"Too much boredom isn't a good thing": Adapting behavioral activation for substance use in a resource-limited South African HIV care setting

Utility of the Alcohol Use Disorder Inventory Test in determining caseness for alcohol use disorder among persons receiving antiretroviral therapy

We sought to determine the utility of the Alcohol Use Disorder Identification Test (AUDIT) in screening for alcohol use disorder (AUD) among 688 users of antiretroviral therapy (ART). We used the receiver operating characteristic (ROC) curve analysis to assess whether the AUDIT reliably detected AUD against the Structured Clinical Interview for the DSM (SCID). Of the samples, 22.09% (CI: 19.05% to 25.38%) of participants met the diagnostic criteria for AUD. Among men (n = 135) and women (n = 553), the prevalence estimates were 31.9% and 19.7%, respectively. For men, a cut-off score of 6 predicted AUD with 88.36% (95%CI: 74.92-96.11) sensitivity and 88.04% (95%CI: 79.61-93.88) specificity. For women, a cut-off score of 4 on the AUDIT yielded an optimal sensitivity of 92.66% (95% CI: 86.05%-96.78%) and a specificity of 93.24% (95% CI: 90.49-95.40%). For men, the AUDIT yielded a positive predictive value (PPV) of 75.55% (95% CI: 66.26%-85.87%) and a negative predictive value (NPV) of 91.49% (95% CI: 87.63-97.37%); for women the PPV and NPV were 77.09% (70.34%-82.68%) and 98.11% (96.37%-99.02%), respectively. The instrument's good sensitivity and specificity indicate it is likely to be useful for screening and referral of ART users who are probably cases of AUD.

Unraveling substance abuse among Malawian street children: A qualitative exploration

This qualitative study adopts a phenomenological and symbolic interactionist approach to comprehensively explore substance abuse among street children in Lilongwe, Malawi. The research aims to uncover the complex sociocultural, economic, and environmental determinants influencing substance abuse within this marginalized cohort. Through in-depth semi-structured interviews, the study engages with street children to understand their subjective experiences, perceptions, and interpretations of substance abuse within their community context. Employing convenience, purposive, and snowball sampling strategies, the research collected data from street children, acknowledging their transient nature and societal challenges. Thematic analysis was conducted on interview transcripts to derive comprehensive insights. Results revealed five key thematic areas: familial absence and emotional void, societal normalization and peer pressure, economic hardships, coping mechanisms, environmental accessibility, and peer influence and belongingness. These themes highlighted the intricate interplay between personal experiences, socio-environmental factors, and peer dynamics, shaping the prevalence and persistence of substance abuse among street children. This study's implications for practice underscore the need for tailored interventions and support mechanisms addressing substance abuse within this demographic. It emphasizes the urgency for context-specific strategies and policy formulations aimed at ameliorating the challenges faced by street children dealing with substance abuse in Malawi. Ultimately, this research contributes to a deeper understanding of substance abuse among marginalized street children, advocating for compassionate and contextually sensitive interventions within this overlooked drug abusers' population subset.

Not Two Sides of the Same Coin: A Qualitative Comparative Analysis of Post-Treatment Abstinence and Relapse

Purpose

Substance use disorder (SUD) can be a chronic relapsing condition with poor treatment outcomes. Studies exploring factors associated with abstinence or relapse after treatment are often quantitative in nature, applying linear statistical approaches, while abstinence and relapse result from non-linear, complex, dynamic and synergistic processes. This study aims to explore these underlying dynamics using qualitative comparative analysis (QCA) as a mixed methods approach to further our understanding of factors contributing to post-treatment abstinence and relapse.

Patients and Methods

In a prospective study, we gathered both qualitative and quantitative data pertaining to post-treatment substance use and the factors linked to substance use outcomes. These factors encompassed psychiatric comorbidity, intellectual disability, social disintegration, post-treatment support, and engagement in activities among patients who had undergone inpatient treatment for severe SUD (n = 58). QCA, a set-theoretic approach that considers the complex interplay of multiple conditions, was applied to discern which factors were necessary or sufficient for the occurrence of either abstinence or relapse.

Results

We found two solutions predicting abstinence, and five for relapse. Post-treatment conditions (support and engagement in activities) were important for retaining abstinence. For relapse, individual baseline characteristics (intellectual disability, social disintegration, psychiatric comorbidity) combined with (post-)treatment factors (post-treatment support, activities) were important.

Conclusion

Although abstinence and relapse represent opposing outcomes, they each exhibit distinct dynamics. To gain a comprehensive understanding of these dynamics, it is advisable to examine them as separate outcomes. For clinical practice, it can be worthwhile to recognize that fostering the conditions conducive to abstinence may differ from preventing the factors that trigger relapse.

