Development of an Evaluation Framework for Planned Parenthood of Central North Carolina's Teen Voices Peer Education Program

Despite an overall decline in incidence in recent years, teen pregnancy remains a public health concern in the central region of North Carolina. In 2009, Durham County ranked 24th in the number of teen pregnancies out of 100 counties, an increase from 44th in 2008 (APPCNC Durham County, 2011). In adjacent Orange County, data indicate disparities in teen pregnancy rates between Hispanic/Latina girls, African-American/Non-Hispanic girls, and White/Non-Hispanic girls (APPCNC Orange County, 2011). These trends and disparities suggest the need for focused pregnancy prevention programming targeting youth in central North Carolina. The need for pregnancy prevention programming in Orange and Durham Counties is being addressed in part by Planned Parenthood of Central North Carolina (PPCNC), which sponsors several sexual and reproductive health peer education programs. The Capstone project described in the following report was designed to support current peer education programs at PPCNC, specifically Teen Voices, as well as provide direction for other peer education initiatives moving forward. The Capstone team achieved this goal through an investigation of relevant scientific literature, formative research focusing on local teens and other community stakeholders, and the development of materials to effectively evaluate the Teen Voices program. The PPCNC Capstone project has produced six major deliverables. Deliverable I is a systematic review of the scientific literature related to adolescent sexual and reproductive health peer education programs and relevant applications of new media technology to enhance information delivery. Deliverable II is a matrix of findings from focus groups conducted with local youth and parents and semi-structured interviews with local adolescent health service providers. Deliverable III is a report of findings from a brief quantitative survey distributed among recent PPCNC Teen Voices program alumni meant to assess attitudes towards proposed program expansion. Deliverable IV is a collection of related documents, consisting of a program brief designed for internal distribution at PPCNC and set of customized fact sheets that synthesize findings from the focus groups, interviews, surveys, and the literature review. These first four deliverables constitute a body of formative research that provides the foundation for the last two deliverables, which are focused on program evaluation. Deliverable V is a process and outcome evaluation plan for the PPCNC Teen Voices program as it currently exists (i.e. before any proposed expansion) and it also includes evaluation recommendations for program expansion. The last product, Deliverable VI, is a set of tools outlined in the evaluation plan that will be used for process and outcome evaluation data collection and analysis of the results. The PPCNC Capstone project work has broad implications for its key stakeholders. The Capstone team gained valuable experience collaborating with a community partner to plan and implement the project. The individual project deliverables presented numerous opportunities for skill development, especially in the development of formative research tools and tailoring materials to suit the needs of a local partner organization. The evaluation of the current Teen Voices program provides support for the existing program and feedback on potential strategies for expanding the program in the future. With broader dissemination efforts, the Teen Voices evaluation can make a meaningful contribution to the body of practice-based evidence related to teen sexual and reproductive health peer education programs.Master of Public Healt

Adherence During Antiviral Treatment Regimens for Chronic Hepatitis C: A Qualitative Study of Patient-reported Facilitators and Barriers

To understand patients’ perceptions of factors which facilitate and hinder adherence in order to inform adherence-enhancing interventions

Higher rates of mental health screening of adolescents recorded after provider training using simulated patients in a Kenyan HIV clinic: results of a pilot study

BackgroundKenyan adolescent girls and young women (AGYW) experience a dual burden of HIV and common mental disorders (CMD). HIV clinics are a key entry point for AGYW in need of integrated CMD and HIV care; however, rates of screening and referral for CMDs are low. Our objective was to test an evidence-based provider training strategy, simulated patient encounters (SPEs), on CMD service delivery for AGYW in a Kenyan HIV clinic.MethodsThis pilot study was conducted in a public HIV clinic in Thika, Kenya from January to November 2021. The simulated patient encounter (SPE) implementation strategy included case script development from prior qualitative work, patient actor training, and a three-day SPE training including four standardized mock clinical encounters followed by quantitative surveys assessing provider competencies for each encounter. We abstracted medical record data related to HIV and CMDs such as HIV status, reason for visit, CMD screening test performed, and counselling or referral information. We conducted an interrupted time series analysis using abstracted HIV and CMD screening rates from AGYW ages 16–25 years visiting the clinic 7 months before and 3 months after SPE training. We used generalized linear models to assess changes in CMD screening rates after training.ResultsA total of 10 providers participated in the training. Competency ratings improved across four mock encounters (mean score from 8.1 to 13.7) between first and fourth encounters. We abstracted all medical records (n = 1,154) including from 888 (76%) AGYW seeking HIV treatment, 243 (21%) seeking prevention services, and 34 (3%) seeking other services. CMD screening rates increased immediately following training from 8 to 21% [relative risk (RR) = 2.57, 95% confidence interval (CI) = 1.34–4.90, p < 0.01]. The 3 months following the SPE training resulted in an 11% relative increase in CMD screening proportion compared to the 7 months pre-SPE (RR: 1.11, 95% CI: 1.04–1.17, p < 0.01). Finally, 1% of all pre-SPE screens resulted in referral versus 5% of post-SPE screens (p = 0.07).ConclusionThe SPE model is a promising implementation strategy for improving HIV provider competencies and CMD service delivery for adolescents in HIV clinics. Future research is needed to explore effects on adolescent clinical outcomes in larger trials

