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1.  Disruptive Innovations for Designing and Diffusing Evidence-based Interventions 
The American psychologist  2012;67(6):463-476.
The numbers of evidence-based interventions (EBIs) have been growing exponentially, both therapeutic and prevention programs. Yet, EBIs have not been broadly adopted in the United States. In order for our EBI science to significantly reduce disease burden, we need to critically re-examine our scientific conventions and norms. Innovation may be spurred by re-examining the biomedical model for validating EBIs and the compartmentalization of EBIs as disease-specific, institutionally-based, counseling programs. The model of Disruptive Innovations suggests that we re-engineer EBIs based on their most robust features in order to reach more people in less time and at lower cost. Four new research agendas will be required to support disruptive innovations in EBI science: synthesize common elements across EBIs; experiment with new delivery formats (e.g., consumer controlled, self-directed, brief, paraprofessional, coaching, and technology and media strategies); adopt market strategies to promote and diffuse EBI science, knowledge, and products; and adopt continuous quality improvement as a research paradigm for systematically improving EBIs, based on ongoing data and feedback. EBI science can have more impact if it can better leverage what we know from existing EBIs in order to inspire, engage, inform, and support families and children to adopt and sustain healthy daily routines and lifestyles.
doi:10.1037/a0028180
PMCID: PMC3951837  PMID: 22545596
Disruptive Innovations; evidence-based interventions; prevention science; mental health treatment
2.  When Life is a Drag: Depressive Symptoms Associated with Early Adolescent Smoking 
Adolescent nicotine use continues to be a significant public health problem. We examined the relationship between the age of youth reporting current smoking and concurrent risk and protective factors in a large state-wide sample. We analyzed current smoking, depressive symptoms, and socio-demographic factors among 4,027 adolescents, ages 12–17 years using multivariate logistic regression (see 2005 California Health Interview Survey (CHIS) Public Use File). Consistent with previous work, Latinos, girls, those whose family incomes were below the poverty level, and those with fair-poor health were more likely to display depressive symptoms. Males, whites, older teens and those in fair-poor health were more likely to be current smokers. In a multivariate analysis predicting depressive symptoms, the interaction between age and current smoking was highly significant (Wald Χ2=15.8, p<.01). At ages 12–14 years, the probability of depressive symptoms was estimated to be four times greater among adolescents who currently smoked, compared to those who were not current smokers. The likelihood of depressive symptoms associated with current smoking decreases with age and becomes non-significant by 17 years. Interventions to reduce smoking may be most useful among youth prior to age 12 years and must be targeted at multiple risks (e.g. smoking and depression).
doi:10.1080/17450128.2013.797129
PMCID: PMC3928103  PMID: 24563657
3.  The impact of paraprofessional home visitors on infants’ growth and health at 18 months 
Paraprofessional home visitors trained to improve multiple outcomes (HIV, alcohol, infant health, and malnutrition) have been shown to benefit mothers and children over 18 months in a cluster randomised controlled trial (RCT). These longitudinal analyses examine the mechanisms which influence child outcomes at 18 months post-birth in Cape Town, South Africa. The results were evaluated using structural equation modelling, specifically examining the mediating effects of prior maternal behaviours and a home visiting intervention post-birth. Twelve matched pairs of neighbourhoods were randomised within pairs to: 1) the control condition, receiving comprehensive healthcare at community primary health care clinics (n=12 neighbourhoods; n=594 pregnant women), or 2) the Philani Intervention Program, which provided home visits by trained, paraprofessional community health workers, here called Mentor Mothers, in addition to clinic care (n=12 neighbourhoods; n=644 pregnant women). Recruitment of all pregnant neighbourhood women was high (98%) with 88% reassessed at six months and 84% at 18 months. Infants’ growth and diarrhoea episodes were examined at 18 months in response to the intervention condition, breastfeeding, alcohol use, social support, and low birth weight, controlling for HIV status and previous history of risk. We found that randomisation to the intervention was associated with a significantly lower number of recent diarrhoea episodes and increased rates and duration of breastfeeding. Across both the intervention and control conditions, mothers who used alcohol during pregnancy and had low birth weight infants were significantly less likely to have infants with normal growth patterns, whereas social support was associated with better growth. HIV-infection was significantly associated with poor growth and less breastfeeding. Women with more risk factors had significantly smaller social support networks. The relationships among initial and sustained maternal risk behaviours and the buffering impact of home visits and social support are demonstrated in these analyses.