Global Is Local: Leveraging Global Mental-Health Methods to Promote Equity and Address Disparities in the United States

Structural barriers perpetuate mental health disparities for minoritized US populations; global mental health (GMH) takes an interdisciplinary approach to increasing mental health care access and relevance. Mutual capacity building partnerships between low and middle-income countries and high-income countries are beginning to use GMH strategies to address disparities across contexts. We highlight these partnerships and shared GMH strategies through a case series of said partnerships between Kenya-North Carolina, South Africa-Maryland, and Mozambique-New York. We analyzed case materials and narrative descriptions using document review. Shared strategies across cases included: qualitative formative work and partnership-building; selecting and adapting evidence-based interventions; prioritizing accessible, feasible delivery; task-sharing; tailoring training and supervision; and mixed-method, hybrid designs. Bidirectional learning between partners improved the use of strategies in both settings. Integrating GMH strategies into clinical science-and facilitating learning across settings-can improve efforts to expand care in ways that consider culture, context, and systems in low-resource settings.

Applying a mutual capacity building model to inform peer provider programs in South Africa and the United States: A combined qualitative analysis

BACKGROUND

Globally, there is a treatment gap for substance use treatment and harm reduction services. As peer-delivered interventions expand to address this gap in both high-income countries (HICs) and low and middle-income countries (LMICs), they provide an opportunity to examine mutual capacity building, the bidirectional exchange of ideas between distinct settings to address common challenges.

METHODS

The aim of this study was to explore the perspectives of patients in Cape Town and Baltimore about the acceptability and feasibility of a peer-delivered intervention using a combined qualitative analysis across a HIC and LMIC. Semi-structured qualitative interviews were conducted with participants in pilot trials in Cape Town, South Africa and Baltimore, USA (n=55). Across both trials, participants received a peer-delivered behavioral intervention focused on problem solving strategies for medication adherence, behavioral activation, and other cognitive-behavioral skills. The datasets from each location were merged and analyzed jointly using thematic analysis to develop codes and themes. Transcripts were coded to theoretical saturation (n=21 from Baltimore, n=16 from Cape Town).

RESULTS

Participants highlighted what they valued about the peer-delivered intervention: 1) behavioral skills learned, 2) relationship with the peer, 3) ability to help others based on what they learned, 4) improved adherence to HIV or substance use medications, and 5) changes in substance use behaviors. In Baltimore, participants were typically more focused on their supportive relationship with the peer, which contrasted with many other relationships in their lives. In Cape Town, many participants highlighted the value of the skills they learned, such as mindfulness and activity scheduling.

CONCLUSIONS

Across sites, participants valued that the peer could support them to accomplish meaningful life goals beyond substance use recovery, such as building relationships or health. Differences between settings may highlight the importance of tailoring peer interventions to fill context-specific gaps in available services.

The development and initial feasibility testing of D-HOMES: a behavioral activation-based intervention for diabetes medication adherence and psychological wellness among people experiencing homelessness

Introduction

Compared to stably housed peers, people experiencing homelessness (PEH) have lower rates of ideal glycemic control, and experience premature morbidity and mortality. High rates of behavioral health comorbidities and trauma add to access barriers driving poor outcomes. Limited evidence guides behavioral approaches to support the needs of PEH with diabetes. Lay coaching models can improve care for low-resource populations with diabetes, yet we found no evidence of programs specifically tailored to the needs of PEH.

Methods

We used a multistep, iterative process following the ORBIT model to develop the Diabetes Homeless Medication Support (D-HOMES) program, a new lifestyle intervention for PEH with type 2 diabetes. We built a community-engaged research team who participated in all of the following steps of treatment development: (1) initial treatment conceptualization drawing from evidence-based programs, (2) qualitative interviews with affected people and multi-disciplinary housing and healthcare providers, and (3) an open trial of D-HOMES to evaluate acceptability (Client Satisfaction Questionnaire, exit interview) and treatment engagement (completion rate of up to 10 offered coaching sessions).

Results

In step (1), the D-HOMES treatment manual drew from existing behavioral activation and lay health coach programs for diabetes as well as clinical resources from Health Care for the Homeless. Step (2) qualitative interviews (n = 26 patients, n = 21 providers) shaped counseling approaches, language and choices regarding interventionists, tools, and resources. PTSD symptoms were reported in 69% of patients. Step (3) trial participants (N = 10) overall found the program acceptable, however, we saw better program satisfaction and treatment engagement among more stably housed people. We developed adapted treatment materials for the target population and refined recruitment/retention strategies and trial procedures sensitive to prevalent discrimination and racism to better retain people of color and those with less stable housing.

