Latinos, now representing 13 percent of the US population, account for 19 percent of cumulative AIDS cases, and 20 percent of persons living with AIDS.1-3 The HIV/AIDS epidemic among Latinos is complicated by a host of interrelated factors that have bearing on how HIV/AIDS social service and prevention providers respond. For example, more than one in five (22.6%) Latinos live in poverty.4 Moreover, Latinos are more likely to delay care after HIV diagnosis, report competing needs and barriers to healthcare, and less likely to have private insurance than do Whites.5
HIV/AIDS social service and prevention providers who serve Latinos at risk for HIV/AIDS must keep programmatic pace with changes in the HIV/AIDS field and the specific needs of those most affected by the epidemic. Theory-based, culturally appropriate capacity building and technical assistance can serve a vital role in helping HIV/AIDS social service and prevention providers remain up-to-date, effective, and responsive to those they serve. This article describes an approach to building HIV prevention capacity of community-based organizations serving Latino communities in the western region of the United States, and the needs assessment process used to inform it.
Developing Capacity in the Use of Evidence-based HIV Prevention Interventions
Consistent with other public health sectors, the HIV/AIDS field has adopted an evidence-based orientation, especially given growing research to support the effectiveness of behavioral interventions in preventing HIV transmission. Efficacy studies of HIV prevention interventions provide a strong argument for their broad-based adoption,6-8 and their use by community-based organizations can play a crucial role in preventing HIV transmission.9 The Centers for Disease Control and Prevention (CDC) now recommends and promotes the use of 12 evidence-based HIV prevention interventions as part of its Diffusion of Effective Behavioral Interventions (DEBI) Project.7 Although some public health professionals view the scaled-up adoption of these evidence-based interventions as the standard in best practices for preventing HIV, transfer of this "technology" has been a challenge. Specifically, community-based organizations, obvious end users of scientifically produced HIV prevention technology, have been slow to embrace or have had trouble integrating these interventions within their respective programs.10
In the HIV/AIDS field, technology transfer refers to the translation of a scientifically tested or evidence-based prevention intervention for use in real-life practice settings. Successful translation can be characterized as the adaptation and adoption of an intervention to address the unique needs of consumers and end users (ie, the community-based organizations or health departments adopting the intervention) who may be different from the target populations and end users for which the intervention was originally intended. Adapting an intervention without seriously compromising the theoretical underpinnings of the intervention is a central feature of the successful translation because the main goal of translation is to facilitate the intervention's cultural acceptability while preserving those elements believed to be linked to the intervention's effectiveness.11
The Importance of Assessing Programmatic Capacity of Community-based Organizations
Community-based organizations play a critical role in the delivery of HIV prevention interventions given their capacity to locate and sustain meaningful relationships with populations that are at high risk for HIV infection. The quality and effectiveness of HIV prevention services, however, are mediated by a complicated interaction of organizational and environmental factors that can affect an agency's capacity to deliver its programs.12 For example, community-based organizations are often underfunded, smaller, and lack organizational infrastructure, experience, and expertise to routinely deliver and evaluate evidence-based HIV prevention programs.10 This is generally true for many Latino-serving community-based agencies in the United States. Because success in reducing HIV incidence is linked to community-based capacity to deliver effective services competently,13 understanding precisely what the programmatic capacity gaps are for a given organization is critical.
Methods
In 2005, AIDS Project Los Angeles (APLA), in collaboration with San Francisco State University's Cesar E. Chavez Institute (CCI), conducted needs assessment site visits and interviews with staff of the CDC-funded community-based organizations delivering HIV prevention services to Latino communities in the western region of the United States. The needs assessment was conducted to inform the content and modes for delivering APLA's CDC-funded capacity-building assistance program. One-day site visits were conducted with 10 of the 12 agencies directly funded by the CDC in this region. APLA and CCI developed an assessment protocol, which included an open-ended questionnaire administered during visits with a total of 16 mid-level management staff (ie, program coordinators and managers). The questionnaire was organized into five domains: general agency information, experience delivering evidence-based HIV prevention interventions, staff skills, Latinos and HIV prevention, and capacity-building needs/expectations. Questionnaire items are presented in Table 1.
