Individual-level Interventions Research Articles

Zwakala Ndoda: a cluster and individually randomized trial aimed at improving testing, linkage, and adherence to treatment for hard-to reach men in KwaZulu-Natal, South Africa

BackgroundMen in sub-Saharan Africa are less likely than women to get tested for HIV, less likely to present for treatment, less likely to be maintained in treatment, more likely to have detectable viral load, more likely to transmit HIV with unprotected intercourse, and more likely to progress to AIDS and die sooner from HIV. The ultimate objective of this research is to provide evidence-based strategies to improve HIV testing and treatment of HIV-infected men.MethodsThis study is being conducted in the Greater Edendale Area and Vulindlela region in KwaZulu-Natal, South Africa. It is a two-stage design of a cluster-randomized trial and an individual randomized trial to test how structural and individual-level interventions address the demand-side factors that affect HIV testing and treatment for hard-to reach, high-risk men. It combines male-focused mobilization, community-based mobile HIV testing services, and a small incentive to determine if the strategies singly and in combination can result in more men diagnosed with HIV, and more men linked to and maintained in care with undetectable viral load.DiscussionA priority for sub-Sahara Africa is developing and evaluating novel and cost-effective strategies for identifying hard-to-reach groups such as men, linking them to HIV testing and care services, and maintaining them in care to the point of viral suppression. We propose a combination prevention intervention that addresses men’s individual, interpersonal, and structural barriers to testing and care. This includes male-led mobilization to encourage uptake of testing and treatment, male-focused testing venues, male-only counselors, developing counseling models that are flexible and responsive to men, and strategies for adhering to clinic visits without missing work and navigating the healthcare system. By thoughtfully combining male-focused mobilization, and testing and addressing some of the barriers to male engagement with health facilities, this study hopes to add to the growing evidence base about how to reach, test, link, and maintain a hard-to-reach group such as men in HIV treatment and care services.Trial registrationClinicalTrials.gov, NCT03794245. Registered on 4 January 2019.

Prevalence and associated factors of burnout among Debre Berhan University medical students: a cross-sectional study

BackgroundBurnout, a measure of professional distress, is more common among medical professionals. About half of medical students have this problem. However, little is known about the burnout status of medical students in Ethiopia. Therefore, the aim of this study was to assess the prevalence and associated factors of burnout among medical students of Debre Berhan University (DBU).MethodsA cross-sectional study was conducted on randomly selected 151 medical students of DBU. Burnout was assessed using the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Participants were reported as having burnout if they scored ≥27 on Emotional Exhaustion (EE), ≥13 on Depersonalization (DP) sub-scales, and ≤ 31 on Personal Accomplishment (PA) sub-scale of the MBI-HSS. EpiData version 3.1 was used for data entry while SPSS version 20 and STATA version 13 for windows were used for data analysis. Both univariable and multivariable binary logistic regression analyses were conducted. The degree of association between variables was assessed using odds ratio (OR) with 95% confidence interval (CI) at two-tailed p-value of < 0.05.ResultOf 144 medical students took part, 34.0% had symptoms of burnout. Regarding domains of burnout, 61.8% scored high on EE, 47.9% scored high on DP and 59.7% scored low on PA. Dissatisfaction with practice lecturer (AOR = 3.8, 95% CI (1.3, 11.6)), moderate social support (AOR = 0.2, 95% CI (0.1, 0.8)), and satisfaction with their education (AOR = 0.1 95% CI (0.0, 0.7)) were associated with burnout.ConclusionMore than one-third of medical students at DBU had burnout. Individual and organizational level interventions targeting students who had poor social support, dissatisfied by their lecturer at the hospitals and their education are recommended.

The Combination of Living in High Crime Neighborhoods and High Rumination Predicts Depressive Symptoms among Adolescents.

