Step 5: Use Results to Improve Programs

Objective

To provide the results of the PLACE assessment to local intervention groups and to use these results to improve HIV/AIDS prevention programs.

Methods

5.1 Clean data and document field work

5.2 Prepare documentation tables

5.3 Prepare maps

5.4 Write Preliminary PLACE Report

5.5 Conduct Local Feedback Workshop

5.6 Prepare Final PLACE Report

5.7 Disseminate Final PLACE Report

5.8 Plan Follow-Up and/or "Roll-Out" PLACE Assessment

Expected Outputs 

• Full documentation of PLACE methods and data sets

• Preliminary PLACE Report for distribution at the Feedback Workshop

• Final PLACE Report including Local Action Plans disseminated at a national forum

• Trained people at local level capable of using PLACE data

• Plan for "Roll-Out" and Follow-Up PLACE Assessments

5.1 Clean data and document field work

At the end of the field work, there are typically four data sets:

• characteristics of community informants obtained in Step 2

• site reports from community informants obtained in Step 2

• characteristics of sites from site verification visits in Step 3 and

• data from interviews with people socializing at sites obtained in Step 4.

Prior to creating the tables for the Preliminary PLACE report, the data should be cleaned and a data documentation notebook prepared that includes fieldwork documentation, the questionnaires, a list of all variables, and any decisions made to clean data.

5.2 Prepare documentation tables

Documentation tables organize the frequency distributions printed in the data documentation notebook by data set and topic. The documentation tables:

• summarize results from the community informant interviews including the number of characteristics of community informants and the number and types of sites reported

• describe the number and types of sites visited during Step 3 and their characteristics including condom availability, patronage by key populations, and number and characteristics of site patrons according to the site informant, and

• describe the patrons socializing at venues including sociodemographic characteristics, venue visiting behaviors, sexual partnerships, condom use, and exposure to prevention programs

Documentation tables are usually printed in the Appendix of a PLACE Final Report. To see an example of a set of documentation tables, visit the MEASURE Evaluation website and search for publications on PLACE.

5.3 Prepare maps

A map of all the venues visited in Step 3 is extremely valuable. Such a map displays the geographic distribution of venues and can be used to visually determine where venues cluster and hence where intervention programs are needed and can also generate insight into contextual factors that may be important. For example, if all of the venues cluster along a main road or near women's colleges, then intervention programs may want to conduct an outreach program with mobile populations that regularly travel the main road in the former case and an outreach program at student dormitories in the latter case.

Program coverage maps are perhaps the most important output of the PLACE method. Program coverage maps indicate the extent to which prevention programs identified in Step 1 are reaching people socializing at PLACE venues. Examples of program coverage maps are provided below for condom availability. A map showing condom availability is a graphic way to document the need for increasing condom distribution.

Criteria for selecting priority venues to receive an intervention will depend on the local epidemic and the amount of resources available to field an intervention response. Criteria that have been used to identify priority venues include:

• Popular Venues: Venues identified most frequently by community informants

• Large Venues: Venues with the largest number of patrons

• Attendance by key population: Venues frequented by members of a specific key population (e.g., sex workers, injecting drug users, men who have sex with men, youth)

• Multiple network venues: Venues frequented by two or more key populations

• High partnership venues: Sites where people socializing report a high rate of new partner acquisition

• Onsite sexual activity: Venues where sex occurs onsite, sex workers solicit, where new partnerships are formed or a combination of sexual behaviors

5.4 Write the Preliminary PLACE Report

The Preliminary PLACE Report is a 20 page summary of the PLACE assessment. It includes an Executive Summary, the documentation tables, a description of the PLACE method, and the key findings from each Step using pie charts and graphics to display the results. Preliminary recommendations are often included in the Preliminary Report to facilitate discussion at the Local Feedback Workshop. The documentation tables and questionnaires are included as an appendix to the Preliminary Report.

