Critique of an Initiative to Train Peers to Help HIV-Positive People Link to Care and Adhere to Treatment
Part I: An analysis based on the ecological model
INTRODUCTION
The initiative
No one understands the reality of HIV better than someone who lives with it every day. Matching a newly diagnosed individual with an HIV-positive peer from that person’s community who has been successful in adhering to treatment has been found to be a promising strategy for helping HIV-positive individuals link to care, adhere to HAART (Highly Active Antiretroviral Therapy) regimens, or return to care if they have dropped out (1). Working as part of an interdisciplinary care team, peers provide a wide range of practical and emotional support services to clients. Recognizing the success of peer programs as an effective treatment adherence intervention (2), particularly among underserved, minority and marginalized populations, the Minority AIDS Initiative (MAI) and U.S. Health Resources and Services Administration (HRSA) funded an initiative in 2005 designed to help health care organizations nationwide establish peer programs to serve their HIV-positive clients. The peer initiative consists of four separate grants: three to national peer education centers, and one to a central resource and evaluation center, called the PEER Center.
The three national peer education centers, each of which has experience with a successful peer program, provide peer training and capacity-building expertise to organizations seeking to establish peer programs. Their efforts are supported and coordinated by the PEER Center, a collaboration between the Boston University School of Public Health’s Health & Disability Working Group (HDWG) and the Justice Resource Institute (JRI). The PEER Center conducts evaluation for the project and draws on the expertise of the three national centers to provide capacity-building resources for organizations who want to establish peer programs.
Now in its third year of a five-year grant, the PEER Center has conducted a nationwide needs assessment of health care organizations with respect to peer programs, collected extensive data on the peer training and peer-client interactions of the three national centers and their associated peer programs, created a website which provides resources and information about peer programs to organizations (www.hdwg.org/peer_center) (3), and is actively promoting the establishment of peer programs through conference presentations, webinars, an email newsletter, and contacts with partners at the national centers. It is also in the process of creating an online peer training-of-trainers (TOT) toolkit which provides best practices, curricula and materials drawn from the three national centers. The toolkit is intended as a resource for trainers, peer supervisors or program directors in organizations who want to train new peers or expand the skills of their existing peers who work to engage and retain people living with HIV in the health care system. The TOT toolkit focuses on three core competencies which peers need to carry out this mission: HIV-related information, communication skills, and the role of the peer within an interdisciplinary care team.
Methods
This paper focuses on the TOT toolkit, examining the role of peers as it is portrayed in the toolkit and how well the toolkit addresses the requirements of the organizations it is intended to serve. It examines this toolkit in the context of the peer initiative based on the ecological model (4-5) to determine its strengths and limitations. It looks at how well the initiative as a whole and the toolkit in particular addresses individual, group, structural, political and environmental factors related to combating HIV disease, focusing on program interactions at two levels: 1) at the peer-client level, assessing the roles for which peers are trained to work with clients, as laid out in the peer training toolkit, and 2) at the center-organization level, assessing how well the toolkit meets the needs of the organizations it is designed to serve.
Summary
The TOT toolkit will be a valuable resource when it is released next year, and organizations who want to establish peer programs have expressed interest in gaining access to it. However, there are three ways in which it could be improved: 1) by providing modules intended to provide greater support for clients generally by leveraging the client’s existing network, combating the effects of stigma, and providing ideas for greater support to rural clients who have difficulty in reaching care 2) by focusing more attention on the cultures and challenges of the various organizations whose clients would benefit from a peer program, with an eye to providing curricula more closely tailored to the peer training needs of these organizations and 3) by expanding the TOT toolkit to include curricula which support additional peer roles, reflecting the range of roles peers play within various AIDS service organizations and a more holistic approach to addressing HIV disease.
FACTORS AT THE INDIVIDUAL LEVEL
Program strength: individual behavioral theories appropriately used
Treatment adherence varies widely according to an individual’s circumstances, so it is appropriate that much of the peer-client interaction is focused at the individual level. In the peer-client relationship as envisioned by the peer initiative, the peer provides both emotional and practical support to the individual client in her attempts to learn to cope with the daily stresses of living with HIV. This peer-client relationship of care builds on the strengths of several behavioral theories which are appropriate to interventions focused at the individual level.
For example, the peer is trained to provide the client with information about the HIV life cycle and how medications work to slow the disease progression, as well as brainstorm ways to solve problems integrating treatment into the client’s daily life. This intervention appropriately uses the Health Belief Model (6-8) to influence a client’s perceived severity of the disease, perceived benefits and costs of adherence, and sometimes a client’s perceived susceptibility to the disease—despite an HIV-positive diagnosis, clients are sometimes in denial about having contracted the disease, especially in the absence of symptoms.
The TOT toolkit also makes effective use of the Transtheoretical Model (9) to help the peer work with the client to move through the process of adopting treatment adherence behavior. For example, one training module outlines the five stages of change—precontemplation, contemplation, preparation, action, maintenance—so the peer can identify where in the process of adapting to treatment a client is. If a client is in the stage of “contemplation: the client wants to change behavior within the next six months,” the peer will provide a different type of support than if the client has already met with a doctor and started a treatment regimen.
FACTORS AT THE SOCIAL/CULTURAL/GROUP
Program strength: Good use of Social Cognitive and Social Network Theories
At the Social/Cultural/Group level, the peer initiative makes good use of Social Cognitive Theory (10-11) principles to encourage client treatment adherence. As someone who is not only effectively adhering to treatment himself but also helping others to do so, the peer is a strong role model to individuals new to treatment. As one peer described it, “You have to let the client know that you are like them, that you have gone through these things before and that if you can go through it, they can go through it. (12)” By coaching the client, the peer reinforces the client’s efforts and helps shape his adherence behavior. This also strengthens the client’s self-efficacy; as the peer and client work through adherence issues together step by step, the client sees that she is able to manage a new behavior that may have seemed overwhelming at the start. Conversely, being a role model to others reinforces the peer’s own self-efficacy and motivation to adhere to treatment as well as increasing her self-esteem.
The behavioral theory which is most apparently at work in the peer-client intervention, however, is the Social Network Theory (13-17). The peer acts as a non-judgmental “natural helper” in the client’s social network. As a member of the client’s community, the peer often shares the same background, experiences, cultural assumptions, and language as the client and provides a communication channel that the client is more likely to understand and accept. This is the major strength of the peer-client interaction and has generally proven very effective. (One caveat, however: One must be careful not to assume that because two people share the same culture, they will work well together or trust each other. The interplay of individual factors is complex--two people from the same culture may find themselves on different sides of a political dispute; two people from the same country of origin may be from rival ethnic groups within that country (18).
Critique #1: More focus on helping the network to support the individual’s behavior
It is in the application of the Social Network Theory that one limitation of the peer intervention manifests itself: although the TOT toolkit provides peer training around helping clients disclose their status to family and friends and encouraging clients to build a support network, it does not address support or education for members of the client’s network. While the decision whether or not to disclose one’s status is a personal one and not every HIV-positive person chooses to let family and friends know his status, individuals who do disclose their status to those close to them have been shown to have a better quality of life (19). In these cases, providing support and education to family members and friends affected by HIV can be a powerful tool in helping to strengthen the client’s adherence behavior. It can also help reduce stigma within the community by providing information, dispelling myths, and exploring/influencing the community’s perceptions and social norms around HIV/AIDS. Leading support groups and participating in programs for family members and others affected by HIV is a role which HIV-positive peers within community-based organizations sometimes take on. For example, Christie’s Place in San Diego, CA, a community-based organization “for families and individuals living with HIV/AIDS (20),” offers peer-led support groups and organized events targeted to children of HIV-positive people or HIV-positive individuals and affected family members. Providing training modules and tools within the TOT toolkit to train peers to take on this role would provide a valuable resource to organizations who want to train peers to provide support to a client’s network.
