Prevention in Focus

Spring 2018 

Practice Guidelines in Peer Health Navigation for People Living with HIV: A new program development resource for community-based organizations (Part 2)

By Logan Broeckaert and Laurel Challacombe

CATIE in collaboration with a national expert working group is publishing guidelines to support the development, implementation and strengthening of peer health navigation programs. Practice guidelines in peer health navigation for people living with HIV is a resource for community-based organizations that provides both evidence- and practice-based recommendations.

This article covers key recommendations related to managing a peer health navigation program. In a previous Prevention in Focus article we reviewed the chapters on assessing the agency’s infrastructure, the roles and responsibilities of peer health navigators and ethical considerations.

Increasing access to a continuum of services for people living with HIV

For a person living with HIV to achieve optimal health outcomes, they need access to a continuum of services, including:

  • HIV testing and diagnosis
  • linkage to appropriate medical care and other health services
  • support while in care
  • access to HIV treatment (ART) when they are ready
  • support while on treatment

However, we know that there are significant barriers to care for some people living with HIV, which makes it difficult for them to be optimally engaged in care. System-level barriers, which are caused by the structure of the healthcare system, can include the appointment scheduling process,1 fragmented service delivery,2,3 and lack of specialized local healthcare services.4

Individual-level barriers to care are specific to each client. Examples of individual barriers are a lack of access to transportation5,6 and adequate food and lodging,6 insufficient finances,6,7 and lack of social support.4, Other significant individual-level barriers to care may also include substance use and mental illness.

What is health navigation?

Health navigation is a programming approach that helps clients to overcome both system-level and individual-level barriers to care.

Health navigation for people living with HIV was defined by the working group as a person-centred approach to guide, connect, refer, educate and accompany people living with HIV through systems of care. The goals of health navigation are to build the capacity of clients to self-manage their HIV care, navigate systems themselves and, ultimately, improve their health and wellness.

Health navigation has a positive impact on the health and well-being of people living with HIV

When HIV-positive clients are supported by navigation services, they are more likely to engage in care, which is an important step in accessing the benefits of treatment and other supports. A number of studies show that HIV health navigators (both peers and professionals) have a positive impact on rates of both engagement and retention in care.8,9,10,11,12,13,14,15,16,17 In addition to improving engagement in care, navigation services have a positive impact on treatment outcomes, such as an increase in CD4 count and a decrease in viral load.8,10,,,,

What are the Practice Guidelines for Health Navigation for People Living with HIV?

CATIE convened a 13-member national expert working group to inform and develop the guidelines on peer health navigation for people living with HIV. The working group was made up of people living with HIV, frontline service providers, program planners, public health practitioners, clinicians and researchers. A participatory process was established to develop and review the guidelines, which resulted in more than one hundred recommendations.

The working group was guided by six core values: the greater involvement and meaningful engagement of people living with HIV (GIPA/MEPA), harm reduction, anti-oppression, self-determination, resiliency and trauma-informed practice.

The aim of the guidelines is to:

  • improve the quality and consistency of peer health navigation programs
  • improve the effectiveness of peer health navigation programs to positively impact the health and wellness of people living with HIV
  • build on existing local/regional models and materials, many of which were developed and informed by people living with HIV

The practice guidelines are based on research and practice evidence, and include three components:

  1. Recommendations. Provide general research-based and practice-based recommendations on how to approach the development, implementation and strengthening of peer health navigation programs. The type of evidence (research or practice) used to inform each recommendation is provided.
  2. Evidence reviews. Synthesize and analyze the best possible evidence from the peer-reviewed and grey literature.
  3. Vignettes. Illustrate how the recommendations may be applied in practice, based on the experience of the expert working group.

Managing a peer health navigation program

Recruitment and selection (Chapter 4)

Host agencies are responsible for managing the recruitment and selection of peer health navigators. In this chapter, there are 32 recommendations that relate to:

  • identifying the competencies candidates should demonstrate
  • developing a process for supporting candidates to self-assess their readiness
  • developing a fair and transparent selection process.

An example recommendation and accompanying vignette is:

RECOMMENDATION 19: Support and guide people with HIV to consider their emotional readiness to work with clients facing similar challenges to their own. (Type of evidence: research and practice)

Vignette:  Samir is considering becoming a peer navigator with his local clinic. The program supervisor, Dani, has prepared a few written vignettes about typical and challenging situations that the clinic deals with. She sits with Samir and talks through how he would approach each situation. This helps Samir conceptualize some of the emotional and ethical realities of being a navigator. This experience helps Samir to consolidate his interest in being a peer navigator and helps Dani to confirm that Samir understands the kind of work he will be doing and that he is ready to take on this new challenge.

