Developing Approaches to Reduce the
Risk of HIV/AIDS Infection in
Farmworkers
Ricky Wascher-Tavares
Border Health Foundation
Kattrina Hancy, MPH
Farmworker Justice
Midwest Stream Farmworker Health Forum
November, 2010
Learning Objectives




List three risk factors that increase farmworkers’ risk
of HIV infection
Name at least two community or group level HIV
prevention programs
Summarize the steps needed to effectively adapt
an evidence based intervention to address the
needs of migrant farmworkers
Identify technical assistance resources
HIV/AIDS and Farmworkers
HIV/AIDS and Latinos

Hispanic/Latinos are disproportionately impacted by
the HIV/AIDS epidemic
16% of the U.S. population
 18% of people living with HIV
 17% of all new infections



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Rate of new HIV infections among Latino men is more
that double that of white men
Rate of new HIV infections among Latina women is
nearly four times that of white women.
Farmworkers are likely to have a similar profile
HIV/AIDS and Farmworkers


Seroprevalence rate of HIV/AIDS in farmworker
communities is unknown.
The vast majority of the epidemiological data on HIV
prevalence among farmworkers is based on small, local
studies, the majority done more than a decade ago.
In 1992, the Centers for Disease Control and Prevention
found a prevalence rate of 5% among 310 farmworkers
tested in Immokalee, FL.
 A few other small studies have reported rates ranging from
0.47% to 13%.

HIV Risk Among Farmworkers
Their Circumstances

Socioeconomically marginalized

Their Actions

Low wages, poverty, poor
housing, lack of health insurance

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Separated families

Social and geographic isolation

No or weak social support

Limited education and
English/Spanish language
proficiency



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Lack of easy access to culturally
competent health services
Immigration status
Sex with commercial sex
workers
Unprotected sex with
regular female partners
Multiple sex partners
Frequent alcohol use
Community-Level Interventions

Group-level Interventions
 Group-level
interventions seek to change individual
behavior within the context of a group setting.

Community-level Interventions
 Community-level
interventions seek to change attitudes,
norms, and values of an entire community/target
population as well as social and environmental context
of risk behaviors of the target population/community.
Adaptation
Making Evidence-Based Interventions Work
for
Migrant Farmworkers
Key Definitions
1.
2.
3.
4.
5.
6.
7.
Core Elements
Key Characteristics
Internal Logic
Re-Invention
Risk Factors
Risk Behaviors
Adaptation
Adaptation
The modification of an intervention without
competing with or contradicting its core
elements or internal logic.
The intervention is modified to fit the:



Cultural context in which it will be implemented
Individual determinants of risk behaviors of the target
population
Circumstances of the agency and other stakeholders
Adaptation
Adaptation may involve
modifications in:





Who receives the intervention
Where it is delivered
When it is delivered
What is addressed
How the message is presented
The Steps (MAP)
1.
2.
3.
4.
5.
Assess the target population, the evidence-based
intervention being considered and the capacity of
the implementing agency
Select the intervention that will work best for the
target population and for the agency
Prepare the intervention for the new population
and prepare the agency
Pilot the adapted version of the intervention
Implement the adapted intervention with fidelity
Map of the Adaptation Process (MAP ) (McKleroy et al. 2006)
Assess





Knowing your target population (e.g., formative
research - needs assessments, focus groups,
stakeholder interviews, etc.)
Knowing proposed evidence-based intervention (e.g.,
intent, internal logic model, original population, etc.)
Considerations for agency (staff capacity, produce
culturally sensitive material, develop role model
stories, apply condoms, etc.)
Checking if the evidence-based intervention will work
(goodness of fit chart)
Stakeholder buy-in
Select
Make a Decision:


Decide to adopt, adapt, or select another
intervention
Build capacity with subject matter and
implementation skills

Consult with the community regarding the decision

Consult with staff regarding the decision
Select
Once these decisions have been made, the
agency should begin the process of
seeking to increase their capacity in areas
noted in the “goodness of fit chart” chart
and during the assess step were they are
weak and to further increase their skills
with regards to the intervention
Prepare

Make necessary changes to the evidence-based
intervention

Begin organizational preparation

Pre-Test

Adjusting the intervention
Prepare
Things to Consider



Culture and Language
Communication
Twin Cs of Adaptation:
Competitive – if even one Core Element was compromised:
STOP
 Consistent – if Core elements are maintained, then all
systems are GO


Logic Model Development
Pilot
Create an Implementation Plan

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Target population
Risk factors
Behavioral determinants
Risk behaviors
Core elements
Key activities
Anticipated immediate
outcomes