Critique #2: More focus on contexts of various organizations
Critics of the Social Network Theory point out that it is a limited intervention which works at a small group level but does not lend itself to broader application (21). The peer initiative seeks to overcome this limitation by helping organizations throughout the country to start or strengthen peer programs. The initiative encourages the replication of peer programs in a wide range of organizations—clinics, community-based organizations, AIDS service organizations—yet it has made limited efforts to understand the cultures and challenges of different types of organizations or in different regions of the country. The program would benefit from using anthropological methods to learn more about the climate and challenges of these organizations in order to develop resources more closely targeted to helping these organizations overcome some of the issues they face in implementing a peer program.
For example, the South is the primary focus area for capacity-building efforts because of the rapid expansion of HIV infection in the region. Hence the PEER Center conducted a needs assessment of Ryan White Care Act Parts A, B, C, and D grantees in the South based on a questionnaire. However, this questionnaire provides little in the way of open-ended questions or opportunities for uncovering issues not specifically addressed by the questions in the questionnaire. Yet through conversations with organizations in the South, PEER Center members have learned that stigma is a major barrier not only in adherence to treatment but in recruitment of peers. Further, one of the national education centers has observed that HIV care efforts are often undertaken by faith-based organizations in the South. These organizations are likely to have very different requirements for peer training and peer roles within their organizations than peer programs in clinical settings or California-based community organizations, which is where the peer initiative draws its expertise. By systematically asking more in-depth questions and gathering more qualitative data (22) about the various kinds of organizations being targeted, the PEER Center can begin to gain a richer understanding of the assumptions, constraints and challenges under which these organizations operate. This would help in the identification of underlying causes which may prevent these organizations from establishing a peer treatment adherence program for their clients.
One tangible outcome of a more in-depth study of organizations might be the creation of new models for peer programs. Currently the peer initiative presents target organizations with two models for peer programs: an internal model, where the organization manages its peers as employees within the organization, and an external model, where peers act as external consultants managed by an outside organization. This distinction has proven valuable to some organizations who want to develop a peer program but have insurmountable obstacles in employing peers as part of their organization. The external model was developed based on the experience of the WORLD (www.womenhiv.org) (23) program, a community-based organization with a different organizational culture and mission from the peer programs associated with the other two national centers, both of which operate in a clinical setting. By learning more about the context of different organizations, the PEER Center may be able to come up with additional models that would address challenges these organizations have encountered.
Within the context of the TOT training manual, a more in-depth understanding of various kinds of organizations seeking to start peer programs would help the PEER Center create several pre-packaged model curricula according to prevalent organizational profiles. This would give the organization a more comfortable starting point than simply looking at the more than 150 training modules available to them to try to decide which ones would meet their organization’s need for peer training.
FACTORS AT THE SOCIOECONOMIC/STRUCTURAL LEVEL
Program strength: navigating the system
Factors at the socioeconomic level include the effects of poverty, education, access to care and services and social stressors on HIV treatment adherence. One area of strength of the peer-client interaction is the one-on-one support clients receive to navigate a sometimes bewildering maze of health care and social services, many of which the client may not trust or understand. Peers often accompany clients to doctor, dentist or social service appointments and help clients ask appropriate questions and understand the doctor’s advice. Peers also make referrals to case managers and other members of the care team to address issues of housing, food security and other practical assistance—although the support the client receives is only as good as the services the referring agencies provide, which vary greatly.
Critique #3: Not adequately addressing stigma and physical distance
Two social stressors affecting peer programs generally and more particularly in the South are stigma within the community and isolation in rural areas. The stigma surrounding HIV prevents people from getting tested, seeking care if they are diagnosed with the disease, revealing their status to family and friends, and adhering to treatment. People who live in fear of being stigmatized may suffer from low self-esteem, depression, and even unemployment and loss of income, all of which contribute to poor health and lower quality of life. Furthermore, if a person has more than one stigmatizing condition, the chances of that person suffering from these effects is greatly increased (24).
As members of a group which is stigmatized, peers are in a unique position to play an advocacy role in combating stigma. Peers may provide a voice of authority at churches, schools and other pubic forums when issues of stigma are addressed. They produce and perform plays with anti-stigma themes. They conduct interviews to obtain evidence to inform policies which protect the rights of people living with HIV (25). They combat stigma within the health care system by serving on consumer advisory boards. While the continuing education section of the TOT toolkit includes one module which discusses the effects of stigma, it does not provide training in peer roles of advocacy and public speaking; including ideas for the contributions peers can make to reducing stigma within the community would provide an additional resource to organizations most impacted by this issue.
In rural areas, the problem of stigma is exacerbated by long distances between clients, health care facilities and other services. Clients often lack transportation to distant HIV health care facilities; they may be afraid to accept affordable transportation when it is offered for fear of being identified as HIV-positive by neighbors (26). The backbone of the peer-client intervention is face-to-face meetings; meetings are often coordinated to coincide with a client’s doctors appointments. The PEER Center could extend the reach of peers by including resources and peer training which provide ideas for alternative networking opportunities, such as regular phone meetings or computer-assisted peer interaction for clients with access to phone or computer.
FACTORS AT THE POLITICAL AND ENVIRONMENTAL LEVEL
Critique #4: Separate sources of funding lead to limitation in roles for which peers can be trained through the toolkit
Perhaps the biggest limitation of the PEER Center initiative occurs at the political level. The PEER Center and the three national centers are funded through the Minority AIDS Initiative which provides funds to HIV/AIDS service agencies to “improve HIV/AIDS-related health outcomes for racial and ethnic minority communities disproportionately affected by HIV/AIDS (27).” The initiative is administered through HRSA’s HIV/AIDS Bureau, which focuses on supporting care and support services to people infected with and affected by HIV/AIDS. As such, prevention efforts administered through HRSA are targeted to HIV-positive individuals, not to the larger community. Peer prevention initiatives targeting a broader community are separately funded and implemented by the Centers for Disease Control (CDC). Each of these organizations has its own procedures, reporting structures and evaluation mechanisms.
Yet increasingly there has been a call for closer integration between prevention and care among communities combating the disease. Last year for World AIDS Day, three staff members of the World Health Organization put out a joint statement that “linking treatment with prevention remains an overriding and critical public health challenge for the health sector (28).” In a recent article, Remien, Berkman et al. recommended a strategic approach to controlling the epidemic by supplementing increased testing with integration of HIV prevention into HIV care settings (29). This kind of integration of prevention and treatment takes place at the community level; community-based AIDS organizations may include outreach, prevention and consumer advocacy programs, and peers may play a part in all of these areas. At the funding level, however, these functions remain separate. Hence the TOT toolkit focuses on training peers for treatment adherence and linkage to care programs, but not for a role related to prevention within the community. Yet in the needs assessment which the PEER Center conducted, one community-based organization in South Carolina stated that they would like to use peers for “outreach, testing, prevention, helping clients with treatment adherence, and support and counseling.”(30) This organization will need to supplement the TOT toolkit in its current format with additional resources to meet all of its peer training needs.
