Utilizing Soccer for Delivery of HIV and Substance Use Prevention for Young South African Men: 6-Month Outcomes of a Cluster Randomized Controlled Trial

Interventions implemented through sporting organisations for promoting healthy behaviour or improving health outcomes

BACKGROUND

Chronic diseases are the leading cause of mortality and morbidity worldwide. Much of this burden can be prevented by adopting healthy behaviours and reducing chronic disease risk factors. Settings-based approaches to address chronic disease risk factors are recommended globally. Sporting organisations are highly prevalent, and engage many people in many countries. As such, they represent an ideal setting for public health interventions to promote health. However, there is currently limited evidence of their impact on healthy behaviour and health outcomes as previous systematic reviews are either limited in their scope (e.g. restricted to professional sporting organisations), or are out of date.

OBJECTIVES

Primary: to assess the benefits and harms of interventions implemented through sporting organisations to promote healthy behaviours (including physical activity, healthy diet) or reduce health risk behaviours (including alcohol consumption, tobacco use). Secondary: to assess the benefits and harms of these interventions to promote health outcomes (e.g. weight), other health-related behaviours (e.g. help-seeking behaviour) or health-related knowledge; to determine whether benefits and harms differ based on the characteristics of the interventions, including target population and intervention duration; to assess unintended adverse consequences of sporting organisation interventions; and to describe their cost or cost-effectiveness.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, one other database and two clinical trial registries, from inception to May 2024, to identify eligible trials. We searched Google Scholar in May 2024. We did not impose language or publication status restrictions. We also searched reference lists of included trials for other potentially eligible trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, of any intervention conducted within or using a sporting organisation for access to a target group, that aimed to improve a health behaviour primary outcome or a secondary review outcome, and had a parallel control group (no intervention, alternative intervention). Eligible participants were any individual exposed to an intervention involving a sporting organisation, including players, members, coaches, and supporters.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We conducted random-effects meta-analyses to synthesise results where we could pool data from at least two trials. Where we could not conduct meta-analysis, we followed Cochrane guidance for synthesis using other methods and reported results according to the Synthesis Without Meta-analysis (SWiM) guidance.

MAIN RESULTS

We included 20 trials (42 trial arms, 8179 participants) conducted in high-income countries, and identified four ongoing trials and four trials awaiting classification. There was considerable heterogeneity in the type of participants, interventions and outcomes assessed across trials. Included trials primarily targeted sporting organisation members (eight trials) or supporters (eight trials), males only (11 trials) and adults (14 trials). Football clubs (e.g. soccer, American football, Australian football league) were the most common intervention setting (15 trials), and interventions targeted various combinations of health behaviours, knowledge and health outcomes. Fourteen trials (10 RCTs and four cluster-RCTs) assessed the impact of a sporting organisation intervention on a primary outcome: physical activity (nine trials); diet (six trials); alcohol consumption (11 trials); and tobacco use (two trials). For RCTs, we assessed the risk of bias for primary outcomes (physical activity, diet, alcohol consumption) and unintended adverse consequences as being at low risk of bias (four outcomes), some concerns (one outcome) or high risk of bias (32 outcomes), due to outcomes being self-reported. For cluster-RCTs, we assessed the risk of bias for all primary outcomes (alcohol consumption, tobacco use) as high risk (eight outcomes), due to outcomes being self-reported. Sporting organisation interventions versus control probably have a small positive effect on the amount of physical activity per day, equivalent to approximately 7.4 minutes of moderate-to-vigorous physical activity (MVPA) per day (standardised mean difference (SMD) 0.36, 95% confidence interval (CI) 0.22 to 0.49; I2 = 3%; 4 trials, 1213 participants; moderate-certainty evidence) and may not reduce sedentary behaviour (mean difference (MD) -15.18, 95% CI -30.82 to 0.47; I2 = 0%; 2 trials, 1047 participants; low-certainty evidence). Sporting organisation interventions versus control may have a moderate positive effect on fruit and vegetable consumption, equivalent to a score increase of 1.25 points on a 12-point scale for frequency of fruit and vegetable consumption (SMD 0.50, 95% CI 0.35 to 0.65; I2 = 0%; 5 trials, 1402 participants; low-certainty evidence). Sporting organisation interventions versus control may reduce sugary drink consumption (equivalent to a reduction of sugary drink consumption by 0.8 times per day), but the evidence is very uncertain (SMD -0.37, 95% CI -0.64 to -0.10; I2 = 0%; 2 trials, 225 participants; very low-certainty evidence). Sporting organisation interventions versus control may have little to no effect on alcohol consumption (equivalent to a reduction of 0.38 units of alcohol consumed per week), but the evidence is very uncertain (MD -0.38, 95% CI -1.00 to 0.24; I2 = 78%; 7 trials, 2313 participants; very low-certainty evidence). Two trials that could not be synthesised reported equivocal findings on tobacco use (low-certainty evidence). The evidence is very uncertain about the effect of sporting club interventions on unintended adverse consequences. Five trials assessed this outcome, with two reporting that there were no adverse consequences, one reporting only non-serious adverse consequences, and two reporting that there were serious unintended adverse consequences in less than 1% of participants.

AUTHORS' CONCLUSIONS

Overall, sporting organisation interventions probably increase MVPA by 7.4 minutes per day, may result in little to no difference in sedentary behaviour, and may increase fruit and vegetable consumption. The evidence is very uncertain about whether sporting organisation interventions decrease sugary drink and alcohol consumption. Findings for tobacco use and unintended adverse consequences were equivocal in the few trials reporting these; thus, the evidence was very uncertain. These findings should be interpreted in the context of the heterogeneity of the interventions, participants and sporting organisations for some outcomes.

"Emotional stress is more detrimental than the virus itself": A qualitative study to understand HIV testing and pre-exposure prophylaxis (PrEP) use among internal migrant men in South Africa

INTRODUCTION

South Africa has one of the highest rates of internal migration on the continent, largely comprised of men seeking labour in urban centres. South African men who move within the country (internal migrants) are at higher risk than non-migrant men of acquiring HIV yet are less likely to test or use pre-exposure prophylaxis (PrEP). However, little is known about the mechanisms that link internal migration and challenges engaging in HIV services.

METHODS

We recruited 30 internal migrant men (born outside Gauteng Province) during August 2022 for in-depth qualitative interviews at two sites in Johannesburg (Gauteng) where migrants may gather, a factories workplace and a homeless shelter. Interviewers used open-ended questions, based in the Theory of Triadic Influence, to explore experiences and challenges with HIV testing and/or PrEP. A mixed deductive inductive content analytic approach was used to review data and explain why participants may or may not use these services.

RESULTS

Migrant men come to Johannesburg to find work, but unreliable income, daily stress and time constraints limit their availability to seek health services. While awareness of HIV testing is high, the fear of a positive diagnosis often overshadows the benefits. In addition, many men lack knowledge about the opportunity for PrEP should they test negative, though they express interest in the medication after learning about it. Additionally, these men struggle with adjusting to urban life, lack of social support and fear of potential stigma. Finally, the necessity to prioritize work combined with long wait times at clinics further restricts their access to HIV services. Despite these challenges, Johannesburg also presents opportunities for HIV services for migrant men, such as greater anonymity and availability of HIV information and services in the city as compared to their rural homes of origin.

CONCLUSIONS

Bringing HIV services to migrant men at community sites may ease the burden of accessing these services. Including PrEP counselling and services alongside HIV testing may further encourage men to test, particularly if integrated into counselling for livelihood and coping strategies, as well as support for navigating health services in Johannesburg.