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Healer Women Fighting Disease Integrated Substance Abuse and HIV Prevention Program for African American Women (HWFD)

Healer Women Fighting Disease Integrated Substance Abuse and HIV Prevention Program for African American Women (HWFD) targets African American women who are 13 to 55 years old and at risk of contracting HIV/AIDS and transmitting HIV through unsafe sexual activity and substance abuse. Program participants are referred from agencies that provide services in primarily urban areas with high poverty and unemployment rates. The curriculum is based on African-centered precepts, values, and beliefs tied with a conceptual framework called "culturecology," which poses that an understanding of African American culture is central to behavior and behavioral change. Through a process of resocialization, or "culturalization," HWFD seeks to instill traditional African and African American health-promoting values that can help participants overcome negative social influences. Goals of the intervention include increasing motivation and sense of self-efficacy, decreasing depression and feelings of hopelessness, increasing knowledge about HIV/AIDS, and promoting less risky sexual practices.

HWFD has four core components: (1) the African Centered Behavioral Change HIV/AIDS & Substance Abuse Prevention Curriculum, (2) the Zola Ngolo Healing Ritual; (3) the Self-Healing Practice: Loving Oneself; and (4) Journaling. HWFD's strategies address women as whole persons in the context of family and community. These strategies include self- and collective-directed veneration, rituals of reflection and healing, and cultural realignment. The intervention is conducted by trained professional and paraprofessional women assisted by a licensed mental health professional and delivered in 16 weekly 2-hour modules. The content of the modules is fixed but can be augmented with input from the participants. The modules incorporate individual sessions and group discussions, behavioral skills practice, lectures, role-playing, viewing of prevention videos, and take-home exercises.

Descriptive Information

Areas of Interest Mental health promotion
Substance abuse prevention
Outcomes Review Date: May 2010
1: Knowledge, attitudes, beliefs, and intentions related to HIV/AIDS and risky sexual behaviors
2: Self-efficacy
3: Attitudes toward drug use
4: Self-worth
5: Hopelessness and depression
Outcome Categories Drugs
Mental health
Social functioning
Ages 13-17 (Adolescent)
18-25 (Young adult)
26-55 (Adult)
Genders Female
Races/Ethnicities Black or African American
Settings Other community settings
Geographic Locations Urban
Implementation History Since its development in the late 1990s, HWFD has been delivered to an estimated 200 women in the San Francisco Bay area of California.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: No
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories Selective
Indicated

Quality of Research
Review Date: May 2010

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Nobles, W. W., Goddard, L. L., & Gilbert, D. J. (2009). Culturecology, women, and African-centered HIV prevention. Journal of Black Psychology, 35(2), 228-246.

Nobles, W. W. (2005). The expanded Healer Women Fighting Disease project: Minority HIV prevention programs. Final grant report for SAMHSA Grant No. SPO9627.

Supplementary Materials

Gilbert, D. J., & Goddard, L. (2007). HIV prevention targeting African American women: Theory, objectives, and outcomes from an African-centered behavior change perspective. Family and Community Health, 30(Suppl. 1), s109-s111.

Outcomes

Outcome 1: Knowledge, attitudes, beliefs, and intentions related to HIV/AIDS and risky sexual behaviors
Description of Measures Knowledge, attitudes, beliefs, and intentions related to HIV/AIDS and risky sexual behaviors were assessed using self-reports.

From the Sexual Relations Scale, the following two subscales were used:

  • Attitudes toward condom use, which consists of items indicating the extent to which a woman has a favorable attitude toward the use of condoms in sexual activity. Examples of items include "Condoms provide no protection against AIDS," "Using a condom during sex prevents a man from enjoying himself," and "If I ask him to use a condom my partner would think I don't trust him."
  • Risky sexual behaviors, which consists of two items that indicate the extent to which a person engages in high-risk sex behaviors: "If a man wants to have sex with me and I like him, I will just do it" and "It is OK to have unprotected sex with someone before you really know that person."

