Intervention Summary

Healing Our Women (HOW)

Healing Our Women (HOW) is a community-based, culturally congruent psychoeducational intervention for HIV-positive women who have a history of child sexual abuse. HOW is designed to enhance participants' coping and emotional problem-solving skills to reduce sexually risky behavior, increase adherence to HIV medication, and alleviate and manage psychological distress. The intervention is guided by cognitive-behavioral approaches to safer sex behaviors and incorporates culture- and gender-specific concepts commonly promoted within the families and religious teachings of ethnic minority women. Six key tenets frame the program model:

Disclosure of childhood sexual abuse and trauma is central to making the link between childhood sexual abuse and HIV;
Emotional and cognitive processing of trauma reduces the effects of trauma;
Making the link between emotions and behavior reduces risk and revictimization;
Coping and resilience maintain health and well-being;
Awareness of culture, gender, and spiritual beliefs enhances well-being; and
Ongoing monitoring of trauma and mental health minimizes the lasting effects of sexual risk-taking.

The HOW curriculum is delivered in 11 weekly sessions, each 2.5 hours in duration. Sessions emphasize the effects of child sexual abuse on personal decisionmaking and the link among past traumatic experiences, HIV infection and current functioning. Techniques include trauma writing, problem-solving strategies, and communication-skills training. Essential components of child sexual abuse treatment, including short-term trauma-focused groups, relaxation training, and peer modeling of disclosure, are integrated into the program. Participants also receive referrals to appropriate individual, couples, or group therapists; or to primary care physicians for medical issues related to sexually transmitted infections, sexual health, or management of HIV. In the study reviewed, participants also received case management support through weekly phone calls.

Groups are conducted in English or Spanish by a trained facilitator with group therapy experience, working in collaboration with a peer facilitator who is HIV-positive, has a history of child sexual abuse, and has received cultural competency training. To enhance the cultural congruence of the intervention, facilitators and peer facilitators should be ethnically similar to the participants.

HOW has also been used for women at risk for HIV.

Descriptive Information

Areas of Interest	Mental health promotion
Outcomes	1: HIV sexual risk behaviors 2: HIV medication adherence 3: Posttraumatic stress disorder (PTSD) symptoms
Outcome Categories	Trauma/injuries Treatment/recovery
Ages	26-55 (Adult) 55+ (Older adult)
Genders	Female
Races/Ethnicities	Black or African American Hispanic or Latino White
Settings	Outpatient Other community settings
Geographic Locations	Urban
Implementation History	HOW has been delivered to roughly 1,150 women in 25 sites since the program was first implemented. Implementation sites have been located in California, Georgia, Massachusetts, Michigan, Missouri, New York, and Washington, D.C.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	All of the program materials necessary to implement HOW are available in both English and Spanish. These materials were initially piloted for use with: African American, Hispanic/Latino, and white women. A pilot study is underway to evaluate a version of the curriculum for transgender women, with adapted content relating to anatomy and physiology, reproduction, medical adherence, and disease transmission.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	Indicated

Quality of Research

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

Wyatt, G. E., Hamilton, A. B., Myers, H. F., Ullman, J. B., Chin, D., Sumner, L. A., et al. Violence prevention among HIV-positive women with histories of violence: Healing women in their communities. Manuscript in preparation.

Wyatt, G. E., Hamilton, A. B., Myers, H. F., Ullman, J. B., Chin, D., Sumner, L. A., et al. Violence prevention among HIV-positive women with histories of violence: Healing women in their communities. Womens Health Issues, 21 (6 Suppl), S255-S260.

Wyatt, G. E., Longshore, D., Chin, D., Carmona, J. V., Loeb, T. B., Myers, H. F., et al.. The efficacy of an integrated risk reduction intervention for HIV-positive women with child sexual abuse histories. AIDS and Behavior, 8(4), 453-462.

Wyatt, G. E., Myers, H. F., Ullman, J. B., Hamilton, A. B., Sumner, L. A., Loeb, T. B., et al. Healing Our Women (HOW): Addressing the mental health needs of HIV-positive ethnic minority women with histories of trauma. Manuscript in preparation.

Supplementary Materials

Chin, D., Myers, H. F., Zhang, M., Loeb, T., Ullman, J. B., Wyatt, G. E., et al. Who improved in a trauma intervention for HIV-positive women with child sexual abuse histories? Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. doi: 10.1037/a0032180.

