Behavioral Decision Research Intervention Reduces Risky Sexual Behavior

Rheumatologist and Patient Mental Models for Treatment of Rheumatoid Arthritis Help Explain Low Treat-to-Target Rates

OBJECTIVE

Despite proven benefits, less than half of patients with rheumatoid arthritis (RA) are treated using a treat-to-target (TTT) strategy. Our objective was to identify critical discrepancies between rheumatologist and patient mental models related to the treatment of RA to inform interventions designed to increase implementation of TTT.

METHODS

We developed rheumatologist and patient mental models using the Mental Models Approach to Risk Communication. We conducted semistructured interviews to elicit views related to RA treatment decisions with 14 rheumatologists and 30 patients with RA. We also included responses (n = 284) to an open-ended question on a survey fielded to augment qualitative descriptions from the interviews. Interviews were transcribed and coded independently by two members of the research team.

RESULTS

Rheumatologist and patient mental models for RA treatment are significantly more complex than the TTT model. Both consider domains (system factors and patient readiness) outside of disease activity measurement, target setting, and risk versus benefit assessment in their decision-making. Furthermore, specific factors were found to be unique to each model. For example, the physician model stresses the importance of evaluating disease activity over time and patient adherence. In contrast, patients discussed the impact of chronic disease weariness, medication-related fatigue, the importance of feeling adequately informed, and stress associated with changing medications.

CONCLUSION

We found several discrepancies primarily related to information gaps and differences in how patients and physicians value trade-offs that can serve as specific targets to improve patient-physician communication and ultimately inform interventions to improve uptake of TTT.

Sexual risk-taking and subcortical brain volume in adolescence

Background

The developmental period of adolescence marks the initiation of new socioemotional and physical behaviors, including sexual intercourse. However, little is known about neurodevelopmental influences on adolescent sexual decision-making.

Purpose

We sought to determine how subcortical brain volume correlated with condom use, and whether those associations differed by gender and pubertal development.

Methods

We used FreeSurfer to extract subcortical volume among N = 169 sexually experienced youth (mean age 16.07 years; 31.95% female). We conducted multiple linear regressions to examine the relationship between frequency of condom use and subcortical volume, and whether these associations would be moderated by gender and pubertal development.

Results

We found that the relationship between brain volume and condom use was better accounted for by pubertal development than by gender, and moderated the association between limbic brain volume and condom use. No significant relationships were observed in reward areas (e.g., nucleus accumbens) or prefrontal cortical control areas.

Conclusions

These data highlight the potential relevance of subcortical socioemotional processing structures in adolescents' sexual decision-making.

Interactive Narrative in a Mobile Health Behavioral Intervention (Tumaini): Theoretical Grounding and Structure of a Smartphone Game to Prevent HIV Among Young Africans

The increasing availability of smartphones, including in low-income countries, offers an unprecedented opportunity to reach individuals with innovative health promotion interventions. Electronic games delivered via smartphone offer promising avenues for sexual health promotion and HIV prevention, especially for young people. By giving players real agency in a virtual and safe environment, well-designed games can provide a level of experiential learning unparalleled by many other behavioral interventions. The design of effective games for health relies on multidisciplinary insight and expertise. However, relatively few studies discuss the theoretical understanding underlying their intervention. Making explicit the theoretical grounding of a game-based intervention allows articulation of assumptions and strategies, anticipation of outcomes, and evaluation of impacts (including intermediate effects), thereby increasing understanding of pathways to change, with a view to contributing to the development of more effective games. It also helps strengthen the credibility and improve the accountability of games for health. We present the multidisciplinary theoretical framework-integrating intervention design, mediators, and behavioral outcomes-and the structure of an HIV prevention game for young African adolescents that has shown promise in a randomized pilot study in Western Kenya. The central component of Tumaini (hope for the future in Kiswahili) is an interactive role-playing narrative in which the player makes choices for characters that determine how their paths unfold. In addition, a series of mini-games reinforce skills, and the "My Story" component links the game world to the player's own life and goals, and a reward system motivates continued play. With its "choose-your-own-adventure" format, Tumaini is intended to be replayed so that players can experience the consequences resulting from different choices made in the role-playing narrative. Grounded in theories of narrative and applied communication and in social behavioral theories, especially Social Cognitive Theory, Tumaini is designed to help young adolescents acquire the information, skills, and motivation they need to avoid and reduce sexual risks. We close by situating Tumaini within discussion of the theory and practice of using interactive narrative in health promotion, with a view to furthering theoretical elaboration.

Reflections on an interdisciplinary collaboration to inform public understanding of climate change, mitigation, and impacts

We describe two interdisciplinary projects in which natural scientists and engineers, as well as psychologists and other behavioral scientists, worked together to better communicate about climate change, including mitigation and impacts. One project focused on understanding and informing public perceptions of an emerging technology to capture and sequester carbon dioxide from coal-fired power plants, as well as other low-carbon electricity-generation technologies. A second project focused on public understanding about carbon dioxide's residence time in the atmosphere. In both projects, we applied the mental-models approach, which aims to design effective communications by using insights from interdisciplinary teams of experts and mental models elicited from intended audience members. In addition to summarizing our findings, we discuss the process of interdisciplinary collaboration that we pursued in framing and completing both projects. We conclude by describing what we think we have learned about the conditions that supported our ongoing interdisciplinary collaborations.

Video Intervention to Increase Perceived Self-Efficacy for Condom Use in a Randomized Controlled Trial of Female Adolescents

STUDY OBJECTIVE

To assess the effects of the Seventeen Days interactive video on young women's perceived self-efficacy for using condoms 6 months after being offered the intervention, relative to a control.

