Randomized clinical trial of brief risk reduction counseling for sexually transmitted infection clinic patients in Cape Town, South Africa

Qualitative insights on sexual health counselling from refugee youth in Bidi Bidi Refugee Settlement, Uganda: Advancing contextual considerations for brief sexuality-related communication in a humanitarian setting

Characteristics of enabling healthcare environments to support brief sexuality-related communication (BSC) are understudied in humanitarian settings. We implemented a qualitative study with refugee youth aged 16-24 living in Bidi Bidi Refugee Settlement to understand the feasibility of implementing BSC in a humanitarian context. We examined feelings toward doctor's visits in general, including types of conversations youth engage in with healthcare providers, as well as comfort, safety, and willingness to talk with healthcare providers about sexual health. We implemented four focus groups with refugee youth in Bidi Bidi, two with young women and two with young men, and applied thematic analysis informed by a social contextual theoretical framework that explores enabling environments for sexual health promotion. Participants (n = 40; mean age: 20 years, standard deviation: 2.2; women: n = 20; men: n = 20) reported relational, symbolic, and material dimensions of context considered important when discussing sexual health. Relational contexts included a) trusting relationship with local healthcare practitioners, including practices that foster comfort and confidentiality, and b) family, friends, and mentors as additional sources of health information. Symbolic contexts refer to values, norms, and beliefs that reflect what is perceived as valuable and worthy, and in turn, what is devalued and stigmatized. Specific to sexual health, participants discussed stigma toward STIs and HIV, devaluation of women in healthcare settings, and generalized fear of doctors and disease as barriers to engaging in dialogue about sexual health with healthcare providers. Material contexts include agency linked with resource access and experiences. Youth narratives revealed that positive experiences accessing medication to manage pain and infections increased their willingness to engage in healthcare discussions, whereby clinic layouts and dynamics that compromised confidentiality and privacy reduced the likelihood of sexual health dialogue. Language barriers and healthcare provider time constraints were additional factors that reduced healthcare engagement. Taken together, findings can inform BSC implementation strategies that consider the inner and outer settings that shape sexual health dialogue and sexual health and wellbeing among refugee youth living in humanitarian settings.

Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries

BACKGROUND

Harmful alcohol use is defined as unhealthy alcohol use that results in adverse physical, psychological, social, or societal consequences and is among the leading risk factors for disease, disability and premature mortality globally. The burden of harmful alcohol use is increasing in low- and middle-income countries (LMICs) and there remains a large unmet need for indicated prevention and treatment interventions to reduce harmful alcohol use in these settings. Evidence regarding which interventions are effective and feasible for addressing harmful and other patterns of unhealthy alcohol use in LMICs is limited, which contributes to this gap in services.

OBJECTIVES

To assess the efficacy and safety of psychosocial and pharmacologic treatment and indicated prevention interventions compared with control conditions (wait list, placebo, no treatment, standard care, or active control condition) aimed at reducing harmful alcohol use in LMICs.

SEARCH METHODS

We searched for randomized controlled trials (RCTs) indexed in the Cochrane Drugs and Alcohol Group (CDAG) Specialized Register, the Cochrane Clinical Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, Embase, PsycINFO, CINAHL, and the Latin American and Caribbean Health Sciences Literature (LILACS) through 12 December 2021. We searched clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform, Web of Science, and Opengrey database to identify unpublished or ongoing studies. We searched the reference lists of included studies and relevant review articles for eligible studies.

SELECTION CRITERIA

All RCTs comparing an indicated prevention or treatment intervention (pharmacologic or psychosocial) versus a control condition for people with harmful alcohol use in LMICs were included.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 66 RCTs with 17,626 participants. Sixty-two of these trials contributed to the meta-analysis. Sixty-three studies were conducted in middle-income countries (MICs), and the remaining three studies were conducted in low-income countries (LICs). Twenty-five trials exclusively enrolled participants with alcohol use disorder. The remaining 51 trials enrolled participants with harmful alcohol use, some of which included both cases of alcohol use disorder and people reporting hazardous alcohol use patterns that did not meet criteria for disorder. Fifty-two RCTs assessed the efficacy of psychosocial interventions; 27 were brief interventions primarily based on motivational interviewing and were compared to brief advice, information, or assessment only. We are uncertain whether a reduction in harmful alcohol use is attributable to brief interventions given the high levels of heterogeneity among included studies (Studies reporting continuous outcomes: Tau² = 0.15, Q =139.64, df =16, P<.001, I² = 89%, 3913 participants, 17 trials, very low certainty; Studies reporting dichotomous outcomes: Tau²=0.18, Q=58.26, df=3, P<.001, I² =95%, 1349 participants, 4 trials, very low certainty). The other types of psychosocial interventions included a range of therapeutic approaches such as behavioral risk reduction, cognitive-behavioral therapy, contingency management, rational emotive therapy, and relapse prevention. These interventions were most commonly compared to usual care involving varying combinations of psychoeducation, counseling, and pharmacotherapy. We are uncertain whether a reduction in harmful alcohol use is attributable to psychosocial treatments due to high levels of heterogeneity among included studies (Heterogeneity: Tau² = 1.15; Q = 444.32, df = 11, P<.001; I²=98%, 2106 participants, 12 trials, very low certainty). Eight trials compared combined pharmacologic and psychosocial interventions with placebo, psychosocial intervention alone, or another pharmacologic treatment. The active pharmacologic study conditions included disulfiram, naltrexone, ondansetron, or topiramate. The psychosocial components of these interventions included counseling, encouragement to attend Alcoholics Anonymous, motivational interviewing, brief cognitive-behavioral therapy, or other psychotherapy (not specified). Analysis of studies comparing a combined pharmacologic and psychosocial intervention to psychosocial intervention alone found that the combined approach may be associated with a greater reduction in harmful alcohol use (standardized mean difference (standardized mean difference (SMD))=-0.43, 95% confidence interval (CI): -0.61 to -0.24; 475 participants; 4 trials; low certainty). Four trials compared pharmacologic intervention alone with placebo and three with another pharmacotherapy. Drugs assessed were: acamprosate, amitriptyline, baclofen disulfiram, gabapentin, mirtazapine, and naltrexone. None of these trials evaluated the primary clinical outcome of interest, harmful alcohol use.   Thirty-one trials reported rates of retention in the intervention. Meta-analyses revealed that rates of retention between study conditions did not differ in any of the comparisons (pharmacologic risk ratio (RR) = 1.13, 95% CI: 0.89 to 1.44, 247 participants, 3 trials, low certainty; pharmacologic in addition to psychosocial intervention: RR = 1.15, 95% CI: 0.95 to 1.40, 363 participants, 3 trials, moderate certainty). Due to high levels of heterogeneity, we did not calculate pooled estimates comparing retention in brief (Heterogeneity: Tau² = 0.00; Q = 172.59, df = 11, P<.001; I2 = 94%; 5380 participants; 12 trials, very low certainty) or other psychosocial interventions (Heterogeneity: Tau² = 0.01; Q = 34.07, df = 8, P<.001; I2 = 77%; 1664 participants; 9 trials, very low certainty). Two pharmacologic trials and three combined pharmacologic and psychosocial trials reported on side effects. These studies found more side effects attributable to amitriptyline relative to mirtazapine, naltrexone and topiramate relative to placebo, yet no differences in side effects between placebo and either acamprosate or ondansetron. Across all intervention types there was substantial risk of bias. Primary threats to validity included lack of blinding and differential/high rates of attrition.

