Defining Behavioral Interventions Michael Sweat, PhD The Johns Hopkins University Bloomberg School of Public Health Department of International Health Thanks to Kevin O’Reilly & WHO, Population Council / Horizons, NIMH

Key Take Away Messages The current language in use regarding interventions is muddled Intervention programs are comprised of multiple intervention components We need clear standards for intervention components We need to consider the blend of intervention components to maximize program success

Background Our work shows that most intervention programs are almost always made up of multiple intervention components Yet they are identified only by the most prominent component; We often have different understandings of what specific interventions are; As a result, intervention evaluation is difficult; A deeper understanding of interventions should include examining the synergy of multiple intervention components;

Theoretical Assumptions To a large degree, how intervention programs are constructed is a reflection of the theory they are based on (either overtly or implicitly) There are a variety of theoretical trajectories to consider Individual-level Community & Social Multi-level and ecological Dynamic / iterative theories

Getting beyond the individual

Bronfenbrenner’s Ecological Model

Program Characteristics: Quality, Intensity, Coverage, Costs Psychological Factors: Knowledge Attitudes Beliefs Perceptions Risk Perception Behaviors: Condom Use Number of Sex Partners Frequency of Sex Environment: -Access to Condoms -Behavior of Partner -HIV Prevalence of Sex Partners Health Outcomes: HIV Incidence Intervention Program Characteristics: Quality, Intensity, Coverage, Costs

Considering causal pathways: at what point do we focus?

Proximal / Distal Causal Effects Organize meetings, train on advocacy, provide legal rights, provide venue… Increased empowerment by women and increased access to financial resources Reduced HIV Incidence Increased Condom Use Social Mobilization

How quickly can we expect interventions to take effect? Cleland Paper Examined the uptake of condoms between 1993-2001 in 18 countries Among young women, median increase of 1.4% per year in condom use for pregnancy prevention by single women Cumulative increases in condom use from 19.3% to 28.4% Year to year effects appear small But cumulative effects are substantial

Individual Level Theories Focus on Psychological Processes Primary target of the intervention is the individual, as opposed to social units Examples: Health Belief Model Theory of Reasoned Action / Planned Behavior Held sway during last few decades Suggests a Health Education strategy for behavior change

Community & Social Theories Focus on social processes Primary Target is social units (e.g. families, communities) as the mechanism for affecting individual level behavior change Examples: Social Capital Participatory Action Research Social Network Theories These strategies often also incorporate psychological theories Suggests interventions that exploit social processes and empowerment (Positive Deviance, Popular Opinion Leader, Community Mobilization) Suggests interventions that are multi-faceted – in fact, views “interventions” as an integrated program, but with a clear goal (Example: 100% Condom Intervention)

Multi-Level and Ecological Theories Focus on integration of strategies across individual, community, and policy levels Argues that behavior change is best affected with simultaneous strategies Examples: Structural & Environmental Ecological Theory Multi-Systemic Therapy

Dynamic Theories Several behavior change theories put strong emphasis on the dynamic nature of behavior Posit that behavior change is an incremental process with interplay between individuals and outside forces Assume that behavior change takes time and is realized through a trial and error process – a learned process Examples: Social Cognitive Theory Social Learning Theory Stages of Change / Trans-theoretical Model There is a strong emphasis in these on self-efficacy and perceived control Suggest interventions that model behavior, reduce environmental barriers, and build self-confidence They also attempt to overcome “learned helplessness” and encourage actors to try and try again Often used in addiction-related behaviors Social Learning Theory often used in community interventions (CBVCT study)

Social Cognitive Theory Behavior Environmental Factors Personal Factors (Cognitive, affective, & Biological events)

How have we been defining HIV interventions? Activity Counseling, Testing, Education, Training, Policy enactment, Condom Distribution Mode of delivery Mass Media Peer Education Faith-based Community-based Target Population & Setting MSM, IDU, CSW, Work Place, School-Based Interventions Commodity Condom Social Marketing Needle Exchange Micro-credit Outcome or Goal Abstinence Empowerment Theory Structural Intervention Policy Intervention

