Microsoft PowerPoint PalmIT CAPS Conference 4 18 08.ppt

PalmIT
Localizing a Structural Intervention
to Improve HIV Test Counseling
and Client Data Collection
Noah Caraher, MA
Nicolas Sheon, PhD
Shelley Facente, MPH
Seung-Hee Lee, PhD
San Francisco DPH (formerly at CAPS)
Jason Euren
UCSF Center for AIDS Prevention
Dale Gluth, MA
Studies
Magnet
Isela Gonzalez, MPA
PART Study Funded by
Forensic AIDS Project
NICHD R01 (Susan Newcomer)
Three CAPS Innovative Grants

Single Session Counseling Timeline
(AHP Training Manual)
“Counseling”
“Health Education”
“Health Education”
“Counseling”
Confirmatory
Introductions and
Sample
Risk Assessment
Result
Results if Prelim.
Informed Consent Collection
(at least 20 minutes)
Disclosure
Positive
1 – 2
weeks
20 minutes for the test to
develop
Introduce the CIF so
Refer to the form to
client knows what it is
ensure all needed info
has been gathered

Goals of the PART Study
(Process Analysis of Rapid Testing)
Explore counselors’ strategies during the session
Examine clients’ responses to these strategies
Ask how clients would like to use the session
Develop a structural intervention to separate data
collection from counseling and streamline data
management
Evaluate the impact of the intervention on the
structure of the sessions and the quality of the
interaction

Process Analysis
triangulates
five methods
to analyze
digital recordings
of 52 rapid HIV
test sessions.

Process Analysis
1. Time Charts of recorded sessions
2. Conversation Analysis using transcripts
3. Focus Groups with counselors
4. Follow-up Interviews with Clients and
Counselors to review session recording
5. Focus Groups with Clients to test the
PalmIT interface

Method 1: Time Charts of Recorded Test Sessions
5
Counseling
Health Education
4
Risk Assessment
3
Data Collection
Sample Collection
2
1
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
What happens, when and for how long
Validate patterns we hear by providing
a visual representation of the session
timeline
Time charts are made with Transana
software

Three Communication Formats
Health Education & Risk Assessment
Counselor is talking
Data Collection
State is talking
Counseling
Client is talking

Rapid Test Sessions at Magnet with CIF
16
Counseling
15
Health Education
14
Risk Assessment
13
Data Collection
12
Sample Collection
11
10
9
8
7
6
5
4
3
2
1
0
5
10
15
20
25
30
35
40
45
50
55
60
65

Rapid Test Sessions at Magnet with CIF
16
15
Health Education
14
Risk Assessment
13
12
11
10
9
8
7
6
5
4
3
2
1
0
5
10
15
20
25
30
35
40
45
50
55
60
65

Rapid Test Sessions at Magnet with CIF
16
15
14
13
Data Collection
12
11
10
9
8
7
6
5
4
3
2
1
0
5
10
15
20
25
30
35
40
45
50
55
60
65

Rapid Test Sessions at Magnet with CIF
16
Counseling
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
5
10
15
20
25
30
35
40
45
50
55
60
65

Phase 1 vs. Phase 2 Sequence Map
1
2
3
4
5
6
7
1
2
3
4
5
6
7

Phase 1 vs. Phase 2 Bar Graph
1
2
3
4
5
6
7
1
2
3
4
5
6
7

Phase 1 vs. Phase 2 Percent Graph
1
2
3
4
5
6
7
1
2
3
4
5
6
7

Method 2: Conversation Analysis
of Session Recordings
C: WOULD you say that when
CA is the Sociology
you drink alcohol (0.4)
that you uhm never
of language use
sometimes (0.4) never
RAREly sometimes or always
focusing on turn taking
combine drinking alcohol
in talk
with sex
(4.6)
Detailed transcripts
P: Rarely never?
include pauses and
C: Rarely or never?
overlaps to focus on
how people construct
P: Yeah
accounts for risk
C: Okay (0.7)((writing))
behavior
more on the rarely side or
collaboratively
P: Yeah

Two publications using CA
Lee, S-H., Sheon, N. (2008) Responsibility
and Risk: Reasons for Seeking an HIV Test.
Sociology of Health and Illness 30(2):167-81.
Sheon, N., Lee, S-H. (in press) Sero-Skeptics:
Sexual Partner HIV Status Disclosure
Discussions between Test Counselors and
their Clients. AIDS Care.

Comparison of CIF Question
Design in Phase 1 vs. 2
Two patterns of CIF use in Phase 1:
Survey versus Conversation
In Phase 2 all counselors switched to
more open ended, conversational
question design
In Phase 2, clients elaborated and
situated their responses within a
conversational narrative

Rapid Test Sessions at Magnet with CIF
16
15
14
13
Data Collection
12
11
10
9
8
7
6
5
4
3
2
1
0
5
10
15
20
25
30
35
40
45
50
55
60
65

Phase 1: Using CIF like a survey
(1) M1-1006
1 C:
Okay. •hh And did you engage in oral sex with a- (.)
2
any of them,
3 P:
Mm hm?
4
(.)
5 C:
•hh And when you engaged in oral sex did you never
6
sometimes or [always wear a condom,
7 P:
[Never
8
(1.8)
9 C:
An:d (0.2) did you engage in anal top sex with any of them,
10
(0.5)
11 P:
Mm hm?
12
(0.2)
13 C:
And when you topped did you never sometimes or always
14
use a condom.
15
(0.6)
16 P:
I’ll say that I sometimes use a condom.
17
(1.4)
18 C:
U:m a:nd did you ever b- bottom for any of your twenty four
19
partners.
20
(0.5)
21 P:
U::m (0.4) I would say:: two.
22 C:
Okay. •hh And when you did did you never sometimes or
23
always use a condom.
24 P:
Always.
25 C:
Okay.

