Peer-led HIV prevention among gay men in London: process evaluation

Acceptability and Comfort Regarding Remotely Delivered PrEP Services in Mississippi

Despite the prevalence of human immunodeficiency virus (HIV) in Mississippi, access to pre-exposure prophylaxis (PrEP) is mostly limited to urban areas. Remote PrEP care via telemedicine, HIV self-testing, and prescription mail delivery can improve care in underserved communities. This mixed methods study assessed the acceptability and feasibility of using remote PrEP care, compared to alternatives. This consisted of (1) a cross-sectional survey and (2) interviews. PrEP-eligible adults were recruited from community-based organizations across Mississippi while accessing HIV testing between December 2019 and May 2022. Those surveyed (n = 63) indicated the greatest comfort in receiving PrEP via mail delivery (m = 5.14) and telemedicine (m = 4.89) and least comfort at gyms (m = 3.92). Comfort significantly differed between mail delivery and gyms (F = 2.90; P < .01). Those interviewed (n = 26) expressed relatively high comfort with remote PrEP care citing enhanced accessibility, privacy, simplicity, and quality. Remote PrEP services were acceptable and feasible among our sample, thus, should be expanded in Mississippi to address unmet needs.

Attitudes Toward Peer-Delivered Sexual-Health Services Among New York City Sexual and Gender Minority Individuals Who Have Sex with Men and Attend Collective Sex Venues

Collective sex venues such as sex clubs are strategic sites to promote sexual health among sexual and gender minority individuals. We present qualitative findings from a multiple-method study on the acceptability of sexual-health services at collective sex venues in New York City (NYC) among attendees who identified as men, transgender, or gender non-conforming. In a survey used for sample selection (n = 342), most respondents (82.7%) agreed that "having outreach workers at sex venues is a good thing." Interviewees (n = 30) appreciated how on-site services could promote sexual health in their community. They felt peer workers should be familiar with collective sex venues and share demographic characteristics with attendees. Some participants felt workers should keep some boundaries from attendees, while others felt they could be fully integrated in the environment, suggesting that either peer outreach or popular-opinion leader types of interventions could be feasible.

A Pragmatic Randomized Controlled Trial to Increase PrEP Uptake for HIV Prevention: 55-Week Results From PrEPChicago

OBJECTIVES

We tested preliminary efficacy of a peer change agent type I network intervention to increase pre-exposure prophylaxis (PrEP) linkage to care among network members connected to young Black men who have sex with men.

DESIGN

Parent study is a pragmatic randomized controlled trial with 110 weeks of total follow-up. Interim midpoint analyses are performed here using participant data before crossover assignment at 55 weeks.

METHODS

We randomly assigned 423 participants in Chicago to receive the network intervention, an opinion leader workshop with telephonic booster sessions, versus a time-matched control from 2016 to 2018. The consolidated surrogate outcome was PrEP referral and linkage to clinical care among network members connected to study participants and was collected from independent administrative data.

RESULTS

Each study participant in the trial (n = 423) had on average 1822 network contacts who could be eligible for PrEP referral and linkage. During the 55-week observation period, PrEP referral was most likely to occur within 3 days of an intervention session compared to control [odds ratio (OR) 0.07 (0.02-0.013); P = 0.007] resulting in 1-2 referrals of network members per session. Network members with referral or linkage were more likely to be connected to study participants in the intervention arm than the control condition [aOR 1.50 (1.09-2.06); P = 0.012].

CONCLUSIONS

A peer change agent type I network intervention is preliminarily effective at diffusing PrEP through a network of individuals highly susceptible to HIV over 55 weeks. This low-intensity intervention demonstrated network-level impact among populations that have experienced limited PrEP care engagement in the United States.

Behind the Wheel: Process Evaluation of a Safe-Transport Program for Older Drivers Delivered in a Randomized Controlled Trial

This process evaluation explores relationships between program outcomes and intervention implementation in a trial evaluating "Behind the Wheel," an education-based safe-transport program for older drivers. Participants (intervention group) were 190 Sydney drivers aged ⩾75 years (M = 80 ± 4years). Process measures included fidelity, dose delivered, and received. Outcomes were self-reported driving regulation and objectively measured driving exposure. Relationships were explored using regression models. Older drivers who took ownership of driving retirement and self-regulation by developing plans were more likely to reduce their weekly driving, (β = 38 km, 95% confidence interval (CI) = [7.5,68.7]), and night driving (β = 7 km, 95% CI = [3.5, 10.4]). Drivers of older age (odds ratio [OR] = 1.1/year older, 95% CI = [1.05, 1.3]) had greater odds of developing driving retirement plans. Female drivers (OR = 2.7,95% CI = [1.1, 6.9]), drivers with poorer function (OR = 1.2/5-point decrease on DriveSafe, 95% CI = [1.04, 1.4]), and worse health (OR = 1.2/additional medication, 95% CI = [1.02, 1.5]) had greater odds of developing safe mobility plans. This program had greatest impact with older, lower functioning drivers. A stronger message was delivered and received, as intended, to older drivers with lower function and poorer health. Our logic model can help channel resources to drivers who benefit most.

