Psychosocial Educational Counseling
for Haitians Living With HIV
Results and Implications of a Culturally Competent Model
Presentation
Topics

Project Overview

Outcome Evaluation

Results

Conclusion 

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HRSA SPNS Steering Committee 
September 16, 1999
 This is a poster presentation that was presented  in Washington D.C. as part of
 the Steering Committee meeting of the HRSA Special Projects of National 
 Significance.  The poster summarizes the successes and achievements of the 
 project and presents preliminary data analysis of final project findings, as the 
 EICMP project completes its five-year funding cycle.

The Massachusetts Haitian Community:

  • Fourth largest in the U.S
  • Estimated size is 80,000
  • Highly impacted by HIV/AIDS 
  • Cumulative Haitian AIDS cases as of 7/1/99 = 684
  • Haitian women increasingly becoming infected
  • "Risk not Specified" accounts for 67% of cases
  • Haitian pediatric cases represent 18% of the state's total pediatric AIDS cases
    Special considerations for Haitians living with HIV/AIDS:
    • Haitians labeled as part of "4H Group" in the 1980's. 
    • This caused fear, discrimination, and stigma towards Haitians and within the community.
    • Undocumented status can create barriers to care
    • Language barriers
    • Level of acculturation can play a role
    • Late entry into the medical system can cause early morbidity and mortality
    • Traditional health beliefs may cause misconceptions, denial about HIV disease
    • Stigma, secrecy can prevent disclosure to loved ones, partners
    Project Overview
    CCHER's Enhanced Innovative Case Management Program (EICMP) provides a psychosocial educational counseling curriculum to HIV+ Haitians. This culturally competent program seeks to reduce linguistic and cultural barriers by: 
    • Increasing consumers' knowledge of how to prevent HIV transmission
    • Increasing consumers' compliance with treatment
    • Improving consumers' utilization of health and social services
    • Increasing consumers' satisfaction with CCHER case management services 

      • and other services received 
    • Reducing risk behaviors
    • Improving consumers' sense of well being
    Methods
    A psychosocial educational counseling curriculum (PEC) of 25 topics was designed to address barriers, attitudes, cultural beliefs, behavioral issues specific to the Haitian HIV consumer. 
    Counseling is:
    • Culturally Competent 
    • One-to-One
    • In Haitian Creole
    • Non-judgmental
    • Flexible to consumer needs
    • Approximately 12-15 sessions of 45 minutes each
    • Takes place at a location that is convenient to the consumer, i.e. home, hospital, CCHER.
     PEC  Curriculum Topics

    Copyright CCHER 1999 Boston
    Sample
    70 Haitian consumers living with HIV/AIDS were enrolled into the project. 46 completed all phases of the project. Selected demographics of all enrollees include the following (N=70):
    • Gender: 44% Male, 56% Female
    •  Age range      Percent

      • 13-19 years             1%
      20-29 years             7%
      30-39 years             44%
      40-49 years             40%
      50+ years                7%
    • Haitian Creole is the primary language of 100% of enrollees

      • Employment Status:  26% Unemployed, seeking; 24% Unemployed, not seeking;
      7% Employed full time; 14% Part time; 27% Disabled; 1% Other
    • Marital Status: 29% married; 24% single; 16% widowed; 11% divorced; 13% separated; 7% common law
    • Self-reported sexual orientation: 96% heterosexual; 4% bisexual
    • Primary source of health care: 90% hospital outpatient clinic; 4% publicly funded community health center; 1% HMO; 4% unknown
    Study Design
    A pre/post questionnaire design was used to assess the EICMP's success in reducing linguistic and cultural barriers.The EICMP has four Phases:

    Outcome Evaluation Criteria:

    • Statistical analysis of baseline and post- program questionnaires
    • Focus group
    • In-depth field interviews with enrollees
    • Comparison Group
    Evaluation of consumers who completed the program has yielded positive outcomes.