Discussion

The research team has used these findings to inform an NIH-funded randomized control pilot trial. We found synergy between community-engaged research and the ORBIT model of behavioral treatment development to develop a new intervention designed for PEH with type 2 diabetes and address health equity gaps in people who have experienced trauma. We conclude that more work and different approaches are needed to address the needs of participants with the least stable housing.

Adaption and pilot testing of a lay HIV supporter program for traditional healers: a mixed methods study in rural Uganda

BACKGROUND

Half of people living with HIV (PLWH) in sub-Saharan Africa default from care within two years. In Uganda, and across sub-Saharan Africa, traditional healers (TH) are ubiquitous and often serve as the first line of health care. We hypothesized that with lay support training, TH could support relinkage to HIV care and ART adherence among rural Ugandan PLWH who have defaulted from HIV care.

METHODS

Following the ADAPT-ITT framework, we adapted an evidence-based layperson HIV support program from South Africa for delivery by Ugandan TH. The ADAPT-ITT framework consists of (1) Assessment of needs; (2) Deciding which evidence-based interventions to adapt; (3) Adaptation of interventions; (4) Production of drafted adapted interventions; (5) Topical expert feedback; (6) Integration of expert feedback; (7) Training personnel; and (8) Testing the adapted intervention. The Testing phase was completed via a pilot mixed methods prospective cohort study. The study population included 12 TH practicing in Mbarara Township and 20 adult PLWH with suboptimal ART adherence (CASE adherence index score < 10) who received care from a participating TH and who resided in Mbarara Township. Primary outcome was re-linkage to HIV care within 14 days. Secondary outcomes were ART re-initiation, ART adherence, retention in care after 9 months, and implementation measures. Qualitative interviews were conducted with all participants.

RESULTS

Data from the Assessment phase indicated that logistical challenges played an important role in disengagement from care among PLWH who receive care from TH, notably geographical distance to clinics and transportation costs. Additionally, HIV-related stigma and lack of social support were identified as barriers to entering and remaining in HIV care. Two core elements of the intervention were identified during the Production phase: (1) TH facilitating rapid re-linkage to HIV care and (2) TH provision of psychosocial support. In the pilot study phase, baseline median CASE adherence score was 3; only 5% of PLWH were adherent to ART via 4-day recall. The TH-delivered support achieved 100% linkage and ART initiation within 14 days, 95% ART adherence, and 100% of PLWH were retained in HIV care after 9 months.

CONCLUSIONS

The ADAPT-ITT framework successfully guided the adaption of a community health worker-delivered intervention for delivery by TH. TH successfully facilitated re-linkage to HIV care, support ART adherence, and retention in care for PLWH when trained as part of a lay support person program. Future studies are needed to evaluate scale-up and long-term impact.

"Sometimes you have to take the person and show them how": adapting behavioral activation for peer recovery specialist-delivery to improve methadone treatment retention

BACKGROUND

Despite efficacy of medication for opioid use disorder, low-income, ethno-racial minoritized populations often experience poor opioid use disorder treatment outcomes. Peer recovery specialists, individuals with lived experience of substance use and recovery, are well-positioned to engage hard-to-reach patients in treatment for opioid use disorder. Traditionally, peer recovery specialists have focused on bridging to care rather than delivering interventions. This study builds on research in other low-resource contexts that has explored peer delivery of evidence-based interventions, such as behavioral activation, to expand access to care.

METHODS

We sought feedback on the feasibility and acceptability of a peer recovery specialist-delivered behavioral activation intervention supporting retention in methadone treatment by increasing positive reinforcement. We recruited patients and staff at a community-based methadone treatment center and peer recovery specialist working across Baltimore City, Maryland, USA. Semi-structured interviews and focus groups inquired about the feasibility and acceptability of behavioral activation, recommendations for adaptation, and acceptability of working with a peer alongside methadone treatment.

RESULTS

Participants (N = 32) shared that peer recovery specialist-delivered behavioral activation could be feasible and acceptable with adaptations. They described common challenges associated with unstructured time, for which behavioral activation could be particularly relevant. Participants provided examples of how a peer-delivered intervention could fit well in the context of methadone treatment, emphasizing the importance of flexibility and specific peer qualities.

CONCLUSIONS

Improving medication for opioid use disorder outcomes is a national priority that must be met with cost-effective, sustainable strategies to support individuals in treatment. Findings will guide adaptation of a peer recovery specialist-delivered behavioral activation intervention to improve methadone treatment retention for underserved, ethno-racial minoritized individuals living with opioid use disorder.