Factors associated with the implementation of community-based peer-led health promotion programs: A scoping review

Peer education is growing in popularity as a useful health promotion strategy. However, optimal conditions for implementing peer-led health promotion programs (HPPs) remain unclear. This scoping review aimed to describe factors that can influence implementation of peer-led HPPs targeting adult populations. Five databases were searched using the keywords "health promotion/prevention", "implementation", "peers", and related terms. Studies were included if they reported at least one factor associated with the implementation of community-based peer-led HPPs. Fifty-five studies were selected for the analysis. The method known as "best fit framework synthesis" was used to analyze the factors identified in the selected papers. Many factors included in existing implementation conceptual frameworks were deemed applicable to peer-led HPPs. However, other factors related to individuals, programs, and implementation context also emerged from the analysis. Based on this synthesis, an adapted theoretical framework was elaborated, grounded in a complex adaptive system perspective and specifying potential mechanisms through which factors may influence implementation of community-based peer-led HPPs. Further research is needed to test the theoretical framework against empirical data. Findings from this scoping review increase our knowledge of the optimal conditions for implementing peer-led HPPs and thereby maximizing the benefits of such programs.

Effectiveness of peer-led interventions to increase HIV testing among men who have sex with men: a systematic review and meta-analysis

HIV testing constitutes a key step along the continuum of HIV care. Men who have sex with men (MSM) have low HIV testing rates and delayed diagnosis, especially in low-resource settings. Peer-led interventions offer a strategy to increase testing rates in this population. This systematic review and meta-analysis summarizes evidence on the effectiveness of peer-led interventions to increase the uptake of HIV testing among MSM. Using a systematic review protocol that was developed a priori, we searched PubMed, PsycINFO and CINAHL for articles reporting original results of randomized or non-randomized controlled trials (RCTs), quasi-experimental interventions, and pre- and post-intervention studies. Studies were eligible if they targeted MSM and utilized peers to increase HIV testing. We included studies published in or after 1996 to focus on HIV testing during the era of combination antiretroviral therapy. Seven studies encompassing a total of 6205 participants met eligibility criteria, including two quasi-experimental studies, four non-randomized pre- and-post intervention studies, and one cluster randomized trial. Four studies were from high-income countries, two were from Asia and only one from sub-Saharan Africa. We assigned four studies a "moderate" methodological rigor rating and three a "strong" rating. Meta-analysis of the seven studies found HIV testing rates were statistically significantly higher in the peer-led intervention groups versus control groups (pooled OR 2.00, 95% CI 1.74-2.31). Among randomized trials, HIV testing rates were significantly higher in the peer-led intervention versus control groups (pooled OR: 2.48, 95% CI 1.99-3.08). Among the non-randomized pre- and post-intervention studies, the overall pooled OR for intervention versus control groups was 1.71 (95% CI 1.42-2.06), with substantial heterogeneity among studies (I2 = 70%, p < 0.02). Overall, peer-led interventions increased HIV testing among MSM but more data from high-quality studies are needed to evaluate effects of peer-led interventions on HIV testing among MSM in low- and middle-income countries.

Exploring how ward staff engage with the implementation of a patient safety intervention: a UK-based qualitative process evaluation

OBJECTIVES

A patient safety intervention was tested in a 33-ward randomised controlled trial. No statistically significant difference between intervention and control wards was found. We conducted a process evaluation of the trial and our aim in this paper is to understand staff engagement across the 17 intervention wards.

DESIGN

Large qualitative process evaluation of the implementation of a patient safety intervention.

SETTING AND PARTICIPANTS

National Health Service staff based on 17 acute hospital wards located at five hospital sites in the North of England.

DATA

We concentrate on three sources here: (1) analysis of taped discussion between ward staff during action planning meetings; (2) facilitators' field notes and (3) follow-up telephone interviews with staff focusing on whether action plans had been achieved. The analysis involved the use of pen portraits and adaptive theory.

FINDINGS

First, there were palpable differences in the ways that the 17 ward teams engaged with the key components of the intervention. Five main engagement typologies were evident across the life course of the study: consistent, partial, increasing, decreasing and disengaged. Second, the intensity of support for the intervention at the level of the organisation does not predict the strength of engagement at the level of the individual ward team. Third, the standardisation of facilitative processes provided by the research team does not ensure that implementation standardisation of the intervention occurs by ward staff.

CONCLUSIONS

A dilution of the intervention occurred during the trial because wards engaged with Patient Reporting and Action for a Safe Environment (PRASE) in divergent ways, despite the standardisation of key components. Facilitative processes were not sufficiently adequate to enable intervention wards to successfully engage with PRASE components.