DESIGN

Multisite randomized controlled trial.

SETTING

Twenty participating health clinics and county health departments in Ohio, Pennsylvania, and West Virginia.

PARTICIPANTS

Sexually active female adolescents ages 14 to 19 years.

INTERVENTIONS

Seventeen Days (treatment intervention; sex education) vs Driving Skills for Life (control intervention; driving education).

MAIN OUTCOME MEASURES

Perceived self-efficacy for condom use.

RESULTS

Participants in the Seventeen Days group reported higher perceived condom acquisition self-efficacy after 6 months than those in the driving group. This finding held after controlling for baseline self-efficacy scores and other covariates.

CONCLUSION

The Seventeen Days program shows promise to improve perceived self-efficacy to acquire condoms among sexually active female adolescents-an important precursor to behavior change.

Brief educational strategies for improving contraception use in young people

BACKGROUND

Global high rates of unplanned pregnancy and abortion among young women demonstrate the need for increased access to modern contraceptive services. In sub-Saharan Africa, the birth rate for those aged 15 to 19 years is 121 per 1000. In the USA, 6% of teens aged 15 to 19 years became pregnant in 2010. Most pregnancies among young women to age 25 are unintended.

OBJECTIVES

The aim was to identify brief educational interventions for improving contraceptive use among young people that are feasible for implementing in a clinic or similar setting with limited resources.

SEARCH METHODS

To 7 March 2016, we searched for studies in CENTRAL, PubMed, POPLINE, Web of Science, ClinicalTrials.gov and ICTRP.

SELECTION CRITERIA

We considered randomized controlled trials (RCTs) that assigned individuals or clusters as well as non-randomized studies (NRS). We included young people to age 25.The intervention had to be sufficiently brief for a clinic, i.e. one to three sessions of 15 to 60 minutes plus potential follow-up. The strategy had to emphasize one or more effective methods of contraception. Primary outcomes were pregnancy and contraceptive use.

DATA COLLECTION AND ANALYSIS

We assessed titles and abstracts identified during the searches. One author extracted and entered the data into Review Manager; a second author verified accuracy. We examined studies for methodological quality.For dichotomous outcomes, we calculated the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). For continuous variables, we computed the mean difference (MD) with 95% CI. We used adjusted measures for cluster RCTs, typically ORs, that the investigators reported. For NRS, which need to control for confounding, we also used reported adjusted measures. We did not conduct meta-analysis due to varied interventions and outcome measures.

MAIN RESULTS

We found 11 studies, published from 1983 to 2015, that included a total of 8338 participants. Ten were from the USA and one was from China. We focused here on intervention effects for our primary outcomes. Five studies showed some effect on contraceptive use. Of three RCTs that examined innovative counseling, one showed an intervention effect. At one year, adolescents with developmental counseling were more likely to use contraception effectively than those with standard counseling (OR 48.38, 95% CI 5.96 to 392.63).Three studies used an audiovisual tool plus counseling; two reported some effect on contraceptive use. An NRS with young men, aged 15 to 18, examined a slide-tape presentation plus reproductive health consultation. At one year, the intervention group was more likely than the standard-care group to report using an effective contraceptive and having a partner who used oral contraceptives (OCs), both at last intercourse (reported adjusted OR 1.51 and 1.66, respectively). Another study utilized a computer program for contraceptive decision-making plus standard counseling for women to age 20. At one year, fewer women in the intervention group at one site had not used OCs compared with the counseling-only group (3.4% versus 8.8%; reported P = 0.05).Three RCTs provided phone follow-up after counseling, one of which showed an effect on contraceptive use among women age 16 to 24. Women who received counseling plus phone calls to encourage contraceptive use were more likely than the counseling-only group to report consistent OC use at three months (OR 1.41, 95% CI 1.06 to 1.87) and six months (OR 1.39, 95% CI 1.03 to 1.87). Also at three months, they were more likely to report condom use at last sex (OR 1.45, 95% CI 1.03 to 2.03).Two cluster randomized trials trained providers on contraceptive methods and counseling. One trial with an intervention effect tested comprehensive contraceptive services for women to age 25, postabortion. At six months, the comprehensive-service group was more likely than the standard-care group to use an effective contraceptive (reported adjusted OR 2.03, 95% CI 1.04 to 3.98) and to use condoms consistently and correctly (reported adjusted OR 5.68, 95% CI 3.39 to 9.53).

AUTHORS' CONCLUSIONS

Few studies tested brief strategies for young people. We noted heterogeneity across studies in participants' ages and life situations. Of five studies with some effect, one provided moderate-quality evidence; four were older studies with low-quality evidence. More intensive strategies could be more effective, but would also be challenging for many clinics to implement.

New perspectives for motivating better decisions in older adults

Decision-making competence in later adulthood is affected by declines in cognitive skills, and age-related changes in affect and experience can sometimes compensate. However, recent findings suggest that age-related changes in motivation also affect the extent to which adults draw from experience, affect, and deliberative skills when making decisions. To date, relatively little attention has been given to strategies for addressing age-related changes in motivation to promote better decisions in older adults. To address this limitation, we draw from diverse literatures to suggest promising intervention strategies for motivating older recipients’ motivation to make better decisions. We start by reviewing the life-span developmental literature, which suggests that older adults’ motivation to put effort into decisions depends on the perceived personal relevance of decisions as well as their self-efficacy (i.e., confidence in applying their ability and knowledge). Next, we discuss two approaches from the health intervention design literature, the mental models approach and the patient activation approach, which aim to improve motivation for decision making by improving personal relevance or by building self-efficacy or confidence to use new information and skills. Using examples from these literatures, we discuss how to construct interventions to motivate good decisions in later adulthood.