AUTHORS' CONCLUSIONS

In LMICs there is low-certainty evidence supporting the efficacy of combined psychosocial and pharmacologic interventions on reducing harmful alcohol use relative to psychosocial interventions alone. There is insufficient evidence to determine the efficacy of pharmacologic or psychosocial interventions on reducing harmful alcohol use largely due to the substantial heterogeneity in outcomes, comparisons, and interventions that precluded pooling of these data in meta-analyses. The majority of studies are brief interventions, primarily among men, and using measures that have not been validated in the target population. Confidence in these results is reduced by the risk of bias and significant heterogeneity among studies as well as the heterogeneity of results on different outcome measures within studies. More evidence on the efficacy of pharmacologic interventions, specific types of psychosocial interventions are needed to increase the certainty of these results.

Implementing HIV Prevention in Sub-Saharan Africa: A Systematic Review of Interventions Targeting Systems, Communities, and Individuals

HIV remains a threat to global public health, disproportionately affecting countries across Sub-Saharan Africa. Although treatment and access to care have improved, prevention remains critical to ending new HIV infections by 2030. A variety of prevention strategies exist, yet their effectiveness is difficult to measure and variable due to the nature of the interventions and vulnerability of the intervention during implementation. This systematic review of 51 studies synthesizes data on the implementation and evaluation of evidence-based HIV prevention interventions across Sub-Saharan Africa. Studies were included if they occurred between January 1, 2008, and December 31, 2019, inclusive in Sub-Saharan Africa, were written in English, implemented an HIV prevention intervention in the field, and had reportable results. Using a modified social-ecological model for HIV prevention, we divided studies into three categories: interventions targeting health systems (n = 16), communities (n = 8), and individuals (n = 27). Across all categories, the data emphasized preventing mother-to-child transmission (PMTCT), medical interventions, and psychosocial interventions. The most successful programs bundled several interventions that were integrated into the health system. There is a notable lack of interventions targeting key populations and there are significant rates of loss to follow up (LTFU) across many studies. This review provides insight into the prioritization of evidence-based HIV prevention interventions across Sub-Saharan Africa.

Empowering Our People: Syndemic Moderators and Effects of a Culturally Adapted, Evidence-Based Intervention for Sexual Risk Reduction among Native Americans with Binge Substance Use

Native American (NA) communities are disproportionately affected by the intersecting, synergistic epidemics of sexually transmitted infections (STIs) and substance use. Targeted approaches to addressing these syndemics are critical given the relative scarcity of mental health and behavioral specialists in NA communities. We conducted a series of moderation analyses using data from a randomized controlled trial of the EMPWR (Educate, Motivate, Protect, Wellness, Respect) intervention for reducing sexual risk behaviors, culturally adapted for NA adults with recent binge substance use living on rural reservations. We considered several potential moderators and substance use and sexual risk outcomes at 6- and 12-months post-baseline. Three hundred and one people participated in the study. Age, marital status, educational attainment, employment, and depressive symptoms were differentially associated with intervention effects. EMPWR could be strengthened with the incorporation of additional skills-building related to condom use negotiation with casual partners. For individuals with lower educational attainment or without employment, additional supports and approaches to intervention may be needed. Importantly, this study did not identify intersecting sexual risk and substance use behaviors as moderators of EMPWR effectiveness, suggesting that NA adults with varying levels of risk behavior may be equally likely to benefit from this intervention.

Association of disability with mortality in the Spanish adult non-institutionalised population

BACKGROUND

There are scant studies focused on measuring the association between disability and all-cause mortality based on large representative national samples of the community-dwelling adult population; moreover, the number of such studies which also include cause-specific mortality is yet lower.

METHODS

Longitudinal cohort study that used baseline data from 162 381 adults who participated in a countrywide disability survey (2008). A nationally representative sample was selected and interviewed in their homes. We present data on people ≥18 years. Disability was considered as any substantial limitation found on a list of 44 life activities that have lasted or are expected to last more than 1 year and originate from an impairment. Cause-specific mortality data were obtained from the Spanish Statistical Office. Subjects contributed follow-up time from baseline interview until death or the censoring date (31 December 2017). We computed standardised rate ratios (SRRs), with age, sex, living with a partner and education level distribution of the total group as standard population.

RESULTS

Adults with disability (11%) had an adjusted mortality rate more than twice as high as adults without disability (SRR 2.37, 95% CI 2.24 to 2.50). The increased mortality risk remained over the 10-year follow-up period. Mortality due to diseases of the nervous system (SRR 4.86, 95% CI 3.93 to 6.01), diseases of the musculoskeletal system (SRR 3.45, 95% CI 2.18 to 5.47), infectious diseases (SRR 3.38, 95% CI 2.27 to 5.01) and diabetes mellitus (SRR 3.56, 95% CI 2.71 to 4.68) was particularly high in those with disability.

CONCLUSIONS

All-cause mortality rates are markedly higher among adults with disability. Preventive measures and health promotion initiatives are needed to reduce mortality risk in this population. Special attention should be paid to disabled people with certain specific diseases.

