Objective: To assess the comparative effectiveness of alternative incentive-based interventions to promote HIV testing among men. Design: Randomized clinical trial.Methods: We enumerated four Ugandan parishes and enrolled men ≥18 years.Participants were randomized to six groups that received incentives of varying type and amount for HIV testing at a 13-day community health campaign. Incentive types were:gain-framed (control): participants were told they would receive a prize for testing; lossframed: participants were told they had won a prize, shown several prizes, asked to select one, then told they would lose the prize if they did not test; lotteries: those who tested had a chance to win larger prizes. Each incentive type had a low and high amount (~US$1 and US$5/participant). The primary outcome was HIV testing uptake at the community health campaign.Results: Of 2,532 participants, 1,924 (76%) tested for HIV; 7.6% of those tested were HIV-positive. There was no significant difference in testing uptake in the two lottery groups (78%; p=0.076) or two loss-framed groups (77%; p=0.235) vs. two gain-framed groups (74%). Across incentive types, testing did not differ significantly in high-cost (76%) vs. low-cost (75%; p=0.416) groups. Within low-cost groups, testing uptake was significantly higher in the lottery (80%) vs. gain-framed (72%; p=0.009) group. Conclusions:Overall, neither offering incentives via lotteries nor framing incentives as losses resulted in significant increases in HIV testing compared to standard gain-framed Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.incentives. However, when offering low-cost incentives to promote HIV testing, providing lottery-based rewards may be a better strategy than gain-framed incentives.Key words: HIV testing, Incentives, Lotteries, Loss aversion, Randomized-controlled trial, Men, UgandaCopyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. IntroductionKnowledge of one's HIV status is a critical first step in accessing HIV prevention and treatment services and is essential for realizing the potential of antiretroviral therapy (ART)-based prevention. Achieving high testing coverage is also imperative for meeting the UNAIDS 90-90-90 targets to end the AIDS epidemic, which begin with a goal of 90% of HIV-infected persons knowing their status by 2020. [1] However, despite expansion of HIV testing services in sub-Saharan Africa nearly half of HIV-infected people remain unaware of their status. [2] Men in particular are more likely to have never having tested for HIV. [2] The impacts of this disparity include delayed entry into HIV care, delayed ART start and higher mortality among men compared to women. [3][4][5] Late or non-diagnosis with HIV infection also results in missed opportunities for HIV prevention.Interventions that can boost testing uptake among men are therefore urgently needed.Economic incentives have been shown to promote a number of health beha...
Background-Viral suppression among HIV-positive individuals is essential for protecting health and preventing HIV transmission. Financial incentives have shown promise in modifying various health behaviors in low-income countries but few studies have assessed whether they can improve HIV treatment outcomes. We aimed to determine the impact of time-limited financial incentives on viral suppression among HIV-positive adults in rural Uganda. Methods-We conducted a randomized trial in four rural Ugandan parishes between June 27, 2016 and May 25, 2018. HIV-positive individuals aged ≥18 years were recruited from community health campaigns that included HIV testing services or at a local government health facility where HIV treatment is offered. Participants included those who were initiating antiretroviral therapy (ART) or already receiving ART. We measured participants' viral load at baseline, 6, 12, 24, and 48 weeks and provided results along with viral load counseling. Participants randomized to the intervention group received financial incentives for viral suppression at 6, 12, and 24 weeks, with incentive amounts escalating from US$4 to US$12.5. The primary outcome was viral suppression (viral load<400 copies per mL) at 24 weeks. To assess longerterm effects of time-limited incentives, the secondary outcome was viral suppression at 48 weeks. This trial is registered with ClinicalTrials.gov (NCT02890459). Findings-400 adults were enrolled in the study, 324 from community health campaigns and 76 from the government clinic. Of these, eight (2%) withdrew from the study and were not included in analyses. Over the 48-week follow-up period, 35 (9%) died or were lost-to-follow-up. Participants' median daily income was US$0.79. At baseline, 300 participants (77%) were virally suppressed. In intention-to-treat analyses, 168 participants (84%) in the intervention group and 156 participants (82%) in the control group were virally suppressed at 24 weeks (odds ratio, OR, 1.14, 95% CI 0.68-1.93, p=0.62. In per-protocol analyses limited to participants with viral load measurements at 24 weeks, there was no difference between study groups in viral suppression (OR 0.91, 95% CI 0.45-1.83, p=0.78). Withdrawal of incentives at 24 weeks did not affect long-term viral suppression, with 176 (88%) and 154 (81%) participants in the intervention and control groups, respectively, being virally suppressed at 48 weeks (p=0.06). Interpretation-Financial incentives had no effect on viral suppression among HIV-positive adults. High baseline viral suppression and provision of viral load results might have contributed to high viral suppression among participants. The results underscore the need for interventions that promote achievement of viral suppression among unsuppressed individuals. * Self-reported. ** Determined based on responses to questions administered at baseline about participants' time preferences for immediate vs. delayed monetary rewards.