Several of the training modules included in the TOT toolkit lend themselves to expanded peer roles of prevention and advocacy within the community. The harm reduction and “prevention for positives” modules, for example, include training in many prevention issues, such as negotiating use of condoms and reducing or eliminating risk behaviors. Modules on workplace issues address many factors that are common across roles, such as general communication skills, communication with coworkers and supervisors, adjusting to a professional work environment, and locating resources for further professional development.
A more holistic approach to fighting HIV/AIDS would involve peers at all levels of intervention. The presence of HIV-positive peers in the community who are willing to share their status and stories of how stigma has affected them empower others to put aside their fears, get tested, or seek treatment if they have been diagnosed with HIV. Peers serve as proponents of HIV-prevention efforts and are strong advocates for HIV testing. More testing leads to earlier detection of HIV disease, resulting in better outcomes. Having peers available to those individuals who are diagnosed with HIV and entering care or who are trying to return to care after having dropped out is another step in a continuum of interventions where peers may play a critical role. Restricting the TOT toolkit to a treatment-adherence peer role without recognizing the additional roles peers may play within an organization limits its usefulness. Organizations hoping to use it as a “one-stop-shopping” resource for training their peers will need to supplement it with additional resources.
CONCLUSION
Learning to live with HIV as a chronic disease is a complex behavior, requiring extensive support at many levels. Clients often require ongoing support from their network of family, friends, and health care and social service providers in order to stick to their regimens. Working as a peer is challenging as well, requiring extensive support from supervisors and others within an organization. Organizations themselves benefit from support and expertise to maintain a successful peer program. The peer initiative goes a long way to providing support at all these levels, either directly or indirectly. But the initiative generally and the TOT toolkit specifically could be improved by strengthening these supports through 1) increased recognition of the needs of the client’s support network as well as the unmet needs for support of isolated rural clients 2) a more tailored response to organizational needs with respect to peer programs through a closer examination of those organizations, and 3) an expansion of peer roles to include prevention and advocacy within the community. The TOT toolkit is in the early stages of development and testing. As organizations begin to apply it to their peer training programs, many of the ideas outlined here may well be incorporated as a result of feedback from those organizations.
SB721
Written Assignment 4
Dec. 11, 2008
Edi Ablavsky
Part II: Enhancing the peer intervention through use of Social Network Theory, Sociological and Anthropological Research Methods and Social Marketing
Introduction
To this point, I have identified four limitations of the peer initiative. They are 1) a lack of focus on the family and friends of people living with HIV as a source of support to clients 2) not addressing the issue of isolation and stigma among rural clients who may have limited access to peer support 3) the need to better understand the requirements of organizations wanting to implement or strengthen peer programs and 4) a limitation in the kinds of peer roles the initiative can address because the funding source limits the peer role to linkage to care and treatment.
Social Network Theory-based interventions to increase social support for people living with HIV
I would address the first two limitations—lack of focus on social network of people living with HIV, and the issue of clients in rural areas with limited access to peer support—using approaches based on the Social Network Theory. This theory posits that the people in a person’s social network have a profound influence on that person’s behavior. I see three ways in which this theory could be used to expand the reach of peers to serve remote clients:
1) Enlist the support of people in the social network of HIV clients by reaching out not only to people infected with HIV but to those affected by it: the network of family and friends surrounding the infected person. For clients who are willing to disclose their status to family and friends, establishing a peer-led support group to educate those members of the person’s network about HIV and how to best support people living with HIV would serve to strengthen the client’s adherence behavior. It would also serve the crucial role of reducing the stigma of the disease through a better understanding, thus changing the norms within the person’s social network and the community. In one recent study, in a majority of the participating families with an HIV-infected parent, family members expressed fears about the spread of HIV in the home (31). Clearly these families would benefit from additional support and education, as well as the client. While this intervention is beneficial to HIV-positive clients regardless of where they live, it would be particularly helpful to rural clients; if a client lives too far away to meet with a peer on a regular basis, enlisting the support of the client’s social network would provide many of the same support functions that a peer would.
2) Create a “buddy system” where two clients living in the same remote area could serve as peers to each other, providing each other with support and making sure they take their medication. This is a strategy being used in resource-limited settings with some success (32).
3) Expand the definition of “networking” to include the Web and other devices. Peers working with the three national education centers have reported using mobile phones to contact their clients with some success. Use of the Internet is more problematic, since less educated, economically disadvantaged and socially marginalized people are least likely to have access to a computer. Nevertheless, access is increasing, and for some rural clients, Web-based applications which provide some of the same kind of health education that peers offer may be a viable alternative (33). Communicating with peers via email or participating in social bulletin boards, such as those found on thebody.com (34), a popular website for information about HIV/AIDS, might be a source of support and connection for some remote clients.
Once these models of support for client networks and rural clients have been developed, the PEER Center training of trainers and capacity-building toolkits could be expanded to include modules to address these additional roles for peers, making them available to organizations who want to include them in their programs. The PEER Center could also use its knowledge of best practices in peer programs to develop interactive Internet-based programs to address some of the roles that peers play, particularly around HIV education.
Using sociological and anthropological methods to research organizations seeking to start peer programs—the first step in a social marketing campaign
In part I, I argued that a better understanding of the kinds of organizations who would benefit from starting or enhancing a peer program was needed in order to address the peer program requirements of these organizations. Researching such organizations is the first step in a social marketing approach. Social marketing techniques are effective for interventions—like the peer initiative— which encourage behavior change or an increase in program use, according to Nedra Kline Weinreich, author of Hands-On Social Marketing. To learn as much as possible about the target markets—such as the many freestanding clinics, clinics within hospitals, community-based organizations, AIDS Service organizations, state health programs, and faith-based organizations—I would turn to the research methods of sociology and cultural anthropology.
The PEER Center has already undertaken a portion of this work by conducting a needs assessment survey. This has yielded some important information about organizations in the South. The research has been limited to the organization’s potential use of peers, however, without regard for the broader context in which the organizations function. The next step would be to broaden the scope of investigation to include not only the South, but a representative sampling of various kinds of organizations throughout the U.S. Conducting focus groups, surveys, and in-depth, open-ended interviews would yield some important information on which to base a social marketing campaign: what constraints these organizations operate under, what their missions are, what populations they serve, how they are organized, what their problems and challenges are, what conferences they attend, what websites they visit, what newsletters they subscribe to, what organizations they partner with. By analyzing the quantitative and qualitative data this research would reveal, the marketing team would be able to uncover some common themes or patterns in different kinds of organizations with respect to the goals of their peer programs, the kinds of roles they expect peers to play, and their methods for recruiting and training peers. This information could be used to segment the target market more finely and develop resources and training modules to address the needs specific to these segments.
Using Social Marketing techniques to market peer programs to organizations
According to Kline Weinreich, “social marketing is the use of commercial marketing techniques to promote the adoption of a behavior that will improve the health or well-being of the target audience or of society as a whole.” (35) However, because we are marketing not to end-user consumers directly, but rather to organizations who will offer services to consumers, the commercial marketing techniques would be those used in “B2B” (business to business) marketing—those of a business offering its products or services for sale to another business. Just as B2B campaigns are used extensively in the business world, these same techniques can be used to market to organizations providing HIV/AIDS care to individuals. For example, we would establish a “customer advisory board” to provide feedback on various aspects of the mix as we develop them. Customer relationship management tools would be renamed as a “technical assistance log”, but the concept—keeping track of which “customers” you contacted when and what the follow up steps should be—would remain the same.
