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Naigino R, Miller AP, Ediau M, Anecho A, Senoga U, Tumwesigye NM, Wanyenze RK, Mukasa B, Hahn JA, Reed E, Sileo KM, Kiene SM. Stakeholder perspectives on the Kisoboka intervention: A behavioral and structural intervention to reduce hazardous alcohol use and improve HIV care engagement among men living with HIV in Ugandan fishing communities. Drug Alcohol Depend 2023; 253:111011. [PMID: 37952352 PMCID: PMC11016226 DOI: 10.1016/j.drugalcdep.2023.111011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/25/2023] [Accepted: 10/20/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND East Africa's fishing communities experience a high burden of two interrelated and frequently co-occurring health issues: HIV and hazardous alcohol use. Nearly two-thirds of Ugandan fisherfolk men meet the criteria for harmful alcohol use. We developed a multilevel intervention to reduce hazardous alcohol use and improve HIV care engagement among fisherfolk men living with HIV (LWHIV) in Wakiso district, Uganda. METHODS This is a qualitative study of stakeholder perspectives on the appropriateness, acceptability, and feasibility of a multilevel intervention for fisherfolk men LWHIV. The proposed intervention, Kisoboka ("It is possible!"), combines a structural component [changing the mode of work payments from cash to mobile money] with a behavioral component [motivational interviewing-based counseling combined with content using behavioral economic principles to promote behavior change]. We conducted one focus group (n=7) and eight in-depth interviews with fisherfolk men LWHIV and 19 key informant (KI) interviews with health workers, employers, and community leaders. These explored the appropriateness, acceptability, and feasibility of specific key intervention components. RESULTS Overall, stakeholders' perspectives supported high intervention acceptability and perceived appropriateness of the proposed intervention. It was perceived to be feasible with some caveats of recommendations for overcoming potential implementation challenges identified (e.g., having a friend assist with documenting savings and alcohol use if an individual was unable to write themselves) which are discussed. CONCLUSION This work highlights the potential of the Kisoboka intervention and the importance of early engagement of key stakeholders in the intervention development process to ensure appropriateness, acceptability, feasibility, and socio-cultural fit.
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Affiliation(s)
- Rose Naigino
- Division of Epidemiology and Biostatistics, San Diego State University School of Public Health, CA, USA; Makerere University School of Public Health, Kampala, Uganda
| | - Amanda P Miller
- Division of Epidemiology and Biostatistics, San Diego State University School of Public Health, CA, USA
| | - Michael Ediau
- Division of Epidemiology and Biostatistics, San Diego State University School of Public Health, CA, USA; Makerere University School of Public Health, Kampala, Uganda
| | - Asha Anecho
- Makerere University School of Public Health, Kampala, Uganda
| | - Umar Senoga
- Makerere University School of Public Health, Kampala, Uganda
| | | | | | | | - Judith A Hahn
- Department of Medicine, University of California San Francisco, CA, USA
| | - Elizabeth Reed
- Division of Health Promotion and Behavioral Science, San Diego State University, CA, USA
| | - Katelyn M Sileo
- Department of Public Health, University of Texas at San Antonio, TX, USA
| | - Susan M Kiene
- Division of Epidemiology and Biostatistics, San Diego State University School of Public Health, CA, USA; Makerere University School of Public Health, Kampala, Uganda.
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Wechsberg WM, van der Drift I, Howard BN, Myers B, Browne FA, Bonner CP, Carney T, Ndirangu J, Washio Y. Gender and Context Matter: Behavioral and Structural Interventions for People Who Use Alcohol and Other Drugs in Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:8661. [PMID: 35886515 PMCID: PMC9316816 DOI: 10.3390/ijerph19148661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/30/2022] [Accepted: 07/05/2022] [Indexed: 12/04/2022]
Abstract
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.
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Affiliation(s)
- Wendee M. Wechsberg
- Substance Use, Gender and Applied Research Program, RTI International, Research Triangle Park, NC 27709, USA; (I.v.d.D.); (B.N.H.); (F.A.B.); (C.P.B.); (J.N.); (Y.W.)
