Comparative Effectiveness of Community-Based vs Clinic-Based Healthy Choices Motivational Intervention to Improve Health Behaviors Among Youth Living With HIV: A Randomized Clinical Trial.

Importance: Youth living with HIV make up one-quarter of new infections and have high rates of risk behaviors but are significantly understudied. Effectiveness trials in real-world settings are needed to inform program delivery. Objective: To compare the effectiveness of the Healthy Choices intervention delivered in a home or community setting vs a medical clinic. Design, Setting, and Participants: This randomized clinical trial was conducted from November 1, 2014, to January 31, 2018, with 52 weeks of follow-up. Participants, recruited from 5 adolescent HIV clinics in the United States, were youths and young adults living with HIV aged 16 to 24 years who were fluent in English, were currently prescribed HIV medication, had a detectable viral load, and had used alcohol in the past 12 weeks. Individuals with an active psychosis that resulted in an inability to complete questionnaires were excluded. Data were analyzed from May to December, 2019. Interventions: Participants were randomized to receive the Healthy Choices intervention in either a home or clinic setting. Four 30-minute individual sessions based on motivational interviewing to improve (1) medication adherence and (2) drinking behavior were delivered during 10 weeks by trained community health workers. In session 1, participants chose which behavior to discuss first. Using motivational interviewing strategies, the community health worker elicited motivational language, guided the development of an individualized change plan while supporting autonomy, delivered feedback, and addressed knowledge gaps. Session 2 focused on the second target behavior. In subsequent sessions, community health workers reviewed the individualized change plan, monitored progress, guided problem solving, and helped maintain changes made. Main Outcomes and Measures: Primary outcomes were viral load and alcohol use change trajectories during 52 weeks of follow-up. Alcohol use severity and frequency were measured using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) (scores range from 0 to 33, with higher scores indicating greater severity of alcohol-related problems) and number of drinks consumed each day over a 30-day period, with timeline followback. Results: A total of 183 young people living with HIV (145 male [79.2%]; mean [SD] age, 21.4 [1.9] y) were randomized to the home setting (n = 90) or clinical setting (n = 93). Using growth-curve analysis, both groups showed declines in viral load after the intervention: among participants with available viral load information, in the home group, 12 participants (21%) had an undetectable viral load at 16 weeks, 12 (22%) at 28 weeks, and 10 (20%) at 52 weeks; in the clinic group, 16 participants (24%) had an undetectable viral load at 16 weeks, 20 (39%) at 28 weeks, and 18 (35%) at 52 weeks. However, the clinic group maintained gains, whereas those counseled at home had a significantly different and increasing trajectory during follow-up (unstandardized ß = -0.07; 95% CI,-0.14 to -0.01; P = .02). A similar pattern was observed in ASSIST scores during follow-up, with reduced ASSIST scores in the clinic group (unstandardized ß = -0.44; 95% CI,-0.81 to -0.07; P = .02). Conclusions and Relevance: In this trial, the Healthy Choices intervention resulted in improvements in viral load and alcohol use over 12 months. Unexpectedly, the clinic setting outperformed home-based delivery for viral suppression. Although cross-sectional differences in ASSIST scores were nonsignificant, clinic delivery did improve the trajectory of ASSIST scores during follow-up. Thus, clinics may be the more effective site for interventions aimed at viral load reduction for young people living with HIV. Trial Registration: ClinicalTrials.gov Identifier: NCT01969461.

Comprehensive Community-Based Intervention and Asthma Outcomes in African American Adolescents.

: media-1vid110.1542/5804911922001PEDS-VA_2017-3737Video Abstract BACKGROUND: African American adolescents appear to be the most at risk for asthma morbidity and mortality even compared with other minority groups, yet there are few successful interventions for this population that are used to target poorly controlled asthma. METHODS: African American adolescents (age 12-16 years) with moderate-to-severe persistent asthma and ≥1 inpatient hospitalization or ≥2 emergency department visits in 12 months were randomly assigned to Multisystemic Therapy-Health Care or an attention control group (N = 167). Multisystemic Therapy-Health Care is a 6-month home- and community-based treatment that has been shown to improve illness management and health outcomes in high-risk adolescents by addressing the unique barriers for each individual family with cognitive behavioral interventions. The attention control condition was weekly family supportive counseling, which was also provided for 6 months in the home. The primary outcome was lung function (forced expiratory volume in 1 second [FEV1]) measured over 12 months of follow-up. RESULTS: Linear mixed-effects models revealed that compared with adolescents in the comparison group, adolescents in the treatment group had significantly greater improvements in FEV1 secondary outcomes of adherence to controller medication, and the frequency of asthma symptoms. Adolescents in the treatment group had greater reductions in hospitalizations, but there were no differences in reductions in emergency department visits. CONCLUSIONS: A comprehensive family- and community-based treatment significantly improved FEV1, medication adherence, asthma symptom frequency, and inpatient hospitalizations in African American adolescents with poorly controlled asthma. Further evaluation in effectiveness and implementation trials is warranted.