Below is an example of a summary table that might appear in the Executive Summary. The summary table ideally highlights the main findings of the PLACE assessment. The summary table usually reflects the decisions made by the Steering Committee in Step 1 regarding the identification of key populations.

*Many definitions are possible; in this table, we followed the definition for determining sites with 3 or more risky behaviors from Exercise 5-1.

Most of the data for the summary indicators can be taken from the documentation tables but some of the indicators require additional data manipulation. Some of these are described below:

Composite variable on new and concurrent partnerships

One of the most important indicators is the proportion of the population with new and/or concurrent sexual partnerships. This indicator is derived from a composite variable based on the number of new and total partners reported in the past 4 weeks and past 12 months. On the summary table, the variable can be collapsed into these three categories and a simple distribution provided of the proportion of the population in each category:

• Highest risk of acquiring and transmitting HIV: Those with either a new partner in the past four weeks or multiple partners in the past four weeks

• High risk of acquiring and transmitting HIV: Those who do did not have new or multiple partners in the past 4 weeks but who had new or multiple partners in the past 12 months

• Least likely to contribute to HIV transmission: Those with neither a new partner nor multiple partners in the past 12 months.

Patronage at Sites by Key Populations

Key populations are identified by the Steering Committee in Step 1. The summary tables provide indicators showing the proportion of venues frequented by each key population as reported during site visits in Step 3, the proportion of the population socializing at sites with reported behaviors associated with each of the key populations, and the size of key populations (See below). These indicators require some data manipulation.

Estimates of the size of the population socializing at sites and estimates of the size of other key populations

A special feature of the PLACE method is its ability to estimate the size of key populations using the resulting data. Having an estimate of population size is important because it enables program managers to know the coverage of their programs. For example, a program reaching 100 commercial sex workers in one year is impressive -- however, interpretation of that achievement has more meaning when knowing the total population of commercial sex workers is 200 and not 500, meaning 50% of sex workers were reached versus 20%. The size of the population socializing at sites in a Priority Prevention Area during a busy time and the size of key populations of interest, such as commercial sex workers, can be estimated.

To estimate the size of the population socializing at sites in the PPA during a busy time, add estimates of the number of men and number of women socializing at the site at a busy time, as reported by site representative. The result provides the intervention team with a rough estimate of the number of people that would be reached by an intervention implemented at sites during a single busy time.

5.5 Conduct Local Feedback Workshops

The purpose of the Local Feedback Workshop is to present the findings to community stakeholders in the area where the PLACE assessment was conducted in order to inform them of the findings, to improve understanding of the findings through discussion with the people who know the community best, to generate renewed local interest in prevention programs, and to develop an action plan that identifies particular steps that could be taken immediately to address program gaps.

Development of an action plan is one of the critical components of the workshop. The action plan is developed through a process that includes identifying what activities can be initiated at the community level without any additional resources and what activities are of highest priority if resources from outside the community can be obtained. After sharing PLACE results with members of the local communities and developing a list of recommendations and action plans, the report is updated and presented to a larger workshop of stakeholders involved in HIV/AIDS prevention at a regional level.

5.6 Prepare a Final PLACE Report

After the main findings of the PLACE assessment are presented to local community and intervention groups, the final report of PLACE results is prepared. This report will include the Action Plans and recommendations from the Local Feedback Workshop. The Final Report can also include additional analyses such as sub-group analyses by age and for key populations. (e.g., injecting drug users, commercial sex workers, and youth).

Linking the data collected during interviews with site representatives with data collected during interviews with individuals socializing at sites can also provide useful insights. The linking of data sets facilitates the comparison of behaviors at sites with differing characteristics. For example,

• To examine whether onsite alcohol consumption is associated with self-reported onsite new sexual partnership formation

• To examine whether condom use reported by people socializing at sites with condoms available is different than at sites where condoms are not available

5.7 Disseminate Final PLACE Report

The Final PLACE Report should be widely disseminated and used to secure additional resources for improving AIDS prevention program coverage. Dissemination at a national meeting could include findings from one or more areas that have completed PLACE assessments.

