Reducing HIV-related risk and mental health problems through a client-centred psychosocial intervention for vulnerable adolescents in Addis Ababa, Ethiopia.

INTRODUCTION: Ethiopia is experiencing an increasingly urban HIV epidemic, alongside a rise in urban adolescent migration. Adolescent migrants are often confronted by unique social challenges, including living in a difficult environment, abuse and mental health problems. These issues can increase adolescents' vulnerability to HIV and compromise their capacity to protect themselves and others from HIV. We piloted and assessed the effects of a targeted psychosocial intervention to reduce mental health problems and improve HIV-related outcomes among migrant adolescents in Addis Ababa. METHODS: A pre- and post-comparison design was used in a cohort of 576 female and 154 male migrant adolescents aged 15 to 18 years in Addis Ababa receiving services from two service delivery organizations, Biruh Tesfa and Retrak. We implemented a three-month client-centred, counsellor-delivered psychosocial intervention, based on findings from formative research among the same target population, to address participants' increased vulnerability to HIV. The intervention package comprised individual, group and creative arts therapy counselling sessions. Key outcome indicators included anxiety, depression, aggressive behaviour, attention problems, social problems, knowledge of HIV, safer sex practices and use of sexual health services. Longitudinal data analysis (McNemar test and random effects regression) was used to assess changes over time in key indicators by gender. RESULTS: For females, aggressive behaviour decreased by 60% (adjusted odds ratio (AOR): 0.4 (0.25 to 0.65)) and any mental health problem decreased by 50% (AOR: 0.5 (0.36 to 0.81)) from baseline to end line. In addition, knowledge of HIV increased by 60% (AOR: 1.6 (1.08 to 2.47)), knowledge of a place to test for HIV increased by 70% (AOR: 1.7 (1.12 to 2.51)) and HIV testing increased by 80% (AOR: 1.8 (1.13 to 2.97)). For males, HIV knowledge increased by 110% (AOR: 2.1 (1.1 to 3.94)), knowledge of a place to test for HIV increased by 290% (AOR: 3.9 (1.02 to 14.9)), HIV testing increased by 630% (AOR: 7.3 (2.6 to 20.7)) and use of sexual health services increased by 220% (AOR: 3.2 (1.62 to 6.27)). We did not find any significant reduction in mental health problems among male adolescents. CONCLUSIONS: Our findings suggest that a psychosocial intervention was associated with increased knowledge and uptake of HIV and sexual health services among both male and female migrant adolescents and with reduced mental health problems among female adolescents. Mental health problems varied significantly for male and female adolescents, suggesting that future interventions should be tailored to address their different needs and would benefit from intensive follow-up efforts.

Experiences in implementation and publication of operations research interventions: gaps and a way forward.

INTRODUCTION: According to UNAIDS, the world currently has an adequate collection of proven HIV prevention, treatment and diagnostic tools, which, if scaled up, can lay the foundation for ending the AIDS epidemic. HIV operations research (OR) tests and promotes the use of interventions that can increase the demand for and supply of these tools. However, current publications of OR mainly focus on outcomes, leaving gaps in reporting of intervention characteristics, which are essential to address for the utilization of OR findings. This has prompted WHO and other international public health agencies to issue reporting requirements for OR studies. The objective of this commentary is to review experiences in HIV OR intervention design, implementation, process data collection and publication in order to identify gaps, contribute to the body of knowledge and propose a way forward to improve the focus on "implementation" in implementation research. DISCUSSION: Interventions in OR, like ordinary service delivery programmes, are subject to the programme cycle, which continually uses insights from implementation and the local context to modify service delivery modalities. Given that some of these modifications in the intervention may influence study outcomes, the documentation of process data becomes vital in OR. However, a key challenge is that study resources tend to be skewed towards documentation and the reporting of study outcomes to the detriment of process data, even though process data is vital for understanding factors influencing the outcomes. CONCLUSIONS: Interventions in OR should be viewed using the lens of programme evaluation, which includes formative assessment (to determine concept and design), followed by process evaluation (to monitor inputs and outputs) and effectiveness evaluation (to assess outcomes and effectiveness). Study resources should be equitably used between process evaluation and outcome measurement to facilitate inclusion of data about fidelity and dose in publications in order to enable explanation of the relationship between dosing and study outcomes for purposes of scaling up and further refinement through research.

Reliability and Validity of an Interviewer-Administered Adaptation of the Youth Self-Report for Mental Health Screening of Vulnerable Young People in Ethiopia.

