What we're asking in public health
Do innovative approaches to teen pregnancy prevention reduce high-risk sexual behaviors in youth?
Teen pregnancy is associated with serious negative maternal health and educational outcomes, including greater risk for pregnancy complications and decreased likelihood of obtaining higher education. Children of teen mothers are at an even higher likelihood of adverse consequences, including cognitive and developmental delays. Despite considerable declines in the last three decades, the U.S. maintains higher teen pregnancy and birth rates than other western industrialized nations. Within the U.S., birth rates for non-Hispanic white teens are significantly lower than rates reported for other races and ethnicities. It is therefore critical to address persistent social inequities and identify evidence-based interventions that can effectively contribute to the reduction of risky sexual behaviors for all U.S. adolescents, with an eye towards reducing the overall incidence of teen pregnancy.
Jenner, E., Jenner, L. W., Walsh, S., Demby, H., Gregory, A., & Davis, E. (2016). Impact of an intervention designed to reduce sexual health risk behaviors of African American adolescents: Results of a randomized controlled trial. American Journal of Public Health, 106(S1), S78-S84.
Jenner, E., & Walsh, S. (2016). Adolescent pregnancy prevention programs and research: A time to revisit theory. American Journal of Public Health, 106(S1), S28-S29.
Davis, E., Demby, H., Jenner, L. W., Gregory, A., & Broussard, M. (2016). Adapting an evidence-based model to retain adolescent study participants in longitudinal research. Evaluation and Program Planning, 54, 102-111.
Walsh, S., Jenner, E., Leger, R., & Broussard, M. (2015). Effects of a sexual risk reduction program for African-American adolescents on social cognitive antecedents of behavior change. American Journal of Health Behavior, 39(5), 610-622.
Demby, H., Gregory, A., Broussard, M., Dickherber, J., Atkins, S., & Jenner, L. W. (2014). Implementation lessons: The importance of assessing organizational “fit” and external factors when implementing evidence-based teen pregnancy prevention programs. Journal of Adolescent Health, 54(3), S37-S44.
Becoming a Responsible Teen (BART). PRG conducted an individual-level RCT with 850 youth participating in a summer job training program through the city of New Orleans. BART is a group-based intervention consisting of eight 2-hour sessions.
Safer Sex. PRG conducted an individual-level RCT with 319 young women, ages 14-19, who were visiting a reproductive health clinic in New Orleans. Safer Sex is a one-on-one intervention implemented by a trained health educator that includes an initial and three follow-up sessions.
Peer Group Connection (PGC). PRG is conducting an individual-level RCT with 9th grade students in rural North Carolina schools and urban New York City schools. PGC is a high school transition and cross-age peer mentoring program that aims to improve goal setting and minimize risky behaviors such as unprotected sexual activity. The sample is fully enrolled and consists of 1,523 students.
Plan A. PRG is conducting an individual-level RCT with 1,770 18–19 year old Hispanic and African American women who are seeking services at Planned Parenthood clinics in central California. Plan A is a 20-minute video based in entertainment education theory.
Practice Self-Regulation (PS-R). PRG is conducting an individual-level RCT with youth who are receiving individual outpatient counseling services in California, Maine, Michigan, New Mexico, and Louisiana. PS-R is a manualized therapy intervention that is trauma-focused and implemented one-on-one over ten sessions by a trained therapist. A total of 432 study participants are enrolled; enrollment is ongoing.
Electronic Practice Self-Regulation (e-PS-R). PRG is conducting an individual-level RCT with juvenile justice-involved youth in West Virginia and New Mexico. e-PS-R is a therapeutic program that combines online and face-to-face instruction for youth ages 14–19 who have experienced trauma. A total of 291 are enrolled; enrollment is ongoing.
Qaragholi, N., Demby, H., Schladale, J. (2019). “Mastering the Art of Partnering to Enhance Successful Outcomes in Adolescent Health Studies.” Adolescent Pregnancy Prevention Grantee Conference. Jun 25-28; New Orleans, LA.
Demby, H., Jenner, L. (2018). “Structuring RCT Partnerships: Exploring Contrasts in Researcher-Practitioner Roles and Responsibilities when Implementing RCTs in Real-World Settings.” American Evaluation Association; Oct 31- Nov 3. Cleveland, OH.
