Behavioral Prevention Interventions Research Articles

S01.2 Systematic reviews of the efficacy and effectiveness of biological, behavioural and structural hiv prevention interventions

Behavioural interventions for HIV prevention work by encouraging people to change behaviours that may make them more susceptible to HIV infection, or more likely to infect another person. There is some evidence that such interventions have led to reductions in HIV risk behaviours, such as having multiple partners, and improvements in other outcomes, such as increased condom use, increased testing, and improved treatment adherence. Behaviour is influenced heavily by socio-cultural contexts and as such, behavioural interventions must be sensitive to these contexts in order to be effective. Examples of behavioural interventions include individual and group level counselling, and providing information and guidelines through community outreach and mass media campaigns. This paper will provide a synthesis of the evidence on the effectiveness of behavioural interventions for HIV prevention. A review of reviews methodology will be followed to identify relevant primary studies. The strength of the evidence from these reviews will be evaluated and recommendations will be made.

Genetic causal attributions for weight status and weight loss during a behavioral weight gain prevention intervention.

PurposeEmerging evidence suggests that attributing one’s weight to genetics may contribute to the adoption of obesogenic behaviors. We examined if weight-related genetic attributions were associated with weight change during a weight gain prevention intervention.MethodsParticipants (n=185) were from a randomized clinical trial of a digital health weight gain prevention intervention for Black women age 25–44 with BMI 25.0–34.9kg/m2. Weight-related genetic attributions (weight status attribution and weight loss attributions) were measured at baseline and 12 months.ResultsAmong intervention participants, high genetic attribution for weight loss was associated with greater weight loss at 12 months (−2.7 kg vs 0.5 kg) and 18 months (−3.0 kg vs 0.9 kg). Among usual care participants, high genetic attribution for weight status was associated with greater 18-month weight gain (2.9 kg vs 0.3 kg). The intervention reduced likelihood of high genetic attribution for weight loss at 12 months (p=0.05). Change in likelihood of genetic attribution was not associated with weight change over 12 months.ConclusionImpact of genetic attributions on weight differs for those enrolled and not enrolled in an intervention. However, weight gain prevention intervention may reduce genetic attribution for weight loss.

Enhancing the Evidence for Behavioral Counseling: A Perspective From the Society of Behavioral Medicine.

U.S. Preventive Services Task Force (USPSTF) clinical guidelines at present rarely assign the highest grade recommendation to behavioral counseling interventions for chronic disease prevention or risk reduction because of concerns about the certainty and quality of the evidence base. As a result, the broad integration of behavioral counseling interventions in primary care remains elusive. Thus, there is an urgent need for novel perspectives on how to generate the highest-quality and -certainty evidence for primary care-focused behavioral counseling interventions. As members of the Society of Behavioral Medicine (SBM)--a multidisciplinary scientific organization committed to improving population health through behavior change--we review the USPSTF mandate and current recommendations for behavioral counseling interventions and provide a perspective for the future that calls for concerted and coordinated efforts among SBM, USPSTF, and other organizations invested in the rapid and wider uptake of beneficial, feasible, and referable primary care-focused behavioral counseling interventions. This perspective highlights five areas for further development, including (1) behavioral counseling-focused practice-based research networks; (2) promotion of USPSTF evidence standards and the increased use of pragmatic RCT design; (3) quality control and improvement procedures for behavioral counseling training; (4) systematic research on effective primary care-based collaborative care models; and (5) methodologic innovations that capitalize on disruptive technologies and healthcare transformation. Collective efforts to improve the health of all Americans in the 21st century and beyond must ensure that effective, feasible, and referable behavioral counseling interventions are embedded in modern primary care practice.

Optimization of Multicomponent Behavioral and Biobehavioral Interventions for the Prevention and Treatment of HIV/AIDS.

To move society toward an AIDS-free generation, behavioral interventions for prevention and treatment of HIV/AIDS must be not only effective, but also cost-effective, efficient, and readily scalable. The purpose of this article is to introduce to the HIV/AIDS research community the multiphase optimization strategy (MOST), a new methodological framework inspired by engineering principles and designed to develop behavioral interventions that have these important characteristics. Many behavioral interventions comprise multiple components. In MOST, randomized experimentation is conducted to assess the individual performance of each intervention component, and whether its presence/absence/setting has an impact on the performance of other components. This information is used to engineer an intervention that meets a specific optimization criterion, defined a priori in terms of effectiveness, cost, cost-effectiveness, and/or scalability. MOST will enable intervention science to develop a coherent knowledge base about what works and does not work. Ultimately this will improve behavioral interventions systematically and incrementally.