From the American Red Cross Behavioral Intent Scale, the following two subscales were used:

  • Intention to change sex behaviors, which includes items such as "Based on what I know about HIV/AIDS, I will (postpone sexual activity, change my sexual habits)."
  • Intention to practice safe sex, which indicates the extent to which a person intends to engage in behavior that provides protection from contracting the virus. The items ask a person to indicate, on the basis of what he or she knows about HIV/AIDS, whether he or she will, for example, "request that [my] partner use condoms," "not share needles with anyone," or "not engage in sexual activity after drinking or doing drugs."

From the Attitudes About HIV/AIDS Scale, the following two subscales were used:

  • Sense of fatalism, which provides an indicator of a person's feelings of helplessness related to the issue of HIV. Examples of items include "I feel helpless against a disease like AIDS," "My risk of getting AIDS is low," and "There is very little a person can do to keep from getting AIDS."
  • Attitudes toward HIV/AIDS, which measures how a person feels about HIV/AIDS. Examples of items include "I feel helpless against a disease like AIDS," "The idea of getting AIDS frightens me," "Condoms provide no protection about AIDS," and "There is very little a person can do to keep from getting AIDS."
In addition, the study employed the HIV/AIDS Knowledge Scale, which assesses a respondent's general knowledge about the disease and its transmission modes and attitudes toward people with HIV/AIDS. Items include questions such as "Do you think a person can catch HIV/AIDS by sharing drug needles, from toilet seats, from kissing someone infected with AIDS, etc.?"
Key Findings Study participants were recruited from community agencies providing services to African American women. Women in the intervention group received the HWFD intervention, while those in the comparison group received the standard services provided by the agencies.

At pretest, the intervention and comparison groups did not differ significantly in attitudes toward condom use, risky sexual behaviors, intention to change sexual behaviors, and intention to practice safe sex.

At posttest, relative to the comparison group, the intervention group showed greater improvement in this outcome, with more supportive attitudes toward condom use (p = .05), less risky sexual behaviors (p = .02), increased intentions to change sexual behaviors (p = .001), and increased intentions to practice safe sex (p = .007).

In pretest-to-posttest analyses, the intervention group members showed a decrease in their sense of fatalism (p = .002), an increase in favorable attitudes toward people with HIV/AIDS (p = .02), and an increase in HIV/AIDS knowledge (p = .005).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.4 (0.0-4.0 scale)
Outcome 2: Self-efficacy
Description of Measures Self-efficacy was measured using self-reports on the following:

  • Control of life subscale from the Modified Piers-Harris Scale, which measures the extent to which respondents believe they are in charge of their own life. Examples of items include "What happens to me is my own doing" and "I feel that I have little control over things that happen to me."
  • Sense of motivation subscale from the Self-Efficacy Scale, which measures respondents' feeling of control of their situation and ability to get things done. Examples of items include "I can become anything I want to be" and "When I decide to do something I go right to work on it."
Key Findings Study participants were recruited from community agencies providing services to African American women. Women in the intervention group received the HWFD intervention, while those in the comparison group received the standard services provided by the agencies.

At pretest, the intervention and comparison groups did not differ significantly in their sense of control in life. At posttest, relative to the comparison group, the intervention group had a higher sense of control in life (p = .009).

In pretest-to-posttest analyses, the intervention group members showed an increase in their sense of motivation (p = .03).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.3 (0.0-4.0 scale)
Outcome 3: Attitudes toward drug use
Description of Measures Attitudes toward drug use were measured using self-reports on items from the Ideas About Drug Use Scale, which was developed for the study. Examples of items include "Using drugs causes people to lose self-control," "Using drugs helps people overcome boredom," and "Illegal drug users have difficulty carrying out daily tasks."
Key Findings Study participants were recruited from community agencies providing services to African American women. Women in the intervention group received the HWFD intervention, while those in the comparison group received the standard services provided by the agencies.