Below is the marketing mix consisting of the “four Ps” of the peer initiative marketing campaign (36):
Product: The product in this case is the idea of peer programs: encouraging organizations to include HIV-positive people in their programs for combating HIV/AIDS. To do this, we need to analyze the research we have conducted on our target organizations to identify the attributes and benefits that would resonate with each distinct segment. One way to do this is to articulate a problem that the organizations are trying to solve. For example, Ryan White-funded organizations are mandated to include consumer input into their programs—peer programs would be an excellent way to meet this requirement. Another is to identify what the competition is for peer programs within particular segments and demonstrate how using a peer program is different or better. For example, if case managers perform many of the functions of peers with HIV clients, we could demonstrate ways in which peers work together with case managers to complement their efforts and free them up to focus their energies on the higher level skills while the peers perform some of the lower level, more time- or labor-intensive tasks. Elements in the product mix would include resources to make it easier for the organization to implement a peer program—tools to make planning, organizational acceptance, hiring, training and supervision of peers, program evaluation, and other capacity-building activities simpler and more efficient. All of these would need to be continuously tested with the customer advisory boards as they are developed and refined.
Price: The price may be monetary—how much will it cost to fund a peer program—but since many of the organizations have already secured Ryan White funding, it is more likely to be the amount of effort an organization must undertake to implement and sustain a peer program. The needs assessment the PEER Center undertook reveals that peer programs are generally viewed as very labor-intensive to implement. The benefits of a peer program to the organization and the people it serves must outweigh these efforts. In addition to highlighting the many benefits of peer programs through promotion (described in more detail below), the peer intervention must demonstrate how the availability of best- practice guides, the many tools available, and the support of the peer education centers make it easier for organizations to implement a peer program. Once more, constant feedback from target organizations on which arguments resonate most with them will help to refine the way price is portrayed in the campaign.
Place: This refers to the distribution channel through which the organizations will receive support in implementing a peer program. The PEER
Center provides the product in part through its website. PEER Center staff increases its availability by conducting one-on-one capacity-building conversations over the phone, making presentations at conferences, and conducting webcasts 0n topics related to implementing peer programs. Place also pertains to the three national peer education centers which conduct outreach to their partners, make site visits, and conduct peer training and supervisor training for organizations who implement peer programs.
Place can also refer to the way a peer program is administered. Peer programs are generally managed and administered within the organizations providing care and services for people living with HIV/AIDS. Occasionally, however, peers may be outsourced to an organization and be administered by another local organization. In this latter case, the marketing mix would need to make sure that the local organization has everything it needs to provide the required support to make the peers successful within the organizations where they work.
Promotion: Promotion refers to making sure that the message about the peer intervention product reaches its intended audience. The purpose of the promotion is to motivate organizations to start or expand peer programs. Because the target audience in this case is relatively small, mass marketing campaigns are less useful than more personalized approaches. The national peer education centers have developed relationships with many of these target organizations and promote the implementation of peer programs through local seminar presentations, one-on-one consultations, site visits, and training opportunities. Drawing on the national peer educations centers’ local expertise, the PEER Center has created a brochure outlining the advantages of peer programs to link people living with HIV in care and treatment, regularly makes presentations at conferences such as the Ryan White All Grantee Annual Meeting. It also publishes an electronic newsletter highlighting successful peer programs and new resources available, conducts webcasts on topics of interest to organizations implementing peer programs. These efforts should be refined by identifying the different types of organizations the initiative is targeting and developing and testing materials with those audiences.
The above components are common to both commercial and social marketing campaigns. Kline Weinreich points out that there are some additional “Ps” specific to social marketing which need to be considered:
Publics: These are all the different audiences which the social marketing campaign must address in order to be successful. It includes not only the target audiences but all of the internal and external groups involved in the peer initiative. When developing a campaign, the team must continually communicate with these audiences to make sure they all understand and buy into the strategy. This would include all involved groups within the organizations which comprise the PEER Center, the three national education centers and their partnering organizations, any other contributing organizations with whom the initiative has partnerships, and the funding and administering government organizations.
Policy: In many cases, policy change is needed to increase the effectiveness of a social marketing campaign. In the case of the peer initiative, any policy that increases the stigma of HIV/AIDS or makes treatment adherence more difficult needs to be addressed at the organizational, local, state, or federal level. Examples of such policies might be laws which make the spread of HIV a crime, or Medicaid coverage for full-blown AIDS but not treatment following an HIV diagnosis. Because of their lived experience, peers can serve as a voice of authority in calling attention to such policy inequities and are sometimes trained as advocates within community-based organizations.
Purse Strings: Unlike business marketing campaigns, where funding generally comes from the marketing budget of the company selling a product, funding for social marketing programs comes from a wide range of sources ranging from government or foundation grants to individual or corporate donations. As outlined in Part I, one of the limitations of the peer initiative is that its funding has a profound impact on the types of roles the initiative can support, regardless of the needs of its target audiences. This issue can be addressed through partnerships as outlined below.
Partnerships: In the case of the peer initiative, partnerships-- the teaming up with other organizations to support the social marketing campaign and the behavior it is trying to encourage --are one of the most important parts of the marketing strategy. The peer initiative is a complex network of partnerships and relationships with other organizations. However, I would recommend one additional partnership: a collaboration between the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) with relation to the peer initiative. The CDC, with its focus on prevention, has several programs in place that provide capacity building to organizations to support a role for peers in testing and prevention. Programs such as the Mpowerment (37) project to prevent the spread of HIV among gay young men and Street Smart (38) to reduce the risk of HIV among runaway youth are completely separate from the peer initiative, which is funded through HRSA and focuses on access to care and treatment. Merging these programs to present a single set of training and capacity-building resources would eliminate administrative redundancies and simplify the task of starting a peer program for organizations who want to create a program which addresses HIV at several points, including HIV testing, linkage to care for newly diagnosed clients, outreach and prevention, advocacy and stigma reduction.
Such a collaboration is not unprecedented. In 2000 the CDC and HRSA partnered with state health departments and correctional facilities to create an initiative which integrated correctional and community-based health care services for prisoners. This initiative tested incoming inmates for HIV, provided linkage to care and treatment for those who tested positive, and provided HIV prevention services to all participants (39). This initiative was very beneficial to the prisons, who often struggle to provide health care and find funding for HIV testing and education. In the peer initiative, the onus currently falls on the organizations to cobble together from separate sources a coherent peer program that meets all their needs. Coordinating the many different ways that peers can be used to address HIV/AIDS at a higher level, rather than at the point of service, removes this burden from community organizations and clinics who are already stretched for resources and understaffed. The result would be an increase in the number and effectiveness of peer programs, resulting in more people being served better.
Conclusion
The peer initiative can be improved by studying the needs of organizations more closely and using this research to develop a marketing strategy to target those organizations with a product closely tailored to their needs. Part of this process would be to join forces at the top funding levels to create this product, as well as expanding the training of peers to include a variety of roles that reflect the needs of HIV/AIDS organizations and their clients.
