1
|
Tozan Y, Kiyingi J, Kim S, Nabayinda J, Namuwonge F, Nsubuga E, Nakabuye F, Sensoy OB, Nabunya P, Mayo-Wilson LJ, McKay MM, Witte SS, Ssewamala FM. Costing of a Combination Intervention (Kyaterekera) Addressing Sexual Risk-Taking Behaviors among Vulnerable Women in Southern Uganda. Am J Trop Med Hyg 2024; 110:1046-1056. [PMID: 38579695 PMCID: PMC11066365 DOI: 10.4269/ajtmh.23-0485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/25/2024] [Indexed: 04/07/2024] Open
Abstract
In Uganda, women engaged in sex work (WESW) are a marginalized population at the intersection of multiple vulnerabilities. The Kyaterekera intervention is targeted at WESW in Rakai and the greater Masaka regions in Uganda and combines a traditional HIV risk-reduction approach with a savings-led economic empowerment intervention and financial literacy training. We estimated the economic costs of the Kyaterekera intervention from a program provider perspective using a prospective activity-based micro-costing method. All program activities and resource uses were measured and valued across the control arm receiving a traditional HIV risk-reduction intervention and the treatment arm receiving a matched individual development savings account and financial literacy training on top of HIV risk reduction. The total per-participant cost by arm was adjusted for inflation and discounted at an annual rate of 3% and presented in 2019 US dollars. The total per-participant costs of the control and intervention arms were estimated at $323 and $1,435, respectively, using the per-protocol sample. When calculated based on the intent-to-treat sample, the per-participant costs were reduced to $183 and $588, respectively. The key cost drivers were the capital invested in individual development accounts and personnel and transportation costs for program operations, linked to WESW's higher mobility and the dispersed pattern of hot spot locations. The findings provide evidence of the economic costs of implementing a targeted intervention for this marginalized population in resource-constrained settings and shed light on the scale of potential investment needed to better achieve the health equity goal of HIV prevention strategies.
Collapse
Affiliation(s)
- Yesim Tozan
- School of Global Public Health, New York University, New York, New York
| | - Joshua Kiyingi
- Brown School, Washington University in St. Louis, St. Louis, Missouri
| | - Sooyoung Kim
- School of Global Public Health, New York University, New York, New York
| | | | - Flavia Namuwonge
- International Center for Child Health and Development, Masaka, Uganda
| | - Edward Nsubuga
- Brown School, Washington University in St. Louis, St. Louis, Missouri
| | - Fatuma Nakabuye
- International Center for Child Health and Development, Masaka, Uganda
| | - Ozge Bahar Sensoy
- Brown School, Washington University in St. Louis, St. Louis, Missouri
| | - Proscovia Nabunya
- Brown School, Washington University in St. Louis, St. Louis, Missouri
| | - Larissa Jennings Mayo-Wilson
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mary M. McKay
- Brown School, Washington University in St. Louis, St. Louis, Missouri
| | - Susan S. Witte
- Columbia University School of Social Work, New York, New York
| | - Fred M. Ssewamala
- Brown School, Washington University in St. Louis, St. Louis, Missouri
| |
Collapse
|
2
|
Kiyingi J, Mayo-Wilson LJ, Nabunya P, Kizito S, Nabayinda J, Nattabi J, Nsubuga E, Bahar OS, Namuwonge F, Nakabuye F, Nanteza F, Filippone PL, Mukasa D, Witte SS, Ssewamala FM. Examining the Intrapersonal, Interpersonal and Community Level Correlates of Access to Medical Care Among Women Employed by Sex Work in Southern Uganda: A cross-sectional Analysis of the Kyaterekera Study. AIDS Behav 2024:10.1007/s10461-024-04333-y. [PMID: 38605251 DOI: 10.1007/s10461-024-04333-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2024] [Indexed: 04/13/2024]
Abstract
Women employed by sex work (WESW) experience significant gaps in accessing necessary healthcare services, leading to unmet health needs. Yet, there is a dearth of literature on the barriers to medical care access among WESW in Uganda. We used data from the Kyaterekera baseline to examine the correlates of access to medical care among WESW, defined as the ability of individuals to obtain the necessary healthcare services they require in a timely, affordable, and equitable manner. The Kyaterekera study recruited 542 WESW aged 18-58 years from Southern Uganda. We conducted a multilevel linear regression model to determine the intrapersonal (age, education level, marital status, HIV knowledge, and asset ownership), interpersonal (family cohesion and domestic violence attitudes), and community (community satisfaction, sex work stigma and distance to health facility) level correlates of access to medical care among WESW. Intrapersonal and interpersonal factors were associated with access to medical care among WESW. There was no significant association between community level factors and access to medical care. WESW with secondary education (β = 0.928, 95% CI = 0.007, 1.849) were associated with increased access to medical care. WESW with high asset ownership (β = -1.154, 95% CI= -1.903, -0.405), high family cohesion (β = -0.069, 95% CI= -0.106, -0.031), and high domestic violence attitudes (β = -0.253, 95% CI= -0.438, -0.068) were associated with decreased access to medical care. The findings emphasize the critical need for targeted family strengthening interventions to enhance family support for WESW and address domestic violence.
Collapse
Affiliation(s)
- Joshua Kiyingi
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO, 63130, USA
| | - Larissa Jennings Mayo-Wilson
- Department of Heath Behavior, Department of Maternal and Child Health, University of North Carolina, 316 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Proscovia Nabunya
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO, 63130, USA
| | - Samuel Kizito
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO, 63130, USA
| | - Josephine Nabayinda
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO, 63130, USA
| | - Jennifer Nattabi
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO, 63130, USA
| | - Edward Nsubuga
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO, 63130, USA
| | - Ozge Sensoy Bahar
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO, 63130, USA
| | - Flavia Namuwonge
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO, 63130, USA
| | - Fatuma Nakabuye
- International Center for Child Health and Development (ICHAD), Masaka, Uganda
| | - Flavia Nanteza
- International Center for Child Health and Development (ICHAD), Masaka, Uganda
| | - Prema L Filippone
- Silver School of Social Work, New York University, 1 Washington Square North, New York, NY, 10003, USA
| | - Dinah Mukasa
- International Center for Child Health and Development (ICHAD), Masaka, Uganda
| | - Susan S Witte
- Columbia University School of Social, Work1255 Amsterdam Avenue, New York, NY, 10027, USA
| | - Fred M Ssewamala
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO, 63130, USA.
- Brown School, Washington University in St. Louis International Center for Child Health and Development (ICHAD), Goldfarb, Room 346 Campus Box 1196, One Brookings Drive, St. Louis, MO, 63130, USA.
| |
Collapse
|
3
|
Janson S, Nyenga L, Saleem H, Mayo-Wilson LJ, Mushy SE, Iseselo MK, van Draanen J, Tucker J, McPherson M, Conserve DF. Residential and inpatient treatment of substance use disorders in Sub-Saharan Africa: a scoping review. Subst Abuse Treat Prev Policy 2024; 19:6. [PMID: 38212834 PMCID: PMC10782522 DOI: 10.1186/s13011-023-00589-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/22/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND With substance use rates increasing in Sub-Saharan Africa (SSA), an understanding of the accessibility and effectiveness of rehabilitative services for people who use alcohol and other drugs (AOD) is critical in the global efforts to diagnose and treat substance use disorders (SUD). This scoping review seeks to address the gaps in knowledge related to the types of research that have been conducted regarding inpatient or residential SUD treatment in SSA, the settings in which the research was conducted, and the study countries. METHODS A search of three databases, PubMED, Scopus, and African Index Medicus, was conducted for publications related to the treatment of SUD in inpatient or residential settings in SSA. Articles were screened at the title/abstract level and at full text by two reviewers. Articles eligible for inclusion were original research, conducted in SSA, published in English, included populations who received or were currently receiving treatment for SUD in inpatient or residential settings, or documented demand for SUD services. RESULTS This scoping review included 82 studies originating from 6 countries in SSA. Three themes emerged within the literature: access and demand for inpatient and residential SUD treatment, quality and outcomes of SUD treatment, and descriptions of the services offered and staffing of these facilities. Barriers to access include financial barriers, limited availability of services, and geographic concentration in cities. Women were shown to access residential and inpatient SUD treatment at lower rates than men, and certain racial groups face unique language and financial barriers in accessing services. Studies indicate mixed success of inpatient and residential SUD treatment in sustained SUD remission for patients. CONCLUSION There are significant gaps in the literature, driven by a lack of longitudinal studies focused on patient outcomes following treatment and the use of a narrow definition of treatment success. Both structural and non-structural barriers, such as stigma and discrimination, are barriers to access. Further research is needed to evaluate approaches to mitigate these barriers and expand access to residential and inpatient SUD treatment.
Collapse
Affiliation(s)
- Samuel Janson
- The George Washington University Milken Institute School of Public Health, Washington, DC, USA.
| | - Lily Nyenga
- The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Haneefa Saleem
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Stella E Mushy
- Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Masunga K Iseselo
- Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Jenna van Draanen
- University of Washington School of Public Health, Seattle, Washington, USA
- University of Washington School of Nursing, Seattle, Washington, USA
| | - Joseph Tucker
- University of North Carolina School of Medicine, Chapell Hill, North Carolina, USA
| | - Mecca McPherson
- Temple University College of Public Health, Philadelphia, PA, USA
| | - Donaldson F Conserve
- The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| |
Collapse
|
4
|
Nabayinda J, Namirembe R, Kizito S, Nsubuga E, Nabunya P, Bahar OS, Magorokosho N, Kiyingi J, Nattabi J, Tozan Y, Mayo-Wilson LJ, Mwebembezi A, Witte SS, Ssewamala FM. Correlates of Intimate Partner Violence Among Young Women Engaged in Sex Work in Southern Uganda. J Interpers Violence 2023; 38:10749-10770. [PMID: 37212371 PMCID: PMC10524718 DOI: 10.1177/08862605231175908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Intimate partner violence (IPV) is a significant global public health problem that results in high social and economic costs to individuals and communities. Compared to women in the general population, women engaged in sex work (WESW) are more likely to experience physical, emotional, and sexual IPV. This study examines the correlates of IPV among young WESW with their intimate partners in Southern Uganda. We used baseline data from the Kyaterekera project, a 5 year NIH-funded longitudinal study aimed at reducing HIV risks among 542 WESW in Southern Uganda. To examine the factors associated with IPV, we fitted three separate multi-level Poisson regression models for physical, emotional, and sexual IPV, respectively. Average age was 31.4 years, and 54% of the women reported being victims of at least one form of IPV from their intimate partners. Model one assessed correlates of sexual IPV. Being married women (β = .71, 95% CI [0.24, 1.17]), divorced/separated/widowed (β = .52, [0.02, 1.02]), depressed (β = .04, [0.02, 0.05]), and having any sexually transmitted infections (STIs) (β = .58, [0.14, 1.01]) were associated with sexual IPV. Model two assessed correlates of physical IPV. Experience of childhood sexual abuse (β = .12, [0.04, 0.19]) was associated with an increase in physical IPV, and increasing age reduced its occurrence (β = -.02, [-0.04, -0.001]). Finally, model three assessed emotional IPV. Women with higher education (β = .49, [0.14, 0.85]) and symptoms of depression (β = .02, [0.001, 0.04]) had higher risks for emotional IPV. For WESW, IPV presents an additional potential pathway for HIV and STIs acquisition and transmission through a lack of negotiating power for safe sex. Efforts to reduce violence against WESW should be prioritized as a strategy for enhancing the well-being of WESW.
Collapse
Affiliation(s)
| | - Rashida Namirembe
- International Center for Child Health and Development (ICHAD), Masaka, Uganda
| | - Samuel Kizito
- Washington University in St. Louis Brown School, MO, USA
| | - Edward Nsubuga
- Washington University in St. Louis Brown School, MO, USA
| | | | | | | | - Joshua Kiyingi
- Washington University in St. Louis Brown School, MO, USA
| | | | | | | | | | - Susan S. Witte
- Columbia University School of Social Work, New York, NY, USA
| | | |
Collapse
|
5
|
Conserve DF, Abu-Ba'are GR, Janson S, Mhando F, Munisi GV, Drezgic B, Rehani A, Sims W, Ritchwood T, Choko A, Mushy S, Johnson C, Mayo-Wilson LJ, Komba A, Urasa P, Nelson L, Mbita G. Peer-based Promotion and Nurse-led Distribution of HIV Self-Testing Among Networks of Men in Dar es Salaam, Tanzania: Development and Feasibility Results of the STEP Intervention. Res Sq 2023:rs.3.rs-3283552. [PMID: 37674705 PMCID: PMC10479444 DOI: 10.21203/rs.3.rs-3283552/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Background According to the 2016-2017 Tanzania HIV Impact Survey, only 45% of men living with HIV (MLWH) were aware of their HIV status. In an effort to increase HIV testing in Tanzania, including among men, the Government of Tanzania passed a law in December 2019 to allowing HIV self-testing (HIVST) to be included in the national testing strategies. The objective of this paper is to describe the development and pilot feasibility assessment of the Self-Testing Education and Promotion (STEP) intervention, which was one of the projects conducted in Tanzania focusing on men to inform policy change. Methods The development and piloting processes were guided by the ADAPT-ITT model and informed by a national PEPFAR/USAID-funded HIV implementation science project called Sauti.The adapted STEP intervention included the following two components: 1) peer-based HIVST promotion; and 2) nurse-led HIVST distribution. For the feasibility assessment, 25 men were selected and trained to promote HIVST among their peers before helping to recruit 253 men to receive instructions and collect an HIVST kit from a nurse at a community-based study tent site. Results Of the 236 participants who completed the 1-month follow-up survey, 98.3% reported using the kit. The majority (92.4%) of participants reported a negative HIVST result while 4.2% (n=10) received a positive result. Most (70%, n=7) of the participants with a positive result sought follow-up services at a healthcare facility while 40.3% (n=95) of the participants with a negative self-test result visited the community-based project site. Most of the men (53%, n =129) did not visit a healthcare facility or the study site. The majority of participants reported having a mobile phone and forty-seven of them called someone to share their results while twenty-seven sent a text message about their results. Conclusion The findings demonstrate that the combined peer-based promotion and nurse-led distribution of HIVST intervention in the community for men was acceptable and feasible. However, the high proportion of men who visited the tent site in the community after self-testing indicated that future research should evaluate the potential for nurses to provide community-based linkage to HIV care and prevention services for self-testers.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stella Mushy
- Muhimbili University of Health and Allied Sciences
| | | | | | - Albert Komba
- Jhpiego Tanzania - An Affiliate of Johns Hopkins University
| | | | | | | |
Collapse
|
6
|
Kiyingi J, Witte SS, Nabunya P, Nsubuga E, Bahar OS, Mayo-Wilson LJ, Kizito S, Nattabi J, Nabayinda J, Ssewamala FM. Predictors of mobility among women engaged in commercial sex work in Uganda using generalized estimating equations model. Int J STD AIDS 2023; 34:633-640. [PMID: 37018458 PMCID: PMC10523898 DOI: 10.1177/09564624231167910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
BACKGROUND Women engaged in commercial sex work (WESW) are at a higher risk of acquiring and transmitting HIV. WESW are highly mobile, and their mobility may increase their economic status, and increased access to healthcare and other social services. However, it may also facilitate the spread of HIV infection from higher to lower prevalence regions. This study examined the predictors of mobility among WESW in Uganda using a generalized estimating equations model. METHODS We defined and measured mobility as the change in residence by WESW between baseline, 6 months, and 12 months follow-up. Participants who changed places were considered mobile, and those who never changed were non-mobile. We used data from a longitudinal study, which recruited 542 WESW from Southern Uganda aged 18-55 years and constructed a Generalized Estimating Equations Model. RESULTS Findings show that 19.6% of WESW changed residence between baseline and 6 months of follow-up and 26.2% (cumulative) between baseline and 12 months of follow-up. Older women (OR = 0.966, 95% CI = 0.935, 0.997) were associated with decreased odds of mobility, whereas WESW who were HIV positive (OR = 1.475, 95% CI = 1.078, 2.018) and those from large households (OR = 1.066, 95% CI = 1.001, 1.134) were associated with increased odds of mobility. WESW residing in rural areas (OR = 0.535, 95% CI = 0.351, 0.817) were associated with decreased odds of mobility compared to those from fishing sites. CONCLUSION The results indicate risk factors for mobility, further research is needed to determine the directionality of these factors in order to design interventions addressing mobility among WESW.