In pretest-to-posttest analyses, the intervention group showed improvement in attitudes toward drug use (p = .03). No significant differences were found between the intervention and comparison groups.
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.4 (0.0-4.0 scale)
Outcome 4: Self-worth
Description of Measures Self-worth was assessed using self-reports on three subscales from the Modified Piers-Harris Scale:

  • Measures of self-worth, designed to assess a person's feelings of his or her own abilities and characteristics.
  • Measures of sense of veneration, designed to assess the extent to which a person has the condition and/or ability to hold himself or herself in high regard and deep respect. Examples of items include "I am able to do things as well as most people," "I feel that I have a number of good qualities," and "I feel that I have much to be proud of."
  • Measures of authenticity, designed to assess understanding and/or recognition of one's essence (genuineness) and that which is consistent with one's essence (goodness). Examples of items include "I feel that I am a person of value," "I manage my own affairs well," and "I have a positive attitude toward myself."
Key Findings Study participants were recruited from community agencies providing services to African American women. Women in the intervention group received the HWFD intervention, while those in the comparison group received the standard services provided by the agencies.

In pretest-to-posttest analyses, the intervention group members showed an increase in their sense of self-worth (p = .02), sense of veneration (p = .01), and sense of authenticity (p = .006). No significant differences were found between the intervention and comparison groups.
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.3 (0.0-4.0 scale)
Outcome 5: Hopelessness and depression
Description of Measures Hopelessness and depression were assessed using self-reports on the following measures:

  • Beck Hopelessness Scale, which measures three major aspects of hopelessness: feelings about the future, loss of motivation, and expectations.
  • Crumbaugh Purpose-in-Life Test, which measures the extent to which an individual perceives life to be meaningful and contains two orthogonal dimensions: despair and enthusiasm.
  • Beck Depression Inventory, which assesses symptoms of depression, including negative attitudes toward self, performance impairment, and somatic (bodily) disturbance.
Key Findings Study participants were recruited from community agencies providing services to African American women. Women in the intervention group received the HWFD intervention, while those in the comparison group received the standard services provided by the agencies.

At pretest, the intervention and comparison groups did not differ significantly in levels of hopelessness and purpose in life. At posttest, relative to the comparison group, the intervention group had lower levels of hopelessness (p = .02) and higher levels of purpose in life (p = .02).

In pretest-to-posttest analyses, the intervention group showed a reduction in depression symptoms (p = .001).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent)
18-25 (Young adult)
26-55 (Adult)
100% Female 100% Black or African American

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Knowledge, attitudes, beliefs, and intentions related to HIV/AIDS and risky sexual behaviors 2.9 3.0 1.5 1.5 3.0 2.5 2.4
2: Self-efficacy 2.5 3.0 1.5 1.5 3.0 2.5 2.3
3: Attitudes toward drug use 3.0 3.0 1.5 1.5 3.0 2.5 2.4
4: Self-worth 2.5 2.5 1.5 1.5 3.0 2.5 2.3
5: Hopelessness and depression 2.9 3.3 1.5 1.5 3.0 2.5 2.5

Study Strengths

Many of the measures used in the study are well established and have good psychometric properties (e.g., Beck Hopelessness Scale, Beck Depression Inventory, Crumbaugh Purpose-in-Life Test); some have been widely used with African American populations, demonstrating good reliability and validity (e.g., American Red Cross Behavioral Intent Scale, HIV/AIDS scales). A curriculum was used to guide implementation of the intervention. Baseline equivalence between groups was established through similarities in employment status, education, age, number of children, and marital status, reducing threats to internal validity from self-selection and statistical regression.

