Intervention to influence behaviors linked to risk of chronic diseases: a multisite randomized controlled trial with African-American HIV-serodiscordant heterosexual couples

Compendium of dyadic intervention techniques (DITs) to change health behaviours: a systematic review

BACKGROUND

Dyadic interventions for health behaviour change involving the romantic partner are promising. However, it often remains unclear how exactly the partner is involved in dyadic interventions. We propose a novel compendium of dyadic intervention techniques (DITs) that facilitates systematic description of dyadic interventions in terms of who performs what for whom during intervention delivery and subsequent implementation.

OBJECTIVE

We aimed to systematically characterise dyadic interventions along their degree of partner involvement and to provide a comprehensive list of DITs used in dyadic interventions with romantic partners.

METHODS

We systematically reviewed dyadic health behaviour change interventions with controlled designs. We included 165 studies describing 122 distinct dyadic interventions with romantic partners. Interventions were classified along their degree of partner involvement, 160 DITs were extracted, and their frequencies of use counted.

RESULTS

The majority of interventions (n = 90, 74%) explicitly instructed partners to interact. Half of the DITs were performed jointly by the couple and also targeted the couple. Mostly, couples were instructed to jointly practice communication skills and to jointly perform problem solving for the couple.

DISCUSSION

The present review contributes to the development of a shared and systematic way of describing dyadic interventions to facilitate cumulation of evidence.

Do syndemic conditions predict HIV medication adherence among urban African American men?

Much progress has been made in advancing antiretroviral (ART) adherence, yet disparities remain. To explore relationships of syndemic conditions - co-occurring health conditions caused by combinations of biological, social, and structural factors - to ART adherence among African American men, we used data from longitudinal assessments of 302 African American men enrolled in a study designed to increase physical activity and healthy eating. Syndemic conditions included alcohol dependency, drug dependency, depression, post-traumatic stress disorder, and unstable housing. A syndemic conditions variable was operationalized to indicate the presence of 0-5 conditions. About 55% of participants had 1 or more syndemic conditions. Age and marriage were positively associated with ART adherence, whereas number of syndemic conditions was negatively associated with adherence during the 12-month period. The interaction of being married and the syndemic conditions variable significantly predicted greater adherence. Similarly, the interaction of more education and the syndemic conditions variable predicted greater adherence. In multiple regression models, the syndemic conditions variable remained significant (-0.018) in predicting adherence; however, there was no significant interaction among the 5 conditions. This study lends evidence to syndemics literature indicating deleterious consequences of negative life experiences on health outcomes.

Effects of a Health Promotion Intervention on Physical Activity in African American Men Living with HIV: Randomized Controlled Trial

HIV and its treatment with antiretroviral therapy increase the risk of noncommunicable diseases (NCDs) tied to physical inactivity. Older African American men are also at high risk for NCDs. We tested the efficacy of a theory-based intervention to increase adherence to federal aerobic and muscle-strengthening physical activity (PA) guidelines among African American men aged 40 years and older living with HIV. We randomized African American men aged 40 years and older living with HIV to a three-session social cognitive theory-informed health promotion intervention targeting PA or a one-session health awareness control condition. The primary outcome was PA guideline adherence assessed (self-reported) preintervention, immediate postintervention, and 3, 6, and 12 months postintervention. Secondary outcomes were the number of days on which participants reported moderate-intensity aerobic PA, vigorous-intensity aerobic PA, and muscle-strengthening PA in the past 7 days. Of 302 participants, 255 completed the 12-month postintervention measures. Generalized estimated equation logistic regression indicated that the health promotion intervention participants had higher odds of meeting PA guidelines than health awareness control participants, adjusting for baseline adherence (p = 0.011). Health promotion intervention participants also reported more muscle-strengthening PA (p = 0.001), vigorous-intensity aerobic PA (p = 0.049), and moderate-intensity aerobic PA (p = 0.010) than control participants. The rise in self-reported adherence to PA guidelines and improvements in muscle-strengthening and aerobic PA considered separately suggest that a relatively brief behavioral intervention can increase PA among African American men aged 40 years and older living with HIV and potentially curb their risk of NCDs that PA can prevent.