Process evaluations in neurological rehabilitation: a mixed-evidence systematic review and recommendations for future research

OBJECTIVE

To systematically review how process evaluations are currently designed, what methodologies are used and how are they developed alongside or within neurological rehabilitation trials.

METHODS

This mixed-methods systematic review had two evidence streams: stream I, studies reporting process evaluations alongside neurorehabilitation trials research and stream II, methodological guidance on process evaluation design and methodology. A search strategy was designed for each evidence stream. Data regarding process evaluation core concepts and design issues were extracted using a bespoke template. Evidence from both streams was analysed separately and then synthesised in a final overarching synthesis proposing a number of recommendations for future research.

RESULTS

A total of 124 process evaluation studies, reporting on 106 interventions, were included in stream I evidence. 30 studies were included as stream II evidence. Synthesis 1 produced 9 themes, and synthesis 2 identified a total of 8 recommendations for process evaluation research. The overall synthesis resulted in 57 'synthesis recommendations' about process evaluation methodology grouped into 9 research areas, including the use of theory, the investigation of context, intervention staff characteristics and the delivery of the trial intervention.

CONCLUSIONS

There remains no consensus regarding process evaluation terminology within the neurological rehabilitation field. There is a need for process evaluations to address the nature and influence of context over time. Process evaluations should clearly describe what intervention staff bring to a trial, including skills and experience prior to joining the research. Process evaluations should monitor intervention staff's learning effects and the possible impact that these may have on trial outcomes.

Participation and diffusion effects of a peer-intervention for HIV prevention among adults in rural Malawi

This paper examines whether a peer group intervention that reduced self-reported risky behaviors for rural adults in Malawi also had impacts on non-participants in the same communities. We randomly assigned two districts to the intervention and control conditions, and conducted surveys at baseline and 18 months post-intervention using unmatched independent random samples of intervention and control communities in 2003-2006. The six-session peer group intervention was offered to same-gender groups by trained volunteers. In this analysis, we divided the post-intervention sample into three exposure groups: 243 participants and 170 non-participants from the intervention district (total n = 415) and 413 control individuals. Controlling for demographics and participation, there were significant favorable diffusion effects on five partially overlapping behavioral outcomes: partner communication, ever used condoms, unprotected sex, recent HIV test, and a community HIV prevention index. Non-participants in the intervention district had more favorable outcomes on these behaviors than survey respondents in the control district. One behavioral outcome, community HIV prevention, showed both participation and diffusion effects. Participating in the intervention had a significant effect on six psychosocial outcomes: HIV knowledge (two measures), hope, condom attitudes, and self-efficacy for community HIV prevention and for safer sex; there were no diffusion effects. This pattern of results suggests that the behavioral changes promoted in the intervention spread to others in the same community, most likely through direct contact between participants and non-participants. These findings support the idea that diffusion of HIV-related behavior changes can occur for peer group interventions in communities, adding to the body of research supporting diffusion of innovations theory as a robust approach to accelerating change. If diffusion occurs, peer group intervention may be more cost-effective than previously realized. Wider implementation of peer group interventions can help meet the global goal of reducing new HIV infections.

Using process data to understand outcomes in sexual health promotion: an example from a review of school-based programmes to prevent sexually transmitted infections

This article discusses how process indicators can complement outcomes as part of a comprehensive explanatory evaluation framework, using the example of skills-based behavioural interventions to prevent sexually transmitted infections and promote sexual health among young people in schools. A systematic review was conducted, yielding 12 eligible outcome evaluations, 9 of which included a process evaluation. There were few statistically significant effects in terms of changes in sexual behaviour outcomes, but statistically significant effects were more common for knowledge and self-efficacy. Synthesis of the findings of the process evaluations identified a range of factors that might explain outcomes, and these were organized into two overarching categories: the implementation of interventions, and student engagement and intervention acceptability. Factors which supported implementation and engagement and acceptability included good quality teacher training, involvement and motivation of key school stakeholders and relevance and appeal to young people. Factors which had a negative impact included teachers' failure to comprehend the theoretical basis for behaviour change, school logistical problems and omission of topics that young people considered important. It is recommended that process indicators such as these be assessed in future evaluations of school-based sexual health behavioural interventions, as part of a logic model.