    Results:
    1. Increased Knowledge of HIV/AIDS
    Pre/Post test analysis of CCHER KAB questionnaire shows significant increase in the number of correct responses. The information gains were maintained after the assimilation period. For example:

    • At baseline, 57% of enrollees knew that using a latex condom during sex can protect someone from getting HIV. Six months following the intervention, this increased to 80% of participants. (P<.0001)
    • At baseline, enrollees were asked "If a person is HIV+, does that mean..." 74% answered "the person has HIV"; 20% answered "the person will develop HIV". Immediately following the intervention, 89% correctly answered "the person has HIV", and just 7% answered "the person will develop HIV".
    • At baseline, 44% of Haitian female participants reported that they did not know that someone can get HIV by engaging in oral sex without condoms. Six months after the intervention, this decreased by 40%.
    • At baseline, just 24% of males and 48% of females knew that cleaning a needle with bleach and water can help protect someone from HIV. Six months following the intervention, this had increased to 43% of males (P=.042) and 72% of females (P=.01) understanding that cleaning a needle with bleach and water can protect someone from HIV.
    • At baseline, 82% of participants knew that having anal sex without a condom can cause HIV; six months after the intervention, this increased to 98%. (P=.0035)
    2. Increased Compliance with Treatment
    • At baseline, 85% of enrollees reported keeping their medical appointments, six months following the intervention, 93% reported keeping their appointments. 
    • CCHER counselors encourage consumers to integrate medication with folk treatments. Counselors report that consumers continue to use traditional Haitian remedies in addition to their prescribed medications.


    3. Improved Utilization of Health and Social Services

    • Upon entering the EICMP program, 48% of consumers reported needing basic support; this was reduced to 10% of participants six months following the intervention.
    • Upon entering the program, 48% of participants indicated a need for housing services; six months after the intervention, 23% indicated a need for housing services, suggesting the success of integrating other CCHER supportive services within a psychosocial educational counseling model.
    • 88% of consumers increased their use of HIV-related medical services six months after the intervention.
    • 78% of enrollees reported they were receiving case management six months after the intervention, evidence that hard-to-reach consumers are being linked to critical services.
    4.  Satisfaction with EICMP and Other   Services Received
    • At baseline, 67% of enrollees reported that they felt their doctor understood their health needs.  Six months after the intervention, 80% reported that they felt their doctor understood their health needs.  Counselors work with consumers to explain the U.S. medical system, clarify roles and consumers? expectations of physicians, and consumers? roles and responsibilities as a patient.
    • Focus Group and in-depth field interviews yielded positive feedback about the program, other CCHER services, and CCHER staff:

      • The counselors:
      •  Provided consumers with essential and important information about  HIV/AIDS
      •  Were ?more than family? in the type of support they provided to consumers
      •  Were easy to talk to because they were non-judgmental,   compassionate, and  understanding, regardless of consumers? class origins or educational levels
       
      The counseling sessions:
        •  Allowed consumers to come to grips with their disease
        •  Enabled consumers to open up and discuss subjects in uninhibited ways
        •  Were informative and illuminating, especially those related to sex and drugs
         
      Benefits of the program:
      •  It helped some consumers to disclose and talk openly to others about their HIV+ status
      •  It helped to change consumers? emotional lives for the better
      •  It helped them to change negative thoughts and to become more proactive in decisions about treatment
    5. Reduction in Risk Behaviors
    Analysis of CCHER Topic Questionnaire and SPNS/TMG module 31 provides evidence of reduction in sexual risk behaviors:
    • At baseline, 86% of males and 88% of females reported that a person with many sexual partners was more likely to get HIV. This increased to 100% and 96% respectively six months after the intervention.
    • At baseline, 67% of males believed that sheep-skin condoms can protect against HIV; six months following the intervention, this had significantly reduced to 33% of males (P=.005).
    • At baseline, 20% of women did not know that a pregnant woman could pass on HIV to her unborn baby; 6 months after the intervention, 100% of women enrollees knew that a pregnant woman could pass on HIV to her unborn baby (P=.022).
    • When first asked how often they use protection with their main sexual partner, 29% of enrollees reported "always"; post intervention, 44% responded "always" (P=.012)
    6. Improved Sense of Well-Being
    • Excerpt from field interview:

      • "My feeling of well-being is increased by coming here. Sometimes, you know, you want information and you can't ask for it. You feel sad. It makes things worse for you. You have to have somewhere you can go when you need to know something. Here they understand you. It makes you feel at ease, it helps you a lot. Sometimes you get up and you don't feel well, people here call you and talk to you, and you feel better. I got information, I got help, I got services".
    Lessons Learned:
    • Given the proper environment, staff experience and sensitivity, HIV+ Haitians can change their attitudes about HIV, increase their HIV knowledge, and can begin to make adjustments in their behaviors
    • Interventions that are culturally appropriate and science-based can reduce psychosocial burdens and medical barriers for many HIV+ Haitians
    • Interventions that integrate "root cause" analysis into their service delivery are more likely to be successful in helping HIV+ Haitians begin to change their attitudes, behaviors and beliefs related to HIV.
    • Once acclimated to the experience of one-to-one counseling, many Haitians want to continue the process
    • The psychosocial needs of HIV+ Haitians must be addressed across all service programs (i.e. case management, housing advocacy, etc.)
    • If providers become aware of internalized stigma suffered by HIV+ Haitians, providers can gradually help them overcome psychosocial burdens
     Challenges the SPNS project presented:
    • Identifying an appropriate evaluator to work with the project team and staff
    • Underestimating the timetable necessary to develop the needed systems to begin the project
    • Need for project staff to handle multiple tasks
    • Underestimating the needed experience and skills required to keep the project underway
    CCHER Project Achievements:
    • Creation of a psychosocial counseling curriculum specifically for the Haitian community
    • Providing critically-needed, culturally competent, in-depth psychosocial counseling and discussion with HIV+ Haitians
    • The Psychosocial Educational Counseling Curriculum (PEC) has been effective in helping Haitians living with HIV/AIDS to understand their illness and to change their behaviors in specific ways that will prolong their health and prevent further transmission.
    • Beginnings of a research-oriented, evaluation mind-set in a Haitian community-based organization through a relationship with a local university
    • Project findings from this seldomly-studied ethnic community will provide significant insights into the belief systems and the psychosocial and educational challenges faced by HIV+ Haitians. These will have important implications for HIV program planning and service provision for this population and other immigrant communities.
    • CCHER counselors have made significant steps in acclimating HIV+ Haitians to the notion of counseling and the benefits of a one-to-one counseling model.
    • Increasing CCHER's collaboration with Haitian CBOs in New York, Miami.
    • Products and deliverables
    • Development of new substance abuse and mental health services at CCHER.
    • Making an impact on consumers' lives
     Products/Deliverables from CCHER's SPNS project
    • Information dissemination at the local and national levels, including American Public Health Association
    • Knowledge base on 70 Haitian consumers
    • CCHER Newsletter in 3 languages (English, French, Creole) for the Haitian community and providers.
    • CCHER website
    • Curriculum resource manual for providers.
    • HIV information booklet in Haitian Creole for consumers and the general community.
       
  • Conclusions
    • This project is the first to examine psychosocial and cultural factors related to HIV among a sample of Haitian men and women.
    • Results thus far are consistent with our expectations: with a culturally appropriate intervention, knowledge can improve, attitudes can change, psychosocial burdens can be reduced, and risk reduction can occur.
    • Limitations: Our study was limited to a small sample (N=70), making it difficult to draw inferences about the Haitian community as a whole.
    • Strengths: Our limitations are countered by the strengths we find in the entire project: extensive data set on HIV+ Haitians, rich qualitative data collected from enrollees.
    • Public Health implications: this project is a first step in systematically collecting information on the behaviors, beliefs, and psychosocial challenges of this unique population.
    • Further studies related to the psychosocial challenges, behaviors, stigma and coping mechanisms of HIV+ Haitians need to be done within the community.
    Data presented is based on preliminary final analysis 
    Acknowledgments:
    CCHER gratefully acknowledges those that have contributed to this project: 
    HRSA SPNS Staff; The Measurement Group; Anna Madison PhD, Univerisity of Massachusetts Boston; Kay Jones MSW and Scott Geron PhD, Boston University  School of Social Work; David  Coppola; Kathy Steger Craven, RN MPH, Boston Medical Center Clinical AIDS Program; Cergine Eusebe; and Nicole César. 

    CCHER Staffs: Eustache Jean-Louis, MD, MPH, Executive Director; Guy Apollon, MD, MPH; Program Director;Janine Walker, MPH, Research Coordinator; Joel Piton, MD ,M.Ed., Research   Assistant; Berthonia Antoine, Pychosocial Counselor
Supported by grant # BRU 900123-02
For more information about this project, contact:
Eustache Jean-Louis, MD MPH
Center for Community Health, Education & Research, Inc.
420 Washington Street
Dorchester, MA 021241
617-265-0628
ejeanlouis@ccher.org 
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