Predictors of Colorectal Cancer Screening Among African American Men Living with HIV

African American men living with HIV are at high risk of colorectal cancer (CRC). Screening to detect CRC is associated with a reduced risk of CRC mortality. However, little is known about CRC screening predictors in this population. This study examined the relation of self-efficacy, a potential mediator of screening that interventions could target, to CRC screening. It also investigated several variables that might identify subpopulations of African American men non-adherent to CRC screening recommendations. We report a secondary analysis on baseline data from a randomized controlled trial of a health promotion intervention for African American men living with HIV. Before their intervention, they completed measures of CRC screening, self-efficacy, marital status, age, education, and adherence to physical activity guidelines and were assessed for obesity. A total of 270 African American men aged 45 to 88 (Mean = 55.07; SD = 6.46) living with HIV participated. About 30% reported CRC screening in the past six months. Multiple logistic regression revealed greater CRC screening self-efficacy and meeting physical activity guidelines were associated with receiving CRC screening. Obese men and men reporting higher education were less likely to report screening. Age and marital status were unrelated to screening. The results of this study suggest CRC screening rates may be low among African American men living with HIV, and interventions targeting self-efficacy may improve their screening uptake. Moreover, public-health efforts to increase screening should prioritize interventions with subpopulations of African American men living with HIV who are physically inactive and obese.

Reasoned Action Approach Correlates of Physical Activity Among African American Men Living With HIV: A Cross-Sectional Study

ABSTRACT

Physical activity (PA) is associated with a reduced incidence of chronic diseases. However, little is known about the predictors of PA among African American men living with HIV. We report secondary analyses examining the strength of the relationships between the reasoned action approach constructs, attitude, subjective norm, descriptive norm, and self-efficacy and intention to exercise and self-reported adherence to Department of Health and Human Services PA guidelines using baseline data from a trial of a PA intervention with 302 African American men, between 40 and 88 years of age (M = 53.9; SD = 7.2) living with HIV. Multiple regression revealed that attitude, subjective norm, and self-efficacy were positively associated with intention. Logistic regression revealed higher odds of meeting PA guidelines as self-efficacy increased. Self-efficacy and descriptive norm predicted meeting the aerobic guideline. Self-efficacy predicted meeting the muscle-strengthening guideline. Interventions targeting reasoned action approach variables may contribute to efforts to improve PA among African American men living with HIV.

Barriers and Facilitators to Engaging African American Men Who Have Sex With Men in the HIV Care Continuum: A Theory-Based Qualitative Study

African American men who have sex with men (MSM) have high rates of HIV, but interventions are needed to address their low rates of engagement in the HIV care continuum. To identify modifiable factors potentially affecting such engagement, we conducted qualitative interviews guided by the Theory of Planned Behavior with 27 African American MSM who had participated in an HIV risk-reduction intervention trial. Qualitative analyses resulted in four overarching themes: stigma, concerns with health care providers (HCPs), social support, and logistical issues. Facilitators of care continuum engagement included reassurance about health, feeling and looking better, receiving treatment, avoiding infecting others, good relations with HCP, and social support. Barriers included HIV stigma, concerns about confidentiality, negative perceptions of HCP, convenience and availability of testing/treatment facilities, cost, and lack of social support. Efforts to improve African American MSM HIV care continuum engagement should focus on individual and health care system changes.

Intervention Increases Physical Activity and Healthful Diet Among South African Adolescents Over 54 Months: A Randomized Controlled Trial

PURPOSE

Scant research has investigated whether health promotion interventions have sustained effects in increasing physical activity and healthful diet among adolescents in sub-Saharan Africa, which is experiencing an epidemiological transition from infectious diseases to noncommunicable diseases as leading causes of mortality. We examined whether an intervention increased adherence to 5-a-day diet and physical activity guidelines during a 54-month postintervention period among South African adolescents and whether its effects weakened at long-term (42 and 54 months postintervention) compared with short-term (3, 6, and 12 months postintervention) follow-up.

METHODS

We randomized 18 randomly selected schools serving grade 6 learners (mean age = 12.6) in a township and a semirural area in Eastern Cape Province, South Africa, to one of the two 12-hour interventions: health promotion, targeting healthful diet and physical activity; attention-matched control, targeting sexual risk behaviors. We tested the intervention's effects on adherence to 5-a-day diet and physical activity guidelines using generalized estimating equations logistic regression models adjusting for baseline behavior and clustering within schools.

RESULTS

Health promotion intervention participants had higher odds of meeting 5-a-day diet and physical activity guidelines than control participants. The effect on 5-a-day diet did not weaken at long-term compared with short-term follow-up, but the effect on physical activity guidelines was weaker at long-term follow-up, mainly because of a reduced effect on muscle-strengthening physical activity. The intervention also increased health promotion attitude and intention and health knowledge and reduced binge drinking compared with the control group.

CONCLUSIONS

A 12-hour intervention in grade 6 shows promise in increasing self-reported adherence to healthful diet and physical activity guidelines during a 4.5-year postintervention period among South African adolescents.