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Department of Psychology, North Carolina State University, Raleigh, NC 27695, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC 27708, USA
| | - Isa van der Drift
- Substance Use, Gender and Applied Research Program, RTI International, Research Triangle Park, NC 27709, USA; (I.v.d.D.); (B.N.H.); (F.A.B.); (C.P.B.); (J.N.); (Y.W.)
| | - Brittni N. Howard
- Substance Use, Gender and Applied Research Program, RTI International, Research Triangle Park, NC 27709, USA; (I.v.d.D.); (B.N.H.); (F.A.B.); (C.P.B.); (J.N.); (Y.W.)
| | - Bronwyn Myers
- Alcohol Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town 7580, South Africa; (B.M.); (T.C.)
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town 7701, South Africa
- Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Perth 6102, Australia
| | - Felicia A. Browne
- Substance Use, Gender and Applied Research Program, RTI International, Research Triangle Park, NC 27709, USA; (I.v.d.D.); (B.N.H.); (F.A.B.); (C.P.B.); (J.N.); (Y.W.)
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Courtney Peasant Bonner
- Substance Use, Gender and Applied Research Program, RTI International, Research Triangle Park, NC 27709, USA; (I.v.d.D.); (B.N.H.); (F.A.B.); (C.P.B.); (J.N.); (Y.W.)
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Tara Carney
- Alcohol Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town 7580, South Africa; (B.M.); (T.C.)
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town 7701, South Africa
| | - Jacqueline Ndirangu
- Substance Use, Gender and Applied Research Program, RTI International, Research Triangle Park, NC 27709, USA; (I.v.d.D.); (B.N.H.); (F.A.B.); (C.P.B.); (J.N.); (Y.W.)
| | - Yukiko Washio
- Substance Use, Gender and Applied Research Program, RTI International, Research Triangle Park, NC 27709, USA; (I.v.d.D.); (B.N.H.); (F.A.B.); (C.P.B.); (J.N.); (Y.W.)
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19122, USA
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Rose AL, Belus JM, Ma T, Lee JS, Wan C, De Los Reyes A, Joska JA, Andersen LS, Myers B, Magidson JF. The Relationship Between Harmful Alcohol Use and Antiretroviral Non-adherence in People Accessing HIV Treatment in Cape Town, South Africa: An Event-Level Analysis. AIDS Behav 2022; 26:2055-2066. [PMID: 35022939 DOI: 10.1007/s10461-021-03552-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Alexandra L Rose
- Department of Psychology, University of Maryland, 4094 Campus Drive, College Park, MD, USA.
| | - Jennifer M Belus
- Department of Psychology, University of Maryland, 4094 Campus Drive, College Park, MD, USA
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Tianzhou Ma
- Department of Epidemiology and Biostatistics, University of Maryland, College Park, MD, USA
| | - Jasper S Lee
- Department of Psychology, University of Miami, Coral Gables, FL, USA
| | - Christine Wan
- Department of Psychology, University of Maryland, 4094 Campus Drive, College Park, MD, USA
| | - Andres De Los Reyes
- Department of Psychology, University of Maryland, 4094 Campus Drive, College Park, MD, USA
| | - John A Joska
- HIV Mental Health Research Unit, University of Cape Town, Cape Town, South Africa
| | - Lena S Andersen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Bronwyn Myers
- Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Bentley, Australia
- Alcohol, Tobacco, and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
- Division of Addiction Psychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Jessica F Magidson
- Department of Psychology, University of Maryland, 4094 Campus Drive, College Park, MD, USA
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4
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Regenauer KS, Kleinman MB, Belus JM, Myers B, Joska JA, Magidson JF. Effects of intersecting internalized stigmas and avoidance on HIV and alcohol-related outcomes among people living with HIV in South Africa. Drug Alcohol Depend 2022; 233:109364. [PMID: 35219998 PMCID: PMC8978067 DOI: 10.1016/j.drugalcdep.2022.109364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Despite HIV and problematic drinking often co-occurring in South Africa (SA), limited research has examined how HIV stigma relates to alcohol outcomes, how alcohol stigma relates to HIV outcomes, and moderators of these associations. This study examined the intersection of HIV and alcohol stigmas on HIV and alcohol outcomes, and the role of avoidant behavior in moderating these relationships in SA. METHODS We assessed biomarker-verified measures of antiretroviral therapy (ART) adherence, HIV viral load (VL), and alcohol consumption, and self-reported measures of internalized HIV/alcohol stigmas, avoidant behavior, ART adherence, and problematic drinking-alcohol use that will likely lead to health or other problems-cross-sectionally among people with HIV (PWH) and problematic drinking (N = 64). We conducted regression analyses with interaction terms. FINDINGS A significant relationship