Anticipated long-term
outcomes
Schedule of
Evaluation/Monitoring
activities
Program’s goals
Program’s objectives
Who is responsible for what
Detailed timeline
Pilot
Create an Evaluation Plan



Process monitoring (e.g. characteristics of population
served, services provided and resources used)
Process evaluation (e.g. how the intervention was
delivered, differences between the intended
population and the population served, and access to
the intervention)
Outcome monitoring (e.g. client outcomes before and
after the intervention, such as knowledge, attitude,
skills or behaviors)
Pilot


Make sure agency is ready
Implement intervention on a small scale with
subgroups to assess adaptability, usefulness and
fidelity
 Each
core element
 Entire intervention

What do you want out of your pilot test?
Pilot
Components of a successful pilot include:




Fidelity to core elements and internal logic of the
adapted intervention
Some movement toward intermediate outcomes
(intentions)
Staff implementation with quality
Participation and positive feedback from
participants
Implement
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Collect process measures on adapted intervention
implementation
Conduct process monitoring and evaluation on
adapted intervention implementation
Collect intervention outcome measures
Conduct outcome monitoring and evaluation
Provide routine, ongoing supervision (including quality
assurance)
Make small changes as needed to staff and
intervention based on process evaluation findings
Use available technical assistance
Group Level Interventions

Safety Counts

Voices/Voces
Safety Counts
Safety Counts is:
An HIV prevention intervention for out-of-treatment
active injection and non-injection drug users aimed at
reducing both high-risk drug use and sexual behaviors
The core elements are:
Group sessions 1 and 2; social events (min 2); individual
counseling session (min 1); follow up contacts
(min 2); counseling and testing
Safety Counts
Group
Session
One
Group
Session
Two
Social Event
One
Months 2, 3, 4
Individual
Counsel.
Session
Follow-Up
Contact
One
Follow-Up
Contact
Two
Social Event
Two
HIV/STD Counseling and Testing Services
Post-Program Interview
Program Enrollment Interview
Month 1
Safety Counts
WHO – Drug users (within past 90 days), adults, not in
treatment
WHERE - Office (training room), community center, etc.
WHEN - 4 months (time of day depends on clients)
WHAT – HIV and viral hepatitis, risk reduction
HOW – Risk reduction success stories (audio, video,
written)
Safety Counts
Safety Counts
BHF Adaptation
Who
Drug users (past 90
days), adults, not in
treatment
Migrant farmworkers that use
drugs
Where
Office or community
center
Home of a former migrant
farmworker
When
Four months;
Time of day unspecified
Two months;
Early evenings
What
HIV and viral hepatitis
risk reduction
Strong emphasis on HIV/STD
101
How
Risk reduction success
stories
Fotonovelas
VOICES/VOCES
VOICES/VOCES is:
A single-session, video-based HIV/STD prevention
workshop designed to encourage condom use and
improve condom negotiation skills among AfricanAmerican and Latino adults.
The core elements are:
Viewing of culturally-specific videos; small-group skillbuilding sessions; condom feature education;
distribution of sample condoms
VOICES/VOCES
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
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
WHO – Heterosexual African-American and Latino
men and women
WHERE - Office (training room), community center,
etc.
WHEN – 45 minutes (time of day depends on clients)
WHAT – Condom education and negotiation skills
HOW – Group discussion, condom board, culturally
relevant video
VOICES/VOCES
BHF Adaptation:

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WHO – migrant farmworkers (men and women)
WHERE - Migrant housing unit
WHEN – 60 minutes/evenings
WHAT – Condom education, negotiation skills,
HIV/STD information
HOW – Group discussion, condom board, culturally
relevant video
Community Level Interventions

Promotores de Salud

Popular Opinion Leader
Roots of Promotores Programs



Community health worker/Promotores de Salud model is
used widely in Mexico and other parts of Latin
America, in areas where doctors are in short supply.
Borrows from popular education theories which
encourage teaching adults by drawing on their life
experiences in order to empower them to solve their
own problems.
Many migrant farmworkers who come to the U.S. from
Mexico and Central America are familiar with the
Promotores model.
Need for Promotores
Promotores de Salud can play a critical role:
 Bringing underserved populations important health
messages and information about available health
services
 Connecting people to health care who have not had
ready access to or felt comfortable utilizing health
care services
 Increasing the availability of culturally and
linguistically competent health services
Activity: La Mano
5 things I know
about
promotores
Characteristics of Promotores
Promotores…
 Are usually drawn from the target population, sharing
the same language, culture and customs as those they
are willing to reach
 Are often willing to work evenings or weekend hours
 Can reach out to community members wherever they
are located and they normally gather
 Are trained to communicate health specific messages in
a manner the target community can understand
 Readily develop relationships of trust with the
community.
Development of a PdS Program