Health-Promotion Intervention Increases Self-Reported Physical Activity in Sub-Saharan African University Students: A Randomized Controlled Pilot Study

To evaluate the efficacy of a health-promotion intervention in increasing self-reported physical activity among university students in Sub-Saharan Africa. Randomly selected second-year students at a university in South Africa were randomized to an intervention based on social cognitive theory: health-promotion, targeting physical activity and fruit, vegetable, and fat consumption; or HIV risk-reduction, targeting sexual-risk behaviors. Participants completed assessments via audio computer-assisted self-interviewing pre-intervention and 6 and 12 months post-intervention. A total of 176 were randomized with 171 (97.2%) retained 12 months post-intervention. Generalized-estimating-equations analyses indicated that the health-promotion-intervention participants were more likely to meet physical-activity guidelines than were control participants, post-intervention, adjusting for pre-intervention physical activity (odds ratio [OR] = 3.35; 95% CI: 1.33-8.41). Health-promotion participants reported a greater number of days they did vigorous-intensity (risk ratio [RR] = 2.01; 95% CI: 1.43-2.83) and moderate-intensity (RR = 1.40; 95% CI: 1.01-1.95) aerobic activity, but not strength-building activity (RR = 1.37; 95% CI: 0.091-2.07). The intervention reduced self-reported servings of fried foods (mean difference = -0.31; 95% CI: -0.60, -0.02). The findings suggest that theory-based, contextually appropriate interventions may increase physical activity among university students in Sub-Saharan Africa.

Strategies for improving the lives of US women aged 40 and above living with HIV/AIDS: an evidence map

BACKGROUND

While in its early years the HIV epidemic affected primarily the male and the young, nowadays, the population living with HIV/AIDS is approximately 24% women, and its age composition has shifted towards older ages. Many of the older women who live with HIV/AIDS also live with the medical and social conditions that accompany aging. This work aims to identify and characterize empirical studies of strategies for the comprehensive management of women over 40, including transgender women, who live with HIV/AIDS. Forty was chosen as an operational age cutoff to identify premenopausal women who are less likely to bear children, as well as peri- and postmenopausal women.

METHODS

We conducted a literature search after discussions with a diverse panel of content experts and other stakeholders and developed an evidence map that identified 890 citations that address questions having to do with programs and barriers to engaging with programs, as well as the role of insurance and comorbidities, and have enrolled older women who live with HIV/AIDS.

RESULTS

Of these, only 37 (4%) reported results of interest for women over 40 who live with HIV/AIDS, or examined interactions between gender and older age that would allow predictions in this subgroup. Few of the 37 eligible studies focused on women facing obvious challenges, such as immigrants, transgender, physically abused, or those recently released from prison. No studies focused on women caring for dependents, including children and grandchildren, or those diagnosed after age 40.

CONCLUSION

The evidence base that is directly applicable to women over 40 who live with HIV/AIDS in the USA is limited, and the research need is broad. We propose research prioritization strategies for this population.

60 Minutes for health: examining the feasibility and acceptability of a low-resource behavioral intervention designed to promote retention in HIV care

Sustained retention in HIV medical care is a key health behavior for the long-term health of people living with HIV (PLWH). Approximately 60% of PLWH in the U.S. are poorly retained in HIV care, yet to date, the few available evidence-based retention-promoting interventions are resource and time intensive to implement. The current study describes the feasibility and acceptability of a theory-based retention-promoting intervention designed to meet the needs of a busy clinical care setting. 60 Minutes for Health reflects a low-resource single-session intervention, implemented by a health educator, to PLWH who have had a recent gap in care (≥6-months) in the past 18-months. Intervention content was informed by a situated application of the Information Motivation Behavioral Skills Model and delivered using a Motivational Interviewing-based format. The intervention uses a workbook to guide a series of activities that: (1) Identify and reduce misinformation guiding HIV care attendance. (2) Enhance motivation to maintain care via personal health goals. (3) Build skills for coping with emotional distress related to living with HIV. (4) Increase self-efficacy for navigating the logistics of maintaining care amidst competing priorities. A small feasibility pilot of this intervention protocol was conducted to assess its potential to improve retention in care and to obtain estimates for a larger-scale efficacy trial. Participants were randomized to the 60-minute intervention session (n = 8), or a theory-based time-and-attention control session focused on diet and nutrition (n = 8). Medical records were abstracted to evaluate changes in participants' retention in care status at 12- and 24-months post-intervention. Findings suggest the intervention is both feasible and acceptable to implement with poorly retained PLWH in a clinic setting. Post-intervention a larger proportion of intervention participants were retained in care (12-months: 87.5%, 24-months: 62.5%), compared control participants (12-months: 50.0%, 24-months: 25.0%). Future work should aim to evaluate a larger-scale efficacy trial.