5.8 Plan Follow-Up and Roll Out PLACE Assessments

An essential part of a PLACE strategy is planning for future assessments. After an initial assessment, the PLACE Steering Committee needs to discuss rolling out the method to other areas in the district or country. To guide this process, the committee again follows the outline presented in Step 1 for considering all epidemiological and contextual information about potential PPAs. The committee also needs to reflect on lessons learned in the first application of the PLACE method in planning subsequent assessments. Plans for a follow-up assessment are also made to monitor program coverage of site-based interventions resulting from the first PLACE study. Time lines for "roll-out" to other areas and for follow-up studies are discussed and funding sources identified.

Exercise

Exercise 7

Objective

To use data collected during site verification and data collected from socializing individuals to compile a list of priority sites for HIV/AIDS intervention activities.

The specific criteria used for selecting priority sites depend on the local epidemic. Priority sites should be those sites where populations key to the transmission of HIV interact. In Port City, sexual transmission rather than transmission through injection drug use is believed to be responsible for the epidemic. Key populations in this area therefore include people who are at high risk for sexual transmission because of risky behaviors such as exchanging sex for money with heterosexual or same-sex partners or forming new sexual partnerships. Priority sites include sites where people who exchange sex for money are socializing and sites where people are having sex on-site. Site size is another potentially important criteria for identifying priority sites, because prevention programs at sites with many visitors at one time will reach a maximum number of people. Finally, sites where youth socialize are important because reaching youth is important for turning around an epidemic.

In the fictitious area of Port City, given budget constraints, it has been decided that a total of 25 sites can be targeted with intervention strategies at this time. In the first part of this exercise, you will use data collected from a knowledgeable person at each site verified in Step 3 to compile a list of 25 priority sites for intervention programs. The dataset for this exercise is called the "Site Verification for Priority Sites" dataset; it is a subset of the data in the Site Verification dataset. This dataset contains data collected and coded as indicated in the Site Verification Form.

In the second part of the exercise, you will use the "Socializing Individuals" dataset (that you used in Exercise 6) to develop a list of sites where site patrons reported engaging in risky behaviors. Information in this dataset was collected during interviews at a sub-set of the sites with men and women socializing, using the Questionnaire for Individuals Socializing at Sites. You will then compare the list of sites where patrons report risky behavior with your list of priority sites from the first part of the exercise. An important point to remember is that the sites where socializing individuals were interviewed are a randomly sampled subset of all sites, so not all priority sites that you selected are expected to show up on the list that you developed from the Site Verification database.

The Site Verification Form, "Site Verification for Priority Sites" dataset, Questionnaire for Individuals Socializing at Sites, and "Socializing Individuals" dataset are provided for you, below. These datasets contain most of the variables currently used in the PLACE protocol.

Excel can be used for analysis of the "Site Verification for Priority Sites" dataset in the first part of the exercise. For the second part, you may choose to use the datasets in Epi Info or in HTML format if you wish to import it into another statistical package. You will need to use a statistical package such as Epi Info to complete the analysis for the second part of the exercise because there are too many observations in the "Socializing Individuals" dataset for you to answer the questions simply by counting. Epi Info is the preferred statistical package for this exercise because this public domain software is available for download at no cost from the United States Centers for Disease Control and Prevention (CDC) at www.cdc.gov.

Forms

• Questionnaire for Individuals Socializing at Sites: [PDF]

• Site Verification Form: [PDF]

Data

• Site Verification for Priority Sites: [MS Excel]

• Socializing Individuals: [Epi-Info]

Exercise 7 Part 1: Questions using Site Verification Dataset and Excel

To help you identify priority sites, answer the questions below. For the first set of questions, you will need to use the Site Verification for Priority Sites dataset, and for the second set of questions you will need to use the Socializing Individuals data. Instructions for using Excel and Epi Info to complete the analysis are available if you need them, here

1. When identifying priority sites, we want to look only at sites that were verified by a completed interview. At how many sites was an interview completed?

