ethics (e.g., Health Insurance Portability and Accountability Act of 1996), and reviews all research-related projects at UCSD. Participant consent forms, protocols, and project activities were reviewed and approved by the UCSD HRPP. Each participant was read a voluntary consent form in his or her preferred language.
Description of Measure | Purpose |
---|---|
1. Outreach (group and individual) | Examine relationship between outreach contacts and HIV testing |
2. Demographics of persons tested for HIV | Provide a profile of people reached for HIV testing |
3. HIV test and return results |
Compare clients who returned for HIV test results with those who did not return |
4. Treatment adherence counseling | Explore psychosocial factors related to HIV medication adherence |
The Southern California Border HIV/AIDS Project required extensive data collection from each participant. Data collection was carried out primarily by clinic staff. The process consumed considerable staff time, particularly that of case managers.
From the project’s inception, the evaluation team worked closely with SYHC and clinic partner sites to address staff concerns and questions regarding data collection activities.
Data processing presented a set of unique challenges, such as tracking missing or incomplete data from forms, ensuring that consent forms were received for each study participant, and monitoring the ways clinic staff were documenting information. On a bimonthly basis, the data manager generated lists of missing or incomplete participant data for staff follow-up. Toward the end of the project, it became increasingly difficult to retrieve missing information from clinic sites. Close attention to missing data throughout the project, however, minimized the total amount of missing information.
One initial challenge for all grantees involved in the Southern California Border HIV/AIDS Project was achieving consensus on the wording and English–Spanish translations of data collection instruments. A professional translator translated the documents, and project leadership reviewed the materials carefully prior to approval. Some regional differences in local word meanings presented challenges, but consensus was reached by including the various meanings in a codebook for personnel administering the instruments. Local instruments also were translated by a professional translator.
For most clinic staff, the Southern California Border HIV/AIDS Project was their first research experience. Training and technical support provided many new learning opportunities. Clinic-specific databases were developed to track patients in case management. In addition, a treatment adherence form was created on the basis of feedback from clinic sites with support from Comprehensive Health Centers’ treatment adherence program. SYHC chose to adopt this form for use in its system beyond the study.
All hard copies of evaluation instruments were maintained in a locked file. Participant data were entered online through the evaluation center server, and local databases used a secure, firewall-protected server. Databases used a URN linked to the participant’s name in a separate database that was password protected and available only to key staff. Individual data were identified using only the URN. Local evaluation instruments captured information described in Table 2.2.
Data collection for local instruments ended June 30, 2004. Multisite data collection ended September 30, 2004. Efforts to locate missing data continued until December 30, 2004. During the last months of Year 5, the evaluation team generated information for a report to HRSA, which included findings to be used for dissemination at professional meetings and for peer-reviewed publications. Project dissemination activities are listed in Appendix 2.B.
The collaboration between the lead agency and partner CHCs in the Southern California Border HIV/AIDS Project strengthened the ties between CHCs in San Diego and Imperial County. The SPNS initiative built trust among staff across partner sites and increased interest in continuing to work together, a result that should benefit the California–Baja California border region as a whole.
Description of Measure |
Select Major Variables |
Total Collected
at All Four Partner Sites (7/1/01–4/04) |
---|---|---|
Case management referrals | Referrals at first contact Common referrals at first contact Successful referrals by verification |
229 |
Client service knowledge |
Knowledge of core services at first contact Knowledge of core services prior to first contact |
192 |
Treatment adherence counseling | Client support available Number of missed medication doses in past 30 days Patient education |
217 (includes repeat measures) |
Outreach by individual contacts |
Number of persons contacted by gender Risk behavior by types |
7,672 |
Outreach by group contacts |
Estimated size of group Risk behavior by types |
398 |
Select demographics of clients tested | Gender and socioeconomic status Number of border crossings |
3,771 |
HIV tests and return numbers | Number of persons tested Number of persons who returned for results |
3,000 |
At the national level, the SPNS initiative enabled lead agency staff to learn about other CHCs providing services along the U.S.–Mexico border as well as about similarities and differences across SPNS sites, particularly with regard to populations served. It became evident that differences needed to be considered in planning HIV/AIDS services to meet the needs of the diverse Latino population living along the U.S.–Mexico border.
Additional lessons from the 5-year project are as follows:
A factor vital to the success of the Southern California Border HIV/AIDS Project was leadership participation in development of project goals at all levels. Both the project coordinator and evaluation team had strong community ties and an understanding of the cultural background of the target population. In addition, SYHC administration supported the goals of the project and the work involved in collaboration with other sites to achieve the goals of the SPNS initiative.