Efficacy and Mediation of a Theory-Based Physical Activity Intervention for African American Men Who Have Sex with Men: A Randomized Controlled Trial

BACKGROUND

Few trials have tested physical-activity interventions among sexual minorities, including African American men who have sex with men (MSM).

PURPOSE

We examined the efficacy and mediation of the Being Responsible for Ourselves (BRO) physical-activity intervention among African American MSM.

METHOD

African American MSM were randomized to the physical-activity intervention consisting of three 90-min one-on-one sessions or an attention-matched control intervention and completed pre-intervention, immediately post-intervention, and 6- and 12-month post-intervention audio computer-based surveys.

RESULTS

Of the 595 participants, 503 completed the 12-month follow-up. Generalized estimating equation models revealed that the intervention increased self-reported physical activity compared with the control intervention, adjusted for pre-intervention physical activity. Mediation analyses suggested that the intervention increased reasoned action approach variables, subjective norm and self-efficacy, increasing intention immediately post-intervention, which increased physical activity during the follow-up period.

CONCLUSIONS

Interventions targeting reasoned action approach variables may contribute to efforts to increase African American MSM's physical activity.

CLINICAL TRIAL REGISTRATION

The trial was registered with the ClinicalTrials.gov Identifier NCT02561286 .

Exploring the effectiveness of couples interventions for adults living with a chronic physical illness: A systematic review

OBJECTIVE

Partners have a significant role in a person's ability to adjust to a chronic physical illness, which warrants their inclusion in couples interventions. However to deliver more specific, tailored support it is necessary to explore which types of couples interventions are most effective across certain chronic illness populations and outcomes.

METHODS

Five databases were searched using selected terms. Thirty-five articles met the eligibility criteria for inclusion.

RESULTS

The majority of studies were from the US, and most interventions targeted cancer populations. Couples interventions fell into two categories according to therapeutic approach; Cognitive Behavioural Skills Training (CBST) and Relationship Counselling (RC). When compared with a patient-only intervention or controls, CBST interventions effectively targeted behavioural, physical/somatic and cognitive outcomes, while RC more effectively targeted interpersonal outcomes.

CONCLUSION

Couples interventions can be more effective than patient-only interventions or controls across various patient and partner outcomes. Couples interventions tend to favour a skills-based or a relationship-based approach, which strongly influences the types outcomes effectively targeted.

PRACTICE IMPLICATIONS

Our findings suggest it could be therapeutically useful to integrate these two approaches to more holistically support couples living with chronic illness. We also identify the need to target understudied illness groups and ethnicities.

Mediation Analysis of the Efficacy of the Eban HIV/STD Risk-Reduction Intervention for African American HIV Serodiscordant Couples

Targeting couples is a promising behavioral HIV risk-reduction strategy, but the mechanisms underlying the effects of such interventions are unknown. We report secondary analyses testing whether Social-Cognitive-Theory variables mediated the Eban HIV-risk-reduction intervention's effects on condom-use outcomes. In a multisite randomized controlled trial conducted in four US cities, 535 African American HIV-serodiscordant couples were randomized to the Eban HIV risk-reduction intervention or attention-matched control intervention. Outcomes were proportion condom-protected sex, consistent condom use, and frequency of unprotected sex measured pre-, immediately post-, and 6 and 12 months post-intervention. Potential mediators included Social-Cognitive-Theory variables: outcome expectancies and self-efficacy. Mediation analyses using the product-of-coefficients approach in a generalized-estimating-equations framework revealed that condom-use outcome expectancy, partner-reaction outcome expectancy, intention, self-efficacy, and safer-sex communication improved post-intervention and mediated intervention-induced improvements in condom-use outcomes. These findings underscore the importance of targeting outcome expectancies, self-efficacy, and safer-sex communication in couples-level HIV risk-reduction interventions.

Mediation of effects of a theory-based behavioral intervention on self-reported physical activity in South African men

OBJECTIVE

Increasing physical activity is an important public-health goal worldwide, but there are few published mediation analyses of physical-activity interventions in low-to-middle-income countries like South Africa undergoing a health transition involving markedly increased mortality from non-communicable diseases. This article reports secondary analyses on the mediation of a theory-of-planned-behavior-based behavioral intervention that increased self-reported physical activity in a trial with 1181 men in Eastern Cape Province, South Africa.