   Delete those sites where no interview was completed successfully.

2. One of the criteria for priority sites is that they are well known or popular places that draw large numbers of socializing individuals. To establish a list of popular sites, make a list that includes sites that were reported by 10 or more community informants and sites where at least 100 people were socializing during a busy time. Interventions aim to reach a large number of people and so it is reasonable to include the sites with the largest number of patrons among the priority sites. To establish a list of popular sites, make a list that includes sites that were reported by 10 or more community informants and sites where at least 100 people were socializing during a busy time.

3. Priority sites often include sites where youth can be reached. In some countries, one of the most important prevention strategies is to keep the epidemic from reaching the next generations by focusing on youth. List those sites where most of the patrons during busiest times are either young men or young women aged 15-19.

4. Lastly, priority sites usually include sites where it seems evident that people are meeting new sexual partners at the site and that the people who visit the site are likely to have new and multiple partnerships. Establish a list of risky behavior sites where any of the following reportedly occur, according to the person knowledgeable about the site interviewed in Step 3: 

   • Someone onsite helps partners to hook up or link up

   • Female sex workers solicit customers

   • Partners who meet onsite have sex onsite

   • Female staff meet new sexual partners

   • Male staff meet new sexual partners

   • Women appear to be buying or selling sex

   • Men appear to be buying or selling sex

   Once you have your complete list of sites, compile an abbreviated list of sites where at least 3 partnership behaviors from this list were reported.

5. To evaluate which 25 sites should be priority sites for intervention, you will need to consider the priority site characteristics and lists that you have developed above. Compile a final table of sites that were either popular (from number 2 above), sites where most people socializing were youth (from number 3 above), and sites with at least 3 risky behaviors (from number 4 above). Make a column for each priority site characteristic so that you can identify those sites with more than one priority characteristic. Which 25 sites would you choose, based on this information? (Note that there are many ways of determining priority sites; this exercise has guided you through one possible way, but you could easily use a different cut-off for site size, or different risk behaviors, and arrive at a different answer!)

Exercise 7 Part 2: Questions using Socializing Individuals Dataset and Epi Info

The determination of priority sites above did not take into account the responses from individuals who were interviewed at a subset of the sites. It is often useful to compare the reports about site patrons obtained in Step 3 with the self-reported behavior of people socializing at the sites where patrons were interviewed. By considering the responses from all persons interviewed in a specific site, it is possible to get an understanding of the extent to which people with high rates of new sexual partner acquisition cluster in particular sites and whether these sites were among those identified as priority sites using data from site verification in Step 3. This exercise explores this association.

1. Sex for money: Some sites where patrons were interviewed may be more likely than others to attract patrons engaged in sex work. Using the data from interviews with people socializing at the site, list all of the sites where 5 or more people interviewed at the site reported exchanging sex for money in the past twelve months.

2. New partners: Some sites may be more likely to attract men and women with high rates of new sexual partner acquisition. List all sites where more than 10 people have at least one new partner in the past 4 weeks.

3. Low condom use: The need for condom promotion messages may also vary by site. To get an insight into the extent to which this may be true in the Port City, list all sites where 5 or more people didn't use a condom the first time they had sex with their most recent new sexual partner in the past year.

4. STD Symptoms: Many people who are infected with a sexually transmitted disease (STD) do not know that they are infected because they do not have any symptoms of infection. Some people with symptoms, however, never visit a clinic to be treated. Review the data to determine if there are sites that may need a visit by an outreach nurse to encourage proper health seeking behaviors when symptoms of STD occur. List all sites where at least 5 men reported having STD symptoms in the past four weeks.

