Development of a trauma-informed substance use and sexual risk reduction intervention for young South African women

Accessibility of intimate partner violence-related services for young women in Spain. Qualitative study on professionals' perspectives

INTRODUCTION

Intimate partner violence (IPV) is common among young people, but the use of IPV resources among young adult women and teenagers is limited. This study aims to analyze professionals' perceptions about the main barriers and facilitators encountered by young women (16-29 years old) exposed to intimate partner violence (IPV) when accessing formal services in Spain.

METHODS

Qualitative study based on 17 in depth interviews carried out in 2019 with professionals who manage resources for IPV care in Madrid (Spain) from different sectors (social services, health care, security forces, women or youth issues offices, associations). A qualitative content analysis was conducted.

RESULTS

The professionals interviewed perceive the following barriers: 1) Time it takes for young women to recognize IPV because the social construction of sexual-affective relationships is permeated by gender inequality; 2) The process of leaving a situation of abuse; 3) Barriers inherent to IPV services. The key aspects to improve access to these resources are related to care services, professional practice, and the young women themselves.

CONCLUSIONS

There are both psychosocial barriers, derived from the process of leaving a situation of violence, as well as structural barriers for young women to access and properly use the recognized services specifically aimed at them or comprehensive IPV care. Services need to be tailored to the needs of young women so they can be truly effective in order to escape IPV.

Family Metacognitive Training (MCT-F): Adapting MCT to Mothers with Psychosis and Their Adolescent Children

Over half of women with psychosis are mothers. Research suggests that mothers with psychosis face unique challenges affecting both their mental health prognosis and their relationship with their children. Moreover, those children have a higher risk of developing a mental disorder. Notwithstanding, interventions specifically tailored to these families remain largely uncovered. Metacognitive Training (MCT) has demonstrated its efficacy in improving cognitive insight, symptom management, and social cognition in people with psychosis. However, there is no evidence of the efficacy of MCT in a family setting (MCT-F). This study describes the first adaptation of MCT for mothers with psychosis and their adolescent children in an online group setting. The phases (assessment, decision, adaptation, production, topical experts' integration) of the ADAPT-ITT model were systematically applied through a participatory approach (n = 22), including a first-person perspective and involving qualitative (e.g., topical expert literature review and consensus groups, interviews, thematic analyses) and quantitative methods. While MCT's core components were retained, participants guided adaptations both in content and delivery. The findings suggest the importance of community engagement and sharing decision-making processes to demonstrate the acceptability and feasibility of the adapted intervention. Employing a structured approach such as the ADAPT-ITT model ensures readiness of the new training for efficacy trials.

ImpACT+, a coping intervention to improve clinical outcomes for women living with HIV and sexual trauma in South Africa: study protocol for a randomized controlled trial

Background

Addressing sexual trauma in the context of HIV care is essential to improve clinical outcomes and mental health among women in South Africa. Women living with HIV (WLH) report disproportionately high levels of sexual trauma and have higher rates of posttraumatic stress disorder. Adherence to antiretroviral therapy (ART) may be difficult for traumatized women, as sexual trauma compounds the stress associated with managing HIV and is often comorbid with other mental health disorders, further compromising care engagement and adherence. ART initiation represents a unique window of opportunity for intervention to enhance motivation, increase care engagement, and address the negative effects of trauma on avoidant coping behaviors. Mental health interventions delivered by non-specialists in low- and middle-income countries have potential to treat depression, trauma, and effects of intimate partner violence among WLH. This study will examine the effectiveness of Improving AIDS Care after Trauma (ImpACT +), a task-shared, trauma-focused coping intervention, to promote viral suppression among WLH initiating ART in a South African clinic setting.

Methods

This study will be conducted in Khayelitsha, a peri-urban settlement situated near Cape Town, South Africa. Using a hybrid type 1 effectiveness-implementation design, we will randomize 350 WLH initiating ART to the ImpACT + experimental condition or the control condition (three weekly sessions of adapted problem-solving therapy) to examine the effectiveness of ImpACT + on viral suppression, ART adherence, and the degree to which mental health outcomes mediate intervention effects. ImpACT + participants will receive six once-a-week coping intervention sessions and six monthly maintenance sessions over the follow-up period. We will conduct mental health and bio-behavioral assessments at baseline, 4, 8, and 12 months, with care engagement data extracted from medical records. We will explore scalability using the Consolidated Framework for Implementation Research (CFIR).