doi:10.1080/17450128.2014.940413
PMCID: PMC4203669  PMID: 25342956
infant diarrhoea; HIV; perinatal health; home visitors
4.  Standardized Functions for Smartphone Applications: Examples from Maternal and Child Health 
Millennium Development Goals (MDGs) are unlikely to be met in most low- and middle-income countries (LMIC). Smartphones and smartphone proxy systems using simpler phones, equipped with the capabilities to identify location/time and link to the web, are increasingly available and likely to provide an excellent platform to support healthcare self-management, delivery, quality, and supervision. Smart phones allow information to be delivered by voice, texts, pictures, and videos as well as be triggered by location and date. Prompts and reminders, as well as real-time monitoring, can improve quality of health care. We propose a three-tier model for designing platforms for both professional and paraprofessional health providers and families: (1) foundational functions (informing, training, monitoring, shaping, supporting, and linking to care); (2) content-specific targets (e.g., for MDG; developmentally related tasks); (3) local cultural adaptations (e.g., language). We utilize the Maternal and Child Health (MCH) MDG in order to demonstrate how the existing literature can be organized and leveraged on open-source platforms and provide examples using our own experience in Africa over the last 8 years.
doi:10.1155/2012/973237
PMCID: PMC3530862  PMID: 23304136
5.  Reductions in sexually transmitted infections associated with popular opinion leaders in China in a randomised controlled trial 
Sexually Transmitted Infections  2011;87(4):337-343.
Objectives
A community level randomised controlled trial of a Community Popular Opinion Leader (C-POL) intervention to reduce bacterial and viral sexually transmitted infections (STIs) and unprotected extramarital sex was carried out over 2 years in five countries. The main study results did not find significant intervention effects. This paper presents a sub-analysis examining the differential intervention impacts among high-risk and low-risk participants in the China site.
Methods
From 2002 – 2006, 3912 migrant market vendors aged 18 and 49 years were recruited at an urban site in China. Markets were randomly assigned to the C-POL intervention (N=20 markets; n=1979) or standard-care control condition (N=20; n=1933). Both study condition venues received HIV/STI education, free condoms, STI testing and treatment, and training for pharmacists in antibiotic treatments. In intervention markets, C-POLs were identified and trained to diffuse messages regarding safer sex, STI treatment and partner discussions of sex. The primary biological outcome was incidence of new STIs (chlamydia, gonorrhoea, syphilis, trichomonas, herpes or HIV). The primary sexual behaviour risk outcome was any unprotected extramarital sex in the prior 3 months.
Results
In unadjusted analyses, women had significantly lower rates of STI infection at 24 months in the C-POL intervention (5.7%) compared to controls (8.3%; p=0.043). In mixed-effects regression models, intervention participants with STIs at previous assessments were about half as likely to have STIs at 24 months (OR 0.47, 95% CI 0.25 to 0.90) compared to controls.
Conclusions
The C-POL intervention lowers HIV risk among those at highest risk (ie, with a STI or engaging in high-risk sexual activities) rather than the general population.
doi:10.1136/sti.2010.046243
PMCID: PMC3098303  PMID: 21278400
6.  Diabetes Buddies: Peer support through a mobile phone buddy system 
The Diabetes educator  2012;38(3):357-365.
Purpose
The purpose of this study is to test the feasibility and acceptability of a mobile phone-based peer support intervention among women in resource-poor settings to self-manage their diabetes. Secondary goals evaluated the intervention’s effectiveness to motivate diabetes-related health choices.
Methods
Women with diabetes (n=22) in Cape Town, South Africa participated in a 12-week program focused on providing and applying knowledge of health routines to manage diabetes. Women were linked with a buddy via a mobile phone for support and also questioned daily about a health behavior via text message. Women were assessed at recruitment, and then 3 and 6 months later by a trained interviewer using a mobile phone for data collection. The women were evaluated on technology uptake, reduction of BMI, blood glucose levels, and increases in positive coping and general health-seeking behaviors.