Qaragholi, N., Demby, H., Jenner, L. (2018). “Implementing an RCT in the Juvenile Justice System: Experiences in Rural New Mexico and West Virginia.” American Evaluation Association; Oct 31- Nov 3. Cleveland, OH.
Falk, G., Aguilar, J., Demby, H., Jenner, L. (2017). “Evaluating a Non-Clinical Intervention in a Clinical Setting: Lessons Learned at Reproductive Health Centers.” American Evaluation Association; Nov 6-11. Washington, D.C.
Hall, S., Lucero, D., McFarlane, J., Gregory, A., Demby, H., Jenner, L. (2017). “Increasing RCT Enrollment in a Mental Health Setting.” American Evaluation Association; Nov 6-11. Washington, D.C.
Qaragholi, N., Demby, H., Jenner, L. (2017). “Lessons Learned: Maximizing Communication in a Juvenile Justice-Based RCT.” American Evaluation Association; Nov 6-11. Washington, D.C.
Smith, T., Barr, S., Burgess, K., Foley, E., Demby, H., Jenner, L. (2017). “Recruitment Lessons Learned in a School-Based RCT.” American Evaluation Association; Nov 6-11. Washington, D.C.
Jenner, E., Walsh, S., Jenner, L., Demby, H., Gregory, A., Davis, E., Leger, R., Broussard, M., Dickherber, J. (2015). “Evaluation of Becoming a Responsible Teen (BART): Findings from a Randomized Controlled Trial.” APHA Annual Meeting and Exposition; Oct 31-Nov 4; Chicago, IL
Randomized Controlled Trial (RCT)
PRG uses the most rigorous study design available to researchers – the randomized controlled trial (RCT) – to evaluate the efficacy of a number of innovative teen pregnancy prevention programs on adolescent sexual behavior. The RCT design is considered to be the strongest approach for evaluating the causal impact of a treatment on an outcome because of its ability to create groups that are equivalent on both observed and unobserved factors. The RCT has the potential to minimize selection bias and, when implemented well, produce findings that can conclusively determine whether an intervention leads to a particular outcome.
PRG has conducted or is conducting a total of ten RCTs to date, including six assessing teen pregnancy prevention (TPP) interventions. Two of these studies were completed in 2015 and produced results which indicated the TPP programs being evaluated were not efficacious in reducing risky adolescent sexual behaviors. The remaining four TPP studies will be completed over the course of the next several years, with a goal to produce findings that will identify effective programs, mechanisms that consistently improve education and health outcomes, and interventions that are not impactful as intended.
Can electronic notification or patient navigation systems help people with HIV link to and remain in care?
Over one million people in the U.S. live with HIV. For these individuals, effective antiretroviral therapy (ART) can suppress viral load, improve health outcomes, prevent AIDS, and reduce the risk of transmitting HIV to others. To be effective, ART must be administered consistently with long-term adherence. For a variety of reasons, many people living with HIV fall out of care or fail to remain in continuous care. Finding ways to improve re-engagement and retention will improve health outcomes for people with HIV and reduce the risk of transmission. Though surveillance systems are widely recommended as tools for systematically tracking new diagnoses and lapses in care, little evidence is available on evidence-based interventions focused on reengagement and retention in HIV care. Through the implementation of large-scale quasi-experimental studies focusing on Louisiana’s most-affected communities, PRG’s research examines the potential impact that statewide surveillance systems can have on linking and retaining disconnected individuals into the HIV care continuum.
Improving engagement in HIV care using a data-to-care and patient navigation system in Louisiana.
An estimated 57% of persons living with HIV (PLWH) in the United States are not connected to regular medical care or have lapsed from regular care (Centers for Disease Control and Prevention, 2018), increasing risk for disease progression and transmission of HIV, and delaying viral suppression. Louisiana has consistently ranked in the top five U.S. states for HIV case rates. We evaluated the impact of a combined data-to-care and patient navigation system that was implemented in 3 cities in Louisiana from 2013-2015. This program, LA Links, used a surveillance system to identify PLWH who were not in regular health care and connected them to a patient navigator. During the intervention period, persons who lapsed from care were 17% more likely to reengage in care than persons in the comparison group, and persons newly diagnosed during the intervention period were 56% more likely to link to care.