was found between internalized alcohol stigma and VL suppression, with higher levels of alcohol stigma associated with a lower likelihood of suppression (OR=1.68, 95%CI[1.11-2.65], p = .02). Avoidance significantly moderated the relationship between internalized HIV stigma and problematic drinking; higher HIV stigma was associated with lower problematic drinking only at low levels of avoidance (b(SE)= -1.92(.85), p = .03). CONCLUSIONS This study is the first to examine associations between HIV and alcohol stigmas, avoidance, and both HIV and alcohol outcomes in SA. Findings contribute to our understanding of how alcohol stigma relates to biological HIV outcomes, and the role of avoidance in the relationship between internalized HIV stigma and problematic drinking. Findings may inform future clinical interventions aiming to address the impact of stigma on HIV treatment outcomes and alcohol use among PWH in SA.
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Affiliation(s)
| | - Mary B. Kleinman
- Department of Psychology, University of Maryland, College Park, United States
| | - Jennifer M. Belus
- Department of Psychology, University of Maryland, College Park, United States,Swiss Tropical and Public Health Institute, Department of Medicine, Basel, Switzerland,University of Basel, Basel, Switzerland
| | - Bronwyn Myers
- Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Perth, Australia,Alcohol, Tobacco and Other Drug Abuse Research Unit, South African Medical Research Council, Tygerberg, South Africa,Division of Addiction Psychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - John A. Joska
- HIV Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Jessica F. Magidson
- Department of Psychology, University of Maryland, College Park, United States
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5
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Magidson JF, Joska JA, Belus JM, Andersen LS, Regenauer KS, Rose AL, Myers B, Majokweni S, O’Cleirigh C, Safren SA. 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. J Int AIDS Soc 2021; 24 Suppl 2:e25720. [PMID: 34164935 PMCID: PMC8222840 DOI: 10.1002/jia2.25720] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/31/2021] [Accepted: 04/08/2021] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
| | - John A Joska
- HIV Mental Health Research UnitDivision of NeuropsychiatryDepartment of Psychiatry and Mental HealthGroote Schuur HospitalCape TownSouth Africa
| | | | - Lena S Andersen
- HIV Mental Health Research UnitDivision of NeuropsychiatryDepartment of Psychiatry and Mental HealthGroote Schuur HospitalCape TownSouth Africa
| | | | | | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research UnitSouth African Medical Research CouncilDivision of Addiction PsychiatryDepartment of Psychiatry and Mental HealthUniversity of Cape TownCape TownSouth Africa
| | - Sybil Majokweni
- HIV Mental Health Research UnitDivision of NeuropsychiatryDepartment of Psychiatry and Mental HealthGroote Schuur HospitalCape TownSouth Africa
| | - Conall O’Cleirigh
- Department of PsychiatryMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
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"Moving Forward with Life": Acceptability of a Brief Alcohol Reduction Intervention for People Receiving Antiretroviral Therapy in South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165706. [PMID: 32784613 PMCID: PMC7459709 DOI: 10.3390/ijerph17165706] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 12/15/2022]
Abstract
Background: In South Africa, interventions are needed to address the impact of hazardous drinking on antiretroviral therapy among people living with HIV (PLWH). Participant feedback about these interventions can identify ways to enhance their acceptability. We interviewed participants in a randomized controlled trial of a brief motivational interviewing and problem-solving therapy (MI-PST) intervention about their perceptions of this alcohol-reduction intervention. Methods: The trial was conducted in HIV treatment clinics operating from six hospitals in the Tshwane region of South Africa. We conducted qualitative in-depth interviews with a random selection of participants. Twenty-four participants were interviewed after the final intervention session and 25 at the six-month follow up. Results: Participants believed that it was acceptable to offer PLWH, an alcohol reduction intervention during HIV treatment. They described how the MI-PST intervention had helped them reduce their alcohol consumption. Intervention components providing information on the health benefits of reduced consumption and building problem-solving and coping skills were perceived as most beneficial. Despite these perceived benefits, participants suggested minor modifications to the dosage, content, and delivery of the intervention for greater acceptability and impact. Conclusions: Findings highlight the acceptability and usefulness of this MI-PST intervention for facilitating reductions in alcohol consumption among PLWH.