Impact of recurrent sexually transmitted infections on HIV seroconversion: Results from multi-state frailty models

After several decades of research, South Africa is still considered to be the epicentre of HIV epidemic. The country also has the highest burden of sexually transmitted infections (STIs) which have been frequently linked to increasing rates of HIV transmission due to biological and behavioural associations between these two pathogeneses. We investigated the cumulative impact of recurrent STIs on subsequent HIV seroconversion among a cohort of South African women. We used the 'frailty' models which can account for the heterogeneity due to the recurrent STIs in a longitudinal setting. The lowest HIV incidence rate was 5.0/100 person-year among women who had no baseline STI and remained negative during the follow-up. This estimate was three times higher among those who had recurrent STIs in the follow-up period regardless of their STI status at baseline (15.8 and 14.0/100 person-year for women with and without STI diagnosis at baseline, respectively). Besides younger age and certain partnership characteristics, our data provided compelling evidence for the impact of recurrent STI. diagnoses on increasing rates of HIV. At the population-level, 65% of HIV infections collectively associated with recurrent STIs. These results have significant clinical and epidemiological implications and may play critical role in the trajectory of the infections in the region.

Quantifying geographical diversity in sexually transmitted infections using population attributable risk: results from HIV prevention trials in South Africa

In this study, we investigated spatial diversities of sexually transmitted infections (STIs) and quantified their impacts on the STIs using population attributable risk (PAR%). The study population was 7,557 women who participated in several HIV prevention trials from KwaZulu-Natal, South Africa. Our results provide compelling evidence for substantial geographical diversities on STI incidence rates in the region. Their population-level impacts on the STIs exceeded the combined impacts of the individual risk factors considered in this study (PAR%: 41% (<25 years), 52% (25-34 years) and 34% (35+ years). When all these factors are considered together, PAR% was the highest among younger women (PAR%: 67%, 82% and 50% for <25, 25-34 and 35+ years old respectively). Results from our study will bring greater insight into the previous research by increasing our understanding of the impacts of the sub-geographical level variations of STI prevalence and incidence rates in the region.

Allocating scarce life-saving resources: the proper role of age

The COVID-19 pandemic has forced clinicians, policy-makers and the public to wrestle with stark choices about who should receive potentially life-saving interventions such as ventilators, ICU beds and dialysis machines if demand overwhelms capacity. Many allocation schemes face the question of whether to consider age. We offer two underdiscussed arguments for prioritising younger patients in allocation policies, which are grounded in prudence and fairness rather than purely in maximising benefits: prioritising one's younger self for lifesaving treatments is prudent from an individual perspective, and prioritising younger patients works to narrow health disparities by giving priority to patients at risk of dying earlier in life, who are more likely to be subject to systemic disadvantage. We then identify some confusions in recent arguments against considering age.

Brief Enhanced Partner Notification and Risk Reduction Counseling to Prevent Sexually Transmitted Infections, Cape Town, South Africa

BACKGROUND

Evidence-based interventions are needed to stem sexually transmitted infections (STIs). Clinic-delivered counseling remains an important avenue for effective STI prevention.

METHODS

A 3-arm randomized clinical trial compared (a) STI health education control condition, (b) risk reduction counseling, and (c) enhanced partner notification counseling. Men and women (n = 1050) were recruited from an STI clinic in Cape Town, South Africa. After baseline assessments, participants were randomly allocated to receive 1 of the 3 single-session counseling interventions and were followed up for 9 months of behavioral assessments and 12 months of electronic medical records abstraction for STI clinic services.

RESULTS

Sexual risk reduction counseling reported greater condom use than did the other 2 conditions during the 3 and 6 months follow-ups. In addition, women receiving risk reduction counseling were significantly less likely to have returned for STI clinic services but did not differ in the number of STI clinic visits over the year.

CONCLUSIONS

Brief single-session STI prevention counseling demonstrates significant targeted outcomes. The findings suggest that counseling approaches to both increase condom use and enhance partner notification may offer more robust and sustained outcomes and should be tested in future research.

Self-reported disability in relation to mortality in rural Malawi: a longitudinal study of over 16 000 adults

OBJECTIVES

We investigated whether self-reported disability was associated with mortality in adults in rural Malawi.

SETTING

Karonga Health and Demographic Surveillance Site (HDSS), Northern Malawi.

PARTICIPANTS

All adults aged 18 and over residing in the HDSS were eligible to participate. During annual censuses in 2014 and 2015, participants were asked if they experienced difficulty in any of six functional domains and were classified as having disabilities if they reported 'a lot of difficulty' or 'can't do at all' in any domain. Mortality data were collected until 31 December 2017. 16 748 participants (10 153 women and 6595 men) were followed up for a median of 29 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used Poisson regression to examine the relationship between disability and all-cause mortality adjusting for confounders. We assessed whether this relationship altered in the context of obesity, hypertension, diabetes or HIV. We also evaluated whether mortality from non-communicable diseases (NCD) was higher among people who had reported disability, as determined by verbal autopsy.

RESULTS

At baseline, 7.6% reported a disability and the overall adult mortality rate was 9.1/1000 person-years. Adults reporting disability had an all-cause mortality rate 2.70 times higher than those without, and mortality rate from NCDs 2.33 times higher than those without.

CONCLUSIONS

Self-reported disability predicts mortality at all adult ages in rural Malawi. Interventions to improve access to healthcare and other services are needed.

Effects of enhanced STI partner notification counselling and provider-assisted partner services on partner referral and the incidence of STI diagnosis in Cape Town, South Africa: randomised controlled trial

Objectives

We investigated the effects of an enhanced partner notification (PN) counselling intervention with the offer of provider-assisted referral among people diagnosed with STI in a Cape Town public clinic.

Methods

Participants were adults diagnosed with STI at a community clinic. After the standard STI consultation, participants were randomly allocated in a 1:1:1 ratio to (1) ‘HE’: 20 min health education; (2) ‘RR’: 45 min risk reduction skills counselling; or (3) ‘ePN’: 45 min enhanced partner notification communication skills counselling and the offer of provider-assisted referral. The primary outcome was the incidence of repeat STI diagnoses during the 12 months after recruitment, and the secondary outcome was participants’ reports 2 weeks after diagnosis of notifying recent partners. Incidence rate ratios (IRRs) were used to compare the incidence rates between arms using a Poisson regression model.

Results

The sample included 1050 participants, 350 per group, diagnosed with STI between June 2014 and August 2017. We reviewed 1048 (99%) participant records, and identified 136 repeat STI diagnoses in the ePN arm, 138 in the RR arm and 141 in the HE arm. There was no difference in the annual incidence of STI diagnosis between the ePN and HE arms (IRR: 1.0; 95% CI 0.7 to 1.3), or between the RR and HE arms (IRR: 0.9; 95% CI 0.7 to 1.2). There was a greater chance of a partner being notified in the ePN condition compared with the HE condition, 64.3% compared with 53.8%, but no difference between the RR and HE arms.

