1 / 36

Behavioral Interventions for HIV/AIDS

Behavioral Interventions for HIV/AIDS. Guest Lecture for Dr. Detels ’ EPI 227 Dallas Swendeman , Ph.D., M.P.H. Co-Director , Global Center for Children and Families (GCCF) Executive Director, Center for HIV Identification, Prevention & Treatment Services (CHIPTS)

harsha
Download Presentation

Behavioral Interventions for HIV/AIDS

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Behavioral Interventions for HIV/AIDS Guest Lecture for Dr. Detels’ EPI 227 Dallas Swendeman, Ph.D., M.P.H. Co-Director, Global Center for Children and Families (GCCF) Executive Director, Center for HIV Identification, Prevention & Treatment Services (CHIPTS) Assistant Professor, Department of Psychiatry and Biobehavioral Sciences David Geffen School of Medicine at UCLA Affiliated Faculty, Department of Epidemiology, UCLA Fielding School of Public Health dswendeman@mednet.ucla.edu http://chipts.ucla.edu/; http://www.uclacommons.com/ April 17, 2013

  2. Behavioral vs. Biomedical • Biomedical interventions • Vaccines, pharmaceutical treatments, & medical devices to prevent & treat disease • Behavioral interventions • Programs that help people change their behaviors to prevent & manage disease • Almost all biomedical interventions require behavior changes – by patients, providers, organizations, etc.

  3. Behavioral vs. Structural • Behavioral Interventions • directly target people to change their behaviors • adoption & utilization of tools or services • adherence to treatments & lifestyle recommendations • Structural Interventions • change in access, availability, or acceptability • Policies, prices, payers, laws • Physical & social environments (culture), organizations, communities

  4. Behavioral vs. Structural • Structural = change in access, avail, accept • Ex. Condom avail, Testing/Tx avail, N&S Exchange/Sale, Policies – States, Orgs, Venues • Behavioral = directly target people to change • Ex. Condom use, Reduce # Partners, Clean Equip., Service Util.

  5. Behaviorally Targeted Structural Interventions • E.g., condom or clean syringe use, treatment util. & adherence • 100% Condom use program – Top Down • Community-led structural intervention (CLSI) • Mobilization of people and resources

  6. Evidence-Based Interventions (EBI) • Systematic programs to support behavior change • Typically a manual guides training & implementation • more structured than an “Evidence-based Practice” • Adopted medical “product development” model • vaccines, pharmaceuticals, devices • Rigorous evaluation of risks and benefits • At least one RCT, but gold standard is 2 RCTs • Some say must be “replicated” by other teams • Some say large-scale “effectiveness” trial needed

  7. A new “Adherence” Paradigm? • “Combination Prevention” of biomedical & behavioral interventions is wave of future • maybe structural • Examples • ART “Treatment as Prevention”, • reduce community viral load & infectio • PrEP & PEP • Reduce susceptibility to HIV exposures • Dependent on uptake & adherence behaviors

  8. What are the Ingredients of Behavioral Interventions? • Not just information • Information is necessary but insufficient for behavioral change • Behavioral intervention design is a “black box” • Not well specified design principles • What are the “Core Elements”?

  9. Behaviors vs. Knowledge, Attitudes, Beliefs (KAB) • Knowledge may be necessary but is often not sufficient for behavior changes • Rational Actor Assumptions  • Health Education vs. Beh. Change (Psychology) • Motivation, Information, Skills, Address Barriers, Support to Sustain change

  10. Behavior Change Theories •  Health Belief Model (Becker) • Knowledge & beliefs • Social Learning theory (Bandura) • Social norms & rewards • Stages of Change (Prochaska & DiClimente) • Pre-contemplation, contemplation, ready, action, relapse, maintenance • Diffusion of Innovations (Rogers) • Community-level • Innovators, early-, middle-, late- adopters

  11. CONSORT Intervention Reporting Domains – Pt. 1 • Content/Elements • Content & How Delivered (oral, written, video, computer, text-message) • Providers • Physicians/Experts/Social Workers vs. Peer/Lay/CHW • Format • Self-help, individual, group, telephone • Setting • Clinic, CBO/NGO, school, classroom, workplace, homes, venues (brothels, bars, clubs) 

  12. CONSORT Intervention Domains Pt. 2 • Recipients • Target populations • Intensity • # of contacts & total contact time • Duration • Period of time & spacing of contacts • Fidelity • Delivered as Intended & Monitored/Measured (M&E) * Need a science of intervention design & delivery

