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Myers B, Regenauer KS, Rose A, Johnson K, Ndamase S, Ciya N, Brown I, Joska J, Bassett IV, Belus JM, Ma TC, Sibeko G, Magidson JF. Community health worker training to reduce mental health and substance use stigma towards patients who have disengaged from HIV/TB care in South Africa: protocol for a stepped wedge hybrid type II pilot implementation trial. Implement Sci Commun 2024; 5:1. [PMID: 38167261 PMCID: PMC10759561 DOI: 10.1186/s43058-023-00537-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/10/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND South Africa has deployed community health workers (CHWs) to support individuals to enter and stay in HIV/TB care. Although CHWs routinely encounter patients with mental health (particularly depression) and substance use (SU) conditions that impact their engagement in HIV/TB care, CHWs are rarely trained in how to work with these patients. This contributes to mental health and SU stigma among CHWs, a known barrier to patient engagement in care. Mental health and SU training interventions could reduce CHW stigma and potentially improve patient engagement in care, but evidence of the feasibility, acceptability, and preliminary effectiveness of these interventions is scarce. Therefore, we designed a hybrid type 2 effectiveness-implementation pilot trial to evaluate the implementation and preliminary effectiveness of a CHW training intervention for reducing depression and SU stigma in the Western Cape, South Africa. METHODS This stepped wedge pilot trial will engage CHWs from six primary care clinics offering HIV/TB care. Clinics will be block randomized into three-step cohorts that receive the intervention at varying time points. The Siyakhana intervention involves 3 days of training in depression and SU focused on psychoeducation, evidence-based skills for working with patients, and self-care strategies for promoting CHW wellness. The implementation strategy involves social contact with people with lived experience of depression/SU during training (via patient videos and a peer trainer) and clinical supervision to support CHWs to practice new skills. Both implementation outcomes (acceptability, feasibility, fidelity) and preliminary effectiveness of the intervention on CHW stigma will be assessed using mixed methods at 3- and 6-month follow-up assessments. DISCUSSION This trial will advance knowledge of the feasibility, acceptability, and preliminary effectiveness of a CHW training for reducing depression and SU stigma towards patients with HIV and/or TB. Study findings will inform a larger implementation trial to evaluate the longer-term implementation and effectiveness of this intervention for reducing CHW stigma towards patients with depression and SU and improving patient engagement in HIV/TB care. TRIAL REGISTRATION ClinicalTrials.gov NCT05282173. Registered on 7 March 2022.
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Affiliation(s)
- Bronwyn Myers
- Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Kent Street, Perth, WA, Australia.
- Mental Health, Alcohol, Substance Use and Tobacco Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa.
- Department of Psychiatry and Mental Health, Division of Addiction Psychiatry, University of Cape Town, Cape Town, South Africa.