The questionnaire was administered face-to-face by two capacity-building specialists, trained in nonprofit consultation and interviewing techniques as part of a weeklong staff planning and professional development meeting prior to the assessment site visits. One capacity-building specialist read the questions aloud in a conversational style interview while the other took notes. Although staff respondents were given a language choice for the interview (English or Spanish), all interviews were conducted in English. Interviews lasted between 90 and 120 minutes. All assessment site visits were completed in 3 months.
After the assessment site visits were completed, staff prepared case study reports for each organization that included background information about each agency and detailed summaries of the responses given to each of the questions posed during the interviews. The team then met, over a 3-month period, to review each of the case reports, read available literature on delivering technical assistance, and discuss possible implications of the findings for designing a capacity-building assistance approach.
Results: Capacity Needs in Technology Exchange, Program Development, and Evaluation
Findings from this needs assessment exercise provided insight into the programmatic capacity-building and technical assistance needs of HIV/AIDS prevention providers who work with Latinos. We learned that 8 of the 10 community-based organizations implementing HIV prevention interventions as part of the CDC's DEBI Project had no prior experience delivering evidence-based interventions. Staff from some of these organizations expressed frustration about the challenges they encountered in integrating evidence-based interventions into their respective program portfolios. One of the most common challenges described was the unavailability of specialized staff training and the length of time agencies had to wait before such trainings became available. One staff respondent commented, "Our staff did not feel trained enough to work with the population so we developed our own training." Other respondents commented about local health department and CDC educational materials review procedures and the length of time it takes to receive approval before being able to utilize the materials they developed. Moreover, staff respondents were frustrated by the conflicting guidance they were receiving from their local health departments and the CDC regarding how to adapt the evidence-based interventions they were trying to adopt. One program manager asserted, "Some of the health department suggested modifications to the intervention we are implementing seem careless, problematic, and depart from the intervention's design and the CDC's instructions."
Staff interviewed offered responses that were suggestive of possible content areas for capacity-building assistance. Specifically, we found that (a) 8 of the 10 community-based organizations visited had not adapted evidence-based interventions they were using at the time of our visit and were eager to receive training on how to tailor interventions with the aim of making them culturally appropriate; (b) 10 of 10 had not conducted formal needs assessment of their respective target populations and expressed a desire for technical assistance and training in how to conduct needs assessments; (c) all 16 staff respondents complained about the dearth of culturally relevant program tools and materials in Spanish and English; and (d) all 16 staff respondents expressed strong interest in receiving capacity building and technical assistance in one or more of the following topic areas: program development, evaluation, group facilitation techniques, consumer recruitment, client retention, and materials development. In addition, staff respondents shared how they hoped capacity-building assistance would be delivered. For example, respondents (a) communicated a desire for in-kind exchange and networking opportunities to share their experiences in using evidence-based HIV prevention interventions with other agencies delivering similar services and (b) expressed apprehension about the usefulness of capacity-building assistance given past experiences, which were not helpful. On this final point, one staff respondent commented, "I was reluctant to request assistance because in the past I would receive multiple letters from capacity-building providers with no clear explanation. The process seemed intimidating and confusing."
Discussion: Strategic Approach to Delivering Capacity-Building Assistance
Findings from assessment site visits lead us to believe that there are three clusters of prerequisite core competencies needed to integrate and sustain evidence-based HIV prevention interventions: (1) program planning, implementation, and development; (2) evaluation and needs assessment; and (3) culturally competent engagement of communities highly impacted by HIV/AIDS. Training and technical assistance in these areas can help to build and support capacity to deliver evidence-based HIV prevention interventions.