Cognitive and Behavioral Contributions to Depression Severity, Quality of Life, and Functioning Among People Living With HIV in South Africa

Cognitive-behavioral treatments for depression typically address both behavioral (e.g., activation) and cognitive (e.g., rumination) components, and consequently improve quality of life (QOL) and function in high-resource settings. However, little is known about the cross-cultural applicability and relative contribution of these components to depression symptom severity, QOL, and functional impairment in South Africa and other resource-limited global settings with high HIV prevalence rates. Persons with HIV (N = 274) from a peri-urban community outside Cape Town, South Africa, were administered multiple measures of depression (Hamilton Depression Scale, Centre for Epidemiological Studies Depression Scale, South African Depression Scale), cognitive and behavioral components related to depression (Ruminative Response Scale, Behavioral Activation for Depression Scale), and measures of QOL and functioning (Sheehan Disability Scale, Quality of Life Enjoyment and Satisfaction Scale-Short Form). Multiple linear regression models were fit to assess the relative contribution of behavioral and cognitive components to depression severity, QOL, and functional impairment in this population. Models accounting for age and sex revealed that lower levels of behavioral activation (BA) were significantly associated with all measures of depression, as well as with QOL and functional impairment (all ps < .01). Rumination was associated with all measures of depression (all ps < .01), but not with QOL or functional impairment. The consistent and unique association of BA with depression, QOL, and functional impairment bolsters its importance as a treatment target for this population.

Behavioral Activation Disseminated by Non-Mental Health Professionals, Paraprofessionals, and Peers: A Systematic Review

There is a striking disparity between the number of individuals with significant mental health concerns and those who are able to access care globally. One promising solution to expanding the mental health taskforce is task-sharing, or employing nonspecialists in the delivery of evidence-based interventions. Behavioral activation (BA), a brief intervention that focuses on scheduling rewarding activities into one's daily life, may have promise for delivery using task-sharing approaches due to its straightforward, flexible nature. The aim of this systematic review was to examine the current state of the literature on non-specialist-delivered BA and evaluate the evidence base of this approach. Three databases (Pubmed, PsycInfo, and Cochrane) were searched, and all articles were screened for inclusion criteria by two research assistants, included the review of titles, abstracts, and full-text. The final dataset consisted of 13 research studies, represented through 15 articles. A meta-analysis was conducted to examine the overall pooled effects of peer-delivered BA on depressive symptoms (the most widely examined clinical outcome). Studies reported on effectiveness and implementation outcomes of non-specialist-delivered BA for depression, substance use, loneliness, trauma survivors, and individuals with comorbid physical health conditions. Results provide initial support for the effectiveness of BA utilizing a task-sharing approach, and highlight the feasibility and acceptability of using nonspecialists to deliver BA in a variety of contexts, including low-resource settings.

Integrating HIV and substance misuse services: a person-centred approach grounded in human rights

Integrating HIV-related care with treatment for substance use disorder provides an opportunity to better meet the needs of people living with these conditions. People with substance use disorder are rendered especially vulnerable by prevailing policies, structural inequalities, and stigmatisation. In this Series paper we analyse existing literature and empirical evidence from scoping reviews on integration designs for the treatment of HIV and substance use disorder, to understand barriers to and facilitators of care integration and to map ways forward. We discuss how approaches to integration address two core gaps in current models: a failure to consider human rights when incorporating the perspectives of people living with HIV and people who use drugs, and a failure to reflect critically on structural factors that determine risk, vulnerability, health-care seeking, and health equity. We argue that successful integration requires a person-centred approach, which is grounded in human rights, treats both concerns holistically, and reconnects with underlying social, economic, and political inequalities.

Gender and Context Matter: Behavioral and Structural Interventions for People Who Use Alcohol and Other Drugs in Africa

Heavy alcohol consumption and other drug use are prominent across Africa and increase the risk of exposure to violence, HIV acquisition, and other life-threatening injuries. This review synthesizes evidence on alcohol and other drug (AOD) interventions in Africa; evaluates the differences between interventions that do and do not specifically target populations that use AODs; and highlights the impact of comprehensive vs. brief interventions and those that address syndemic issues from a gender and contextualized lens. Literature searches were conducted to identify research outcomes of randomized interventions published between January 2010 and May 2022 that address AOD use in Africa. Thirty-five full-text articles were included in this review. Most of the identified research studies were concentrated in a few countries. Most studies were conducted in South Africa. Many of the studies comprised brief interventions. However, the most comprehensive interventions were the most effective for AOD outcomes. Several studies indicated the importance of addressing AOD use alongside gender-based violence, mental health needs, gender roles, and other social determinants that affect health outcomes. Intervening on AOD use and addressing social determinants from a gender and contextually relevant perspective is essential to ensuring the long-term health and well-being of people in Africa.