Collapse
Affiliation(s)
- Joshua Kiyingi
- Washington University in St Louis Brown School, International Center for Child Health and Development (ICHAD), St Louis, MO, USA
| | - Susan S Witte
- Columbia University, School of Social Work, New York, NY, USA
| | - Proscovia Nabunya
- Washington University in St Louis Brown School, International Center for Child Health and Development (ICHAD), St Louis, MO, USA
| | - Edward Nsubuga
- Washington University in St Louis Brown School, International Center for Child Health and Development (ICHAD), St Louis, MO, USA
| | - Ozge Sensoy Bahar
- Washington University in St Louis Brown School, International Center for Child Health and Development (ICHAD), St Louis, MO, USA
| | | | - Samuel Kizito
- Washington University in St Louis Brown School, International Center for Child Health and Development (ICHAD), St Louis, MO, USA
| | - Jennifer Nattabi
- Washington University in St Louis Brown School, International Center for Child Health and Development (ICHAD), St Louis, MO, USA
| | - Josephine Nabayinda
- Washington University in St Louis Brown School, International Center for Child Health and Development (ICHAD), St Louis, MO, USA
| | - Fred M Ssewamala
- Washington University in St Louis Brown School, International Center for Child Health and Development (ICHAD), St Louis, MO, USA
| |
Collapse
|
7
|
Jennings Mayo-Wilson L, Coleman Lewis J, MacCarthy S, Linnemayr S. Assessing behavioral economic biases among young adults who have increased likelihood of acquiring HIV: a mixed methods study in Baltimore, Maryland. AIDS Res Ther 2023; 20:25. [PMID: 37150823 PMCID: PMC10165802 DOI: 10.1186/s12981-023-00521-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/18/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND Behavioral economic (BE) biases have been studied in the context of numerous health conditions, yet are understudied in the field of HIV prevention. This aim of this study was to quantify the prevalence of four common BE biases-present bias, information salience, overoptimism, and loss aversion-relating to condom use and HIV testing in economically-vulnerable young adults who had increased likelihood of acquiring HIV. We also qualitatively examined participants' perceptions of these biases. METHODS 43 participants were enrolled in the study. Data were collected via interviews using a quantitative survey instrument embedded with qualitative questions to characterize responses. Interviews were transcribed and analyzed using descriptive statistics and deductive-inductive content analyses. RESULTS 56% of participants were present-biased, disproportionately discounting future rewards for smaller immediate rewards. 51% stated they were more likely to spend than save given financial need. Present-bias relating to condom use was lower with 28% reporting they would engage in condomless sex rather than wait one day to access condoms. Most participants (72%) were willing to wait for condom-supported sex given the risk. Only 35% knew someone living with HIV, but 67% knew someone who had taken an HIV test, and 74% said they often think about preventing HIV (e.g., high salience). Yet, 47% reported optimistically planning for condom use, HIV discussions with partners, or testing but failing to stick to their decision. Most (98%) were also averse (b = 9.4, SD ±.9) to losing their HIV-negative status. Qualitative reasons for sub-optimal condom or testing choices were having already waited to find a sex partner, feeling awkward, having fear, or not remembering one's plan in the moment. Optimal decisions were attributed qualitatively to self-protective thoughts, establishing routine care, standing on one's own, and thinking of someone adversely impacted by HIV. 44% of participants preferred delayed monetary awards (e.g., future-biased), attributed qualitatively to fears of spending immediate money unwisely or needing time to plan. CONCLUSION Mixed methods BE assessments may be a valuable tool in understanding factors contributing to optimal and sub-optimal HIV prevention decisions. Future HIV prevention interventions may benefit from integrating savings products, loss framing, commitment contracts, cues, or incentives.
Collapse
Affiliation(s)
- Larissa Jennings Mayo-Wilson
- Department of Health Behavior, Department of Maternal and Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 310 Rosenau Hall CB #7400, 135 Dauer Drive, Chapel Hill, NC, 27599, USA.
| | - Jessica Coleman Lewis
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Sarah MacCarthy
- Department of Health Behavior, University of Alabama at Birmingham School of Public Health, 1665 University Boulevard, Birmingham, AL, USA
| | | |
Collapse
|
8
|
Jennings Mayo-Wilson L, Peterson SK, Kiyingi J, Nabunya P, Sensoy Bahar O, Yang LS, Witte SS, Ssewamala FM. Examining Cash Expenditures and Associated HIV-Related Behaviors Using Financial Diaries in Women Employed by Sex Work in Rural Uganda: Findings from the Kyaterekera Study. Int J Environ Res Public Health 2023; 20:ijerph20095612. [PMID: 37174132 PMCID: PMC10178413 DOI: 10.3390/ijerph20095612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/19/2023] [Accepted: 04/04/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Women employed by sex work (WESW) have a high risk of human immunodeficiency virus (HIV) infection and experience economic barriers in accessing care. However, few studies have described their financial lives and the relationship between expenditures and HIV-related behaviors. METHODS This exploratory study used financial diaries to collect expenditure and income data from WESW in Uganda over 6 months. Data were collected as part of a larger trial that tested the efficacy of an HIV prevention intervention method. Descriptive statistics were used to quantify women's income, relative expenditures, and negative cash balances. Bivariate and multivariate logistic regressions were used to examine the odds of sexual risk behavior or use of HIV medications for several cash scenarios. RESULTS A total of 163 WESW were enrolled; the participants mean age was 32 years old. Sex work was the sole source of employment for most WESW (99%); their average monthly income was $62.32. Food accounted for the highest proportion of spending (44%) followed by sex work (20%) and housing expenditures (11%). WESW spent the least on health care (5%). Expenditures accounted for a large but variable proportion of these women's income (56% to 101%). Most WESW (74%) experienced a negative cash balance. Some also reported high sex work (28%), health care (24%), and education (28%) costs. The prevalence of condomless sex (77%) and sex with drugs/alcohol (70%) was high compared to use of ART/PrEP (Antiretroviral therapy/Pre-exposure prophylaxis) medications (45%). Women's cash expenditures were not statistically significantly associated with HIV-related behaviors. However, the exploratory study observed a consistent null trend of lower odds of condomless sex (adjusted odds ratio (AOR) = 0.70, 95% confidence interval (CI): 0.28-1.70), sex with drugs/alcohol (AOR = 0.93, 95% CI: 0.42-2.05), and use of ART/PrEP (AOR = 0.80, 95% CI: 0.39-1.67) among women who experienced a negative cash balance versus those who did not. Similar trends were observed for other cash scenarios. CONCLUSION Financial diaries are a feasible tool to assess the economic lives of vulnerable women. Despite having paid work, most WESW encountered a myriad of financial challenges with limited spending on HIV prevention. Financial protections and additional income-generating activities may improve their status. More robust research is needed to understand the potentially complex relationship between income, expenditures, and HIV risk among vulnerable sex workers.
Collapse
Affiliation(s)
- Larissa Jennings Mayo-Wilson
- Department of Health Behavior, Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, Chapel Hill, NC 27599, USA
| | - Summer K Peterson
- Department of Health Behavior, Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, Chapel Hill, NC 27599, USA
| | - Joshua Kiyingi
- Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO 63130, USA
- International Center for Child Health and Development, Masaka Field Office, Mutuba Ave, Masaka 319, Uganda
| | - Proscovia Nabunya
- Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO 63130, USA
- International Center for Child Health and Development, Masaka Field Office, Mutuba Ave, Masaka 319, Uganda
| | - Ozge Sensoy Bahar
- Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO 63130, USA
- International Center for Child Health and Development, Masaka Field Office, Mutuba Ave, Masaka 319, Uganda
| | - Lyla S Yang
- School of Social Work, Columbia University, 1255 Amsterdam Avenue, New York, NY 10027, USA
| | - Susan S Witte
- School of Social Work, Columbia University, 1255 Amsterdam Avenue, New York, NY 10027, USA
| | - Fred M Ssewamala
- Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO 63130, USA
- International Center for Child Health and Development, Masaka Field Office, Mutuba Ave, Masaka 319, Uganda
| |
Collapse
|
9
|
Gamarel KE, Jadwin-Cakmak L, King WM, Reyes LA, Trammell R, Neilands TB, Connolly MD, Jennings Mayo-Wilson L. Community-Led Response to Address Economic Vulnerability due to COVID-19 with, for, and by Transgender Women of Color: A Qualitative Pilot Evaluation. Transgend Health 2023; 8:195-199. [PMID: 37013097 PMCID: PMC10066767 DOI: 10.1089/trgh.2021.0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose Intersectional stigma fuels inequities among transgender women of color, which have been exacerbated by coronavirus disease 2019 (COVID-19). This study evaluated a community-led emergency assistance program for transgender women of color. Methods We conducted a pilot program evaluation (n=8). Results Retention was 87.5% over the follow-up. Funds were primarily used for bills, food, and housing. Requesting and receiving funds was described as "somewhat to extremely easy." Participants identified the need for economic empowerment components in future programming, specifically gender affirmation, skill-building for education and employment, and entrepreneurial opportunities. Conclusion Findings highlight the need to invest in community-led strategies to address inequities experienced by transgender women of color.
Collapse
Affiliation(s)
- Kristi E. Gamarel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Laura Jadwin-Cakmak
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Wesley M. King
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | | | - Racquelle Trammell
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- Trans Sistas of Color Project, Detroit, Michigan, USA
| | - Torsten B. Neilands
- Center for AIDS Prevention Studies, University of California, San Francisco, California, USA
| | | | | |
Collapse
|
10
|
Nabayinda J, Kizito S, Witte S, Nabunnya P, Kiyingi J, Namuwonge F, Nsubuga E, Bahar OS, Mayo-Wilson LJ, Yang LS, Nattabi J, Magorokosho N, Ssewamala FM. Factors Associated with Consistent Condom Use Among Women Engaged in Sex Work: Lessons From the Kyaterekera Study in Southwestern Uganda. AIDS Behav 2023; 27:969-977. [PMID: 36112259 PMCID: PMC9974574 DOI: 10.1007/s10461-022-03833-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2022] [Indexed: 11/01/2022]
Abstract
We examined the factors associated with consistent condom use among women engaged in sex work in the Southern parts of Uganda. We used baseline data from a longitudinal study involving WESW from 19 hotspots in Southern Uganda. We conducted hierarchical models to determine the individual, economic, behavioral, and health-related factors associated with consistent condom use. We found that, alcohol use (b=-0.48, 95% CI=-0.77, -0.19), accepting money for condomless sex (b=-0.33, 95% CI=-0.38, -0.28), multiple customers (b=-0.01, 95% CI=-0.01, -0.005), being married (b = 0.50, 95% CI = 0.01, 0.99), owning more assets (b = 0.08, 95% CI = 0.05, 0.13), having another income earner in the household (b = 0.55, 95% CI = 0.27, 0.83), condom use self-efficacy (b = 0.11, 95% CI = 0.03, 0.19), condom use communication (b = 0.06, 95% CI = 0.001, 0.12), and being knowledgeable about HIV/STIs transmission (b = 0.08, 95% CI = 0.01, 0.15) were associated with consistent condom use. Additionally, 29% of the women were consistent condom users. Hence, there is need to implement interventions that promote consistent condom use among WESW.
Collapse
Affiliation(s)
- Josephine Nabayinda
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Samuel Kizito
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Susan Witte
- Columbia University School of Social Work, 1255 Amsterdam Avenue, 10027, New York, NY, USA
| | - Proscovia Nabunnya
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Joshua Kiyingi
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Flavia Namuwonge
- International Center for Child Health and Development (ICHAD), Masaka Office, Kampala, Uganda
| | - Edward Nsubuga
- International Center for Child Health and Development (ICHAD), Masaka Office, Kampala, Uganda
| | - Ozge Sensoy Bahar
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Larissa Jennings Mayo-Wilson
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 170 Rosenau Hall CB7400, 27599, Chapel Hill, NC, USA
| | - Lyla Sunyoung Yang
- Columbia University School of Social Work, 1255 Amsterdam Avenue, 10027, New York, NY, USA
| | - Jennifer Nattabi
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Natasja Magorokosho
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Fred M Ssewamala
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA.
| |
Collapse
|
11
|
Kiyingi J, Nabunya P, Kizito S, Nabayinda J, Nsubuga E, Bahar OS, Jennings Mayo-Wilson L, Namuwonge F, Nattabi J, Magorokosho N, Tozan Y, Witte SS, Ssewamala FM. Self-Reported Adherence to Antiretroviral Therapy (ART) Among Women Engaged in Commercial Sex Work in Southern Uganda. AIDS Behav 2023; 27:1004-1012. [PMID: 36066764 PMCID: PMC9974600 DOI: 10.1007/s10461-022-03837-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 11/01/2022]
Abstract
We examined the correlates of self-reported adherence to antiretroviral therapy (ART) among women engaged in commercial sex work (WESW) in Uganda. We used baseline data from a longitudinal study, which recruited 542 WESW in Southern Uganda. We used nested regression models to determine the individual and family, and economic level correlates of self-reported adherence. Study findings show that older age (OR = 1.07, 95% CI = 1.013, 1.139), secondary education (OR = 2.01, 95% CI = 1.306, 3.084), large household size (OR = 1.08, 95% CI = 1.020, 1.136), high family cohesion (OR = 1.06, 95% CI = 1.052, 1.065), and high financial self-efficacy (OR = 1.07, 95% CI = 1.006, 1.130) were associated with good self-reported adherence to ART. Married women (OR=-0.39, 95% CI = 0.197, 0.774), depression (OR = 0.85, 95% CI = 0.744, 0.969), alcohol use (OR = 0.72, 95% CI = 0.548, 0.954), ever been arrested (OR = 0.58, 95% CI = 0.341, 0.997), and high household assets ownership (OR = 0.48, 95% CI = 0.313, 0.724) were associated with poor self-reported adherence to ART. Findings suggest a need to adopt a multi-level approach to address gaps in ART adherence among WESW.