County of San Diego, Health and Human Services Agency, Public Health Services. (2007). HIV/AIDS epidemiology report 2007. San Diego, CA: County of San Diego. Retrieved June 15, 2007, from www2.sdcounty.ca.gov/hhsa/documents/AnnualReport2007final.pdf
Health Resources and Services Administration, HIV/AIDS Bureau. (2003). Advancing HIV/AIDS care along the U.S./Mexico border: A report on the Border Health Initiative. Rockville, MD: U.S. Department of Health and Human Services. Available at: www.ask.hrsa.gov/detail.cfm?PubID=HAB00326
Ramirez, R., & de la Cruz, G. P. (2003, June). The Hispanic population in the United States: March 2002. Current Population Reports (U.S. Census Bureau Pub. No. P20-545). Washington, DC: U.S. Department of Commerce. Retrieved July 2007 from www.census.gov/prod/2003pubs/p20-545.pdf
Ryan White HIV/AIDS Treatment Modernization Act of 2006, Pub. L. 109–415.
San Diego Association of Governments. (2000). Data warehouse. Retrieved August 8, 2007, from http://datawarehouse.sandag.org/default.asp?g=2&gs=35&t20=%2B&o=d&l=1.
San Diego Association of Governments. (2003). Census 2000 profile: San Ysidro Community Planning Area, City of San Diego. Retrieved June 15, 2007, from http://profilewarehouse.sandag.org/profiles/cen00/sdcpa1433cen00.pdf
San Diego Association of Governments. (2006). Population and housing estimates, Subregional Area 22: South Bay. Fast facts. Retrieved August 8, 2007, from http://profilewarehouse.sandag.org/profiles/est/sra22est.pdf
UCLA Center for Health Policy Research. (2002). The state of health insurance in California: Findings from the 2001 California Health Interview Survey. Retrieved August 8, 2007, from www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=28
U.S. Census Bureau. (2001). Census
2000 demographic profile highlights. Retrieved July 30, 2007, from http://factfinder.census.gov/home/saff/main.html?_lang=en
Outcomes** |
||||||
---|---|---|---|---|---|---|
Inputs* | Activities |
Outputs* | Initial | Intermediate | Long-Term | |
Program Goal I: Increase early detection of Latino/a population infected with HIV | ||||||
1a |
Clinicas de Salud del Pueblo
Imperial County
|
HIV education and testing outreach |
|
Increase number of persons tested 1. Local testing form |
Increase HIV+ access to primary care referral
|
Early identification of clients at risk for HIV infection and enrollment into primary care systems at earlier stage of disease |
1b | San Ysidro Health Center
|
HIV education and testing outreach |
|
Increase number of persons tested 1. Local testing form |
|
Early identification of clients at risk for HIV infection and enrollment into primary care systems at earlier stage of disease |
1c | Family Health Centers
|
HIV education and testing outreach |
|
Increase number of persons tested 1. Local testing form |
|
Early identification of clients at risk for HIV infection and enrollment into primary care systems at earlier stage of disease |
1d | Vista Community Clinic
|
HIV education and testing outreach |
|
Increase number of persons tested 1. Local testing form |
|
Early identification of clients at risk for HIV infection and enrollment into primary care systems at earlier stage of disease |
2 | SPNS coordinator
|
Implement referral program (access to testing) | Approximately 5,000 referral cards distributed (tracked in monthly report) | Number of clients who come for testing and indicate receipt of a referral card | — | Improved client access to and use of services |
3 |
|
Social marketing plan for four individual sites | Culturally appropriate marketing tools developed to reach at least 2,000 of target population | Number of clients indicating knowledge of marketing effort | — | Improved client access to and use of services |
Program Goal II: Increase access to comprehensive HIV primary care for individuals diagnosed with HIV/AIDS | ||||||
4 | SPNS coordinator
|
Strengthen referral network (includes referring clients for services in Mexico as well as United States) | Develop supplement to existing resource guide | Resource guide to be distributed to four CHC sites and a minimum of 20 county agencies | — | Improve system response by increasing access to primary care |
Program Goal III: Enhance capacity of ambulatory care/primary clinics to provide culturally effective care for individuals with HIV/AIDS | ||||||
5 | SPNS coordinator
|
AETC miniresidency | Clinic providers receive AETC training as needed | Provider needs and self-perceived confidence assessed | — | Increase quality of medical care |
6 |
|
Promote adoption of coordinated services (use South Bay Region model to promote clientcentered services) | Client-centered service model implemented in Clinicas de Salud del Pueblo (CSP) | Increase number of San Ysidro Health Center model core services at CSP | — | Increase quality of medical care and social services at CSP |
7 |
|
|
|
Increase in provider knowledge of delivering culturally effective care | — | Enhance quality of HIV primary care services and social services |
Many dissemination activities were conducted through-out the project period. Project dissemination included the following activities:
Adams, A., Miller-Korth, N., & Brown, D. (2004). Learning to work together: Developing academic and community research partnerships. Web Media Journal, 103(2), 15–19.
Aday, L. A., Anderson, R., & Flemming, G. V. (1980). Health care in the U.S.: Equitable for whom? Beverly Hills, CA: Sage.