These strategies for defining interventions are often unsatisfactory Reduces the intervention to uni-dimensional aspects They are not very descriptive Makes it difficult to evaluate and compare across programs Can be pejorative and harmful Defining interventions by risk groups Reduces people to a behavior Can stigmatize “General Population” intervention Code for “Normal People” Interventions contain elements of all of these categories Activity Delivery Mode Target Population & Setting Commodity (often) Outcome Theory Becomes even more complex when an “intervention” is a program that include various intervention components

Data from the Synthesizing Intervention Effectiveness Study

Methods Define the topic Develop inclusion criteria Create a list of search terms Systematically search the literature Screen search results Acquire articles Screen full-text articles and select studies for inclusion Extract study data into standardized format (code) Resolve coding discrepancies Assess study rigor Analyze, synthesize and interpret results

Psychosocial Support for HIV-Infected Persons: Flow Chart from Synthesis Search Abstracts excluded during screening process for not meeting search criteria (N=38) Articles retrieved for more detailed evaluation (N=31) Potentially relevant abstracts identified during initial computer based search, hand search & secondary search (N=69) Articles excluded for not meeting inclusion criteria or background criteria (N=0) Articles meeting eligibility for inclusion in the systematic review (N=1) Articles identified as background material (N=30)

Intervention topics Completed reviews: Voluntary counseling and testing (VCT) Condom social marketing Partner notification Family planning for HIV infected women Mass media Abstinence and abstinence only Peer education Needle syringe exchange Psychosocial support Treatment

Intervention topics Reviews in progress or upcoming: Comprehensive sex education Free condom distribution Behavioral counseling Income generation Diffusion interventions Built environment interventions Interpersonal skills training Policy interventions

Overlap in intervention components FP+ MM PE NE Condom dist Comp sex Educ VCT 1 2 CSM 5 Abs 3

Most studies were conducted in urban settings

Few studies among younger people (except for abstinence) Note: 39 study reports (of 83) did not report on age of study subjects.

Gender of Study Participants by Topic

5 Intervention Areas Condom Social Marketing Peer Education Micro-Finance Social Mobilization Structural Interventions to Reduce Gender-Based Violence

The way forward… Define interventions more holistically Consider Activity, Delivery Mode, Target Population & Setting, Commodity, Outcome, Theory Recognize that intervention programs include multiple components Establish guidelines for key components Communicate the multi-component nature of intervention programs

Creating Standards Create standards based on empiric research Generate consensus on standards Publish these standards Refer to the standard model with short-hand Has been done effectively with HIV Voluntary Counseling and Testing A set of principles developed Consensus efforts taken Guidelines published Guidelines updated as the epidemic has changed Many analogs in medicine Standard treatment approaches Often complex Guidelines Available – Good Clinical Practice Standards Example: Angioplasty

Pros of Standardization Allows for standard delivery which can avoid unintended and unethical consequences; Assists in training and quality control; Facilitates a common understanding of what the intervention is; Enhances ability to evaluate and replicate; Works best for intervention components that have clear causes and effects

Cons of Standardization Dissuades from tailoring intervention approach to complex needs and populations; Complex intervention components are more difficult to standardization

Value of Bundling Interventions Examples of ethical mandates to provide packages of interventions; Testing and treatment; In lieu of treatment preventative benefit of testing may mitigate this mandate; Diagnosis of infectious status and partner notification / risk reduction facilitation (access to condoms); Enhancing efficacy with bundling interventions: Meeting multiple needs; Enhancing efficiency; Referral strategies; Challenges of clustering interventions: Training and standardization of component parts; Cost and complexity

5 Intervention Areas Condom Social Marketing Peer Education Micro-Finance Social Mobilization Structural Interventions to Reduce Gender-Based Violence

Components of a Potential Intervention Women are provided micro-finance to procure a small stall where they can sell condoms to their peers. The condoms are branded and promoted by a national CSM program. The women are trained in risk reduction education, and they are supported to meet regularly to share ideas, support and protect one another, and make recommendations on the overall project.

Condom Social Marketing Social Mobilization Peer Education This program includes all of these components, each of which can have standards of excellence Condom Social Marketing Social Mobilization Peer Education Micro-Finance Structural Interventions to Reduce Gender-Based Violence

Group Work Review the definition provided and reflect on the following: Core Activities Delivery Mode Target Population & Setting Commodity (if appropriate) Outcome Theory

What do we mean by a “structural intervention” Structural – a written policy or law Environmental – interventions that strive to change the physical or social environment to affect behavior change We recognize that there are other definitions….