Compensation (Chapter 5)

Host agencies are responsible for compensating peer health navigators for their work. In this chapter, there are four recommendations that relate to:

  • compensating peer health navigators equitably
  • developing compensation policies and procedures.

An example recommendation and accompanying vignette is:

RECOMMENDATION 3:  Involve peer health navigators in the development of compensation policies that address their needs. Policies should reflect the limits on earnings of social assistance and disability programs. They should also clearly define the benefits to which navigators who receive salaries, stipends, wages or honoraria are entitled. Compensation policies need to comply with other agency policies and provincial and territorial legislation related to payment and benefits. (Type of evidence: research and practice) 

Vignette: Yu is offered a part-time peer health navigator position that will give him 17 hours of work a week with an hourly wage. When he is offered the job Yu asked his supervisor Obim how this might affect his income support program. They determine that the money is not sufficient for him to leave his income support program because it will have an impact on the amount he pays for his housing and on the amount he receives from the program. Yu and Obim look into other options to pay him.  

Obim understands that using gift cards will cause a number of legal and ethical complications so he reviews the agency’s compensation policy. It states that agency members who are employed will receive a cheque commensurate with the hours worked and the pay scale associated with that position. Obim and Yu have a discussion to determine the optimal number of hours for Yu to work to maximize his income between paid employment and income support. 

Supervision, support and mentorship (Chapter 6)

Host agencies are responsible for the supervisor, support and mentorship of peer health navigators. In this chapter there are 12 recommendations that relate to:

  • peer health navigator supervision, support and mentorship
  • navigator and client matching
  • peer health navigator self-care

An example recommendation and accompanying vignette is:

RECOMMENDATION 6: When a health navigator and client match is not working, try to determine why and assess whether the issue can be resolved before transitioning a client to another navigator. (Type of evidence: practice)

Vignette: During regular supervision, Tammy, a peer health navigator, talks about her challenges with a client. Initially things had gone very well, but the client has recently relapsed to heavy alcohol use. During the last couple of meetings, the client has made several negative comments about Tammy’s ongoing sobriety. Tammy discloses that the relationship is feeling unsafe for her. The program supervisor suggests that the client’s team have a meeting about the situation to determine whether the client should be matched with another navigator, or if other approaches can help maintain the relationship during this period.

Training (Chapter 7)

Host agencies are responsible for providing peer health navigators with the necessary training to take on their roles and responsibilities. In this chapter, there are 27 recommendations that relate to:

  • peer health navigator training methods
  • peer health navigator training content

An example recommendation and accompanying vignette is:

RECOMMENDATION 8: Identify and provide ongoing relevant training and professional development opportunities to peer health navigators based on peer navigator and client needs, and developments in HIV, hepatitis C and sexually transmitted infections (STI) knowledge. Navigators should also identify additional topics for further learning. (Type of evidence: research and practice)

Vignette: Georgie supervises a peer health navigation program. She understands learning happens for people in different ways and at different paces. All new navigators receive a core training from Georgie, augmented with shadowing with more experienced navigators. Georgie also provides annual performance reviews where learning goals are jointly agreed upon with the navigators. 

As part of ongoing professional development, navigators are encouraged and compensated to attend workshops and lunch and learn sessions provided by the host agency and external partners. In addition, the agency has set aside some money for professional development for the navigators. Georgie and the navigators use that money to attend external trainings, meetings and conferences that they identify as important to their development as navigators.

Monitoring and evaluation (Chapter 8)

Host agencies are responsible for monitoring and evaluating their peer health navigation program. In this chapter, there are six recommendations that relate to:

  • Developing an evaluation strategy
  • Determining the outcomes to measure
  • Collecting program delivery statistics
  • Using a variety of evaluation methods

An example recommendation and accompanying vignette is:

RECOMMENDATION 1: Develop a culturally and organizationally appropriate and relevant evaluation strategy to assess the peer health navigation program and plan to integrate learnings back into the program. (Type of evidence: research and practice)

Vignette: Iggy, the peer health navigation program supervisor, and Ama, the health authority manager responsible for funding the navigation program, meet to develop a program evaluation strategy. They agree to develop a logic model for the program that establishes what indicators will best reflect if the program is doing what it intended to do and what the impact of the program is for clients and health navigators. They also consider how this data can be collected and consult with a representative group of clients for input through a focus group. Iggy identifies existing data-gathering activities at his agency that can be used, like client intake, which already records the demographic information of new clients. Iggy and Ama also agree on additional data collection activities that would be manageable for the program, such as a quarterly survey to assess client satisfaction. Taken altogether, the selected indicators and evaluation activities will help Iggy and Ama understand how the peer navigation program is doing, and provide data to improve the program and advocate for additional resources, if needed.