| | - Kristen S Regenauer
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Alexandra Rose
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Kim Johnson
- Mental Health, Alcohol, Substance Use and Tobacco Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa
| | - Sibabalwe Ndamase
- Mental Health, Alcohol, Substance Use and Tobacco Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa
| | - Nonceba Ciya
- Mental Health, Alcohol, Substance Use and Tobacco Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa
| | - Imani Brown
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - John Joska
- Department of Psychiatry and Mental Health, Division of Neuropsychiatry, University of Cape Town, HIV Mental Health Research Unit, Cape Town, South Africa
| | - Ingrid V Bassett
- Division of Infectious Diseases, Medical Practice Evaluation Center, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Jennifer M Belus
- Department of Clinical Research, Division of Clinical Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Tianzhou Charles Ma
- Department of Epidemiology and Biostatistics, University of Maryland, College Park, MD, USA
| | - Goodman Sibeko
- Department of Psychiatry and Mental Health, Division of Addiction Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
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Speizer IS, Zule WA, Carney T, Browne FA, Ndirangu J, Wechsberg WM. Changing sex risk behaviors, gender norms, and relationship dynamics among couples in Cape Town, South Africa: Efficacy of an intervention on the dyad. Soc Sci Med 2018; 209:95-103. [PMID: 29843074 DOI: 10.1016/j.socscimed.2018.05.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 05/01/2018] [Accepted: 05/12/2018] [Indexed: 11/18/2022]
Abstract
RATIONALE South Africa continues to experience new HIV infections, with the highest risk among Black Africans living in poor communities. Most HIV prevention interventions target women or men separately and only a small number target couples jointly. OBJECTIVE This study examines varying strategies to engage women and men around HIV prevention and improved couple interactions. METHODS The study comprises three arms: (1) a couple-based intervention delivered to women and men jointly; (2) women and men both offered a gender-focused intervention that is delivered to them separately; and (3) an intervention offered to women only and their male partners receive standard HIV testing and counseling (comparison arm). Between June 2010 and April 2012, men were identified in and around drinking establishments in a large disadvantaged community in Cape Town and asked to participate in the study if they drink regularly, had recent unprotected sex with their partner, and have a female partner who was willing to participate in the study. RESULTS A total of 299 couples completed the baseline assessment and 276 were included in the analysis of sexual risk, partner communication, conflict resolution, and gender norm outcomes at baseline and six-month follow-up. Couples that participated in the couple-level intervention and couples where both partners received the intervention separately had better couple-level gender norms than couples in the comparison arm (women only receive intervention). Further, couples in the couple-level intervention and the both partners exposed separately arms were more likely to have the man only report consistent condom use than neither partner report consistent condom use than couples in the comparison arm. CONCLUSION Community-based HIV prevention intervention programs need to consider strategies to engage women and men and, if feasible, reach both partners jointly. Couple-level interventions are promising to improve gender norms and subsequently improve health outcomes, including reduced HIV risk among women, men, and couples.
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Affiliation(s)
| | | | - Tara Carney
- South African Medical Research Council, Cape Town, South Africa
| | | | | | - Wendee M Wechsberg
- University of North Carolina, Chapel Hill, NC, USA; RTI International, Research Triangle Park, NC, USA; Duke University School of Medicine, Durham, NC, USA; North Carolina State University, Raleigh, NC, USA.
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Watt MH, Guidera KE, Hobkirk AL, Skinner D, Meade CS. Intimate partner violence among men and women who use methamphetamine: A mixed-methods study in South Africa. Drug Alcohol Rev 2016; 36:97-106. [PMID: 27246967 DOI: 10.1111/dar.12420] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/25/2016] [Accepted: 03/03/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The prevalence of methamphetamine use has risen dramatically in parts of South Africa. Globally, methamphetamine has been linked to intimate partner violence (IPV) and other forms of aggression. The aim of this mixed-methods study was to examine the experiences of physical IPV and its contextual factors among methamphetamine users in an urban community in Cape Town, South Africa. METHODS Active methamphetamine users were recruited using respondent driven sampling. All participants (n = 360) completed structured surveys, and a subset (n = 30) completed in-depth interviews with discussions of personal IPV experiences. Quantitative data were examined separately by gender, and regression models were used to identify factors that were associated with physical IPV victimisation and perpetration. Qualitative data were analysed to provide contextual understanding. RESULTS In the past 3 months, 47% of women and 31% of men reported being a victim of IPV, and 30% of women and 28% men reported being a perpetrator of IPV. Victimisation and perpetration were highly correlated, and both were significantly associated with histories of other traumas. Although the survey data suggests gender equivalence in IPV, the qualitative data provides a more nuanced context, with female victimisation by male partners being particularly frequent and intense. In narratives, IPV was a product of male aggression while using methamphetamine, norms around sex trading and gender-based attitudes endorsing violence against women. CONCLUSION Addiction to methamphetamine creates heightened risks of IPV, especially among those with previous traumas. The findings emphasise the importance of identifying and addressing IPV among methamphetamine users in South Africa. [Watt MH, Guidera KE, Hobkirk AL, Skinner D, Meade CS. Intimate partner violence among men and women who use methamphetamine: A mixed-methods study in South Africa. Drug Alcohol Rev 2017;36:97-106].
