AIDS case rates for Asian Pacific Islander (API) populations in the United States remain low compared with other communities of color, however, the numbers are steadily rising. One of the largest challenges to HIV prevention among APIs is effectively reducing HIV risk in an extremely diverse population. In southern California, the API population is largely immigrant and represents several continents, more than 50 different languages, and distinct cultural norms.
Researchers have found that stigma, racism, homophobia, shame, and linguistic isolation result in a lack of language-specific programs, reduced access to healthcare, avoidance of HIV testing, and delay of care until later stages of HIV/AIDS among APIs.1,2 To complicate matters further, API immigrants experience added barriers to HIV prevention/testing, such as fear about denial of permanent residency due to HIV-positive status and lack of health coverage.3 There are also cultural obstacles, including sexuality and disease as taboo subjects, distrust of physicians, and more general mistrust of social institutions outside local communities because of societal fears concerning global terrorism and epidemics such as SARS and most recently Avian flu.4
In the context of these myriad challenges, how can organizational capacity be expanded in culturally appropriate ways for HIV prevention? To address this question, the goals of this article are to outline a culturally appropriate model of organizational capacity building and to examine the experiences of a 3-year capacity-building program guided by this model targeting API social service agencies and API social organizations focused on lesbian, gay, bisexual, transgender, and questioning (LGBTQ) populations in southern California. The article proceeds in the following way. First, we provide background on capacity building and cultural appropriateness. Next, we outline our conceptual model, consisting of three components: organizational stability and viability; HIV knowledge environments; and organizational aspirations centering on HIV/AIDS issues. We then describe Asian Pacific AIDS Intervention Team's (APAIT's) program, and discuss the program's experiences using the results of an organizational survey (conducted at baseline, mid-program, and end of the 3-year program), and the observations by APAIT program staff. Finally, we summarize the major conclusions and identify implications for building capacity.
Capacity and Cultural Appropriateness: Background
Organizational capacity in general is the degree to which organizations can solve problems and attain desired objectives and goals. In terms of health, capacity can be defined as broadly as improved national health outcomes or as narrowly as improvements in the ability of organizations to respond to new technological advancements. Researchers have found that factors internal and external to organizations are significant in determining capacity, especially resources (funding, information, etc), relationships (including agency networks and trust with program participants), and leadership.5,6 Crisp and her colleagues7 identified four general approaches to capacity building in health research: top-down (procedural change); bottom-up (training and skills development); partnerships (collaboration and relationship building)8; and community organizing (participation and mobilization). These four general approaches lead to specific strategies and measures to assess the impacts of such efforts (Table 1). Effectiveness of these approaches depends in large degree on the scope of the issue and the time frame for results.
In addition, capacity for HIV prevention requires conveying complex information to at-risk populations who have a wide array of needs and obstacles to healthcare (eg, poverty, unemployment, housing instability, and lack of transportation)9 and for whom HIV/AIDS remains highly stigmatized.10,11 Although cultural appropriateness and competency have become common terms used in public health and social service delivery to address such challenges, they, like organizational capacity, comprise a wide range of definitions and strategies. At a simple level, culturally appropriate HIV prevention requires multiethnic staff with multilingual skills. But cultural competency also includes sensitivity to diverse sexual identities, gaining trust of groups distrustful of public agencies and biomedicine, and accommodating daily challenges faced by groups at work/school, home, and in the community.12 To develop appropriate strategies, researchers argue that staff should reevaluate assumptions about human behavior and understand culturally distinct worldviews held by target groups.13 But to sustain and deepen cultural awareness, organizations should open decision making to staff, clients/service users, and community members, incorporating antiracism ideologies and expanding social justice.14
Culturally Appropriate Capacity Building-A Conceptual Model
We take this research base as a starting point and argue that there are three critical components to organizational capacity building: organizational stability and viability; organizational commitment to HIV/AIDS issues; and HIV knowledge environments (Figure 1).