Integrating peer health navigators into a host agency (Chapter 9)

Host agencies are responsible for orienting existing and any new staff and volunteers to the peer health navigation program. In this chapter, there are six recommendations that relate to:

  • Training staff on GIPA/MEPA
  • Orienting host agency staff on peer health navigators in the workplace
  • Providing specific training to peer health navigation program supervisors

An example recommendation and accompanying vignette is:

RECOMMENDATION 4:  Provide all host agency staff with a clear understanding of how peer health navigators are situated within an agency’s structure to help guide respectful interactions between staff and peers and ensure appropriate boundaries are kept. (Type of evidence: practice)

Vignette: A local community-based organization is establishing a peer health navigation program in the new fiscal year. Ollie, the program supervisor hired to oversee the program, has been preparing to integrate peer health navigators into the host agency’s services. Ollie sets up orientation sessions for all host agency staff. With two HIV-positive facilitators, Ollie hosts a series of sessions that help staff understand the unique role of navigators in the support of other people with HIV, the challenges they may face as service users and service providers, and guides them, through safe discussion, on how to work with navigators. 

Integrating peer health navigators into healthcare settings (Chapter 10)

Host agencies should consider formally partnering with HIV care teams in healthcare settings, such as hospitals and clinics, to provide more integrated healthcare services for clients. This includes work to determine how navigators can be integrated into existing healthcare services. In this chapter, there are four recommendations that relate to:

  • Negotiating integration of peer health navigators onto healthcare teams
  • Orienting staff in health care settings on peer health navigators in the workplace
  • Establishing open communication channels between the peer health navigators and other healthcare team members.

An example recommendation and accompanying vignette is:

RECOMMENDATION 4: Establish open communication channels between peer health navigators and other healthcare team members. Communication channels may develop over time or may need to be established using mechanisms such as guidelines for respectful communication or regular all-team meetings. (Type of evidence: research and practice)

Vignette: In a local clinic–community partnership to deliver peer navigation services, multiple formal and informal communication channels exist between peer health navigators and other healthcare team members. For example, navigators attend the regular staff meetings to discuss the day-to-day operations of the clinic, and participate in patient advisory meetings to provide feedback from patients. The peer health navigation program supervisor meets regularly with a member of the healthcare team to hear any staff issues or concerns related to the program and to bring attention to navigator concerns.  

One-on-one mentoring is also a big part of how navigators and other healthcare team members communicate. When the clinic is slow, navigators ask healthcare staff about topics they feel they don’t know enough about as a way to expand their knowledge and skills. In turn, healthcare staff often ask navigators about their personal experience as gay people, people who use drugs, or about other common experiences the navigators and their clients may share. 

Community engagement and development for peer health navigation programs (Chapter 11)

Host agencies are responsible for community engagement and development work to support the work of peer health navigators with external community based agencies. In this chapter there are six recommendations that relate to:

  • Developing a community engagement strategy
  • Educating and engaging community agencies to support the program
  • Creating memoranda of understanding with community partners
  • Supporting peer navigators to acquire and maintain up-to-date knowledge of community services
  • Facilitating integration of peer health navigators into the community.

An example recommendation and accompanying vignette is:

RECOMMENDATION 3: Engage external community agencies to support the peer health navigation program in an ongoing way after navigators have started to work with clients in the community. In support of GIPA/MEPA, facilitate opportunities for peer health navigators to participate as advisors to this process, as ambassadors for the program, or in other appropriate and relevant ways. (Type of evidence: practice)

Vignette: Ryan, the peer health navigation program supervisor, and his team of peer health navigators are excited to have received the Certificate of Community Contribution in Healthcare, which acknowledges their ongoing community engagement work of the last year. Ryan now wants to formalize his team’s existing informal collaborations with community agencies and initiate new ones. With input from the navigators, Ryan standardizes the referral process from the local First Nations health centre, secures satellite space for regular shifts for navigators at HIV testing clinics around the city, and signs a memorandum of understanding so that navigators can shadow service providers at two harm reduction agencies as part of their training.  The high point in the team’s community engagement efforts is a finalized agreement between the peer health navigation program and the local medical school. Starting in the fall, peer health navigators will be hired as patient instructors for medical students.

Check out CATIE’s peer health navigation portal

The guidelines and case studies and evidence reviews can be found on the CATIE website.

References

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About the author(s)

Logan Broeckaert holds a Master’s degree in History and was a researcher/writer at CATIE. Before joining CATIE, Logan worked on provincial and national research and knowledge exchange projects for the Canadian AIDS Society and the Ontario Public Health Association.

Laurel Challacombe holds a Masters degree in Epidemiology and is currently Associate Director, Research/Evaluation and Prevention Science at CATIE. Laurel has worked in the field of HIV for more than 10 years and has held various positions in both provincial and regional organizations, working in research and knowledge transfer and exchange.