HIV Prevention and Treatment Behavior Change and the Situated Information Motivation Behavioral Skills (sIMB) Model: A Qualitative Evaluation of a Community Health Worker Intervention in Rakai, Uganda

Motivational interviewing experiences from a community health worker-led HIV prevention and care intervention in rural Uganda: a qualitative study

Motivational Interviewing (MI) and Community Health Workers (CHWs) are increasingly utilized in global settings to improve HIV outcomes, yet research exploring implementation strategies using MI and CHWs is lacking. We examined the experiences of CHWs and their clients in a counseling intervention which used MI-informed counseling to increase engagement in HIV prevention and treatment. This study was nested within the mLAKE cluster-randomized trial in a high HIV prevalence fishing community in rural Rakai District, Uganda. We conducted in-depth interviews with purposively-sampled CHWs (n = 8) and clients (n = 51). Transcripts were analyzed thematically to characterize CHWs' implementation of the intervention. Main themes identified included use of specific MI strategies (including evocation, guidance towards positive behavior change, active listening, and open-ended questions), and MI spirit (including collaboration, power-sharing, trust, and non-judgmental relationship building). Through these specific MI mechanisms, CHWs supported client behavior change to facilitate engagement with HIV services. This study provides evidence from a low-resource setting that CHWs with no previous experience in MI can successfully implement MI-informed counseling that is well-received by clients. CHW-led MI-informed counseling appears to be a feasible and effective approach to increase uptake of HIV prevention and care services in low-resource, HIV endemic regions.

Exploring the inherent mechanism of residents' participation behavior in neighborhood regeneration projects: an empirical study using an extended IMB model in China

Introduction

Resident participation has gained increasing prominence and significance in the pursuit of sustainable neighborhoods regeneration. However, the current state of resident participation practices remains beset by several challenges, which present formidable impediments to the initiation and execution of neighborhood regeneration initiatives. This study aims to investigate the underlying mechanisms of residents' participation behavior to enhance resident participation in neighborhood regeneration projects.

Methods

The present study employs the extended Information-Motivation-Behavioral (IMB) model to examine the determinants and mechanisms influencing residents' willingness and participation in neighborhood regeneration projects, with a specific focus on the Chinese context. Drawing upon data from 477 meticulously validated questionnaires administered to residents, the study applies structural equation modeling (SEM) to unravel the intrinsic dynamics of residents' participation behavior.

Results

The empirical findings of this research reveal that information, motivation, and the perceived local government support all exert a significant impact on residents' participation willingness. Notably, motivation emerges as the most influential factor.

Discussion

This study uncovers a direct influence of local government organizations on both residents' willingness and their actual participation, suggesting that government organizations can spearhead innovative strategies to bolster residents' willingness and furnish avenues for translating willingness into tangible participation. The outcomes of this study furnish an indispensable theoretical framework and offer policy recommendations that hold paramount importance for the deployment of novel interventions geared toward stimulating active involvement of residents in neighborhood regeneration.

How a menu of adherence support strategies facilitated high adherence to HIV prevention products among adolescent girls and young women in sub-Saharan Africa: a mixed methods analysis

INTRODUCTION

Effective use of pre-exposure prophylaxis (PrEP) has been low among adolescent girls and young women (AGYW) in sub-Saharan Africa. The MTN-034/REACH trial offered AGYW a menu of adherence support strategies and achieved high adherence to both daily oral PrEP and the monthly dapivirine vaginal ring. Understanding how these strategies promoted product use could inform the design of adherence support systems in programmatic settings.

METHODS

REACH was a randomized crossover trial evaluating the safety of and adherence to the ring and oral PrEP among 247 HIV-negative AGYW (ages 16-21) in South Africa, Uganda and Zimbabwe from January 2019 to September 2021 (NCT03593655). Adherence support included monthly counselling sessions with drug-level feedback (DLF) plus optional daily short message service (SMS) reminders, weekly phone or SMS check-ins, peer support clubs, "peer buddies" and additional counselling. Counsellors documented adherence support choices and counselling content on standardized forms. Through focus groups, serial in-depth interviews (IDIs) and single IDIs (n = 119 total), we explored participants' experiences with adherence support and how it encouraged product use.