OBJECTIVE: Evaluate the reliability and validity of the Youth Self-Report (YSR) as a screening tool for mental health problems among young people vulnerable to HIV in Ethiopia. DESIGN: A cross-sectional assessment of young people currently receiving social services. METHODS: Young people age 15-18 participated in a study where a translated and adapted version of the YSR was administered by trained nurses, followed by an assessment by Ethiopian psychiatrists. Internal reliability of YSR syndrome scales were assessed using Chronbach's alpha. Test-retest reliability was assessed through repeating the YSR one month later. To assess validity, analysis of the sensitivity and specificity of the YSR compared to the psychiatrist assessment was conducted. RESULTS: Across the eight syndrome scales, the YSR best measured the diagnosis of anxiety/depression and social problems among young women, and attention problems among young men. Among individual YSR syndrome scales, internal reliability ranged from unacceptable (Chronback's alpha = 0.11, rule-breaking behavior among young women) to good (α≥0.71, anxiety/depression among young women). Anxiety/depression scores of ≥8.5 among young women also had good sensitivity (0.833) and specificity (0.754) to predict a true diagnosis. The YSR syndrome scales for social problems among young women and attention problems among young men also had fair consistency and validity measurements. Most YSR scores had significant positive correlations between baseline and post-one month administration. Measures of reliability and validity for most other YSR syndrome scales were fair to poor. CONCLUSIONS: The adapted, personally administered, Amharic version of the YSR has sufficient reliability and validity in identifying young vulnerable women with anxiety/depression and/or social problems, and young men with attention problems; which were the most common mental health disorders observed by psychiatrists among the migrant populations in this study. Further assessment of the applicability of the YSR among vulnerable young people for less common disorders in Ethiopia is needed.

Contribution of off-road tests to predicting on-road performance: a critical review of tests.

BACKGROUND/AIM: Driving is an essential activity of daily living. Because it is easily disrupted by illness or injury, it is a common subject of occupational therapy assessment. Assessments of driving are critically important and carry legal implications for therapists. A full occupational therapy assessment comprising both off- and on-road testing is time and labour intensive and therefore expensive. Off-road tests are used to inform on-road assessments, and, if they have sufficient sensitivity and specificity they may replace an on-road assessment for some clients. The twofold purpose of this article is to compare and critique off-road tests to predict driving performance and to determine if any is sufficiently accurate to identify drivers who do not require an on-road assessment. METHODS: We reviewed tests commonly used by researchers to predict driving capacity (i) that have been used in research since 2000 and (ii) for which sensitivity and specificity had been (or could be) calculated. We compared the tests on five characteristics: diagnostic makeup of samples, sample sizes, outcome measures, sensitivity and specificity and potential for use as a supplement to on-road assessment or to identify drivers for whom an on-road assessment is not necessary. RESULTS AND CONCLUSIONS: No gold standard off-road test exists for predicting on road performance. DriveSafe/DriveAware and SMC Tests had the highest reported sensitivity and specificity. Thus, with further research, one or both may be found to predict on-road performance accurately and to minimise the need for on road assessment. Several other tests are a useful supplement to on-road testing.

Predicting fitness to drive in people with cognitive impairments by using DriveSafe and DriveAware.

OBJECTIVES: To examine the psychometric properties of DriveSafe and DriveAware and their predictive validity. DESIGN: Prospective study compared screening tests with criterion standard. SETTING: Two driving rehabilitation centers affiliated with a university and a geriatric rehabilitation facility. PARTICIPANTS: Consecutive sample of drivers with functional impairments (n=115) and subgroup of drivers with cognitive impairments (n=96) referred for a driving assessment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Driving performance was measured by a standardized assessment in real traffic. RESULTS: Rasch analysis provided evidence for construct validity and internal reliability of both tests. Tests trichotomized drivers into unsafe, safe, and further testing categories. The optimal lower cutoff identified unsafe drivers with a specificity of 97% (95% confidence interval [CI], 83-100) in the test sample and 96% (95% CI, 80-100) in the validation sample. The optimal upper cutoff identified safe drivers with a sensitivity of 93% (95% CI, 77-99) and 95% (95% CI, 76-100), respectively. CONCLUSIONS: By using DriveSafe and DriveAware, drivers with cognitive impairments referred for a driving assessment can be categorized as unsafe, safe, or requiring further testing, with only 50% needing an on-road assessment. Before clinical practice is changed, these findings should be replicated.

Awareness of driving ability in senior drivers with neurological conditions.

OBJECTIVE: We sought to determine the agreement between rating of awareness based on scores on the Driving Awareness Questionnaire (DriveAware) and global judgments of awareness awarded after on-road assessment, thereby establishing the possibility of measuring drivers' awareness. METHOD: A prospective cohort study of 60 senior drivers with neurological conditions who were referred for driving assessment. Awareness was rated as intact, partial, or absent on the basis of the discrepancy score between participants' and clinicians' responses to DriveAware. A second clinician (masked to these results) rated awareness on the same scale at the completion of the on-road assessment. Agreement of categorical ratings was adjusted for chance using the kappa statistic. RESULTS: Results yielded a kappa of .69 (SE = .08), indicating agreement substantially beyond chance. CONCLUSION: Results indicate that awareness of driving ability may be measured with substantial accuracy using DriveAware in senior drivers with neurological impairments. The psychometric properties of DriveAware require further research.