METHOD

Twenty-two matched-pairs of neighborhoods were randomly selected. Within pairs, neighborhoods were randomized to a health-promotion intervention or an attention-matched control intervention with baseline, immediate-post, and 6- and 12-month post-intervention assessments. Theory-of-planned-behavior constructs measured immediately post-intervention were tested as potential mediators of the primary outcome, self-reported physical activity averaged over the 6- and 12-month post-intervention assessments, using a product-of-coefficients approach in a generalized-estimating-equations framework. Data were collected in 2007-2010.

RESULTS

Attitude, subjective norm, self-efficacy, and intention were significant mediators of intervention-induced increases in self-reported physical activity. The descriptive norm, not affected by the intervention, was not a mediator, but predicted increased self-reported physical activity.

CONCLUSION

The results suggest that interventions targeting theory-of-planned-behavior constructs may contribute to efforts to increase physical activity to reduce the burden of non-communicable diseases among South African men.

Theory-based behavioral intervention increases self-reported physical activity in South African men: a cluster-randomized controlled trial

OBJECTIVE

To determine whether a health-promotion intervention increases South African men's adherence to physical-activity guidelines.

METHOD

We utilized a cluster-randomized controlled trial design. Eligible clusters, residential neighborhoods near East London, South Africa, were matched in pairs. Within randomly selected pairs, neighborhoods were randomized to theory-based, culturally congruent health-promotion intervention encouraging physical activity or attention-matched HIV/STI risk-reduction control intervention. Men residing in the neighborhoods and reporting coitus in the previous 3 months were eligible. Primary outcome was self-reported individual-level adherence to physical-activity guidelines averaged over 6-month and 12-month post-intervention assessments. Data were collected in 2007-2010. Data collectors, but not facilitators or participants, were blind to group assignment.

RESULTS

Primary outcome intention-to-treat analysis included 22 of 22 clusters and 537 of 572 men in the health-promotion intervention and 22 of 22 clusters and 569 of 609 men in the attention-control intervention. Model-estimated probability of meeting physical-activity guidelines was 51.0% in the health-promotion intervention and 44.7% in attention-matched control (OR=1.34; 95% CI, 1.09-1.63), adjusting for baseline prevalence and clustering from 44 neighborhoods.

CONCLUSION

A theory-based culturally congruent intervention increased South African men's self-reported physical activity, a key contributor to deaths from non-communicable diseases in South Africa.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01490359.

A pilot evaluation of the efficacy of a couple-tailored print intervention on colorectal cancer screening practices among non-adherent couples

The objective of this study was to evaluate the efficacy of a couple-tailored print (CTP) intervention on colorectal cancer screening (CRCS), CRCS intentions, and on knowledge and attitudes among couples in which neither partner is on schedule with regard to CRCS. A total of 168 married couples with both members non-adherent with CRCS were randomly assigned to receive either a CTP pamphlet accompanied by a generic print (GP) pamphlet or a GP pamphlet only. Couples completed measures of CRCS, intentions, relational perspective on CRCS, discussions about CRCS, spouse support for CRCS, spouse influence strategies, CRC knowledge, perceived CRC risk, and CRCS benefits and barriers. Results indicated there was no significant benefit of CTP vs. GP on CRCS, but there was a significant increase in CRCS intentions in CTP compared with GP. There was also a significant increase in relationship perspective on CRCS, a significant increase in husbands' support of their wives' CRCS, and a significant increase in CRCS benefits in CTP. In summary, CTP did not increase CRCS practices but increased intentions and perceived benefits of CRCS as well as improving couples' ability to view CRCS as having benefit for the marital relationship.

Interventions to address chronic disease and HIV: strategies to promote exercise and nutrition among HIV-infected individuals

Food insecurity, micronutrient deficits, dyslipidemia, insulin resistance, obesity, cardiovascular disease, and bone disorders complicate the treatment of HIV infection. Nutrition and exercise interventions can be effective in ameliorating these symptoms that are associated with HIV and antiretroviral therapy (ART). In this literature review, we examine the most recent nutrition and exercise interventions for HIV-infected patients. Macronutrient supplementation can be useful in treating malnutrition and wasting. Multivitamin (vitamin B complex, vitamin C, and vitamin E) supplements and vitamin D may improve quality of life and decrease morbidity and mortality. Nutritional counseling and exercise interventions are effective for treating obesity, fat redistribution, and metabolic abnormalities. Physical activity interventions improve body composition, strength, and fitness in HIV-infected individuals. Taken collectively, the evidence suggests that a proactive approach to nutrition and physical activity guidance and interventions can improve outcomes and help abrogate the adverse metabolic, cardiovascular, and psychological consequences of HIV and its treatments.