The Detroit Young Adult Asthma Project: Pilot of a Technology-Based Medication Adherence Intervention for African-American Emerging Adults.

PURPOSE: To conduct a randomized controlled pilot of a multicomponent, technology-based intervention promoting adherence to controller medication in African-American emerging adults with asthma. The intervention consisted of two computer-delivered sessions based on motivational interviewing combined with text messaged reminders between sessions. METHODS: Participants (N = 49) were 18-29 years old, African-American, with persistent asthma requiring controller medication. Participants had to report poor medication adherence and asthma control. Youth were randomized to receive the intervention or an attention control. Data were collected through computer-delivered self-report questionnaires at baseline, 1, and 3 months. Ecological Momentary Assessment via two-way text messaging was also used to collect "real-time" data on medication use and asthma control. RESULTS: The intervention was feasible and acceptable to the target population, as evidenced by high retention rates and satisfaction scores. Changes in study outcomes from pre- to postintervention favored the intervention, particularly for decrease in asthma symptoms, t (42) = 2.22, p < .05 (Cohen's d = .071). CONCLUSIONS: Results suggest that the intervention is feasible and effective. However, findings are preliminary and should be replicated with a larger sample and more sophisticated data analyses.

Effects of family treatment on parenting beliefs among caregivers of youth with poorly controlled asthma.

OBJECTIVE: Caregiver involvement is critical in ensuring optimal adolescent asthma management. The study investigated whether multisystemic therapy (MST), an intensive home-based family therapy, was superior to family support for changing beliefs regarding asthma-related positive parenting among caregivers of African-American youth with poorly controlled asthma. The relationship between parenting beliefs and asthma management at the conclusion of the intervention was also assessed. METHODS: A randomized controlled trial was conducted with 167 adolescents with moderate-to-severe, persistent, poorly controlled asthma and their primary caregivers. Families were randomly assigned to MST or family support (FS), a home-based family support condition. Data were collected at baseline and 7-month posttest. Changes in caregiver ratings of importance and confidence for engaging in asthma-related positive parenting were assessed through questionnaire. Illness management was assessed by the Family Asthma Management System Scale. RESULTS: Participation in MST was associated with more change in caregiver beliefs as compared with FS for both importance (t = 2.39, p = .02) and confidence (t = 2.04, p = .04). Caregiver beliefs were also significantly related to youth controller medication adherence at the conclusion of treatment (importance: r = .21, p = .01; confidence: r = .23, p = .004). CONCLUSION: Results support the effectiveness of MST for increasing parental beliefs in the value of asthma-related positive parenting behaviors and parental self-efficacy for these behaviors among families of minority adolescents with poorly controlled asthma.

Multisystemic therapy for high-risk African American adolescents with asthma: a randomized clinical trial.

OBJECTIVE: The primary purpose of the study was to determine whether Multisystemic Therapy adapted for health care settings (MST-HC) improved asthma management and health outcomes in high-risk African American adolescents with asthma. METHOD: Eligibility included self-reported African American ethnicity, ages 12 to 16, moderate to severe asthma, and an inpatient hospitalization or at least 2 emergency department visits for asthma in the last 12 months. Adolescents and their families (N = 170) were randomized to MST-HC or in-home family support. Data were collected at baseline and posttreatment (7 months) based on an asthma management interview, medication adherence phone diary, and lung function biomarker (forced expiratory volume in 1 s [FEV1]). Analyses were conducted using linear mixed modeling for continuous outcomes and generalized linear mixed modeling for binary outcomes. RESULTS: In intent-to-treat analyses, adolescents randomized to MST-HC were more likely to improve on 2 of the measures of medication adherence and FEV1. Per-protocol analysis demonstrated that MST-HC had a medium effect on adherence measures and had a small to medium effect on lung function and the adolescent's response to asthma exacerbations. CONCLUSION: There are few interventions that have been shown to successfully improve asthma management in minority youth at highest risk for poor morbidity and mortality. MST, a home-based psychotherapy originally developed to target behavior problems in youth, improved asthma management and lung function compared to a strong comparison condition. Further follow-up is necessary to determine whether MST-HC reduces health care utilization accounting for seasonal variability. A limitation to the study is that a greater number of participants in the control group came from single-parent families than in the MST group.