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INTRODUCTION
The initiative
No one understands the reality of HIV better than someone who lives with it every day. Matching a newly diagnosed individual with an HIV-positive peer from that person’s community who has been successful in adhering to treatment has been found to be a promising strategy for helping HIV-positive individuals link to care, adhere to HAART (Highly Active Antiretroviral Therapy) regimens, or return to care if they have dropped out (1). Working as part of an interdisciplinary care team, peers provide a wide range of practical and emotional support services to clients. Recognizing the success of peer programs as an effective treatment adherence intervention (2), particularly among underserved, minority and marginalized populations, the Minority AIDS Initiative (MAI) and U.S. Health Resources and Services Administration (HRSA) funded an initiative in 2005 designed to help health care organizations nationwide establish peer programs to serve their HIV-positive clients. The peer initiative consists of four separate grants: three to national peer education centers, and one to a central resource and evaluation center, called the PEER Center.
The three national peer education centers, each of which has experience with a successful peer program, provide peer training and capacity-building expertise to organizations seeking to establish peer programs. Their efforts are supported and coordinated by the PEER Center, a collaboration between the Boston University School of Public Health’s Health & Disability Working Group (HDWG) and the Justice Resource Institute (JRI). The PEER Center conducts evaluation for the project and draws on the expertise of the three national centers to provide capacity-building resources for organizations who want to establish peer programs.
Now in its third year of a five-year grant, the PEER Center has conducted a nationwide needs assessment of health care organizations with respect to peer programs, collected extensive data on the peer training and peer-client interactions of the three national centers and their associated peer programs, created a website which provides resources and information about peer programs to organizations (www.hdwg.org/peer_center) (3), and is actively promoting the establishment of peer programs through conference presentations, webinars, an email newsletter, and contacts with partners at the national centers. It is also in the process of creating an online peer training-of-trainers (TOT) toolkit which provides best practices, curricula and materials drawn from the three national centers. The toolkit is intended as a resource for trainers, peer supervisors or program directors in organizations who want to train new peers or expand the skills of their existing peers who work to engage and retain people living with HIV in the health care system. The TOT toolkit focuses on three core competencies which peers need to carry out this mission: HIV-related information, communication skills, and the role of the peer within an interdisciplinary care team.
Methods
This paper focuses on the TOT toolkit, examining the role of peers as it is portrayed in the toolkit and how well the toolkit addresses the requirements of the organizations it is intended to serve. It examines this toolkit in the context of the peer initiative based on the ecological model (4-5) to determine its strengths and limitations. It looks at how well the initiative as a whole and the toolkit in particular addresses individual, group, structural, political and environmental factors related to combating HIV disease, focusing on program interactions at two levels: 1) at the peer-client level, assessing the roles for which peers are trained to work with clients, as laid out in the peer training toolkit, and 2) at the center-organization level, assessing how well the toolkit meets the needs of the organizations it is designed to serve.
Summary
The TOT toolkit will be a valuable resource when it is released next year, and organizations who want to establish peer programs have expressed interest in gaining access to it. However, there are three ways in which it could be improved: 1) by providing modules intended to provide greater support for clients generally by leveraging the client’s existing network, combating the effects of stigma, and providing ideas for greater support to rural clients who have difficulty in reaching care 2) by focusing more attention on the cultures and challenges of the various organizations whose clients would benefit from a peer program, with an eye to providing curricula more closely tailored to the peer training needs of these organizations and 3) by expanding the TOT toolkit to include curricula which support additional peer roles, reflecting the range of roles peers play within various AIDS service organizations and a more holistic approach to addressing HIV disease.
FACTORS AT THE INDIVIDUAL LEVEL
Program strength: individual behavioral theories appropriately used
Treatment adherence varies widely according to an individual’s circumstances, so it is appropriate that much of the peer-client interaction is focused at the individual level. In the peer-client relationship as envisioned by the peer initiative, the peer provides both emotional and practical support to the individual client in her attempts to learn to cope with the daily stresses of living with HIV. This peer-client relationship of care builds on the strengths of several behavioral theories which are appropriate to interventions focused at the individual level.
For example, the peer is trained to provide the client with information about the HIV life cycle and how medications work to slow the disease progression, as well as brainstorm ways to solve problems integrating treatment into the client’s daily life. This intervention appropriately uses the Health Belief Model (6-8) to influence a client’s perceived severity of the disease, perceived benefits and costs of adherence, and sometimes a client’s perceived susceptibility to the disease—despite an HIV-positive diagnosis, clients are sometimes in denial about having contracted the disease, especially in the absence of symptoms.
The TOT toolkit also makes effective use of the Transtheoretical Model (9) to help the peer work with the client to move through the process of adopting treatment adherence behavior. For example, one training module outlines the five stages of change—precontemplation, contemplation, preparation, action, maintenance—so the peer can identify where in the process of adapting to treatment a client is. If a client is in the stage of “contemplation: the client wants to change behavior within the next six months,” the peer will provide a different type of support than if the client has already met with a doctor and started a treatment regimen.
FACTORS AT THE SOCIAL/CULTURAL/GROUP
Program strength: Good use of Social Cognitive and Social Network Theories
At the Social/Cultural/Group level, the peer initiative makes good use of Social Cognitive Theory (10-11) principles to encourage client treatment adherence. As someone who is not only effectively adhering to treatment himself but also helping others to do so, the peer is a strong role model to individuals new to treatment. As one peer described it, “You have to let the client know that you are like them, that you have gone through these things before and that if you can go through it, they can go through it. (12)” By coaching the client, the peer reinforces the client’s efforts and helps shape his adherence behavior. This also strengthens the client’s self-efficacy; as the peer and client work through adherence issues together step by step, the client sees that she is able to manage a new behavior that may have seemed overwhelming at the start. Conversely, being a role model to others reinforces the peer’s own self-efficacy and motivation to adhere to treatment as well as increasing her self-esteem.
The behavioral theory which is most apparently at work in the peer-client intervention, however, is the Social Network Theory (13-17). The peer acts as a non-judgmental “natural helper” in the client’s social network. As a member of the client’s community, the peer often shares the same background, experiences, cultural assumptions, and language as the client and provides a communication channel that the client is more likely to understand and accept. This is the major strength of the peer-client interaction and has generally proven very effective. (One caveat, however: One must be careful not to assume that because two people share the same culture, they will work well together or trust each other. The interplay of individual factors is complex--two people from the same culture may find themselves on different sides of a political dispute; two people from the same country of origin may be from rival ethnic groups within that country (18).
Critique #1: More focus on helping the network to support the individual’s behavior
It is in the application of the Social Network Theory that one limitation of the peer intervention manifests itself: although the TOT toolkit provides peer training around helping clients disclose their status to family and friends and encouraging clients to build a support network, it does not address support or education for members of the client’s network. While the decision whether or not to disclose one’s status is a personal one and not every HIV-positive person chooses to let family and friends know his status, individuals who do disclose their status to those close to them have been shown to have a better quality of life (19). In these cases, providing support and education to family members and friends affected by HIV can be a powerful tool in helping to strengthen the client’s adherence behavior. It can also help reduce stigma within the community by providing information, dispelling myths, and exploring/influencing the community’s perceptions and social norms around HIV/AIDS. Leading support groups and participating in programs for family members and others affected by HIV is a role which HIV-positive peers within community-based organizations sometimes take on. For example, Christie’s Place in San Diego, CA, a community-based organization “for families and individuals living with HIV/AIDS (20),” offers peer-led support groups and organized events targeted to children of HIV-positive people or HIV-positive individuals and affected family members. Providing training modules and tools within the TOT toolkit to train peers to take on this role would provide a valuable resource to organizations who want to train peers to provide support to a client’s network.