Rewarding altruism: addressing the issue of payments for volunteers in public health initiatives

Lay involvement in public health programmes occurs through formalised lay health worker (LHW) and other volunteer roles. Whether such participation should be supported, or indeed rewarded, by payment is a critical question. With reference to policy in England, UK, this paper argues how framing citizen involvement in health only as time freely given does not account for the complexities of practice, nor intrinsic motivations. The paper reports results on payment drawn from a study of approaches to support lay people in public health roles, conducted in England, 2007-9. The first phase of the study comprised a scoping review of 224 publications, three public hearings and a register of projects. Findings revealed the diversity of approaches to payment, but also the contested nature of the topic. The second phase investigated programme support matters in five case studies of public health projects, which were selected primarily to reflect role types. All five projects involved volunteers, with two utilising forms of payment to support engagement. Interviews were conducted with a sample of project staff, LHWs (paid and unpaid), external partners and service users. Drawing on both lay and professional perspectives, the paper explores how payment relates to social context as well as various motivations for giving, receiving or declining financial support. The findings show that personal costs are not always absorbed, and that there is a potential conflict between financial support, whether sessional payment or expenses, and welfare benefits. In identifying some of the advantages and disadvantages of payment, the paper highlights the complexity of an issue often addressed only superficially. It concludes that, in order to support citizen involvement, fairness and value should be considered alongside pragmatic matters of programme management; however policy conflicts need to be resolved to ensure that employment and welfare rights are maintained.

Comparison between peer-led and teacher-led education in tuberculosis prevention in rural middle schools in Chongqing, China

The aim of this study was to investigate the efficacy of tuberculosis (TB) education through a comparison of peer-led and teacher-led methods of education about TB prevention among middle school students in rural Chongqing, China. A preintervention and postintervention questionnaire survey was conducted in 2 different middle school student groups to measure changes in knowledge, attitude, and practice (KAP) status of those students before and after each TB education program. Of 1265 students participating in the preintervention survey, 1176 completed the postintervention survey. KAP scores of both peer-led and teacher-led groups after intervention improved by as much as 2 times compared with before the intervention and those of the control group (P < .01). KAP scores of immediate evaluation were higher than those of long-term evaluation in the teacher-led education group (P < .01). The teacher-led group had a larger improvement than the peer-led group in practice scores (P < .01) in immediate effect evaluation.

Towards a methodology for cluster searching to provide conceptual and contextual "richness" for systematic reviews of complex interventions: case study (CLUSTER)

Background

Systematic review methodologies can be harnessed to help researchers to understand and explain how complex interventions may work. Typically, when reviewing complex interventions, a review team will seek to understand the theories that underpin an intervention and the specific context for that intervention. A single published report from a research project does not typically contain this required level of detail. A review team may find it more useful to examine a “study cluster”; a group of related papers that explore and explain various features of a single project and thus supply necessary detail relating to theory and/or context.

We sought to conduct a preliminary investigation, from a single case study review, of techniques required to identify a cluster of related research reports, to document the yield from such methods, and to outline a systematic methodology for cluster searching.

Methods

In a systematic review of community engagement we identified a relevant project – the Gay Men’s Task Force. From a single “key pearl citation” we conducted a series of related searches to find contextually or theoretically proximate documents. We followed up Citations, traced Lead authors, identified Unpublished materials, searched Google Scholar, tracked Theories, undertook ancestry searching for Early examples and followed up Related projects (embodied in the CLUSTER mnemonic).

Results

Our structured, formalised procedure for cluster searching identified useful reports that are not typically identified from topic-based searches on bibliographic databases. Items previously rejected by an initial sift were subsequently found to inform our understanding of underpinning theory (for example Diffusion of Innovations Theory), context or both. Relevant material included book chapters, a Web-based process evaluation, and peer reviewed reports of projects sharing a common ancestry. We used these reports to understand the context for the intervention and to explore explanations for its relative lack of success. Additional data helped us to challenge simplistic assumptions on the homogeneity of the target population.

Conclusions

A single case study suggests the potential utility of cluster searching, particularly for reviews that depend on an understanding of context, e.g. realist synthesis. The methodology is transparent, explicit and reproducible. There is no reason to believe that cluster searching is not generalizable to other review topics. Further research should examine the contribution of the methodology beyond improved yield, to the final synthesis and interpretation, possibly by utilizing qualitative sensitivity analysis.

Judgment, resources, and complexity: a qualitative study of the experiences of systematic reviewers of health promotion

Systematic reviews play an increasingly important role in decision making in health promotion and public health. However, little has been published on how systematic reviewers acquire necessary knowledge and skills, and on the challenges they face in producing reviews. Semistructured interviews were conducted with a purposive sample of 17 systematic reviewers of health promotion. They described practice, training, and mentoring as being key ways that they learned reviewing skills, often in combination. Practice-based learning was considered to be particularly beneficial. Training was generally easy to access, though questions were raised about the feasibility of training stakeholders such as health professionals to become reviewers. It was suggested that an understanding of research methods is beneficial for novice reviewers. While funding opportunities for doing reviews are available, long-term investment is needed to support an infrastructure for the production of high-quality systematic reviews of important health promotion priorities.