Adherence to asthma medication regimens in urban African American adolescents: application of self-determination theory.

OBJECTIVE: Asthma medication adherence is low, particularly among African American adolescents, a high-risk group with respect to asthma prevalence, morbidity, and mortality. This study tested the utility of self-determination theory (SDT), a theory of motivation, to explain adherence to asthma medication regimens in African American adolescents. METHOD: We used baseline data from 168 urban African American adolescents (Mage = 13.94 years; 61% male) with poorly controlled asthma who were part of a trial testing the efficacy of interventions to improve adherence. Participants and their caregivers were interviewed using the Family Asthma Management System Scale; this study used the Asthma Medication Adherence subscale. Adolescents completed four asthma-specific scales representing the SDT constructs of autonomous motivation (one importance scale), competence (one confidence scale), and relatedness (two scales--family routines and parental support). Using multiple linear regression, we tested the hypothesis that SDT variables would predict adherence. RESULTS: Adherence was significantly correlated with three SDT variables--importance, confidence, and family routines. In multivariate analysis, family routines was the only significant predictor of asthma adherence (p < .001). Asthma management behaviors integrated into and shared among family members was associated with better adherence. Greater confidence was marginally associated with increased adherence (p = .07). CONCLUSION: Though several variables representing SDT constructs were correlated with adherence, results demonstrate that family routines may be more relevant for African American adolescents' adherence than other SDT constructs. Thus, helping families to share and better integrate asthma care into daily schedules may be an important intervention strategy to improve medication adherence among high-risk African American adolescents.

Asthma medication device skills in high-risk African American adolescents.

OBJECTIVE: To describe the asthma medication device skills of high-risk African American adolescents and associations between skills and other components of illness management, METHODS: 170 African American adolescents, with at least one hospitalization or two emergency department visits in the last year, demonstrated how they use their asthma quick-relief and controller medication devices. Observations were scored using an in vivo observation asthma skills checklist. To assess other areas of asthma management, adolescents and their primary caregiver were interviewed using the Family Asthma Management System Scales, RESULTS: Only 5% of adolescents correctly demonstrated all controller skills, and none of the adolescents correctly showed all quick-relief inhaler skills (5% showed between 90 and 95% of skills). Several components of asthma management predicting controller medication skills were attendance at an asthma specialty clinic, collaboration with provider, medication adherence, and quick-relief medication skills. These variables accounted for a total of 24% of the variance in controller medication skills, CONCLUSIONS: Results indicate the need for interventions directly targeting observed asthma management skills and the importance of relationship with providers.

Text messaging to measure asthma medication use and symptoms in urban African American emerging adults: a feasibility study.

OBJECTIVE: Urban African American adolescents and young adults face disproportionate risk of asthma morbidity and mortality. This study was the first to assess the feasibility of Ecological Momentary Assessment via text messaging to measure asthma medication use and symptoms in African Americans aged 18-25 years. METHODS: This study used automated text messaging with N = 6 participants for 14 consecutive days. Participants sent event-based messages whenever they experienced asthma symptoms or took asthma rescue or controller medications. They also received time-based messages daily that prompted for a response about asthma medications or symptoms. RESULTS: Feasibility was assessed using response rates and participant feedback. Rates of event-based messages were relatively low (M = 0.85 messages sent per participant/day), but participants were very responsive to time-based messages (78.5%). All participants expressed positive feedback about the program, though 40.0% reported confusion with event-based messages and most preferred time-based messages. The assessment found low medication adherence rates and reasons for missing medication consistent with previous research with youth with asthma. CONCLUSION: Text messaging may be a useful method to measure medication use and symptoms in "real time," particularly using time-based prompts. Results could be used to provide personalized feedback on adherence as part of a tailored intervention.

Development and preliminary validation of an indirect screener for drug use in the perinatal period.