The Relationship Between Harmful Alcohol Use and Antiretroviral Non-adherence in People Accessing HIV Treatment in Cape Town, South Africa: An Event-Level Analysis

Harmful alcohol consumption can significantly compromise adherence to antiretroviral therapy (ART). Prior research has identified aggregate relationships between alcohol use and ART non-adherence, largely relying on concurrent assessment of these domains. There is relatively limited evidence on more nuanced day-level associations between alcohol use and ART non-adherence, despite potentially important clinical implications. We recruited adults with HIV treatment adherence challenges and harmful alcohol use (n = 53) from HIV care in South Africa. We examined relationships between alcohol use and same and next day ART adherence, accounting for the role of weekends/holidays and participant demographics, including gender. Results demonstrated that ART adherence was significantly worse on weekend/holiday days. Next day adherence was significantly worse in the context of weekend alcohol use and among men. These results suggest the importance of tailoring intervention strategies to support ART adherence during weekend drinking and for men engaged in heavy episodic drinking.

Loneliness and Depression in College Students During the COVID-19 Pandemic: the Role of Boredom and Repetitive Negative Thinking

The COVID-19 pandemic triggered increased rates of depression, especially among college students. Due to social distancing guidelines, loneliness has been suspected as a prominent factor in depression during the pandemic. Research is needed to identify possible mechanisms through which loneliness conveys risk for pandemic-era depression. Two potential mechanisms are boredom and repetitive negative thinking (RNT). This study examined cross-sectional associations between depression, loneliness, boredom, and RNT in a sample of college students (N = 199) in April 2020 immediately following campus closure. Results showed a serial indirect effect of loneliness on depression through boredom then RNT. Moreover, specific indirect effects of loneliness on depression were found through boredom and RNT, individually. Though limited by the cross-sectional design, these data align with cognitive-behavioral theory and identify boredom and RNT as possible mechanisms of the association between loneliness and depression in college students during the COVID-19 pandemic.

Learn, Engage, Act, Dedicate (LEAD): development and feasibility testing of a task-shifted intervention to improve alcohol use, depression and family engagement for fathers

BACKGROUND

Men's depression, alcohol use, and family problems commonly co-occur to create of cluster of mental health problems. Yet, few treatments exist to address these problems, especially in low and middle-income countries (LMICs). This paper describes the development and initial feasibility and acceptability of a novel task-shifted intervention to address this cluster of men's mental health problems with a focus on engaging and retaining men in treatment.

METHODS

The intervention, Learn, Engage, Act, Dedicate (LEAD), is based in behavioral activation blended with motivational interviewing and was pilot tested in Kenya. To develop LEAD, we engaged in a community-engaged multi-step, collaborative process with local Kenyan stakeholders. LEAD was piloted with nine fathers reporting problem drinking. To assess initial feasibility and acceptability, recruitment and participation were tracked and descriptive statistics were generated given engagement of men was key for proof of concept. Semi-structured interviews were conducted with participants and analyzed using thematic content analysis.

RESULTS

The development process resulted in a weekly 5-session intervention rooted in behavioral activation, motivational interviewing, and masculinity discussion strategies. These approaches were combined and adapted to fit contextually salient constructs, such as the importance of the man as provider, and streamlined for lay providers. Feasibility and acceptability results were promising with high attendance, acceptability of delivery and intervention content, and perceived intervention helpfulness.

CONCLUSION

Results describe an acceptable task-shifted treatment that may engage men in care and addresses a cluster of common mental health problems among men in ways that consider social determinants like masculinity. Findings set the stage for a larger trial. Trial registration ISRCTN, ISRCTN130380278. Registered 7 October 2019-Retrospectively registered, http://www.isrctn.com/ISRCTN13038027.

Patient and provider perceptions of a peer-delivered intervention ('Khanya') to improve anti-retroviral adherence and substance use in South Africa: a mixed methods analysis

BACKGROUND

Despite a high prevalence of problematic substance use among people living with HIV in South Africa, there remains limited access to substance use services within the HIV care system. To address this gap, our team previously developed and adapted a six-session, peer-delivered problem-solving and behavioral activation-based intervention (Khanya) to improve HIV medication adherence and reduce substance use in Cape Town. This study evaluated patient and provider perspectives on the intervention to inform implementation and future adaptation.