The cost and intensity of behavioral interventions to promote HIV treatment for prevention among HIV-positive men who have sex with men.

Recently, behavioral prevention interventions for HIV have been criticized as being ineffective, costly, or inefficient. In this commentary, using HIV-positive men who have sex with men (MSM) as an illustrative high-risk population, we argue that the opposite is true-that behavioral interventions for HIV prevention, if implemented with the populations who need them, are affordable and critical for future prevention efforts. We base this argument on recent evidence showing that (1) adherence to antiretroviral treatment (ART) for prevention purposes is necessary to suppress HIV replication and reduce transmissibility, (2) individuals living with HIV have multiple psychosocial concerns that impact self-care and moderate the potential effectiveness of health behavior interventions, and (3) intensive interventions targeting both concerns together (psychosocial and HIV care) can show clinically significant improvement. We follow by comparing the cost of these types of interventions to the cost of standard clinical treatment for HIV with ART and demonstrate a cost-savings of potential intensive behavioral interventions for, in this case, HIV-positive MSM who have uncontrolled virus. Keeping this evidence in mind, we conclude that individual intervention must remain a mainstay of HIV prevention for certain critical populations.

The Flawed Reliance on Randomized Controlled Trials in Studies of HIV Behavioral Prevention Interventions for People Who Inject Drugs and Other Populations

This article discusses ways in which randomized controlled trials do not accurately measure the impact of HIV behavioral interventions. This is because: 1. Such trials measure the wrong outcomes. Behavior change may have little to do with changes in HIV incidence since behavior change in events between HIV-concordant people have no impact on incidence. Even more important, the comparison of HIV incidence rates between study arms of individual-level RCTs does not measure the true outcome of interest—whether or not the intervention reduces HIV transmission at the community level. This is because this comparison cannot measure the extent to which the intervention stops transmission by HIV-infected people in the study to those outside it. (And this is made even worse if HIV-infected are excluded from the evaluation of the intervention.) 2. There are potential harms implicit in most cognitively oriented behavioral interventions that are not measured in current practice and may not be measurable using RCTs. Intervention trials often reinforce norms and values of individual self-protection. They rarely if ever measure whether doing this reduces community trust, solidarity, cohesion, organization, or activism in ways that might facilitate HIV transmission. 3. Many interventions are not best conceived of as interventions with individuals but rather with networks, cultures of risks, or communities. As such, randomizing individuals leads to effective interventions that diffuse protection through a community; but these are evaluated as ineffective because the changes diffuse to the control arm, which leads to systematic and erroneous reductions in the evaluated effectiveness as RCTs measure it. The paper ends by discussing research designs that are superior to individual-level RCTs at measuring whether an intervention reduces or increases new HIV transmission.

Prevention of overweight and obesity in children and youth: a systematic review and meta-analysis.

One-third of Canadian children are overweight or obese. This problem carries considerable concern for negative impacts on current and future health. Promoting healthy growth and development is critical. This review synthesized evidence on the effectiveness of behavioural interventions for preventing overweight and obesity in children and adolescents. We updated the search of a previous Cochrane review. Five databases were searched up to August 2013. Randomized trials of primary care-relevant behavioural (diet, exercise and lifestyle) interventions for preventing overweight and obesity in healthy normal- or mixed-weight children or youth aged 0-18 years were included if 12-week postbaseline data were provided for body mass index (BMI), BMI z-score, or prevalence of overweight or obesity. Any study reporting harms was included. Meta-analyses were performed if possible. Features of interventions showing significant benefits were examined. Ninety studies were included, all with mixed-weight populations. Compared with controls, interventions showed a small but significant effect on BMI and BMI z-score (standardized mean difference -0.07, 95% confidence interval [CI] -0.10 to -0.03, I (2) = 74%), a reduction in BMI (mean difference -0.09 kg/m(2), 95% CI -0.16 to -0.03, I (2) = 76%) and a reduced prevalence of overweight and obesity (risk ratio [RR]; RRintervention - RRcontrol 0.94, 95% CI 0.89 to 0.99, I (2) = 0%; number needed to treat 51, 95% CI 29 to 289). Little evidence was available on harms. There was variability across efficacious interventions, although many of the interventions were short-term, involved school-aged children and were delivered in educational settings. Behavioural prevention interventions are associated with small improvements in weight outcomes in mixed-weight populations of children and adolescents. No intervention strategy consistently produced benefits. PROSPERO no. CRD42012002754.