Attitudinal, behavioral, and biological outcomes of a community popular opinion leader intervention in China

The effects of a community popular opinion leader (CPOL) intervention were examined among market vendors in a city on the eastern coast of China. Employees of 40 food markets were enrolled in a study that provided HIV-related education and tests, and treatment for sexually transmitted diseases (STDs). Twenty markets were randomly assigned to a CPOL intervention (N = 1,695) and 20 markets to a control condition (N = 1,616). Market employees in the intervention condition reported positive attitudes regarding STD/HIV prevention and more frequent discussions about safe sex than those in the control condition. Compared with baseline, the prevalence of unprotected sexual acts and new STDs were significantly lower within each study condition 24 months later. Although the CPOL intervention achieved its goal of shifting attitudes within food markets, the gains did not lead to the expected behavioral and biological outcomes.

Why some MSM present late for HIV testing: a qualitative analysis

Although initiatives are under way in the UK to diagnose HIV infection early, late presentation is still a major issue and often results in serious health complications for the individual and has implications for society, including high costs and increased rates of transmission. Intervention strategies in the UK have aimed at increasing testing opportunities but still a significant proportion of those with HIV infection either decline testing or continue to test late. The main objective of this study is to identify ideas and themes as to why testing was not carried out earlier in men who have sex with men (MSM) who presented with late HIV infection. Semi-structured interviews were carried out with MSM presenting late with a CD4 cell count of <200. A structured framework approach was used to analyse the data collected and generate ideas as to why they did not seek testing earlier. Seventeen MSM were interviewed and four main themes were identified: psychological barriers, including fear of illness and dying, stigma surrounding testing for HIV and in living with a positive diagnosis, perceived low risk for contracting HIV despite participants reporting having a good understanding of HIV and its transmission and strong views that a more active approach by healthcare services, including general practice, is necessary if the uptake of HIV testing is to increase. Late presentation with HIV infection continues to be a problem in the UK despite government initiatives to expand opportunities for testing. Recurring themes for late testing were a low perceived risk for HIV infection and a fear of HIV and a positive diagnosis. Population-targeted health promotion alongside a more proactive approach by healthcare professionals and making HIV testing more convenient and accessible may result in earlier testing.

Experiences of outreach workers in promoting smoking cessation to Bangladeshi and Pakistani men: longitudinal qualitative evaluation

BACKGROUND

Despite having high smoking rates, there have been few tailored cessation programmes for male Bangladeshi and Pakistani smokers in the UK. We report on a qualitative evaluation of a community-based, outreach worker delivered, intervention that aimed to increase uptake of NHS smoking cessation services and tailor services to meet the needs of Bangladeshi and Pakistani men.

METHODS

This was a longitudinal, qualitative study, nested within a phase II cluster randomised controlled trial of a complex intervention. We explored the perspectives and experiences of five outreach workers, two stop smoking service managers and a specialist stop smoking advisor. Data were collected through focus group discussions, weekly diaries, observations of management meetings, shadowing of outreach workers, and one-to-one interviews with outreach workers and their managers. Analysis was undertaken using a modified Framework approach.

RESULTS

Outreach workers promoted cessation services by word of mouth on the streets, in health service premises, in local businesses and at a wide range of community events. They emphasised the reasons for cessation, especially health effects, financial implications, and the impact of smoking on the family. Many smokers agreed to be referred to cessation services, but few attended, this in part being explained by concerns about the relative inflexibility of existing service provision. Although outreach workers successfully expanded service reach, they faced the challenges of perceived lack of awareness of the health risks associated with smoking in older smokers and apathy in younger smokers. These were compounded by perceptions of "lip service" being given to their role by community organisations and tensions both amongst the outreach workers and with the wider management team.

CONCLUSIONS

Outreach workers expanded reach of the service through taking it to diverse locations of relevance to Pakistani and Bangladeshi communities. The optimum method of outreach to retain and treat Bangladeshi and Pakistani smokers effectively in cessation programmes needs further development.

'Think differently and be prepared to demonstrate trust': findings from public hearings, England, on supporting lay people in public health roles

Professional support processes are critical for the establishment and maintenance of community health worker programmes. This paper reports on three public hearings held in England, UK, that were conducted as part of a national study into approaches to develop and support lay people in public health roles. Individuals with relevant theoretical or practical expertise, including lay activists, presented evidence in public as expert witnesses. Formal presentations, questions and plenary discussions were recorded and later analysed as qualitative data. This paper presents the results and critically examines emergent issues relating to the sustainability of lay health worker programmes. Consideration is given to the diversity of contemporary practice in England. Barriers seen to affect sustainability included organizational culture and onerous bureaucratic processes. Major themes emerging from the expert evidence included recruitment and training strategies, financial support and the need for a robust infrastructure. The expert hearings, in creating a public space for deliberation, opened up discussion on the levels and type of programme support required to foster lay health worker programmes. The paper concludes that professional support needs to be accompanied by a reorientation of public services to support lay engagement in programme delivery.