RESULTS

Participants received counselling at nearly all visits. DLF was provided at 54.3% of sessions and, across sites, 49%-68% received results showing high adherence for oral PrEP, and 73%-89% for the ring. The most popular support strategies were in-person clubs and weekly calls, followed by online clubs, additional counselling and SMS. Preferences differed across sites but were similar for both products. Qualitative results demonstrated that the REACH strategies supported adherence by providing information about HIV and PrEP, continually motivating participants, and supporting the development of behavioural skills and self-efficacy, aligning with the Information, Motivation, and Behavioural Skills (IMB) model. Effectiveness was supported by three foundational pillars: strong interpersonal relationships with counsellors; ongoing, easily accessible support and resources; and establishing trust in the counsellors and study products through counsellor relationships, peer-to-peer exchange and DLF.

CONCLUSIONS

Implementation programmes could support effective PrEP use by offering a small menu of counsellor- and peer-based support options that are youth-friendly and developmentally appropriate. The same menu options can support both ring and oral PrEP users, though content should be tailored to the individual products.

Mixed Methods, Implementation Science Evaluation of a Community Health Worker Strategy for HIV Service Engagement in Uganda

BACKGROUND

A trial found that a community health worker (CHW) strategy using "Health Scouts" improved HIV care uptake and ART coverage. To better understand outcomes and areas for improvement, we conducted an implementation science evaluation.

METHODS

Using the RE-AIM framework, quantitative methods included analyses of a community-wide survey (n = 1903), CHW log books, and phone application data. Qualitative methods included in-depth interviews (n = 72) with CHWs, clients, staff, and community leaders.

RESULTS

Thirteen Health Scouts logged 11,221 counseling sessions; 2532 unique clients were counseled. 95.7% (1789 of 1891) of residents reported awareness of the Health Scouts. Overall, reach (self-reported receipt of counseling) was 30.7% (580 of 1891). Unreached residents were more likely to be male and HIV seronegative ( P < 0.05). Qualitative themes included the following: (1) reach was promoted by perceived usefulness but deterred by busy client lifestyles and stigma, (2) effectiveness was enabled through good acceptability and consistency with the conceptual framework, (3) adoption was facilitated by positive impacts on HIV service engagement, and (4) implementation fidelity was initially promoted by the CHW phone application but deterred by mobility. Maintenance showed consistent counseling sessions over time. The findings suggested the strategy was fundamentally sound but had suboptimal reach. Future iterations could consider adaptations to improve reach to priority populations, testing the need for mobile health support, and additional community sensitization to reduce stigma.

CONCLUSIONS

A CHW strategy to promote HIV services was implemented with moderate success in an HIV hyperendemic setting and should be considered for adoption and scale-up in other communities as part of comprehensive HIV epidemic control efforts.

TRIAL REGISTRATION

ClinicalTrials.gov Trial Number NCT02556957.

Impact of community health worker intervention on PrEP knowledge and use in Rakai, Uganda: A mixed methods, implementation science evaluation

BACKGROUND

Effective models of support for HIV pre-exposure prophylaxis (PrEP) are needed for populations at elevated risk. In a hyperendemic Ugandan fishing community, PrEP counseling was provided through a situated Information, Motivation, and Behavioral Skills (sIMB)-based community health worker (CHW) intervention. We evaluated the intervention using a mixed-methods, implementation science design.

METHODS

We surveyed all community members aged 15-49 through the Rakai Community Cohort Study. We used multivariable logistic regressions with generalized estimating equations to estimate the intervention's effect on PrEP knowledge and utilization. To understand intervention experiences and mechanisms, we conducted 74 qualitative interviews with 5 informant types (clients, CHWs, program staff, community leaders, health clinic staff) and analyzed data using an iterative, deductive approach. A mobile phone application provided intervention process implementation data.