Results
Women exchanged 16739 text messages to buddies and received 3144 texts from the project. Women responded to 29% of texted questions (n=1321/14582). Women attended at least 9 of 12 possible intervention sessions; a third attended all 12 sessions (n = 8/22). Between baseline and three months, women increased their sleep and reported a higher level of positive action and social support coping, yet, blood glucose increased by 3.3 points. From 3 to 6 months, spiritual hope decreased and diastolic blood pressure increased. One year later, the 22 women continue to attend meetings.
Conclusion
Mobile phones are an easy and reliable way to provide peer support and disseminate health messages. Both positive and negative changes were observed in this pilot study.
doi:10.1177/0145721712444617
PMCID: PMC4059372  PMID: 22546740
7.  Outcomes of Home Visits for Pregnant Mothers and their Infants: a Cluster Randomised Controlled Trial 
AIDS (London, England)  2013;27(9):1461-1471.
Objective
To evaluate the effect of home visits by Community Health Workers (CHW) on maternal and infant well-being from pregnancy through the first six months of life for women living with HIV (WLH) and all neighbourhood mothers.
Design and Methods
In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to either: 1) Standard Care, comprehensive healthcare at clinics (SC; n=12 neighbourhoods; n=169 WLH; n=594 total mothers), or 2) Philani Intervention Program, home visits by CHW in addition to SC (PIP; n=12 neighbourhoods; n=185 WLH; n=644 total mothers). Participants were assessed during pregnancy (2% refusal) and reassessed at one week (92%) and six months (88%) post-birth. We analysed PIP’s effect on 28 measures of maternal and infant well-being among WLH and among all mothers using random effects regression models. For each group, PIP’s overall effectiveness was evaluated using a binomial test for correlated outcomes.
Results
Significant overall benefits were found in PIP compared to SC among WLH and among all participants. Secondarily, compared to SC, PIP WLH were more likely to complete tasks to prevent vertical transmission, use one feeding method for 6 months, avoid birth-related medical complications, and have infants with healthy height-for-age measurements. Among all mothers, compared to SC, PIP mothers were more likely to use condoms consistently, breastfeed exclusively for 6 months, and have infants with healthy height-for-age measurements.
Conclusions
PIP is a model for countries facing significant reductions in HIV funding whose families face multiple health risks.
doi:10.1097/QAD.0b013e3283601b53
PMCID: PMC3904359  PMID: 23435303
HIV; maternal health; perinatal health
8.  Reducing Risky Sexual Behavior and Substance Use Among Currently and Formerly Homeless Adults Living With HIV 
American journal of public health  2008;99(6):1100-1107.
Objectives
We examined the efficacy of the Healthy Living Program in reducing risky sexual behavior and substance use among adults with HIV infection who were marginally housed (i.e., homeless at some point over a 37-month period).
Methods
We had previously conducted a randomized controlled trial with 936 adults living with HIV infection. In that study, 3 intervention modules of 5 sessions each addressed different goals: reducing risky sexual acts and drug use, improving the quality of life, and adhering to healthful behaviors. Participants were interviewed at baseline and at 5, 10, 15, 20, and 25 months; 746 completed 4 or more assessments. In this study, we analyzed sexual behavior and drug use outcomes for the 35% (n=270 of 767) of participants who were considered marginally housed.
Results
Among the marginally housed participants, there were significantly greater reductions in unprotected risky sexual acts, the number of sexual partners of HIV negative or unknown serostatus, alcohol or marijuana use, and hard drug use among the intervention group than among the control group.
Conclusions
Intensive, skill-focused intervention programs may improve the lives of marginally housed adults living with HIV infection.
doi:10.2105/AJPH.2007.121186
PMCID: PMC2679793  PMID: 18799777
9.  Opportunities for HIV Combination Prevention to Reduce Racial and Ethnic Health Disparities 
The American psychologist  2013;68(4):237-246.