These findings also point to the need for carefully designed strategic approaches to delivering capacity-building assistance. APLA and CCI developed a theory-based, seven-pronged process of delivering capacity-building assistance we have named Accion Mutua (Shared Action). The seven components are (1) Establishing Strategic Partnerships; (2) Securing Stakeholder Involvement; (3) Facilitating Organizational Self-assessment; (4) Developing Culturally & Linguistically Appropriate Materials; (5) Delivering Interactive Training; (6) Providing Tailored Onsite Technical Assistance; and (7) Creating Professional Networking Opportunities. The importance of theory-based, principled approaches to delivering capacity-building assistance has been discussed previously in the literature on nonprofit organizational capacity.14,15 Each component is described more fully below.
Strategic partnerships
Evidence-based public health requires strong research-practice partnerships. In 2003, APLA entered into a partnership with CCI that aims to create democratic and reciprocal program development and research processes that bring multiple stakeholders (researchers, practitioners, policy makers, research participants, and service consumers alike) together in formulating research questions and solutions to problems of everyday living for the benefit of the people with whom we wish to work.16-19 APLA and CCI recognize the benefits of combining the resources of a respected academic institution with the equally respected expertise of an AIDS service organization that has delivered services to people living with or at high risk for HIV/AIDS for nearly 25 years.20 In doing so, we expanded our own capacity to assist other organizations. We predicate the importance of strategic research-practice partnerships upon the belief that such partnerships are likely to produce creative and sustainable programs,21 facilitate reciprocal learning, and reinforce evidence-based practice through collaborative program planning, implementation, and evaluation.22,23
Stakeholder involvement
Securing the input and buy-in from various stakeholders, both within and outside of particular organizations that utilize or may be in need of capacity-building assistance services, is critical to the success of the capacity-building process.15 APLA and CCI convene and support a regional community advisory board (CAB) as a strategy for securing stakeholder involvement. The CAB is interdisciplinary in composition and includes community-based HIV prevention providers from organizations receiving capacity-building assistance services, health departments, other capacity-building assistance providers, and university-based researchers. Our CAB plays a central role in quality management planning and represents a mechanism for soliciting feedback and input from various consumers of training and technical assistance services offered by APLA and CCI. The CAB meets quarterly (one face-to-face meeting and three conference calls) and advises APLA and CCI staff on all aspects of the program.
Organizational self-assessment: A mechanism for reflexivity
Assessing need is a key prerequisite to the delivery of all capacity-building assistance activities. Needs assessment activities should always include opportunities for organizational "self"-assessment or reflexivity. Organizational self-assessment activities help to frame the need for and expectations about capacity-building assistance. Self-assessment implies the active engagement of the consumer in a broader problem-solving process.23-25 In our view, community-based organizations should never be treated as the passive recipients of training and technical assistance. Ultimately, organizations that are actively involved in assessing their own needs are better overall consumers of capacity-building assistance services. Moreover, taking this approach allows us to model a needs assessment process that is different from a more top-down, unidirectional approach that is commonly utilized by community-based organizations with their clients. As discussed earlier, APLA and CCI use an assessment protocol that involves multiple and ongoing in-depth discussions with the staff and leadership of the participating organization that are designed to facilitate organizational reflexivity and facilitate action planning related to capacity building.
Culturally & linguistically appropriate materials development
APLA and CCI emphasize the development of culturally relevant and linguistically appropriate educational materials as an intricate part of the capacity-building assistance services we provide. We have and continue to create a series of consumer-oriented, bilingual fact sheets anchored in research about subpopulations that are highly impacted by the HIV/AIDS epidemic (ie, gay men and other men who have sex with men, injection drug users, women at sexual risk, and transgender communities). In addition, APLA and CCI have created topic-oriented technical bulletins, literature reviews, and informational materials on topics gleaned from needs assessment activities described above. These materials are used as centerpieces around which we have designed and implemented specific trainings. Some examples include materials with accompanying training on evaluation, needs assessment, group facilitation, client recruitment, and the delivery of culturally relevant services to Latino populations at greatest risk for HIV infection. Materials are also distributed regionally as a strategy to stimulate interest in training opportunities from other organizations.