Anderson, S., Henley, C., Lass, K., Burgess, S., & Jenner, E. Improving engagement in HIV care using a data-to-care and patient navigation system in Louisiana. Journal of the Association of Nurses in AIDS Care.
Public Health Information Exchange in Louisiana (LA PHIE)
This study tests whether a bi-directional information exchange system designed to alert clinicians of lapses in treatment for HIV-positive patients increases the likelihood of reengagement in care. LaPHIE generated a notification within the electronic medical records system when an HIV+ individual who was out of care came into the emergency room, for example with a broken ankle – LaPHIE then prompted the clinician to have a conversation with the patient about HIV care. This quasi-experimental study compares people living with HIV/AIDS (PLWH) who were eligible to be flagged by the information exchange system with individuals in a historical comparison group. Findings demonstrate that turning on the information exchange system led to modest but potentially meaningful increases in the rate at which newly diagnosed people reengaged in care, suggesting the potential efficacy of these systems in ensuring a continuum of care for PLWH.
This brief describes results from PRG’s implementation and impact studies of LA Links, a patient navigation and HIV treatment adherence intervention developed by the Louisiana Office of Public Health.
Natural Experiment (QED)
In the absence of a randomized controlled trial, either because of practical or ethical constraints, researchers may opt to use a number of different quasi-experimental techniques that have the capacity to generate reasonably equivalent treatment and comparison groups to study the effectiveness of an intervention or policy change. When researchers do not have access to sufficient data to match individuals through conventional methods (e.g., propensity score matching), and when individuals do not self-select into the treatment or comparison group, a natural experiment is often the most rigorous approach. A natural experiment is an empirical study in which assignment to the either the treatment or control condition is outside the control of both the researchers and study participants; assignment, therefore, resembles random allocation.
PRG has completed eleven QED studies and employed the natural experiment technique to conduct a number of studies that examine the effectiveness HIV prevention and treatment interventions and policies in Louisiana. PRG conducted a natural experiment that examined the effectiveness of the Louisiana Public Health Information Exchange (LaPHIE), a bi-directional information exchange system designed to alert clinicians of lapses in treatment for HIV-positive patients, to increase the likelihood of reengagement in care. Because LaPHIE was a statewide policy implemented by the Office of Public Health, and not a program that individuals opted into, the policy implementation date served as the assignment mechanism by which individuals were assigned to either the treatment or comparison group.
Do financial incentives directed toward individuals with HIV improve treatment retention and viral suppression?
Inconsistent adherence to antiretroviral therapy (ART) for HIV can pose a number of threats to health outcomes for individuals living with HIV, including reduced treatment efficacy, the development of more resistant viral strains, and progression to AIDS. Previous research suggests that failure to attend clinic visits is a significant predictor of treatment failure, and that individuals living with HIV face personal, structural, and sociological barriers to healthcare maintenance. There is limited research available on the effectiveness of financial incentives programs to improve health outcomes along the HIV continuum of care and even less available on the acceptability of these programs among healthcare providers who facilitate them. Employing approaches that range from a large-scale quasi-experimental study, a city-wide outcome study, and in-depth interviews with healthcare providers, PRG aims to address the gap in current research regarding the effectiveness and acceptability of financial incentive programs to improve health outcomes for individuals living with HIV.
Perspectives of HIV clinic staff on the implementation of a client financial incentives program targeting viral suppression
Using data from in-depth interviews with HIV healthcare providers, this paper examines the acceptability of a financial incentive program implemented at three HIV healthcare clinics in Louisiana. Though research suggests that incentives may be an effective method for improving medication adherence for persons living with HIV, the success of incentive programs is dependent in part on their acceptability to the healthcare providers who facilitate these programs. Understanding staff and leadership perceptions of such programs, which can be unfamiliar and potentially controversial, can inform planning and ultimately improve the implementation of these programs. This study, published in the Journal of the Association of Nurses in AIDS Care in 2017, finds that among the providers who were interviewed, most found the program to be helpful in caring for their patients and for clinic operations in general.