American Foundation for AIDS Research. (2001). People with HIV face U.S. immigration ban. Retrieved August 6, 2002, from www.amfar.org/cgi-bin/iowa/news/record.html?record=70
Besser, R. E., Pakiz, B., Schulte, J. M., Alvarado, S., Zell, E. R., Kenyon, T. A., et al. (2001). Risk factors for positive Mantou tuberculin skin tests in children in San Diego, California: Evidence for boosting and possible foodborne transmission. Pediatrics, 108(2), 305–310.
Centers for Disease Control and Prevention. (2001). HIV testing among racial/ethnic minorities—United States, 1999. MMWR: Morbidity and Mortality Weekly Report, 50(47):1054–1058. Retrieved January 26, 2003, from www.cdc.gov/mmwr/preview/mmwrhtml/mm5047a3.htm
Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention, Division of HIV/AIDS Prevention. (2002). HIV/AIDS among Hispanics in the United States. Retrieved March 11, 2002, from www.cdc.gov/hiv/hispanics/resources/factsheets/hispanic.htm
Denzin, N. K., & Lincoln, Y. S. (Eds.). (1994). Handbook of qualitative research. Thousand Oaks, CA: Sage.
Doyle, T. J., & Bryan, R. T. (2000). Infectious disease morbidity in the U.S. region bordering Mexico, 1990–1998. Journal of Infectious Diseases, 182, 1503–1510.
Guendelman, S., & Jasis, M. (1992). Giving birth across the border: The San Diego–Tijuana connection. Social Science and Medicine, 34(4), 419–425.
Guendelman, S., & Jasis, M. (1990). Measuring Tijuana residents’ choice of Mexican or U.S. health care services. Public Health Reports, 105(6), 575–583.
Guzman, B. (2001). The Hispanic population (Census 2000 Brief). Washington, DC: U.S. Census Bureau. Retrieved June 15, 2007, from www.census.gov/prod/2001pubs/c2kbr01-3.pdf
Kaiser Family Foundation. (2004). State health facts online. Retrieved January 26, 2003, from www.statehealthfacts.org
Land,
H., & Hudson, S. (2002). HIV serostatus and factors related to physical
and mental well-being
in Latina family AIDS caregivers. Social Science
Medicine, 54, 157–159.
Notzon, S. (2004). Healthy Gente 2010: History and health measures. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Health Statistics. Retrieved July 2007 from http://www.borderhealth.net/notzon.ppt
Organista, K. C., Balls Organista, P., Garcia de Alba, G. J. E., Castillo Moran, M. A., & Ureta Carrillo, M. E. (1997). Survey of condom-related beliefs, behaviors, and perceived social norms in Mexican migrant laborers. Journal of Community Health, 22(3), 185–198.
Qualitative Solutions and Research. (1997). Non-Numerical Unstructured Data Indexing, Searching and Theorizing user guide. Thousand Oaks, CA: Sage.
Ruiz, J. D. (2002, March). HIV prevalence, risk behaviors and access to care among young Latino MSM in San Diego, California and Tijuana, Mexico (data presentation). Sacramento: California Department of Health Services, Epidemiology Branch, Office of AIDS.
Salgado de Snyder, V. N., Diaz Perez, M. J., & Maldonado, M. (1996). AIDS: Risk behaviors among rural Mexican women married to migrant workers in the United States. AIDS Education and Prevention, 8(2), 134–142.
San Diego County Office of AIDS Coordination and San Diego HIV Health Services Planning Council. (2002). Comprehensive plan for services 2004–2006 for people living with HIV/AIDS in San Diego County. San Diego, CA: Author.
San Diego County Office of AIDS Coordination. (2002). San Diego County AIDS cases: Regional proportion of cases by five year cohort, reported through March 31, 2002. San Diego, CA: Author.
Secretaría de Salud de México, Centro Nacional Para la Prevención y Control del VIH/SIDA. (2003). Epidemiología del VIH/SIDA en México en el año 2003. Retrieved January 26, 2003, from www.salud.gob.mx/conasida
Southern California Border HIV/AIDS Project. (2002). Unpublished data. University of California, San Diego.
United States–Mexico Border Health Commission. (2003). Healthy Border 2010: An agenda for improving health on the United States–Mexico Border. Retrieved June 10, 2004, from www.borderhealth.org/files/res_63.pdf
Van der Veer Martens, B. (2001) Research techniques for information management [Science and Technology Center Course: IST 501]. Syracuse, NY: Syracuse University. Retrieved June 10, 2004, from http://www.theorywatch.com/ist501/syllabus.html
Webb, C., & Kevern, J. (2000). Focus groups as a research method: A critique of some aspects of their use in nursing research. Journal of Advanced Nursing, 33(6), 798–805.
4 In this chapter, Latino refers to both men and women of Hispanic heritage, unless otherwise specified.