Living in high crime areas and rumination each have been identified as risk factors for depression among youth, yet it is unclear how crime and rumination may synergistically increase the risk of adolescent depression. Adolescents (N = 309; 51% female, Mage= 12.9, SD = 0.61) completed self-report measures of rumination, depressive symptoms, and provided local addresses, which were used to match police district crime statistics. Approximately one year later, participants again reported depressive symptoms. Moderation analyses indicated that the tendency to ruminate exacerbated the relationship between violent crime rates, but not non-violent crime, and higher prospective levels of depressive symptoms among adolescents. These findings suggest that individual-level interventions that promote more adaptive emotion response styles may lower the risk of depression among adolescents residing in high crime areas.

Update on Addressing Mental Health and Burnout in Physicians: What Is the Role for Psychiatry?

To highlight an emerging understanding of burnout and physician mental health. This review will provide a discussion of conceptual and diagnostic issues of the burnout syndrome with its relevance to psychiatry, and how psychiatry may interface with other medical disciplines to provide support in creating burnout prevention and treatment programs. Descriptive data of burnout correlations and risk factors are available while an understanding of burnout best practices is lacking but growing. Two recent meta-analyses provide efficacy data along with key subgroup analyses that point to greater efficacy among systemic/organizational over individual level interventions. Among individual interventions, groups work better than individual therapy and the incorporation of Mindfulness-Based Stress Reduction and/or Cognitive Behavioral Therapy modalities provide greater efficacy over other therapies. Ultimately, addressing burnout will be an iterative process specific to institutional cultures and therefore should be thought of as quality improvement initiatives involving leadership to adopt the quadruple aim of physician wellness and to seek institution-specific collaboration and feedback. Psychiatry is uniquely positioned to help change institutional cultures regarding the burnout syndrome, which has been labeled a national crisis. Combinatorial strategies that combine efficacious individual-level interventions with systemic-level interventions that enhance workflow will likely provide the most sustainable model for preventing and treating burnout. Psychiatry should be involved, especially at the level of the liaison psychiatrist to assist with how these types of interventions may be best implemented in specific institutions.

Childhood conditions, pathways to entertainment work and current practices of female entertainment workers in Cambodia: Baseline findings from the Mobile Link trial.

BackgroundEntertainment venues have been identified as an important location for HIV prevention due to the increasing number of young female entertainment and sex workers at these venues. The purpose of this study is to increase understanding of the childhood conditions, pathways to entertainment work and current practices of female entertainment workers (FEWs) in Cambodia.MethodsData used for this study were collected in April 2018 as part of the baseline survey of the Mobile Link, a randomized controlled trial to improve sexual and reproductive health of FEWs in Cambodia. We used a stratified random sampling method to recruit 600 FEWs for face-to-face interviews using a structured questionnaire. Descriptive analyses were performed.ResultsMost participants came from childhood homes without electricity (82.0%) or running water (87.0%). Most women moved to the city in the last ten years (80.5%) for economic reasons (43.7%). About a third worked in the garment industry prior to the entertainment industry (36.7%). Participation in transactional sex in the past three months was reported by 36.0%. Women reported low condom use practices with non-paying partners (23.4% used a condom at last sex), excessive and forced alcohol use at work (33.1% reported being forced to drink alcohol at work more than once a month), low modern contraception use (31.4% was using modern contraception), and experiences of gender-based violence (23.3% reported verbal threats, physical abuse or forced sex in the past six months).ConclusionsThis information will help to support the development of future individual and structural level interventions for the safety and support of FEWs. In addition, these results may contribute to an evidence base that can inform policy level changes intended to support the realization of full human rights for entertainment works in Cambodia including the rights to health, safety and respectful employment.

Reducing sexual risk and promoting acceptance of men who have sex with men living with HIV in India: Outcomes and process evaluation of a pilot randomised multi-level intervention