Organizational stability and viability are crucial. There is little doubt that community-based organizations and public health agencies face severe pressures (eg, funding, policy mandates, changing population needs), and must constantly adapt programs to accommodate changing conditions. With high turnover associated with typically low wages for frontline staff, funding, strategic management, and staff development must be expanded if HIV prevention capacity building is to have any meaningful impact.* Maintaining organizational viability and stability may however work at cross-purposes. Viability, especially for community-based agencies, often requires new funding sources (leading to more staff and programs), diversified target populations, and more partnerships.15 Stability in contrast aims for steady-state conditions and relative certainty in staff size/composition, program delivery, and funding streams.
Culturally appropriate HIV prevention capacity building requires organizational commitment to HIV/AIDS issues. Organizational aspirations,* leadership, and vision must be tied to HIV/AIDS. Without organizational commitment, organizational stability/viability will likely not result in ongoing investment in enhancing HIV knowledge environments.
Knowledge environments are usually associated with the capacity of private firms to exploit new sources of information to produce and sell products. From this view, Cohen and Levinthal16 argue that knowledge environments are defined by (1) gathering information from both inside and outside the organization; (2) accessing technical knowledge, and particularly, if knowledge is not available within the organization, accessing experts; and (3) having some redundancy within organizations, or "cross-functioning," along with diverse skills so that mutual understanding is possible across the organization-mutual understanding facilitates innovation in addressing new and emerging problems. For HIV prevention capacity, three subcomponents are important: biomedical and social science knowledge about HIV prevention; knowledge about cultural norms and community issues that define HIV/AIDS in target populations; and organizational commitment to reducing stigma within the agency toward HIV/AIDS.
Technical assistance can be used to enhance any of these components, using top-down, bottom-up, partnerships, and community organizing approaches following Crisp et al.7 For example, organizational viability may be improved through technical assistance to executive directors on strategic planning and fundraising (top-down), whereas technical assistance may help stability through increasing staff expertise (bottom-up). Technical assistance might provide tools for coalition expansion (partnerships) and strategies for mobilizing communities for organizational visibility (community organizing). However, without capacity building across all components simultaneously, sustaining culturally appropriate prevention programs is unlikely.
APAIT's Capacity-Building Program
APAIT's program aimed at capacity building across these critical components. Funded by the US Office of Minority Health (2003-2006), the program goal was to establish and strengthen a network of community-based social service and LGBTQ social organizations that target APIs in southern California to increase culturally appropriate HIV/AIDS prevention and treatment available to underserved, hard-to-reach API populations. The criteria for selecting participating organizations were commitment to HIV/AIDS prevention in API communities, commitment to participate in program development and training activities, and willingness to enter into a subcontract to complete program goals. Organizational participants were asked about their organizational commitment to HIV/AIDS issues prior to their inclusion in the program (those that indicated their commitment were invited to participate); consequently, capacity building in the program focused on organizational stability/viability and HIV knowledge environments (rather than building institutional commitment to HIV/AIDS issues). The participating organizations were provided $5,000 per year as incentives; this funding was also seed money for the participating organizations to develop new workshops/training and to make existing programs more sensitive to API HIV/AIDS and LGBTQ issues.
APAIT's program provided technical assistance in organizational stability/viability: One-on-one contacts/organizational "coaching" (at least once per quarter with APAIT staff) and workshops (about one per month; eg, board development, project management, collaboration, needs assessments/research, strategic planning) provided strategies and skills for enhancing stability and viability; and two symposia (eg, hate crimes, crystal meth) led to further meetings between participating organizations and other agencies (eg, law enforcement), thereby increasing potential partnerships. The program also provided technical assistance on HIV knowledge environments: workshops on HIV prevention (eg, HIV 101, STD 101, Introduction to Community Planning) and diverse populations (eg, API LGBTQ, crystal meth in the Filipino community) expanded knowledge about cultural norms and obstacles to HIV prevention; and program meetings held once per quarter at the different organizational partner sites created opportunities for reducing stigma and expanding knowledge about cultural norms (ie, meeting at different sites encouraged interaction and improved mutual understanding).