  13. Recipient “Target Population” Risks: • Diagnosed or Infected • High-Risk • Behavioral, genetic, & epidemiological risk factors • At-Risk • Potential for high-risk or infection if there is shift in behavior, environment, or epidemiology • Low-risk * Address stigma & “victim blaming”

  14. Intensity & Duration: • Brief vs. Comprehensive • Sustaining Impact  Generalizing Impact • Duration of behavioral changes • Breadth of behavioral changes

  15. Delivery Formats: • Mass Media (inform vs. behavior change) • Community-level & Networks • Small Group • One-on-One • New Delivery Formats: • Mobile Phones & Internet

  16. Providers: • Professionals (Physicians, Therapists) • vs. • CHWs – Task Shifting • Self-directed? • Stigma

  17. Settings: • Clinical vs. Community (CBO / NGO) • Disease-Specific vs. Wellness & General Health • Age & Gender Segregated vs. Family Focused

  18. Content/Elements: • Almost completely unspecified • new work in this area • Manuals scripted & sequenced • Theory? • Explains hypothesized change process & targets • Rarely specifies the content or techniques • More in common than different (use multiple) • Common Elements • Principles, Processes, Techniques, Practices, • Common Factors • Standardized Functions

  19. Core Elements defined by researcher-developers are not consistent in scope Theoretical Concepts Key Skills Social Support Specific Activities Population characteristics & challenges Delivery formats Recruitment & Outreach Strategies Key Outcomes

  20. The common factors of EBI are: • Frame issue to motivate change • Apply health information to daily life • Build feel, think, do skills • Address environmental barriers • Build sustainable social support

  21. “Framing to Motivate Change” for adolescent HIV prevention Protecting oneself is a source of ethnic or gender pride Protecting virginity demonstrates hope for marriage Protecting partners demonstrates caring and loving relationship

  22. Common Principles of EBI: • Believe in your worth & right to future • Distinguish fact from myth • Evaluate options & consequences • Commit to change • Plan ahead & be prepared • Practice self-control • Know pleasurable alternatives • Negotiate verbally, not non-verbally • Choose to limit your own freedom • Act to help others protect themselves

  23. Plan Ahead and Be Prepared

  24. Common Processes of EBI: Highly Structured Goals, Agendas, Teacher Role Strategies for Group Management Support, Cohesiveness, Self-disclosure, Active Engagement, Cultural Sensitivity Behavioral Management, Fun Feel, Think, Do Skills Cognitive, Affective, & Behavioral Developmental Issues Social identity, Sense of self, Set rules, Promote morality, Focus on future

  25. Fidelity: • Fidelity to what? • Scripted manuals • Essential practices (i.e., Core Elements) • Common factors, processes, principles, practices • Adaptation & Standards of Evidence • Multi-phase trial borrowed from biomedical • If adapted, is it still an EBI? New trial needed? • M&E vs. CQI Feedback Systems

  26. Provider-level Intervention •  Behavior Change like any other • Adopt new practices • Implement with fidelity • Adaptation?

  27. mHealth CHW System (from www.Mobenzi.com, also see www.dimagi.com )

  28. Technology – Mobile Phones • 5 standardized functions for behavioral intv. • Inform – about disease risks, protection, services • Train - new health behaviors and routines • Monitor – behaviors and risks • Shape – behaviors over time with feedback • Support – from peers/family to sustain behaviors • Also for care coordination, CHW support, M&E

  29. SMS “Text-Messaging” & IVR • Text-messaging (SMS) • Interactive Voice Response (IVR) • Multi-media Messaging (MMS) • universally available on all phones (except MMS) • only time-stamped data and time-based prompts • no GPS/location prompts or unobtrusive data • need SMS/IVR back-end system & programming for anything but small-scale SMS applications

  30. Smartphone Apps • maximum options • time, location/GPS, unobtrusive/background, etc. • more technically involved programming • especially for unobtrusive data, battery life, etc. • App incompatibility across phones • even with same OS (Android) not all devices will work • most likely have to provide phones to participants • Researcher/Clinician authorable web-interfaces • under development, e.g., Ohmage.org

  31. Fidelity Monitoring & Support for Intervention Deliverers (& Dose/Exp.)

  32. If we build it, will they come? • Hard to reach populations (stigma) • Engagement Strategies • Costs & Cost-effectiveness • Payers & Sustainability

More Related