ABSTRACTHIV-positive men who have sex with men (HIV+MSM) in India need culturally-relevant interventions to promote safer sex. We tested a multi-level intervention among HIV+MSM that targeted individual, interpersonal, and community factors, based on the Social-Personal and Social Ecological Models. We conducted a 2 × 2 factorial RCT with 119 HIV+MSM randomised to receive either an individual-level intervention (ILI) using motivational interviewing to promote safer sex, a community-level intervention (CLI) to strengthen community norms toward safer sex and reduce stigma among MSM communities, a multi-level intervention combining the individual- and community-level interventions (ILI + CLI), or standard-of-care control. Participants completed pre- and post-intervention assessments of a composite sexual risk score and a process evaluation to assess fidelity and satisfaction. Out of the 119 HIV+MSM, 106 (89.0%) completed pre- and post-intervention assessments. Generalised Estimating Equation models showed that both CLI (Incidence Rate Ratio [IRR] = .67, 95% CI .47 to .96) and ILI + CLI (IRR = .66, 95% CI .48 to .91) groups had a statistically significant decrease in sexual risk compared to the standard-of-care. The interventions had high levels of fidelity and satisfaction. This pilot RCT demonstrated feasibility and potential effectiveness of a multi-level intervention that addresses individual, interpersonal and community-level contributors of sexual risk among HIV+MSM.

Individual-level interventions to reduce personal exposure to outdoor air pollution and their effects on long-term respiratory conditions

Individual-level interventions to reduce personal exposure to outdoor air pollution and their effects on long-term respiratory conditions

Individual-level intervention assessing short-term effects of blue spaces

OPS 33: Health impact of interventions 2, Room 411, Floor 4, August 28, 2019, 10:30 AM - 12:00 PM In contrast with green spaces, there is still a lack of evidence regarding health and well-being benefits of exposure to blue spaces. The objective of this randomized crossover study was to evaluate short-term well-being effects that office workers experience after walks on different environments (blue space vs. urban space). We also assessed the persistence of these potential effects over time. A sample of 60 office workers were randomly assigned to a different exposure (blue, urban, or control) each week. They walked for 20 minutes per day along a predefined route for each of the exposures, except the week they were exposed to control that they rested for 20 minutes in the study room. Participants’ well-being was measured with questionnaires answered before and after the exposure. Preliminary results of this study found that subjects reported better quality of life and well-being scores after being exposed to blue space compared with urban space. Better sleep quality was also suggested although it was not statistically significant. From 4 hours after the exposure, well-being benefits persisted, and scores were higher when participants had been exposed to blue space compared with urban space. These findings might improve our understanding on the effects of blue spaces on well-being.

Public Health England Annual Conference 2019

Public Health England's (PHE's) Chief Executive, Duncan Selby, opened the PHE annual conference with an upbeat message—the argument for prevention has been won, England will see the first increase in government spending on public health for several years and the government's support for prevention is evident from its recent ‘Advancing Our Health’ green paper. The Secretary of State for Health and Social Care, Matt Hancock, reiterated this new commitment to public health, and praised policies such as the soft drinks sugar levy, but also made clear that this government's vision is for “personalised prevention”—efficiently delivering individual-level interventions using big data and genomics.

Meaningful work and well-being: a study of the positive side of veterinary work

ObjectivesMental health is a growing concern in many healthcare professions, including veterinary medicine, as research suggests that veterinarians report higher levels of distress, burnout and suicidal ideation than other healthcare...

Equity-Specific Effects of Interventions to Promote Physical Activity among Middle-Aged and Older Adults: Development of a Collaborative Equity-Specific Re-Analysis Strategy.

Reducing social inequalities in physical activity (PA) has become a priority for public health. However, evidence concerning the impact of interventions on inequalities in PA is scarce. This study aims to develop and test the application of a strategy for re-analyzing equity-specific effects of existing PA intervention studies in middle-aged and older adults, as part of an international interdisciplinary collaboration. This article aims to describe (1) the establishment and characteristics of the collaboration; and (2) the jointly developed equity-specific re-analysis strategy as a first result of the collaboration. To develop the strategy, a collaboration based on a convenience sample of eight published studies of individual-level PA interventions among the general population of adults aged ≥45 years was initiated (UK, n = 3; The Netherlands, n = 3; Belgium, n = 1; Germany, n = 1). Researchers from these studies participated in a workshop and subsequent e-mail correspondence. The developed strategy will be used to investigate social inequalities in intervention adherence, dropout, and efficacy. This will allow for a comprehensive assessment of social inequalities within intervention benefits. The application of the strategy within and beyond the collaboration will help to extend the limited evidence regarding the effects of interventions on social inequalities in PA among middle-aged and older adults.