Despite advances in HIV prevention and care, African American and Latino Americans remain at much higher risk of acquiring HIV, are more likely to be unaware of their HIV-positive status, are less likely to be linked to and retained in care, or to have suppressed viral load than are Whites. The first National HIV/AIDS Strategy (NHAS) has reducing these disparities as one of its three goals by encouraging the implementation of combination high impact HIV intervention strategies. Federal agencies have expanded their collaborations in order to decrease HIV-related disparities by: better implementation of data-driven decision-making; integration and consolidation of the continuum of HIV care; and the reorganization of relationships among public health agencies, researchers, community-based organizations (CBO), and HIV advocates. Combination Prevention, the integration of evidence-based and impactful behavioral, biomedical, and structural intervention strategies to reduce HIV incidence, provides the tools to address the HIV epidemic. Unfortunately, health disparities exist at every step along the HIV testing-to-care continuum. This provides an opportunity and a challenge to everyone involved in HIV prevention and care to understand and address health disparities as integral to ending the HIV epidemic in the U.S. To further reduce health disparities, successful implementation of NHAS and combination prevention strategies will require multi-disciplinary teams, including psychologists with diverse cultural backgrounds and experiences, to successfully engage groups at highest risk for HIV and those already HIV-infected. In order to utilize the comprehensive care continuum, psychologists and behavioral scientists have a role to play in re-conceptualizing the continuum of care, conducting research to address health disparities, and creating community mobilization strategies.
doi:10.1037/a0032711
PMCID: PMC3947902  PMID: 23688091
10.  Adoption of Self-management Interventions for Prevention and Care 
Primary care  2012;39(4):649-660.
Seventy-five percent of spiraling healthcare costs can be attributed to chronic diseases, making prevention and management of chronic conditions one of our highest healthcare priorities, especially as we organize for patient-centered medical homes. Collaborative patient self-management in primary care has been repeatedly demonstrated to be efficacious in reducing both symptoms and increasing quality of life, yet there is no consensus on what, how, when, and by whom self-management programs are best implemented. In this article, we argue that self-management interventions effectively span the continuum of prevention and disease management. Self-management interventions rest on a foundation of five core actions: 1) activate motivation to change; 2) apply domain-specific information from education and self-monitoring; 3) develop skills; 4) acquire environmental resources; and 5) build social support. A range of delivery vehicles, including group interventions, primary care providers, and advanced wireless technology, are described and evaluated in terms of diffusion and cost-containment goals.
doi:10.1016/j.pop.2012.08.006
PMCID: PMC3990217  PMID: 23148958
self-management; self-regulation; chronic illness; chronic disease; interventions; prevention
11.  Vocational Training with HIV Prevention for Ugandan Youth 
AIDS and behavior  2012;16(5):1133-1137.
In a pilot study, young people in slums in Kampala, Uganda received an HIV prevention program (Street Smart) and were randomized to receive vocational training immediately (Immediate) or four months later (Delayed). Youth were monitored at recruitment, 4 months (85% retention), and 24 months (74% retention). Employment increased dramatically: Only 48% had ever been employed at recruitment, 86% were employed from months 21 to 24 post recruitment. Over two years, decreases were recorded in the number of sexual partners, mental health symptoms, delinquent acts, and drug use; condom use increased. Providing employment in low income countries, in conjunction with HIV prevention, may provide sustained support to young people to prevent HIV acquisition.
doi:10.1007/s10461-011-0007-y
PMCID: PMC3947885  PMID: 21800180
vocational training; Ugandan youth; HIV/AIDS prevention
12.  Attitudinal, Behavioral, and Biological Outcomes of a Community Popular Opinion Leader Intervention in China 
The effects of a community popular opinion leader (CPOL) intervention were examined among market vendors in a city on the eastern coast of China. Employees of 40 food markets were enrolled in a study that provided HIV-related education and tests, and treatment for sexually transmitted diseases (STDs). Twenty markets were randomly assigned to a CPOL intervention (N = 1695) and 20 markets to a control condition (N = 1616). Market employees in the intervention condition reported positive attitudes regarding STD/HIV prevention and more frequent discussions about safe sex than those in the control condition. Compared to baseline, the prevalence of unprotected sexual acts and new STDs were significantly lower within each study condition 24 months later. Although the CPOL intervention achieved its goal of shifting attitudes within food markets, the gains did not lead to the expected behavioral and biological outcomes.
