A Multilevel Analysis of the Impact of Socio-Structural and Environmental Influences on Condom Use Among Female Sex Workers

This study uses multilevel analysis to examine individual, organizational and community levels of influence on condom use among female commercial sex workers (FSW) in the Philippines. A randomized controlled study involving 1,382 female commercial sex workers assigned to three intervention groups consisting of peer education, managerial training, combined peer and managerial intervention and a usual care control group was conducted. The results of the multilevel analysis show that FSWs who work in establishments with condom use rules tend to have a higher level of condom use (β = .70, P < 0.01). Among the different intervention groups, the combined peer and managerial intervention had the largest effect on condom use (β = 1.30, P < 0.01) compared with the usual care group. Using a three-level hierarchical model, we found that 62% of the variation lies within individuals, whereas 24% and 14% of the variation lies between establishments, and communities, respectively. Standard errors were underestimated when clustering of the FSWs in the different establishments and communities were not taken into consideration. The results demonstrate the importance of using multilevel analysis for community-based HIV/AIDS intervention programs to examine individual, establishment and community effects

Age-Related Differences in Socio-demographic and Behavioral Determinants of HIV Testing and Counseling in HPTN 043/NIMH Project Accept

Youth represent a large proportion of new HIV infections worldwide, yet their utilization of HIV testing and counseling (HTC) remains low. Using the post-intervention, cross-sectional, population-based household survey done in 2011 as part of HPTN 043/NIMH Project Accept, a cluster-randomized trial of community mobilization and mobile HTC in South Africa (Soweto and KwaZulu Natal), Zimbabwe, Tanzania and Thailand, we evaluated age-related differences among socio-demographic and behavioral determinants of HTC in study participants by study arm, site, and gender. A multivariate logistic regression model was developed using complete individual data from 13,755 participants with recent HIV testing (prior 12 months) as the outcome. Youth (18–24 years) was not predictive of recent HTC, except for high-risk youth with multiple concurrent partners, who were less likely (aOR 0.75; 95% CI 0.61–0.92) to have recently been tested than youth reporting a single partner. Importantly, the intervention was successful in reaching men with site specific success ranging from aOR 1.27 (95% CI 1.05–1.53) in South Africa to aOR 2.30 in Thailand (95% CI 1.85–2.84). Finally, across a diverse range of settings, higher education (aOR 1.67; 95% CI 1.42, 1.96), higher socio-economic status (aOR 1.21; 95% CI 1.08–1.36), and marriage (aOR 1.55; 95% CI 1.37–1.75) were all predictive of recent HTC, which did not significantly vary across study arm, site, gender or age category (18–24 vs. 25–32 years)