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Petersen Williams P, Brooke-Sumner C, Joska J, Kruger J, Vanleeuw L, Dada S, Sorsdahl K, Myers B. Young South African Women on Antiretroviral Therapy Perceptions of a Psychological Counselling Program to Reduce Heavy Drinking and Depression. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2249. [PMID: 32230712 PMCID: PMC7178219 DOI: 10.3390/ijerph17072249] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/12/2020] [Accepted: 03/19/2020] [Indexed: 01/06/2023]
Abstract
Young women in South Africa remain most at risk for HIV infection. Several factors contribute to the high incidence rate in this population, including hazardous drinking and depression. Addressing common mental disorders (CMDs) such as depression and alcohol use disorders is key to effective HIV treatment. We explored the experiences and perceptions of young South African women on antiretroviral therapy (ART) of a lay health worker (LHW)-delivered psychosocial intervention based on motivational interviewing (MI) and problem-solving therapy (PST) to reduce heavy drinking and depression. We conducted 27 in-depth interviews with young women (aged 18-35) recruited from 16 primary care clinics in the Western Cape province of South Africa. Discussion topics included young women's life experiences leading to their enrollment in the program, their perceptions of the counselling sessions and the quality of their interaction with the counsellor. Qualitative data were analyzed using a framework approach. The findings highlighted the impact adverse life experiences and stressful life circumstances have on young women's use of alcohol and symptoms of depression and the effect this has on ART adherence. The findings suggest that women found the intervention components that helped them develop strategies for coping with their past experiences, managing current life stressors, and regulating negative thoughts and emotions most beneficial. Taken together, these findings confirm the acceptability of LHW-delivered MI-PST counselling for this population, but suggest that the relevance of the MI-PST intervention for this highly vulnerable population could be further enhanced by including a focus on psychological trauma.
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Affiliation(s)
- Petal Petersen Williams
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie van Zyl Drive, Tygerberg 7505, South Africa; (C.B.-S.); (S.D.); (B.M.)
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town 7700, South Africa
| | - Carrie Brooke-Sumner
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie van Zyl Drive, Tygerberg 7505, South Africa; (C.B.-S.); (S.D.); (B.M.)
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town 7700, South Africa;
| | - John Joska
- HIV Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town 7700, South Africa;
| | - James Kruger
- Western Cape Department of Health., 8 Riebeeck Street, Cape Town 8000, South Africa;
| | - Lieve Vanleeuw
- Health Systems Research Unit, South African Medical Research Council, Francie van Zyl Drive, Tygerberg 7505, South Africa;
| | - Siphokazi Dada
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie van Zyl Drive, Tygerberg 7505, South Africa; (C.B.-S.); (S.D.); (B.M.)
| | - Katherine Sorsdahl
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town 7700, South Africa;
| | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie van Zyl Drive, Tygerberg 7505, South Africa; (C.B.-S.); (S.D.); (B.M.)