doi:10.1521/aeap.2011.23.5.448
PMCID: PMC3917310  PMID: 22010808
13.  Comparisons of HIV-Affected and Non-HIV-Affected Families Over Time 
This study compares HIV-affected families and their non-HIV-affected neighbors’ behavioral health outcomes and family conflict. To compare two groups from the same neighborhoods at four points over 18 months, mothers with HIV (MLH) (N=167) and their school-age children (age 6 to 20) were recruited from clinical care settings in Los Angeles, CA and neighborhood control mothers (NCM) without HIV (N=204) were recruited from modal neighborhoods. In addition, children living at home who were 12 years and older were recruited. We assessed parenting behaviors, family conflict, mental health, sexual behavior, substance use, and HIV-related health behaviors over time. MLH perceived greater economic insecurity at baseline, less employment, and involvement in romantic relationships. MLH reported more emotional distress and substance use than NCM. MLH, however, reported lowered HIV transmission risk. The random regressions indicated that MLH exhibited higher levels and became significantly less depressed and less anxious over time than their non-HIV-affected neighbors. MLH also reported less initial family violence and conflict reasoning than NCM; violence decreased and conflict increased over time for MLH relative to NCM. Children of MLH decreased their marijuana use but hard drug users of MLH increased their risk, over time, compared to children of NCM. Moreover, children of MLH reported more internalizing behaviors than children of NCM. Even when compared to other families living in the same economically disadvantaged communities, MLH and their children continue to face challenges surrounding family conflict, and key behavioral health outcomes, especially with respect to substance use and mental health outcomes. These families, however, show much resilience and MLH report lowered levels of HIV transmission risk, their children report no greater levels of HIV transmission risk and levels of family violence were lower than reported by families in the same neighborhoods.
doi:10.1080/17450128.2012.713532
PMCID: PMC3650635  PMID: 23671458
HIV+ Mothers; Family interventions; Parenting behaviors; Sexual behavior; substance abuse
14.  Intervention Outcomes among HIV-affected Families Over 18 Months 
AIDS and Behavior  2012;16(5):1265-1275.
We evaluate the efficacy of a family-based intervention over time among HIV-affected families. Mothers Living with HIV (MLH; n=339) in Los Angeles and their school-aged children were randomized to either an intervention or control condition and followed for 18 months. MLH and their children in the intervention received 16 cognitive-behavioral, small-group sessions designed to help them maintain physical and mental health, parent while ill, address HIV-related stressors, and reduce HIV-transmission behaviors. At recruitment, MLH reported few problem behaviors related to physical health, mental health, or sexual or drug transmission acts. Compared to MLH in the control condition, intervention MLH were significantly more likely to monitor their own CD4 cell counts and their children were more likely to decrease alcohol and drug use. Most MLH and their children had relatively healthy family relationships. Family-based HIV interventions should be limited to MLH who are experiencing substantial problems.
doi:10.1007/s10461-011-0075-z
PMCID: PMC3338883  PMID: 22020758
HIV+ Mothers; Family interventions; Parenting behaviors; Sexual behavior; substance abuse
15.  Collecting Maternal Health Information From HIV-Positive Pregnant Women Using Mobile Phone-Assisted Face-to-Face Interviews in Southern Africa 
Background
Most of the world’s women living with human immunodeficiency virus (HIV) reside in sub-Saharan Africa. Although efforts to reduce mother-to-child transmission are underway, obtaining complete and accurate data from rural clinical sites to track progress presents a major challenge.
Objective
To describe the acceptability and feasibility of mobile phones as a tool for clinic-based face-to-face data collection with pregnant women living with HIV in South Africa.
Methods
As part of a larger clinic-based trial, 16 interviewers were trained to conduct mobile phone–assisted personal interviews (MPAPI). These interviewers (participant group 1) completed the same short questionnaire based on items from the Technology Acceptance Model at 3 different time points. Questions were asked before training, after training, and 3 months after deployment to clinic facilities. In addition, before the start of the primary intervention trial in which this substudy was undertaken, 12 mothers living with HIV (MLH) took part in a focus group discussion exploring the acceptability of MPAPI (participant group 2). Finally, a sample of MLH (n=512) enrolled in the primary trial were asked to assess their experience of being interviewed by MPAPI (participant group 3).