Popular opinion leaders in London: a response to Kelly

Controlled trials conducted in the USA provide clear evidence that peer education can bring about a reduction in high risk sexual behaviour among gay men. HIV prevention interventions that systematically identified, recruited, trained and engaged popular opinion leaders (POLs) made a significant impact on sexual behaviour at a community level in small US towns. However, recent trials conducted in the UK have failed to replicate these findings. A POL intervention in London made no significant impact at a community level on the risk behaviours of gay men. Jeffrey Kelly, one of the authors of the US studies, has identified nine core elements central to the popular opinion leader model. In Kelly's view 'the UK projects were not tests of the popular opinion leader model because they did not employ most of these POL core elements'. The absence of any significant impact of the UK programmes on sexual risk behaviour at a community level was not, therefore, surprising. In fact, the London POL project incorporated all the core elements into its design and succeeded in employing seven out of nine in its delivery. Attempts to employ all the core elements, however, were hampered by problems in recruiting popular opinion leaders as well as barriers to communication. Process evaluation revealed that it was these obstacles which limited diffusion. This in turn explained the absence of any impact of the London POL project on sexual risk behaviour at a community level. The obstacles to successful diffusion in London have provided a valuable opportunity for examining the processes that underlie the POL model. Our study raises the question as to whether social interventions shown to be effective in one setting, place or moment in time can be replicated in another.

Sexual risk behaviors and HIV infection among men who have sex with men who use the internet in Beijing and Urumqi, China

OBJECTIVES

To assess HIV and syphilis infections among men who have sex with men who use the internet (MSMUI) and their risk behaviors.

METHODS

In 2007, 429 MSMUI were recruited via the internet in Beijing and Urumqi, China. A questionnaire was administered, and a blood specimen was collected and tested for HIV and syphilis.

RESULTS

Median age of participants was 25 years. Median number of lifetime sexual partners was 10. 90.7% ever had sex with a cyber friend. Rates of condom use in the last oral, insertive, and receptive anal sex were 9.1%, 66.3%, and 60.4%, respectively. Infection rates of HIV, syphilis, and HIV/syphilis coinfection were 4.8%, 11.4%, and 1.7%, respectively. Factors associated with HIV infection were being < or =24 years [odds ratio (OR) = 2.85, 95% confidence interval (CI): 1.05 to 7.75], syphilis positive (OR = 4.78, 95% CI: 1.68 to 13.58), used non-water-based liquid as lubricant (OR = 8.03, 95% CI: 1.03 to 62.52), and having bleeding gums or oral ulcers during condom-free oral sex (OR = 3.17, 95% CI: 1.13 to 8.88).

CONCLUSIONS

MSMUI engage in high-risk sexual behaviors and have a high prevalence of HIV and syphilis infections. The internet is the predominant venue for the majority of MSMUI to find sexual partners. It is urgent to implement effective intervention programs targeting this group.

Community-based health programmes: role perceptions and experiences of female peer facilitators in Mumbai's urban slums

Community-based initiatives have become a popular approach to addressing the health needs of underserved populations, in both low- and higher-income countries. This article presents findings from a study of female peer facilitators involved in a community-based maternal and newborn health intervention in urban slum areas of Mumbai. Using qualitative methods we explore their role perceptions and experiences. Our findings focus on how the facilitators understand and enact their role in the community setting, how they negotiate relationships and health issues with peer groups, and the influence of credibility. We contextualize this within broader conceptualizations of peer-led health interventions and offer recommendations for similar community-based health initiatives.

Embodied work: insider perspectives on the work of HIV/AIDS peer counselors

Our aim in this study was to explore HIV/AIDS peer counseling from the perspective of women actively engaged in this work within the context of a community-based program in rural areas of the southeastern United States. Based on this research we suggest that the embodied work of HIV/AIDS peer counselors is constructed around their personal identities and experiences. This work involves gaining entry to other HIV-positive women's lives, building relationships, drawing on personal experiences, facing issues of fear and stigma, tailoring peer counseling for diversity, balancing risks and benefits, and terminating relationships. Peer counselors recognize the personal and collective value of their work, which, like much of women's work within the context of family and community, lacks public visibility and acknowledgment. We discuss implications for the training and support of peer-based interventions for HIV and other women's health issues across diverse contexts and settings.

Participatory communication and HIV/AIDS prevention in a Chinese marginalized (MSM) population

HIV/AIDS in China has entered a critical stage of rapid and widespread increase. It has been estimated that more than one million people in China have been infected with HIV and the rate of increase tops the world. The number could swell to 10 million by 2010 if more intense and effective preventive measures are not adopted immediately. Sex between men has been a mostly 'hidden' source of the spread of HIV in China. Homosexuality is no longer a criminal act in China, however, traditional 'official-led' so-called peer education programmes among men who have sex with men (MSM) have little effect in adopting and diffusing a key message to their networks. This is because the climate in HIV prevention through community-based advocacy among MSM has not been substantially changed which is due to these men still facing strong opposition and resistance from society, as a quite marginalized population in China. This study carried out in Chengdu is the first to explore how to use a socially and culturally appropriate participatory communication to promote safer sex behaviour with gay men and MSM in Chengdu, China. The study examined effectiveness of peer-led health message diffusion in promoting condom use through a participatory communication approach among these men in the programme. Key findings showed that the peer-based participatory communication strategy was effective for encouraging condom use with casual sexual partners in the intervention group. There was no significant change in the comparison group. It indicates that participatory involvement is the major driving force for HIV-related safer sex behaviour change and can be recommended to promote safer sex practice among gay men and MSM in their broad contexts.