Conclusions

PN counselling and education with provider-assisted services has the potential to change the behaviour of people diagnosed with STIs, increasing the number of partners they notify by more than 10%. However, these changes in behaviour did not lead to a reduction of repeat STI diagnoses.

Trial registration number

PACTR201606001682364.

Impact of Counseling Received by Adolescents Undergoing Voluntary Medical Male Circumcision on Knowledge and Sexual Intentions

Background

Little is known regarding the impact of counseling delivered during voluntary medical male circumcision (VMMC) services on adolescents’ human immunodeficiency virus (HIV) knowledge, VMMC knowledge, or post-VMMC preventive sexual intentions. This study assessed the effect of counseling on knowledge and intentions.

Methods

Surveys were conducted with 1293 adolescent clients in 3 countries (South Africa, n = 299; Tanzania, n = 498; Zimbabwe, n = 496). Adolescents were assessed on HIV and VMMC knowledge-based items before receiving VMMC preprocedure counseling and at a follow-up survey approximately 10 days postprocedure. Sexually active adolescents were asked about their sexual intentions in the follow-up survey. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated by modified Poisson regression models with generalized estimating equations and robust variance estimators.

Results

Regarding post-VMMC HIV prevention knowledge, older adolescents were significantly more likely than younger adolescents to know that a male should use condoms (age 10–14 years, 41.1%; 15–19 years, 84.2%; aPR, 1.38 [95% CI, 1.19–1.60]), have fewer sex partners (age 10–14 years, 8.1%; age 15–19 years, 24.5%; aPR, 2.10 [95% CI, 1.30–3.39]), and be faithful to one partner (age 10–14 years, 5.7%; age 15–19 years, 23.2%; aPR, 2.79 [95% CI, 1.97–3.97]) to further protect himself from HIV. Older adolescents demonstrated greater improvement in knowledge in most categories, differences that were significant for questions regarding number of sex partners (aPR, 2.01 [95% CI, 1.18–3.44]) and faithfulness to one partner post-VMMC (aPR, 3.28 [95% CI, 2.22–4.86]). However, prevention knowledge levels overall and HIV risk reduction sexual intentions among sexually active adolescents were notably low, especially given that adolescents had been counseled only 7–10 days prior.

Conclusions

Adolescent VMMC counseling needs to be improved to increase knowledge and postprocedure preventive sexual intentions.

Feeling Under Pressure: Perspectives of the Meaning of Love and Sexual Relationships Amongst Young Men in KwaZulu-Natal Province, South Africa

This study aimed to explore perspectives on the meaning of love and sexual relations amongst young men in KwaZulu-Natal province of South Africa. Gaining insights into these perspectives will help to understand the sexual behaviors of these young men better and to eventually develop more effective HIV prevention interventions. Focus group discussions were conducted in two study areas using a predetermined semistructured discussion guide. The findings indicate that the phenomenon of romantic relationship try-outs together with the idea of "feeling under pressure" to propose love to more than one woman seem to be accepted practices that often lead to multiple concurrent sexual partners and therefore potentially risky sexual behaviors. The fear of impregnating a woman is seen to be of a more significant concern than acquiring a sexually transmitted infection due to the stigma and embarrassment associated with pregnancy outside marriage. Given these findings, it is recommended that future studies investigate perspectives on sexuality and reproductive health in male populations in great detail prior to the development of behavioral change interventions because failure to do so may hamper well-intended but poorly targeted health interventions.

The Effect of a Brief HIV Prevention Program on Risk Reduction Behaviors Among Thai Men Diagnosed With Sexually Transmitted Infections

PURPOSE

Men diagnosed with sexually transmitted infections (STIs) are at greater risk for Human Immunodeficiency Virus (HIV) infection and STIs reinfection. This study aimed to test the effectiveness of a brief human immunodeficiency virus (B-HIV) prevention program on HIV and sexually transmitted infection (STI) knowledge, perceived benefits of condom use, risk reduction self-efficacy, risk reduction behaviors, and reinfection rate among Thai men with STIs.

METHODS

A quasi-experimental design was conducted. Participants were selected from men with STI symptoms. They were randomly assigned to a B-HIV prevention program or usual care, 100 each. The program consisted of 3 modules. Key messages for HIV prevention were sent weekly through Line. Outcomes were HIV and STI knowledge, perceived benefits of condom use, risk reduction self-efficacy, risk reduction behaviors (condom use, the number of sexual partners, and condomless sex), and STI reinfection rate. Independent t-test and binary logistic regression were performed.

RESULTS

The B-HIV prevention program significantly increased HIV and STI knowledge and resulted in perception of greater benefits from condoms and greater risk reduction self-efficacy. Program participants used condoms more frequently with many types of partners, especially with casual partners and sex workers. The intervention group practiced condomless sex less frequently than the control group. The program did not improve participants' condom use with lovers/steady partners and did not decrease the number of sexual partners and STI reinfection rate at 3-month follow-up.

CONCLUSIONS

A B-HIV prevention program could reduce the risk of HIV infection among male clients with current STIs by enhancing their condom use with casual partners and sex workers. Strategies to improve condom use with lovers/steady partners among this high-risk population is needed.

Behaviour change techniques in brief interventions to prevent HIV, STI and unintended pregnancies: A systematic review

BACKGROUND

Behaviour-change interventions have been consistently considered an essential part of comprehensive HIV, STI and unintended pregnancy prevention. In 2015, the World Health Organization reviewed and assessed existing evidence on brief behavioural interventions, leading to the publication of Brief sexuality-related communication: recommendations for a public health approach. This guideline recommends the use of brief behaviour intervention and communication programmes to promote sexual health and to prevent HIV, STIs, and unintended pregnancies in primary health services, particularly sexual and reproductive health services.

OBJECTIVE

With the purpose of informing the development of a brief behaviour intervention in sexual and reproductive health, we conducted a systematic review of brief intervention to prevent HIV, STI and unintended pregnancies, to identify behaviour change techniques (BCTs) used in health care settings.

METHODS

Participants from all ages and genders were included. Brief interventions delivered in ≤ 60 minutes were included. Data was extracted, and interventions were coded following the Behaviour Change Techniques Taxonomy (BCTTv1) guidelines.

RESULTS

Of the 6.687 articles identified, 355 were reviewed and 37 studies were included. In effective interventions, we identified 48 behaviour change techniques (BCTs). A core set of 8 frequently used behaviour change techniques was identified: "Problem solving", "Feedback on behaviour", "Social support (unspecified)", "Instructions on how to perform the behaviour", "Information about health consequences", "Information about social and environmental consequences", "Demonstration of the behaviour" and "Credible source".