Novel interventions to prevent HIV and HCV among persons who inject drugs.

Persons who inject drugs (PWID) are at high risk for infection with and poor outcomes from HIV and hepatitis C virus (HCV). Well-established interventions for HIV/HCV prevention among PWID include syringe access, opioid agonist maintenance treatment, and supervised injection facilities, yet these interventions remain unavailable or inadequately resourced in much of the world. We review recent literature on biomedical and behavioral interventions to reduce the burden of HIV/HCV among PWID, with an emphasis on randomized controlled trials and quasi-experimental studies. Since 2013, there have been significant advancements in utilizing antiviral therapy and behavioral interventions for prevention among PWID, including approaches that address the unique needs of couples and sex workers. In addition, there have been significant developments in pharmacotherapies for substance use and the implementation of naloxone for opioid overdose prevention. Notwithstanding multiple ongoing structural challenges in delivering HIV/HCV prevention interventions to PWID, these emerging and rigorously evaluated interventions expand possibilities for prevention among PWID.

Sibanye Methods for Prevention Packages Program Project Protocol: Pilot Study of HIV Prevention Interventions for Men Who Have Sex With Men in South Africa.

BackgroundHuman immunodeficiency virus (HIV) prevention intervention programs and related research for men who have sex with men (MSM) in the southern African region remain limited, despite the emergence of a severe epidemic among this group. With a lack of understanding of their social and sexual lives and HIV risks, and with MSM being a hidden and stigmatized group in the region, optimized HIV prevention packages for southern African MSM are an urgent public health and research priority.ObjectiveThe objective of the Sibanye Health Project is to develop and evaluate a combination package of biomedical, behavioral, and community-level HIV prevention interventions and services for MSM in South Africa.MethodsThe project consists of three phases: (1) a comprehensive literature review and summary of current HIV prevention interventions (Phase I), (2) agent-based mathematical modeling of HIV transmission in southern African MSM (Phase II), and (3) formative and stigma-related qualitative research, community engagement, training on providing health care to MSM, and the pilot study (Phase III). The pilot study is a prospective one-year study of 200 men in Cape Town and Port Elizabeth, South Africa. The study will assess a package of HIV prevention services, including condom and condom-compatible lubricant choices, risk-reduction counseling, couples HIV testing and counseling, pre-exposure prophylaxis (PrEP) for eligible men, and non-occupational post-exposure prophylaxis for men with a high risk exposure. The pilot study will begin in October 2014.ResultsPreliminary results from all components but the pilot study are available. We developed a literature review database with meta-data extracted from 3800 documents from 67 countries. Modeling results indicate that regular HIV testing and promotion of condom use can significantly impact new HIV infections among South African MSM, even in the context of high coverage of early treatment of HIV-positive men and high coverage of PrEP for at-risk HIV-negative men. Formative qualitative research consisted of 79 in-depth interviews, and six focus group discussions in Cape Town and Port Elizabeth. Analysis of these data has informed pilot study protocol development and has been documented in peer-reviewed manuscripts. Qualitative work regarding stigma faced by South African MSM resulted in finalized scales for use in the pilot study questionnaire. A total of 37 health care providers completed training designed to facilitate clinically and culturally competent care for MSM in the Eastern Cape.ConclusionsThe design of a future, larger study of the HIV prevention package will be conducted at the end of the pilot study, powered to detect efficacy of the prevention package. Data from the updated mathematical model, results of the pilot study, acceptability data, and advancements in HIV prevention sciences will be considered in developing the final proposed package and study design.Trial RegistrationClinicalTrials.gov NCT02043015; http://clinicaltrials.gov/show/NCT02043015 (Archived by WebCite at http://www.webcitation.org/6THvp7rAj).