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town 7700, South Africa
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Satinsky EN, Doran K, Felton JW, Kleinman M, Dean D, Magidson JF. Adapting a peer recovery coach-delivered behavioral activation intervention for problematic substance use in a medically underserved community in Baltimore City. PLoS One 2020; 15:e0228084. [PMID: 32004328 PMCID: PMC6993963 DOI: 10.1371/journal.pone.0228084] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 01/07/2020] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Emily N. Satinsky
- Department of Psychology, University of Maryland, College Park, Maryland, United States of America
| | - Kelly Doran
- Department of Nursing, University of Maryland, Baltimore, Maryland, United States of America
| | - Julia W. Felton
- Department of Public Health, Michigan State University, Flint, Michigan, United States of America
| | - Mary Kleinman
- Department of Psychology, University of Maryland, College Park, Maryland, United States of America
| | - Dwayne Dean
- Department of Nursing, University of Maryland, Baltimore, Maryland, United States of America
| | - Jessica F. Magidson
- Department of Psychology, University of Maryland, College Park, Maryland, United States of America
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Carney T, Chimbambo V, Johnson K, Louw J, Myers B. The adaptation of an evidence-based brief intervention for substance-using adolescents and their caregivers. Psychother Res 2019; 30:728-738. [PMID: 31438777 DOI: 10.1080/10503307.2019.1656352] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Objective: Adolescent substance use is prevalent and associated with additional risk behaviours. Research shows that evidence-based brief interventions with adolescents and their main caregiver may mitigate the progression of substance use. Method: We used the ADAPT-ITT framework to develop a needs-based, culturally-sensitive intervention. Five focus groups with adolescents (n = 30), three focus groups with separate main caregivers of adolescents who use substances (n = 21), key informant interviews and an expert meeting, were conducted. Results: Adolescents described the need to decrease risk behaviours, while adolescents and caregivers requested additional support. The core components of the original intervention were retained, with some additions. The newly adapted RAD-PAL intervention was viewed as acceptable. Conclusion: Despite apparent acceptability, we need to test feasibility and efficacy in a trial.
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Affiliation(s)
- Tara Carney
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa.,Division of Addiction Psychiatry, Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | - Kim Johnson
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Johann Louw
- Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa.,Division of Addiction Psychiatry, Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Duko B, Toma A, Abraham Y. Alcohol use disorder and associated factors among individuals living with HIV in Hawassa City, Ethiopia: a facility based cross- sectional study. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2019; 14:22. [PMID: 31109353 PMCID: PMC6528325 DOI: 10.1186/s13011-019-0212-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/09/2019] [Indexed: 01/17/2023]
Abstract
Background Individuals living with HIV/AIDS with co-occurring harmful alcohol use may require specialized intervention or even multi-disciplinary team follow-up and management. This study was aimed to assess alcohol use disorder and associated factors among people living with HIV/AIDS in Hawassa city, Ethiopia, 2019. Methods A facility based cross-sectional study was conducted among 195 people living with HIV/AIDS who had follow-up visit at Hawassa University Comprehensive Specialized hospital. A systematic sampling technique was used to recruit the study participants. Alcohol used disorders identification test (AUDIT) was used to measure alcohol consumption, drinking behaviors, and alcohol-related problems. The binary logistic regression model was used to see the association between alcohol use disorder (AUD) and the independent variables. The strength of association was measured by odds ratios with 95% confidence intervals. Statistical significance declared at P < 0.05. Results The mean age of the study participants was 29.88 (±SD = 10.89) years. The magnitude of alcohol use disorder among people living with HIV/AIDS was 31.8%. Being male [AOR = 2.43, (95% CI: 1.76, 5.76)], having poor social support [AOR = 1.34, (95% CI: 1.12, 6.73)], being medication non-adherent [AOR = 1.78, (95% CI: 1.33, 6.79)], current khat chewing [AOR = 1.67, (95% CI: 1.16, 5.45)] and current cigarette smoking [AOR = 3.76, (95% CI: 2.16, 7.54)] had statistically significant association with alcohol use disorder. Conclusion In the current study, magnitude of alcohol use disorder among people living with HIV was high and, calls for integrating services provided to HIV patients in HIV care and treatment clinic which enhances timely detection and management of AUD cases. This also alerts the stakeholders in HIV prevention and control programs to invest a greater efforts to retain patients in addiction treatment and rehabilitation centers. Lastly, appropriate screening and health education on consequences of alcohol use disorder is warranted.