Critique #2: More focus on contexts of various organizations
Critics of the Social Network Theory point out that it is a limited intervention which works at a small group level but does not lend itself to broader application (21). The peer initiative seeks to overcome this limitation by helping organizations throughout the country to start or strengthen peer programs. The initiative encourages the replication of peer programs in a wide range of organizations—clinics, community-based organizations, AIDS service organizations—yet it has made limited efforts to understand the cultures and challenges of different types of organizations or in different regions of the country. The program would benefit from using anthropological methods to learn more about the climate and challenges of these organizations in order to develop resources more closely targeted to helping these organizations overcome some of the issues they face in implementing a peer program.
For example, the South is the primary focus area for capacity-building efforts because of the rapid expansion of HIV infection in the region. Hence the PEER Center conducted a needs assessment of Ryan White Care Act Parts A, B, C, and D grantees in the South based on a questionnaire. However, this questionnaire provides little in the way of open-ended questions or opportunities for uncovering issues not specifically addressed by the questions in the questionnaire. Yet through conversations with organizations in the South, PEER Center members have learned that stigma is a major barrier not only in adherence to treatment but in recruitment of peers. Further, one of the national education centers has observed that HIV care efforts are often undertaken by faith-based organizations in the South. These organizations are likely to have very different requirements for peer training and peer roles within their organizations than peer programs in clinical settings or California-based community organizations, which is where the peer initiative draws its expertise. By systematically asking more in-depth questions and gathering more qualitative data (22) about the various kinds of organizations being targeted, the PEER Center can begin to gain a richer understanding of the assumptions, constraints and challenges under which these organizations operate. This would help in the identification of underlying causes which may prevent these organizations from establishing a peer treatment adherence program for their clients.
One tangible outcome of a more in-depth study of organizations might be the creation of new models for peer programs. Currently the peer initiative presents target organizations with two models for peer programs: an internal model, where the organization manages its peers as employees within the organization, and an external model, where peers act as external consultants managed by an outside organization. This distinction has proven valuable to some organizations who want to develop a peer program but have insurmountable obstacles in employing peers as part of their organization. The external model was developed based on the experience of the WORLD (www.womenhiv.org) (23) program, a community-based organization with a different organizational culture and mission from the peer programs associated with the other two national centers, both of which operate in a clinical setting. By learning more about the context of different organizations, the PEER Center may be able to come up with additional models that would address challenges these organizations have encountered.
Within the context of the TOT training manual, a more in-depth understanding of various kinds of organizations seeking to start peer programs would help the PEER Center create several pre-packaged model curricula according to prevalent organizational profiles. This would give the organization a more comfortable starting point than simply looking at the more than 150 training modules available to them to try to decide which ones would meet their organization’s need for peer training.
FACTORS AT THE SOCIOECONOMIC/STRUCTURAL LEVEL
Program strength: navigating the system
Factors at the socioeconomic level include the effects of poverty, education, access to care and services and social stressors on HIV treatment adherence. One area of strength of the peer-client interaction is the one-on-one support clients receive to navigate a sometimes bewildering maze of health care and social services, many of which the client may not trust or understand. Peers often accompany clients to doctor, dentist or social service appointments and help clients ask appropriate questions and understand the doctor’s advice. Peers also make referrals to case managers and other members of the care team to address issues of housing, food security and other practical assistance—although the support the client receives is only as good as the services the referring agencies provide, which vary greatly.
Critique #3: Not adequately addressing stigma and physical distance
Two social stressors affecting peer programs generally and more particularly in the South are stigma within the community and isolation in rural areas. The stigma surrounding HIV prevents people from getting tested, seeking care if they are diagnosed with the disease, revealing their status to family and friends, and adhering to treatment. People who live in fear of being stigmatized may suffer from low self-esteem, depression, and even unemployment and loss of income, all of which contribute to poor health and lower quality of life. Furthermore, if a person has more than one stigmatizing condition, the chances of that person suffering from these effects is greatly increased (24).
As members of a group which is stigmatized, peers are in a unique position to play an advocacy role in combating stigma. Peers may provide a voice of authority at churches, schools and other pubic forums when issues of stigma are addressed. They produce and perform plays with anti-stigma themes. They conduct interviews to obtain evidence to inform policies which protect the rights of people living with HIV (25). They combat stigma within the health care system by serving on consumer advisory boards. While the continuing education section of the TOT toolkit includes one module which discusses the effects of stigma, it does not provide training in peer roles of advocacy and public speaking; including ideas for the contributions peers can make to reducing stigma within the community would provide an additional resource to organizations most impacted by this issue.
In rural areas, the problem of stigma is exacerbated by long distances between clients, health care facilities and other services. Clients often lack transportation to distant HIV health care facilities; they may be afraid to accept affordable transportation when it is offered for fear of being identified as HIV-positive by neighbors (26). The backbone of the peer-client intervention is face-to-face meetings; meetings are often coordinated to coincide with a client’s doctors appointments. The PEER Center could extend the reach of peers by including resources and peer training which provide ideas for alternative networking opportunities, such as regular phone meetings or computer-assisted peer interaction for clients with access to phone or computer.
FACTORS AT THE POLITICAL AND ENVIRONMENTAL LEVEL
Critique #4: Separate sources of funding lead to limitation in roles for which peers can be trained through the toolkit
Perhaps the biggest limitation of the PEER Center initiative occurs at the political level. The PEER Center and the three national centers are funded through the Minority AIDS Initiative which provides funds to HIV/AIDS service agencies to “improve HIV/AIDS-related health outcomes for racial and ethnic minority communities disproportionately affected by HIV/AIDS (27).” The initiative is administered through HRSA’s HIV/AIDS Bureau, which focuses on supporting care and support services to people infected with and affected by HIV/AIDS. As such, prevention efforts administered through HRSA are targeted to HIV-positive individuals, not to the larger community. Peer prevention initiatives targeting a broader community are separately funded and implemented by the Centers for Disease Control (CDC). Each of these organizations has its own procedures, reporting structures and evaluation mechanisms.
Yet increasingly there has been a call for closer integration between prevention and care among communities combating the disease. Last year for World AIDS Day, three staff members of the World Health Organization put out a joint statement that “linking treatment with prevention remains an overriding and critical public health challenge for the health sector (28).” In a recent article, Remien, Berkman et al. recommended a strategic approach to controlling the epidemic by supplementing increased testing with integration of HIV prevention into HIV care settings (29). This kind of integration of prevention and treatment takes place at the community level; community-based AIDS organizations may include outreach, prevention and consumer advocacy programs, and peers may play a part in all of these areas. At the funding level, however, these functions remain separate. Hence the TOT toolkit focuses on training peers for treatment adherence and linkage to care programs, but not for a role related to prevention within the community. Yet in the needs assessment which the PEER Center conducted, one community-based organization in South Carolina stated that they would like to use peers for “outreach, testing, prevention, helping clients with treatment adherence, and support and counseling.”(30) This organization will need to supplement the TOT toolkit in its current format with additional resources to meet all of its peer training needs.