Interactive training
Culturally appropriate training activities (ie, workshops, Web seminars, etc) are important in helping HIV/AIDS providers remain up-to-date, effective, and responsive to the social service and prevention needs of Latino communities highly impacted by HIV/AIDS. APLA and CCI utilize popular education strategies based on the work of Paulo Freire.26 Popular education is a form of adult education that encourages critical self-reflection and action for social change. Key characteristics of popular education include shared leadership in teaching and learning, use of learners' experiences and concerns, and high participation.27 Using these principles, APLA and CCI hold in high regard the professionals who participate in training activities and the expertise that they can bring to the learning process. We actively encourage training participants to tap into their own resources, knowledge, and on-the-job experience as a strategy for strengthening their programs.
Tailored onsite technical assistance
In addition to training, individualized onsite technical assistance is important for organizations that wish to address insights gained through self-assessment and/or operationalize specific ideas and concepts learned through their participation in training. Technical assistance can be tailored to the specific capacity needs of an organization. On a request-by-request basis, APLA and CCI assign capacity-building assistance specialists to agencies with consideration given to "goodness of consultant to organization fit." Using information collected from an organization's self-assessment, APLA and CCI determine goodness of fit by reviewing the following factors: technical assistance needs; staff skills and areas of expertise; staff availability; and an agency's time commitment. Technical assistance plans and goals are created in collaboration with staff participating in the consultation process. Technical assistance can involve individualized training of staff, management coaching, materials review or development, and linkage to additional resources as needed.
Professional networking
Opportunities for the exchange of expertise and professional networking can complement and reinforce training and technical assistance services already provided. Professional networking opportunities contextualize gaps in capacity and facilitate additional learning opportunities through interorganizational information exchange. Consistent with popular education principles, APLA and CCI adhere to a philosophy of learning that is experiential, strengths based, participatory, and democratic.28,29 APLA and CCI create professional, networking opportunities (ie, provider meetings, forums, etc) grouped by the target populations or intervention types several community-based organizations have in common. Professional networking opportunities can help to facilitate important collaborations and new interagency relationships necessary to strengthen organizational capacity.30
Implications
APLA and CCI sought to create an approach that is dynamic and flexible yet focused. The seven components of our approach rely on ongoing input from and exchange between various stakeholders, including organizational consumers, which we believe helps to keep capacity-building assistance not only dynamic but also more responsive. In addition, community-based organizations have multiple ways of engaging capacity-building assistance through the range of service activities available-materials, training, tailored technical assistance, and professional networking opportunities. The three clusters of prerequisite core competencies we have identified enable us to develop practical, focused, and easy-to-implement action plans for capacity building.
Finally, our approach to assessing needs through facilitating organizational reflexivity led us to formalize our self-assessment questionnaire. The Accion Mutua team is currently pilot testing the questionnaire with a larger group of organizations. This approach is receiving broad preliminary support from community-based organizations that find the process extremely helpful because of its open-ended and participatory qualities. Agencies even seem to welcome the idea of conducting self-assessment exercises in a group format with other organizations. In this respect, self-assessment exercises can become professional networking events in which organizations troubleshoot and problem solve collectively. The role of the capacity-building assistance provider in this model is to therefore facilitate a larger community process. Further research that broadens ideas about capacity-building and interorganizational exchange processes is needed. We hope to publish the pilot test findings and share the questionnaire with other capacity-building assistance providers in the near future.
The approach described in this article is limited by the small number of community-based organizations we visited and staff we interviewed during our needs assessment exercise. Although our interviews with mid-management-level staff yielded important information about their needs and subjective experiences as HIV prevention providers, these findings may not be generalizable to other community-based organizations. In addition, the approach we chose to adopt was developed in the context of the specific relationships we have formed with these organizations, and therefore make sense in the context of those relationships. Great care must be taken when applying these ideas in different contexts. We hope that the concepts reflected in this article are useful in formulating varied approaches that are tailored to the specific needs of the capacity-building assistance consumers in question.
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