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Affiliation(s)
- Bereket Duko
- Faculty of Health Sciences, College of Medicine and Health Sciences, Hawassa University, P. O. Box 1560, Hawassa, Ethiopia.
| | - Alemayehu Toma
- Faculty of Medical Sciences, College of Medicine and Health Sciences, Hawassa University, P. O. Box 1560, Hawassa, Ethiopia
| | - Yacob Abraham
- Faculty of Health Sciences, College of Medicine and Health Sciences, Hawassa University, P. O. Box 1560, Hawassa, Ethiopia
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Myers B, Carney T, Browne FA, Wechsberg WM. A trauma-informed substance use and sexual risk reduction intervention for young South African women: a mixed-methods feasibility study. BMJ Open 2019; 9:e024776. [PMID: 30782918 PMCID: PMC6368003 DOI: 10.1136/bmjopen-2018-024776] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Sexual and physical trauma and substance use are intersecting risks for HIV among young women. This study assesses the feasibility, acceptability and preliminary effects of a novel trauma-informed substance use and sexual risk reduction intervention for young South African women. DESIGN A single arm feasibility test and qualitative interviews of participants. PARTICIPANTS Sixty women, between 18 and 25 years of age, who reported trauma exposure, substance use and recent condom-less sex were recruited. Twenty participants were randomly selected for qualitative interviews. INTERVENTION A six-session group-based intervention. MAIN OUTCOME MEASURES We examined the proportion of women who provided consent, completed counselling and were retained in the study. Qualitative interviews explored intervention acceptability. Preliminary effects of the intervention on substance use, mental health (depression, psychological distress and trauma symptoms) and sexual risk outcomes (STI symptoms, number of partners and condomless sex) were explored. RESULTS Of the 66 eligible women, 91% were enrolled. Intervention completion rates were low; 35% attended all sessions. On average, participants attended four sessions (M=3.8, SD=1.3). A 93% follow-up rate was achieved at the 3-month endpoint. In this single group design, reductions in the proportion of participants who tested positive for methamphetamine, cannabis and methaqualone were observed at the 3-month endpoint. Symptoms of depression, psychological distress and trauma; number of STI symptoms; and number of sexual partners also decreased. Outcomes were similar for participants who completed up to four and those who completed five or more sessions. Participants thought the intervention was highly beneficial and proposed modifications to enhance acceptability. CONCLUSIONS This novel intervention seems acceptable and holds potential benefits for trauma-exposed women who use substances. Truncating the intervention may enhance the likelihood of its implementation. The efficacy of the intervention for improving substance use, sexual risk and mental health outcomes requires testing in a controlled design.
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Affiliation(s)
- Bronwyn Myers
- Alcohol, Tobacco and 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 and 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
| | - Felicia A Browne
- Substance Use and Gender Research (SUGAR) Program, Research Triangle Institute (RTI) International, Research Triangle Park, North Carolina, USA
| | - Wendee M Wechsberg
- Substance Use and Gender Research (SUGAR) Program, Research Triangle Institute (RTI) International, Research Triangle Park, North Carolina, USA
- Gillings Global School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Psychology in the Public Interest, North Carolina State University, Raleigh, North Carolina, USA
- Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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Myers B, Lund C, Lombard C, Joska J, Levitt N, Butler C, Cleary S, Naledi T, Milligan P, Stein DJ, Sorsdahl K. Comparing dedicated and designated models of integrating mental health into chronic disease care: study protocol for a cluster randomized controlled trial. Trials 2018; 19:185. [PMID: 29548302 PMCID: PMC5857135 DOI: 10.1186/s13063-018-2568-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 02/26/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In low- and middle-income countries (LMIC), it is uncertain whether a "dedicated" approach to integrating mental health care (wherein a community health worker (CHW) has the sole responsibility of delivering mental health care) or a "designated" approach (wherein a CHW provides this service in addition to usual responsibilities) is most effective and cost-effective. This study aims to compare the effectiveness and cost-effectiveness of these two models of service integration relative to treatment as usual (TAU) for improving mental health and chronic disease outcomes among patients with HIV or diabetes. METHODS/DESIGN This is a cluster randomised trial. We will randomise 24 primary health care facilities in the Western Cape Province of South Africa to one of three study arms. Within each cluster, we will