Several of the training modules included in the TOT toolkit lend themselves to expanded peer roles of prevention and advocacy within the community. The harm reduction and “prevention for positives” modules, for example, include training in many prevention issues, such as negotiating use of condoms and reducing or eliminating risk behaviors. Modules on workplace issues address many factors that are common across roles, such as general communication skills, communication with coworkers and supervisors, adjusting to a professional work environment, and locating resources for further professional development.
A more holistic approach to fighting HIV/AIDS would involve peers at all levels of intervention. The presence of HIV-positive peers in the community who are willing to share their status and stories of how stigma has affected them empower others to put aside their fears, get tested, or seek treatment if they have been diagnosed with HIV. Peers serve as proponents of HIV-prevention efforts and are strong advocates for HIV testing. More testing leads to earlier detection of HIV disease, resulting in better outcomes. Having peers available to those individuals who are diagnosed with HIV and entering care or who are trying to return to care after having dropped out is another step in a continuum of interventions where peers may play a critical role. Restricting the TOT toolkit to a treatment-adherence peer role without recognizing the additional roles peers may play within an organization limits its usefulness. Organizations hoping to use it as a “one-stop-shopping” resource for training their peers will need to supplement it with additional resources.
CONCLUSION
Learning to live with HIV as a chronic disease is a complex behavior, requiring extensive support at many levels. Clients often require ongoing support from their network of family, friends, and health care and social service providers in order to stick to their regimens. Working as a peer is challenging as well, requiring extensive support from supervisors and others within an organization. Organizations themselves benefit from support and expertise to maintain a successful peer program. The peer initiative goes a long way to providing support at all these levels, either directly or indirectly. But the initiative generally and the TOT toolkit specifically could be improved by strengthening these supports through 1) increased recognition of the needs of the client’s support network as well as the unmet needs for support of isolated rural clients 2) a more tailored response to organizational needs with respect to peer programs through a closer examination of those organizations, and 3) an expansion of peer roles to include prevention and advocacy within the community. The TOT toolkit is in the early stages of development and testing. As organizations begin to apply it to their peer training programs, many of the ideas outlined here may well be incorporated as a result of feedback from those organizations.
SB721
Written Assignment 4
Dec. 11, 2008
Edi Ablavsky
Part II: Enhancing the peer intervention through use of Social Network Theory, Sociological and Anthropological Research Methods and Social Marketing
Introduction
To this point, I have identified four limitations of the peer initiative. They are 1) a lack of focus on the family and friends of people living with HIV as a source of support to clients 2) not addressing the issue of isolation and stigma among rural clients who may have limited access to peer support 3) the need to better understand the requirements of organizations wanting to implement or strengthen peer programs and 4) a limitation in the kinds of peer roles the initiative can address because the funding source limits the peer role to linkage to care and treatment.
Social Network Theory-based interventions to increase social support for people living with HIV
I would address the first two limitations—lack of focus on social network of people living with HIV, and the issue of clients in rural areas with limited access to peer support—using approaches based on the Social Network Theory. This theory posits that the people in a person’s social network have a profound influence on that person’s behavior. I see three ways in which this theory could be used to expand the reach of peers to serve remote clients:
1) Enlist the support of people in the social network of HIV clients by reaching out not only to people infected with HIV but to those affected by it: the network of family and friends surrounding the infected person. For clients who are willing to disclose their status to family and friends, establishing a peer-led support group to educate those members of the person’s network about HIV and how to best support people living with HIV would serve to strengthen the client’s adherence behavior. It would also serve the crucial role of reducing the stigma of the disease through a better understanding, thus changing the norms within the person’s social network and the community. In one recent study, in a majority of the participating families with an HIV-infected parent, family members expressed fears about the spread of HIV in the home (31). Clearly these families would benefit from additional support and education, as well as the client. While this intervention is beneficial to HIV-positive clients regardless of where they live, it would be particularly helpful to rural clients; if a client lives too far away to meet with a peer on a regular basis, enlisting the support of the client’s social network would provide many of the same support functions that a peer would.
2) Create a “buddy system” where two clients living in the same remote area could serve as peers to each other, providing each other with support and making sure they take their medication. This is a strategy being used in resource-limited settings with some success (32).
3) Expand the definition of “networking” to include the Web and other devices. Peers working with the three national education centers have reported using mobile phones to contact their clients with some success. Use of the Internet is more problematic, since less educated, economically disadvantaged and socially marginalized people are least likely to have access to a computer. Nevertheless, access is increasing, and for some rural clients, Web-based applications which provide some of the same kind of health education that peers offer may be a viable alternative (33). Communicating with peers via email or participating in social bulletin boards, such as those found on thebody.com (34), a popular website for information about HIV/AIDS, might be a source of support and connection for some remote clients.
Once these models of support for client networks and rural clients have been developed, the PEER Center training of trainers and capacity-building toolkits could be expanded to include modules to address these additional roles for peers, making them available to organizations who want to include them in their programs. The PEER Center could also use its knowledge of best practices in peer programs to develop interactive Internet-based programs to address some of the roles that peers play, particularly around HIV education.
Using sociological and anthropological methods to research organizations seeking to start peer programs—the first step in a social marketing campaign
In part I, I argued that a better understanding of the kinds of organizations who would benefit from starting or enhancing a peer program was needed in order to address the peer program requirements of these organizations. Researching such organizations is the first step in a social marketing approach. Social marketing techniques are effective for interventions—like the peer initiative— which encourage behavior change or an increase in program use, according to Nedra Kline Weinreich, author of Hands-On Social Marketing. To learn as much as possible about the target markets—such as the many freestanding clinics, clinics within hospitals, community-based organizations, AIDS Service organizations, state health programs, and faith-based organizations—I would turn to the research methods of sociology and cultural anthropology.
The PEER Center has already undertaken a portion of this work by conducting a needs assessment survey. This has yielded some important information about organizations in the South. The research has been limited to the organization’s potential use of peers, however, without regard for the broader context in which the organizations function. The next step would be to broaden the scope of investigation to include not only the South, but a representative sampling of various kinds of organizations throughout the U.S. Conducting focus groups, surveys, and in-depth, open-ended interviews would yield some important information on which to base a social marketing campaign: what constraints these organizations operate under, what their missions are, what populations they serve, how they are organized, what their problems and challenges are, what conferences they attend, what websites they visit, what newsletters they subscribe to, what organizations they partner with. By analyzing the quantitative and qualitative data this research would reveal, the marketing team would be able to uncover some common themes or patterns in different kinds of organizations with respect to the goals of their peer programs, the kinds of roles they expect peers to play, and their methods for recruiting and training peers. This information could be used to segment the target market more finely and develop resources and training modules to address the needs specific to these segments.
Using Social Marketing techniques to market peer programs to organizations
According to Kline Weinreich, “social marketing is the use of commercial marketing techniques to promote the adoption of a behavior that will improve the health or well-being of the target audience or of society as a whole.” (35) However, because we are marketing not to end-user consumers directly, but rather to organizations who will offer services to consumers, the commercial marketing techniques would be those used in “B2B” (business to business) marketing—those of a business offering its products or services for sale to another business. Just as B2B campaigns are used extensively in the business world, these same techniques can be used to market to organizations providing HIV/AIDS care to individuals. For example, we would establish a “customer advisory board” to provide feedback on various aspects of the mix as we develop them. Customer relationship management tools would be renamed as a “technical assistance log”, but the concept—keeping track of which “customers” you contacted when and what the follow up steps should be—would remain the same.