Clinical prediction rules for failed nonoperative reduction of intussusception

Jiraporn Khorana,1 Jayanton Patumanond,2 Nuthapong Ukarapol,3 Mongkol Laohapensang,4 Pannee Visrutaratna,5 Jesda Singhavejsakul1 1Department of Surgery, Division of Pediatric Surgery, Chiang Mai University Hospital, Chiang Mai, 2Center of Excellence in Applied Epidemiology, Thammasat University Hospital, Bangkok, 3Department of Pediatrics, Division of Gastroenterology, Chiang Mai University Hospital, Chiang Mai, 4Department of Surgery, Division of Pediatric Surgery, Siriraj Hospital, Mahidol University, Bangkok, 5Department of Radiology, Chiang Mai University Hospital, Chiang Mai, Thailand Purpose: The nonoperative reduction of intussusception in children can be performed safely if there are no contraindications. Many risk factors associated with failed reduction were defined. The aim of this study was to develop a scoring system for predicting the failure of nonoperative reduction using various determinants.Patients and methods: The data were collected from Chiang Mai University Hospital and Siriraj Hospital from January 2006 to December 2012. Inclusion criteria consisted of patients with intussusception aged 0&ndash;15&nbsp;years with no contraindications for nonoperative reduction. The clinical prediction rules were developed using significant risk factors from the multivariable analysis.Results: A total of 170 patients with intussusception were included in the study. In the final analysis model, 154 patients were used for identifying the significant risk factors of failure of reduction. Ten factors clustering by the age of 3&nbsp;years were identified and used for developing the clinical prediction rules, and the factors were as follows: body weight &lt;12&nbsp;kg (relative risk [RR] =1.48, P=0.004), duration of symptoms &gt;48&nbsp;hours (RR =1.26, P&lt;0.001), vomiting (RR =1.63, P&lt;0.001), rectal bleeding (RR =1.50, P&lt;0.001), abdominal distension (RR =1.60, P=0.003), temperature &gt;37.8&deg;C (RR =1.51, P&lt;0.001), palpable mass (RR =1.26, P&lt;0.001), location of mass (left over right side RR =1.48, P&lt;0.001), ultrasound showed poor prognostic signs (RR =1.35, P&lt;0.001), and the method of reduction (hydrostatic over pneumatic, RR =1.34, P=0.023). Prediction scores ranged from 0 to 16. A high-risk group (scores 12&ndash;16) predicted a greater chance of reduction failure (likelihood ratio of positive [LR+] =18.22, P&lt;0.001). A low-risk group (score 0&ndash;11) predicted a lower chance of reduction failure (LR+ =0.79, P&lt;0.001). The performance of the scoring model was 80.68% (area under the receiver operating characteristic curve).Conclusion: This scoring guideline was used to predict the results of nonoperative reduction and forecast the prognosis of the failed reduction. The usefulness of these prediction scores is for informing the parents before the reduction. This scoring system can be used as a guide to promote the possible referral of the cases to tertiary centers with facilities for nonoperative reduction if possible. Keywords: intussusception, nonoperative reduction, failure rate, clinical prediction rule

Clinical prediction rules for failed nonoperative reduction of intussusception

Jiraporn Khorana,1 Jayanton Patumanond,2 Nuthapong Ukarapol,3 Mongkol Laohapensang,4 Pannee Visrutaratna,5 Jesda Singhavejsakul1 1Department of Surgery, Division of Pediatric Surgery, Chiang Mai University Hospital, Chiang Mai, 2Center of Excellence in Applied Epidemiology, Thammasat University Hospital, Bangkok, 3Department of Pediatrics, Division of Gastroenterology, Chiang Mai University Hospital, Chiang Mai, 4Department of Surgery, Division of Pediatric Surgery, Siriraj Hospital, Mahidol University, Bangkok, 5Department of Radiology, Chiang Mai University Hospital, Chiang Mai, Thailand Purpose: The nonoperative reduction of intussusception in children can be performed safely if there are no contraindications. Many risk factors associated with failed reduction were defined. The aim of this study was to develop a scoring system for predicting the failure of nonoperative reduction using various determinants.Patients and methods: The data were collected from Chiang Mai University Hospital and Siriraj Hospital from January 2006 to December 2012. Inclusion criteria consisted of patients with intussusception aged 0&ndash;15&nbsp;years with no contraindications for nonoperative reduction. The clinical prediction rules were developed using significant risk factors from the multivariable analysis.Results: A total of 170 patients with intussusception were included in the study. In the final analysis model, 154 patients were used for identifying the significant risk factors of failure of reduction. Ten factors clustering by the age of 3&nbsp;years were identified and used for developing the clinical prediction rules, and the factors were as follows: body weight &lt;12&nbsp;kg (relative risk [RR] =1.48, P=0.004), duration of symptoms &gt;48&nbsp;hours (RR =1.26, P&lt;0.001), vomiting (RR =1.63, P&lt;0.001), rectal bleeding (RR =1.50, P&lt;0.001), abdominal distension (RR =1.60, P=0.003), temperature &gt;37.8&deg;C (RR =1.51, P&lt;0.001), palpable mass (RR =1.26, P&lt;0.001), location of mass (left over right side RR =1.48, P&lt;0.001), ultrasound showed poor prognostic signs (RR =1.35, P&lt;0.001), and the method of reduction (hydrostatic over pneumatic, RR =1.34, P=0.023). Prediction scores ranged from 0 to 16. A high-risk group (scores 12&ndash;16) predicted a greater chance of reduction failure (likelihood ratio of positive [LR+] =18.22, P&lt;0.001). A low-risk group (score 0&ndash;11) predicted a lower chance of reduction failure (LR+ =0.79, P&lt;0.001). The performance of the scoring model was 80.68% (area under the receiver operating characteristic curve).Conclusion: This scoring guideline was used to predict the results of nonoperative reduction and forecast the prognosis of the failed reduction. The usefulness of these prediction scores is for informing the parents before the reduction. This scoring system can be used as a guide to promote the possible referral of the cases to tertiary centers with facilities for nonoperative reduction if possible. Keywords: intussusception, nonoperative reduction, failure rate, clinical prediction rule