Results
Acceptability of the method was found to be high among the 16 interviewers in group 1. Perceived usefulness was reported to be slightly higher than perceived ease of use across the 3 time points. After 3 months of field use, interviewer perceptions of both perceived ease of use and perceived usefulness were found to be higher than before training. The feasibility of conducting MPAPI interviews in this setting was found to be high. Network coverage was available in all clinics and hardware, software, cost, and secure transmission to the data center presented no significant challenges over the 21-month period. For the 12 MHL participants in group 2, anxiety about the multimedia capabilities of the phone was evident. Their concern centered on the possibility that their privacy may be invaded by interviewers using the mobile phone camera to photograph them. For participants in group 3, having the interviewer sit beside vs across from the interviewee during the MPAPI interview was received positively by 94.7% of MHL. Privacy (6.3%) and confidentiality (5.3%) concerns were low for group 3 MHL.
Conclusions
Mobile phones were found both to be acceptable and feasible in the collection of maternal and child health data from women living with HIV in South Africa.
Trial Registration
Clinicaltrials.gov NCT00972699; http://clinicaltrials.gov/ct2/show/NCT00972699 (Archived by WebCite at http://clinicaltrials.gov/ct2/show/NCT00972699)
doi:10.2196/jmir.2207
PMCID: PMC3713928  PMID: 23748182
mobile phones; human immunodeficiency virus; mobile health
16.  Adjustment of trendy, gaming and less assimilated tweens in the United States 
Youth transitioning from childhood to adolescence (tweens) are exposed to increasing amounts of media and advertisement. Tweens have also emerged as a major marketing segment for corporate America with increasing buying power.We examine how tweens relate to popular culture messages and the association of different orientations to popular culture on adjustment. A secondary data analysis was conducted on a marketing survey of 3527 tweens, aged 10–14 years, obtained from 49 schools using stratified sampling methods. A sample of children nationwide described their preferences on popular culture and measures of psychosocial adjustment. Using cluster analysis, we identified three main clusters or adaptation styles of tweens: (1) those who enjoyed gaming, (2) trendy youth and (3) youth less assimilated into popular culture. There were differences in clusters based on adjustment indices. Gaming and trendy tweens reported higher self-perceptions of being smart, caring and confident compared to less assimilated tweens. However, gaming and trendy tweens worried more about fitting in than less assimilated tweens. Gaming and trendy tweens also endorsed future goals and traditional values more strongly than less assimilated tweens. Trendy tweens reported the strongest positive feelings about substance use. Results suggest that for each method of adaptation (gamer, trendy and less assimilated), there are unique differences in adjustment that can impact the child’s future. Parents and service providers must recognize the complexity of these decisions and be sensitive to the unique needs of youth as they move from childhood to adolescence.
doi:10.1080/17450128.2011.597794
PMCID: PMC4288444  PMID: 25580153
adolescence; materialism; media; popular culture; tween
17.  The old solutions are the new problem: How do we better use what we already know about reducing the burden of mental illness? 
Kazdin and Blase (2011) propose that traditional models of delivering therapy require more resources than are available to address the scope of mental illness. We argue that finding new platforms and avenues for our existing treatments is a good start but not enough. We contend that the field also needs to develop formal strategies to reorganize its increasing abundance of knowledge, in order to address the scarcity of resources for its application. If we can better utilize our existing knowledge, treatment delivery and service resource allocation can become more efficient and effective. If the field continues with its almost singular emphasis on knowledge proliferation (e.g., developing new treatments), as opposed to knowledge management (e.g., developing new ways to design, apply, and organize existing treatments), the problem outlined by Kazdin and Blase cannot be solved.
doi:10.1177/1745691611418240
PMCID: PMC4288450  PMID: 25580154
18.  Alcohol consumption among HIV-positive pregnant women in KwaZulu-Natal, South Africa: prevalence and correlates 
Drug and alcohol dependence  2011;120(1-3):113-118.
Background
HIV-positive pregnant women who drink put their children at risk of both HIV and fetal alcohol spectrum disorders. The province of KwaZulu-Natal (KZN) has the highest prevalence of HIV in South Africa, but has not before been considered an area of high alcohol consumption among women. This paper analyzes a large sample of HIV+ pregnant women in KZN to examine alcohol consumption in that population.
Methods
Data came from assessments of women enrolled in Prevention of Mother-To-Child Transmission programs at 8 clinics in KZN. Descriptive statistics and logistic regressions were used to examine the prevalence and correlates of alcohol consumption and binge drinking.