Evidencing the Impact of Web-Based Coproduction With Youth on Mental Health Research: Qualitative Findings From the MindKind Study

BACKGROUND: Public involvement in research is a growing phenomenon as well as a condition of research funding, and it is often referred to as coproduction. Coproduction involves stakeholder contributions at every stage of research, but different processes exist. However, the impact of coproduction on research is not well understood. Web-based young people's advisory groups (YPAGs) were established as part of the MindKind study at 3 sites (India, South Africa, and the United Kingdom) to coproduce the wider research study. Each group site, led by a professional youth advisor, conducted all youth coproduction activities collaboratively with other research staff. OBJECTIVE: This study aimed to evaluate the impact of youth coproduction in the MindKind study. METHODS: To measure the impact of web-based youth coproduction on all stakeholders, the following methods were used: analysis of project documents, capturing the views of stakeholders using the Most Significant Change technique, and impact frameworks to assess the impact of youth coproduction on specific stakeholder outcomes. Data were analyzed in collaboration with researchers, advisors, and YPAG members to explore the impact of youth coproduction on research. RESULTS: The impact was recorded on 5 levels. First, at the paradigmatic level, a novel method of conducting research allowed for a widely diverse group of YPAG representations, influencing study priorities, conceptualization, and design. Second, at the infrastructural level, the YPAG and youth advisors meaningfully contributed to the dissemination of materials; infrastructural constraints of undertaking coproduction were also identified. Third, at the organizational level, coproduction necessitated implementing new communication practices, such as a web-based shared platform. This meant that materials were easily accessible to the whole team and communication streams remained consistent. Fourth, at the group level, authentic relationships developed between the YPAG members, advisors, and the rest of the team, facilitated by regular web-based contact. Finally, at the individual level, participants reported enhanced insights into mental well-being and appreciation for the opportunity to engage in research. CONCLUSIONS: This study revealed several factors that shape the creation of web-based coproduction, with clear positive outcomes for advisors, YPAG members, researchers, and other project staff. However, several challenges of coproduced research were also encountered in multiple contexts and amid pressing timelines. For systematic reporting of the impact of youth coproduction, we propose that monitoring, evaluation, and learning systems be designed and implemented early