CONCLUSIONS

The technical content of brief behaviour interventions was identified in a reliable and standardized way providing preliminary indications on potentially effective techniques to achieve behaviour change.

Factors associated with program effectiveness in the implementation of a sexual risk reduction intervention for female sex workers across Mexico: Results from a randomized trial

OBJECTIVE

The overall aim of this paper is to examine effectiveness of an evidence-based intervention in community settings, and the factors associated with effectiveness. Limited research in the area of HIV prevention has focused on evaluating intervention program effectiveness in real-world settings.

METHODS

We implemented an efficacious theory-based sexual risk reduction intervention for female sex workers (FSW) called Mujer Segura across 13 different clinics in 13 sites across Mexico. The overall design was a cluster randomized Type I design simultaneously testing intervention program effectiveness with an observational study of implementation factors. We aimed to examine the effectiveness of Mujer Segura at reducing HIV/STI incidence among FSW participants at each site, and to examine the client-, provider-, organization-, and structure-related factors associated with program effectiveness.

RESULTS

We found lower HIV/STI incidence density in the intervention relative to the control group in 5 sites we labeled as "program effective sites," but not in 8 sites we labeled as "program ineffective sites." Using generalized estimating equations controlling for site and computed mean difference effect sizes, we examined statistically and practically significant differences, respectively, between the two groups of sites along various client-, provider-, organization-, and structure-related characteristics. Results indicated that client-level HIV/AIDS related knowledge, and proficiency and engagement in the organizational social context were associated with program effectiveness.

CONCLUSIONS

Enormous resources are required to systematically and adequately test the role of multilevel factors on program effectiveness. We successfully implemented Mujer Segura in 13 sites in Mexico. Results suggest that other measures may need to be included in future implementation studies than the ones included here. We were able to point to a few specific factors that should be targeted to increase effectiveness of similar evidence-based programs in low- and other middle-income countries like Mexico.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01465607.

Action and inaction in multi-behaviour recommendations: a meta-analysis of lifestyle interventions

This meta-analysis examined theoretical predictions about the effects of different combinations of action (e.g., start an exercise regime) and of inaction (e.g., reduce screen time, rest in between weight lifting series) recommendations in smoking, diet, and physical activity multiple-domain interventions. The synthesis included 150 research reports of interventions promoting multiple behaviour domain change and measuring change at the most immediate follow-up. The main outcome measure was an indicator of overall change that combined behavioural and clinical effects. There were two main findings. First, as predicted, interventions produced the highest level of change when they included a predominance of recommendations along one behavioural dimension (i.e., predominantly inaction or predominantly action). Unexpectedly, within interventions with predominant action or inaction recommendations, those including predominantly inaction recommendations had greater efficacy than those including predominantly action recommendations. This effect, however, was limited to interventions in the diet and exercise domains, but reversed (greater efficacy for interventions with predominant action vs. inaction recommendations) in the smoking domain. These findings provide important insights on how to best combine recommendations when interventions target clusters of health behaviours.

Single-Session Behavioral Interventions for Sexual Risk Reduction: A Meta-Analysis

BACKGROUND

Evidence-based, single-session STI/HIV interventions to reduce sexual risk taking are potentially effective options for implementation in resource-limited settings and may solve problems associated with poor participant retention.

PURPOSE

The purpose of the study is to estimate the efficacy of single-session, behavioral interventions in reducing unprotected sex or increasing condom use.

METHODS

Data sources were searched through April 2013 producing 67 single-session interventions (52 unique reports; N = 20,039) that included outcomes on condom use and/or unprotected sex.

RESULTS

Overall, participants in single-session interventions reduced sexual risk taking relative to control groups (d ₊  = 0.19, 95 % CI = 0.11, 0.27). Within-group effects of the interventions were larger than the between-groups effects when compared to controls.

CONCLUSIONS

Brief, targeted single-session sexual risk reduction interventions demonstrate a small but significant effect and should be prioritized.

WHO guideline for brief sexuality-related communication: implications for STI/HIV policy and practice

Brief sexuality-related communication (BSC) aims to identify current and potential sexual concerns and motivate those at risk to change their sexual behaviour or maintain safe sexual behaviour. BSC in primary health care can range from 5 to 60 minutes and takes into account biological, psychological and social dimensions of sexual health and wellbeing. It focuses on opportunistic rather than systematic or continuous communication and can be used in conjunction with already established prevention programs. The informational and motivational techniques of BSC enable health care providers to communicate more effectively with their patients, encouraging them to take steps to avoid HIV and sexually transmitted infections. The WHO Department of Reproductive Health and Research, following a review and assessment of existing evidence with regards to BSC, has recently published the guideline on Brief Sexuality-Related Communication: Recommendations for a Public Health Approach.

How common and frequent is heterosexual anal intercourse among South Africans? A systematic review and meta-analysis

BACKGROUND

HIV is transmitted more effectively during anal intercourse (AI) than vaginal intercourse (VI). However, patterns of heterosexual AI practice and its contribution to South Africa's generalized epidemic remain unclear. We aimed to determine how common and frequent heterosexual AI is in South Africa.

METHODS

We searched for studies reporting the proportion practising heterosexual AI (prevalence) and/or the number of AI and unprotected AI (UAI) acts (frequency) in South Africa from 1990 to 2015. Stratified random-effects meta-analysis by sub-groups was used to produce pooled estimates and assess the influence of participant and study characteristics on AI prevalence. We also estimated the fraction of all sex acts which were AI or UAI and compared condom use during VI and AI.

RESULTS

Of 41 included studies, 31 reported on AI prevalence and 14 on frequency, over various recall periods. AI prevalence was high across different recall periods for sexually active general-risk populations (e.g. lifetime = 18.4% [95%CI:9.4-27.5%], three-month = 20.3% [6.1-34.7%]), but tended to be even higher in higher-risk populations such as STI patients and female sex workers (e.g. lifetime = 23.2% [0.0-47.4%], recall period not stated = 40.1% [36.2-44.0%]). Prevalence was higher in studies using more confidential interview methods. Among general and higher-risk populations, 1.2-40.0% and 0.7-21.0% of all unprotected sex acts were UAI, respectively. AI acts were as likely to be condom protected as vaginal acts.

CONCLUSION

Reported heterosexual AI is common but variable among South Africans. Nationally and regionally representative sexual behaviour studies that use standardized recall periods and confidential interview methods, to aid comparison across studies and minimize reporting bias, are needed. Such data could be used to estimate the extent to which AI contributes to South Africa's HIV epidemic.