METHODS

Following intervention completion, we conducted semi-structured individual interviews with patients (n = 23) and providers (n = 9) to understand perspectives on the feasibility, acceptability, and appropriateness of Khanya and its implementation by a peer. Patients also quantitatively ranked the usefulness of individual intervention components (problem solving for medication adherence 'Life-Steps', behavioral activation, mindfulness training, and relapse prevention) at post-treatment and six months follow-up, which we triangulated with qualitative feedback to examine convergence and divergence across methods.

RESULTS

Patients and providers reported high overall acceptability, feasibility, and appropriateness of Khanya, although there were several feasibility challenges. Mindfulness and Life-Steps were identified as particularly acceptable, feasible, and appropriate components by patients across methods, whereas relapse prevention strategies were less salient. Behavioral activation results were less consistent across methods.

CONCLUSIONS

Findings underscore the importance of examining patients' perspectives on specific intervention components within intervention packages. While mindfulness training and peer delivery models were positively perceived by consumers, they are rarely used within task-shared behavioral interventions in low- and middle-income countries.

The Role of Social Adjustment in a Collegiate Behavioral Activation Program

The transition to college is associated with significant changes in social support networks and concomitant increases in depressive symptoms. First-year students who are more socially engaged within their new academic settings may experience greater overall wellbeing. Behavioral activation (BA) is an evidence-based intervention which promotes individuals' engagement with valued activities and has been examined as a possible primary prevention for depressive symptoms among first-year students. Yet, the important role of social adjustment, and its impact on students' activity level, has not yet been considered. The current study is a secondary data analysis of research evaluating a BA-based intervention embedded into a first-year orientation course. The aim of the project was to evaluate the efficacy of BA on improving social adjustment and the effect of social adjustment on subsequent depressive symptoms. A diverse sample of college students (n = 71) attending a state university in the mid-Atlantic region reported on their levels of depression, behavioral activation, and social adjustment. Students then received either BA or standard programming. Results suggest that improved engagement in valued activities at mid-intervention was associated with increases in students' perceptions of their own social adjustment. This, in turn, predicted steeper decreases in rates of depressive symptoms post-intervention. Findings also indicate that greater social adjustment improved the efficacy of a BA-based intervention in reducing depressive symptoms, but had no impact on depressive symptoms for students receiving the standard orientation programming.

Loneliness and Mobile Phone Addiction Among Chinese College Students: The Mediating Roles of Boredom Proneness and Self-Control

INTRODUCTION

Mobile phones bring convenience to people's lives, but also affect their physical and mental health (especially in college students). Previous studies have revealed that mobile phone addiction is positively related to loneliness. This study further explored the mediating effects of boredom proneness and self-control on the relationship between loneliness and mobile phone addiction.

METHODS

A cross-sectional design was conducted in the present study. The investigation employed the Chinese version of the UCLA Loneliness Self-report Scale, Boredom Proneness Scale-Short Form, the Chinese version of the Self-control scale, and the Mobile Phone Addiction Index. Out of 1122 college students, 1078 completed the questionnaire survey and became our final subjects. PROCESS macro of SPSS 21 was used to conduct explore the mediating roles of boredom proneness and self-control in the relationship between loneliness and mobile phone addiction.

RESULTS

Loneliness, boredom proneness, and mobile phone addiction were significantly and positively correlated with each other, as well as significantly negatively correlated with self-control. Boredom proneness and self-control, when operating in parallel, partially mediated the relationship between loneliness and mobile phone addiction. By contrast, when occurring sequentially, they fully mediated the relationship between loneliness and mobile phone addiction.

CONCLUSION

Mobile phone addiction among lonely college students can be eliminated by exercising self-control and alleviating boredom proneness.

The role of reward and reinforcement in understanding alcohol use among adults living with HIV in South Africa

OBJECTIVE

Most research investigating reinforcement in alcohol use is from high-income countries. The current study sought to understand the association of different reinforcement types (alcohol-specific reward, environmental reward, behavioral activation) with multiple measures of alcohol use and cravings among individuals living with HIV in South Africa.

METHOD

Baseline data were obtained from a substance use clinical trial in Cape Town (N = 65). Unhealthy alcohol use was measured using the biomarker phosphatidylethanol (PEth), Alcohol Use Identification Test (AUDIT-C), average number of drinks from the timeline follow back (TLFB), and self-reported cravings. Reinforcement was measured using the proportion of income spent on alcohol (alcohol-specific reward), both subscales of the Reward Probability Index (environmental reward), and the Behavioral Activation Depression Scale (activation). Poisson and linear regression analyses were conducted.

