AIDS, Sexual Behavior, and Intravenous Drug Use (1989) / Chapter Skim
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5 Evaluating the Effects of AIDS Interventions
5 Evaluating the Effects of AIDS Interventions
Pages 316-356
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From page 316... ...
Evaluation is the process that will enable us to learn from experience. The committee recommencis that the Office of the Assistant Secretary for Health take responsibility for an evaluation strategy that will provide timely information on the relative effectiveness of different AIDS intervention programs.
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From page 317... ...
Discussions with many people who have been on the front lines of AIDS prevention activities since the early days of the epidemic reveal their clesire for evaluation of their work. To ciate, however, most of these individuals have not conducted evaluations—not because they were unwilling but because they lacked the capability.
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From page 318... ...
At its best, a process in which program innovations are informed by feedback from careful, prompt evaluations can lead to the timely elimination of ineffective concepts and designs and the selection and adoption of effective ones. A successful evaluation of an intervention program must provide answers to several key questions: 1.
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From page 319... ...
Many AIDS prevention programs have chosen knowledge as the outcome measure; it is easier to gauge than behavior but less relevant to the process of preventing the spread of HIV infection. It is not unusual for programs to include multiple outcome measures that vary in importance.
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From page 320... ...
The consistency of the outcome measures or effects of a particular intervention during repetitions of it is critical in appraising the intervention. It is important to remember that repetitions of a treatment or intervention are counted as the number of treatment units to which the intervention is applied.
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From page 321... ...
Recent work conducted by the Center for AIDS Prevention Studies in San Fiancisco investigated three stages in the prevention process: (1) ensuring that individuals
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From page 322... ...
The American Public Health Association has developed criteria for health education programs that have been used in the design of a university-based AIDS program that seeks to reduce risk-associated behavior (VaTcliserri et al., 1987~. Defining ant} Measuring Outcomes As noted earlier, there are two dimensions to outcome measures: relevance and feasibility.
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From page 323... ...
An outcome may simply be impossible to measure. For example, the incidence of HIV infection in the general population is not known because such knowledge wouIc!
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From page 324... ...
For example, the incidence of STDs can serve as a prompt, sensitive indicator of behavioral change to prevent sexually acquired HIV infection because STDs and HIV can be spread by the same behaviors. If a particular outcome is simply too difficult to measure accurately, a major component of that outcome may serve as a reasonable alternative.
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it is impossible to determine whether observed differences are due to treatment or are merely artifacts of noncomparable outcome measurement. The foregoing ideas are central to randomized clinical trials and randomized field experiments, which are discussed in the next section.
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From page 326... ...
This, unfortunately, has been the case with randomized trials of some drug treatment strategies: for example, many {V drug users prefer methadone maintenance over detoxification, making it difficult to recruit subjects for random assignment treatment studies. Constraints on Evaluation The above sections have described the basic characteristics of evaluation.
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From page 327... ...
In this section, we propose and examine the use of the ranclomized field experiment in the behavioral sciences. A randomized field experiment is a particular kind of controlled experiment; it requires that individuals, organizations, or other treatment units be randomly assigned to one of two or more treatments or program variations.
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From page 328... ...
are other interventions that have been tester] in randomized field experiments (Solomon et al., 1986~.
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, there was no detectable program effect on the reduction of risk-associated behavior. In evaluations of programs that have been designed to reduce risky behavior among adolescents, the treatment units have been institutions (e.g., schools)
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From page 330... ...
on compliance with therapeutic regimens. Randomized field experiments also encourage those who manage such projects to pay more attention to details that contribute to the proper execution and evaluation of the program.
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Affirmative answers to these questions justify serious consideration of the use of ranclomized experiments. A fifth consideration concerns the role of coercion in recruiting subjects, a condition that must be consiclered for AIDS interventions, especially among such vulnerable populations as institutionalized men and women.
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In one sense, the question of whether there are good alternatives to randomized experiments is easy to answer. Random assignment produces equivalent groups that make subsequent comparisons as unambiguous as possible.
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In fact, as noted earlier in this chapter, evidence from randomized experiments in the social sciences has become increasingly important to decision making over the last decade. Voluntary Participation In considering the use of experiments in institutional contexts, the Federal Judicial Center (1981)
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From page 334... ...