Utilization of prevention research: searching for evidence

OBJECTIVE

Understanding the process of translating prevention research into practice calls for systematic efforts to assess the state of the published literature on the utilization of prevention research in public health programs and policy. This review describes the search strategy, methods, results, and challenges in identifying and reviewing literature relevant to this objective.

METHODS

Systematic searches of topics related to prevention research in literature published in 1995-2002 revealed 86 empiric articles in 12 public health areas.

RESULTS

A lack of uniform terminology, variation in publication sources, and limited descriptions of the stages of research utilization (e.g., adoption and implementation) in the published literature posed major challenges to identifying articles that met study criteria. Most accepted articles assessed the adoption or implementation of prevention research; four examined long-term sustainability. There was approximately equal distribution of reported research set in either health services or public health settings. Few of the articles contained search terms reflecting all four concept areas (prevention, public health, research, and use) targeted by the literature search.

CONCLUSIONS

Refining terms used in prevention research and research utilization could address lack of shared and unique definitions. Expanded reporting of research utilization stages in reports of prevention research could lead to improved literature searches and contribute to more successful adoption, implementation, and further use of prevention research products.

Assessment of generalisability in trials of health interventions: suggested framework and systematic review

Most evaluations of new treatments use highly selected populations, making it difficult to decide whether they would work elsewhere. Systematic evaluation and reporting of applicability is required

Conceptualizing the Influence of Social Agents of Behavior Change: A Meta-Analysis of the Effectiveness of HIV-Prevention Interventionists for Different Groups

A meta-analysis of 166 HIV-prevention interventions tested theoretical predictions about the effects of experts, lay community members, and similar and dissimilar others, as agents of change. In general, expert interventionists produced greater behavior change than lay community members, and the demographic and behavioral similarity between the interventionist and the recipients facilitated behavioral change. Equally importantly, there were differences across groups in the efficacy of various sources, especially among populations of low status and/or power. These findings support the hypothesis that unempowered populations are more sensitive to characteristics of the interventionists who can facilitate access to various resources. In addition, they suggest the need to ensure the availability of health professionals from diverse demographic and behavioral backgrounds.

Process evaluation in randomised controlled trials of complex interventions

Most randomised controlled trials focus on outcomes, not on the processes involved in implementing an intervention. Using an example from school based health promotion, this paper argues that including a process evaluation would improve the science of many randomised controlled trials

Popular opinion leaders and HIV prevention peer education: resolving discrepant findings, and implications for the development of effective community programmes

A series of community-level trials undertaken in the United States over the past 10 years established the effectiveness of an HIV prevention intervention that systematically identifies, recruits, trains, and engages the popular opinion leaders (POLs) of a population to serve as behaviour change endorsers. Recently, several investigators reported unsuccessful attempts to implement peer education programmes for men who have sex with men in the United Kingdom and raised questions about whether peer-based programmes are effective or feasible. However, POL is a theory-based and very specialized intervention, and the UK peer education programmes did not incorporate many of POL's core or essential elements. Consequently, they were not evaluations of POL. In this article, core elements of the popular opinion leader model are presented; interpretations are made of possible reasons for the discrepant findings of the UK peer education and US POL interventions; and practical issues for applied programme development are discussed.

Diffusion of innovations and HIV/AIDS

As the HIV/AIDS epidemic continues its relentless spread in many parts of the world, DOI provides a useful framework for analyzing the difficulties in achieving behavior change necessary to reduce HIV rates. The DOI concepts most relevant to this question include communication channels, the innovation-decision process, homophily, the attributes of the innovation, adopter categories, and opinion leaders. The preventive measures needed to halt the transmission of HIV constitute a "preventive innovation." This article describes the attributes of this preventive innovation in terms of relative advantage, compatibility, complexity, trialability, and observability. It reviews studies that incorporated DOI into HIV/AIDS behavior change interventions, both in Western countries and in the developing world. Finally, it discusses possible reasons that the use of DOI has been fairly limited to date in HIV/AIDS prevention interventions in developing countries.

If HIV prevention works, why are rates of high-risk sexual behavior increasing among MSM?