AIMS: This study sought to develop and begin validation of an indirect screener for identification of drug use during pregnancy, without reliance on direct disclosure. DESIGN: Women were recruited from their hospital rooms after giving birth. Participation involved (i) completing a computerized assessment battery containing three types of items: direct (asking directly about drug use), semi-indirect (asking only about drug use prior to pregnancy) and indirect (with no mention of drug use), and (ii) providing urine and hair samples. An optimal subset of indirect items was developed and cross-validated based on ability to predict urine/hair test results. SETTING: Obstetric unit of a university-affiliated hospital in Detroit. PARTICIPANTS: Four hundred low-income, African American, post-partum women (300 in the developmental sample and 100 in the cross-validation sample); all available women were recruited without consideration of substance abuse risk or other characteristics. MEASUREMENTS: Women first completed the series of direct and indirect items using a Tablet PC; they were then asked for separate consent to obtain urine and hair samples that were tested for evidence of illicit drug use. FINDINGS: In the cross-validation sample, the brief screener consisting of six indirect items predicted toxicology results more accurately than direct questions about drug use (area under the ROC curve = 0.74, P < 0.001). Traditional direct screening questions were highly specific, but identified only a small minority of women who used drugs during the last trimester of pregnancy. CONCLUSIONS: Indirect screening may increase the accuracy of mothers' self-reports of prenatal drug use.

A randomized trial of computer-delivered brief intervention and low-intensity contingency management for smoking during pregnancy.

INTRODUCTION: Implementation of evidence-based interventions for smoking during pregnancy is challenging. We developed 2 highly replicable interventions for smoking during pregnancy: (a) a computer-delivered 5As-based brief intervention (CD-5As) and (b) a computer-assisted, simplified, and low-intensity contingency management (CM-Lite). METHODS: A sample of 110 primarily Black pregnant women reporting smoking in the past week were recruited from prenatal care clinics and randomly assigned to CD-5As (n = 26), CM-Lite (n = 28), CD-5As plus CM-Lite (n = 30), or treatment as usual (n = 26). Self-report of smoking, urine cotinine, and breath CO were measured 10 weeks following randomization. RESULTS: Participants rated both interventions highly (e.g., 87.5% of CD-5As participants reported increases in likelihood of quitting), but most CM-Lite participants did not initiate reinforcement sessions and did not show increased abstinence. CD-5As led to increased abstinence as measured by cotinine (43.5% cotinine negative vs. 17.4%; odds ratio [OR] = 10.1, p = .02) but not for CO-confirmed 7-day point prevalence (30.4% abstinent vs. 8.7%; OR = 5.7, p = .06). Collapsing across CM-Lite status, participants receiving the CD-5As intervention were more likely to talk to a doctor or nurse about their smoking (60.5% vs. 30.8%; OR = 3.0, p = .02). CONCLUSIONS: Low-intensity participant-initiated CM did not affect smoking in this sample, but the CD-5As intervention was successful in increasing abstinence during pregnancy. Further research should seek to replicate these results in larger and more diverse samples. Should CD-5As continue to prove efficacious, it could greatly increase the proportion of pregnant smokers who receive an evidence-based brief intervention.

Drug use during pregnancy: validating the Drug Abuse Screening Test against physiological measures.

This study examined the ability of the Drug Abuse Screening Test (DAST-10) to identify prenatal drug use using hair and urine samples as criterion variables. In addition, this study was the first to use "best practices," such as anonymity, ACASI technology, and a written screener, to facilitate disclosure in this vulnerable population. 300 low-income, post-partum women (90.3% African-American) were recruited from their hospital rooms after giving birth. Participation involved (a) completing a computerized assessment battery that contained the DAST-10 and (b) providing urine and hair samples. Twenty-four percent of the sample had a positive drug screen. The sensitivity of the DAST-10 was only .47. Nineteen percent of the sample had a positive toxicology screen but denied drug use on the DAST-10. Findings suggest that brief drug use screeners may have limited utility for pregnant women and that efforts to facilitate disclosure via reassurance and anonymity are unlikely to be sufficient in this population.

Health literacy and antiretroviral adherence among HIV-infected adolescents.

OBJECTIVE: This study investigates HIV positive adolescents' health literacy and whether factors associated with health literacy in HIV-positive adults are associated with health literacy among HIV-positive adolescents. METHODS: Adolescents in this study were behaviorally and perinatally HIV-infected youth (n=186) from five U.S. cities. Participants had a mean age of 20.5, and 49.5% were male. RESULTS AND CONCLUSIONS: Contrary to findings for adult HIV-positive patients, among adolescents health literacy was not significantly associated with: medication adherence adjusting for age and education level; viral load; or self-efficacy to adhere to medication regimens. The only significant association was of health literacy with medical care received. PRACTICE IMPLICATIONS: Practice implications are discussed.