The term community organization is used to denote a variety of formal and informal units; thus, towns, neighborhoods, youth gangs, and pharmacies, diverse though they may be, are all appropriate units for controlled ranclomized tests of AIDS intervention programs. The primary motive in considering the use of communities as treatment units in randomized field experiments is that of practicality.
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From page 335... ...
community-based organizations for a variety of health promotion programs. Although there are no examples among AIDS prevention programs of the randomized assignment of organizations to treatment or control groups, strategies that have been employed for non-AIDS programs can provide useful information.
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Local demands are not unique to randomized field experiments, however; (remonstration projects have also been required to be responsive to local conditions.
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SPECIAL CONCERNS OF EVALUATION IN THE CONTEXT OF HIV INFECTION AND AIDS Research on HIV infection and AIDS presents many methodological challenges. Although some of them have been met, at least in part, by research programs on other sensitive, controversial, or illegal behaviors, there are methoclological impediments inherent in this epidemic that can be overcome only by first investing in methodological research.
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From page 338... ...
and Riecken and coworkers (1974~. Developing the ability to locate and identify individuals who are at risk for AIDS and then engage them in field tests requires new information and perhaps new methods.
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In turn, outreach worker training can be informed by local ethnographic work and those with experience in longitudinal surveys of other har~l-to-reach groups (e.g., homeless people or IV drug users)
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From page 340... ...
Objectives of AIDS Intervention Programs The main objective of an AIDS intervention program in the United States is to retard the spread of HIV infection. Yet HIV infection is a difficult outcome to measure.
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The quality of measurement of certain behaviors may not allow researchers to discern whether in fact change has really occurred. Improved surveys of {V drug users, for instance, may show an increase in drug use when no increase has actually happened; such differences simply reflect the use of more accurate measures.
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Procedural approaches have used nontechnical devices, such as eliciting information from individuals who remained anonymous; this approach has been used frequently in AIDS prevention programs. Its limitations are not inconsequential: it is impossible to ascertain the reliability of self-reportec!
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From page 343... ...
Approaches to resolving ethical problems engen~lere(1 by ran(lomized experiments have been a topic of serious interest since the early 1970s. Thoughtful treatments of constitutional law and the court's views of randomized tests are given in Breger (1983)
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By comparing a selected subgroup of those randomly assigned to treatment with the entire control group, the authors confounded their finding: they created a situation in which the estimate of the program's effect is tangled inextricably with unknowable differences between the treatment group and the control group. Attrition and noncompliance problems occur in experiments on various topics, including studies of drug trials At.
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From page 345... ...
Survey research conducted over the past 20 years has provided a great deal of information about controlling attrition. Reports on this topic regularly appear in such periodicals as the Annual Proceedings of the American Statistical Association, Evaluation Review, Proceedings of the Annual Census Conference, and International Statistical Review.
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From page 346... ...
correlates self-reported data with direct observations of IV drug use and the shared use of needles; . correlates retrospective self-reports of sexual behavior among prostitutes, {V drug users, and others at risk for HIV infection with monitoring (e.g., more frequent interviews or the use of diaries)
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From page 347... ...
The committee recommencis that evaluation support be provided to ensure collaboration between practitioners and evaluation researchers. The challenge to leadership and management is to remove impediments to evaluation.
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In reviewing AIDS intervention programs, the committee found that the descries tive information typically published about an actual intervention does not provi(le sufficient de-tai! to permit its replication.
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The committee sees two steps as sufficient to initiate this process. First, CDC land any other agency that undertakes AIDS prevention programs)
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(1986) Understanding respondent cooperation: Field experiments versus surveys.
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. Center for AIDS Prevention Studies, Department of Psychiatry and Department of Medicine, University of California at San Francisco.
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(1988) Implementing Randomized Field Experiments: An Analysis of Civil and Criminal Justice Research.
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(1988) AIDS Prevention in Gay and Bisexual Men: Experimental Evaluation of Attitude Change from Two Risk Reduction Interventions.
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(1987) An Evaluation of Using Ex-Addict Outreach Workers to Educate Intravenous Drug Users About AIDS Prevention.
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(1986b) Recent sexually transmitted disease prevention efforts and their implications for AIDS health education.
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From page 356... ...
Health Education Quarterly 13:73-91. Teitlebaum, L
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