Gender-specific HIV and substance abuse prevention strategies for South African men: study protocol for a randomized controlled trial

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

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.

Designing Evidence-Based Preventive Interventions That Reach More People, Faster, and with More Impact in Global Contexts

This article demonstrates the substantial similarities globally among preventive, evidence-based interventions (EBIs) designed to address HIV by providing four examples: an HIV family-focused intervention, the Community Popular Opinion Leader intervention, a South African maternal/child health program, and an EBI for sex workers in India. Each identified the key problems in the target population, utilized well-established social cognitive theories, created processes for engaging the target population, set standards for staff accountability, and included routine data collection to facilitate iterative program improvements over time. Building EBIs based on these common, robust features is an alternative design strategy to replication with fidelity. These components provide a road map for researchers, especially those using new technologies, and for local providers seeking to deliver EBIs that match their clients' and communities' needs. Technology platforms and community organizations may serve as resources for designers of the next generation of EBIs, offering an alternative to repeatedly validating the same interventions and replicating them with fidelity.

"I'm Not Afraid of Dying Because I've Got Nothing to Lose": Young Men in South Africa Talk About Nonfatal Suicidal Behavior

First-person narratives of suicidal behavior may provide novel insights into how individuals with lived experience of suicide understand and narrate their behavior. Our aim was to explore the narratives of young men hospitalized following nonfatal suicidal behavior (NFSB), in order to understand how young suicidal men construct and understand their actions. Data were collected via narrative interviews with 14 men (aged 18–34 years) admitted to hospital following an act of NFSB in Cape Town, South Africa. Narrative analysis was used to analyze the data. Two dominant narratives emerged in which participants drew on tropes of the “great escape” and “heroic resistance,” performing elements of hegemonic masculinity in the way they narrated their experiences. Participants position themselves as rational heroic agents and present their suicidal behavior as goal-directed action to solve problems, assert control, and enact resistance. This dominant narrative is incongruent with the mainstream biomedical account of suicide as a symptom of psychopathology. The young men also articulated two counter-narratives, in which they deny responsibility for their actions and position themselves as defeated, overpowered, wary, and unheroic. The findings lend support to the idea that there is not only one narrative of young men’s suicide, and that competing and contradictory narratives can be found even within a dominant hyper-masculine account of suicidal behavior. Gender-sensitive suicide prevention strategies should not assume that all men share a common understanding of suicide. Suicide can be enacted as both a performance of masculinity and as a resistance to hegemonic gender roles.

Who can we reach and who can we keep? Predictors of intervention engagement and adherence in a cluster randomized controlled trial in South Africa

BACKGROUND

Engaging and retaining young men in community-based interventions is highly challenging. The purpose of this study was to investigate the individual factors that predict intervention engagement and adherence in a sample of at-risk South African men.

METHODS

Baseline data were collected as a part of a cluster randomised control trial (RCT) situated in Khayelitsha and Mfuleni, two peri-urban settlements situated on the outskirts of Cape Town, South Africa. Neighbourhoods were randomised to one of three intervention conditions. We performed univariate descriptive statistics to report neighbourhood and individual socio-demographic factors, and ran multivariate models, adjusting for entry of study, to determine if high adherence and consistency of engagement with the intervention were associated with socio-behavioural demographics and risk behaviours, such as hazardous substance use, gangsterism, and criminal activity.

RESULTS

Total of 729 men were on average 22.5 years old (SD 2.8), with a mean of 10 years of education. More than half of the sample were single (94%), lived with their parents (66%) and had an income below ~$30 (52%). The overall mean of adherence is 0.41 (SD 0.24) and mean of consistency of engagement is 0.61 (SD 0.30). Our data indicated that completing more years of education, living with parents, and having higher socioeconomic status were significantly associated with higher rates of engagement and adherence. Men with a history of gang membership demonstrated higher levels of adherence and consistent engagement with the intervention, compared with other men who were recruited to the intervention. Crucially, our data show that young men with a history of substance use, and young men who report symptoms of depression and high levels of perceived stress are equally likely as other young men to adhere to the intervention and attend intervention sessions consistently.

CONCLUSION

Our results may contribute to a better understanding of young men's patterns of engagement and adherence to public health interventions. The results may have important implications for policy and practice, as they may be useful in planning more effective interventions and could potentially be used to predict which young men can be reached through community-based interventions.