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Affiliation(s)
- Melissa H Watt
- Duke Global Health Institute, Duke University, Durham, USA
| | | | - Andréa L Hobkirk
- Duke Global Health Institute, Duke University, Durham, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, USA
| | - Donald Skinner
- Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Christina S Meade
- Duke Global Health Institute, Duke University, Durham, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, USA
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Wechsberg WM, Zule WA, El-Bassel N, Doherty IA, Minnis AM, Novak SD, Myers B, Carney T. The male factor: Outcomes from a cluster randomized field experiment with a couples-based HIV prevention intervention in a South African township. Drug Alcohol Depend 2016; 161:307-15. [PMID: 26946991 PMCID: PMC5645020 DOI: 10.1016/j.drugalcdep.2016.02.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 02/10/2016] [Accepted: 02/10/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND This study examined the effects of the Couples Health CoOp intervention on heavy drinking, condom use, and HIV incidence. METHODS Thirty neighborhoods from one South African township were cluster randomized into three intervention arms: Couples Health CoOp (CHC), Women's Health CoOp/Men's Health CoOp (WHC/MHC), or a comparison arm. We recruited 290 men from informal drinking establishments who reported drinking alcohol regularly. We also recruited their main heterosexual sex partners. RESULTS At 6-month follow-up, men in the CHC arm were less likely to report heavy drinking (OR 0.47, 95% CI: 0.25, 0.90) and were more likely to report consistent condom use during the past month (OR 2.66, 95% CI: 1.23, 5.76) than men in the comparison arm. At baseline, 26% of women and 13% of men were HIV-infected; at 6-month follow-up, 16 females and 5 males had seroconverted. HIV incidence was significantly lower among women in the CHC arm (IRR 0.22, 95% CI: 0.04, 1.01) than in the WHC/MHC arm. CONCLUSIONS A couples-based intervention focusing on intersecting risks for HIV can improve biobehavioral outcomes, underscoring the importance of engaging couples together in HIV prevention.
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Affiliation(s)
- Wendee M Wechsberg
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, United States; University of North Carolina, Chapel Hill, NC, United States; Department of Psychology in the Public Interest, North Carolina State University, Raleigh, NC, United States; Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States.
| | - William A Zule
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, United States
| | - Nabila El-Bassel
- Columbia University School of Social Work, New York, NY, United States
| | - Irene A Doherty
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, United States; University of North Carolina, Chapel Hill, NC, United States
| | - Alexandra M Minnis
- RTI International, 351 California Street, San Francisco, CA, United States
| | - Scott D Novak
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC, United States
| | - Bronwyn Myers
- Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Tara Carney
- Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
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Doherty IA, Myers B, Zule WA, Minnis AM, Kline TL, Parry CD, El-Bassel N, Wechsberg WM. Seek, Test and Disclose: knowledge of HIV testing and serostatus among high-risk couples in a South African township. Sex Transm Infect 2015; 92:5-11. [PMID: 26175479 DOI: 10.1136/sextrans-2014-051882] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 06/20/2015] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES HIV testing and disclosure of results to partners is an important strategy in HIV prevention but is under-researched within heterosexual partnerships. To address this gap, we describe patterns of HIV testing, discrepancies between beliefs and biologically confirmed HIV status of each partner, and characteristics of mutually correct knowledge of HIV status among heterosexual couples in a high-prevalence community. METHODS The study recruited 290 high-risk heterosexual couples in stable relationships from a township in Cape Town, South Africa. Male patrons of shebeens (drinking establishments) were approached to participate with their main partner in an intervention designed to reduce substance use, violence and unsafe sex. All participants were tested for HIV at baseline and asked about their partner's past HIV testing and current status. Using the couple as the unit of analysis, we conducted logistic regression to identify partnership and individual characteristics associated with having mutually correct knowledge of partner's HIV status. RESULTS Half (52%) of women and 41% of men correctly knew whether their partner had ever been tested for HIV. 38% of women, 28% of men and in 17% of couples, both members reported mutually correct knowledge of their partner's HIV status. Correlates of correct knowledge included married/cohabitating (aOR 2.69, 95% CI 1.35 to 5.40), both partners HIV-negative (aOR 3.32 (1.38 to 8.00)), women's acceptance of traditional gender roles (aOR 1.17 (1.01 to 1.40)) and men's relationship satisfaction (aOR 2.22 (1.01 to 4.44)). CONCLUSIONS Findings highlight the need to improve HIV testing uptake among men and to improve HIV disclosure among women in heterosexual partnerships. TRIAL REGISTRATION NUMBER ClinicalTrials.gov registration NCT01121692.