Factors Associated with Use of Recreational Facilities and Physical Activity Among Low-Income Latino Adults.

The purpose of this study was to identify longitudinal correlates of low-income, urban, Latino adults' use of recreational facilities and engagement in physical activity (PA). This secondary data analysis is from a placed-based initiative; the parent study recruited a cohort of parents of kindergarteners from schools in intervention and control communities. Using a self-administered questionnaire, we collected baseline correlates and 1-year follow-up recreational facilities use and PA outcomes. We conducted ordinal logistic regression to assess correlates for recreational facilities use and PA outcomes. Our sample of 273 Latino adults was mostly female and married or living with partners. Meeting PA guidelines at baseline was associated with higher odds of using parks, walking, and moderate- and vigorous-intensity PA. Those who considered PA to be important had higher odds of using trails (adjusted OR=2.36, 95% CI 1.15-4.84) and of moderate-intensity PA (adjusted OR=2.68, 95% CI 1.21-5.91). Reported perception that the neighborhood is very safe to walk was associated with higher odds of using trails (adjusted OR3.45, 95% CI 1.39-8.53) and parks (adjusted OR 2.92, 95% CI 1.19-7.16). Quality of recreational facilities was directly associated with walking (adjusted OR=1.61 95% CI 1.01-2.57). Speaking English was associated with higher odds of engaging in moderate-intensity PA (adjusted OR=3.28 95% CI 1.70-6.33). Results from this study of urban, low-income Latinos indicate that promotion is needed not only for sustained use of recreational facilities among current users, but also for concerted efforts to reach less acculturated Latinos and make recreational facilities appealing to currently inactive adults. Both individual-level and neighborhood-level interventions are needed to build positive attitudes towards PA, while also enhancing neighborhood safety and the quality of neighborhood recreational facilities.

Intimate Partner Violence and the Sexual and Reproductive Health Outcomes of Women in Ghana.

Few studies have examined the relationships between intimate partner violence (IPV) and the sexual and reproductive health outcomes of women in sub-Saharan countries in general and Ghana specifically. This study began to fill the gap by investigating whether individual- and community-level IPV influenced unwanted pregnancy and pregnancy loss among women in Ghana. Nationally representative cross-sectional data were collected from 2,289 ever-married women, and multilevel modeling was used to estimate individual- and community-level effects. At the individual level, IPV was significantly associated with unwanted pregnancy and pregnancy loss. Women with experience of both physical and sexual violence were more likely to have reported an unwanted pregnancy and a pregnancy loss. However, only those experiencing sexual violence reported unwanted pregnancies. Similarly, community-level IPV was associated with sexual health outcomes. Respondents in communities with higher levels of sexual violence were significantly more likely to have had unwanted pregnancies. The findings corroborate calls for policy makers to consider IPV a reproductive health issue. They also emphasize the need to move beyond individual-level interventions to consider structural and community contexts when addressing the sexual and reproductive health outcomes of women in Ghana.

Estimating the Relative Impact of Clinical and Preventive Community-Based Interventions: An Example Based on the Community Transformation Grant Program.

IntroductionPublic health focuses on a range of evidence-based approaches for addressing chronic conditions, from individual-level clinical interventions to broader changes in policies and environments that protect people’s health and make healthy living easier. This study examined the potential long-term impact of clinical and community interventions as they were implemented by Community Transformation Grant (CTG) program awardees.MethodsWe used the Prevention Impacts Simulation Model, a system dynamics model of cardiovascular disease prevention, to simulate the potential 10-year and 25-year impact of clinical and community interventions implemented by 32 communities receiving a CTG program award, assuming that program interventions were sustained during these periods.ResultsSustained clinical interventions implemented by CTG awardees could potentially avert more than 36,000 premature deaths and $3.2 billion in discounted direct medical costs (2017 US dollars) over 10 years and 109,000 premature deaths and $8.1 billion in discounted medical costs over 25 years. Sustained community interventions could avert more than 24,000 premature deaths and $3.4 billion in discounted direct medical costs over 10 years and 88,000 premature deaths and $9.1 billion in discounted direct medical costs over 25 years. CTG clinical activities had cost-effectiveness of $302,000 per death averted at the 10-year mark and $188,000 per death averted at the 25-year mark. Community interventions had cost-effectiveness of $169,000 and $57,000 per death averted at the 10- and 25-year marks, respectively.ConclusionClinical interventions have the potential to avert more premature deaths than community interventions. However, community interventions, if sustained over the long term, have better cost-effectiveness.