Collapse
Affiliation(s)
- Joshua Kiyingi
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Proscovia Nabunya
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Samuel Kizito
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Josephine Nabayinda
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Edward Nsubuga
- International Center for Child Health and Development (ICHAD), Masaka, Uganda
| | - Ozge Sensoy Bahar
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Larissa Jennings Mayo-Wilson
- University of North Carolina Gillings School of Global Public Health, 170 Rosenau Hall, 27599, Chapel Hill, NC, USA
| | - Flavia Namuwonge
- International Center for Child Health and Development (ICHAD), Masaka, Uganda
| | - Jennifer Nattabi
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Natasja Magorokosho
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA
| | - Yesim Tozan
- New York University College of Global Public Health, 14 East 4th street, 3rd floor, 10003, New York, NY, USA
| | - Susan S Witte
- Columbia University School of Social Work, 1255 Amsterdam Avenue, 10027, New York, NY, USA
| | - Fred M Ssewamala
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, 63130, St. Louis, MO, USA.
| |
Collapse
|
12
|
Jennings Mayo-Wilson L, Yen BJ, Nabunya P, Bahar OS, Wright BN, Kiyingi J, Filippone PL, Mwebembezi A, Kagaayi J, Tozan Y, Nabayinda J, Witte SS, Ssewamala FM. Economic Abuse and Care-seeking Practices for HIV and Financial Support Services in Women Employed by Sex Work: A Cross-Sectional Baseline Assessment of a Clinical Trial Cohort in Uganda. J Interpers Violence 2023; 38:NP1920-NP1949. [PMID: 35510547 PMCID: PMC9636073 DOI: 10.1177/08862605221093680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Economic hardship is a driver of entry into sex work, which is associated with high HIV risk. Yet, little is known about economic abuse in women employed by sex work (WESW) and its relationship to uptake of HIV prevention and financial support services. This study used cross-sectional baseline data from a multisite, longitudinal clinical trial that tests the efficacy of adding economic empowerment to traditional HIV risk reduction education on HIV incidence in 542 WESW. Mixed effects logistic and linear regressions were used to examine associations in reported economic abuse by demographic characteristics, sexual behaviors, HIV care-seeking, and financial care-seeking. Mean age was 31.4 years. Most WESW were unmarried (74%) and had less than primary school education (64%). 48% had savings, and 72% had debt. 93% reported at least one economic abuse incident. Common incidents included being forced to ask for money (80%), having financial information kept from them (61%), and being forced to disclose how money was spent (56%). WESW also reported partners/relatives spending money needed for bills (45%), not paying bills (38%), threatening them to quit their job(s) (38%), and using physical violence when earning income (24%). Married/partnered WESW (OR = 2.68, 95% CI:1.60-4.48), those with debt (OR = 1.70, 95% CI:1.04-2.77), and those with sex-work bosses (OR = 1.90, 95% CI:1.07-3.38) had higher economic abuse. Condomless sex (β = +4.43, p < .05) was higher among WESW experiencing economic abuse, who also had lower odds of initiating PrEP (OR = .39, 95% CI:.17-.89). WESW experiencing economic abuse were also more likely to ask for cash among relatives (OR = 2.36, 95% CI:1.13-4.94) or banks (OR = 2.12, 95% CI:1.11-4.03). The high prevalence of HIV and economic abuse in WESW underscores the importance of integrating financial empowerment in HIV risk reduction interventions for WESW, including education about economic abuse and strategies to address it. Programs focusing on violence against women should also consider economic barriers to accessing HIV prevention services.
Collapse
Affiliation(s)
- Larissa Jennings Mayo-Wilson
- University of North Carolina Gillings School
of Global Public Health, Chapel Hill,
NC, USA
- Community, Global and Public Health
Division, Johns
Hopkins University School of Nursing,
Baltimore, MD, USA
| | - Bing-Jie Yen
- Department of Applied Health
Science, Center for Sexual Health Promotion, Indiana University School of Public
Health, Bloomington, IN, USA
| | - Proscovia Nabunya
- Washington University in St. Louis, Brown
School, St. Louis, MO, USA
- International Center for Child Health and
Development, Masaka, Uganda
| | - Ozge Sensoy Bahar
- Washington University in St. Louis, Brown
School, St. Louis, MO, USA
- International Center for Child Health and
Development, Masaka, Uganda
| | - Brittanni N. Wright
- Department of Applied Health
Science, Center for Sexual Health Promotion, Indiana University School of Public
Health, Bloomington, IN, USA
| | - Joshua Kiyingi
- Washington University in St. Louis, Brown
School, St. Louis, MO, USA
- International Center for Child Health and
Development, Masaka, Uganda
| | | | - Abel Mwebembezi
- International Center for Child Health and
Development, Masaka, Uganda
- Reach the Youth
Uganda, Kampala, Uganda
| | | | - Yesim Tozan
- New York University College of Global Public
Health, New York, NY, USA
| | - Josephine Nabayinda
- Washington University in St. Louis, Brown
School, St. Louis, MO, USA
- International Center for Child Health and
Development, Masaka, Uganda
| | | | - Fred M. Ssewamala
- Washington University in St. Louis, Brown
School, St. Louis, MO, USA
- International Center for Child Health and
Development, Masaka, Uganda
| |
Collapse
|
13
|
Sensoy Bahar O, Nabunya P, Nabayinda J, Witte S, Kiyingi J, Nsubuga E, Schriger S, Nattabi J, Mayo-Wilson LJ, Nakigudde J, Tozan Y, Ssewamala FM. "I decided in my heart I have to complete the sessions": A qualitative study on the acceptability of an evidence-based HIV risk reduction intervention among women engaged in sex work in Uganda. PLoS One 2023; 18:e0280138. [PMID: 36634037 PMCID: PMC9836279 DOI: 10.1371/journal.pone.0280138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The HIV burden remains a critical public health concern and women engaged in sex work [WESW] are at significantly higher risk compared to the general adult population. Similar to other sub-Saharan African countries, Uganda reports high rates of HIV prevalence among WESW. Yet, they have not been targeted by theory-informed HIV prevention intervention approaches. METHODS We conducted semi-structured in-depth interviews with 20 WESW upon intervention completion to explore their experiences with an evidence-based HIV risk reduction intervention that was implemented as part of a combination intervention tested in a clinical trial in Uganda (2018-2023. Specifically, we explored their initial motivations and concerns for participating in the intervention, barriers and facilitators to attendance, and their feedback on specific intervention characteristics. RESULTS The main expectations revolved around access to health-related information, including information on STIs, HIV, and PrEP as well as on how one can protect themselves while engaging in sex work. Initial concerns were around potential breach of confidentiality and fear of arrest. The main facilitators for session attendance were the motivation to learn health-related information, the attitude of facilitators, and the incentives received for participation, whereas main challenges were related to family commitments and work schedules. WESW appreciated the group format of the intervention and found the location and times of the intervention delivery acceptable. DISCUSSION AND CONCLUSIONS Overall, our findings suggest that the HIV risk reduction intervention was appropriate and acceptable to WESW. Yet, WESW experience unique concerns and barriers that need to be accounted for when designing interventions targeting this population, especially in resource-limited settings where sex work is illegal and highly stigmatized. CLINICAL TRIAL REGISTRATION NCT03583541.
Collapse
Affiliation(s)
- Ozge Sensoy Bahar
- Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- * E-mail:
| | - Proscovia Nabunya
- Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Josephine Nabayinda
- Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Susan Witte
- Columbia University School of Social Work, New York City, NY, United States of America
| | - Joshua Kiyingi
- Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Edward Nsubuga
- International Center for Child Health and Development Field Office, Masaka, Uganda
| | - Simone Schriger
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Jennifer Nattabi
- Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Larissa Jennings Mayo-Wilson
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | - Janet Nakigudde
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Yesim Tozan
- School of Global Public Health, New York University, New York City, NY, United States of America
| | - Fred M. Ssewamala
- Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, United States of America
| |
Collapse
|
14
|
Kiyingi J, Nabunya P, Bahar OS, Mayo-Wilson LJ, Tozan Y, Nabayinda J, Namuwonge F, Nsubuga E, Kizito S, Nattabi J, Nakabuye F, Kagayi J, Mwebembezi A, Witte SS, Ssewamala FM. Prevalence and predictors of HIV and sexually transmitted infections among vulnerable women engaged in sex work: Findings from the Kyaterekera Project in Southern Uganda. PLoS One 2022; 17:e0273238. [PMID: 36174054 PMCID: PMC9522279 DOI: 10.1371/journal.pone.0273238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 08/03/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Women engaged in sex work (WESW) have an elevated risk of the human immunodeficiency virus (HIV) and sexually transmitted infections (STI). Estimates are three times higher than the general population. Understanding the predictors of HIV and STI among WESW is crucial in developing more focused HIV and STI prevention interventions among this population. The study examined the prevalence and predictors of HIV and STI among WESW in the Southern part of Uganda. METHODOLOGY Baseline data from the Kyaterekera study involving 542 WESW (ages 18-55) recruited from 19 HIV hotspots in the greater Masaka region in Uganda was utilized. HIV and STI prevalence was estimated using blood and vaginal fluid samples bioassay. Hierarchical regression models were used to determine the predictors of HIV and STI among WESW. RESULTS Of the total sample, 41% (n = 220) were found to be HIV positive; and 10.5% (n = 57) tested positive for at least one of the three STI (Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis) regardless of their HIV status. Older age (b = 0.09, 95%CI = 0.06, 0.13, p≤0.001), lower levels of education (b = -0.79, 95%CI = -1.46, -0.11, p≤0.05), fewer numbers of children in the household (b = -0.18, 95%CI = -0.36, -0.01), p≤0.05), location (i.e., fishing village (b = 0.51, 95%CI = 0.16, 0.85, p≤0.01) or small town (b = -0.60, 95%CI = -0.92, -0.28, p≤0.001)), drug use (b = 0.58, 95%CI = 0.076, 1.08, p≤0.05) and financial self-efficacy (b = 0.05, 95%CI = -0.10, 0.00, p≤0.05), were associated with the risk of HIV infections among WESW. Domestic violence attitudes (b = -0.24, 95%CI = -0.42, -0.07, p≤0.01) and financial distress (b = -0.07, 95%CI = -0.14, -0.004, p≤0.05) were associated with the risk of STI infection among WESW. CONCLUSION Study findings show a high prevalence of HIV among WESW compared to the general women population. Individual and family level, behavioural and economic factors were associated with increased HIV and STI infection among WESW. Therefore, there is a need for WESW focused HIV and STI risk reduction and economic empowerment interventions to reduce these burdens.
Collapse
Affiliation(s)
- Joshua Kiyingi
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis Brown School, St. Louis, Missouri, United States of America
- Reach the Youth Uganda, Kampala, Uganda
| | - Proscovia Nabunya
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis Brown School, St. Louis, Missouri, United States of America
| | - Ozge Sensoy Bahar
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis Brown School, St. Louis, Missouri, United States of America
| | - Larissa Jennings Mayo-Wilson
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, Indiana, United States of America
| | - Yesim Tozan
- College of Global Public Health, New York University, New York, NY, United States of America
| | - Josephine Nabayinda
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis Brown School, St. Louis, Missouri, United States of America
| | - Flavia Namuwonge
- International Center for Child Health and Development (ICHAD), Masaka, Uganda
| | - Edward Nsubuga
- International Center for Child Health and Development (ICHAD), Masaka, Uganda
| | - Samuel Kizito
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis Brown School, St. Louis, Missouri, United States of America
| | - Jennifer Nattabi
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis Brown School, St. Louis, Missouri, United States of America
| | - Fatuma Nakabuye
- International Center for Child Health and Development (ICHAD), Masaka, Uganda
| | | | | | - Susan S. Witte
- School of Social Work, Columbia University, New York, NY, United States of America
| | - Fred M. Ssewamala
- International Center for Child Health and Development (ICHAD), Brown School, Washington University in St. Louis Brown School, St. Louis, Missouri, United States of America
| |
Collapse
|
15
|
Sensoy Bahar O, Nabunya P, Nabayinda J, Witte SS, Kiyingi J, Mayo-Wilson LJ, Filippone P, Yang LS, Nakigudde J, Tozan Y, Ssewamala FM. "I expected little, although I learned a lot": perceived benefits of participating in HIV risk reduction sessions among women engaged in sex work in Uganda. BMC Womens Health 2022; 22:162. [PMID: 35562821 PMCID: PMC9100307 DOI: 10.1186/s12905-022-01759-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 05/06/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The global HIV burden remains a public health concern. Women engaged in sex work (WESW) are at higher risk of acquiring HIV compared to the general adult population. Uganda reports high rates of HIV prevalence among WESW. While WESW in Uganda have long been the subject of surveillance studies, they have not been targeted by theory-informed HIV prevention intervention approaches. In this study, we explored the perceived benefits of an evidence-based HIV risk reduction intervention that was implemented as part of a combination intervention tested in a clinical trial in Uganda. METHODS As part of a larger randomized clinical trial, we conducted semi-structured in-depth interviews with 20 WESW selected using a stratified purposive sampling. All interviews were conducted in Luganda, language spoken in the study area, and audio-recorded. They were transcribed verbatim and translated to English. Thematic analysis was used to analyze the data. RESULTS WESW's narratives focused on: (1) condom use; (2) alcohol/drug consumption; (3) PrEP use; (4) "handling" customers; and (5) "massaging" customers. WESW agreed that male condom was one of the important learning points for them and planned to continue using them while female condoms were received with mixed reactions. Many women appreciated receiving information about the risks of consuming alcohol and drugs, and discussed how they reduced/ eliminated their consumption. PrEP information was appreciated though identified by fewer WESW. Handling a client was discussed as a helpful strategy for safer sex through improved ability to convince customers to use condoms or avoiding sex. Massaging was also beneficial to avoid penetrative sex, but similar to female condom, massaging also yielded mixed perceptions. CONCLUSION WESW found the intervention beneficial and described ways in which it improved their ability to engage in safer sex and stay healthy. The fact that WESW identified other strategies beyond condom use as helpful underlines the importance of adopting a comprehensive approach to behavioral interventions targeting HIV prevention even when combined with other interventions. Additionally, WESW's narratives suggest that incorporating the tenets of social cognitive theory and harm reduction approaches in HIV prevention among this population can result in risk behavior change.
Collapse
Affiliation(s)
- Ozge Sensoy Bahar
- Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA.