Health inequalities in the Netherlands: trends in quality-adjusted life expectancy (QALE) by educational level

BACKGROUND

Quality-adjusted life expectancy (QALE) has been proposed as a summary measure of population health because it encompasses multiple health domains as well as length of life. However, trends in QALE by education or other socio-economic measure have not yet been reported. This study investigates changes in QALE stratified by educational level for the Dutch population in the period 2001-2011.

METHODS

Using data from multiple sources, we estimated mortality rates and health-related quality of life (HRQoL) as functions of age, gender, calendar year and educational level. Subsequently, predictions from these regressions were combined for calculating QALE at ages 25 and 65. QALE changes were decomposed into effects of mortality and HRQoL.

RESULTS

In 2001-2011, QALE increased for men and women at all educational levels, the largest increases being for highly educated resulting in a widening gap by education. In 2001, at age 25, the absolute QALE difference between the low and the highly educated was 7.4 healthy years (36.7 vs. 44.1) for men and 6.3 healthy years (39.5 vs. 45.8) for women. By 2011, the QALE difference increased to 8.1 healthy years (38.8 vs. 46.9) for men and to 7.1 healthy years (41.3 vs. 48.4) for women. Similar results were observed at age 65. Although the gap was largely attributable to widening inequalities in mortality, widening inequalities in HRQoL were also substantial.

CONCLUSIONS

In the Netherlands, population health as measured by QALE has improved, but QALE inequalities have widened more than inequalities in life expectancy alone.

HIV-Alcohol Risk Reduction Interventions in Sub-Saharan Africa: A Systematic Review of the Literature and Recommendations for a Way Forward

Sub-Saharan Africa bears 69 % of the global burden of HIV, and strong evidence indicates an association between alcohol consumption, HIV risk behavior, and HIV incidence. However, characteristics of efficacious HIV-alcohol risk reduction interventions are not well known. The purpose of this systematic review is to summarize the characteristics and synthesize the findings of HIV-alcohol risk reduction interventions implemented in the region and reported in peer-reviewed journals. Of 644 citations screened, 19 met the inclusion criteria for this review. A discussion of methodological challenges, research gaps, and recommendations for future interventions is included. Relatively few interventions were found, and evidence is mixed about the efficacy of HIV-alcohol risk reduction interventions. There is a need to further integrate HIV-alcohol risk reduction components into HIV prevention programming and to document results from such integration. Additionally, research on larger scale, multi-level interventions is needed to identify effective HIV-alcohol risk reduction strategies.

Do Assessments of HIV Risk Behaviors Change Behaviors and Prevention Intervention Efficacy? An Experimental Examination of the Influence of Type of Assessment and Risk Perceptions

BACKGROUND

Behavioral assessments may change behaviors and responses to behavioral interventions, depending on assessment type and respondents' motivations.

PURPOSE

We observed effects on sexual behavior and human immunodeficiency virus (HIV) prevention intervention efficacy of interviews assessing recent HIV risk behavior frequency or HIV risk behavior events among respondents with different perceptions of their risk for HIV.

METHODS

Young South African sexually transmitted infection (STI) clinic clients (N=1,728) participated in a 3 (event-based vs. frequency-based vs. no interview) by 2 (evidence-based vs. standard of care risk-reduction session) RCT.

RESULTS

The interviews increased reported safer sexual behavior among youth with higher but not lower risk perceptions. The intervention session was less effective when combined with interviews, particularly among lower risk perception youth. Patterns replicated for both interviews.

CONCLUSIONS

HIV risk behavior assessments may increase resistance to interventions among unmotivated youth and enhance safer sexual behavior among motivated youth. Behavioral assessments may reduce HIV risk among motivated individuals.

Brief condom interventions targeting males in clinical settings: a meta-analysis

OBJECTIVE

The objective of this study is to assess the effectiveness of brief clinic-based condom skills interventions that target males.

STUDY DESIGN

We searched PubMed, Cumulative Index of Nursing and Allied Health Literature and PsychInfo for studies published from January 1980 through September 2014, using relevant search terms. We included studies if interventions taught about condoms lasting 60 min or shorter, used randomized or quasi-experimental design, were conducted in a clinical setting and targeted males. Two investigators sequentially reviewed abstracts. We abstracted and reviewed data from 16 studies that met the selection criteria. Where outcomes were poolable, we conducted meta-analyses using a random-effects model and I(2) index to assess heterogeneity. Outcome measures included condom knowledge, attitudes, behaviors, sexually transmitted infections (STIs)/human immunodeficiency virus and unintended pregnancy.

RESULTS

Across studies, teaching about condoms was nested within sexual risk reduction curricula. Most interventions were one on one and conducted in STI clinics. Pooled analyses indicated that intervention receipt was associated with increases in percent of sex acts with condoms (standardized mean difference=0.29 [0.18, 0.41]; 0.19 [0.06, 0.33]) and reductions in STIs at 12-month follow-up or longer {odds ratio (OR)=0.82 [95% confidence interval: 0.67, 0.99]}. One study assessed unintended pregnancy and did not find an intervention effect.

CONCLUSIONS

Study findings hold promise for considering brief condom skills interventions in clinical settings that can result in improvements in males' condom behaviors and possibly biological outcomes.

Predictors of poor adherence among people on antiretroviral treatment in Cape Town, South Africa: a case-control study

A case-control study was conducted to describe the frequency with which structural- and individual-level barriers to adherence are experienced by people receiving antiretroviral (ARV) treatment and to determine predictors of non-adherence. Three hundred adherent and 300 non-adherent patients from 6 clinics in Cape Town completed the LifeWindows Information-Motivation-Behavioral Skills ART Adherence Questionnaire, the Substance Abuse and Mental Illness Symptoms Screener and the Structural Barriers to Clinic Attendance (SBCA) and Medication-taking (SBMT) scales. Overall, information-related barriers were reported most frequently followed by motivation and behaviour skill defects. Structural barriers were reported least frequently. Logistic regression analyses revealed that gender, behaviour skill deficit scores, SBCA scores and SBMT scores predicted non-adherence. Despite the experience of structural barriers being reported least frequently, structural barriers to medication-taking had the greatest impact on adherence (OR: 2.32, 95% CI: 1.73 to 3.12), followed by structural barriers to clinic attendance (OR: 2.06, 95% CI: 1.58 to 2.69) and behaviour skill deficits (OR: 1.34, 95% CI: 1.05 to 1.71). Our data indicate the need for policy directed at the creation of a health-enabling environment that would enhance the likelihood of adherence among antiretroviral therapy users. Specifically, patient empowerment strategies aimed at increasing treatment literacy and management skills should be strengthened. Attempts to reduce structural barriers to antiretroviral treatment adherence should be expanded to include increased access to mental health care services and nutrition support.