Protection motivation theory in predicting intention to engage in protective behaviors against schistosomiasis among middle school students in rural China.

BackgroundAmong millions of people who suffer from schistosomiasis in China, adolescents are at increased risk to be infected. However, there is a lack of theory-guided behavioral prevention intervention programs to protect these adolescents. This study attempted to apply the Protection Motivation Theory (PMT) in predicting intentions to engage in protective behaviors against schistosomiasis infection.MethodsThe participants were selected using the stratified cluster sampling method. Survey data were collected using anonymous self-reported questionnaire. The advanced structural equation modeling (SEM) method was utilized to assess the complex relationship among schistosomiasis knowledge, previous risk exposure and protective measures in predicting intentions to engage in protective behavior through the PMT constructs.Principal FindingsApproximately 70% of participants reported they were always aware of schistosomiasis before exposure to water with endemic schistosomiasis, 6% of the participants reported frequency of weekly or monthly prior exposure to snail-conditioned water. 74% of participants reported having always engaged in protective behaviors in the past three months. Approximately 7% were unlikely or very unlikely to avoid contact with snail-conditioned water, and to use protective behaviors before exposure. Results from SEM analysis indicated that both schistosomiasis knowledge and prior exposure to schistosomiasis were indirectly related to behavior intentions through intrinsic rewards and self-efficacy; prior protective behaviors were indirectly related to behavior intentions through severity, intrinsic rewards and self-efficacy, while awareness had an indirect relationship with behavior intentions through self-efficacy. Among the seven PMT constructs, severity, intrinsic rewards and self-efficacy were significantly associated with behavior intentions.ConclusionsThe PMT can be used to predict the intention to engage in protective behaviors against schistosomiasis. Schistosomiasis intervention programs should focus on the severity, intrinsic rewards and self-efficacy of protection motivation, and also increase the awareness of infection, and enrich the contents of schistosomiasis education.

Europe needs a central, transparent, and evidence-based approval process for behavioural prevention interventions.

Fabrizio Faggiano and colleagues discuss how a central, transparent, and evidence-based approval process is needed for behavioral prevention interventions in Europe and propose a way forward. Please see later in the article for the Editors' Summary.

Europe needs a central, transparent, and evidence-based approval process for behavioural prevention interventions

Problem Prevention interventions tackling health compromising behaviours have the potential to play a major role in reducing the burden of non-communicable diseases. However, in Europe no prior evaluation is required for the implementation of prevention interventions, thus leading to widespread dissemination of potentially ineffective or harmful interventions. Description of the problem The misevaluated complexity of prevention interventions is often responsible for their failure. They are usually based on a range of approaches and …

Differences in weight loss and health outcomes among African Americans and whites in multicentre trials.

The efficacy of behavioural lifestyle interventions (BLI) for weight loss and prevention and treatment of diabetes and hypertension is well established but may vary among racial/ethnic subgroups. This report reviews literature from 1990 to 2012 to determine if outcomes were similar among African Americans (AA) and whites participating in multicentre BLIs funded by the National Institutes of Health. We identified seven relevant trials that reported subgroup analyses for AA. On average, AA lost less weight at 6 months (AA: -1.6 to -7.5 kg; whites: -3.8 to -8.2 kg), but also had less or similar weight regain compared with whites. There were no reported differences between races in diabetes incidence. Three analyses reported no differences in blood pressure; however, a fourth reported that AA women were the only group that did not experience a significant change in blood pressure. Despite increased attention to cultural relevance, race-specific differences in weight loss persist in trials spanning 20 years; however, risk factor modification was similar across race/ethnic groups. Additional research is needed to understand the mechanisms of risk factor modification, and potential for weight change to promote even greater risk factor modification for AA than has been observed to date.

Driving Self-Restriction and Age: A Study of Emergency Department Patients.