recruit 25 patients from HIV and 25 from diabetes services for a total sample of 1200 participants. Eligible patients will be aged 18 years or older, take medication for HIV or diabetes, and screen positive on the Alcohol Use Disorder Identification Test for hazardous/harmful alcohol use or depression on the Centre for Epidemiology Scale on Depression. Participants recruited in clinics assigned to the designated or dedicated approach will receive three sessions of motivational interviewing and problem-solving therapy, while those recruited at TAU-assigned clinics will be referred for further assessment. Participants will complete an interviewer-administered questionnaire at baseline, and at 6 and 12 months post-enrolment to assess change in self-reported outcomes. At these end points, we will test HIV RNA viral load for participants with HIV and HbA1c levels for participants with diabetes. Primary outcomes are reductions in self-reported hazardous/harmful alcohol use and risk of depression. Secondary outcomes are improvements in adherence to chronic disease treatment, biomarkers of chronic disease outcomes, and health-related quality of life. Mixed-effect linear regression models will model the effect of the interventions on primary and secondary outcomes. The cost-effectiveness of each approach will be assessed using incremental cost-effectiveness ratios. DISCUSSION Study findings will guide decision-making around how best to integrate mental health counselling into chronic disease care in a LMIC setting. TRIAL REGISTRATION Pan African Clinical Trials Registry, Trial registration number: ACTR201610001825403 . Registered 17 October 2016.
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Affiliation(s)
- Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie van Zyl Drive, Tygerberg, Cape Town, 7505 South Africa
- Division of Addiction Psychiatry, Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Crick Lund
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Francie van Zyl Drive, Tygerberg, Cape Town, 7505 South Africa
| | - John Joska
- HIV and Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Naomi Levitt
- Division for Diabetes and Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Christopher Butler
- Nuffield Department of Primary Care Health Services, Oxford University, Oxford, UK
| | - Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tracey Naledi
- Western Cape Department of Health, 8 Riebeeck Street, Cape Town, South Africa
| | - Peter Milligan
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- Western Cape Department of Health, Valkenberg Hospital, Cape Town, South Africa
| | - Dan J. Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- Unit on Anxiety and Stress Disorders, South African Medical Research Council, Cape Town, South Africa
| | - Katherine Sorsdahl
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Myers B, Joska JA, Lund C, Levitt NS, Butler CC, Naledi T, Milligan P, Stein DJ, Sorsdahl K. Patient preferences for the integration of mental health counseling and chronic disease care in South Africa. Patient Prefer Adherence 2018; 12:1797-1803. [PMID: 30271123 PMCID: PMC6154740 DOI: 10.2147/ppa.s176356] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To describe patient perceptions of the acceptability of integrating mental health counseling within primary care facilities in the Western Cape province of South Africa and their preferences for the way in which this care is delivered. PATIENTS AND METHODS Qualitative interviews with 30 purposively selected patients receiving treatment for HIV or diabetes within primary care facilities who screened positive for depression using the Center for Epidemiological Studies Depression Scale or hazardous alcohol use through the Alcohol Use Disorders Identification Test. RESULTS Participants articulated high levels of unmet need for mental health services and strong associations between poor mental health and the challenges of living with a chronic disease. Consequently, they considered it acceptable to offer screening and mental health counseling within the context of chronic disease care. They thought counseling would be highly relevant if it helped patients develop adaptive strategies for coping with stress and negative emotions. Irrespective of chronic disease, patients indicated a preference for lay counselors rather than existing clinicians as potential delivery agents, supporting a task-shared approach to mental health counseling delivery in primary care settings. Some expressed concern about the feasibility of using lay counselors already present in facilities to deliver this service, suggesting that additional counselors might be needed. CONCLUSION Findings demonstrate a need for mental health counseling within the context of chronic disease care in South Africa. Task-shared approaches, using lay counselors, seem acceptable to patients - provided counselors are selected to ensure they possess the qualities associated with effective counselors. Findings have informed the design of a task-shared mental health program that is responsive to the preferences of patients with chronic diseases.