Organizational Capacity Program Experience
Data and methods
A survey was conducted of the API social service agencies and LGBTQ social organizations at three points in time (baseline: January-February 2004; mid-program: April-June 2005; and end of program: February-March 2006). The English-language questionnaires, which took about 20 minutes to complete, were distributed by APAIT staff to the primary contact person at the participating organizations and returned to APAIT staff via e-mail, fax, or mail. At baseline, there were six organizational partners that completed the questionnaire; the participants dropped to four by the end of the program (one organization disbanded, and another failed to complete program requirements). The names of the participating organizations are not provided to maintain confidentiality; results from the survey are reported by organizational type (social service agencies compared with LGBTQ social organizations). The questionnaire was developed collaboratively with APAIT staff to measure the capacity of partner organizations across a variety of stability/viability and HIV knowledge environments*: human resources, financial, service delivery, external relations, partnerships, strategic planning, and HIV knowledge. APAIT staff were also consulted for their observations about capacity changes.
Organizational stability/viability
The disbanding of one organization and the inability of another to fulfill the obligations of the subcontract indicate the importance of organizational stability and viability in culturally appropriate HIV prevention organizational capacity building. As discussed earlier, both viability and stability are necessary components for capacity building to be sustained, but these two aims are often in conflict. The participants experienced both increased viability/instability and some added stability. Increased viability was reflected in diversification of funding sources. At baseline, most of the organizations relied on private sources (on average 71% of organizational budgets), but by the end of the program, private sources constituted 48 percent of organizational budgets on average. There was also stability exhibited in funding in that budgets tended to remain the same in terms of size over the program time frame (most annual budgets were $50,000 or less; though one organization increased its budget from baseline, $1 million-$1,999,999, to end of the program, $2 million or more).
Perhaps, as a consequence of fund diversification, the organizations experienced human resources instability through substantial growth in paid staff, interns, and board membership, and some reduction in volunteers. The average number of paid full time staff increased 43 percent, paid part time staff increased 76 percent, interns increased 317 percent, and board members increased 65 percent. The average number of volunteers declined 16 percent between baseline and end of the program. There was instability reflected in the growth of the number of collaborations, but also enhanced stability since the partnerships were longer lasting (37% longer at the end of program than at baseline).
More detailed changes in stability/viability were measured in several areas: human resources, financial, service delivery, external relations, collaboration, and strategic management. The responses to the capacity measures were on a 5-point Likert-type scale. To create an average measure, values were attached to each of the response categories: 0 = "no or never done this," 1 = "not very much," 2 = "somewhat," 3 = "most of the time," and 4 = "yes or always." The responses for each area were summed to create an index for each area, and averages across organizational type (social service compared with LGBTQ social organizations) were compared across the three time periods (baseline, time 2/mid-program, and time 3/end of program).
Human resources capacity was measured using 11 questions including the effectiveness of the organizational structure, well-organized meetings, and having personnel procedures. Social service respondents showed a 7 percent increase on average from baseline to time 3/end of program (Figure 2). LGBTQ respondents showed a 175 percent increase on average.
Financial capacity was measured using seven questions including timely financial records, dealing with IRS requirements, having diversified funding, and having a fundraising plan. Social service respondents showed a 55 percent increase on average in financial capacity from baseline to time 3/end of program (Figure 3). LGBTQ respondents showed a 94 percent increase.
Service delivery capacity was measured using seven questions including having a client outreach plan, meeting program goals, and conducting program evaluation. Social service respondents showed an 18 percent increase on average from baseline to time 3/end of program (Figure 4). LGBTQ respondents showed a 26 percent increase.*
External relations capacity was measured using five questions including receiving favorable media coverage, regularly distributing materials, and having a leadership role in the community. Social service respondents showed a 22 percent increase on average from baseline to time 3/end of program, whereas LGBTQ respondents showed a 58 percent increase (Figure 5).