Systematic reviews of HIV prevention research provide clear evidence that behavioral interventions can influence the sexual behavior of men who have sex with men (MSM). However, if HIV prevention works, why are rates of high-risk sexual behavior increasing among MSM in major European, Australian, Canadian, and U.S. cities? The evidence generated by systematic reviews alone may not provide a clear answer to this question. This is because (a) it is uncertain whether experimental interventions shown to be effective in one setting, place, or moment in time can be repeated successfully in another; (b) we have limited understanding of the processes that underlie the interventions; (c) interventions shown to work in an experimental study may not necessarily be effective in everyday life. To answer the question, we need to be alert to the changing risk environment in which men have sex with other men. We also need to develop a new program of research addressing the transferability, sustainability, and effectiveness of sexual health promotion among MSM. Randomized controlled trials will remain one of the optimal means of evaluating behavioral interventions in such a program. By further strengthening the evidence base, we may identify opportunities for innovative as well as effective HIV prevention initiatives.

Peer HIV/AIDS education with volunteer trishaw drivers in Yaan, People's Republic of China: process evaluation

Peer-based HIV prevention education has become increasingly popular in China. Few studies have explored culturally appropriate strategies or the effectiveness of this approach among the growing population of Chinese self-employed young people--a group quite vulnerable to HIV and other sexually transmissible infections. The findings presented here are from a process evaluation of a peer-led demonstration project with self-employed trishaw drivers in Yaan, China. This study examines sexual health message diffusion from 150 volunteers in a direct training group to 705 peers in an indirect training group. A key finding was that success in diffusing sexual health messages was significantly related to drivers' attachment to their subculture. The successful elements of the project augur well for the development of HIV peer education in the broader arena of self-employed young people in China and pose a challenge to the traditional approach of "official-led" peer education with its uniform prescription of officially sanctioned printed materials.

Context matters: the educational potential of gay bars revisited

Gay bars have been frequently identified as suitable environments in which to conduct HIV prevention activities among homosexually active men. In theory, they provide easy access to a relatively diverse group of men. However, gay bars are environments in which the primary purpose is a social one. Gay men use them to take time out, to socialize, and, on occasions, to find new sexual partners. They are also settings in which social reputations often have to be managed. This study examined the HIV/AIDS educational potential of four gay bars in London, Britain. Semistructured observations and interviews took place in four contrasting bars with a focus on men's perceptions of HIV/AIDS-related health promotion activities including condom promotion, the use of posters and small media, and understandings of safer sex. Respondents were ambivalent about AIDS-related health education activities being undertaken. The implications of such responses for the development of HIV primary prevention activities in such settings are discussed.

Early adoption of BRCA1/2 testing: who and why

PURPOSE

Relatively little is known about the characteristics of women who chose to undergo BRCA1/2 testing soon after testing became available, including how they became aware of and chose to pursue testing. Diffusion of innovation theory states that acceptance of an innovation is a function of the potential adopter's value for innovation and perceptions of the compatibility, complexity, and relative advantage of the innovation. These factors may contribute to early uptake of BRCA1/2 testing. The purpose of this study was to describe the characteristics of women who were "early adopters" of clinical BRCA1/2 testing and to determine whether diffusion theory explains variation in uptake of testing after participation in genetic counseling for BRCA1/2 testing.

METHODS

A retrospective cohort study of participants in genetic counseling for BRCA1/2 testing was conducted at a clinical program in a large academic health system. Measures included components of diffusion of innovation theory (participant's value for innovation, i.e., "innovativeness," and perceptions of the compatibility, complexity, and relative advantage of BRCA1/2 testing), characteristics of how the participant became aware of and sought BRCA1/2 testing, and decisions about testing after counseling.

RESULTS

From the 229 respondents, 71 (31%) had undergone testing at the time of the survey. Fifty-seven women (25%) had sought BRCA1/2 testing because a family member had breast or ovarian cancer and 37 (16%) because they had breast or ovarian cancer. Only 15 women (7%) reported seeking testing because of a physician's recommendation. After multivariate adjustment, higher innovativeness and higher ratings of the compatibility of BRCA1/2 testing were associated with undergoing testing after counseling [relative risk (RR) 1.76, 95% confidence interval (CI) 1.2-2.6]. However, ratings of the complexity or relative advantage of testing were not associated with testing decisions. Higher innovativeness was associated with being the first in the family to undergo testing (RR 4.85, 95% CI 1.6-14.9), becoming aware of BRCA1/2 testing through the media (RR 1.50, 95% CI 1.0-2.4), and being aware of BRCA1/2 testing prior to counseling (RR 1.25, 95% CI 1.1-1.4).

CONCLUSIONS

The uptake of BRCA1/2 testing among women undergoing genetic counseling was associated with innovative characteristics of the participant and the perceived compatibility of the test with existing values and needs, but not with the complexity or relative advantage of the test. Most "early adopters" had heard of BRCA1/2 testing from a source other than their physician and had sought testing because of a personal or family member's cancer diagnosis. These findings can inform predictions surrounding the introduction of future genetic susceptibility tests and strategies for guiding the further diffusion of BRCA1/2 testing.