Study Weaknesses

Cronbach's alpha coefficients indicate that reliability is questionable or modest at best for some subscales, including, for example, the measures of fatalism, attitudes toward people with HIV/AIDS, and some subscales from the Modified Piers-Harris Scale. Criterion validity was not established. There is limited documentation of process evaluation involving direct observation of the intervention or control groups, record keeping for attendance at sessions, or records for determining the quality or fidelity of intervention delivery. Attrition was high. Reasons for the attrition rate and how attrition was addressed were not clearly specified. The method used to address missing data was not appropriate. A different data analytic strategy would have been more appropriate given the unequal sample sizes for the intervention and comparison groups.

Readiness for Dissemination
Review Date: May 2010

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Institute for the Advanced Study of Black Family Life and Culture. (2000). Healer Women Fighting Disease: Agency implementation procedures guidelines. Oakland, CA: Author.

Institute for the Advanced Study of Black Family Life and Culture. (n.d.). Healer Women Fighting Disease: African centered behavioral change HIV & SA prevention training curriculum manual. Oakland, CA: Author.

Institute for the Advanced Study of Black Family Life and Culture. (n.d.). Healer Women Fighting Disease: Assessment/evaluation guidelines manual. Oakland, CA: Author.

Institute for the Advanced Study of Black Family Life and Culture. (n.d.). Healer Women Fighting Disease: Healer woman "You Work on You" participant workbook. Oakland, CA: Author.

Institute for the Advanced Study of Black Family Life and Culture. (n.d.). Healer Women Fighting Disease: Replication manual. Oakland, CA: Author.

Institute for the Advanced Study of Black Family Life and Culture. (n.d.). Healer Women Fighting Disease: Trainer's manual. Oakland, CA: Author.

Institute for the Advanced Study of Black Family Life and Culture. (n.d.). Healer Women Fighting Disease: Training resource materials handouts manual. Oakland, CA: Author.

Nobles, W. W., Goddard, L. L., & Gilbert, D. J. (2009). Culturecology, women, and African-centered HIV prevention. Journal of Black Psychology, 35(2), 228-246.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.2 3.5 2.4 3.0

Dissemination Strengths

The implementation guide is well written and comprehensive. Information on recruiting and retaining participants is offered to implementers, along with useful organizational guidance for adopting this intervention. A thorough, coherent outline guides the content of implementer training. Process and outcome measures previously used for research purposes are listed as possible tools for ongoing quality assurance.

Dissemination Weaknesses

Step-by-step procedures for the intervention and sequencing of program components are not clearly described. Implementation materials appear to be geared toward implementation in a particular site versus broader replication. Training materials lack the systematic structure and procedural approach of a standardized training curriculum. Actual fidelity and outcome measures are not provided, and little information is provided on how data derived from the identified measures should be used to improve program delivery.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Trainer's manual $340 each Yes
Curriculum manual (includes outcome evaluation procedures) $25 each or $180 for 10 Yes
Replication manual $5 each Yes
Agency implementation procedures guidelines $75 each Yes
Essential training materials kit $630 each No
2.5-day, on- or off-site standard training (includes 7-14 hours of follow-up technical assistance consultation by phone or email)
  • $3,400 per person plus trainer's travel expenses if applicable, or
  • $23,000 for six participants, plus $3,000 for each additional participant and trainer's travel expenses if applicable
Yes
6-day, on-site advanced training (includes 16-20 hours of follow-up technical assistance consultation by phone or email) $47,500 for six participants, plus trainer's travel expenses No
Assessment/evaluation guidelines manual $30 each, one per site Yes

Additional Information

Typical start-up costs other than training include staffing ($25,000-$42,000 per year plus benefits, varying by region) and incidental costs such as supplies, incentives, photocopying, food/snacks, and child care.

Replications

No replications were identified by the developer.

Contact Information

To learn more about implementation, contact:
Wade W. Nobles, Ph.D.
(510) 836-3245
drnobles@iasbflc.org

To learn more about research, contact:
Lawford L. Goddard, Ph.D.
(510) 836-3245
lgoddard@iasbflc.org

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.