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, USA.
| | - Proscovia Nabunya
- Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Josephine Nabayinda
- International Center for Child Health and Development Field Office, Masaka, Uganda
| | - Susan S Witte
- Columbia University School of Social Work, New York City, NY, USA
| | - Joshua Kiyingi
- Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Prema Filippone
- Columbia University School of Social Work, New York City, NY, USA
| | | | - Janet Nakigudde
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Yesim Tozan
- School of Global Public Health, New York University, New York City, NY, USA
| | - Fred M Ssewamala
- Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA
- International Center for Child Health and Development, Brown School, Washington University in St. Louis, St. Louis, MO, USA
| |
Collapse
|
16
|
Jennings Mayo-Wilson L, Kang BA, Mathai M, Mak'anyengo MO, Ssewamala FM. Mobile phone access, willingness, and usage for HIV-related services among young adults living in informal urban settlements in Kenya: A cross-sectional analysis. Int J Med Inform 2022; 161:104728. [PMID: 35228007 PMCID: PMC8940651 DOI: 10.1016/j.ijmedinf.2022.104728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/24/2022] [Accepted: 02/21/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Mobile phone-based health (mHealth) interventions have the potential to improve HIV outcomes for high-risk young adults living in informal urban settlements in Kenya. However, less is known regarding young adults' differential access to mobile phones and their willingness and use of mobile phone technologies to access HIV prevention, care, and treatment services. This is important as young adults make up the largest demographic segment of impoverished, informal urban settlements and are disproportionately impacted by HIV. METHODS This study used observational survey data from 350 young adults, aged 18-22, who were living informal urban settlements in Nairobi, Kenya. Respondent driven sampling methods were used to recruit and enroll eligible youth. Using descriptive statistics and logistical regressions, we examined the prevalence of mobile phone access, willingness, and use for HIV services. We also assessed associated demographic characteristics in the odds of access, willingness, and use. RESULTS The mean age of participants was 19 years (±1.3). 56% were male. Mobile phone coverage, including text messaging and mobile internet, was high (>80%), but only 15% of young adults had ever used mobile phones to access HIV services. Willingness was high (65%), especially among those who had individual phone access (77%) compared to lower willingness (18%) among those who shared a phone. More educated (OR = 1.84, 95 %CI:1.14-2.97) and employed (OR = 1.70, 95 %CI:1.02 = 2.83) young adults were also more willing to use phones for HIV services. In contrast, participants living in large households (OR = 0.47, 95 %CI:0.24-0.921), were religious minorities (OR = 0.56, 95 %CI:0.32-0.99), partnered/married (OR = 0.30, 95 %CI:0.10-0.91), or female (OR = 0.29, 95 %CI:0.16-0.55) were significantly less likely to have mobile phone access or usage, limiting their potential participation in HIV-related mHealth interventions. Given the low usage of mobile phones currently for HIV services, no differences in demographic characteristics were observed. CONCLUSION Mobile health technologies may be under-utilized in HIV services for at-risk youth. Our findings highlight the importance of preliminary, formative research regarding population differences in access, willingness, and use of mobile phones for HIV services. More efforts are needed to ensure that mHealth interventions account for potential differences in preferences for mobile phone-based HIV interventions by gender, age, religion, education, and/or employment status.
Collapse
Affiliation(s)
- Larissa Jennings Mayo-Wilson
- Indiana University School of Public Health, Department of Applied Health Sciences, 1025 E. 7th Street, Bloomington, IN 47405, USA; Johns Hopkins University, Bloomberg School of Public Health, Department of International Health, 615 N. Wolfe Street, Baltimore, MD, USA.
| | - Bee-Ah Kang
- Johns Hopkins University, Bloomberg School of Public Health, Department of International Health, 615 N. Wolfe Street, Baltimore, MD, USA
| | - Muthoni Mathai
- University of Nairobi, College of Health Sciences, Department of Psychiatry. Kenyatta National Hospital, Off-Ngong Road, Nairobi, Kenya; National Health and Development Organization (NAHEDO), Kenyatta National Hospital, Department of Mental Health, Ralph Bunche Road, P.O. Box 20453 Nairobi, Kenya
| | - Margaret O Mak'anyengo
- National Health and Development Organization (NAHEDO), Kenyatta National Hospital, Department of Mental Health, Ralph Bunche Road, P.O. Box 20453 Nairobi, Kenya
| | - Fred M Ssewamala
- Washington University in St. Louis, The Brown School, Goldfarb, Room 235, Campus Box 1196, One Brookings, Drive, St. Louis, MO 63130, USA.
| |
Collapse
|
17
|
Olakunde BO, Alemu D, Conserve DF, Mathai M, Mak'anyengo MO, Jennings Mayo-Wilson L. Awareness of and willingness to use oral HIV self-test kits among Kenyan young adults living in informal urban settlements: a cross-sectional survey. AIDS Care 2022:1-11. [PMID: 35266433 PMCID: PMC9463408 DOI: 10.1080/09540121.2022.2050176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Self-administered HIV testing may be a promising strategy to improve testing in hard-to-reach young adults, provided they are aware of and willing to use oral HIV self-testing (HIVST). This study examined awareness of and willingness to use oral HIVST among 350 high-risk young adults, aged 18-22, living in Kenya's informal urban settlements. Bivariate and multivariate logistic regressions were used to examine differences in HIVST awareness and willingness by demographic and sexual risk factors. Findings showed that most participants were male (56%) and less than 20 years old (60%). Awareness of oral HIVST was low (19%). However, most participants (75%) were willing to use an oral HIV self-test in the future and ask their sex partner(s) to self-test before having sex (77%). Women (OR = 1.80, 95%CI:1.11, 2.92), older participants (aged 20+) (OR = 2.57, 95% CI:1.48, 4.46), and more educated participants (OR = 2.25, 95%CI:1.36, 3.70) were more willing to use HIVST as compared to men, teen-aged, and less educated participants, respectively. Young adults who reported recent engagement in high-risk sexual behaviors, such as unprotected sex, sex while high or drunk, or sex exchange, were significantly less likely to be willing to use an oral HIV self-test kit (OR = 0.34, 95%CI:0.13,0.86). Those with the highest monthly income (OR = 0.47, 95%CI: 0.25, 0.89) were also less willing to use HIVST. More community- and peer-based efforts are needed to highlight the range of benefits of HIVST (i.e., social, clinical, and structural) to appeal to various youth demographics, in addition to addressing concerns relating to HIVST.
Collapse
Affiliation(s)
- Babayemi O Olakunde
- Department of Community Prevention and Care Services, National Agency for the Control of AIDS, Abuja, NG, USA.,Department of Social Medicine, Ohio University, Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Dawit Alemu
- Department of Social Medicine, Ohio University, Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Donaldson F Conserve
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Muthoni Mathai
- Department of Psychiatry, Kenyatta National Hospital, University of Nairobi, College of Health Sciences, Nairobi, Kenya
| | - Margaret O Mak'anyengo
- Department of Mental Health, National Health and Development Organization (NAHEDO), Kenyatta National Hospital, Nairobi, Kenya
| | -
- Department of Mental Health, National Health and Development Organization (NAHEDO), Kenyatta National Hospital, Nairobi, Kenya
| | - Larissa Jennings Mayo-Wilson
- Department of Applied Health Sciences, Indiana University School of Public Health, Bloomington, IN, USA.,Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
18
|
Witte SS, Filippone P, Ssewamala FM, Nabunya P, Bahar OS, Mayo-Wilson LJ, Namuwonge F, Damulira C, Tozan Y, Kiyingi J, Nabayinda J, Mwebembezi A, Kagaayi J, McKay M. PrEP acceptability and initiation among women engaged in sex work in Uganda: Implications for HIV prevention. EClinicalMedicine 2022; 44:101278. [PMID: 35128367 PMCID: PMC8808048 DOI: 10.1016/j.eclinm.2022.101278] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/21/2021] [Accepted: 01/13/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Women engaged in sex work (WESW) are disproportionately affected by HIV. In Uganda, HIV prevalence among WESW is estimated at 37%, accounting for 18% of all new infections in the country. WESW experience poverty, gender-based violence, and other issues that reduce their power and limit their ability to negotiate condom use. Female-controlled strategies, including pre-exposure prophylaxis (PrEP), may afford women more transmission protection, but barriers to access and use persist. This cross-sectional study examined baseline PrEP acceptability and initiation among WESW recently enrolled in a randomized clinical trial in Uganda to test the impact of a combination HIV risk reduction and economic empowerment intervention on sexual risk outcomes (clinicaltrials.gov, NCT03583541). METHODS A total of 542 WESW from 19 high HIV-prevalent geographical areas were enrolled in the Kyaterekera study between June 2019 and March 2020. Women were eligible for the study if they: (1) were age 18 or over; (2) reported engagement in transactional sex (a sex act in exchange for pay) in the past 30 days; and (3) reported engagement in one or more episodes of unprotected sex in the past 30 days. Women completed a baseline assessment, were tested for HIV and other sexually transmitted infections (STIs) at enrollment, and were connected with antiretroviral therapy (ART), STI treatment, or PrEP, based on need and interest. Descriptive statistics examined baseline data on PrEP acceptability and initiation. Independent variables (i.e. years in sex work, recent sexual coercion, perceived HIV and sex work stigmas, harmful alcohol use, barriers to medical care, and social support) were derived from the empirical literature and women's self-report. Bivariate analysis was performed to test associations between main effects of these variables. Using binomial logistic regression, predictive models were evaluated for two distinct outcomes-PrEP acceptability and PrEP initiation/uptake. FINDINGS At baseline, 59% of women (n = 322) tested HIV negative. Among WESW testing negative, 11% (n = 36) were already PrEP enrolled. Most women reported willingness to use PrEP (n = 317; 91%). Slightly over half of WESW not already on PrEP agreed to initiate PrEP (n = 158; 55%). Logistic regression models demonstrate that acceptability of or willingness to use PrEP was significantly associated with fewer years engaged in sex work (AOR= ·18, 95% CI 0·05-·66, p<·01) and greater perceived social support from family (AOR= 1·39, 95% CI 1·03 -1.88, p<·05). PrEP initiation was negatively associated with greater perceived social support from friends (AOR=·81, 95% CI ·68-0·97, p<·05) and positively associated with higher perceived stigma due to sex work among family members (AOR=2·20, 95% CI 1·15-4·22, p<·05). INTERPRETATION Despite endorsing PrEP use, many WESW remain reluctant to use it. This gap in prevention practice highlights the heart of a failing PrEP prevention cascade. Findings point to the important role family and friend support may play in destigmatizing sex work and PrEP use for women. Social and structural-level efforts are needed to improve educational messaging and to integrate positive messaging into health promotion campaigns for women and their families, while also working toward decriminalizing sex work. FUNDING This paper was made possible with funding from United States National Institute of Mental Health (Grant number: R01MH116768).
Collapse
Affiliation(s)
- Susan S. Witte
- Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027, United States
- Corresponding author.
| | - Prema Filippone
- Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027, United States
| | - Fred M. Ssewamala
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | - Proscovia Nabunya
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | - Ozge Sensoy Bahar
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | - Larissa Jennings Mayo-Wilson
- Department of Applied Health Science, Indiana University School of Public Health, 1025 E. 7TH Street, Bloomington, IN 47405, United States
| | - Flavia Namuwonge
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | - Christopher Damulira
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | - Yesim Tozan
- New York University School of Global Public Health, 708 Broadway, 4rd floor, New York, NY 10003, United States
| | - Joshua Kiyingi
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | - Josephine Nabayinda
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| | | | - Joseph Kagaayi
- Rakai Health Sciences Program, P.O Box 279, Kalisizo, Uganda
| | - Mary McKay
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO 63130, United States
| |
Collapse
|
19
|
Johnson CA, Tran DN, Mwangi A, Sosa-Rubí SG, Chivardi C, Romero-Martínez M, Pastakia S, Robinson E, Jennings Mayo-Wilson L, Galárraga O. Incorporating respondent-driven sampling into web-based discrete choice experiments: preferences for COVID-19 mitigation measures. Health Serv Outcomes Res Methodol 2022; 22:297-316. [PMID: 35035272 PMCID: PMC8747856 DOI: 10.1007/s10742-021-00266-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 09/22/2021] [Accepted: 11/25/2021] [Indexed: 11/28/2022]
Abstract
To slow the spread of COVID-19, most countries implemented stay-at-home orders, social distancing, and other nonpharmaceutical mitigation strategies. To understand individual preferences for mitigation strategies, we piloted a web-based Respondent Driven Sampling (RDS) approach to recruit participants from four universities in three countries to complete a computer-based Discrete Choice Experiment (DCE). Use of these methods, in combination, can serve to increase the external validity of a study by enabling recruitment of populations underrepresented in sampling frames, thus allowing preference results to be more generalizable to targeted subpopulations. A total of 99 students or staff members were invited to complete the survey, of which 72% started the survey (n = 71). Sixty-three participants (89% of starters) completed all tasks in the DCE. A rank-ordered mixed logit model was used to estimate preferences for COVID-19 nonpharmaceutical mitigation strategies. The model estimates indicated that participants preferred mitigation strategies that resulted in lower COVID-19 risk (i.e. sheltering-in-place more days a week), financial compensation from the government, fewer health (mental and physical) problems, and fewer financial problems. The high response rate and survey engagement provide proof of concept that RDS and DCE can be implemented as web-based applications, with the potential for scale up to produce nationally-representative preference estimates.
Collapse
Affiliation(s)
- Courtney A Johnson
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-2, Providence, RI 02912 USA
| | - Dan N Tran
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA USA
| | - Ann Mwangi
- Department of Behavioural Science, School of Medicine, Moi University, Eldoret, Kenya
| | | | - Carlos Chivardi
- National Institute of Public Health (INSP), Cuernavaca, Morelos Mexico
| | | | - Sonak Pastakia
- Center for Health Equity and Innovation, Purdue University College of Pharmacy, Indianapolis, IN USA
| | | | | | - Omar Galárraga
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-2, Providence, RI 02912 USA
| |
Collapse
|
20
|
MacCarthy S, Mendoza-Graf A, Jennings Mayo-Wilson L, Wagner Z, Saya U, Chemusto H, Mukasa B, Linnemayr S. A qualitative exploration of health-related present bias among HIV-positive adults in Uganda. AIDS Care 2021; 35:883-891. [PMID: 34802344 PMCID: PMC9123094 DOI: 10.1080/09540121.2021.2004298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Decision-making errors such as present bias (PB) can have important consequences for health behaviors, but have been largely studied in the financial domain. We conducted a mixed-method study on PB in the context of ART adherence among clinic-enrolled adults in Uganda (n = 39). Specifically, we quantified PB by asking about preferences between medication available sooner to minimize headaches versus available later to cure headaches. We describe demographic similarities among PB participants and qualitatively explored how participants reflected on their PB (or absence thereof) in the context of health. Participants reporting PB were predominantly male, single/unmarried, older, had higher levels of education and income and more advanced HIV progression. Three common reasons for more present-biased choices provided were: (1) wanting to avoid pain, (2) wanting to return to work, and (3) fear of one's health worsening if s/he did not address their illness immediately. While PB in the financial domain often suggests that poorer individuals are more likely to prefer immediate rewards over their wealthier counterparts, our results suggest poor health is potentially a driving factor of PB. Further research is needed to build on these finding and inform how programs can frame key messages regarding ART adherence to patients displaying PB.Trial registration: ClinicalTrials.gov identifier: NCT03494777.
