Transcript Defining Behavioral Interventions

Defining Behavioral
Interventions
Michael Sweat, PhD
The Johns Hopkins University
Bloomberg School of Public Health
Department of International Health
Thanks to Kevin O’Reilly & WHO, Population Council / Horizons, NIMH
Key Take Away Messages
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The current language in use regarding
interventions is muddled
Intervention programs are comprised of
multiple intervention components
We need clear standards for intervention
components
We need to consider the blend of
intervention components to maximize
program success
Background
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Our work shows that most intervention programs
are almost always made up of multiple intervention
components
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Yet they are identified only by the most prominent
component;
We often have different understandings of what
specific interventions are;
As a result, intervention evaluation is difficult;
A deeper understanding of interventions should
include examining the synergy of multiple
intervention components;
Theoretical Assumptions
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To a large degree, how intervention programs
are constructed is a reflection of the theory
they are based on (either overtly or
implicitly)
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There are a variety of theoretical trajectories to
consider
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Individual-level
Community & Social
Multi-level and ecological
Dynamic / iterative theories
Getting beyond the individual
Bronfenbrenner’s Ecological Model
Psychological
Factors:
Knowledge
Attitudes
Beliefs
Perceptions
Risk
Perception
Environment:
-Access to
Condoms
-Behavior of
Partner
-HIV Prevalence
of Sex Partners
Intervention
Program Characteristics:
Quality, Intensity, Coverage,
Costs
Behaviors:
Condom Use
Number of Sex
Partners
Frequency of Sex
Health Outcomes:
HIV Incidence
Considering causal pathways:
at what point do we focus?
Proximal / Distal Causal Effects
Organize
meetings,
train on
advocacy,
provide legal
rights, provide
venue…
Social
Mobilization
Increased
empowerment
by women and
increased
access to
financial
resources
Increased
Condom
Use
Reduced
HIV
Incidence
How quickly can we expect interventions
to take effect? Cleland Paper
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Examined the uptake of condoms
between 1993-2001 in 18 countries
Among young women, median increase
of 1.4% per year in condom use for
pregnancy prevention by single women
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Cumulative increases in condom use from
19.3% to 28.4%
Year to year effects appear small
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But cumulative effects are substantial
How have we been defining HIV
interventions?
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Activity
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Mode of delivery
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Mass Media
Peer Education
Faith-based
Community-based
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MSM, IDU, CSW, Work Place, School-Based Interventions
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Target Population & Setting
Commodity
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Condom Social Marketing
Needle Exchange
Micro-credit
Outcome or Goal
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Counseling, Testing, Education, Training, Policy enactment, Condom Distribution
Abstinence
Empowerment
Theory
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Structural Intervention
Policy Intervention
These strategies for defining
interventions are often unsatisfactory
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Reduces the intervention to uni-dimensional aspects
They are not very descriptive
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Makes it difficult to evaluate and compare across programs
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Defining interventions by risk groups
Can be pejorative and harmful
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Reduces people to a behavior
Can stigmatize
“General Population” intervention
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Interventions contain elements of all of these categories
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Code for “Normal People”
Activity
Delivery Mode
Target Population & Setting
Commodity (often)
Outcome
Theory
Becomes even more complex when an “intervention” is a program that include
various intervention components
Data from the Synthesizing
Intervention Effectiveness
Study
Methods
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Define the topic
Develop inclusion criteria
Create a list of search terms
Systematically search the literature
Screen search results
Acquire articles
Screen full-text articles and select studies for
inclusion
Extract study data into standardized format (code)
Resolve coding discrepancies
Assess study rigor
Analyze, synthesize and interpret results
Psychosocial Support for HIV-Infected Persons: Flow Chart from Synthesis Search
Potentially relevant
abstracts identified during
initial computer based
search, hand search &
secondary search (N=69)
Abstracts excluded during
screening process for not
meeting search criteria (N=38)
Articles retrieved for more
detailed evaluation (N=31)
Articles identified as
background material (N=30)
Articles excluded for not
meeting inclusion criteria or
background criteria (N=0)
Articles meeting eligibility for
inclusion in the systematic
review (N=1)
Intervention topics
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Completed reviews:
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Voluntary counseling and testing (VCT)
Condom social marketing
Partner notification
Family planning for HIV infected
women
Mass media
Abstinence and abstinence only
Peer education
Needle syringe exchange
Psychosocial support
Treatment
Intervention topics
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Reviews in progress or upcoming:
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Comprehensive sex education
Free condom distribution
Behavioral counseling
Income generation
Diffusion interventions
Built environment interventions
Interpersonal skills training
Policy interventions
Overlap in intervention
components
FP+
VCT
CSM
MM
PE
1
Condom Comp sex
Educ
dist
2
5
MM
1
Abs
1
PE
NE
5
1
3
1
5 Intervention Areas
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Condom Social Marketing
Peer Education
Micro-Finance
Social Mobilization
Structural Interventions to Reduce
Gender-Based Violence
The way forward…
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Define interventions more holistically
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Consider Activity, Delivery Mode, Target
Population & Setting, Commodity, Outcome,
Theory
Recognize that intervention programs include
multiple components
Establish guidelines for key components
Communicate the multi-component nature of
intervention programs
Creating Standards
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Create standards based on empiric research
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Has been done effectively with HIV Voluntary Counseling and
Testing
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A set of principles developed
Consensus efforts taken
Guidelines published
Guidelines updated as the epidemic has changed
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Standard treatment approaches
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Generate consensus on standards
Publish these standards
Refer to the standard model with short-hand
Many analogs in medicine
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Often complex
Guidelines Available – Good Clinical Practice Standards
Example: Angioplasty
Pros of Standardization
Pros:
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Allows for standard delivery which can avoid
unintended and unethical consequences;
Assists in training and quality control;
Facilitates a common understanding of what the
intervention is;
Enhances ability to evaluate and replicate;
Works best for intervention components
that have clear causes and effects
Cons of Standardization
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Cons:
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Dissuades from tailoring intervention
approach to complex needs and
populations;
Complex intervention components are
more difficult to standardization
Value of Bundling Interventions
Examples of ethical mandates to provide packages of
interventions;
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Testing and treatment;
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Diagnosis of infectious status and partner notification / risk
reduction facilitation (access to condoms);
Enhancing efficacy with bundling interventions:
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In lieu of treatment preventative benefit of testing may mitigate this
mandate;
Meeting multiple needs;
Enhancing efficiency;
Referral strategies;
Challenges of clustering interventions:
Training and standardization of component parts;
Cost and complexity
5 Intervention Areas
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Condom Social Marketing
Peer Education
Micro-Finance
Social Mobilization
Structural Interventions to Reduce
Gender-Based Violence
Components of a Potential
Intervention
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Women are provided micro-finance to
procure a small stall where they can sell
condoms to their peers.
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The condoms are branded and promoted by a
national CSM program.
The women are trained in risk reduction
education, and they are supported to meet
regularly to share ideas, support and protect
one another, and make recommendations on
the overall project.
This program includes all of these components,
each of which can have standards of excellence
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Condom Social Marketing
Social Mobilization
Peer Education
Micro-Finance
Structural Interventions to Reduce
Gender-Based Violence
Group Work
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Review the definition provided and
reflect on the following:
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Core Activities
Delivery Mode
Target Population & Setting
Commodity (if appropriate)
Outcome
Theory
What do we mean by a
“structural intervention”
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Structural – a written policy or law
Environmental – interventions that
strive to change the physical or social
environment to affect behavior change
We recognize that there are other definitions….