BackgroundDriving self-restriction is well-documented among older drivers but might also occur among younger drivers. Little is known about the driving patterns of emergency department (ED) patients, who may be a high-risk population for motor vehicle crashes (MVCs). We sought to compare the driving patterns and MVCs of younger and older adult ED patients in order to inform development of injury prevention interventions in EDs.MethodsWe surveyed English-speaking younger adult (age 25–64) and older adult (age ≥65) ED patients, excluding non-drivers and those who were cognitively-impaired or too sick to participate. We compared drivers by age group and used logistic regression with adjustment for driving frequency to examine factors associated with driving self-restriction.ResultsOf those eligible, 82% (n = 178) of younger adult and 91% (n = 134) of older adult patients participated; approximately half were women. Similar proportions of younger and older adult patients reported driving everyday/almost everyday (80%) but also self-restricting driving in inclimate weather (48%), heavy traffic (27%), in unfamiliar places (21%), when travelling with passengers (1.6%) or when alone (1.3%). Fewer younger adult than older adult patients avoided driving at night (22% versus 49%) or on highways (6.7% versus 26%). In multivariable logistic regression, factors significantly associated self-imposed driving restriction in ≥1 driving situation were female gender (Odds Ratio [OR] 2.40; 95% CI 1.42-4.05) and ever feeling “confused, nervous or uncomfortable” while driving (OR 1.87; 95% CI 1.03-3.39). There was a non-significant trend for differences in proportions between younger adult (11%) and older adult (6.8%) drivers reporting ≥1 MVC as a driver in the past 12 months.ConclusionsSimilar proportions of younger and older adult ED patients self-restrict driving, albeit in different situations, which has implications for behavioral interventions for injury prevention and for education of patients and medical providers.Electronic supplementary materialThe online version of this article (doi:10.1186/s40621-014-0018-z) contains supplementary material, which is available to authorized users.

Effectiveness of Behavioral Interventions for Promoting Sun-Protection and Preventing Skin Cancer in Solid Organ Transplant Recipients: A Systematic Review.

Background and Aim: The incidence of skin cancer is increased in solid organ transplant recipients. We aimed to assess the effectiveness of behavioral interventions for sun-protection and prevention of skin cancer in transplant recipients. Methods: We systematically searched MEDLINE, Embase, CINAHL, and the Cochrane Trials Register to December 2012 to identify randomized and nonrandomized trials that evaluated behavioral interventions to promote sun protection in solid organ transplant recipients. Results: Five studies (n=747 participants) were included. Study outcomes included change in knowledge, sun-protective behaviors, incidence of actinic keratosis and non-melanoma skin cancer (Table 1). Provision of sunscreen reduced the incidence of actinic keratosis, basal cell carcinoma and squamous cell carcinoma. Knowledge of sun protective behaviors was not improved as a result of passive interventions (e.g. pamphlets). Some specific sun-protective behaviors (e.g. sun screen use) were improved compared to standard care. Conclusion: Ready supply of sunscreen appears effective in reducing the incidence of skin cancer related outcomes in solid organ transplant recipients. Active interventions (e.g. counseling, dermatology clinics) rather than passive interventions are promising strategies for improving sun-protective behavior.Table: No Caption available.

Reducing youth internalizing symptoms: Effects of a family-based preventive intervention on parental guilt induction and youth cognitive style

This study utilized structural equation modeling to examine the associations among parental guilt induction (a form of psychological control), youth cognitive style, and youth internalizing symptoms, with parents and youth participating in a randomized controlled trial of a family-based group cognitive-behavioral preventive intervention targeting families with a history of caregiver depression. The authors present separate models utilizing parent report and youth report of internalizing symptoms. Findings suggest that families in the active condition (family-based group cognitive-behavioral group) relative to the comparison condition showed a significant decline in parent use of guilt induction at the conclusion of the intervention (6 months postbaseline). Furthermore, reductions in parental guilt induction at 6 months were associated with significantly lower levels of youth negative cognitive style at 12 months. Finally, reductions in parental use of guilt induction were associated with lower youth internalizing symptoms 1 year following the conclusion of the intervention (18 months postbaseline).

Challenges with cost-utility analyses of behavioural interventions among older adults at risk for dementia

BackgroundCognitive decline is one of the most prominent healthcare issues of the 21st century. Within the context of combating cognitive decline through behavioural interventions, physical activity is a promising approach....