Collapse
Affiliation(s)
| | | | - Larissa Jennings Mayo-Wilson
- Indiana University School of Public Health, Bloomington, IN, USA.,Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | | | | | | | | | | |
Collapse
|
21
|
Poteat T, Mayo-Wilson LJ, Pereira N, Wright BN, Smout SA, Sawyer AN, Cathers L, Zimmerman RS, Grigsby SR, Benotsch EG. U.S. transgender women's preferences for microeconomic interventions to address structural determinants of HIV vulnerability: a qualitative assessment. BMC Public Health 2021; 21:1394. [PMID: 34261464 PMCID: PMC8281671 DOI: 10.1186/s12889-021-11471-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022] Open
Abstract
Background Transgender women in the United States (U.S.) experience a disproportionate burden of HIV infection and challenges to engagement in HIV prevention and care. This excess burden is driven by structural and economic inequities. Microeconomic interventions may be effective strategies for reducing HIV inequities for this population. However, few studies have explored transgender women’s preferences for microeconomic interventions to address structural determinants of HIV vulnerability. Methods We conducted individual interviews with 19 adult transgender women in 2 U.S. cities (Richmond, VA and St. Louis, MO) who reported one or more sexual risk behaviors and recent economic hardship related to employment/income, housing, or food security. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Results The majority (74%) of transgender women were racial/ethnic minorities with mean age of 26.3 years. 89% were currently economically vulnerable; and 23% were employed full-time. 37% reported living with HIV. Participants expressed strong support for unrestricted vouchers, with many expressing the need for funds to support gender-affirming interventions. Assistance with how to budget and save and support for job acquisition, career planning, and employment sustainment were also preferred, including access to non-stigmatizing employment. Visible transgender leadership, group empowerment, and small (rather than large) numbers of participants were considered important aspects of intervention design for transgender women, including outreach through existing transgender networks to facilitate inclusion. Incorporating HIV counseling and testing to reduce vulnerability to HIV was acceptable. However, transgender women enrolled in the study preferred that HIV not be the focus of an intervention. Conclusions Flexible microeconomic interventions that support gender affirming interventions, improve financial literacy, and provide living-wage non-stigmatizing employment are desired by economically vulnerable transgender women. While not focused on HIV, such interventions have the potential to reduce the structural drivers of HIV vulnerability among transgender women.
Collapse
Affiliation(s)
- Tonia Poteat
- Department of Social Medicine, University of North Carolina at Chapel Hill School of Medicine, CB #7240, Chapel Hill, NC, 27516, USA.
| | - Larissa Jennings Mayo-Wilson
- Department of Applied Health Sciences, Indiana University School of Public Health, 1025 E. 7th Street, Bloomington, IN, 47405, USA.,Global & Public Health Division, Johns Hopkins University School of Nursing, Community, 525 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Nastacia Pereira
- Department of Social Medicine, University of North Carolina at Chapel Hill School of Medicine, CB #7240, Chapel Hill, NC, 27516, USA
| | - Brittanni N Wright
- Department of Applied Health Sciences, Indiana University School of Public Health, 1025 E. 7th Street, Bloomington, IN, 47405, USA
| | - Shelby A Smout
- Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Richmond, VA, 23284, USA
| | - Ashlee N Sawyer
- Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Richmond, VA, 23284, USA
| | - Lauretta Cathers
- Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Richmond, VA, 23284, USA
| | - Rick S Zimmerman
- Wayne State University, College of Nursing, 5557 Cass Avenue, Detroit, MI, 48202, USA
| | - Sheila R Grigsby
- University of Missouri St. Louis, College of Nursing, 221 NAB South Campus, University Blvd, St. Loius, MO, 63121, USA
| | - Eric G Benotsch
- Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Richmond, VA, 23284, USA
| |
Collapse
|
22
|
Nabunya P, Kiyingi J, Witte SS, Sensoy Bahar O, Jennings Mayo-Wilson L, Tozan Y, Nabayinda J, Mwebembezi A, Tumwesige W, Mukasa B, Namirembe R, Kagaayi J, Nakigudde J, McKay MM, Ssewamala FM. Working with economically vulnerable women engaged in sex work: Collaborating with community stakeholders in Southern Uganda. Glob Public Health 2021; 17:1215-1231. [PMID: 33881949 DOI: 10.1080/17441692.2021.1916054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03583541.
Collapse
Affiliation(s)
- Proscovia Nabunya
- Brown School, Washington University in St. Louis, St. Louis, MO, USA.,International Center for Child Health and Development, Washington University in St. Louis, St. Louis, MO, USA
| | - Joshua Kiyingi
- Brown School, Washington University in St. Louis, St. Louis, MO, USA.,International Center for Child Health and Development, Washington University in St. Louis, St. Louis, MO, USA
| | - Susan S Witte
- School of Social Work, Columbia University, New York, NY, USA
| | - Ozge Sensoy Bahar
- Brown School, Washington University in St. Louis, St. Louis, MO, USA.,International Center for Child Health and Development, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Yesim Tozan
- School of Global Public Health, New York University, New York, NY, USA
| | - Josephine Nabayinda
- International Center for Child Health and Development, Washington University in St. Louis, St. Louis, MO, USA
| | - Abel Mwebembezi
- International Center for Child Health and Development, Washington University in St. Louis, St. Louis, MO, USA.,Reach the Youth (RTY) Uganda, Kampala, Uganda
| | - Wilberforce Tumwesige
- Brown School, Washington University in St. Louis, St. Louis, MO, USA.,International Center for Child Health and Development, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Rashida Namirembe
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Janet Nakigudde
- Department of Psychiatry, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Mary M McKay
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Fred M Ssewamala
- Brown School, Washington University in St. Louis, St. Louis, MO, USA.,International Center for Child Health and Development, Washington University in St. Louis, St. Louis, MO, USA
| |
Collapse
|
23
|
Nabunya P, Byansi W, Damulira C, Bahar OS, Jennings Mayo-Wilson L, Tozan Y, Kiyingi J, Nabayinda J, Braithwaite R, Witte SS, Ssewamala FM. Predictors of Depressive Symptoms and Post Traumatic Stress Disorder Among Women Engaged in Commercial Sex Work in Southern Uganda. Psychiatry Res 2021; 298:113817. [PMID: 33636517 PMCID: PMC8005481 DOI: 10.1016/j.psychres.2021.113817] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/17/2021] [Indexed: 02/08/2023]
Abstract
This study examined the factors associated with depressive symptoms and post traumatic depressive disorder (PTSD) among economically vulnerable women engaged in commercial sex work (WESW) in southern Uganda. Baseline data from a longitudinal cluster randomized study involving 542 self-identified WESW (18-55 years), recruited from 19 HIV hotspots were analyzed. Hierarchical linear regression modelling was utilized to estimate individual, family-level and economic-level predictors of depressive symptoms and PTSD. Family cohesion, sex work stigma, HIV status, financial distress, household assets, number of children and number of household income earners, were associated with PTSD. Similarly, family cohesion, number of people in the household, HIV status, sex work stigma, financial distress, and household assets, were associated with depressive symptoms. Women engaged in commercial sex work are at a higher risk of HIV and poor mental health outcomes. Sex work stigma and financial distress elevate levels of depressive symptoms and PTSD, over and above an individual's HIV status. Family and economic-level factors have the potential to mitigate the risk of poor mental health outcomes. As such, integrating stigma reduction and economic strengthening components in the programming targeting WESW-a key population, may be critical to address their mental health outcomes.
Collapse
Affiliation(s)
- Proscovia Nabunya
- Washington University in St. Louis Brown School, International Center for Child Health and Development (ICHAD), 1 Brookings Drive, St. Louis, MO 63130, USA.
| | - William Byansi
- Washington University in St. Louis Brown School, International Center for Child Health and Development (ICHAD), 1 Brookings Drive, St. Louis, MO 63130, USA.
| | - Christopher Damulira
- Washington University in St. Louis Brown School, International Center for Child Health and Development (ICHAD), 1 Brookings Drive, St. Louis, MO 63130, USA.
| | - Ozge Sensoy Bahar
- Washington University in St. Louis Brown School, International Center for Child Health and Development (ICHAD), 1 Brookings Drive, St. Louis, MO 63130, USA.
| | - Larissa Jennings Mayo-Wilson
- Indiana University School of Public Health, Department of Applied Health Science, 1025 E. 7(TH) Street, Bloomington, IN 47405, USA.
| | - Yesim Tozan
- New York University College of Global Public Health, 14 East 4(th) street, 3(rd) floor. New York, NY 10003, USA.
| | - Joshua Kiyingi
- Washington University in St. Louis Brown School, International Center for Child Health and Development (ICHAD), 1 Brookings Drive, St. Louis, MO 63130, USA.
| | - Josephine Nabayinda
- Washington University in St. Louis Brown School, International Center for Child Health and Development (ICHAD), 1 Brookings Drive, St. Louis, MO 63130, USA.
| | - Rachel Braithwaite
- Washington University in St. Louis Brown School, International Center for Child Health and Development (ICHAD), 1 Brookings Drive, St. Louis, MO 63130, USA.
| | - Susan S Witte
- Columbia University School of Social Work1255 Amsterdam Avenue, New York, NY 10027, USA.
| | - Fred M Ssewamala
- Washington University in St. Louis Brown School, International Center for Child Health and Development (ICHAD), 1 Brookings Drive, St. Louis, MO 63130, USA.
| |
Collapse
|
24
|
Ssewamala FM, Shu-Huah Wang J, Brathwaite R, Sun S, Mayo-Wilson LJ, Neilands TB, Brooks-Gunn J. Impact of a Family Economic Intervention (Bridges) on Health Functioning of Adolescents Orphaned by HIV/AIDS: A 5-Year (2012-2017) Cluster Randomized Controlled Trial in Uganda. Am J Public Health 2021; 111:504-513. [PMID: 33476237 DOI: 10.2105/ajph.2020.306044] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To investigate the long-term impacts of a family economic intervention on physical, mental, and sexual health of adolescents orphaned by AIDS in Uganda.Methods. Students in grades 5 and 6 from 48 primary schools in Uganda were randomly assigned at the school level (cluster randomization) to 1 of 3 conditions: (1) control (n = 487; 16 schools), (2) Bridges (1:1 savings match rate; n = 396; 16 schools), or (3) Bridges PLUS (2:1 savings match rate; n = 500; 16 schools).Results. At 24 months, compared with participants in the control condition, Bridges and Bridges PLUS participants reported higher physical health scores, lower depressive symptoms, and higher self-concept and self-efficacy. During the same period, Bridges participants reported lower sexual risk-taking intentions compared with the other 2 study conditions. At 48 months, Bridges and Bridges PLUS participants reported better self-rated health, higher savings, and lower food insecurity. During the same period, Bridges PLUS participants reported reduced hopelessness, and greater self-concept and self-efficacy. At 24 and 48 months, Bridges PLUS participants reported higher savings than Bridges participants.Conclusions. Economic interventions targeting families raising adolescents orphaned by AIDS can contribute to long-term positive health and overall well-being of these families.Trial Registration. ClinicalTrials.gov registration no. NCT01447615.
Collapse
Affiliation(s)
- Fred M Ssewamala
- Fred M. Ssewamala, Rachel Brathwaite, and Sicong Sun are with Brown School and the International Center for Child Health and Development, Washington University in St Louis, St Louis, MO. Julia Shu-Huah Wang is with the University of Hong Kong, Department of Social Work and Social Administration, Hong Kong. Larissa Jennings Mayo-Wilson is with Indiana University, School of Public Health, Department of Applied Health Science, Bloomington, IN. Torsten B. Neilands is with the Division of Prevention Science, University of California, San Francisco. Jeanne Brooks-Gunn is with Teachers College and Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Julia Shu-Huah Wang
- Fred M. Ssewamala, Rachel Brathwaite, and Sicong Sun are with Brown School and the International Center for Child Health and Development, Washington University in St Louis, St Louis, MO. Julia Shu-Huah Wang is with the University of Hong Kong, Department of Social Work and Social Administration, Hong Kong. Larissa Jennings Mayo-Wilson is with Indiana University, School of Public Health, Department of Applied Health Science, Bloomington, IN. Torsten B. Neilands is with the Division of Prevention Science, University of California, San Francisco. Jeanne Brooks-Gunn is with Teachers College and Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Rachel Brathwaite
- Fred M. Ssewamala, Rachel Brathwaite, and Sicong Sun are with Brown School and the International Center for Child Health and Development, Washington University in St Louis, St Louis, MO. Julia Shu-Huah Wang is with the University of Hong Kong, Department of Social Work and Social Administration, Hong Kong. Larissa Jennings Mayo-Wilson is with Indiana University, School of Public Health, Department of Applied Health Science, Bloomington, IN. Torsten B. Neilands is with the Division of Prevention Science, University of California, San Francisco. Jeanne Brooks-Gunn is with Teachers College and Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Sicong Sun
- Fred M. Ssewamala, Rachel Brathwaite, and Sicong Sun are with Brown School and the International Center for Child Health and Development, Washington University in St Louis, St Louis, MO. Julia Shu-Huah Wang is with the University of Hong Kong, Department of Social Work and Social Administration, Hong Kong. Larissa Jennings Mayo-Wilson is with Indiana University, School of Public Health, Department of Applied Health Science, Bloomington, IN. Torsten B. Neilands is with the Division of Prevention Science, University of California, San Francisco. Jeanne Brooks-Gunn is with Teachers College and Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Larissa Jennings Mayo-Wilson
- Fred M. Ssewamala, Rachel Brathwaite, and Sicong Sun are with Brown School and the International Center for Child Health and Development, Washington University in St Louis, St Louis, MO. Julia Shu-Huah Wang is with the University of Hong Kong, Department of Social Work and Social Administration, Hong Kong. Larissa Jennings Mayo-Wilson is with Indiana University, School of Public Health, Department of Applied Health Science, Bloomington, IN. Torsten B. Neilands is with the Division of Prevention Science, University of California, San Francisco. Jeanne Brooks-Gunn is with Teachers College and Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Torsten B Neilands
- Fred M. Ssewamala, Rachel Brathwaite, and Sicong Sun are with Brown School and the International Center for Child Health and Development, Washington University in St Louis, St Louis, MO. Julia Shu-Huah Wang is with the University of Hong Kong, Department of Social Work and Social Administration, Hong Kong. Larissa Jennings Mayo-Wilson is with Indiana University, School of Public Health, Department of Applied Health Science, Bloomington, IN. Torsten B. Neilands is with the Division of Prevention Science, University of California, San Francisco. Jeanne Brooks-Gunn is with Teachers College and Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jeanne Brooks-Gunn
- Fred M. Ssewamala, Rachel Brathwaite, and Sicong Sun are with Brown School and the International Center for Child Health and Development, Washington University in St Louis, St Louis, MO. Julia Shu-Huah Wang is with the University of Hong Kong, Department of Social Work and Social Administration, Hong Kong. Larissa Jennings Mayo-Wilson is with Indiana University, School of Public Health, Department of Applied Health Science, Bloomington, IN. Torsten B. Neilands is with the Division of Prevention Science, University of California, San Francisco. Jeanne Brooks-Gunn is with Teachers College and Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| |
Collapse
|
25
|
Linnemayr S, Jennings Mayo-Wilson L, Saya U, Wagner Z, MacCarthy S, Walukaga S, Nakubulwa S, Karamagi Y. HIV Care Experiences During the COVID-19 Pandemic: Mixed-Methods Telephone Interviews with Clinic-Enrolled HIV-Infected Adults in Uganda. AIDS Behav 2021; 25:28-39. [PMID: 32918641 PMCID: PMC7486807 DOI: 10.1007/s10461-020-03032-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
COVID-19 measures that restrict movement may negatively impact access to HIV care and treatment. To contribute to the currently limited evidence, we used telephone interviews with quantitative and qualitative questions to examine how clients perceived COVID-19 and its effect on their HIV care and ART adherence. One hundred (n = 100) Ugandan adults on ART from an existing study were randomly selected and enrolled. Interviews were recorded, transcribed, and analyzed using descriptive statistics and rapid content analyses. 76% of clients indicated that COVID-19 negatively impacted travel to HIV clinics; 54% perceived that coming to the clinic increased their risk of acquiring COVID-19; and 14% said that COVID-19 had negatively impacted their ART adherence. Qualitative feedback suggests that fear of COVID-19 infection discouraged clinic attendance while stay-at-home orders helped routinize ART adherence and employ new community-based approaches for HIV care. Addressing negative unintended consequences of COVID-19 lockdowns on HIV care is urgently needed.