Results
Of 1201 women assessed, 18% reported drinking during pregnancy, and 67% of drinkers usually binged when drinking (had 3+ drinks in one sitting). Over one-third of drinkers binged twice a month or more. Women living in urban and peri-urban locations were more likely to drink, as were those with indicators of higher economic status and greater social engagement. Married women were less likely to drink, while women who had poorer mental health, used tobacco, or had a greater history of sexual risk-taking were more likely to drink.
Conclusion
Health care workers in KZN should be aware that pregnant women who drink are likely to do so at a level that is dangerous for their babies. Some factors associated with drinking indicate social/environmental influences that need to be counteracted by greater dissemination of information about the dangers of drinking, and greater support for abstinence or moderation.
doi:10.1016/j.drugalcdep.2011.07.004
PMCID: PMC3223298  PMID: 21820252
Alcohol; HIV; pregnancy; South Africa
19.  Leveraging paraprofessionals and family strengths to improve coverage and penetration of nutrition and early child development services 
Children need to be protected in intergenerational networks, with parents who have positive mood, resources to feed their children, and skills to promote early childhood development (ECD). Globally, more than 200 million children are raised annually without these resources. This article reviews the potential contributions of increasing coverage and penetration of services for these children, challenges to achieving penetration of services in high risk families, the opportunities created by bundling multiple services within one provider, the potential leveraging of paraprofessionals to deliver care, and mobilizing communities to support children in households at high risk for negative outcomes. We end with a number of suggestions for how to ensure the equitable scale up of integrated ECD and nutrition services that take into account current global priorities, as well as coverage and penetration of services.
doi:10.1111/nyas.12269
PMCID: PMC4005291  PMID: 24117669
20.  Improving Health and Mental Health for People Living with HIV/AIDS: 12-month Assessment of a Behavioral Intervention in Thailand 
American journal of public health  2010;100(12):2418-2425.
Objectives
. People living with HIV (PLH) in Thailand face multiple stressors. We examined findings from a randomized controlled intervention trial designed to improve the quality of life of PLH in Thailand.
Methods
. A total of 507 PLH were recruited from four district hospitals in northern and northeastern Thailand and were randomized to an intervention group (n = 260) or a standard care group (n = 247). Computer-assisted personal interviews were administered at baseline, 6, and 12 months.
Results
At baseline, the characteristics of PLH in the intervention and the standard care condition were comparable. The mixed effects models used to assess the effect of the intervention revealed that PLH in the intervention condition reported significant improvement in their general health (β = 2.51, P = .001) and mental health (β = 1.57, P = .02) over 12 months, compared to those in the standard care condition.
Conclusions
We demonstrated successful efficacy of an intervention designed to improve the quality of life of PLH in Thailand. Interventions must be performed in a systematic, collaborative manner to ensure their cultural relevance, sustainability, and overall success.
doi:10.2105/AJPH.2009.185462
PMCID: PMC2978166  PMID: 20966372
21.  A US Policy Perspective on Oral Preexposure Prophylaxis for HIV 
American journal of public health  2011;101(6):982-985.
Orally administered pre-exposure prophylaxis is an innovative and controversial HIV prevention strategy involving the regular use of antiretroviral medications by uninfected individuals.
Antiretroviral medications protect against potential HIV infection by reducing susceptibility to the virus.
Recent clinical trial results indicate that preexposure prophylaxis can be safe and efficacious for men who have sexual intercourse with men, yet there remain policy considerations surrounding costs, opportunity costs, and ethical issues that must be addressed before broad implementation in the United States. Resources for HIV prevention are limited, thus cost-effectiveness analyses of PrEP implementation in non-experimental situations are needed to allocate prevention funding most productively. Findings from the randomized clinical trials that PrEP is efficacious should mark the beginning of the policy discussion, not its end.
doi:10.2105/AJPH.2010.300066
PMCID: PMC3093264  PMID: 21493945
22.  A Cluster Randomised Controlled Effectiveness Trial Evaluating Perinatal Home Visiting among South African Mothers/Infants 
PLoS ONE  2014;9(10):e105934.
Background
Interventions are needed to reduce poor perinatal health. We trained community health workers (CHWs) as home visitors to address maternal/infant risks.