Validity, reliability and predictive accuracy of the Driving Awareness Questionnaire.

PURPOSE: To examine the psychometric properties of the Driving Awareness Questionnaire (DriveAware) and to compare this rating of awareness of driving ability with the rating made in the context of an on-road assessment. METHOD: A prospective design was employed to examine the psychometric properties of DriveAware using Rasch analysis. Participants (n = 91) with varying diagnoses were recruited from two driving rehabilitation centres in Sydney, Australia. They completed DriveAware in the context of a standard driving assessment. Awareness of driving ability determined by DriveAware was compared with awareness determined in the on-road assessment. RESULTS: Rasch analysis provided good evidence for construct validity and inter-rater reliability and some evidence for internal reliability of DriveAware. The item hierarchy was logical and goodness-of-fit statistics for four of five items were within an acceptable range. The test had a moderate reliability index (0.73). Measurement precision could be improved by including more items to assess drivers with little awareness. When compared with the on-road measure of awareness, the best DriveAware cut-off score yielded sensitivity of 84% and specificity of 94%. CONCLUSION: This short and easy-to-administer test could provide a useful tool with sound psychometric properties to measure awareness of driving ability.

Predicting fitness to drive using the visual recognition slide test (USyd).

OBJECTIVE: The authors examined the construct and predictive validity and internal reliability of the Visual Recognition Slide Test developed at the University of Sydney (VRST-USyd). METHOD: A historical cohort study using retrospective descriptive analysis of VRST-USyd scores and on-road driving performance for 838 drivers with impairments was conducted. RESULTS: Rasch analysis provided evidence for the construct validity and internal reliability of the VRST-USyd. Goodness-of-fit statistics for all items were acceptable. The test had high participant and item reliability indexes and separated the participants into four groups with varying levels of skill. Using a cutoff score of 95/164, the sensitivity of the test was 81%, and the specificity was 90%. However, when coupled with clinicians' judgment of participants' awareness of their driving performance during the on-road assessment, this score improved. CONCLUSION: There is evidence for reliability and construct and predictive validity of the VRST-USyd. The measurement of awareness requires further research.

Validity and reliability of the on-road driving assessment with senior drivers.

The on-road driving assessment is widely regarded as the criterion measure for driving performance despite a paucity of evidence concerning its psychometric properties. The purpose of this study was 2-fold. First, we examined the psychometric properties of an on-road driving assessment with 100 senior drivers between 60 and 86 years (80 healthy volunteers and 20 with specific vision deficits) using Rasch modeling. Second, we compared the outcome of the gestalt decision made by trained professionals with that based on weighted error scores from the standardized assessment. Rasch analysis provided good evidence for construct validity and inter-rater reliability of the on-road assessment and some evidence for internal reliability. Goodness of fit statistics for all items were within an acceptable range and the item hierarchy was logical. The test had a moderate reliability index (0.67). The best cut off score yielded sensitivity of 81% and specificity of 95% compared with the gestalt decision. Further research is required with less competent drivers to more fully examine reliability. Healthy senior drivers failed to check blind spots when changing lanes and made errors when asked to report road markings and traffic signs as they drove. In addition unsafe drivers had difficulty negotiating intersections and lane changes.

Current licensing authority standards for peripheral visual field and safe on-road senior aged automobile driving performance.

BACKGROUND: The current licensing authority's (Austroads) visual field standards are met when a person demonstrates an intact visual field extending horizontally at least 120 degrees within 10 degrees above and below the horizontal midline. A person cannot be licensed unconditionally if they have a hemianopia, quadrantanopia or any significant visual field loss (scotoma) that is likely to impede driving performance. Despite fairly rigorous implementation of these vision standards by licensing authorities, there is little scientific evidence available to demonstrate that a driver will or will not be safe on road depending on the extent of their visual field. METHODS: This study was developed to examine if the current licensing authority vision standards predict safe on-road driver performance in a cohort of 100 senior drivers. The study consisted of four stages in which participants underwent on-road assessment by a multidisciplinary team including a driving instructor, orthoptist and occupational therapist; off-road occupational therapy cognitive skills assessment using the Visual Recognition Slide Test (VRST-USyd); off-road orthoptic assessment including history, visual acuity and visual fields; and feedback from the team regarding the participant's visual and driving status. Visual fields were assessed using both the Goldmann and Esterman tests. Correlations were calculated to determine the relationship between visual field results and on-road driving performance. RESULTS: Generally it was found that visual field test results did not predict driving performance accurately for both participants with and without visual field loss. CONCLUSION: The results bring into question the current Austroads visual field standards for safe driving.