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Affiliation(s)
- Irene A Doherty
- Substance Abuse Treatment Evaluation & Interventions, RTI International, Research Triangle Park, North Carolina, USA
| | - Bronwyn Myers
- Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - William A Zule
- Substance Abuse Treatment Evaluation & Interventions, RTI International, Research Triangle Park, North Carolina, USA
| | - Alexandra M Minnis
- Substance Abuse Treatment Evaluation & Interventions, RTI International, Research Triangle Park, North Carolina, USA
| | - Tracy L Kline
- Substance Abuse Treatment Evaluation & Interventions, RTI International, Research Triangle Park, North Carolina, USA
| | - Charles D Parry
- Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | - Nabila El-Bassel
- Columbia University, School of Social Work, New York, New York, USA
| | - Wendee M Wechsberg
- Substance Abuse Treatment Evaluation & Interventions, RTI International, Research Triangle Park, North Carolina, USA Department of Psychology in the Public Interest, North Carolina State University, Raleigh, North Carolina, USA
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Minnis AM, Doherty IA, Kline TL, Zule WA, Myers B, Carney T, Wechsberg WM. Relationship power, communication, and violence among couples: results of a cluster-randomized HIV prevention study in a South African township. Int J Womens Health 2015; 7:517-25. [PMID: 25999767 PMCID: PMC4435250 DOI: 10.2147/ijwh.s77398] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Inequitable gender-based power in relationships and intimate partner violence contribute to persistently high rates of HIV infection among South African women. We examined the effects of two group-based HIV prevention interventions that engaged men and their female partners together in a couples intervention (Couples Health CoOp [CHC]) and a gender-separate intervention (Men’s Health CoOp/Women’s Health CoOp [MHC/WHC]) on women’s reports of power, communication, and conflict in relationships. Methods The cluster-randomized field experiment included heterosexual couples from a high-density South African township in which neighborhoods were randomized to one of the intervention arms or a control arm that received the WHC only. Participants completed in-person study visits at baseline and 6-month follow-up. We examined group differences using one-way analysis of variance and multivariable regression models. Results Of the 290 couples enrolled, 255 women remained in the same partnership over 6 months. Following the intervention, women in the CHC arm compared with those in the WHC arm were more likely to report an increase in relationship control (β=0.92, 95% confidence interval [CI]: 0.02, 1.83, P=0.045) and gender norms supporting female autonomy in relationships (β=0.99, 95% CI: 0.07, 1.91, P=0.035). Women in the MHC/WHC arm were more likely to report increases in relationship equity, relative to those in the CHC arm, and had a higher odds of reporting no victimization during the previous 3 months (MHC/WHC vs WHC: odds ratio =3.05, 95% CI: 1.55, 6.0, P=0.001; CHC vs MHC/WHC: odds ratio =0.38, 95% CI: 0.20, 0.74, P=0.004). Conclusion Male partner engagement in either the gender-separate or couples-based interventions led to modest improvements in gender power, adoption of more egalitarian gender norms, and reductions in relationship conflict for females. The aspects of relationship power that improved, however, varied between the couples and gender-separate conditions, highlighting the need for further attention to development of both gender-separate and couples interventions.