Discussion

This trial is expected to yield important new information on psychologically informed intervention models that benefit the mental health and clinical outcomes of WLH with histories of sexual trauma. The proposed ImpACT + intervention, with its focus on building coping skills to address traumatic stress and engagement in HIV care and treatment, could have widespread impact on the health and wellbeing of individuals and communities in sub-Saharan Africa.

Trial registration

Clinicaltrials.gov NCT04793217. Retrospectively registered on 11 March 2021.

Adverse Childhood Experiences among a Sample of Youth Living with HIV in the Deep South

The southern region of the United States, often referred to as the Deep South, is disproportionately affected by HIV. In fact, the highest rates of new HIV infections occur in the Deep South. Approximately one in five new HIV infections are among youth. Youth living with HIV (YLWH) have several behavioral health risks, including co-occurring mental health and substance abuse disorders, which negatively affect medication adherence, contribute to less engagement in HIV care, and result in poor health outcomes. Research suggests that adverse childhood experiences (ACEs) contribute to HIV risk behaviors and that people living with HIV may be more vulnerable to the negative health outcomes and adverse effects of stressors. Using existing program evaluation data, we examined data from 41 YLWH aged 17-24 screened for ACEs in an integrated care setting. Most participants were Black/African American young men who identified as homosexual, bisexual, or questioning, and who acquired HIV behaviorally. Approximately, one-third of YLWH screened positive or in the high-risk range on an ACEs screener. Scores fell in the intermediate range for nearly half of the sample. Results did not reveal a significant relationship between ACEs and HIV biological indicators. In this paper, we describe these findings and the importance of incorporating trauma-informed approaches into HIV prevention and treatment programs targeting youth in the Deep South.

The Association of Recurrent and Multiple Types of Abuse with Adverse Mental Health, Substance Use, and Sexual Health Outcomes among Out-of-School Adolescent Girls and Young Women in Cape Town, South Africa

Although physical and sexual abuse exposure is a well-established risk for poor health, the dimensions of abuse associated with health among socially vulnerable adolescent girls and young women (AGYW) remain underexamined. This article describes associations between combinations of abuse type and timing with mental health, substance use, and sexual risk outcomes among a sample of 499 AGYW (aged 16 to 19) who had left school early and were recruited for a cluster randomized trial in Cape Town, South Africa. Approximately one-third (33.5%; 95% CI: 28.7, 38.6) of participants reported lifetime abuse. Exposure to more than one type of abuse was associated with increased risk of depression (β = 3.92; 95% CI: 2.25, 5.59) and anxiety (β = 3.70; 95% CI: 2.11, 5.28), and greater odds of polydrug use (OR = 2.10; 95% CI: 1.02, 4.34) and substance-impaired sex (OR = 2.17; 95% CI: 1.31, 3.86). Exposure to multiple types of abuse during childhood/early adolescence and again in late adolescence was associated with increased risk of depression (β = 4.65; 95% CI: 3.15, 6.14), anxiety (β = 4.35; 95% CI: 2.70, 6.02), and polydrug use (OR = 2.37; 95% CI: 1.03, 5.73). Findings underscore the need for trauma-informed interventions that reduce mental health, substance use, and sexual risks among AGYW who have experienced multiple forms of abuse and recurrent abuse.

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.

Using ADAPT-ITT to Modify a Telephone-Based HIV Prevention Intervention for SMS Delivery: Formative Study

BACKGROUND

African American adolescent females are disproportionately affected by sexually transmitted infections (STIs) and HIV. Given the elevated risk of STIs and HIV in African American women, there is an urgent need to identify innovative strategies to enhance the adoption and maintenance of STI and HIV preventive behaviors. Texting is a promising technology for creating preventive maintenance interventions (PMIs) that extend the efficacy of the original intervention. However, little guidance in public health literature is available for developing this type of application.

OBJECTIVE

This paper describes a formative pilot study that incorporates user experience methods to design and test PMI texts for Afiya, an original evidence-based intervention (EBI) specifically designed for African American adolescent females. This study aims to describe the adaptation process of health educator-led phone calling to text-based communication.