Collapse
Affiliation(s)
| | - Larissa Jennings Mayo-Wilson
- Department of Applied Health Science, Indiana University School of Public Health, 1025 E. 7th Street, Bloomington, IN, USA
| | - Uzaib Saya
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA
| | - Zachary Wagner
- RAND Corporation, 1776 Main Street, Santa Monica, CA, USA
| | | | | | | | | |
Collapse
|
26
|
Jennings Mayo-Wilson L, Coleman J, Timbo F, Latkin C, Torres Brown ER, Butler AI, Conserve DF, Glass NE. Acceptability of a feasibility randomized clinical trial of a microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices (EMERGE) in young adults: a mixed methods assessment. BMC Public Health 2020; 20:1846. [PMID: 33267860 PMCID: PMC7709242 DOI: 10.1186/s12889-020-09904-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acceptability is a critical requisite in establishing feasibility when planning a larger effectiveness trial. This study assessed the acceptability of conducting a feasibility randomized clinical trial of a 20-week microenterprise intervention for economically-vulnerable African-American young adults, aged 18 to 24, in Baltimore, Maryland. Engaging MicroenterprisE for Resource Generation and Health Empowerment (EMERGE) aimed to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors. METHODS Thirty-eight participants were randomized to experimental (n = 19) or comparison group (n = 19). The experimental group received text messages on job openings plus educational sessions, mentoring, a start-up grant, and business and HIV prevention text messages. The comparison group received text messages on job openings only. Qualitative and quantitative post-intervention, in-person interviews were used in addition to process documentation of study methods. RESULTS Our results found that the study design and interventions showed promise for being acceptable to economically-vulnerable African-American young adults. The largely positive endorsement suggested that factors contributing to acceptability included perceived economic potential, sexual health education, convenience, incentives, and encouraging, personalized feedback to participants. Barriers to acceptability for some participants included low cell phone connectivity, perceived payment delays, small cohort size, and disappointment with one's randomization assignment to comparison group. Use of peer referral, network, or wait-list designs, in addition to online options may enhance acceptability in a future definitive trial. Expanding administrative and mentoring support may improve overall experience. CONCLUSION Microenterprise interventions are acceptable ways of providing young adults with important financial and sexual health content to address HIV risks associated with economic vulnerability. TRIAL REGISTRATION ClinicalTrials.gov. NCT03766165 . Registered 04 December 2018.
Collapse
Affiliation(s)
- Larissa Jennings Mayo-Wilson
- Department of Applied Health Science, Indiana University School of Public Health, 1025 E. 7th Street, Bloomington, IN 47405 USA
- Department of International Health, Johns Hopkins University School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Jessica Coleman
- Department of International Health, Johns Hopkins University School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Fatmata Timbo
- Department of International Health, Johns Hopkins University School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Carl Latkin
- Department of International Health, Johns Hopkins University School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Elizabeth R. Torres Brown
- HEBCAC Youth Opportunity (YO!) Program, Johns Hopkins University School of Medicine, 1212 N. Wolfe Street, Baltimore, MD USA
| | - Anthony I. Butler
- AIRS, Inc., Empire Homes of Maryland, Inc., City Steps, 1800 N Charles Street, 7th Floor, Baltimore, MD USA
| | - Donaldson F. Conserve
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 915 Green Street, Columbia, SC 29208 USA
| | - Nancy E. Glass
- Department of International Health, Johns Hopkins University School of Public Health, 615 N. Wolfe Street, Baltimore, MD USA
- Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Baltimore, MD USA
| |
Collapse
|
27
|
Jennings Mayo-Wilson L, Coleman J, Timbo F, Ssewamala FM, Linnemayr S, Yi GT, Kang BA, Johnson MW, Yenokyan G, Dodge B, Glass NE. Microenterprise Intervention to Reduce Sexual Risk Behaviors and Increase Employment and HIV Preventive Practices Among Economically-Vulnerable African-American Young Adults (EMERGE): A Feasibility Randomized Clinical Trial. AIDS Behav 2020; 24:3545-3561. [PMID: 32494942 PMCID: PMC7667139 DOI: 10.1007/s10461-020-02931-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Economic vulnerability, such as homelessness and unemployment, contributes to HIV risk among U.S. racial minorities. Yet, few economic-strengthening interventions have been adapted for HIV prevention in this population. This study assessed the feasibility of conducting a randomized clinical trial of a 20-week microenterprise intervention for economically-vulnerable African-American young adults. Engaging MicroenterprisE for Resource Generation and Health Empowerment (EMERGE) aimed to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors. The experimental group received text messages on job openings plus educational sessions, mentoring, a start-up grant, and business and HIV prevention text messages. The comparison group received text messages on job openings only. Primary feasibility objectives assessed recruitment, randomization, participation, and retention. Secondary objectives examined employment, sexual risk behaviors, and HIV preventive behaviors. Outcome assessments used an in-person pre- and post-intervention interview and a weekly text message survey. Several progression criteria for a definitive trial were met. Thirty-eight participants were randomized to experimental (n = 19) or comparison group (n = 19) of which 95% were retained. The comparison intervention enhanced willingness to be randomized and reduced non-participation. Mean age of participants was 21.0 years; 35% were male; 81% were unemployed. Fifty-eight percent (58%) of experimental participants completed ≥ 70% of intervention activities, and 74% completed ≥ 50% of intervention activities. Participation in intervention activities and outcome assessments was highest in the first half (~ 10 weeks) of the study. Seventy-one percent (71%) of weekly text message surveys received a response through week 14, but responsiveness declined to 37% of participants responding to ≥ 70% of weekly text message surveys at the end of the study. The experimental group reported higher employment (from 32% at baseline to 83% at week 26) and lower unprotected sex (79% to 58%) over time compared to reported changes in employment (37% to 47%) and unprotected sex (63% to 53%) over time in the comparison group. Conducting this feasibility trial was a critical step in the process of designing and testing a behavioral intervention. Development of a fully-powered effectiveness trial should take into account lessons learned regarding intervention duration, screening, and measurement.Trial Registration ClinicalTrials.gov. NCT03766165. Registered 04 December 2018. https://clinicaltrials.gov/ct2/show/NCT03766165.
Collapse
Affiliation(s)
- Larissa Jennings Mayo-Wilson
- Indiana University School of Public Health, Department of Applied Health Science, 1025 E. 7th Street, Bloomington, IN USA
- Johns Hopkins University School of Public Health, Department of International Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Jessica Coleman
- Johns Hopkins University School of Public Health, Department of International Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Fatmata Timbo
- Johns Hopkins University School of Public Health, Department of International Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Fred M. Ssewamala
- The Brown School, Washington University in St. Louis, Goldfarb, One Brookings, Drive, St. Louis, MO USA
| | | | - Grace T. Yi
- Johns Hopkins University School of Public Health, Department of International Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Bee-Ah Kang
- Johns Hopkins University School of Public Health, Department of International Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Matthew W. Johnson
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, 5510 Nathan Shock Drive, Baltimore, MD USA
| | - Gayane Yenokyan
- Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics, 615 N. Wolfe Street, Baltimore, MD USA
| | - Brian Dodge
- Johns Hopkins University School of Public Health, Department of International Health, 615 N. Wolfe Street, Baltimore, MD USA
| | - Nancy E. Glass
- Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Baltimore, MD USA
| |
Collapse
|
28
|
Jack SM, Munro-Kramer ML, Williams JR, Schminkey D, Tomlinson E, Jennings Mayo-Wilson L, Bradbury-Jones C, Campbell JC. Recognising and responding to intimate partner violence using telehealth: Practical guidance for nurses and midwives. J Clin Nurs 2020; 30:588-602. [PMID: 33141467 DOI: 10.1111/jocn.15554] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/18/2020] [Accepted: 10/23/2020] [Indexed: 11/28/2022]
Abstract
AIMS To synthesise the current, global evidence-informed guidance that supports nurses and midwives to recognise and respond to intimate partner violence (IPV), and how these practices can be translated from face-to-face encounters to care that is delivered through telehealth. BACKGROUND COVID-19-related social and physical distancing measures increase the risk for individuals who are socially isolated with partners who perpetuate violence. Providing support through telehealth is one strategy that can mitigate the pandemic of IPV, while helping patients and providers stay safe from COVID-19. DESIGN AND METHODS In this discursive paper, we describe how practical guidance for safely recognising and responding to IPV in telehealth encounters was developed. The ADAPT-ITT (Assessment, Decisions, Administration, Production, Topical Experts, Integration, Testing, Training) framework was used to guide the novel identification and adaptation of evidence-informed guidance. We focused on the first six stages of the ADAPT-ITT framework. CONCLUSIONS This paper fills a gap in available guidance, specifically for IPV recognition and response via telehealth. We present strategies for prioritising safety and promoting privacy while initiating, managing or terminating a telehealth encounter with patients who may be at risk for or experiencing IPV. Strategies for assessment, planning and intervention are also summarised. System-level responses, such as increasing equitable access to telecommunication technology, are also discussed. RELEVANCE TO CLINICAL PRACTICE Integrating innovative IPV-focused practices into telehealth care is an important opportunity for nurses and midwives during the current global COVID-19 pandemic. There are also implications for future secondary outbreaks, natural disasters or other physically isolating events, for improving healthcare efficiency, and for addressing the needs of vulnerable populations with limited access to health care.
Collapse
Affiliation(s)
- Susan M Jack
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | | | - Jessica R Williams
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donna Schminkey
- School of Nursing, College of Health and Behavioral Studies, James Madison University, Harrisonburg, VA, USA
| | | | | | | | | |
Collapse
|
29
|
Yang F, Ketende S, Jennings Mayo-Wilson L, Lyons CE, Liestman B, Diouf D, Drame FM, Coly K, Turpin G, Mboup S, Toure-Kane C, Castor D, Cheng A, Diop-Ndiaye H, Leye-Diouf N, Kennedy C, Baral S. Associations Between Economic Factors and Condom Use Behavior Among Female Sex Workers in Dakar and Mbour, Senegal. AIDS Behav 2020; 24:2829-2841. [PMID: 32180091 DOI: 10.1007/s10461-020-02832-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Condom use remains a mainstay of HIV prevention programs around the world. However, data characterizing economic determinants of condom use among female sex workers (FSW) are limited, including in Senegal. We recruited 718 FSWs via respondent-driven sampling. Bivariate and multivariable regressions were conducted to assess the associations between economic variables and condom use at last sex. Paying rent (aRR: 1.07, 95%CI 1.01-1.13) was positively associated with condom use at last sex with new clients. No statistically significant associations were found between condom use and financial responsibility for dependent children, having additional source of income, sharing sex work earnings, or the ability to borrow from other FSWs, regardless of sexual partner types. The relationship between economic marginalization and consistent condom use among sex workers is complex reinforcing the need for behavioral economic research and prevention to be integrated into HIV prevention and treatment research and programs.
Collapse
Affiliation(s)
- Fan Yang
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, USA.
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, USA.
- School of Medicine, University of North Carolina, Project-China, Guangzhou, China.
| | - Sosthenes Ketende
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, USA
| | | | - Carrie E Lyons
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, USA
| | - Benjamin Liestman
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, USA
| | | | - Fatou M Drame
- Enda Santé, Dakar, Senegal
- Gaston Berger University, Saint-Louis, Senegal
| | - Karleen Coly
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, USA
| | - Gnilane Turpin
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, USA
| | - Souleymane Mboup
- Institut de Recherche en Santé, de Surveillance Epidemiologique Et de Formations, Dakar, Senegal
- Laboratoire de Bacteriologie-Virologie, CHU Aristide Le Dantec, Dakar, Senegal
| | - Coumba Toure-Kane
- Laboratoire de Bacteriologie-Virologie, CHU Aristide Le Dantec, Dakar, Senegal
| | - Delivette Castor
- USAID, Office of HIV/AIDS, Bureau for Global Health, Arlington, VA, USA
| | - Alison Cheng
- USAID, Office of HIV/AIDS, Bureau for Global Health, Arlington, VA, USA
| | | | - Nafissatou Leye-Diouf
- Institut de Recherche en Santé, de Surveillance Epidemiologique Et de Formations, Dakar, Senegal
| | - Caitlin Kennedy
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, USA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, USA
| |
Collapse
|
30
|
Jennings Mayo-Wilson L, Glass NE, Labrique A, Davoust M, Ssewamala FM, Linnemayr S, Johnson MW. Feasibility of Assessing Economic and Sexual Risk Behaviors Using Text Message Surveys in African-American Young Adults Experiencing Homelessness and Unemployment: Single-Group Study. JMIR Form Res 2020; 4:e14833. [PMID: 32706656 PMCID: PMC7395246 DOI: 10.2196/14833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 03/11/2020] [Accepted: 03/29/2020] [Indexed: 11/29/2022] Open
Abstract
Background Text messages offer the potential to better evaluate HIV behavioral interventions using repeated longitudinal measures at a lower cost and research burden. However, they have been underused in US minority settings. Objective This study aims to examine the feasibility of assessing economic and sexual risk behaviors using text message surveys. Methods We conducted a single-group study with 17 African-American young adults, aged 18-24 years, who were economically disadvantaged and reported prior unprotected sex. Participants received a text message survey once each week for 5 weeks. The survey contained 14 questions with yes-no and numeric responses on sexual risk behaviors (ie, condomless sex, sex while high or drunk, and sex exchange) and economic behaviors (ie, income, employment, and money spent on HIV services or products). Feasibility measures were the number of participants who responded to the survey in a given week, the number of questions to which a participant responded in each survey, and the number of hours spent from sending a survey to participants to receiving their response in a given week. One discussion group was used to obtain feedback. Results Overall, 65% (n=11/17) of the participants responded to at least one text message survey compared with 35% (n=6/17) of the participants who did not respond. The majority (n=7/11, 64%) of the responders were women. The majority (n=4/6, 67%) of nonresponders were men. An average of 7.6 participants (69%) responded in a given week. Response rates among ever responders ranged from 64% to 82% across the study period. The mean number of questions answered each week was 12.6 (SD 2.7; 90% of all questions), ranging from 72% to 100%. An average of 6.4 participants (84%) answered all 14 text message questions in a given week, ranging from 57% to 100%. Participants responded approximately 8.7 hours (SD 10.3) after receiving the survey. Participants were more likely to answer questions related to employment, condomless sex, and discussions with sex partners. Nonresponse or skip was more often used for questions at the end of the survey relating to sex exchange and money spent on HIV prevention services or products. Strengths of the text message survey were convenience, readability, short completion time, having repeated measures over time, and having incentives. Conclusions Longitudinal text message surveys may be a valuable tool for assessing HIV-related economic and sexual risk behaviors. Trial Registration ClinicalTrials.gov NCT03237871; https://clinicaltrials.gov/ct2/show/NCT03237871
Collapse
Affiliation(s)
- Larissa Jennings Mayo-Wilson
- Department of Applied Health Science, Indiana University School of Public Health, Bloomington, IN, United States.,Department of International Health, Johns Hopkins University School of Public Health, Baltimore, MD, United States
| | - Nancy E Glass
- Johns Hopkins University School of Nursing, Baltimore, MD, United States
| | - Alain Labrique
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, MD, United States
| | - Melissa Davoust
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, MD, United States.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Fred M Ssewamala
- The Brown School, Washington University in St Louis, St Louis, MO, United States
| | | | - Matthew W Johnson
- Behavioral Pharmacology Research, John Hopkins University School of Medicine, Baltimore, MD, United States
| |
Collapse
|
31
|
Mhando F, Dovel K, Jennings Mayo-Wilson L, Rwehumbiza D, Thompson N, Nwaozuru U, Rehani A, Iwelunmor J, Nelson LE, Conserve DF. Microfinance and Peer Health Leadership Intervention Implementation for Men in Dar es Salaam, Tanzania: A Qualitative Assessment of Perceived Economic and Health Outcomes. Am J Mens Health 2020; 14:1557988320936892. [PMID: 32627650 PMCID: PMC7492860 DOI: 10.1177/1557988320936892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/20/2020] [Accepted: 05/28/2020] [Indexed: 12/17/2022] Open
Abstract
Men in sub-Saharan Africa continue to experience health disparities that are exacerbated by low employment. This study qualitatively assessed men's perceptions of the economic and health-care-seeking effects of participation in an integrated microfinance and peer health leadership intervention on violence and HIV risk reduction in Tanzania. Three focus group discussions with 27 men, aged 20 to 44 years, examined the perceived effects on income generation, employability, mental health, and uptake of HIV and related health services. All discussions were recorded, transcribed, and analyzed using deductive and inductive coding methods. Men reported that the benefits of the intervention included increased employability and income-earning activities due to greater access to entrepreneurial training, low-interest microfinancing, and male-oriented group supports to start or strengthen their businesses. Increased wages through business or other forms of employment were also attributed to men's lower anxiety and distress as financial providers for their families. However, men indicated that apart from the uptake of free HIV testing services, there was limited change in overall health-care-seeking behavior given the high clinic fees and lost time to earn income when attending routine health visits. Men recommended that future microfinance and health promotion interventions provide larger loan amounts, less frequent repayment intervals, and access to health and social insurance. Microfinance and peer health leadership interventions may help to address economic and health disparities in poor, urban men. Efforts are needed to assist lower income men in accessing financial tools as well as fee-based preventive and health-care services.