5. Now, compile a table of all the sites where interviews with socializing individuals were conducted. Make a column for each of characteristics (sex work, new partners, low condom use, STD symptoms) described in numbers 6-9 above and indicate which sites met or exceeded each threshold specified above. Make a fifth column with the total number of times (range 0 to 4) that a threshold was met or exceeded at the site. Finally, add a sixth column to show which of these sites were identified as sites with three or more risky behaviors from the Site Verification dataset above in the first part of this exercise.

To summarize your comparison of risky behaviors in the site verification data and in the individual interview data, use the table you have created to fill in the table below. Do the two datasets reach a similar conclusion about sites where risky behaviors take place?

Answers

Exercise 7

1. When identifying priority sites, we want to look only at sites that were verified by a completed interview. At how many sites was an interview completed?

   Interviews were successfully conducted in 128 sites.

   Delete those sites where no interview was completed successfully.

   14 site records were deleted.

2. One of the criteria for priority sites is that they are well known or popular places that draw large numbers of socializing individuals. To establish a list of popular sites, make a list that includes sites that were reported by 10 or more community informants and sites where at least 100 people were socializing during a busy time. Interventions aim to reach a large number of people and so it is reasonable to include the sites with the largest number of patrons among the priority sites. To establish a list of popular sites, make a list that includes sites that were reported by 10 or more community informants and sites where at least 100 people were socializing during a busy time.

   You only need to produce one final table, but intermediate tables for each criteria are shown below, before the final combined table.

Table 1: Popular sites reported by at least 10 community informants and sites where at least 100 people are socializing during a busy time

1. Priority sites often include sites where youth can be reached. In some countries, one of the most important prevention strategies is to keep the epidemic from reaching the next generations by focusing on youth. List those sites where most of the patrons during busiest times are either young men or young women aged 15-19.

Table 2: Priority sites for youth.

1. Lastly, priority sites usually include sites where it seems evident that people are meeting new sexual partners at the site and that the people who visit the site are likely to have new and multiple partnerships. Establish a list of risky behavior sites where any of the following reportedly occur, according to the person knowledgeable about the site interviewed in Step 3:

   • Someone onsite helps partners to hook up or link up

   • Female sex workers solicit customers

   • Partners who meet onsite have sex onsite

   • Female staff meet new sexual partners

   • Male staff meet new sexual partners

   • Women appear to be buying or selling sex

   • Men appear to be buying or selling sex

   Once you have your complete list of sites, compile an abbreviated list of sites where at least 3 partnership behaviors from this list were reported.

Table 3: List of sites where selected risky behaviors are reported to take place

Table 4: List of sites where at least 3 risky behaviors were reported

1. To evaluate which 25 sites should be priority sites for intervention, you will need to consider the priority site characteristics and lists that you have developed above. Compile a final table of sites that were either popular (from number 2 above), sites where most people socializing were youth (from number 3 above), and sites with at least 3 risky behaviors (from number 4 above). Make a column for each priority site characteristic so that you can identify those sites with more than one priority characteristic. Which 25 sites would you choose, based on this information? (Note that there are many ways of determining priority sites; this exercise has guided you through one possible way, but you could easily use a different cut-off for site size, or different risk behaviors, and arrive at a different answer!)

   We chose a list of 25 priority sites by the following criteria: A site had to have at least two priority site characteristics: popular (reported by 10 or more community informants or with 100 or more people socializing), youth site (where most people socializing are either male or female youth aged 15-19), or risky (sites with at least 3 selected risky behaviors).

Table 5: List of all popular sites (reported by 10 or more community informants or with 100 or more people socializing), sites where most people socializing are youth aged 15-19, and sites with at least 3 selected risky behaviors. Sites with at least 2 characteristics (popular, youth, or risky) are in bold.

Table 6: List of 25 priority sites

We have created a map of priority sites below.