METHODS

The formative process followed the assessment, decision, adaptation, production, topical experts-integration, training, testing (ADAPT-ITT) framework for adapting EBIs and using them in a new setting, for a new target population or a modified intervention strategy. This study presents the details of how the phases of the ADAPT-ITT framework were applied to the design of the adaptation. An advisory board was constituted from the target population, consisting of 6 African American women aged 18-24 years, participating in formative activities for 12 weeks, and involving components of the PMI design. As Afiya included a telephone-based PMI, developers of the original Afiya phone scripts crafted the initial design of the SMS-based texts and texting protocol. The advisory board participated in the 1-day Afiya workshop, followed by 4 weeks of texting PMI messages and a midcourse focus group, followed by 4 more weeks of texting PMI messages, ultimately ending with a final focus group. At the advisory board's request, this phase included an optional, additional week of text-based PMI messages.

RESULTS

The methods provided a rich source of data and insights into the fundamental issues involved when constructing SMS-based PMI for this target population and for this EBI. Prior contact and context are essential as the health educator was identified as a key persona in the process and the messages were situated in the original (workshop) context. Narrative adaptations for personas emerged from advisory board discussions. Suggestions on how to expand the PMI to current, specific social contexts indicated that the use of narrative analysis is warranted.

CONCLUSIONS

The use of existing EBIs incorporating telephone-based PMI scripts facilitated the initial design of the texts, with a subsequent narrative analysis of the advisory board data providing additional adjustments given the actual context. Additional examination of the advisory board feedback revealed that personas would offer insight into and opportunities for a persona-specific modification of texting narratives.

Acceptability and feasibility of a brief substance use intervention for adolescents in Cape Town, South Africa: A pilot study

Substance use is prevalent among South African adolescents, but few interventions exist to reduce risk of harm. This study assesses the feasibility, acceptability and preliminary effects of a brief intervention for reducing adolescent substance use and other risk behaviours. This single-arm feasibility test recruited 30 substance-using adolescents and their primary caregiver. Participants received separate interventions (2 sessions for adolescents, 1 session for caregivers), with a subsample randomly selected for post-intervention interviews. Feasibility was measured by the proportion of eligible adolescents who were enrolled and retained in the study. Interviews explored acceptability, and changes in outcomes from baseline to 1-month follow-up assessed preliminary effects of the intervention. Thirty of 43 (69.8%) eligible adolescents and their caregivers were enrolled, with 29 adolescents (96.7%) and 28 caregivers (93.3%) completing the intervention. Twenty-eight adolescents (93.3%) and 29 caregivers (96.7%) were retained at follow-up. Frequency of alcohol, cannabis use and delinquent-type behaviours decreased significantly from baseline to follow-up. Participants appreciated the intervention content and delivery and felt that it facilitated behaviour change. Suggestions for improving the intervention were provided. This study found that the intervention is feasible, acceptable and had promising effects on adolescent behaviour. Efficacy must be established with a randomised controlled trial.

Young South African Women on Antiretroviral Therapy Perceptions of a Psychological Counselling Program to Reduce Heavy Drinking and Depression

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.

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

South Africa has the largest HIV/AIDS burden globally. In South Africa, substance use is prevalent and interferes with HIV treatment adherence and viral suppression, and yet it is not routinely treated in HIV care. More research is needed to adapt scalable, evidence-based therapies for substance use for integration into HIV care in South Africa. Behavioral activation (BA), originally developed as an efficacious therapy for depression, has been feasibly used to treat depression in low- and middle-income countries and substance use in high-income settings. Yet, to date, there is limited research on using BA for substance use in low- and middle-income countries. Guided by the ADAPT-ITT framework, this study sought to adapt BA therapy for substance use in HIV care in South Africa. We conducted semistructured individual interviews among patients (n = 19) with moderate/severe substance use and detectable viral load, and HIV care providers and substance use treatment therapists (n = 11) across roles and disciplines at 2 clinic sites in a peri-urban area of Cape Town. We assessed patient and provider/therapist views on the appropriateness of the BA therapy model and sought feedback on isiXhosa-translated BA therapy components. Participants identified the central role of boredom in contributing to substance use and saw the BA therapy model as highly appropriate. Participants identified church and religious practices, sports, and yard/housework as relevant substance-free activities. These findings will inform adaptations to BA therapy for substance use and HIV medication adherence in this setting. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The relationship between intimate partner violence and probable depression among adolescent girls and young women in Lilongwe, Malawi