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Affiliation(s)
- Alexandra M Minnis
- RTI International, Research Triangle Park, NC, USA ; School of Public Health, University of California, Berkeley, CA, USA
| | - Irene A Doherty
- RTI International, Research Triangle Park, NC, USA ; University of North Carolina, Chapel Hill, NC, USA
| | | | | | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, University of Cape Town, Cape Town, South Africa ; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Tara Carney
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, University of Cape Town, Cape Town, South Africa
| | - Wendee M Wechsberg
- RTI International, Research Triangle Park, NC, USA ; University of North Carolina, Chapel Hill, NC, USA ; North Carolina State University, Raleigh, NC, USA ; Duke University School of Medicine, Durham, NC, USA
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Wechsberg WM, El-Bassel N, Carney T, Browne FA, Myers B, Zule WA. Adapting an evidence-based HIV behavioral intervention for South African couples. Subst Abuse Treat Prev Policy 2015; 10:6. [PMID: 25888856 PMCID: PMC4344778 DOI: 10.1186/s13011-015-0005-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 02/16/2015] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND In South Africa, heterosexual couples are at risk for HIV infection and transmission through substance use, gender-based violence and traditional gender roles, and sex risk behaviors such as having multiple partners and unsafe sex. METHODS To address these interconnected HIV risks among heterosexual couples, we used the ADAPT framework to modify an existing, efficacious women's HIV prevention intervention (the Western Cape Women's Health CoOp) to include components of an evidence-based couple's intervention from the United States (Project Connect) and components from the Men as Partners program that has been used successfully in South Africa. We conducted focus groups with men, women and couples, and obtained feedback from a long-standing Community Collaborative Board (CCB) to guide the synthesis of elements of these three interventions into a new intervention. We then piloted the adapted intervention for feasibility and acceptability. RESULTS The new intervention is called the Couples' Health CoOp. This intervention targets men who use alcohol and other drugs and engage in unprotected sex, and their main female sex partners. The intervention addresses substance use, sex risk, HIV and other sexually transmitted infections, gender roles, gender-based violence, communication skills, and goal-setting activities to increase sexy (eroticize) safe-sex behaviors. The Couples' Health CoOp also includes "voices" from the focus group members to ground the intervention in the experiences of these at-risk couples. In addition, it utilizes a participant handbook that reiterates workshop content and includes homework assignments for couples to complete together to increase problem-solving skills within their relationship, and to improve their sexual relationship and help sustain HIV risk-reduction strategies. All of these adaptations were based on participants' suggestions made during formative work and pilot testing. CONCLUSIONS The Couples' Health CoOp is a couple-based HIV prevention intervention that targets alcohol and other drug use to reduce sexual risk, reduce gender-based violence and offer alternatives for conflict resolution, promote healthy relationships, and modify traditional gender roles in South Africa. TRIAL REGISTRATION NUMBER NCT01121692 .
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Affiliation(s)
- Wendee M Wechsberg
- Substance Abuse Treatment Evaluations and Interventions Research Program, RTI International, Research Triangle Park, NC, USA.
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
- Psychology in the Public Interest, North Carolina State University, Raleigh, NC, USA.
- Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, NC, USA.
| | | | - Tara Carney
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa.
| | | | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa.
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
| | - William A Zule
- Substance Abuse Treatment Evaluations and Interventions Research Program, RTI International, Research Triangle Park, NC, USA.
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Cooper HLF, Tempalski B. Integrating place into research on drug use, drug users' health, and drug policy. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2014; 25:503-7. [PMID: 24746862 PMCID: PMC4135510 DOI: 10.1016/j.drugpo.2014.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 03/06/2014] [Accepted: 03/13/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Hannah L F Cooper
- Rollins School of Public Health at Emory University, Atlanta, GA, USA
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