Depression and HIV Pre-Exposure Prophylaxis Use among sub-Saharan African Women

Thesis (Ph.D.)--University of Washington, 2019Daily, oral pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) is a highly efficacious HIV prevention strategy for key populations at high risk of HIV, including women, in sub-Saharan Africa. However, open-label studies and demonstration projects have reported that young women have difficulty adhering to PrEP over time, which limits its effectiveness as a prevention option. PrEP projects are now exploring modifiable barriers to adherence among women to maximize its public health benefit as it is being rapidly rolled out worldwide. Mental health factors, including depression, traumatic stress symptoms, and stigma, are highly prevalent among women at high risk of HIV acquisition and are barriers to medication use and health promotion behaviors. However, there has been little consideration until now of how such factors might also influence PrEP adherence among women in sub-Saharan Africa. The aims in this dissertation attempt to fill this research gap by: 1) exploring the impact of depressive symptoms on PrEP adherence among women; 2) examining the mechanisms by which depressive symptoms influence PrEP adherence; 3) describing the broader context of HIV-related stigma and empowerment on PrEP use; and 4) integrating depression screening into HIV care delivery to improve mental health and HIV outcomes. Two studies have examined the influence of depression on PrEP adherence and found that depressive symptoms have a negative effect on daily PrEP use for transgender women and men who have sex with men. Ours is the first study to examine links between depression and PrEP adherence among cisgender women in sub-Saharan Africa. We used marginal structural models to estimate the association between depressive symptoms and PrEP adherence while adjusting for time-varying confounding by sexual behavior, stigma, and social support. We found that probable depression was significantly associated with poor PrEP adherence among women, but not men, suggesting that mental health and depression experiences have differential impact on HIV prevention behaviors by gender. This work also led to questions about the mechanism of this association and whether there were important mediators of the relationship between depression and PrEP adherence that could explain at least some of this total effect. We conducted a mediation analysis using marginal structural models to estimate the controlled direct effect of depression on PrEP adherence, after accounting for the potentially mediating influence of HIV-related stigma, social support, and optimism about PrEP effectiveness. We found a significant negative direct influence of depression on PrEP adherence but this relationship was not strongly mediated by other psychosocial factors. Future research is needed to explore additional potential mediators of this relationship and identify areas for intervention. Qualitative research methods allow us to explore narratives around PrEP use, experiences of stigma, and concerns about mental health that are not captured by quantitative data. We analyzed serial in-depth interview data from a cohort of young women using PrEP to understand the broader context around their pill-taking, mental health, and relationships. In this study, we found that women described experiences of HIV-related stigma when they began taking PrEP which influenced their ability to take PrEP and their feelings about themselves. However, over time, women became more empowered to use PrEP and combat HIV-related stigma by becoming “ambassadors” of PrEP in their communities. This work highlights the potential for empowerment-based interventions to improve PrEP adherence and reduce community stigma and the richness of serially collected qualitative data. In Aims 1-3, we found evidence of a strong negative impact of depression on PrEP adherence and high rates of depression among women at risk of HIV. This work suggests that integrated depression screening and treatment with HIV prevention service delivery could improve mental health outcomes and PrEP effectiveness for women. To support the design of future integrated interventions, we conducted cognitive interviews assessing comprehensibility and acceptability of a widely used depression screening tool in the context of a PrEP delivery intervention among pregnant and postpartum women in Thika, Kenya. We found that the tool was largely acceptable and well-understood, but several minor changes to item wording and instructions would improve symptom screening and linkage to mental health care. These changes are part of our recommendations for the future use of this tool. The collective results presented in this dissertation illustrate the negative influence of depression and related psychosocial factors on consistent PrEP use for women, opportunities for stigma-reduction and empowerment-based intervention approaches to improve mental health symptoms and PrEP use in this population, and the potential to administer depression screening within the context of HIV prevention service delivery. This work contributes to a better understanding of the links between mental health and HIV risk for women and highlights the importance of integrating mental health and empowerment-based interventions with PrEP delivery to improve mental health screening and treatment and PrEP effectiveness for women in sub-Saharan Africa

Advancing considerations of context in the evaluation and implementation of evidence-based biomedical HIV prevention interventions: a review of recent research.

PURPOSE OF REVIEW: A paradigm shift is needed in how we think about biomedical HIV prevention product effectiveness. Often, we expect randomized trial findings to be generalizable across populations and settings where products will be delivered, without consideration of key contextual drivers that could impact effectiveness. Moreover, researchers and policy-makers generally discount products with varied effect sizes across contexts, rather than explicating the drivers of these differences and using them to inform equitable product choice and delivery. We conducted a review of the recent HIV prevention research to advance considerations of context in choices of when, why, and how to implement biomedical HIV prevention products, with a particular focus on daily oral preexposure prophylaxis (PrEP) and the dapivirine vaginal ring (DPV). RECENT FINDINGS: Findings across recent studies of PrEP and DPV emphasize that products that do not work well in one context might be highly desirable in another. Key contextual drivers of PrEP and DPV effectiveness, use, and implementation include population, health system, cultural, and historical factors. We recommend conceptualization, measurement, and analysis approaches to fully understand the potential impact of context on prevention product delivery. Execution of these approaches has real-world implications for HIV prevention product choice and could prevent the field from dismissing biomedical HIV prevention products based on trial findings alone. SUMMARY: Ending the HIV epidemic will require tailored, person-centered, and equitable approaches to design, implement, and evaluate HIV prevention products which necessitates considerations of context in ongoing research and implementation