Outcomes

Outcome 1: HIV sexual risk behaviors
Description of Measures	Analyses for HIV sexual risk behaviors were based on women who reported at posttest that they had sex with a main partner in the past 3 months. Focus was given to sex with the main partner because very few women reported having had sex other than with their main partner. At baseline and posttest, women were asked how many times within the past 3 months they had vaginal sex with their main partner and how many times they or their partner had "used a condom from start to finish." For each 3-month period, the number of times condoms were used was divided by the number of occasions of vaginal sex, yielding a percentage measure of condom use. A score of "1," indicating a reduction in HIV sexual risk behaviors, was assigned if any of the following applied: The percentage of condom use was 100% at both baseline and posttest. The percentage of condom use increased from baseline to posttest. Any condom use was reported at posttest, and the woman reported at baseline that she was either sexually abstinent or sexually active with zero condom use. All other patterns of condom use or nonuse were scored "0," indicating no reduction in HIV sexual risk behaviors.
Key Findings	HIV-positive women with a history of child sexual abuse were randomly assigned to the intervention or an attention control condition. Women in the intervention group participated in HOW sessions and received case management support through weekly phone calls. Women in the control group also received weekly calls from case managers, attended one group meeting in which they received information on HIV prevention and child sexual abuse, and were wait-listed for the intervention. All women were offered additional services, including child care, food, housing, referrals for medical, legal, and dental care, and referrals for psychological counseling. At posttest, women in the intervention group were about 1.5 times more likely to report reduced HIV sexual risk behaviors (i.e., increased condom use, 100% condom use, or regular condom use after initiating sexual activity following periods of abstinence) compared with women in the control group (odds ratio = 2.96, p = .039, one-tailed). The analysis used an intent-to-treat model and adjusted for covariates.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.1 (0.0-4.0 scale)

Outcome 2: HIV medication adherence
Description of Measures	HIV medication adherence was assessed by asking women at posttest how many days in the past 2 weeks they had taken their HIV medication "exactly as prescribed (on schedule and the correct dose)." Those reporting adherence on all 14 days were scored "1." All other women received a medication adherence score of "0." Women with no current prescription for HIV medication were omitted from the analysis.
Key Findings	HIV-positive women with a history of child sexual abuse were randomly assigned to the intervention or an attention control condition. Women in the intervention group participated in HOW sessions and received case management support through weekly phone calls. Women in the control group also received weekly calls from case managers, attended one group meeting in which they received information on HIV prevention and child sexual abuse, and were wait-listed for the intervention. All women were offered additional services, including child care, food, housing, referrals for medical, legal, and dental care, and referrals for psychological counseling. At posttest, women in the intervention group who attended at least eight intervention sessions reported higher medication adherence compared with those attending seven or fewer sessions (p = .044, one-tailed) and women in the control group (p = .0128). The analysis used an intent-to-treat model and adjusted for covariates.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.0 (0.0-4.0 scale)

Outcome 3: Posttraumatic stress disorder (PTSD) symptoms
Description of Measures	Symptoms of PTSD were assessed using the PTSD diagnostic module of the University of Michigan version of the Composite International Diagnostic Interview (UM-CIDI). Women first answered a series of questions about past sexual experiences to identify potentially traumatic sexual experiences or instances of sexual abuse. They were then asked 16 questions about the impact the event(s) may have had on them, such as: "Did you keep remembering any of the events when you did not want to?" "Did you keep having dreams or nightmares about them afterward?" "Did you get very upset when you were in a situation that reminded you of any of these events?" At baseline, posttest, and 3-month follow-up, women reported if these symptoms had occurred at any time since the event(s); at 6-month follow-up, they reported symptoms in the past 3 months. "Yes" responses were coded "1," and "no" responses were coded "0." "Yes" responses were totaled to yield a PTSD symptoms score.
Key Findings	HIV-positive women with a history of child sexual abuse were randomly assigned to the intervention or an attention control condition. Women in the intervention group participated in HOW sessions and received case management support through weekly phone calls. Women in the control group also received weekly calls from case managers, attended one group meeting in which they received information on HIV prevention and child sexual abuse, and were wait-listed for the intervention. All women were offered additional services, including child care, food, housing, referrals for medical, legal, and dental care, and referrals for psychological counseling. Women in the control group had the option to enroll in the intervention after completing the posttest assessment. Just over one third opted to enroll as a delayed intervention group, while the remainder continued in the control condition. At their respective posttest assessments, both intervention groups reported greater reductions in PTSD symptoms compared with the control group, although the control group also showed a reduction in symptoms (p < .05). This finding is associated with a medium effect size (eta-squared = .11). At 6-month follow-up, both intervention groups continued to show greater reductions in PTSD symptoms relative to the control group, with the immediate intervention group showing the fastest reduction in symptoms (p < .05).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.5 (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	26-55 (Adult) 55+ (Older adult)	100% Female	53.7% Black or African American 40.1% Hispanic or Latino 6.1% White