Brief sexuality communication--a behavioural intervention to advance sexually transmitted infection/HIV prevention: a systematic review

BACKGROUND

Throughout the last decade substantial research has been undertaken to develop evidence-based behaviour change interventions for sexual health promotion. Primary care could provide an opportunistic entry for brief sexual health communication.

OBJECTIVES

We conducted a systematic review to explore opportunistic sexual and reproductive health services for sexual health communication delivered at primary health care level.

SEARCH STRATEGY

We searched for studies on PubMed, ProQuest, CINAHL, Jstor, Scopus/Science Direct, Cochrane database of systematic reviews, EBSCO, CINAHL, PsychoInfo, and Web of Knowledge. Both published and unpublished articles were reviewed.

SELECTION CRITERIA

All randomised controlled trials and controlled clinical trials were included. Participants of all ages, from adolescence onwards were included. Brief (10-60 minutes) interventions including some aspect of communication on sexual health issues were included.

DATA COLLECTION AND ANALYSIS

Data were extracted by two reviewers independently using a standardised form. Interventions differed from each other, hence meta-analysis was not performed, and results are presented individually.

MAIN RESULTS

A total of 247 articles were selected for full-text evaluation, 31 of which were included. Sexually transmitted infections (STIs)/HIV were less often reported in the intervention group compared with the control group. Condom use was higher in most studies in the intervention group. Numbers of sexual partners and unprotected sexual intercourse were lower in the intervention groups.

CONCLUSIONS

There is evidence that brief counselling interventions have some effect in the reduction and prevention of STIs/HIV. Some questions could not be answered, such as the effect over time and in different settings and population groups.

Mediators of behavior change resulting from a sexual risk reduction intervention for STI patients, Cape Town, South Africa

Theory-based sexual risk reduction interventions are often demonstrated effective, but few studies have examined the mechanisms that mediate their behavior changes. In addition, critical contextual factors, such as alcohol use, are often not accounted for by social cognitive theories and may add to the explanatory value of intervention effects. The purpose of this study is to examine the underlying mechanisms driving condom use following a brief sexual risk reduction intervention grounded in the information, motivation, behavioral skills (IMB) model of behavior change. We examined IMB theoretical constructs and alcohol-related contextual factors as potential mediators in separate models. Patients (n = 617) from an STI clinic in Cape Town, South Africa were randomly assigned to either a brief risk reduction intervention or an education-only control condition. We assessed IMB, and alcohol-related variables at baseline, 3, 6, 9, and 12 months and modeled IMB constructs and alcohol-related factors as mediators of behavior change. Results of growth-curve mediational modeling showed that 1 year after counseling, the intervention indirectly affected sexual risk behavior through alcohol-related constructs, but not IMB constructs. Alcohol use and related factors play critical roles in explaining HIV and STI risk reduction intervention effects. Interventions that directly address alcohol use as a factor in sexual risk behavior and behavior change should be the focus of future research.

Hazardous drinking and HIV-risk-related behavior among male clients of female sex workers in Tijuana, Mexico

BACKGROUND AND OBJECTIVES

Male clients of female sex workers (FSWs) are at high risk for HIV. Whereas the HIV risks of alcohol use are well understood, less is known about hazardous alcohol use among male clients of FSWs, particularly in Mexico. We sought to identify risk factors for hazardous alcohol use and test associations between hazardous alcohol use and HIV risk behavior among male clients in Tijuana.

METHOD

Male clients of FSWs in Tijuana (n = 400) completed a quantitative interview in 2008. The AUDIT was used to characterize hazardous alcohol use. Multivariate logistic regression was used to determine independent associations of demographic and HIV risk variables with hazardous alcohol use (vs. non-hazardous).

RESULTS

Forty percent of our sample met criteria for hazardous alcohol use. Variables independently associated with hazardous drinking were reporting any sexually transmitted infection (STI), having sex with a FSW while under the influence of alcohol, being younger than 36 years of age, living in Tijuana, and ever having been jailed. Hazardous drinkers were less likely ever to have been deported or to have shared injection drugs.

DISCUSSION AND CONCLUSIONS

Hazardous alcohol use is associated with HIV risk, including engaging in sex with FSWs while intoxicated and having an STI among male clients of FSWs in Tijuana.

SCIENTIFIC SIGNIFICANCE

We systematically described patterns and correlates of hazardous alcohol use among male clients of FSWs in Tijuana, Mexico. The results suggest that HIV/STI risk reduction interventions must target hazardous alcohol users, and be tailored to address alcohol use.

Food insecurity and alcohol use among pregnant women at alcohol-serving establishments in South Africa

South Africa has the highest rate of fetal alcohol syndrome (FAS) in the world. While efforts have been made to curb the high rate of FAS, little is known about situational factors that may contribute to alcohol use during pregnancy. In the current paper, we focus on the role of food insecurity and its relationship to alcohol use among pregnant women. Women completed computer-assisted interviews. Generalized linear modeling was used in all analyses. Women attending alcohol-serving establishments in a township in Cape Town, South Africa were recruited for the study. Five hundred sixty women were sampled and 95 women reported being pregnant. High levels of alcohol use were reported among pregnant women: 65 % of women consumed alcohol at least every month and 29 % consumed alcohol as often as two to three times per week. Thirty-four percent of the women reported having six or more drinks per occasion on at least a weekly basis. The majority (87 %) of pregnant women reported experiencing some form of food insecurity (e.g., food unavailable, eating less) in the past month. Alcohol use was significantly associated with food insecurity, even when controlling for relevant demographic variables. Intervention with pregnant women who consume alcohol is urgently needed. Future research should focus on understanding the intersection of food insecurity and alcohol, and how the experience of food insecurity may contribute to greater rates of alcohol use and abuse among pregnant women.

Optimizing lay counsellor services for chronic care in South Africa: a qualitative systematic review

OBJECTIVE

To conduct a qualitative systematic review on the use of lay counsellors in South Africa to provide lessons on optimizing their use for psychological and behavioural change counselling for chronic long-term care in scare-resource contexts.

METHOD

A qualitative systematic review of the literature on lay counsellor services in South Africa.