RESULTS

Each percentage point increase in income spent on alcohol was significantly associated with PEth, RR = 1.004 [95% CI (1.001, 1.007)], which translates to a 13.6% increase in the relative risk of unhealthy alcohol use for the average person in the study. More alcohol-specific reward was significantly associated with higher scores on the AUDIT-C, higher average number of drinks on the TLFB, and more cravings. Higher activation was associated with lower scores on the AUDIT-C. Neither subscale of environmental reward was associated with model outcomes.

CONCLUSION

Greater alcohol-specific reward and less behavioral activation were associated with more frequent and unhealthy alcohol use in this setting, but not environmental reward. Findings highlight how different reinforcement types potentially influence alcohol use in a low-resource global setting. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Project Khanya: results from a pilot randomized type 1 hybrid effectiveness-implementation trial of a peer-delivered behavioural intervention for ART adherence and substance use in HIV care in South Africa

INTRODUCTION

South Africa (SA) has the highest number of people living with HIV (PLWH) globally, and a significant burden of alcohol and other drug use (AOD). Although integrating AOD treatment into HIV care may improve antiretroviral therapy (ART) adherence, this is not typically routine practice in SA or other low-resource settings. Identifying interventions that are feasible and acceptable for implementation is critical to improve HIV and AOD outcomes.

METHODS

A pilot randomized hybrid type 1 effectiveness-implementation trial (N = 61) was conducted to evaluate the feasibility and acceptability of Khanya, a task-shared, peer-delivered behavioral intervention to improve ART adherence and reduce AOD in HIV care in SA. Khanya was compared to enhanced treatment as usual (ETAU), a facilitated referral to on-site AOD treatment. Implementation outcomes, defined by Proctor's model, included feasibility, acceptability, appropriateness and fidelity. Primary pilot effectiveness outcomes were ART adherence at post-treatment (three months) measured via real-time electronic adherence monitoring, and AOD measured using biomarker and self-report assessments over six months. Data collection was conducted from August 2018 to April 2020.

RESULTS AND DISCUSSION

Ninety-one percent of participants (n = 56) were retained at six months. The intervention was highly feasible, acceptable, appropriate and delivered with fidelity (>90% of components delivered as intended by the peer). There was a significant treatment-by-time interaction for ART adherence (estimate = -0.287 [95% CI = -0.507, -0.066]), revealing a 6.4 percentage point increase in ART adherence in Khanya, and a 22.3 percentage point decline in ETAU. Both groups evidenced significant reductions in alcohol use measured using phosphatidylethanol (PEth) (F(2,101) = 4.16, p = 0.01), significantly decreased likelihood of self-reported moderate or severe AOD (F(2,104) = 7.02, p = 0.001), and significant declines in alcohol use quantity on the timeline follow-back (F(2,102) = 21.53, p < 0.001). Among individuals using drugs and alcohol, there was a greater reduction in alcohol use quantity in Khanya compared to ETAU over six months (F(2,31) = 3.28, p = 0.05).

CONCLUSIONS

Results of this pilot trial provide initial evidence of the feasibility and acceptability of the Khanya intervention for improving adherence in an underserved group at high risk for ongoing ART non-adherence and HIV transmission. Implementation results suggest that peers may be a potential strategy to extend task-sharing models for behavioral health in resource-limited, global settings.

Global policy responses to the COVID-19 pandemic: proportionate adaptation and policy experimentation: a study of country policy response variation to the COVID-19 pandemic

Background: Concern for the development of actions against COVID-19 has continued to grow since February 2020. Government responses remain a crucial part of preventing virus transmission through policy formulation and strengthening national capacity.

Methods: This study has used quantitative analysis, using secondary data from 177 countries. The variables consist of Global Health Security (GHS) category and COVID-19 pandemic. An analysis of the appropriateness of the government’s policy response in dealing with the COVID-19 pandemic was carried out by comparing the two variables.

Results: The study indicated a significant relationship between global health security category and pandemic score (P < 0.01). There were 37 countries out of 177 (20.9%) categorized as under-reaction and least-reaction.

Conclusion: Pandemic COVID-19 score, rated based on doubling time, is directly significant with the health security category. The government should improve its responsiveness and preparation to improve national capacity during the novel coronavirus pandemic.