Phase 2: No CIF
(4) M2-2004
1 C:
•hhh How u::m how do you feel about condom:s=and like
2
your:- your history of using them,
3
(1.0)
4 P:
You know (0.2) I:- (0.2) would say ninety nine: (0.5)
5
percent of the time, I use them.
6 C:
Okay,
7
(0.5)
8 P:
So: that's where I- (1.4) I guess par:t of it is just
9
looking back at that- (0.2) situation that I ha:d back
10
in: (0.5) February, (0.5) u:m (0.5) w- why: did I le:t
11
(0.6) that point (1.4) happen?

Designing and Implementing
Structural Interventions
1.
Evaluate and describe the situation or issue
(PART study examined the role of the HIV6 form in counseling)
2.
Identify what should be changed and why. Determine
the values that will make the change possible and
worthwhile (Should eliminate the form from the session
because it inhibits the counseling both parties desire)
3.
Design an intervention geared towards these values
decided upon in #2 (PalmIT self-administers the form before
the session, increasing client privacy, increasing client and
counselor satisfaction, and improving the overall efficiency of
HIV CTL at the site)

Structural Change
4.
In the original situation there was a structure with a
particular set of values attached to it. Implementing a
structural change should lead to a new set of values.
(Using PalmIT instead of paper forms shifts the value away from
data collection and toward the personal interaction)
5.
Continue evaluation and description to see whether the
change works to shift values (Counselor focus groups, client
satisfaction surveys, input from coordinators, and continuous
tweaking)
6.
Reproduce 1 – 5 in each setting where you apply the
intervention (As we will see in the case examples from
Magnet in the Castro and the Forensic AIDS Project in the San
Francisco jails, survey language is different, clinic flow is
different, certain elements are specifically tailored based on site
and population needs)

Magnet Counselor Inservice
Concerns about not having the form
I use the CIF to do my counseling. [If] I see some red
flags…would you like to talk about this?
No longer having the ability to clarify form questions in the
moment of them being asked
Sometimes it does allow you to fill time…if you’ve got
somebody who’s very knowledgeable.
This form allows us as the counselor to engage the person.
I do think that this new procedure assumes that there’s a
good way to spend that 20 minutes.

Magnet Counselor Inservice
How do you know when you’ve done a good job?
When the client comes in with concerns and we’re able to give
them some answers.
They feel like they’ve been invested in coming here; it’s not
just a drill they do every 6 months.
A lot of my favorite sessions have been those where we hardly
talked about HIV but talked about something that sort of
seemed peripheral but was really related to their experience.
I think the more successful sessions have this element of
helping to identify the larger cofactors that are at work and
putting them at risk – homophobia, loss. Larger things that
are not necessarily tangible but are wearing them down, and
they’re not necessarily conscious of it wearing them down.

PalmIT at Magnet
Wanted it to be site-wide
Had input to the design
Data would improve
Administrative time would be freed
up
Training for counselors would focus
on counseling, not data collection

PalmIT comes to Magnet

Demographics

What do customers really
think?

Forensic AIDS Project
Rapid HIV testing in the jails
Preparations began in July 2007 and
rollout happened in September 2007
Initial challenges and setbacks to
implementing computerized data
collection
Politics of the Sheriff’s Department
Electronics and inmates
Safety and security

Kiosk at County Jail 8

Language
Magnet version was designed for gay men in
Castro.
Version #1: How frequently have you used
condoms while topping with men in the last two
years?
How to use language that would be easy to
understand for inmates.

Experimental phase
We experimented with making the language
more graphic and descriptive.
Version #2: In the last two years, how
frequently did you use condoms when you were
having sex in the butt (when your dick was in his
butt)?

Feedback and Revision
Focus group at CAPS
User feedback in the jails
Positive and negative aspects to the
more graphic speech
Humor

Balanced Language
In its final form we tried to avoid offensive
speech and still convey the meaning of each
question.
Version #3: In the past 12 months, did you have
anal sex with a man, when you put your penis in
his butt?

Spanish Language Version
First version was done by a
professional translator
We revised this line by line using a
team of bi-lingual staff from FAP

Spanish Language Version
In Version #1 by professional translator:
¿En los últimos dos años, Con qué
frecuencia ha usado condones cuando los
hombres que lo/la penetran a usted?
In Version #2 revised by the FAP team
¿En los últimos 12 meses, tuviste sexo anal
con un hombre (metiste tu pene en su
ano)?

Computer Voices
We also considered what kind of voice we would
use on the computer for reading the survey
questions.
Alberto:
Paulina:
“¿En los últimos 12 meses, tuviste sexo anal con un
hombre (metiste tu pene en su ano)?”

PalmIT at the
Forensic AIDS Project
Counseling flow
Client issues
Confidentiality and disclosure

Future directions at FAP
VOICE study
Pod testing: challenges and rewards of
testing in the population at the jail

Future directions at Magnet
Expansion of services
Integration of PalmIT into a larger
electronic system for customer services
overall

Old Flow of Data
Entry of paperwork
State OA
QA of
paperwork
Review of paperwork

Flow with electronic data collection
data imported to main database monthly
State OA
records are prepped and
transmitted daily
devices synced daily

Where to go from here?
We need scalable technology, which likely
means a web-based application that can
support multiple users
Integration will be key
We’re interested in collaborative development
of a software tool that will meet these needs
Expensive (shared cost is good)
Flexible (multiple needs will force flexibility)

Thank you!!
www.palmpal.org