“On a Journey to Appreciate What My Body Does for Me”: Qualitative Results from a Positive Body Image Pilot Intervention Study

ABSTRACTResearch suggests body appreciation is related to mental, physical, and sexual health behaviors and outcomes that are relevant to social workers and public health clinicians. As such, it is imperative to develop and test interventions that aim to improve body appreciation. The current study is part of a larger pilot intervention study that utilized 3D scanning technology. During the intervention, 18–25-year-old women digitally “painted” their avatar on a computer based on a series of prompts from the researcher. The purpose of this study is to qualitatively explore how a small subsample of the participants (n = 18) experienced this innovative intervention and how they view themselves differently post-intervention. Using thematic analysis, we uncovered three themes: 1) ways of defining body image, 2) importance of body function over aesthetics, and 3) body acceptance and appreciation. This study provides support for the use of one-time individual-level interventions focused on body appreciation and functionality over appearance. Implications are discussed.

An educational intervention on the risk perception of pesticides exposure and organophosphate metabolites urinary concentrations in rural school children in Maule Region, Chile

BackgroundOrganophosphate (OP) pesticides can be hazardous to human health if not applied with appropriate precautions. There is evidence in the Maule region of Chile that rural schoolchildren are exposed to OP pesticides. ObjectiveTo evaluate the effectiveness of an educational intervention on OP exposure and understanding of pesticides and their hazards (risk perception) in two school communities in the Maule Region of Chile during 2016. MethodWe conducted a quasi-experimental study about the effects on OP pesticide exposure of a community outreach and education program (COEP) administered in four 2-h sessions that's included hands-on activities among 48 schoolchildren from two rural schools. The intervention was directed to groups of parents and school-children separately, and aimed to educate them about the risks of exposure to pesticides and their effects on health. We measured 3,5,6-trichloro-2-pyridinol (TCPy), 2-isopropyl-4-methyl-6-hydroxypyrimidine (IMPY), malathion dicarboxylic acid (MDA), p-nitrophenol (PNP), specific urinary metabolites of the OP pesticides chlorpyrifos, diazinon, malathion and parathion, respectively, as well as the non-specific diethylakylphosphates (DEAPs) and dimethylalkylphosphates (DMAPs) in 192 urine samples of schoolchildren collected before and after the intervention. The risk perception of school children and their parents was also assessed through a questionnaire before and after the intervention. Generalized Estimated Equations were used to account for each child’s repeated measures during four sessions, two in September 2016 (pre-intervention) and two in November 2016 (post-intervention). ResultsThe intervention level had significant effect on the risk perception of adults and children, which increased after the intervention. However, the intervention was not associated with reduced of urinary metabolites levels, with no significant differences between the pre and post measures. The detection frequencies were 1.1% (MDA), 71.4% (TCPy), 43.3% (IMPY), 98.96% (PNP), and 100% (DEAPs and DMAPs). Higher DEAPs urine concentrations were associated with eating more fruit at school (p = 0.03), a younger age (p = 0.03), and being male (p = 0.01). DMAPs showed no associations with potential predictor variables (e.g. OPs applied at home, fruit consumption at school, among others). Higher TCPy was associated with attending a school closer to farms (p = 0.04) and living in a home closer to farm fields (p = 0.01); higher PNP was marginally associated with children younger age (p = 0.035). ConclusionEnvironmental exposure to OP pesticides was unchanged even after behavior changes. It is possible that a longer time period is needed to observe changes in both behavior and urinary metabolites. The levels of DEP and DMP metabolites found here are above the reference population of the US, and our findings indicate exposure to a wide variety of OP pesticides. Given that individual-level interventions were not associated with lower exposures, efforts to reduce exposure must occur upstream and require stricter regulation and control of pesticide use by government agencies.