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:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
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: HIV sexual risk behaviors	3.0	3.0	3.3	3.0	3.0	3.3	3.1
2: HIV medication adherence	2.8	2.8	3.0	3.0	3.5	3.3	3.0
3: Posttraumatic stress disorder (PTSD) symptoms	4.0	4.0	3.3	3.0	3.0	3.5	3.5

Study Strengths

The measure used to assess PTSD symptoms has well-documented validity and interrater and test-retest reliability. Internal consistency for this measure was high in the study reviewed. The measures used to assess HIV sexual risk reduction and HIV medication adherence had adequate internal consistency in this study as well as face validity. Several strategies were used to ensure accurate data reporting, including repeating critical questions and using a scale to test for social desirability in participants' self-reporting. Implementer training was provided, although its duration varied across staff members. Fidelity was assessed by supervisors using a curriculum observation form and fidelity checklist at each session, with very high fidelity reported. Interrater agreement was .96. A training manual was created and provided to all staff members; as well as frequent supervision sessions. Missing data and attrition were low. Level of education was related to study attrition and was included as a covariate. Random assignment of participants to study condition was used for two of the three outcomes reviewed, HIV sexual risk reduction and HIV medication adherence. The analysis approach followed an intent-to-treat methodology. Use of multivariate modeling was appropriate. Power analysis was conducted.

Study Weaknesses

Attrition differed between study groups. There were several potential confounding variables. Differential time with a counselor may have contributed to group differences. The observed dose-response finding for HIV medication adherence may have been confounded by other, unmeasured variables. For example, it is possible that those participants who completed more sessions were different from those who completed fewer sessions (e.g., less severe symptoms, more conscientious, less hectic lives, more free time) which also allowed them to adhere better to their medication regimen. The investigators appear to have overfit the analytic models by including all possible covariates without providing sufficient justification, especially given a relatively small sample size. Analyses of HIV sexual risk reduction and HIV medication adherence used a one-tailed test of significance, which tends to inflate the probability of a Type I error.

Readiness for Dissemination

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.

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

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

Availability of implementation materials
Availability of training and support resources
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
3.1	3.3	3.0	3.1

Dissemination Strengths

The detailed program manual is readily available online in English and Spanish and includes suggestions for increasing participation, such as instituting reminder calls and using a buddy system. The manual and curriculum provide some discussion regarding overcoming potential barriers to participation, which include providing childcare and transportation to participants. The inclusion of extensive lessons learned, tips, "do's" and "don'ts," and the interactive nature of the training itself, combined with the comprehensiveness of the manual, all work together to support effective implementation. The program's process, which is to go over the scores with facilitators to offer suggestions on how to improve skills and scores, has the potential to boost implementation quality. The provision of the detailed scripts supports implementation fidelity, and the content for the 11 sessions contains clear goals and is scripted to assist with fidelity. The quality assurance (QA) products are available in English and Spanish and include a few templates, such as the facilitator observation form, participant satisfaction survey, and outcome survey.

Dissemination Weaknesses

An explanation should be included, along with suggestions for changes that could be considered when adapting the screening tool. Given the vast differences in content between the 11 sessions, and the health and safety implications of the material covered, the Quality Assurance (QA) materials could be strengthened by including a rating category in the observer form. This category could show the extent to which the facilitator sufficiently covered session-specific content as opposed to the process alone.

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
Healing Our Women Curriculum, Facilitator Training Manual, and Participant Workbook	Free online, or $600 per hard copy	Yes
2- to 5-day, on-site training for facilitators for up to 15 participants (includes quality assurance materials)	Varies depending on site needs and location	Yes