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
Planning
Formative research
Materials development
Field testing
Evaluation and follow-up
Development Process



Planning: Identifying areas of interest/need in the
community, and assess agency resources
Formative Research: Literature review, focus group
discussions, in-depth interviews
Materials Development: Use formative research
findings to develop materials for use by promotores.
Pre-test the materials with community members, and
modify materials based on feedback.
Implementation and Evaluation Process


Fielding Testing: Capacity building with promotores
de salud to implement project, monitor and provide
support.
Evaluation and Follow-up: Develop evaluation
tools at the beginning of process, train promotores
on the importance of evaluation and how to
implement the tool with the community, and
disseminate evaluation findings.
Promotores Program Materials

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
Training curriculum
Manual for Promotores
Materials to distribute
Evaluation materials
Popular Opinion Leader (POL)




An effective behavioral
intervention currently being
promoted in the CDC DEBI project
Originally implemented with gay
men in Mississippi in the 1980s
How it works: Friends influence
friends to instill a risk reduction
norm among themselves
Has been widely adapted with
new target populations, including
with farmworkers
Young Latino Promotores Project (YLP)

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
Based on POL intervention
YLP targeted young, migrant, Latino Men Who
Have Sex With Men (MSM)
Incorporated concepts from the promotores de salud
model
Took place in Vista, CA and McAllen, TX
 Vista Community Clinic and Valley AIDS Council
were Farmworker Justice’s local partners
Considerations for Adapting POL for
Migrant Latino MSM





Project Staff
Language and
Literacy
HIV Knowledge
Sexual Orientation
Other Considerations
Project Staff and Volunteers

Familiar with local Latino issues and norms

Comfort working with migrant community

Bilingual in Spanish and English

Latino MSM served as project coordinators
Adaptation: Language and Literacy

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Surveys in Spanish and English
POL training sessions and materials in English and
Spanish
Activities and lessons were designed to
accommodate people with low literacy skills
Focused on communication skills with Latino
audiences and changed role play situations
Presented underlying theory briefly and in simple
terms
Adaptation: HIV Knowledge

Community discovery
process revealed low HIV
knowledge, requiring
certain curriculum
modifications:
 Expanded module on
HIV
 Addressed prevailing
and persistent myths
about HIV in the
community
Adaptation: Sexual Identity



Added session on sexual identity and sexual
orientation
Addressed stigma and discrimination associated
with behaviors
 Sexual
 Communicative
Adapted module on sexual health
 More information on other STIs
Young Latino Promotores Project


Initial community surveys showed that more than
60% of the target group engaged in unprotected
sex
Results after 2 and 3 years:
 Increases
in frequency of condom use in receptive anal
sex
 Myths about HIV transmission were reduced
Capacity Building Assistance

What is Capacity Building Assistance

Technical Assistance

Contact Us!
What is Capacity Building Assistance
A way of providing
organizations with additional
skills, training, or technical
assistance to enable them to
improve delivery of services.
Capacity Building Assistance (CBA) is available free to any
organization interested in implementing an evidence-based HIV
prevention program or promotores de salud program, who would
like additional help getting that program off the ground.
Technical Assistance

AIDS Education and Training Centers


Prevention Training Centers


Centers across the country with specialists for rural providers
Regional centers in Berkeley, CA; Rochester, NY; Denver,
CO; and Dallas, TX.
CDC Capacity Building Branch

Funds CBA providers nationwide to help organizations
develop, implement, and evaluate effective HIV prevention
programs

Farmworker Justice and Border Health Foundation are
organizations funded by CDC to provide CBA
Questions???
Thank You!!
Farmworker Justice
Border Health Foundation
Kattrina Hancy, MPH
Ricky Wascher-Tavares, Project
Director
Capacity Building Assistance Project
[email protected]
Project Coordinator
Poder Sano
[email protected]
1126 16th St. NW, Suite 270
Washington, DC 20036
3365 N. Campbell Avenue, Suite 141
Tucson, Arizona 85719
(202) 293 – 5420 ext. 313
www.podersano.org
www.farmworkerjustice.org
Toll Free 877.749.3727, Ext. 24
www.borderhealthfoundation.org
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Migrant Farmworkers` Risks of HIV/STD Infection and Developing