Effectiveness of a Universal, Classroom-Based Preventive Intervention (PAX GBG) in Estonia: a Cluster-Randomized Controlled Trial.

The PAX Good Behavior Game (PAX GBG) is a behavior management strategy that has demonstrated positive effects on children's behavior and well-being in trials conducted mainly in the USA. This study assessed the impact of the PAX GBG on students' mental health and behavior 7 and 19 months post-baseline in Estonia. This matched-pair, cluster-randomized, waitlist-controlled, open-label trial included 42 Estonian elementary schools with 708 first-grade students. The primary outcome was children's overall mental health rated by teachers, while secondary objectives were to examine whether the effects of the intervention extended to the home context. Teachers also rated their self-efficacy and overall classroom behavior. Intervention adherence and children's exposure to the intervention were also measured. Modified intention to treat analysis involved 696 students on first post-baseline and 647 on second post-baseline. Intervention had positive effects on children's mental health at the end of the first academic year, which lasted and strengthened during the second academic year. Moderation analysis demonstrated positive effects on mental health and prosocial behavior for high-risk students during the first year. A few positive effects extended to the home environment during the second academic year. Implementation fidelity was satisfactory. The intervention also had a positive lasting effect on teacher's self-efficacy and overall classroom behavior. This study shows the positive effects of the PAX GBG in Estonian schools and supports broader implementation of the intervention in Estonian elementary schools. TRIAL REGISTRATION: ClinicalTrials.gov No. NCT02865603.

Effectiveness of a universal classroom-based preventive intervention (PAX GBG): A research protocol for a matched-pair cluster-randomized controlled trial.

INTRODUCTION: The PAX Good Behavior Game (PAX GBG) is a universal classroom-based program that promotes children's mental health. In Estonia, the intervention is delivered to first grade students (aged seven to eight) within the regular school curriculum. The current work describes a protocol for a cluster-randomized controlled trial (RCT) of the PAX GBG conducted in Estonia. DESIGN AND METHODS: This is an ongoing, pragmatic, two-year, matched-pair, cluster-RCT conducted in Estonian elementary schools. Schools were matched to pairs based on their geographical location and number of students per classroom. One school in each pair was randomly selected to receive the intervention and the other placed on a wait-list as a control. 42 schools provided baseline data during the autumn of 2016. Data is collected at two more points in time - seven months and 19 months post-baseline. Outcomes of children's mental health and behavior are measured by the teacher- and parent-rated Strengths and Difficulties Questionnaire, parent-rated Swanson, Nolan, and Pelham - IV Questionnaire and the Go/No-Go task completed by children. Teachers also rate their self-efficacy and overall classroom behavior. DISCUSSION: This study aims to test the effectiveness of the intervention in Estonian classrooms with a newer version of the rigorously tested GBG program. To our knowledge, this study is the first to measure the effects of the intervention on children's inhibitory control, which has been associated with externalizing problems in the literature. The results from this trial will provide further understanding into how the program influences children's well-being and self-control. TRIAL REGISTRATION: ClinicalTrials.gov registry (NCT02865603).

HIV Epidemic in Estonia: analysis of Strategic Information: case study

This publication describes an in-depth retrospective secondary data analysis, using triangulation principles, that was conducted to analyse the course of the HIV/AIDS epidemic in Estonia, describe the interventions implemented and provide guidance and input for priority setting. The researchers also highlighted main data gaps and made recommendations to improve surveillance and interventions. The exercise showed that: HIV transmission is slowly but steadily decreasing in Estonia, injecting drug use remains the most important transmission route and the HIV epidemic continues to affect vulnerable populations more, particularly injecting drug users (IDUs) and their sexual partners.Many HIV/AIDS interventions were significantly scaled up in Estonia over the last decade, and the decline in newly diagnosed HIV cases among young people indicates that prevention efforts are affecting this group’s behaviour and are having a positive impact on the epidemic. Further scale-up and quality improvement of harm-reduction services are important to prevent infection in IDUs. The authors recommend scaling up HIV testing in all settings, improving post-test counselling, developing more active partner counselling and contact-tracing services, more active referral systems to infectious disease services, support for adherence to treatment and intervention monitoring. As behaviour-change interventions for people living with HIV are very limited in Estonia, counselling on sexual behaviour and drug use and access to services for sexual health and sexually transmitted infections should be improved.

Evaluating recruitment among female sex workers and injecting drug users at risk for HIV using respondent-driven sampling in Estonia.

Few recent publications have highlighted theoretical and methodological challenges using respondent-driven sampling (RDS). To explore why recruitment with RDS may work in some populations and not in others, we assess the implementation of RDS to recruit female sex workers (FSWs) and injection drug users (IDUs) into a human immunodeficiency virus biological and risk behavior survey in Tallinn, Estonia. Recruitment of FSWs was slower and more challenging than that of IDUs. The IDU study recruited 350 participants within 7 weeks, while the FSW study recruited 227 participants over 28 weeks. Implementation modifications that did not negatively impact key RDS theoretical and methodological requirements were used to improve recruitment during the FSW study. We recommend that all RDS studies include a formative research process to involve the participation of target populations and key persons associated with these populations in the study planning and throughout the implementation processes to improve recruitment from the outset and to respond to poor recruitment during data collection.

Efficacy of convenience sampling through the internet versus respondent driven sampling among males who have sex with males in Tallinn and Harju County, Estonia: challenges reaching a hidden population.

This paper examines challenges obtaining representative samples of males who have sex with males (MSM) in Estonia and provides descriptive HIV behavioral data gathered from four cross-sectional surveys; three using the internet, and one using respondent driven sampling (RDS) to recruit MSM in Tallinn and Harju County. Estonian MSM were sampled between March and May in 2004 (n=193), August and November in 2005 (n=146) and September and December in 2007 (n=238) using internet websites. MSM in Tallinn and Harju County were sampled between April and June in 2007 (n=59) using RDS. Recruitment of MSM using RDS did not acquire the calculated sample size. The RDS study reached a less diverse group of MSM than did the internet studies which recruited a larger proportion of MSM who were older, bisexual, having female sexual partners during the last six months, and unlikely to have been tested for HIV. The findings and observations presented in this paper could inform researchers in Estonia, and the region, about the efficacy of and socio-cultural challenges to sampling MSM to collect HIV biological and/or behavioral data.