RESULTS

Individuals self-reporting receipt of the CHW intervention showed significantly higher PrEP knowledge (N = 1848, PRR: 1.10, 95% CI: 1.06-1.14, p = <.0001), PrEP ever use (N = 1176, PRR: 1.77, 95% CI: 1.33-2.36, p = <.0001), and PrEP current use (N = 1176, PRR: 1.86, 95% CI: 1.22-2.82, p = 0.0039) compared to those who did not. Qualitative findings attributed positive PrEP outcomes to CHW counseling and effective use of motivational interviewing skills by CHWs. Salient themes across the RE-AIM framework included support for the CHW intervention and PrEP across clients, community, and implementers. Mobile application data demonstrated consistent delivery of the PrEP module throughout implementation.

CONCLUSIONS

CHWs improved PrEP knowledge and use among clients in an HIV hyperendemic fishing community. Mixed-methods, implementation science evaluations can inform adaptation of similar PrEP implementation strategies.

Feasibility of a Theory-Based, Online Tailored Message Program to Motivate Healthier Behaviors in College Women

We aimed to test the feasibility of an online survey and tailored message program in young women. Recruited from college campuses, women (n = 189) completed an online survey assessing preference for and behaviors toward diet and physical activity as well as theory-based influencers of these behaviors (knowledge/information, motivation, and confidence). Health messages were tailored to the participant’s survey responses and learning style to address misconceptions and motivate or reinforce healthy physical activity and dietary behaviors. Most women reported the survey as relevant (92%) and useful for reflecting on their health (83%), with survey responses variable in level of nutrition and physical activity knowledge, motivation, and confidence. Each woman received four tailored messages—most reported the messages as relevant (80%) and learning new information (60%). Across all messages, nearly half of the participants (~48%) reported willingness to try or maintain healthier behaviors and confidence in their ability. Body size discrepancy and dietary restraint had small effects message responses of information learned, and the motivation and confidence in trying healthier behaviors. In summary, these data support the feasibility of this online tailored message program. The college women found the tailored message program acceptable and useful to motivate healthier behaviors. The findings provide direction for behaviorally focused interventions to improve dietary and physical activity behaviors.

Barriers and facilitators to chemotherapy initiation and adherence for patients with HIV-associated Kaposi’s sarcoma in Kenya: a qualitative study

Background

Kaposi sarcoma is one of the most prevalent HIV-associated malignancies in sub-Saharan Africa and is often diagnosed at advanced stage of disease. Only 50% of KS patients who qualify for chemotherapy receive it and adherence is sub-optimal.

Methods

57 patients > 18 years with newly diagnosed KS within the AMPATH clinic network in Western Kenya were purposively selected to participate in semi-structured interviews stratified by whether they had completed, partially completed, or not completed chemotherapy for advanced stage KS. We based the interview guide and coding framework on the situated Information, Motivation, Behavioral Skills (sIMB) framework, in which the core patient centered IMB constructs are situated into the socioecological context of receiving care.

Results

Of the 57 participants, the median age was 37 (IQR 32–41) and the majority were male (68%). Notable barriers to chemotherapy initiation and adherence included lack of financial means, difficulty with convenience of appointments such as distance to facility, appointment times, long lines, limited appointments, intrapersonal barriers such as fear or hopelessness, and lack of proper or sufficient information about chemotherapy. Factors that facilitated chemotherapy initiation and adherence included health literacy, motivation to treat symptoms, improvement on chemotherapy, prioritization of self-care, resilience while experiencing side effects, ability to carry out behavioral skills, obtaining national health insurance, and free chemotherapy.

Conclusion

Our findings about the barriers and facilitators to chemotherapy initiation and adherence for KS in Western Kenya support further work that promotes public health campaigns with reliable cancer and chemotherapy information, improves education about the chemotherapy process and side effects, increases oncology service ability, supports enrollment in national health insurance, and increases incorporation of chronic disease care into existing HIV treatment networks.