This analysis estimates prevalence of intimate partner violence (IPV) and its association with probable depression among adolescent girls and young women (AGYW) in Lilongwe, Malawi, and whether partner's controlling behaviour modifies this relationship. Baseline data was utilised from the Girl Power-Malawi study of 1000 15-24-year-old AGYW in Lilongwe. Emotional, physical, and sexual IPV experiences with a current or recent partner were measured using the modified Conflict Tactics Scale. Probable depression was measured by scoring ≥10 on the Centre for Epidemiologic Studies-Short Depression Scale (CES-D-10). Generalised linear models with log-link and binomial distribution estimated prevalence ratios (PR) and 95% confidence intervals (CI) for the association between IPV types and probable depression. Partner's controlling behaviour was examined as an effect modifier. Participants' mean age was 19.2 years, with 70% never-married. IPV prevalence varied for emotional (59%), physical (36%), sexual (46%), and all forms (20%). Prevalence of probable depression was 47%. AGYW who experienced each IPV type had a higher prevalence of probable depression: physical (PR:1.54, CI:1.28-1.86), sexual (1.46, CI:1.21-1.75), emotional (1.37, CI:1.14-1.64), all forms (1.72, CI:1.41-2.09). IPV and probable depression were prevalent and strongly associated, especially among AGYW reporting controlling behaviour. Interventions addressing IPV and controlling behaviour may positively impact depression among AGYW.

Service providers' perceptions of barriers to the implementation of trauma-focused substance use services for women in Cape Town, South Africa

BACKGROUND

A substantial number of South African women with substance use disorders also report psychological trauma related to experiences of physical and sexual abuse. Trauma-focused substance use programmes may support recovery from co-occurring substance use disorders and psychological trauma, yet integrated programmes are not widely available in South Africa. As part of the process of developing a trauma-focused substance use programme for South African women, we explored service providers' views of the feasibility of implementing trauma-focused substance use interventions within usual care settings in Cape Town, including potential barriers that need to be considered when planning for implementation.

METHODS

We conducted 16 in-depth interviews with key informants responsible for planning or delivering substance use, psychological trauma or gender-based violence services to women in Cape Town. Guided by Extended Normalisation Process Theory, interviews explored participants' perceptions of the potential value of trauma-focused substance use programmes, the feasibility of their implementation, and factors that may facilitate or hinder the implementation of trauma-focused substance use programmes. Qualitative data were analysed using the framework approach.

RESULTS

Three themes emerged: (1) Potential for the implementation of trauma-focused substance use programmes, describing participants' views of the acceptability of these programmes; (2) Capacity for intersectoral collaboration, which participants considered necessary for limiting barriers to implementation; and (3) Co-operation with community structures to enhance capability for implementation.

CONCLUSION

Findings show potential for implementing trauma-focused substance use interventions in South Africa, however context-specific capacity and capability barriers need to be considered and addressed for implementation to be successful.

A South African Couple-Based HIV Prevention Program: Preliminary Evidence of the Long-Term Effects

The goal of our study was to provide qualitative data on the long-term effects of a couple-based HIV prevention program, the Couples Health Co-Op (CHC), in South Africa. Qualitative focus group discussions were conducted with nonrandomly selected Black South African men (n = 27) and women (n = 23) who had participated in the Couples Health Co-Op 4 to 6 years prior to our study. The study evaluated: (a) salient content and skills learned, (b) long-term changes and challenges, and (c) recommendations for intervention improvement. Findings revealed (a) communication/problem-solving, safe sexual behaviors, and negative effects of alcohol were most salient; (b) long-term changes occurred in communication and healthier sexual behavior; alcohol use remained challenging; and (c) participants recommended continuing the couple format and suggested targeting teenage couples. We offer preliminary evidence of the strengths and weaknesses of the Couples Health Co-Op and provide a basis for future studies to build on these results.

The adaptation of an evidence-based brief intervention for substance-using adolescents and their caregivers

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.

A trauma-informed substance use and sexual risk reduction intervention for young South African women: a mixed-methods feasibility study

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.