Collapse
Affiliation(s)
- Frank Mhando
- Department of Geography,
University of Dar es Salaam, Dar es Salaam, Tanzania
| | - Kathryn Dovel
- Division of Infectious Diseases,
David Geffen School of Medicine, University of California Los Angeles
(UCLA), Los Angeles, USA
| | - Larissa Jennings Mayo-Wilson
- Department of Applied Health
Science, Indiana University School of Public Health, Bloomington, IN,
USA
- Department of International
Health, Johns Hopkins University School of Public Health, Baltimore, MD,
USA
| | | | - Noah Thompson
- Department of Health Promotion,
Education, and Behavior, University of South Carolina, Columbia, SC,
USA
| | - Ucheoma Nwaozuru
- Department of Behavioral Science
and Health Education, Saint Louis University, Saint Louis, MO, USA
| | | | - Juliet Iwelunmor
- Department of Behavioral Science
and Health Education, Saint Louis University, Saint Louis, MO, USA
| | | | - Donaldson Fadael Conserve
- Department of Health Promotion,
Education, and Behavior, University of South Carolina, Columbia, SC,
USA
| |
Collapse
|
32
|
Jennings Mayo-Wilson L, Devoto B, Coleman J, Mukasa B, Shelton A, MacCarthy S, Saya U, Chemusto H, Linnemayr S. Habit formation in support of antiretroviral medication adherence in clinic-enrolled HIV-infected adults: a qualitative assessment using free-listing and unstructured interviewing in Kampala, Uganda. AIDS Res Ther 2020; 17:30. [PMID: 32513192 PMCID: PMC7278190 DOI: 10.1186/s12981-020-00283-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 05/15/2020] [Indexed: 12/03/2022] Open
Abstract
Background Despite initial high motivation, individuals receiving antiretroviral therapy (ART) for several years may experience incomplete adherence over time, increasing their risk of HIV-related morbidity and mortality. Habits, defined as automatic and regular practices, do not rely on conscious effort, and may therefore support high long-term ART adherence. Methods This qualitative study contributes to the evidence on how clients with adherence problems remember and form habits to take ART medications. Free-listing and unstructured interviewing were used among 42 clinic-enrolled adults in Kampala, Uganda who were receiving ART and participating in a randomized clinical trial for treatment adherence (clinicaltrials.gov: NCT03494777). Data were coded and analyzed using inductive content analysis. Results Findings indicated that clients’ most routine habits (eating, bathing, sleeping) did not always occur at the same time or place, making it difficult to reliably link to pill-taking times. Efforts to improve ART habits included having a relative to ask about pill-taking, re-packaging medications, leaving medications in view, using alarms, carrying water, or linking pill-taking to radio/prayer schedules. Reported challenges were adhering to ART schedules during changing employment hours, social activities, and travel. Conclusion While habit-forming interventions have the potential to improve ART adherence, targeting treatment-mature clients’ existing routines may be crucial in this population.
Collapse
|
33
|
Jennings Mayo-Wilson L, Benotsch EG, Grigsby SR, Wagner S, Timbo F, Poteat T, Cathers L, Sawyer AN, Smout SA, Zimmerman RS. Combined effects of gender affirmation and economic hardship on vulnerability to HIV: a qualitative analysis among U.S. adult transgender women. BMC Public Health 2020; 20:782. [PMID: 32456674 PMCID: PMC7249630 DOI: 10.1186/s12889-020-08902-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
Background Transgender women (“trans women”), particularly African-American and Latina trans women, have disproportionately high prevalence of HIV in the United States (U.S.). In order to decrease gender dysphoria and overcome discrimination, trans women affirm their gender through social and medical transition, often in contexts of economic hardship and sexual risk. This study qualitatively examined how gender-affirming behaviors enhance or diminish vulnerability to HIV in light of structural and economic barriers to gender transition. Methods We conducted individual interviews with 19 adult trans women in two U.S. cities (Richmond, VA and St. Louis, MO) who reported one or more sexual risk behaviors and recent economic hardship related to employment/income, housing, or food security. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Results The majority (74%) of trans women were racial/ethnic minorities with mean age of 26.3 years. Gender-affirming behaviors varied with 58% of trans women having legally changed their name and gender marker; 79% having initiated hormone therapy; and 11% having not initiated any medical or legal changes. None had undertaken surgical changes. Findings suggested that the process of gender transitioning resulted in both increasing and decreasing HIV risk. The high need for gender affirmation by male sex partners contributed to trans women’s exposure to sexual objectification, sexual risk behaviors, and conflicting interests in HIV prevention messaging. Loss of housing and employment due to transition along with the high costs of transition products and medical visits increased reliance on sex work and created new obstacles in accessing HIV services. Trans women experienced lower HIV risk as they acquired legal and medical transition services, reshaped interactions with sex partners, and received gender-affirming support by others, including health providers, employers, peers, and housing professionals. Sexual abstinence was viewed as a negative consequence of incomplete transition, although characterized as a period of low HIV risk. Conclusions Structural and policy initiatives that promote safe gender transition and economic stability in trans women may play a critical role in reducing HIV in this population. Addressing the harmful pressures for U.S. trans women to conform to perceived feminine stereotypes may also serve an important role.
Collapse
Affiliation(s)
- Larissa Jennings Mayo-Wilson
- Indiana University School of Public Health, Department of Applied Health Sciences, Center for Sexual Health Promotion, 1025 E. 7th Street, Bloomington, IN, 47405, USA. .,Johns Hopkins Bloomberg School of Public Health, Department of International Health, Social and Behavioral Interventions Program, 615 N. Wolfe Street, Room E5038, Baltimore, MD, 21205, USA.
| | - Eric G Benotsch
- Virginia Commonwealth University, Department of Psychology, 806 West Franklin Street, Richmond, VA, 23284, USA
| | - Sheila R Grigsby
- University of Missouri - St. Louis, College of Nursing, 221 NAB South Campus, University Blvd St. Louis, St. Louis, MO, 63121, USA
| | - Sarah Wagner
- Indiana University School of Public Health, Department of Applied Health Sciences, Center for Sexual Health Promotion, 1025 E. 7th Street, Bloomington, IN, 47405, USA
| | - Fatmata Timbo
- Indiana University School of Public Health, Department of Applied Health Sciences, Center for Sexual Health Promotion, 1025 E. 7th Street, Bloomington, IN, 47405, USA
| | - Tonia Poteat
- University of North Carolina, Department of Social Medicine, CB #7240, Chapel Hill, NC, 27516, USA
| | - Lauretta Cathers
- University of Missouri - St. Louis, College of Nursing, 221 NAB South Campus, University Blvd St. Louis, St. Louis, MO, 63121, USA
| | - Ashlee N Sawyer
- Virginia Commonwealth University, Department of Psychology, 806 West Franklin Street, Richmond, VA, 23284, USA
| | - Shelby A Smout
- Virginia Commonwealth University, Department of Psychology, 806 West Franklin Street, Richmond, VA, 23284, USA
| | - Rick S Zimmerman
- Louisiana State University Health New Orleans School of Nursing, 1900 Gravier Street, Room 5B14, New Orleans, LA, 70112, USA
| |
Collapse
|
34
|
Jennings Mayo-Wilson L, Mathai M, Yi G, Mak’anyengo MO, Davoust M, Massaquoi ML, Baral S, Ssewamala FM, Glass NE. Lessons learned from using respondent-driven sampling (RDS) to assess sexual risk behaviors among Kenyan young adults living in urban slum settlements: A process evaluation. PLoS One 2020; 15:e0231248. [PMID: 32275677 PMCID: PMC7147752 DOI: 10.1371/journal.pone.0231248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 03/19/2020] [Indexed: 12/02/2022] Open
Abstract
Background Respondent-driven sampling (RDS) is a peer-referral sampling methodology used to estimate characteristics of underserved groups that cannot be randomly sampled. RDS has been implemented in several settings to identify hidden populations at risk for HIV, but few studies have reported the methodological lessons learned on RDS design and implementation for assessing sexual risk behaviors in marginalized youth. Methods We used RDS to recruit N = 350 young adults, aged 18 to 22, who were living in urban slum settlements in Nairobi, Kenya. A structured survey was used to assess sexual risk behaviors. Twenty seeds were selected and asked to recruit up to three eligible peers. We used small monetary incentives and a three-day recruitment coupon with sequential numbers linking recruiters to their recruits. Results Data collection was completed in 8 days with a maximum chain length of 6 waves. Each seed yielded 16 to 21 eligible recruits. Three (15%) seeds were unproductive and were replaced. RDS benefits were high identification rates (90% coupons returned per coupons given), high eligibility rates (100% eligible recruits per coupons returned), and high efficiency (~39 eligible recruits per day). 44% of the sample was female. Most recruits (74%) reported being “friends” for 7+ years with their recruiter. RDS overcame feasibility concerns of household-, clinic-, and school-based sampling methodologies in that underserved youth who were unemployed (68%), out of school (48%), ethnic minorities (26%), and having prior residential instability (≥2 moves in the past year) (20%) were successfully recruited, based on weighted analyses. Youth reporting HIV risk behaviors, including unprotected sex (38%), sex while high/drunk (35%), and sex exchange for pay (14%), were also enrolled. However, 28% were not sexually active within the last 6 months. Challenges included managing wait times during peaks and participant referral expectations. Community engagement, use of study-stamped coupons, broad inclusion criteria, incentives, and study sites within walking distances all contributed to the successful implementation of the sampling methodology. Conclusion RDS is an important tool in reaching a diverse sample of underserved and at-risk young adults for study participation. Implications for optimizing RDS for behavioral studies in this population are discussed.
Collapse
Affiliation(s)
- Larissa Jennings Mayo-Wilson
- Department of Applied Health Sciences, Indiana University School of Public Health, Bloomington, Indiana, United States of America
- Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Muthoni Mathai
- Department of Psychiatry, University of Nairobi, College of Health Sciences, Kenyatta National Hospital, Nairobi, Kenya
- Department of Mental Health, National Health and Development Organization (NAHEDO), Kenyatta National Hospital, Nairobi, Kenya
| | - Grace Yi
- Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Margaret O. Mak’anyengo
- Department of Psychiatry, University of Nairobi, College of Health Sciences, Kenyatta National Hospital, Nairobi, Kenya
- Department of Mental Health, National Health and Development Organization (NAHEDO), Kenyatta National Hospital, Nairobi, Kenya
| | - Melissa Davoust
- Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Massah L. Massaquoi
- Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Fred M. Ssewamala
- Washington University in St. Louis, The Brown School, Goldfarb, One Brookings, Drive, St. Louis, Missouri, United States of America
| | - Nancy E. Glass
- Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
| | - NAHEDO Study Group
- Department of Mental Health, National Health and Development Organization (NAHEDO), Kenyatta National Hospital, Nairobi, Kenya
| |
Collapse
|
35
|
Tingey L, Larzelere F, Goklish N, Rosenstock S, Jennings Mayo-Wilson L, Pablo E, Goklish W, Grass R, Sprengeler F, Parker S, Ingalls A, Craig M, Barlow A. Entrepreneurial, Economic, and Social Well-Being Outcomes from an RCT of a Youth Entrepreneurship Education Intervention among Native American Adolescents. Int J Environ Res Public Health 2020; 17:E2383. [PMID: 32244495 PMCID: PMC7177681 DOI: 10.3390/ijerph17072383] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/21/2020] [Accepted: 03/28/2020] [Indexed: 12/02/2022]
Abstract
Background: Entrepreneurship education has demonstrated positive impacts in low-resource contexts. However, there is limited evidence of such programs evaluated among Native American (NA) youth in a rural reservation. Methods: A 2:1 randomized controlled trial evaluated the impact of the Arrowhead Business Group (ABG) entrepreneurship education program on entrepreneurship knowledge, economic empowerment, and social well-being among 394 NA youth. An intent to treat analysis using mixed effects regression models examined within and between study group differences from baseline to 24 months. An interaction term measured change in the intervention relative to change in the control. ABG participants were purposively sampled to conduct focus groups and in-depth interviews. Results: Significant intervention vs. control group improvements were sustained at 12 months for entrepreneurship knowledge and economic confidence/security. Significant within-group improvements were sustained for ABG participants at 24 months for connectedness to parents, school, and awareness of connectedness. Qualitative data endorses positive impacts on social well-being among ABG participants. Conclusion: Observed effects on entrepreneurship knowledge, economic empowerment, and connectedness, supplemented by the experiences and changes as described by the youth themselves, demonstrates how a strength-based youth entrepreneurship intervention focused on developing assets and resources may be an innovative approach to dually address health and economic disparities endured in Native American communities.