Brief report: maintenance of effects of motivational enhancement therapy to improve risk behaviors and HIV-related Health in a randomized controlled trial of youth living with HIV.

OBJECTIVE: To examine the maintenance of effects of Motivational Enhancement Therapy (MET) shown to improve risk behaviors and viral load in youth living with HIV (YLH) immediately posttreatment. METHODS: Sixty-five youth (ages 16-25 years) were randomized to Healthy Choices or a waitlist control. Frequency of substance use, frequency of unprotected intercourse, and viral load were obtained at baseline, 3, and 6 months after study entry. The waitlist control then received intervention. An additional data collection was obtained at 9 months for follow-up of the original treatment group. RESULTS: One-tailed ANOVA showed that the treatment group had greater reductions in viral load and alcohol use from baseline to 6 months. These reductions appeared to be maintained at 9-month follow-up. Improvements in sexual risk were not evident. CONCLUSIONS: MET showed significant promise in reducing substance use and in improving HIV-related health in YLH immediately posttreatment. These effects were maintained after treatment termination.

Social support and disclosure as predictors of mental health in HIV-positive youth.

The purpose of this study was to describe mental health symptoms in a sample of 66 HIV-positive youth (ages 16-25) and to evaluate social support, disclosure, and physical status as predictors of symptoms. Data were collected from January 2002 to May 2003. As measured by the Brief Symptom Inventory (BSI), 50% of the youth scored above the cutoff for clinically significant mental health symptoms, thus highlighting the need for mental health services. Lower social support, higher viral load, HIV-status disclosure to acquaintances, and being gay/lesbian/bisexual (GLB) were all significantly correlated with more mental health symptoms, but disclosure to family and close friends and contact with service providers were not. Furthermore, regression analysis showed that social support, viral load, and disclosure to acquaintances predicted 32% of the variance in mental health symptoms. Being GLB was no longer significant, most likely because of shared variance with low social support. Results suggest the importance of mental health interventions, and the potential of social support interventions to improve mental health. Further research addressing the role of HIV-related stigma and homophobia is warranted.

Stigma scale revised: reliability and validity of a brief measure of stigma for HIV+ youth.

The purpose of this study was to shorten a human immunodeficiency virus (HIV) stigma scale to make it less burdensome for HIV-positive (HIV+) youth without compromising psychometric properties. The shortened questionnaire showed good internal consistency and validity, suggesting that a 10-item measure of stigma has promise for assessing this important construct in HIV+ youth.

Healthy choices: motivational enhancement therapy for health risk behaviors in HIV-positive youth.

This study piloted a brief individual motivational intervention targeting multiple health risk behaviors in HIV-positive youth aged 16-25. Interviews about sexual behavior and substance use and viral load testing were obtained from 51 HIV-positive youth at baseline and post intervention. Youth were randomized to receive a four-session motivational enhancement intervention (N = 25) or to a wait-list control (N = 26). Of the eligible youth approached, 88% agreed to participate, and 80% percent of participants completed at least three of four sessions. The treatment group showed significantly greater reductions in unprotected sex acts and in viral load compared with controls. Although change scores for substance use were not significantly different between the two groups, paired t tests demonstrated that reductions in alcohol use and marijuana use were significant for the treatment group at the trend level. There were no significant differences in substance use from baseline to posttest for the control group. Findings demonstrate the potential of a brief motivational enhancement intervention to improve health risk behaviors in HIV-positive youth. Larger randomized clinical trials are warranted. Resources required for retention should not be underestimated.

Psychosocial factors and medication adherence in HIV-positive youth.

The purpose of this study was to test variables consistently identified in the adult HIV literature as predictors of adherence (self-efficacy, social support, and psychological distress) in a sample of 24 HIV-positive youth (ages 16-24). Self-efficacy and psychological distress were significantly correlated with adherence but social support was not. Social support specific to taking medications was correlated with self-efficacy. In regression analysis, both self-efficacy and psychological distress were independently related to adherence and together accounted for 47% of the variance. Results suggest the potential of mental health interventions that boost self-efficacy and reduce psychological distress but require replication with larger samples.