Spreading the Word: Delivering Research Results to the Field

Even with these positive results, the HHD team knew it would not be enough to simply publish papers on their results. “The staff was absolutely tenacious about moving forward with the funder and the field to ensure that this intervention, along with others, made it to
the field,” says Adler, the video and materials developer. Too often, she and her team
members noted, effective programs sit on a shelf after their initial clinical trial is complete.
Team member Duran adds, “If you plug away long enough, you keep on contributing to the body of knowledge. And then you have to keep on saying, ‘Look, it’s not enough.
It’s not enough if it doesn’t get out there.’ ”

In 1997, the CDC selected the intervention, now called VOICES/VOCES (Video opportunities for Innovative Condom Education and Safer Sex) to participate in its
rigorous Replicating Effective Programs (REP) project, based on evidence of its effectiveness. One of just a handful of programs selected across the country to participate in this program, VOICES/VOCES was positioned to be disseminated throughout the country.

Replication Study:
Expanding the Intervention to Other Health Settings
HHD knew from its work in diffusion of innovation, technology transfer, and institutional change that STD clinics or health centers would be unlikely to implement the program without some technical assistance that addressed the particular needs of theirsetting.With CDC support and collaboration, HHD began designing and implementing a technical assistance plan and a package of materials that STD clinics and other health centers could use to replicate this project. The package includes an Administrator’s Preview Guide, a bilingual VOICES/VOCES Implementation Manual, and two videos.

As part of this package, the CDC provided funding to develop a new video for African Americans. The original video for this population, Let’s Do Something Different, was created prior to the HIV epidemic — indeed, there is no mention of HIV. Following the video development process used earlier, staff began working on a new video called Love Exchange. Again, extensive input from a community advisory board and a focus group of men and women was used to construct the story lines, content and key messages.When paired with Porque Si, this new video provides health agencies with culturally relevant
videos for African American and Latino men and women.

Pilot Test of the Replication Package
The VOICES/VOCES replication package of materials and accompanying training and technical assistance was then piloted in five diverse health care settings. These included
two STD clinics, a family planning clinic, and two neighborhood health centers. This broad audience was solicited in part because the numbers of men and women seeking treatment for STDs through public STD clinics was declining, with patients seeking services elsewhere. HHD staff also wanted to develop an intervention that could be used broadly in diverse settings.

Agencies received the package, and HHD staff trained agency providers to deliver the program. Research staff also provided technical assistance that included ways to integrate
the intervention into the clinic flow and how to recruit participants for intervention
sessions. Research staff also monitored program implementation, observing how the intervention was being used and ways it could be adapted and strengthened by local
agencies.

Agency staff at each of these pilot replication sites, along with a VOICES/VOCES community advisory board similar to those created during formative work, provided
ongoing input into the revision of the replication package. The information obtained through the pilot was used to finalize the VOICES/VOCES replication package.

Cost Analysis and Effectiveness Studies
The replication project showed that this intervention could be used in other health care settings. HHD staff and the CDC agreed that another step was needed to inform the
prevention field: a study of the costs and cost-effectiveness of the VOICES/VOCES program. Conducting a cost analysis provides agencies and funders with estimates of the
monetary resources that are necessary to run a program. Such costs include staff time, equipment, and materials. Obtaining information on costs is also essential for conducting a cost-effectiveness study, which then models whether the costs of implementing an intervention are effective in reducing both the human and financial costs of disease, and its treatment.

“ If you assemble enough cost-effectiveness data, then you can allow people to pick and choose and say this would work in our setting or this would not work in our setting. It really starts to target where to put very scarce, valuable resources to be effective,” says Carl O’Donnell who, along with consultant Dr.Michael Sweat from Johns Hopkins School of Public Health, served as the methodologists on the cost studies.

To conduct the cost analysis and estimate the cost-effectiveness of this intervention, the team used data on effectiveness from the randomized clinical trial in New York City along with updated data on the costs of intervention from four replication sites. STD incidence and self-reported behavioral data were used to make estimates of reduction in HIV incidence among study participants. In “Cost-effectiveness of a brief video-based HIV
intervention for African American and Latino sexually transmitted disease clinic clients” (AIDS 2001) HHD researchers reported that:

• The brief VOICES/ VOCES intervention is feasible and cost-effective when targeted to STD clinic clients at high risk of contracting and transmitting infections, indicating that this strategy should be considered for inclusion in HIV prevention programming.
  

Replicating the Effectiveness of VOICES/ VOCES in Diverse Settings
With the replication package developed, HHD is currently evaluating whether VOICES/VOCES is also effective when implemented by community-based staff rather than research staff. Again with funding from the CDC, HHD staff have started to forge new partnerships with clinics, including a new clinic in Puerto Rico. The HHD team will provide clinics with VOICES/VOCES materials, training, and technical assistance, while clinic staff will take on the challenge of implementing the program in their busy settings. HHD
researchers will then evaluate effectiveness using the same criteria as in the Morrisania trial: Are there demonstrable improvements in patient knowledge, attitudes, and intentions
to adopt safer behaviors? Are clients who receive the intervention more likely to redeem coupons for condoms? And, are there fewer new STD infections among those who
have been exposed to the intervention?

In addition, as the study progresses, evaluators will monitor and identify factors that lead to success or failure in implementing the intervention and look for ways to improve the process for practitioners to conduct these types of interventions.