Ethical Issues in Pragmatic Cluster-Randomized Trials in Dialysis Facilities

A pragmatic cluster-randomized trial (CRT) is a research design that may be used to efficiently test promising interventions that directly inform dialysis care. While the Ottawa Statement on the Ethical Design and Conduct of Cluster Randomized Trials provides general ethical guidance for CRTs, the dialysis setting raises additional considerations. In this article, we outline ethical issues raised by pragmatic CRTs in dialysis facilities. These issues may be divided into 7 key domains: justifying the use of cluster randomization, adopting randomly allocated individual-level interventions as a facility standard of care, conducting benefit-harm analyses, gatekeepers and their responsibilities, obtaining informed consent from research participants, patient notification, and including vulnerable participants. We describe existing guidelines relevant to each domain, illustrate how they were considered in the Time to Reduce Mortality in End-Stage Renal Disease (TiME) trial (a prototypical pragmatic hemodialysis CRT), and highlight remaining areas of uncertainty. The following is the first step in an interdisciplinary mixed-methods research project to guide the design and conduct of pragmatic CRTs in dialysis facilities. Subsequent work will expand on these concepts and when possible, argue for a preferred solution.

Novel Approaches to Value Assessment Within the Cost-Effectiveness Framework

Novel Approaches to Value Assessment Within the Cost-Effectiveness Framework

2432-PUB: Predictors of Imminent Glycemic Worsening in Adults with Screen-Detected Diabetes

Reliable clinical indicators of near-term risk of worsening glycemia in type 2 diabetes (T2D) could help guide individual-level interventions. Here we analyzed data from the Early Diabetes Intervention Program (EDIP) to identify predictors of near-term glycemic progression. EDIP evaluated progression of fasting blood glucose (FBG) above 140 mg/dl on consecutive quarterly measurements in individuals with screen-detected T2D and FBG below 140 at study entry (age 52.6 + 11.5 years, 41.9% male, mean entry FBG 121±14 mg/dL; mean 2-hour OGTT glucose 236±30; mean HbA1C 6.4+0.57%). We investigated accessible clinical parameters (weight, glycemia, lipids, and insulin levels) as potential near-term predictors of progression, evaluating absolute levels and yearly changes preceding progression. Variables were evaluated individually in age/sex/race-adjusted analyses and in combination in multivariable Cox progression models. Change over the preceding 1 year in fasting glucose, but not in weight or insulin levels, was predictive of glycemic progression in the subsequent year in adjusted univariate analyses (p&amp;lt;0.03). In multivariable modeling, the FBG concentration (hazard ratio HR 1.14) and the antecedent 1-year change in FBG (HR 0.90) were the strongest predictors of progression, and both retained significance in multivariable models including all specified variables (p&amp;lt; 0.0001). Adding changes in fasting insulin, HOMA-IR, or oral disposition index to the modeling did not change this result. There was a significant correlation between current FBG and the antecedent 1-year change (r=0.587; p&amp;lt;0.01), highlighting that change in FBG was contributing in part via its effect on current FBG. In the EDIP study population with screen-detected T2D, current FBG and antecedent 1-year change in FBG were the best predictors of upcoming glycemic worsening. These data underscore the value of serially monitoring fasting glucose, and suggest a similar monitoring paradigm should be evaluated in prediabetes. Disclosure R.S. Aguirre: None. T.S. Hannon: Advisory Panel; Self; Eli Lilly and Company. R. Considine: None. M. Kirkman: Research Support; Self; Bayer AG, Novo Nordisk A/S, Theracos, Inc. K.J. Mather: Advisory Panel; Self; Roche Diabetes Care. Research Support; Self; Abbott, Merck &amp; Co., Inc., Novo Nordisk A/S, Sanofi.

Development of a Recurrent Neural Network Model for Prediction of Dengue Importation

Development of a Recurrent Neural Network Model for Prediction of Dengue Importation