Part 2: Questions using Socializing Individuals Dataset and Epi Info

The determination of priority sites above did not take into account the responses from individuals who were interviewed at a subset of the sites. It is often useful to compare the reports about site patrons obtained in Step 3 with the self-reported behavior of people socializing at the sites where patrons were interviewed. By considering the responses from all persons interviewed in a specific site, it is possible to get an understanding of the extent to which people with high rates of new sexual partner acquisition cluster in particular sites and whether these sites were among those identified as priority sites using data from site verification in Step 3. This exercise explores this association.

1. Sex for money: Some sites where patrons were interviewed may be more likely than others to attract patrons engaged in sex work. Using the data from interviews with people socializing at the site, list all of the sites where 5 or more people interviewed at the site reported exchanging sex for money in the past twelve months.

   207 Wentworth Alice Archies Athletic Park Boccachios Creature Comforts Elizabeth Good Karma

   Grace Hoky Speaks Ironhead Masks Jack's Road Majestic Marquee Mara Market Square Mall Michael's Eatery

   Phoenix Downtown Publishers Haven Sparrow's Hair St. Paddy's Place The Coffee Shack Water World

1. New partners: Some sites may be more likely to attract men and women with high rates of new sexual partner acquisition. List all sites where more than 10 people have at least one new partner in the past 4 weeks.

   Alice Amani Archies Athletic Park Dollar Inn Good Karma Great Dane Gunnels Express

   Hoky Speaks Jack's Road Majestic Marquee Miami's Vice Michael's Eatery Peacock

   Poplin's Rest Sparrow's Hair St. Paddy's Place Stary Night Sun Hotel The Coffee Shack

1. Low condom use: The need for condom promotion messages may also vary by site. To get an insight into the extent to which this may be true in the Port City, list all sites where 5 or more people didn't use a condom the first time they had sex with their most recent new sexual partner in the past year.

   207 Wentworth Alice Archies Athletic Park Creature Comforts Elizabeth Jack's Road Land Lubbers

   Majestic Marquee Mara Market Square Mall Miami's Vice Michael's Eatery Phoenix Downtown Phydeaux

   Poplin's Rest Sparrow's Hair St. Paddy's Place Stary Night Sun Hotel The Coffee Shack Water World

1. STD Symptoms: Many people who are infected with a sexually transmitted disease (STD) do not know that they are infected because they do not have any symptoms of infection. Some people with symptoms, however, never visit a clinic to be treated. Review the data to determine if there are sites that may need a visit by an outreach nurse to encourage proper health seeking behaviors when symptoms of STD occur. List all sites where at least 5 men reported having STD symptoms in the past four weeks.

   Land Lubbers Magestic Marquee Mojo And Co. Peacock Gunnels Express Elmore's Friends Creature Comforts

   Boccachinos Hoky Speaks 207 Wentworth Jack's Road Poplin's Rest Mara Malibu Beach

   Miami's Vice Phoenix Downtown Dollar Inn St. Paddy's Place The Coffee Shack Water World Good Karma

1. Now, compile a table of all the sites where interviews with socializing individuals were conducted. Make a column for each of characteristics (sex work, new partners, low condom use, STD symptoms) described in numbers 6-9 above and indicate which sites met or exceeded each threshold specified above. Make a fifth column with the total number of times (range 0 to 4) that a threshold was met or exceeded at the site. Finally, add a sixth column to show which of these sites were identified as sites with three or more risky behaviors from the Site Verification dataset above in the first part of this exercise

Table 7: Table of all selected behaviors at all sites where interviews with socializing individuals were conducted, with comparison to behaviors reported during site verification.

To summarize your comparison of risky behaviors in the site verification data and in the individual interview data, use the table you have created to fill in the table below. Do the two datasets reach a similar conclusion about sites where risky behaviors take place?

Information about behaviors from the site verification data is confirmed by information from interviews with individuals socializing at each site. Sites where three or more risky behaviors were reported during site verification tended to have a higher prevalence of risky behaviors reported at the individual level; sites where less than three risky behaviors were reported during site verification tended to have a lower prevalence of risky behaviors reported at the individual level.