Using participatory mapping to inform a community-randomized trial of HIV counseling and testing

Participatory mapping and transect walks were used to inform the research and intervention design and to begin building community relations in preparation for Project Accept, a community-randomized trial sponsored by the National Institute of Mental Health. Project Accept is being conducted at five sites in four countries: Thailand, Zimbabwe, South Africa, and Tanzania. Results from the mapping exercises informed decisions such as defining community boundaries and identifying appropriate criteria for matching community pairs for the trial as well as where to situate the services. The mapping also informed intervention-related decisions such as where to situate the services. The participatory methods enabled researchers at each site to develop an understanding of the communities that could not have been derived from existing data or data collected through standard data collection techniques. Furthermore, the methods lay the foundation for collaborative community research partnerships.

Evaluating HIV/STD interventions in developing countries: do current indicators do justice to advances in intervention approaches?

HIV continues to spread unabated in many developing countries. Here we consider the interventions that are currently in place and critically discuss the methods that are being used to evaluate them as reported in the published literature. In recent years there has been a move away from highly individual-oriented interventions towards more participatory approaches that emphasise techniques such as community-led peer education and group discussions. However, this move towards more community orientated intervention techniques has not been matched by the development of evaluation methods with which to capture and explain the community and social changes which are often necessary preconditions for health-enhancing behaviour change. Evaluation research continues to rely on quantitative methodologies that fail to elucidate the complex changes that the newer interventions seek to promote within target communities. In addition, these methods of evaluation tend to rely on the use of highly individualistic and quantitative biomedical indicators such as HIV/STD rates, or knowledge, attitude, perception and behaviour (KAPB) survey questionnaires. We argue that such approaches are inadequate for the task of tracking and measuring important determinants of programme success such as psycho-social changes, features of the community-intervention interface and the degree of trust and identification with which members of target communities regard particular interventions. Rigorously conducted qualitative process evaluations taking account of the above factors could make a key contribution to the development of more successful HIV-prevention interventions

Project Accept (HPTN 043): a community-based intervention to reduce HIV incidence in populations at risk for HIV in sub-Saharan Africa and Thailand

Background: Changing community norms to increase awareness of HIV status and reduce HIV-related stigma has the potential to reduce the incidence of HIV-1 infection in the developing world. Methods: We developed and implemented a multilevel intervention providing community-based HIV mobile voluntary counseling and testing, community mobilization, and posttest support services. Forty-eight communities in Tanzania, Zimbabwe, South Africa, and Thailand were randomized to receive the intervention or clinic-based standard voluntary counseling and testing (VCT), the comparison condition. We monitored utilization of community-based HIV mobile voluntary counseling and testing and clinic-based standard VCT by community of residence at 3 sites, which was used to assess differential uptake. We also developed quality assurance procedures to evaluate staff fidelity to the intervention. Findings: In the first year of the study, a 4-fold increase in testing was observed in the intervention versus comparison communities. We also found an overall 95% adherence to intervention components. Study outcomes, including prevalence of recent HIV infection and community-level HIV stigma, will be assessed after 3 years of intervention. Conclusions: The provision of mobile services, combined with appropriate support activities, may have significant effects on utilization of voluntary counseling and testing. These findings also provide early support for community mobilization as a strategy for increasing testing rates.