TRIAL REGISTRATION

ClinicalTrials.gov registration, NCT02358226. Prospectively registered 24 November 2014.

Associations between violence, criminality, and cognitive control deficits among young men living in low resource communities in South Africa

Despite empirical support for "Self-control theory" in criminology, there is controversy about how self-control should be operationalized. Working within the framework of "self-control theory," we investigated if violence and criminal behaviors are associated with nine distinct dimensions of cognitive control in a community sample of young men (n = 654) living in peri-urban townships in South Africa. Cognitive control was assessed using the Behavior Rating Inventory of Executive Function. Multivariate statistical analysis was used, to identify associations between violence and criminality, and deaggregated measures of nine distinct components of cognitive control. Fifteen percent of the sample reported recent violence, 27% had been in physical fights with family/friends in the preceding 6 months, 10% reported being arrested, 4% reported forced sexual contact, and 26% reported intimate partner violence (IPV). Controlling for substance use and sociodemographic variables, contact with the criminal justice system and violence were associated with deficits in all domains of cognitive control. Forced sexual contact was associated with behavioral dysregulation. IPV was associated with behavior dysregulation and executive control dysfunction. Future studies might utilize deaggregated measures of self-control to provide further insight into links between particular components of cognitive control and various forms of offending and violence.

The Experiences of Young Men, Their Families, and Their Coaches Following a Soccer and Vocational Training Intervention to Prevent HIV and Drug Abuse in South Africa

Young men in South Africa are at high-risk for HIV, substance abuse, and gender-based violence. This article presents qualitative results from a pilot study testing soccer leagues and vocational training to engage young-adult township men to deliver preventive interventions, including rapid HIV and alcohol/drug testing, shifting attitudes toward gender-based violence, and promoting other prosocial behaviors. Three groups participated in focus groups and in-depth interviews on experiences with the program: (1) a subset of 15 participants, (2) 15 family members, and (3) five intervention coaches. Results suggest that participants first reduced substance use on tournament days and then gradually reduced to practice days and beyond. Families suggested that "keeping young men occupied" and encouragement of prosocial behaviors was critical to risk reduction and led to increased community respect for the men. Coaches noted that behavioral and attitudinal changes were incremental and slow. The use of incentives was problematic and more research is needed to understand how incentives can be used in interventions of this nature.

Community context and individual factors associated with arrests among young men in a South African township

BACKGROUND

In high-income countries, individual- and community-level factors are associated with increased contact with the criminal justice system. However, little is known about how these factors contribute to the risk of arrest in South Africa, which has one of the highest rates of arrests globally. We examine both individual- and community-level factors associated with arrests among young men living in the townships of Cape Town.

METHODS

Data were collected from a stratified community sample of 906 young men aged 18-29 years old living in 18 township neighborhoods. Communities with high and low rates of arrest were identified. Logistic regression models were used to assess which individual-level (such as substance use and mental health status) and community-level (such as infrastructure and presence of bars and gangs) factors predict arrests.

RESULTS

Significant predictors of arrests were substance use, gang activity, being older, more stressed, and less educated. Living in communities with better infrastructure and in more recently established communities populated by recent immigrants was associated with having a history of arrests.

CONCLUSIONS

When considering both individual- and community-level factors, substance use and gang violence are the strongest predictors of arrests among young men in South Africa. Unexpectedly, communities with better infrastructure have higher arrest rates. Community programs are needed to combat substance use and gang activity as a pathway out of risk among South African young men.

TRIAL REGISTRATION

ClinicalTrials.gov registration #NCT02358226, registered Nov 24, 2014.

The pull of soccer and the push of Xhosa boys in an HIV and drug abuse intervention in the Western Cape, South Africa

There is growing interest in engaging men and boys in health and development programmes targeting the intersection of HIV risk, substance abuse, and violence. Understanding the conceptualisations of masculinities or masculine identities that shape both behaviours and opportunities for intervention is central to advancing the global agenda to engage men in health and development interventions. This paper examines an intervention using soccer and job training to engage and deliver activities for HIV prevention, substance abuse, and gender-based violence in a South African township. A literature review provides theoretical, historical and social context for the intersection of gender, masculinity, soccer, violence, and sexual relationships. Qualitative data from in-depth interviews and focus groups is analysed using theoretical and contextual frames to elucidate the negotiation of shifting, contradictory, and conflicting masculine roles. Results highlight how changing risky, normative behaviours among young men is a negotiated process entailing men's relationships with women and with other men.