RESULTS

Twenty-nine studies met the inclusion criteria. Five randomized control trials and two cohort studies reported that lay counsellors can provide behaviour change counselling with good outcomes. One multi-centre cohort study provided promising evidence of improved anti-retroviral treatment adherence and one non-randomized controlled study provided promising results for counselling for depression. Six studies found low fidelity of lay counsellor-delivered interventions in routine care. Reasons for low fidelity include poor role definition, inconsistent remuneration, lack of standardized training, and poor supervision and logistical support.

CONCLUSION

Within resource-constrained settings, adjunct behaviour change and psychological services provided by lay counsellors can be harnessed to promote chronic care at primary health care level.

PRACTICE IMPLICATIONS

Optimizing lay counsellor services requires interventions at an organizational level that provide a clear role definition and scope of practice; in-service training and formal supervision; and sensitization of health managers to the importance and logistical requirements of counselling.

Barriers to accessing HIV-prevention in clinic settings: Higher alcohol use and more sex partners predict decreased exposure to HIV-prevention counseling

Understanding barriers to accepting HIV-prevention counseling among vulnerable populations is of critical importance, as prevention efforts can only have a public health impact if high-risk populations are willing to enroll. A correlational field study was conducted in a health care setting with a high-risk community sample (N = 350) to determine if number of sex partners and alcohol consumption predict acceptance of an invitation to take part in HIV-prevention counseling. Findings indicated that participants engaging in the least risky behavior (i.e. individuals reporting no alcohol consumption and few sex partners) were more likely to accept an offer to receive HIV-prevention counseling. Moreover, heavy drinking was associated with decreased exposure to HIV-prevention counseling, regardless of the number of sex partners reported (b = .12, p > .05). Given associations between heavy drinking and sexual risk taking, finding ways to increase exposure to HIV-prevention counseling programs among heavy drinkers could serve a vital public health function.

Men who report recent male and female sex partners in Cape Town, South Africa: an understudied and underserved population

The HIV/AIDS epidemic in South Africa has largely focused on the needs of heterosexual men and women. However, little is known about the sexual risk histories of men who have sex with both men and women (MSMW). Furthermore, we know very little about the psychosocial health needs or of the possibility of a syndemic (numerous interrelated epidemics) among MSMW. We surveyed 1,203 men attending drinking establishments in a township located in Cape Town, South Africa. We compared the behaviors and experiences of MSMW to men reporting only having sex with women (MSW). Twelve percent of the sample reported having sex with both men and women in the past 4 months. MSMW were twice as likely as MSW to report being HIV positive (10.5 vs. 4.6 %). MSW were more likely to be married than MSMW but reported similar numbers of female sex partners. MSMW were more likely to report a history of childhood sexual abuse, recent experienced and perpetrated physical and sexual partner violence, both receiving and giving sex for money, drugs, or shelter, and a recent STI. These factors were found to be interrelated among MSW but not MSMW. Although MSMW demonstrate considerable risk taking and report higher rates of HIV infection than MSW, their needs are largely unmet and underemphasized. Findings suggest the need to better understand factors contributing to sexual risk taking among MSMW. HIV prevention interventions should consider psychosocial health problems unique to MSMW residing in South African townships.

Prevalence and correlates of alcohol dependence disorder among TB and HIV infected patients in Zambia

Objectives

To determine the prevalence and correlates of alcohol dependence disorders in persons receiving treatment for HIV and Tuberculosis (TB) at 16 Primary Health Care centres (PHC) across Zambia.

Methods

649 adult patients receiving treatment for HIV and/or TB at PHCs in Zambia (363 males, 286 females) were recruited between 1st December 2009 and 31st January 2010. Data on socio-demographic variables, clinical disease features (TB and HIV), and psychopathological status were collected. The Mini International Neuropsychiatric Interview (MINI) was used to diagnose alcohol dependence disorder. Correlates of alcohol dependence were analyzed for men only, due to low prevalence in women. Univariable and multivariable logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI), using general estimating equations to allow for within-PHC clustering.

Results

The prevalence of alcohol dependence was 27.2% (95%CI: 17.7-39.5%) for men and 3.9% (95%CI: 1.4-0.1%) for women. Factors associated with alcohol dependence disorder in men included being single, divorced or widowed compared with married (adjusted OR = 1.47, 95%CI: 1.00-2.14) and being unemployed (adjusted OR=1.30, 95%CI: 1.01-1.67). The highest prevalence of alcohol dependence was among HIV-test unknown TB patients (34.7%), and lowest was among HIV positive patients on treatment but without TB (14.1%), although the difference was not statistically significant (p=0.38).

Conclusions

Male TB/HIV patients in this population have high prevalence of alcohol dependence disorder, and prevalence differs by HIV/TB status. Further work is needed to explore interventions to reduce harmful drinking in this population.

Measuring factors affecting implementation of health innovations: a systematic review of structural, organizational, provider, patient, and innovation level measures

BACKGROUND

Two of the current methodological barriers to implementation science efforts are the lack of agreement regarding constructs hypothesized to affect implementation success and identifiable measures of these constructs. In order to address these gaps, the main goals of this paper were to identify a multi-level framework that captures the predominant factors that impact implementation outcomes, conduct a systematic review of available measures assessing constructs subsumed within these primary factors, and determine the criterion validity of these measures in the search articles.

METHOD

We conducted a systematic literature review to identify articles reporting the use or development of measures designed to assess constructs that predict the implementation of evidence-based health innovations. Articles published through 12 August 2012 were identified through MEDLINE, CINAHL, PsycINFO and the journal Implementation Science. We then utilized a modified five-factor framework in order to code whether each measure contained items that assess constructs representing structural, organizational, provider, patient, and innovation level factors. Further, we coded the criterion validity of each measure within the search articles obtained.

RESULTS

Our review identified 62 measures. Results indicate that organization, provider, and innovation-level constructs have the greatest number of measures available for use, whereas structural and patient-level constructs have the least. Additionally, relatively few measures demonstrated criterion validity, or reliable association with an implementation outcome (e.g., fidelity).

DISCUSSION

In light of these findings, our discussion centers on strategies that researchers can utilize in order to identify, adapt, and improve extant measures for use in their own implementation research. In total, our literature review and resulting measures compendium increases the capacity of researchers to conceptualize and measure implementation-related constructs in their ongoing and future research.

Engaging men in prevention and care for HIV/AIDS in Africa

Ed Mills and colleagues argue that a more balanced approach to gender is needed so that both men and women are involved in HIV treatment and prevention.