Methods
In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to 1) the control, healthcare at clinics (n = 12 neighbourhoods; n = 594 women), or 2) a home visiting intervention by CBW trained in cognitive-behavioural strategies to address health risks (by the Philani Maternal, Child Health and Nutrition Programme), in addition to clinic care (n = 12 neighbourhoods; n = 644 women). Participants were assessed during pregnancy (2% refusal) and 92% were reassessed at two weeks post-birth, 88% at six months and 84% at 18 months later. We analysed 32 measures of maternal/infant well-being over the 18 month follow-up period using longitudinal random effects regressions. A binomial test for correlated outcomes evaluated overall effectiveness over time. The 18 month post-birth assessment outcomes also were examined alone and as a function of the number of home visits received.
Results
Benefits were found on 7 of 32 measures of outcomes, resulting in significant overall benefits for the intervention compared to the control when using the binomial test (p = 0.008); nevertheless, no effects were observed when only the 18 month outcomes were analyzed. Benefits on individual outcomes were related to the number of home visits received. Among women living with HIV, intervention mothers were more likely to implement the PMTCT regimens, use condoms during all sexual episodes (OR = 1.25; p = 0.014), have infants with healthy weight-for-age measurements (OR = 1.42; p = 0.045), height-for-age measurements (OR = 1.13, p<0.001), breastfeed exclusively for six months (OR = 3.59; p<0.001), and breastfeed longer (OR = 3.08; p<0.001). Number of visits was positively associated with infant birth weight ≥2500 grams (OR = 1.07; p = 0.012), healthy head-circumference-for-age measurements at 6 months (OR = 1.09, p = 0.017), and improved cognitive development at 18 months (OR = 1.02, p = 0.048).
Conclusions
Home visits to neighbourhood mothers by CHWs may be a feasible strategy for enhancing maternal/child outcomes. However, visits likely must extend over several years for persistent benefits.
Trial Registration
ClinicalTrials.gov NCT00996528
doi:10.1371/journal.pone.0105934
PMCID: PMC4207699  PMID: 25340337
23.  Spontaneous remission of sexually transmitted diseases must be considered in randomised controlled trials 
doi:10.1136/sextrans-2011-050009
PMCID: PMC3252597  PMID: 21459899
Sexually transmitted diseases; spontaneous remission; randomised controlled trials; HIV women; Africa; antenatal HIV; behavioural science; HIV; China; public health; social science; psychology; epidemiology; mathematical model; law ethics; notification; chlamydia; sexual health; behavioural interventions
24.  Family-Based Processes Associated with Adolescent Distress, Substance Use and Risky Sexual Behavior in Families Affected by Maternal HIV 
The present study investigated how maternal HIV and mediating family processes are associated with adolescent distress, substance use, and risky sexual behavior. Mother–adolescent (ages 12–21) dyads (N=264) were recruited from neighborhoods where the HIV-affected families resided (161 had mothers with HIV). Mediating family processes were youth aggressive conflict style, maternal bonding, maternal role reversal expectations, and overall family functioning. Results of structural equation modeling indicated that youth aggressive conflict resolution style was strongly associated with adolescent distress, substance use, and risky sexual behavior. In HIV-affected families, youth less frequently reported using an aggressive conflict resolution style and more frequently reported positive maternal bonds; their mothers reported less positive family functioning than control families. Finally, maternal distress indirectly affected adolescent distress and risk behavior via youth aggressive conflict resolution style.
doi:10.1080/15374411003691677
PMCID: PMC4186713  PMID: 20419574
25.  TEST–RETEST RELIABILITY FOR SELF-REPORTS OF SEXUAL BEHAVIOR AMONG THAI AND KOREAN RESPONDENTS 
The purpose of this study was to examine the test-retest reliability for reports of sexual behavior from the National Institutes of Mental Health Multisite HIV Prevention Trial survey for two Asian samples. Thai (N = 37) and Korean (N = 46) respondents aged 19–37 years (M= 29, SD = 4.61) completed face-to-face interviews to assess their sexual risk in their ethnic language 3–7 days apart. Test-retest coefficients ranged from .65 to 1.00 demonstrating acceptable reliability of the survey among Thai and Korean adults. The discussion focuses on the development of HIV risk assessments that take into consideration ethnic diversity found within the Asian and Pacific Islander community.
PMCID: PMC2953373  PMID: 11565590

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