Military Service, War, and Families: Considerations for Child Development, Prevention and Intervention, and Public Health Policy—Part 2

As the longest war in US history winds down, military families are preparing for a new phase of dealing with its impact: the enduring consequences of deployment separations, physical and psychological injuries, and loss. The urgency and uniqueness of two simultaneous wars of long duration fought by an all-volunteer military have propelled the rapid evolution of research and practice regarding the impact of war on military families. Consistent with existing developmental and prevention science research, data emerging from the study of military and veteran families suggest that both stress and resilience reverberate across the family system. There is growing evidence that the impact of war and its sequelae are experienced by not only the service member or veteran, but also their children, partners, and other family members. Recognizing that the implications of these experiences do not end with active duty service, but may cascade for decades underscores the need for ongoing research focused not only on the impact of wartime military service on children and families, but also on shaping a science-informed approach to costeffective, and scalable behavioral health preventive interventions and treatment for military and veteran families. The scale and tempo of this war has left our country with a large social, psychological, and medical footprint that now must be addressed by our systems of care; an undertaking that may well require unprecedented levels of support and coordination across military, veteran and public health institutions for years to come. Both Parts 1 and 2 of this special issue are designed to contribute to the current national dialogue on how best to plan for and provide services for our military families. Part 1

Behavioral Treatment for Weight Gain Prevention Among Black Women in Primary Care Practice

Few weight loss treatments produce clinically meaningful weight loss outcomes among black women, particularly in the primary care setting. New weight management strategies are necessary for this population. Weight gain prevention might be an effective treatment option, with particular benefits for overweight and class 1 obese black women. To compare changes in weight and cardiometabolic risk during a 12-month period among black women randomized to a primary care-based behavioral weight gain prevention intervention, relative to usual care. Two-arm randomized clinical trial (the Shape Program). We recruited patients from a 6-site community health center system. We randomized 194 overweight and class 1 obese (body mass index [calculated as weight in kilograms divided by height in meters squared], 25-34.9) premenopausal black women aged 25 to 44 years. Enrollment began on December 7, 2009; 12- and 18-month assessments were completed in February and October 2, 2012. The medium-intensity intervention included tailored behavior change goals, weekly self-monitoring via interactive voice response, monthly counseling calls, tailored skills training materials, and a gym membership. Twelve-month change in weight and body mass index and maintenance of change at 18 months. Participants had a mean age of 35.4 years, a mean weight of 81.1 kg, and a mean body mass index of 30.2 at baseline. Most were socioeconomically disadvantaged (79.7% with educational level less than a college degree; 74.3% reporting annual income <$30,000). The 12-month weight change was larger among intervention participants (mean [SD], -1.0 [0.5] kg), relative to usual care (0.5 [0.5] kg; mean difference, -1.4 kg [95% CI, -2.8 to -0.1 kg]; P = .04). At month 12, 62% of intervention participants were at or below their baseline weights compared with 45% of usual-care participants (P = .03). By 18 months, intervention participants maintained significantly larger changes in weight (mean difference, -1.7 kg; 95% CI, -3.3 to -0.2 kg). A medium-intensity primary care-based behavioral intervention demonstrated efficacy for weight gain prevention among socioeconomically disadvantaged black women. A "maintain, don't gain" approach might be a useful alternative treatment for reducing obesity-associated disease risk among some premenopausal black women. clinicaltrials.gov Identifier: NCT00938535.

Military Service, War, and Families: Considerations for Child Development, Prevention and Intervention, and Public Health Policy

As the longest war in US history winds down, military families are preparing for a new phase of dealing with its impact: the enduring consequences of deployment separations, physical and psychological injuries, and loss. The urgency and uniqueness of two simultaneous wars of long duration fought by an all-volunteer military have propelled the rapid evolution of research and practice regarding the impact of war on military families. Consistent with existing developmental and prevention science research, data emerging from the study of military and veteran families suggest that both stress and resilience reverberate across the family system. There is growing evidence that the impact of war and its sequelae are experienced by not only the service member or veteran, but also their children, partners, and other family members. Recognizing that the implications of these experiences do not end with active duty service, but may cascade for decades underscores the need for ongoing research focused not only on the impact of wartime military service on children and families, but also on shaping a science-informed approach to costeffective, and scalable behavioral health preventive interventions and treatment for military and veteran families. The scale and tempo of this war has left our country with a large social, psychological, and medical footprint that now must be addressed by our systems of care; an undertaking that may well require unprecedented levels of support and coordination across military, veteran and public health institutions for years to come. Both Parts 1 and 2 of this special issue are designed to contribute to the current national dialogue on how best to plan for and provide services for our military families. Part 1