Collapse
Affiliation(s)
- Lauren Tingey
- Department of International Health, Johns Hopkins Center for American Indian Health, 415 N. Washington St., Baltimore, MD 21231, USA; (S.R.); (A.I.); (A.B.)
| | - Francene Larzelere
- Department of International Health, Johns Hopkins Center for American Indian Health, 308 Kuper St., Whiteriver, AZ 85941, USA; (F.L.); (N.G.); (E.P.); (W.G.); (R.G.); (F.S.); (S.P.); (M.C.)
| | - Novalene Goklish
- Department of International Health, Johns Hopkins Center for American Indian Health, 308 Kuper St., Whiteriver, AZ 85941, USA; (F.L.); (N.G.); (E.P.); (W.G.); (R.G.); (F.S.); (S.P.); (M.C.)
| | - Summer Rosenstock
- Department of International Health, Johns Hopkins Center for American Indian Health, 415 N. Washington St., Baltimore, MD 21231, USA; (S.R.); (A.I.); (A.B.)
| | - Larissa Jennings Mayo-Wilson
- Department of International Health, Johns Hopkins Center for American Indian Health, 415 N. Washington St., Baltimore, MD 21231, USA; (S.R.); (A.I.); (A.B.)
- Department of Applied Health Science, Center for Sexual Health Promotion, Indiana University School of Public Health, 1025 E. 7th St., Bloomington, IN 47405, USA;
| | - Elliott Pablo
- Department of International Health, Johns Hopkins Center for American Indian Health, 308 Kuper St., Whiteriver, AZ 85941, USA; (F.L.); (N.G.); (E.P.); (W.G.); (R.G.); (F.S.); (S.P.); (M.C.)
| | - Warren Goklish
- Department of International Health, Johns Hopkins Center for American Indian Health, 308 Kuper St., Whiteriver, AZ 85941, USA; (F.L.); (N.G.); (E.P.); (W.G.); (R.G.); (F.S.); (S.P.); (M.C.)
| | - Ryan Grass
- Department of International Health, Johns Hopkins Center for American Indian Health, 308 Kuper St., Whiteriver, AZ 85941, USA; (F.L.); (N.G.); (E.P.); (W.G.); (R.G.); (F.S.); (S.P.); (M.C.)
| | - Feather Sprengeler
- Department of International Health, Johns Hopkins Center for American Indian Health, 308 Kuper St., Whiteriver, AZ 85941, USA; (F.L.); (N.G.); (E.P.); (W.G.); (R.G.); (F.S.); (S.P.); (M.C.)
| | - Sean Parker
- Department of International Health, Johns Hopkins Center for American Indian Health, 308 Kuper St., Whiteriver, AZ 85941, USA; (F.L.); (N.G.); (E.P.); (W.G.); (R.G.); (F.S.); (S.P.); (M.C.)
| | - Allison Ingalls
- Department of International Health, Johns Hopkins Center for American Indian Health, 415 N. Washington St., Baltimore, MD 21231, USA; (S.R.); (A.I.); (A.B.)
| | - Mariddie Craig
- Department of International Health, Johns Hopkins Center for American Indian Health, 308 Kuper St., Whiteriver, AZ 85941, USA; (F.L.); (N.G.); (E.P.); (W.G.); (R.G.); (F.S.); (S.P.); (M.C.)
| | - Allison Barlow
- Department of International Health, Johns Hopkins Center for American Indian Health, 415 N. Washington St., Baltimore, MD 21231, USA; (S.R.); (A.I.); (A.B.)
| |
Collapse
|
36
|
Glass N, Remy MM, Mayo-Wilson LJ, Kohli A, Sommer M, Turner R, Perrin N. Comparative effectiveness of an economic empowerment program on adolescent economic assets, education and health in a humanitarian setting. BMC Public Health 2020; 20:170. [PMID: 32019539 PMCID: PMC7001195 DOI: 10.1186/s12889-020-8219-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 01/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adolescence is a critical period of human development, however, limited research on programs to improve health and well-being among younger adolescents living in conflict-affected and humanitarian settings exists. The purpose of this study was to assess the comparative effectiveness of an economic empowerment program on young adolescent outcomes in a complex humanitarian setting. METHODS This longitudinal, mixed methods study examined the relative effectiveness of an integrated parent (Pigs for Peace, PFP) and young adolescent (Rabbits for Resilience, RFR) animal microfinance/asset transfer program (RFR + PFP) on adolescent outcomes of asset building, school attendance, mental health, experienced stigma, and food security compared to RFR only and PFP only over 24 months. A sub-sample of young adolescents completed in-depth qualitative interviews on the benefits and challenges of participating in RFR. RESULTS Five hundred forty-two young adolescents (10-15 years) participated in three groups: RFR + PFP (N = 178), RFR only (N = 187), PFP only (N = 177). 501 (92.4%) completed baseline surveys, with 81.7% (n = 442) retention at endline. The group by time interaction (24 months) was significant for adolescent asset building (X2 = 16.54, p = .002), school attendance (X2 = 12.33, p = .015), and prosocial behavior (X2 = 10.56, p = .032). RFR + PFP (ES = 0.31, ES = 0.38) and RFR only (ES-0.39, ES = 0.14) adolescents had greater improvement in asset building and prosocial behavior compared to PFP only, respectively. The odds of missing two or more days of school in the past month were 78.4% lower in RFR only and 45.1% lower in RFR + PFP compared to PFP only. No differences between groups in change over time were found for internalizing behaviors, experienced stigma, or food security. Differences by age and gender were observed in asset building, prosocial behavior, school attendance, experienced stigma, and food security. The voices of young adolescents identified the benefits of the RFR program through their ability to pay for school fees, help their families meet basic needs, and the respect they gained from family and community. Challenges included death of rabbits and potential conflict within the household on how to use the rabbit asset. CONCLUSION These findings underscore the potential for integrating economic empowerment programs with both parents and young adolescents to improve economic, educational, and health outcomes for young adolescents growing up in rural and complex humanitarian settings. TRIAL REGISTRATION NCT02008695. Retrospectively registered 11 December 2013.
Collapse
Affiliation(s)
- Nancy Glass
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA.
| | - Mitima Mpanano Remy
- Programme d'Appui aux Initiatives Economiques (PAIDEK), Bukavu, Democratic Republic of Congo
| | - Larissa Jennings Mayo-Wilson
- School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- School of Public Health, Indiana University, Bloomington, Indiana, USA
| | - Anjalee Kohli
- Institute of Reproductive Health, Georgetown University, Washington, District of Columbia, USA
| | - Marni Sommer
- Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Rachael Turner
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nancy Perrin
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
37
|
Mayo-Wilson LJ, Ssewamala FM. Financial and Behavioral Economic Factors Associated With HIV Testing In AIDS-Affected Adolescents in Uganda: A Cross-Sectional Analysis. J Health Care Poor Underserved 2019; 30:339-357. [PMID: 30827987 DOI: 10.1353/hpu.2019.0025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Provision of free HIV counseling and testing services (HCTS) helps remove financial barriers to care. Little is known on whether uptake of free HCTS by households impoverished by AIDS is influenced by financial and behavioral economic factors. We examined use of free HCTS by employment status, cash savings, food/income security, and present-bias preferences among 346 adolescent AIDS orphans and their household members in Uganda. HIV testing was low for all. Adolescents cared for by present-biased guardians (those who disproportionately weighted the present while discounting the future) were more likely to be HIV tested (OR=2.64, 95%CI:1.04-6.70) than adolescents cared for by guardians who weighted future gains. Guardians (OR=2.02; 95% CI:1.19-3.41) and non-guardian adults (OR=2.38; 95% CI:1.30-4.34) in households with savings were more likely to have been tested. Financially-insecure households (OR=0.59, 95%CI:0.35-0.97) were less likely to have been tested. Interventions addressing would-be HIV testers' economic needs may prove beneficial.
Collapse
|
38
|
Ssewamala FM, Sensoy Bahar O, Tozan Y, Nabunya P, Mayo-Wilson LJ, Kiyingi J, Kagaayi J, Bellamy S, McKay MM, Witte SS. A combination intervention addressing sexual risk-taking behaviors among vulnerable women in Uganda: study protocol for a cluster randomized clinical trial. BMC Womens Health 2019; 19:111. [PMID: 31419968 PMCID: PMC6697981 DOI: 10.1186/s12905-019-0807-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/31/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa (SSA) has the highest number of people living with HIV/AIDS, with Nigeria, South Africa, and Uganda accounting for 48% of new infections. A systematic review of the HIV burden among women engaged in sex work (WESW) in 50 low- and middle-income countries found that they had increased odds of HIV infection relative to the general female population. Social structural factors, such as the sex work environment, violence, stigma, cultural issues, and criminalization of sex work are critical in shaping sexually transmitted infection (STI)/HIV risks among WESW and their clients in Uganda. Poverty is the most commonly cited reason for involvement in sex work in SSA. Against this backdrop, this study protocol describes a randomized controlled trial (RCT) that tests the impact of adding economic empowerment to traditional HIV risk reduction (HIVRR) to reduce new incidence of STIs and HIV among WESW in Rakai and the greater Masaka regions in Uganda. METHODS This three-arm RCT will evaluate the efficacy of adding savings, financial literacy and vocational training/mentorship to traditional HIVRR on reducing new incidence of STI infections among 990 WESW across 33 hotspots. The three arms (n = 330 each) are: 1) Control group: only HIVRR versus 2) Treatment group 1: HIVRR plus Savings plus Financial Literacy (HIVRR + S + FL); and 3) Treatment group 2: HIVRR plus S plus FL plus Vocational Skills Training and Mentorship (V) (HIVRR + S + FL + V). Data will be collected at baseline (pre-test), 6, 12, 18 and 24-months post-intervention initiation. This study will use an embedded experimental mixed methods design where qualitative data will be collected post-intervention across all conditions to explore participant experiences. DISCUSSION When WESW have access to more capital and/or alternative forms of employment and start earning formal income outside of sex work, they may be better able to improve their skills and employability for professional advancement, thereby reducing their STI/HIV risk. The study findings may advance our understanding of how best to implement gender-specific HIV prevention globally, engaging women across the HIV treatment cascade. Further, results will provide evidence for the intervention's efficacy to reduce STIs and inform implementation sustainability, including costs and cost-effectiveness. TRIAL REGISTRATION ClinicalTrials.gov , ID: NCT03583541 .
Collapse
Affiliation(s)
- Fred M Ssewamala
- Brown School, Washington University in St. Louis, Campus Box 1196, One Brookings Drive, St. Louis, MO, 63130, USA.
| | - Ozge Sensoy Bahar
- Brown School, Washington University in St. Louis, Campus Box 1196, One Brookings Drive, St. Louis, MO, 63130, USA
| | - Yesim Tozan
- College of Global Public Health, New York University, New York City, NY, USA
| | - Proscovia Nabunya
- Brown School, Washington University in St. Louis, Campus Box 1196, One Brookings Drive, St. Louis, MO, 63130, USA
| | | | - Joshua Kiyingi
- International Center for Child Health and Development, Masaka, Uganda
| | | | | | - Mary M McKay
- Brown School, Washington University in St. Louis, Campus Box 1196, One Brookings Drive, St. Louis, MO, 63130, USA
| | - Susan S Witte
- Columbia University School of Social Work, New York City, NY, USA
| |
Collapse
|
39
|
Mayo-Wilson LJ, Glass NE, Ssewamala FM, Linnemayr S, Coleman J, Timbo F, Johnson MW, Davoust M, Labrique A, Yenokyan G, Dodge B, Latkin C. Microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices in economically-vulnerable African-American young adults (EMERGE): protocol for a feasibility randomized clinical trial. Trials 2019; 20:439. [PMID: 31315685 PMCID: PMC6637550 DOI: 10.1186/s13063-019-3529-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/15/2019] [Indexed: 01/08/2023] Open
Abstract
Background Economic vulnerability, such as homelessness and unemployment, contributes to the HIV risk among racial minorities in the U.S., who are disproportionately infected. Yet, few economic-strengthening interventions have been adapted for HIV prevention in economically-vulnerable African-American young adults. Engaging Microenterprise for Resource Generation and Health Empowerment (EMERGE) is a feasibility randomized clinical trial of an HIV prevention microenterprise intervention with integrated text messages (“nudges”) that are informed by behavioral economic principles. The trial aims to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors. Methods/design In total, 40 young adults who are African-American, aged 18–24, live in Baltimore City, have experienced at least one episode of homelessness in the last 12 months, are unemployed or underemployed (fewer than 10 h per week), are not enrolled in school, own a cell phone with text messaging, and report at least one episode of unprotected or unsafe sex in the prior 12 months will be recruited from two community-based organizations providing residential supportive services to urban youth. Participants will undergo a 3-week run-in period and thereafter be randomly assigned to one of two groups with active interventions for 20 weeks. The first group (“comparison”) will receive text messages with information on job openings. The second group (“experimental”) will receive text messages with information on job openings plus information on HIV prevention and business educational sessions, a mentored apprenticeship, and a start-up grant, and business and HIV prevention text messages based on principles from behavioral economics. The two primary outcomes relate to the feasibility of conducting a larger trial. Secondary outcomes relate to employment, sexual risk behaviors, and HIV preventive practices. All participants will be assessed using an in-person questionnaire at pre-intervention (prior to randomization) and at 3 weeks post-intervention. To obtain repeated, longitudinal measures, participants will be assessed weekly using text message surveys from pre-intervention up to 3 weeks post-intervention. Discussion This study will be one of the first U.S.-based feasibility randomized clinical trials of an HIV prevention microenterprise intervention for economically-vulnerable African-American young adults. The findings will inform whether and how to conduct a larger efficacy trial for HIV risk reduction in this population. Trial registration ClinicalTrials.gov, NCT03766165. Registered on 4 December 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3529-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Larissa Jennings Mayo-Wilson
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E5038, Baltimore, MD, 21205, USA. .,Department of Applied Health Science, Indiana University School of Public Health, 1025 E. 7th Street, Bloomington, IN, USA.
| | - Nancy E Glass
- Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Baltimore, MD, USA
| | - Fred M Ssewamala
- Washington University in St. Louis, The Brown School, Goldfarb, One Brookings, Drive, St. Louis, MO, USA
| | | | - Jessica Coleman
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E5038, Baltimore, MD, 21205, USA
| | - Fatmata Timbo
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E5038, Baltimore, MD, 21205, USA
| | - Matthew W Johnson
- Behavioral Pharmacology Research, Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD, USA
| | - Melissa Davoust
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E5038, Baltimore, MD, 21205, USA
| | - Alain Labrique
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E5038, Baltimore, MD, 21205, USA
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA
| | - Brian Dodge
- Department of Applied Health Science, Indiana University School of Public Health, 1025 E. 7th Street, Bloomington, IN, USA
| | - Carl Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Hampton House 737, Baltimore, MD, USA
| |
Collapse
|