COVID-19 has presented itself with an extreme impact on the resources of its epi-centres. In Uganda, there is uncertainty about what will happen especially in the main urban hub, the Greater Kampala Metropolitan Area (GKMA). Consequently, public health professionals have scrambled into resource-driven strategies and planning to tame the spread. This paper, therefore, deploys spatial modelling to contribute to an understanding of the spatial variation of COVID-19 vulnerability in the GKMA using the socioeconomic characteristics of the region. Based on expert opinion on the prevailing novel Coronavirus, spatially driven indicators were generated to assess vulnerability. Through an online survey and auxiliary datasets, these indicators were transformed, classified, and weighted based on the BBC vulnerability framework. These were spatially modelled to assess the vulnerability indices. The resultant continuous indices were aggregated, explicitly zoned, classified, and ranked based on parishes. The resultant spatial nature of vulnerability to COVID-19 in the GKMA sprawls out of major urban areas, diffuses into the peri-urban, and thins into the sparsely populated areas. The high levels of vulnerability (24.5% parishes) are concentrated in the major towns where there are many shopping malls, transactional offices, and transport hubs. Nearly half the total parishes in the GKMA (47.3%) were moderately vulnerable, these constituted mainly the parishes on the outskirts of the major towns while 28.2% had a low vulnerability.
BackgroundFew studies have explored how economic incentives influence behavioral outcomes. This study aimed to identify pathways of action of an incentives-based intervention to increase men’s participation in HIV testing.MethodsThe qualitative study was embedded in a randomized-controlled trial that compared effectiveness of gain-framed, loss-framed and lottery-based incentives to increase HIV testing among men. Following testing at a community health campaign, 60 in-depth interviews were conducted with men systematically sampled on the basis of age, incentive group, and campaign attendance. Data were coded deductively and inductively for thematic content analysis.ResultsIncentives addressed men’s structural, interpersonal and individual-level barriers to testing: offered at convenient locations, incentives offset costs of testing, in lost wages, which are exacerbated when livelihoods required mobility. Interpersonal barriers included anticipated stigma/fear of disclosure, social obligations, and negative peer influences. Providing incentives in public settings provided “social proof” that prizes could be won, and facilitated social support and positive norms by promoting testing with trusted others. Incentives had little influence when men appraised prize values to be low, disbelieved they would win a prize, or were already intrinsically motivated to test. Yet, incentives provided a behavioral ‘cue to action’ for many men who perceived themselves to be susceptible to HIV and perceived HIV disease to be severe, acting as secondary motivator for testing that “sweetened the deal”.ConclusionIncentives can be an important ‘lever’ to promote men’s healthy behaviors in resource-poor settings. HIV testing in convenient, public settings, when paired with incentives, provides multiple pathways to stimulate men’s testing uptake.Trial registrationRegistered with ClinicalTrials.gov on 08/10/2016, ID: NCT02890459. The first participant was enrolled on 11th April 2016.
Background Safeguarding the psychological well-being of healthcare workers (HCWs) is crucial to ensuring sustainability and quality of healthcare services. During the COVID-19 pandemic, HCWs may be subject to excessive mental stress. We assessed the risk perception and immediate psychological state of HCWs early in the pandemic in referral hospitals involved in the management of COVID-19 patients in Uganda. Methods We conducted a cross-sectional survey in five referral hospitals from April 20–May 22, 2020. During this time, we distributed paper-based, self-administered questionnaires to all consenting HCWs on day shifts. The questionnaire included questions on socio-demographics, occupational behaviors, potential perceived risks, and psychological distress. We assessed risk perception towards COVID-19 using 27 concern statements with a four-point Likert scale. We defined psychological distress as a total score > 12 from the 12-item Goldberg’s General Health Questionnaire (GHQ-12). We used modified Poisson regression to identify factors associated with psychological distress. Results Among 335 HCWs who received questionnaires, 328 (98%) responded. Respondents’ mean age was 36 (range 18–59) years; 172 (52%) were male. The median duration of professional experience was eight (range 1–35) years; 208 (63%) worked more than 40 h per week; 116 (35%) were nurses, 52 (14%) doctors, 30 (9%) clinical officers, and 86 (26%) support staff. One hundred and forty-four (44%) had a GHQ-12 score > 12. The most common concerns reported included fear of infection at the workplace (81%), stigma from colleagues (79%), lack of workplace support (63%), and inadequate availability of personal protective equipment (PPE) (56%). In multivariable analysis, moderate (adjusted prevalence ratio, [aPR] = 2.2, 95% confidence interval [CI] 1.2–4.0) and high (aPR = 3.8, 95% CI 2.0–7.0) risk perception towards COVID-19 (compared with low-risk perception) were associated with psychological distress. Conclusions Forty-four percent of HCWs surveyed in hospitals treating COVID-19 patients during the early COVID-19 epidemic in Uganda reported psychological distress related to fear of infection, stigma, and inadequate PPE. Higher perceived personal risk towards COVID-19 was associated with increased psychological distress. To optimize patient care during the pandemic and future outbreaks, workplace management may consider identifying and addressing HCW concerns, ensuring sufficient PPE and training, and reducing infection-associated stigma.
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