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Affiliation(s)
- Bronwyn Myers
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa,
- Division of Addiction Psychiatry, Psychiatry and Mental Health,
| | - John A Joska
- HIV and Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health
| | - Crick Lund
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Naomi S Levitt
- Division for Diabetes and Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Services, Oxford University, Oxford, UK
| | - Tracey Naledi
- Western Cape Department of Health, Cape Town, South Africa
- Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Peter Milligan
- KwaZulu-Natal Department of Health, KwaZulu-Natal, South Africa
| | - Dan J Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- SAMRC Unit on Anxiety and Stress Disorders, Cape Town, South Africa
| | - Katherine Sorsdahl
- Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Parry CDH, Tomlinson M, Bryant K, Rotherham-Borus MJ. Fresh Perspectives on the Alcohol and HIV Nexus: A Call for Action in an Era of Increased Opportunities and Challenges. AIDS Behav 2017; 21:121-125. [PMID: 28956194 PMCID: PMC5839632 DOI: 10.1007/s10461-017-1917-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Charles D H Parry
- Alcohol Tobacco & Other Drug Research Unit, South African Medical Research Council, Tygerberg, South Africa.
- Department of Psychiatry, Stellenbosch University, PO Box 19070, Tygerberg, 7505, South Africa.
| | - Mark Tomlinson
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | - Kendall Bryant
- HIV/AIDS and Alcohol Research Program, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Mary Jane Rotherham-Borus
- Global Center for Children and Families, Semel Institute and the Department of Psychiatry, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
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Liu Y, Ruan Y, Strauss SM, Yin L, Liu H, Amico KR, Zhang C, Shao Y, Qian HZ, Vermund SH. Alcohol misuse, risky sexual behaviors, and HIV or syphilis infections among Chinese men who have sex with men. Drug Alcohol Depend 2016; 168:239-246. [PMID: 27723554 PMCID: PMC5523945 DOI: 10.1016/j.drugalcdep.2016.09.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/21/2016] [Accepted: 09/25/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Few studies have employed standardized alcohol misuse measures to assess relationships with sexual risk and HIV/syphilis infections among Chinese men who have sex with men (MSM). METHODS We conducted a cross-sectional study among MSM in Beijing during 2013-2014. An interviewer-administered survey was conducted to collect data on sociodemographics, high-risk behaviors, and alcohol use/misuse patterns (hazardous/binge drinking and risk of alcohol dependence) in the past 3 months using Alcohol Use Disorder Identification Test-Consumption (AUDIT-C). We defined AUDIT-C score ≥4 as recent hazardous drinkers, and drinking ≥6 standard drinks on one occasion as recent binge drinkers. RESULTS Of 3588 participants, 14.4% reported hazardous drinking, 16.8% reported binge drinking. Hazardous and binge drinking are both associated with these factors (p<0.05): older age, being migrants, living longer in Beijing, township/village origin, being employed, higher income, self-perceived low/no HIV risk, and sex-finding via non-Internet venues. Hazardous (vs non-hazardous) or binge (vs. non-binge) drinkers were more likely to use illicit drugs, use alcohol before sex, have multiple partnerships, pay for sex, and have condomless insertive anal intercourse. MSM who reported binge (AOR, 1.34, 95% CI, 1.02-1.77) or hazardous (AOR, 1.36, 95% CI, 1.02-1.82) drinking were more likely to be HIV-infected. MSM at high risk of current alcohol dependence (AUDIT-C ≥8) were more likely to be HIV- (AOR, 2.37, 95% CI, 1.39-4.04) or syphilis-infected (AOR, 1.96, 95% CI, 1.01-3.86). CONCLUSIONS Recent alcohol misuse was associated with increased sexual and HIV/syphilis risks among Chinese MSM, emphasizing the needs of implementing alcohol risk reduction programs in this population.
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Affiliation(s)
- Yu Liu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA
| | - Yuhua Ruan
- State Key Laboratory of Infectious Disease Prevention and Control (SKLID), Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Shiela M. Strauss
- The Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Lu Yin
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA
| | - Hongjie Liu
- The Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, Michigan, USA
| | - Chen Zhang
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA
| | - Yiming Shao
- State Key Laboratory of Infectious Disease Prevention and Control (SKLID), Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Han-Zhu Qian
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA,Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sten H. Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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