Below is the marketing mix consisting of the “four Ps” of the peer initiative marketing campaign (36):
Product: The product in this case is the idea of peer programs: encouraging organizations to include HIV-positive people in their programs for combating HIV/AIDS. To do this, we need to analyze the research we have conducted on our target organizations to identify the attributes and benefits that would resonate with each distinct segment. One way to do this is to articulate a problem that the organizations are trying to solve. For example, Ryan White-funded organizations are mandated to include consumer input into their programs—peer programs would be an excellent way to meet this requirement. Another is to identify what the competition is for peer programs within particular segments and demonstrate how using a peer program is different or better. For example, if case managers perform many of the functions of peers with HIV clients, we could demonstrate ways in which peers work together with case managers to complement their efforts and free them up to focus their energies on the higher level skills while the peers perform some of the lower level, more time- or labor-intensive tasks. Elements in the product mix would include resources to make it easier for the organization to implement a peer program—tools to make planning, organizational acceptance, hiring, training and supervision of peers, program evaluation, and other capacity-building activities simpler and more efficient. All of these would need to be continuously tested with the customer advisory boards as they are developed and refined.
Price: The price may be monetary—how much will it cost to fund a peer program—but since many of the organizations have already secured Ryan White funding, it is more likely to be the amount of effort an organization must undertake to implement and sustain a peer program. The needs assessment the PEER Center undertook reveals that peer programs are generally viewed as very labor-intensive to implement. The benefits of a peer program to the organization and the people it serves must outweigh these efforts. In addition to highlighting the many benefits of peer programs through promotion (described in more detail below), the peer intervention must demonstrate how the availability of best- practice guides, the many tools available, and the support of the peer education centers make it easier for organizations to implement a peer program. Once more, constant feedback from target organizations on which arguments resonate most with them will help to refine the way price is portrayed in the campaign.
Place: This refers to the distribution channel through which the organizations will receive support in implementing a peer program. The PEER
Center provides the product in part through its website. PEER Center staff increases its availability by conducting one-on-one capacity-building conversations over the phone, making presentations at conferences, and conducting webcasts 0n topics related to implementing peer programs. Place also pertains to the three national peer education centers which conduct outreach to their partners, make site visits, and conduct peer training and supervisor training for organizations who implement peer programs.
Place can also refer to the way a peer program is administered. Peer programs are generally managed and administered within the organizations providing care and services for people living with HIV/AIDS. Occasionally, however, peers may be outsourced to an organization and be administered by another local organization. In this latter case, the marketing mix would need to make sure that the local organization has everything it needs to provide the required support to make the peers successful within the organizations where they work.
Promotion: Promotion refers to making sure that the message about the peer intervention product reaches its intended audience. The purpose of the promotion is to motivate organizations to start or expand peer programs. Because the target audience in this case is relatively small, mass marketing campaigns are less useful than more personalized approaches. The national peer education centers have developed relationships with many of these target organizations and promote the implementation of peer programs through local seminar presentations, one-on-one consultations, site visits, and training opportunities. Drawing on the national peer educations centers’ local expertise, the PEER Center has created a brochure outlining the advantages of peer programs to link people living with HIV in care and treatment, regularly makes presentations at conferences such as the Ryan White All Grantee Annual Meeting. It also publishes an electronic newsletter highlighting successful peer programs and new resources available, conducts webcasts on topics of interest to organizations implementing peer programs. These efforts should be refined by identifying the different types of organizations the initiative is targeting and developing and testing materials with those audiences.
The above components are common to both commercial and social marketing campaigns. Kline Weinreich points out that there are some additional “Ps” specific to social marketing which need to be considered:
Publics: These are all the different audiences which the social marketing campaign must address in order to be successful. It includes not only the target audiences but all of the internal and external groups involved in the peer initiative. When developing a campaign, the team must continually communicate with these audiences to make sure they all understand and buy into the strategy. This would include all involved groups within the organizations which comprise the PEER Center, the three national education centers and their partnering organizations, any other contributing organizations with whom the initiative has partnerships, and the funding and administering government organizations.
Policy: In many cases, policy change is needed to increase the effectiveness of a social marketing campaign. In the case of the peer initiative, any policy that increases the stigma of HIV/AIDS or makes treatment adherence more difficult needs to be addressed at the organizational, local, state, or federal level. Examples of such policies might be laws which make the spread of HIV a crime, or Medicaid coverage for full-blown AIDS but not treatment following an HIV diagnosis. Because of their lived experience, peers can serve as a voice of authority in calling attention to such policy inequities and are sometimes trained as advocates within community-based organizations.
Purse Strings: Unlike business marketing campaigns, where funding generally comes from the marketing budget of the company selling a product, funding for social marketing programs comes from a wide range of sources ranging from government or foundation grants to individual or corporate donations. As outlined in Part I, one of the limitations of the peer initiative is that its funding has a profound impact on the types of roles the initiative can support, regardless of the needs of its target audiences. This issue can be addressed through partnerships as outlined below.
Partnerships: In the case of the peer initiative, partnerships-- the teaming up with other organizations to support the social marketing campaign and the behavior it is trying to encourage --are one of the most important parts of the marketing strategy. The peer initiative is a complex network of partnerships and relationships with other organizations. However, I would recommend one additional partnership: a collaboration between the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA) with relation to the peer initiative. The CDC, with its focus on prevention, has several programs in place that provide capacity building to organizations to support a role for peers in testing and prevention. Programs such as the Mpowerment (37) project to prevent the spread of HIV among gay young men and Street Smart (38) to reduce the risk of HIV among runaway youth are completely separate from the peer initiative, which is funded through HRSA and focuses on access to care and treatment. Merging these programs to present a single set of training and capacity-building resources would eliminate administrative redundancies and simplify the task of starting a peer program for organizations who want to create a program which addresses HIV at several points, including HIV testing, linkage to care for newly diagnosed clients, outreach and prevention, advocacy and stigma reduction.
Such a collaboration is not unprecedented. In 2000 the CDC and HRSA partnered with state health departments and correctional facilities to create an initiative which integrated correctional and community-based health care services for prisoners. This initiative tested incoming inmates for HIV, provided linkage to care and treatment for those who tested positive, and provided HIV prevention services to all participants (39). This initiative was very beneficial to the prisons, who often struggle to provide health care and find funding for HIV testing and education. In the peer initiative, the onus currently falls on the organizations to cobble together from separate sources a coherent peer program that meets all their needs. Coordinating the many different ways that peers can be used to address HIV/AIDS at a higher level, rather than at the point of service, removes this burden from community organizations and clinics who are already stretched for resources and understaffed. The result would be an increase in the number and effectiveness of peer programs, resulting in more people being served better.
Conclusion
The peer initiative can be improved by studying the needs of organizations more closely and using this research to develop a marketing strategy to target those organizations with a product closely tailored to their needs. Part of this process would be to join forces at the top funding levels to create this product, as well as expanding the training of peers to include a variety of roles that reflect the needs of HIV/AIDS organizations and their clients.
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Labels: Cultural Issues, Green, HIV/AIDS, Sexual and Reproductive Health
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