Adapting a Behavioral Intervention for Alcohol Use and HIV Medication Adherence for Lay Counselor Delivery in Cape Town, South Africa: A Case Series

Human immunodeficiency virus (HIV) and problematic alcohol use are two ongoing and interconnected epidemics in South Africa, with untreated problematic alcohol use associated with poorer HIV treatment outcomes and disease progression. A lack of trained mental health providers is a primary barrier to increasing access to evidence-based treatment in this setting. To address this gap, we integrated evidence-based intervention components for problematic alcohol use and antiretroviral therapy (ART) adherence, adapted for lay provider delivery in an HIV primary care setting in Cape Town, South Africa. The intervention, locally termed "Khanya" in isiXhosa, which means glow, direction, or light, comprises Life Steps adherence counseling, motivational interviewing, behavioral activation, and relapse prevention, including mindfulness-based relapse prevention components. In this case series, we present a detailed description of the intervention and provide three clinical cases of individuals who received the Khanya intervention to showcase necessary clinical adaptations and the supervision needed for optimal treatment delivery, flexibility in intervention delivery, and overall successes and challenges. We present descriptive data on alcohol use and ART adherence outcomes for the cases to supplement the narrative discussion. Successes of intervention delivery included participant uptake of mindfulness skills, reductions in alcohol use despite varying levels of motivation, and interventionist mastery over various clinical skills. Challenges included delivering the intervention within the allotted time and the strong influence of substance-using social networks. Overall, a pragmatic approach to intervention delivery was necessary, as was ongoing support for the interventionist to promote fidelity to both treatment components and therapeutic skills.

Trial registration

ClinicalTrials.gov identifier: NCT03529409. Trial registered on May 18, 2018.

Project Khanya: a randomized, hybrid effectiveness-implementation trial of a peer-delivered behavioral intervention for ART adherence and substance use in Cape Town, South Africa

BACKGROUND

Substance use is prevalent in South Africa and associated with poor HIV treatment outcomes, yet, it is largely unaddressed in HIV care. Implementing an evidence-based, task-shared intervention for antiretroviral therapy (ART) adherence and substance use integrated into HIV care may be a feasible and effective way to improve HIV treatment outcomes and reduce substance use in this population.

METHODS

Guided by the RE-AIM framework, a randomized, hybrid type 1 effectiveness-implementation trial (n = 60) is being used to evaluate a peer-delivered intervention that integrates evidence-based intervention components, including Life-Steps (problem solving and motivational skills for HIV medication adherence), behavioral activation to increase alternative, substance-free rewarding activities in one's environment, and relapse prevention skills, including mindfulness. The comparison condition is enhanced standard of care, which includes facilitating a referral to a local substance use treatment clinic (Matrix). Participants are followed for a period of 6 months. Implementation outcomes are defined by Proctor's model for implementation and include mixed methods evaluations of feasibility, acceptability, and fidelity, and barriers and facilitators to implementation. Primary patient-level effectiveness outcomes are ART adherence (Wisepill) and substance use (WHO-ASSIST and urinalysis); viral load is an exploratory outcome.

DISCUSSION

Results of this trial will provide important evidence as to whether peer delivery of an integrated intervention for ART adherence and substance use is feasible, acceptable, and effective. Implementation outcomes will provide important insight into using peers as an implementation strategy to extend task sharing models for behavioral health in resource-limited settings globally.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03529409. Trial registered on May 18, 2018.

Adapting a peer recovery coach-delivered behavioral activation intervention for problematic substance use in a medically underserved community in Baltimore City

Low-income, racial/ethnic minority groups have disproportionately high rates of problematic substance use yet face barriers in accessing evidence-based interventions (EBIs). Peer recovery coaches (PRCs), individuals with lived experience with problematic substance use, may provide an effective approach to reaching these individuals. Traditionally PRCs have focused on bridging to other types of care rather than delivering EBIs themselves. The aim of this study was to assess perceptions of the appropriateness of a PRC-delivered adapted behavioral activation (BA) intervention to reduce problematic substance use for individuals not engaged in care. This study was conducted at a community resource center in Baltimore, Maryland serving low-income and homeless clients who have high rates of problematic substance use yet also face barriers to accessing care. Guided by the ADAPT-ITT framework, we conducted semi-structured key informant interviews with clients (n = 30) with past or present problematic substance use, and a focus group with community providers, including staff at the community resource center (n = 5) and PRCs (n = 6) from the community. Thirty percent (n = 9) of clients interviewed reported past problematic substance use and 70% (n = 21) met criteria for current use, most commonly cocaine and opioids. Clients, center staff, and PRCs shared that PRC-delivered BA could be acceptable and appropriate with suggested adaptations, including adding peer-delivered case-management and linkage to care alongside BA, and tailoring BA to include activities that are accessible and feasible in the community. These findings will inform the adaptation of PRC-delivered BA to address problematic substance use in this setting.