Collaboration capacity was measured using three questions including collaboration in the organization's strategic plan, having a plan for pursuing collaborations, and taking a leadership role in fostering partnerships. Social service respondents showed a 16 percent increase on average in collaboration and partnerships management capacity from baseline to time 3/end of program (Figure 6). LGBTQ respondents showed a 76 percent increase.
Strategic management capacity was measured using nine questions including selectively adding new programs, dissolving programs that do not meet client needs, ensuring that new programs meet the organization's mission, having three to five core organizational values, and having a strategic plan that is understood by the board. Social service respondents showed a slight increase (8%) in strategic management capacity at time 3/end of program compared with baseline whereas LGBTQ respondents showed a 55 percent increase (Figure 7). This was the one area where LGBTQ respondents showed a higher increase in capacity than social service respondents.
Knowledge environments: HIV knowledge
HIV information was provided to the organizational participants during workshops and one-on-one interactions between APAIT staff and the organizational participants. To measure HIV knowledge, the survey questionnaire included seven basic questions about HIV transmission. The participating organizations showed a high degree of knowledge about HIV transmission at baseline, mid-program, and end of program. The one question that indicated some lack of knowledge at baseline (concerning use of bleach in cleaning needles) was answered correctly by all respondents at mid-program and end of program.*
Knowledge environments: Cultural norms and stigma
To expand knowledge about cultural norms and to reduce stigma, the central program strategy was the interaction of the diverse organizations. As mentioned earlier, interaction consisted of joint attendance at APAIT workshops/symposia, and participating organizations providing workshops and training for the other participants on the cultural issues and obstacles to HIV prevention and testing experienced by their own target populations. APAIT staff observed that by end of program all the social service agencies had changed their procedures to be more inclusive of LGBTQ groups (eg, adding LGBTQ categories to intake processes, and making existing programs focused on domestic violence and youth more sensitive to LGBTQ issues), educated the members of their boards about LGBTQ issues, and obtained grant funding for programs that sustained APAIT's capacity-building efforts (HIV/AIDS education, services for LGBTQ populations, and capacity building for other API organizations, especially Pacific Islanders). The participating LGBTQ social organizations were able to build leaders internally and start partnering with non-LGBTQ organizations targeting similar ethnic groups in their geographic areas.
Conclusions
The APAIT capacity-building program appears to have been effective (though it is difficult to attribute organizational capacity expansion to this program alone). What is clear is that the participating organizations were generally more capable across the model components by the end of the 3-year program. The areas where organizational viability increases were largest were (in order of increases): financial management, external relations, and strategic management. Expanding viability may have come at the cost of organizational stability, however, in particular, large increases in staff and boards. Both types of organizations increased their organizational viability across similar areas, suggesting that the interaction between social service and LGBTQ organizational participants may have contributed to capacity increases. Building capacity also meant that organizations needed different types of skills as capacities changed-for example, at end of program, several participants wanted more strategic planning assistance, and skills to incorporate program evaluation into program design. Thus, technical assistance focused on viability/growth (eg, fundraising, strategic management) may be useful to most organizations, while assistance with stability/streamlining (eg, program evaluation) may be most useful to organizations that have reached a critical level of sustainable capacity.
The important lessons from this experience are that (1) culturally appropriate capacity building must address organizational stability/viability, organizational commitment to HIV/AIDS, and HIV knowledge environments at the same time; (2) capacity can be expanded in a relatively short period of time, even in a context of severe budget challenges and organizational turbulence; (3) HIV knowledge environments can be affected by process as well as content-workshops and one-on-one contacts are useful for conveying information and developing skills, but, in particular, stigma can be effectively reduced through processes that include organizations with distinct missions (LGBTQ and non-LGBTQ) that provide substantive opportunities for interaction; and, (4) as capacity increases, viability/stability and knowledge environments will change, meaning that different types of technical assistance will be needed.
The experiences described in this article suggest that APAIT's program is a useful model for designing culturally appropriate programs for community-based organizations. The model might also be useful in larger institutional settings, such as public health departments and community health centers, and in diverse ethnic communities. More research is needed to ascertain the transferability of this conceptual model to other ethnic groups, organizations, and geographic areas.
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