Anderson S., Jenner E., Lass K. & Burgess S. (2017). Perspectives of HIV clinic staff on the implementation of a client financial incentives program targeting viral suppression, Journal of the Association of Nurses in AIDS Care, doi: 10.1016/j.jana.2017.05.007.
Health Models Clinician Qualitative Study
PRG conducted in-depth interviews with 27 HIV healthcare providers at three clinics in Louisiana in May-June 2017 to examine their perspectives on the Health Models financial incentive program that sought to improve treatment adherence and viral suppression among clinic clients. Many providers and staff welcomed the program, but some were concerned about sustainability and the ethics of programs that pay patients to receive care. Most clinicians said they ultimately found the program to be helpful for patients and clinic operations – by facilitating partnerships between providers and patients, improving appointment keeping, providing opportunities for patient education, engaging patients in care, and helping patients form new prevention habits.
What are the current care service needs of people living with HIV in Louisiana?
Over 20,000 Louisiana residents are living with HIV; of these, roughly half have an AIDS diagnosis. In 2017, Louisiana ranked 4th in the nation for HIV case rates (22.1 per 100,000 population) and 10th in the estimated number of HIV cases. Comparatively high rates are also seen for AIDS in Louisiana. Of large metropolitan areas in the U.S., Baton Rouge and New Orleans have among the highest HIV and AIDS case rates. Support services – such as medical and dental care, housing assistance, and supplemental nutrition – can increase viral load suppression rates, decrease transmission rates, and improve quality of life for people living with HIV (PLWH).
Since 2008, PRG has worked with the New Orleans Office of Public Health (OPH) STD/HIV program to conduct a biennial statewide needs assessment for PLWH. The needs assessment provides OPH with cross-sectional data of HIV-related background characteristics, health behaviors, service needs, and service gaps.
Louisiana Needs Assessment
The Louisiana Needs Assessment provides an estimate of the extent of PLWH’s unmet primary care and HIV-related support service needs, experiences in accessing services, and knowledge of services available throughout the state. The report below presents 2019 results from the New Orleans Eligible Metropolitan Area; findings indicate that PLWH in New Orleans are in greatest need of emergency financial assistance and housing support services.
Which communities are most vulnerable to the rapid spread of HIV and Hepatitis C due to injection drug use?
In 2014, an outbreak of HIV and hepatitis C virus (HCV) among persons who inject drugs in Scott County, Indiana raised concerns among public health experts about the potential for the opioid epidemic (and increased illicit injection opioid use) to drive dual HIV and HCV epidemics. The Centers for Disease Control and Prevention (CDC) indicate that from 2014 to 2015, 181 individuals residing in Scott County were newly diagnosed with HIV; 92% of these individuals were coinfected with HCV. Previously, fewer than 5 cases of HIV were diagnosed each year. The case of Scott County underscores the intersection of HIV, HCV, and the opioid epidemic. It has highlighted a need to identify places particularly vulnerable to the rapid spread of bloodborne infections due to opioid misuse in order to intervene early and prevent outbreak. PRG’s research addresses this need by examining opioid and infectious disease vulnerability and risk of HCV outbreak across Louisiana.
Opioids Vulnerability Assessment
In collaboration with The Louisiana Department of Health’s Office of Public Health STD, HIV, and Hepatitis (OPH SHP) program, PRG conducted a statewide vulnerability assessment identifying areas in Louisiana most vulnerable to outbreak of injection drug-related HIV, HCV, or overdose death.
PRG interviewed experts on the opioid epidemic and bloodborne illnesses in Louisiana and compiled a list of potential indicators that could be predictive of high-risk injection drug use in Louisiana. We then used data reduction techniques to develop a parsimonious model that predicted the rate of chronic HCV in persons under the age of 40 (our proxy measure of high-risk injection drug use) and mapped predicted vulnerability across the state. We solicited feedback on the assessment of vulnerability from local experts who identified high impact services and resources that are needed across the state; where data were available resources and gaps in services in vulnerable areas were also mapped.
Detailed findings – including a map depicting predicted vulnerability in Louisiana – can be found below.
Opioids Vulnerability Assessment
This brief describes methods employed by PRG to construct predictor variables, a statistical model, and a vulnerability index for a statewide vulnerability assessment of injection drug-related HIV, HCV, and overdose death in Louisiana.